18 studies with 33 540 patients were included in this systematic review and meta-analysis comparing anterior cruciate ligament reconstruction (ACLR) with non-operative management following anterior cruciate ligament (ACL) injury. Pooled outcomes of interest included radiographic knee osteoarthritis, secondary meniscal surgery, and total knee arthroplasty (TKA). The meta-analysis demonstrated no significant difference in the long-term prevalence of radiographic osteoarthritis between ACLR and non-operative treatment, and rates of secondary meniscal surgery were also similar. However, ACLR was associated with a significantly lower risk of subsequent TKA. These findings suggest that while ACLR does not appear to prevent degenerative joint changes, it may improve long-term knee function and stability sufficiently to reduce the need for knee replacement.