The tibial tubercle osteotomy (TTO) is a versatile tool for unloading patellar and trochlear focal chondral defects as well as treating patellofemoral arthritis with or without patellofemoral instability. The TTO indirectly functions to address chondral defects in the patellofemoral joint (PFJ) by unloading compressive forces in the affected area and preventing further chondral deterioration and pain. Since its inception, the TTO technique has undergone iterative modification and refinement. The Fulkerson anteromedialization has persisted as the workhorse of modern TTO procedures with good surgical results, though it is not without limitations. Recently, the use of novel surgical systems such as the multidirectional tibial tubercle transfer as well as concomitant soft tissue balancing procedures have been implemented to address challenges posed by the classic Fulkerson technique and improve TTO customizability and reproducibility. In addition, TTO has increasingly been used in conjunction with concomitant procedures such as autologous chondrocyte implantation and osteochondral allograft transfer in the PFJ, to protect the restored cartilage from repeat injury. Though the anteriorization TTO has long been supported to help alleviate pathologic joint compression, recent advancements in surgical guides as well as combined procedures involving multiplane TTO, cartilage restoration, and soft tissue balancing allow for customization of treatment that more thoroughly addresses the complex anatomy and pathology in the PFJ. This article aims to provide an overview of the rationale and recent advancements in the use of TTO to unload and treat chondral defects in the PFJ.