Syndesmosis sprain is not uncommon in unstable ankle fractures. Surgical stabilization of the syndesmosis can be achieved with either trans-syndesmotic screws or a suture-endobutton device. The suture-endobutton provides for potential advantages including more anatomical mobility of the joint, quicker return to weight-bearing, and no need for implant removal. In this article, we describe the indications and surgical technique for management of a bimalleolar ankle fracture requiring repair of the syndesmosis. This technique focuses on methods of intraoperative reduction and assessment using fluoroscopic imaging of the contralateral ankle for reference. We also demonstrate the use of a suture-endobutton for syndesmosis fixation.