Much has evolved in the past in the understanding of patellofemoral instability (PFI). Most importantly, the more individualized approach to the patient changes the treatment dramatically. From an approach trying to find an optimal treatment for all with persistent PFI, every patient is evaluated differently based upon several factors such as age, symptoms, clinical findings, and different imaging modalities, where magnetic resonance imaging (MRI) scans are obligatory today. The paradigm about only surgery for persistent PFI has also changed, and surgery for first-time patella dislocation has gained ground. The understanding and importance of different predisposing factors have guided us into more complex algorithms of treatments. From a more patient-focused standpoint, we have revealed how seriously the symptoms of PFI can affect quality of life. The introduction of MPFL reconstruction approximately two decades ago has been a positive game-changer. However, we also started to realize that it is not a panacea. In an undefined number of cases, bony procedures like tibial tubercle osteotomy, trochleoplasty, derotational, and varising osteotomies must be applied, and even patellofemoral arthroplasties.