The ankle is one of the primary weight-bearing joints comprising isolated or combined, single or multiplanar deformities. These deformities can result from congenital or metabolic diseases, posttraumatic malunions, physical disturbances or degenerative joint diseases. Conventional surgical approaches are commonly inadequate for the treatment. Malalignment causing an altered load distribution leads to early ankle joint arthritis. The fibular shift of the ground reaction force widens the tibiofibular joint relation and mortise structure. The realignment of the distal tibia using acute or gradual correction with external fixation is a valuable procedure in the treatment. Therefore, a systematic approach and careful deformity analysis are required for the restoration of the joint orientation and distal tibia alignment. In this article, distal tibia and ankle deformities will be discussed in a systematic order with the etiologies, classifications, treatment options, and surgical methods.