Dr. Hiemstra’s study adds a provocative and important contribution to the literature on trochleoplasty, a poorly understood and infrequently used procedure for the treatment of patella instability in the setting of trochlear dysplasia. Trochleoplasty is a technically challenging procedure; unlike most orthopaedic osteotomies, the surgeon performs a geometrically complex intra-articular osteotomy that radically reshapes a convex trochlea into a concave one by creating a highly mobile articular cartilage flap. Naturally, this raises fears of incongruity, catastrophic articular cartilage damage and subsequent arthritis. Dr. Hiemstra’s study, based on a systematic review of 29 studies with nearly 1,000 patients, shows that trochleoplasty significantly improved clinical outcomes and patella stability at an average of 50 months. Importantly, complication rates, including rates of arthritis, were low. The vast majority of these patients were treated in Europe, where the most commonly performed thin flap (Swiss) and thick flap (Lyon) procedures originated more than 25 years ago. Several important questions remain unanswered. There was significant variability in patient selection, and it remains unclear which patients may require this procedure or could undergo a less invasive and less complex one. Another question is whether results from the decades-long experience of European surgeons can be replicated elsewhere. From personal experience, I agree that good results with acceptable complication rates can be achieved with trochleoplasty, but for the majority of patients with patella instability, other procedures, such as medial patellofemoral ligament reconstruction and distal realignment, can also achieve excellent outcomes.