Ninety-seven patients with acute syndesmotic injuries (with or without ankle fracture) were randomized to receive surgical treatment with a suture button or a syndesmotic screw. The primary outcome of interest was the American Orthopaedic Foot and Ankle Society Hindfoot (AOFASh) score. Secondary outcomes of interest included the Olerud Molander Ankle Score (OMAS), EQ-5D, EQ-5D Visual Analog Scale (EQ-VAS), VAS pain and range of motion. Follow up took place up to 5 years post-operation. Results of the study revealed significantly favourable AOFASh and OMAS scores at 5 years in the suture button group compared to the syndesmotic screw button. At 5 years, no significant differences in EQ-5D, EQ-5D VAS, VAS pain during rest, VAS pain during walking, VAS pain at night or VAS pain during daily activity were observed between the two groups. The incidence of advanced osteoarthritis was not significantly different between the two groups.