Purpose <p>A lag screw is not always used in treating unstable Weber B ankle fractures, and evidence supporting its necessity remains limited. Therefore, recovery and surgical outcomes will be compared between surgery with and without a lag screw in patients with a Weber B ankle fracture.</p> Methods <p>A retrospective cohort study was conducted, including patients with a Weber B fracture who underwent surgery at Máxima Medical Center between 2012 and 2022. Surgery duration, complications, recovery, and reoperation rate and reasons were compared between patients treated with and without a lag screw. A questionnaire, including the Foot and Ankle Outcome Score, was sent to the same cohort to assess current ankle functionality and treatment satisfaction.</p> Results <p>A total of 302 patients were included, of which 194 with a lag screw. The overall complication rate did not differ (p=0.87), while the distribution of complications did (p=0.01). More wound complications were observed in the no lag screw group (14.8% vs 9.3%), whereas less nerve injuries (0.0% vs 4.6%) and implant complaints (0.9% vs 3.1%) were observed. Surgery duration, recovery, reoperation rate and reasons did not differ between the groups. The questionnaire was completed by 141 patients, of which 92 with a lag screw. Foot and Ankle Outcome subscale scores and treatment satisfaction did not differ between the groups.</p> Conclusion <p>This study demonstrates that the use of a lag screw is not essential in treating Weber B ankle fractures, as no differences in recovery and surgical outcomes were found between the two groups.</p>