Despite being common, syndesmotic injuries are challenging to diagnose and treat. Anatomic reduction of the ankle syndesmosis is critical for good clinical outcomes. Intraoperative three-dimensional radiography and direct syndesmotic visualization can improve rates of anatomic reduction. The so-called gold-standard syndesmotic screw fixation is being brought increasingly into question as new fixation techniques emerge. Syndesmotic screw removal remains controversial, but may allow spontaneous correction of malreductions.