186 patients with an unstable distal tibiofibular syndesmosis injury from a bi- or tri-malleolar fracture were randomized to receive management through either a bioabsorbable or metallic screw. Patients were followed-up for a mean 55.8 months in comparing outcomes between the two screw types. Bioabsorbable, polylevolactic acid (PLLA) screws were associated with increased ankle dorsiflexion and plantar-flexion. Functional outcome was overall similar between groups, although the "ability to work" subscale of the Baird score favoured PLLA screws. Complications were more common with PLLA screws, particularly foreign body reactions. Three cases of heterotopic ossification were recorded in the PLLA screw group.