A growing randomized literature has compared dynamic suture-button devices with syndesmotic screws for unstable ankle syndesmosis injuries. This meta-analysis pooled eight randomized trials and evaluated complications, reoperations, radiographic reduction and functional outcomes. The pooled evidence found no major difference in syndesmotic malreduction or overall health-related quality of life, but several clinically relevant outcomes favoured the suture-button group. Complication rates and unplanned reoperation were lower, while common functional measures such as the AOFAS and Olerud-Molander scores were modestly better. The findings support the concept that a dynamic fixation strategy may reduce some downstream hardware-related problems without sacrificing reduction quality. However, the review also highlights that implant selection should not distract from the fundamental surgical objective: restoring the correct relationship between the distal tibia and fibula. Differences in fracture morphology, associated injuries and reduction technique can affect outcomes independently of implant type. For surgeons, the paper is most useful as a decision aid rather than a mandate. Suture buttons are a strong option for many acute syndesmotic injuries, particularly when minimising reoperation is valued, but screw fixation remains reasonable when used appropriately and followed by sound postoperative management.