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Surgical procedures for reconstruction of a torn anterior cruciate ligament (ACL) have changed considerably over the last 30 years. They have evolved from open surgery to advanced all-inside endoscopic techniques. Arthroscopic transtibial ACL reconstructions have been largely used in recent decades. However, a trend toward more anatomic ACL reconstructions has started in recent years due to the high rates of persistent rotatory instability observed after vertically oriented graft. Placing a single femoral tunnel at the center of the anatomic insertions of the ACL may restore the rotational stability of the knee as well as a double-bundle technique. A thorough knowledge of the anatomical attachment sites of the ACL is required for precise anatomic ACL reconstruction.

Interest in isolated tears of one of the two bundles of the anterior cruciate ligament has increased over recent years. It is thought that by only reconstructing the ruptured bundle while preserving the uninjured bundle contributes to faster graft healing, a better proprioceptive outcome as well as faster recovery. However, this is still to be proven. This chapter describes the difficulty in assessing and confirming partial anterior cruciate ligament injuries. Attention to clinical examination and imaging must also be done. The main purpose of this section is to detail the arthroscopic examination and reconstruction of isolated anterior cruciate ligament bundle ruptures.

Both the meniscus and ACL are frequently injured in sports-related trauma. Regardless of the knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes. Although the ability of the meniscal tissue to heal is known to be limited, its repair at the time of ACL reconstruction has the best chance of healing and so it is currently done by most knee surgeons. ACL-deficient patients with a significant meniscal defect, particularly on the medial side, might benefit from the increase in stability provided by a meniscal transplantation carried out at the time of ACL reconstruction.

The etiology of the patellar instability involves multiple factors and it can often be successfully managed with conservative treatment. This is particularly so in cases of primary dislocation. If there is no clinical improvement with nonoperative management, surgery may be considered especially in cases of recurrent patellar dislocation. In these patients, a complete physical examination and some imaging studies are mandatory.