Patellofemoral instability (PFI) is an increasingly prevalent issue affecting pediatric and adolescent patients. Anatomic factors including lateralization of the tibial tubercle and patella alta can contribute to increased risk of initial and recurrent PFI. Additionally, especially in the case of recurrent PFI, chondral injuries of the patellofemoral compartment can occur. These anatomic pathologies can be surgically addressed using tibial tubercle osteotomy (TTO), adjusting the angle and direction of the osteotomy as needed to achieve the desired correction. We discuss the indications and present our technique for performing TTO, including the modifications that can be made to the procedure to address the specific pathoanatomy of the patient.