The most frequent combined knee ligament injury involves the anterior cruciate ligament (ACL) and medial collateral ligament (MCL). Conservative treatment of MCL in a brace followed by delayed ACL reconstruction is the preferred treatment due to the intrinsic healing capacity of the MCL. Residual medial laxity at the time of ACL surgery can be addressed by medial collateral ligament reconstruction. ACL injuries can also be a component of knee dislocations/multiligament injuries. Repair of all injured structures in the first three weeks after injury is advisable. Staged surgery may also be employed to prevent stiffness; however, all reconstructions should have been completed before the patients start weight bearing. Tibial eminence avulsions can be managed with internal fixation. Auto or allograft reconstruction should be performed for mid-substance injuries of the ACL. Single bundle anatomical cruciate ligament reconstructions should be preferred to decrease surgical time and cost-effective use of allografts. Strong graft materials and stable fixation methods should be employed to be able start early knee motion and rehabilitation. The knee should be stable at all flexion angles at the end of ligament reconstruction. The outcomes of ACL surgery in multi-ligament injuries are inferior to those of isolated ACL reconstructions. The goal of surgery should be to achieve a stable and painless knee in activities of daily living. Return to sports is possible but rarely matches the pre-injury level.