In an 18-year review period, 10 patients were identified with debilitating anterior knee pain and severe rotational malalignment of the lower extremity. Eight of the most symptomatic knees in 7 of these patients were treated with a rotational osteotomy of the tibia performed proximal to the tibial tubercle. Six of the 7 patients who fit a previously described spectrum of rotational deformity consisting of mild femoral anteversion, severe external tibial torsion, mild tibia vara, and pes planovalgus deformity, underwent unilateral procedures for external tibial torsion. Duration of preoperative symptoms averaged 6.3 years. Intraoperative torsional correction obtained with internal rotation of the tibia averaged 19.7 degrees. Subjectively, 1 excellent, 5 good, and 1 fair result were obtained. Functionally, 3 excellent and 4 good results were obtained. Follow-up evaluation averaging 10 years revealed no deterioration of the results, proving the success of the procedure in this group of select individuals over the long term.