The patellofemoral joint has a complex unique geometry with multiple noncontractile and contractile stabilizers. Due to its complex regional anatomy, there are various surgical procedures described to restore the native anatomy or to correct anatomical variations leading to patellofemoral instability. Patellofemoral instabilities have always been a spectrum of issue that needs particular focus and attention. The variation in anatomy from person to person guides the treatment strategies. The medial patellofemoral ligament is the smallest part of the complex medial anatomy that contributes significantly to the patellofemoral stability. Anatomic MPFL tear location determines whether or not MPFL surgical repair or reconstruction is indicated. For recurrent or post-traumatic patients with instability, MPFL reconstruction in isolation or in addition to the proximal or distal realignment procedures should be done. The key to success for any surgical procedure is proper patient selection and understanding surgical treatment goals. Because of procedural complexity, complications may occur following MPFL surgical repair or reconstruction. Surgical complication risks can be minimized by establishing and adhering to well-planned guidelines, paying meticulous attention to each intraoperative procedural step, and insuring patient compliance with a well-designed postoperative rehabilitation program.