Acute syndesmotic injures are commonly associated with ankle fractures, and can have long-term implications on patient function and stability. Suture buttons and syndesmotic screws are the two most commonly used techniques to treat these injuries. The authors randomized 97 patients to suture button versus syndesmotic screw fixation. Outcomes included the American Orthoapedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), Olerud-Molander Ankle score (OMA), pain on walking on a visual analogue scale (VAS), and the EuroQol-5-D (EQ-5D). Follow-up time was five years post-operatively. The suture button had significantly higher AOFAS and OMA scores, significantly less frequent ankle osteoarthritis and better maintenance of reduction. There was no difference in terms of VAS or EQ-5D. Overall, suture button appears to be a promising option and may be preferable to syndesmotic screw.