A review of distal realignment procedures for patellofemoral disorders is presented, with the pertinent anatomy, biomechanics, and a historical review of these procedures. These procedures can be divided into two basic types—the soft-tissue procedures, which are most useful in the skeletally immature, and the tibial tubercle transfer procedures. In the mature individual, the tibial tubercle procedures can be used to address malalignment of the extensor mechanism, patellofemoral incongruence, patellar articular degeneration, or a combination. A specific approach to this treatment, based on the specific pathology found by clinical, radiographic, and arthroscopic studies, is detailed.