Sixty patients with malleolar fractures and distal tibiofibular joint (DTFJ) instability were randomized to receive either standard surgical fixation evaluated by radiographic imaging (n=30) or fixation guided by direct visualization of anatomical landmarks via anterior capsulotomy (n=30). The primary outcome was radiologic quality of syndesmotic reduction measured via bilateral CT scans. Secondary outcomes included fibula rotation and length, anterior translation, relative torsion, and clinical function assessed via AOFAS scores at 3, 6, and 12 months. Overall, the results of the study revealed that anatomical landmark-guided reduction led to significantly improved fibula rotation, length restoration, and early functional outcomes. The findings suggest that direct visualization using anatomical landmarks is a more accurate and clinically beneficial method for reducing the DTFJ.