Background: Distal tibiofibular syndesmosis injury is either isolated injury or accompanied with ankle fractures. Isolated syndesmosis injury occurs in up to 11% of ankle sprains. Objective: The aim of the current study was to use a custom-made suture button (SB) compared to 4.5 mm syndesmotic screws (SS). Patients and methods: This prospective study was carried out in Orthopedic Surgery Department, Zagazig University Hospital. Forty patients with tibiofibular syndesmotic injury were equally divided to the SB group or the SS group. We used a custom-made suture button consists of two buttons connected by a fiber wire. Results: Age and BMI did not significantly differ across groups. Male gender predominated in both groups. There was no significant difference between groups regarding AOFAS immediately postoperatively, but SB group was significantly higher than SS group at 6 weeks and 6 months. There was no significant difference between groups regarding VAS immediately postoperatively, but SB group was significantly lower than SS group at 6 weeks and 6 months. Conclusion: In comparison to the SS approach, the SB technique yields better functional outcomes and reduced incidence of fractured implants and joint mal-reduction. Therefore, at present moment, the SB approach is advised for the treatment of syndesmosis injuries.