When surgical intervention becomes necessary in the treatment of a patient with isolated patellofemoral arthritis, the primary alternatives to arthroplasty are tubercle anteriorization or anteromedialization, patellectomy, and cartilage transplantation. The relative merits of these options should be discussed with each patient. There must be healthy central and proximal patella cartilage in order to expect a good result from a tibial tubercle anteriorization. Patellectomy leaves a well-defined functional deficit and therefore is better to avoid whenever possible, although relief of pain after patellectomy can be substantial. Cartilage resurfacing of the trochlea is an attractive alternative. Combining a resurfacing procedure with decompression of the joint by anteromedial or anterior tibial tubercle transfer should help protect the resurfaced area. Replacement of the patellofemoral joint, properly done on a well aligned extensor mechanism, is most attractive when both patella and trochlea are deficient or when an alternative procedure is unacceptable.