BACKGROUND: Complex tibial plateau fractures present significant challenges due to severe articular comminution and soft tissue complications. There is still no consensus in the current literature regarding the optimal treatment for these fractures. This study aims to evaluate the clinical and radiological outcomes of complex tibial plateau fractures treated with Ilizarov external fixation with or without minimal internal fixation. METHODS: This retrospective study analyzed 62 patients with Schatzker type V or VI tibial plateau fractures, with a minimum follow-up duration of three years. Patients were divided into two groups: one treated with circular external fixation (Ilizarov method) combined with minimal internal fixation and the other treated with circular external fixation alone. Clinical, functional, and radiological outcomes were assessed, including knee range of motion (ROM), Knee Society Score (KSS), Kujala Score, and Visual Analog Scale (VAS) score. RESULTS: At the latest follow-up, Group 1 demonstrated better functional and clinical outcomes compared to Group 2. The mean knee range of motion in Group 1 was 116.56° versus 97.83° in Group 2 (p<
0.05). Group 1 also had higher KSS scores (92.43 vs. 79.06) and Kujala Scores (94.75 vs. 90.6) and lower VAS scores (1.13 vs. 3.33) (all p<
0.05). Flexion contracture and extension lag were significantly less prevalent in Group 1, with fewer cases and lower severity. Circular external fixators were removed earlier in Group 1 (120.43 days) compared to Group 2 (157.06 days) (p<
0.05), with a lower incidence of delayed union in Group 1. Varus malalignment was also less frequent and less severe in Group 1. No major complications, such as neurovascular injuries, septic nonunion, or deep venous thrombosis, were reported in either group. Both groups exhibited similar rates of minor complications, primarily pin tract infections, which resolved with appropriate treatment. CONCLUSION: Ilizarov external fixation, with or without minimal internal fixation, is an effective treatment method for complex tibial plateau fractures. However, patients in whom the joint was anatomically reduced demonstrated better anatomical reduction, improved range of motion, earlier weight-bearing, and enhanced functional recovery, highlighting the superiority of this approach. These findings support the recommendation of this combined technique as the preferred treatment for such challenging fractures.