Background/Objectives: To compare the radiographic, perioperative, and patient-reported outcomes between anterior vertebral body tethering (VBT) and posterior spinal fusion (PSF) in adolescents with idiopathic scoliosis. Methods: A systematic search of PubMed, Scopus, Web of Science, and Google Scholar was performed through May 2025. Studies directly comparing anterior VBT and PSF in skeletally immature patients with adolescent idiopathic scoliosis were included. Data were pooled using random-effects meta-analysis and expressed as mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs). The NIH quality assessment tool was used to evaluate risk of bias. Results: Ten studies comprising 1168 patients (573 VBT, 595 PSF) were included. At 2 years, VBT showed a significantly greater main thoracic curve (MD = 5.03°; 95% CI: 1.87–8.20) and proximal thoracic curve (MD = 3.27°; 95% CI: 1.16–5.38), but no difference in lumbar or main curve Cobb angles. VBT was associated with significantly reduced thoracic kyphosis (MD = −2.68°), increased T1 tilt (MD = 1.50°), shorter operative time (MD = −99.23 min), less blood loss (MD = −405.44 mL), and shorter hospital stay (MD = −1.34 days). However, VBT had a significantly higher revision rate (OR = 5.54; 95% CI: 2.81–10.94). No significant differences were noted in SRS-22 domains, except for higher mental health scores in the VBT group (MD = 0.56; 95% CI: 0.07–1.06). Conclusions: Anterior VBT offers perioperative advantages and comparable radiographic correction to PSF in selected adolescents with idiopathic scoliosis, but at the cost of higher revision rates.