Objective To investigate the application effects of bilateral, anterolateral and anterior median plate internal fixation in complex tibial plateau fractures, in order to select the surgical approach with higher application effect and value for patients. Methods A retrospective analysis of the clinical data of 80 patients with complex tibial plateau fractures treated by Puning Overseas Chinese Hospital from March 2020 to January 2021 were divided into 3 groups according to different surgical approaches. Patients in the group A (30 cases) were adopted bilateral approach, patients in the group B (25 cases) were adopted anterolateral approach, and patients in the group C (25 cases) were adopted anterior median approach. The clinical indicators of the 3 groups , the levels of serum inflammatory factors before and 3 d after the operation, the knee joint function excellent and good rate 6 months after the operation, the score of the New York Special Surgery Hospital (HSS), and the occurrence of complications were compared. Results The intraoperative blood loss in the group A was significantly more than those in the groups B and C. The weight-bearing activities and fracture healing time were significantly shorter than those in the groups B and C. The hospital stay was significantly longer than those in the groups B and C. The postoperative drainage in the groups A and B was significantly more than that in the groups C. Compared with preoperation, the levels of C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the 3 groups were significantly higher 3 d after the operation. However, the group A was significantly higher than those of groups B and C; the scores of the pain, function, joint range of motion, muscle strength, flexion deformity, joint stability and HSS total scores of the group A were significantly higher than those of group B and C (all P<0.05); there was no significant difference between the knee joint function excellent and good rate and the total incidence of complications in the 3 groups (all P>0.05). Conclusion The 3 surgical approaches have good results in the surgical treatment of complex tibial plateau fractures, compared with the unilateral approach, the bilateral approach steel plate internal fixation is more conducive to the recovery of knee joint function, shortening the healing time of fractures and improving the overall rehabilitation effect.