The treatment of patellar instability in skeletally immature patients can be challenging. Patients presenting at a young age often have more severe underlying malalignment (i.e. trochlear dysplasia) that typically leads to the development of symptoms prior to skeletal maturity. While soft tissue procedures (medial patellofemoral ligament reconstruction or proximal realignment) may be appropriate in some patients, many patients with developmental patellar dislocations have significant bony abnormalities (i.e. lateralized tibial tubercle) that are not addressed with soft tissue procedures alone. In our experience, the results of these procedures have not been reliable. Given the lack of reliable treatment options in patients with underlying bony malalignment, skeletally immature patients are frequently counseled to wait until skeletal maturity for definitive treatment (tibial tubercle osteotomy). Particularly in the young child with significant growth remaining, worsening of trochlear dysplasia and patellar instability often occur and can result in abnormalities that are difficult (if not impossible) to correct at skeletal maturity. We present the surgical technique for medial patellar tendon transfer with proximal realignment in this patient population. We have found this technique to be a reliable surgical solution with low rates of complication in this challenging patient population.