This prospective randomized study included 100 patients with unstable rotational ankle fractures and arthroscopically confirmed syndesmotic injury. Patients were randomized into trans-syndesmotic screw (SS) fixation (n=50) or suture button (SB) fixation (n=50), both performed under direct syndesmotic visualization. The primary outcome was the syndesmotic malreduction rate, assessed via bilateral post-operative CT scans. Secondary outcomes included pain (VAS), functional outcomes (FAAM, SF-36), and complication rates. The malreduction rate was higher in the SS group (14%) than the SB group (4%), though the difference was not statistically significant (p = 0.160). Both groups showed significant post-operative improvement in pain and functional scores, with no significant differences between fixation methods. These findings suggest that direct syndesmotic visualization and reduction improve alignment in both fixation techniques, potentially narrowing the gap in malreduction rates between screw and suture button fixation.