103 patients with fibular fractures proximal to an associated syndesmosis injury were randomized to receive internal reduction and fixation with either a knotless TightRope device or screw fixation. Outcomes of interest included radiographic outcomes, the Foot and Ankle Disability Index (FADI), the EQ-5D quality of life questionnaire, the Olerud-Molander (OM) Ankle score, the rate of unplanned re-operation, the rate of malreduction, and the Work Productivity and Impairment (WPAI) score. Follow up was performed at 3 months post-operation for radiographic outcomes, and up to 12 months for clinical outcomes. Results revealed significantly lower rates of unplanned re-operation and lower rates of malreduction in the TightRope group compared to the screw fixation group. Additionally, patients in the TightRope group had a significantly favourable WPAI daily activity rating at 6 weeks compared to the screw fixation group, although total scores were not significantly different. No significant differences in all radiographic or clinical outcomes were observed between the two groups.