Seventy-five patients with isolated ACL rupture were randomized to bone–patellar tendon–bone (BPTB), single-bundle quadrupled hamstring tendon (HT), or over-the-top HT plus lateral extra-articular tenodesis (HT+LET) (n=25 per arm initially). At final assessment (mean 23.0±1.1 years), 61 completed PROMs, 37 underwent clinical testing, and 35 had radiographs. The primary outcomes were clinical failure/revision and long-term knee function; secondary outcomes included instrumented laxity (KT-1000; pivot-shift), and tibiofemoral/patellofemoral Osteoarthritis (OA) on standardized radiographs. Overall, the results of the study revealed no between-group differences for most PROMs; Tegner activity was slightly higher with HT+LET vs BPTB, AP laxity was lower with BPTB vs HT, and patellofemoral OA was more frequent after BPTB vs HT+LET. There were no differences in tibiofemoral OA or objective IKDC grades. In sum, all three techniques produced satisfactory very long-term outcomes; HT+LET did not increase lateral compartment OA risk and BPTB showed more patellofemoral degeneration.