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Objective: With or without screw stabilization for diastatic syndesmosis in advanced pronation‐external rotation (PE) ankle injuries has not yet been well‐determined. Both techniques were retrospectively compared to investigate the superiority of either of the two. Methods: A retrospective cohort study was carried out. From January 1, 2008, to December 31, 2017, 81 consecutive adult patients (average, 42 years; range, 18–78 years; 44 men and 37 women) with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was rechecked by external rotation and hook tests. The necessity of cortical screw insertion to stabilize diastatic syndesmosis was decided by the individual orthopaedic surgeon. Postoperatively, a short leg splint was used for 6 weeks. The syndesmotic screw was removed based on the surgeon's policy. The removal of internal fixation for malleolar fractures was required after 1 year. The outcomes of both approaches were compared clinically, and ankle function was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) score. For statistical comparison, the chi‐square test was used for categorical data and the Mann–Whitney U test was used for numerical data. Results: Seventy‐one patients (average, 40 years; range, 18–78 years; 40 men and 31 women) were followed for at least 1 year (87.7%; average, 2 years; range, 1–11 years). Group 1 (with syndesmotic stabilization) had 22 patients and Group 2 (without syndesmotic stabilization), 49 patients. The union rate in Group 1 patients was 100% (22/22), and in Group 2 patients, 91.8% (45/49; p = 0.17). One deep wound infection occurred in Group 1 patients and two in Group 2 patients. Syndesmosis re‐diastasis occurred in 13.6% (3/22) of Group 1 patients and 30.6% (15/49) of Group 2 patients (p = 0.13). One syndesmotic screw broke at 6 months. Satisfactory ankle function according to the AOFAS score was noted in 86.4% (19/22) of Group 1 patients and 65.3% (32/49) of Group 2 patients (p = 0.07). Conclusion: Insertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable. [ABSTRACT FROM AUTHOR]