Patellofemoral pain and instability are common knee disorders that can significantly impact patients’ quality of life. Tibial tubercle osteotomy (TTO) is a surgical intervention correcting patellar malalignment, improving patellar stability, and unloading degenerated and overloaded patellofemoral arthritis, thus reducing pain. This procedure involves repositioning the tibial tubercle to address abnormal patellar tracking, abnormal patellofemoral joint pressure, and alleviate symptoms. This chapter reviews the indications, surgical techniques, and outcomes of tibial tubercle osteotomy for the treatment of patellofemoral pain and instability. A selected literature review was conducted, focusing on most relevant studies that assessed the efficacy of TTO in patients with patellofemoral pain and instability. Key parameters evaluated included the indication for surgery, preoperative assessment, surgical technique, postoperative rehabilitation, and clinical outcomes. Studies have demonstrated that TTO effectively reduces patellofemoral overload, pain, and improves patellar stability. Patient satisfaction rates are high, and the procedure has been associated with a significant reduction in patellofemoral joint peak load, and the recurrence of patellar dislocation. Complications are rare and time to bone healing fast. Tibial tubercle osteotomy for distalization and medialization are important surgical option for patients with patellofemoral pain and instability, offering substantial improvements in knee function and quality of life. Rarely posteriorization or anteriorization may be beneficial. Careful patient selection, precise surgical technique, and avoiding overcorrection are crucial for achieving optimal outcomes.