Focal dome tibial osteotomy (FDTO) is a crucial joint-preserving procedure that addresses tibial deformities contributing to ankle osteoarthritis and malalignment. By using the principles of center of rotation and angulation, this technique allows for precise angular correction without significant translation, thereby maintaining biomechanical integrity. Various osteotomy techniques, including dome, opening wedge, and closing wedge osteotomies, provide different benefits and limitations based on individual patient needs. Despite its advantages, FDTO presents challenges such as prolonged recovery, technical complexity, and risks of complications. Future advancements in CT-guided assistance, patient-specific instrumentation, and biological enhancements hold promise for improving surgical precision and patient outcomes.