Chronic patellofemoral instability may lead to pain and early osteoarthrosis. Recurrent dislocations of the patella, lateral subluxation and chronic dislocation are summarized under this generic term. There are five different factors which may be responsible of the development of chronic patellofemoral instability: 1) elongation of the medial patellofemoral ligament (MPFL), 2) patella alta, 3) increased distance between tibial tuberosity and trochlea groove (TTTG) distance, 4) trochlea dysplasia and 5) torsional malalignment. To rule out these factors clinical examination, radiological diagnostics (luxation, subluxation in the Defilée view, trochlea morphology, patella alta) and magnetic resonance imaging (MRI) of TTTG distance and trochlea morphology are crucial. The indications of operative treatment are chronic pain with subluxation, chronic dislocation and recurrent dislocation. Currently the former frequently and universally used lateral release is only indicated in cases of subluxation and positive tilt. Biomechanical studies have shown that a lateral release will otherwise increase patellofemoral instability. The choice of the surgical technique depends on the factors underlying patellofemoral instability, the conditions of growth plate and cartilage damage. Among the different surgical options proximal and distal realignment procedures are differentiated. In cases of MPFL elongation and mild passive instability a medial reefing might be successful. In cases of MPFL elongation, high passive instability up to 30° of flexion (with or without trochlear dysplasia) MPFL reconstruction may be the treatment of choice. A trochleoplasty is rarely indicated. This treatment may be considered in cases of high grade trochlea dysplasia and passive instability at more than 30° of flexion. If the TTTG distance is increased (>20 mm) or in cases of patella alta distal realignment with tibial tubercle transfer should be considered. This operation might also be useful in the presence of lateral cartilage damage as an anteromedialization of the patella.