Anterior Cruciate Ligament Reconstruction (ACLR) is a commonly performed surgery particularly in young active patients. Though it generally has shown promising results in the short term, long-term results are less clear, and there are concerns with regards to osteoarthritis and over-constraint. In this long-term (30-year) follow-up study, the authors randomized 150 patients to three different groups: primary ACL repair, ACLR with a synthetic augment, or ACLR with autologous bone-patellar tendon-bone (BPTB) graft. At 30-year follow-up, patients in the BPTB group had significantly lower rates of revision surgery than the other two groups. There were no significant differences in terms of range of motion, laxity, function, incidence of osteoarthritis, or activity level between the three groups.