Patella instability is a complex and frequently observed condition. Although most initial dislocations are successfully treated nonoperatively, some patients with recurrent instability require surgical intervention. Recurrent instability can be associated with structural abnormalities including a tibial tubercle trochlear groove distance greater than 20 mm, trochlear dysplasia, or patella alta. For patients with closed growth plates who have recurrent instability episodes and have failed a nonoperative course of therapy, patellar taping, and bracing, a distal realignment procedure should be considered. The Elmslie-Trillat procedure is a distal bony realignment with medial soft tissue tightening that offers a more rapid recovery than more extensive distal realignments with established excellent long-term results in nonarthritic patients.