44 skeletally mature patients with displaced distal third tibial fractures were randomized to undergo combined internal and external fixation (CIEF) versus minimally invasive percutaneous plate osteosynthesis (MIPPO), with the purpose of comparing the efficacy of both surgical techniques. Both treatments resulted in similar time to bone union, time to recovery to work, function, alignment, and total AOFAS score. The CIEF group achieved significantly shorter operative and radiation time compared to the MIPPO group. Fewer patients in the CIEF group experienced wound complications, ankle pain, and required secondary procedures for painful implant removal, although none of these differences were statistically significant.