Rupture of the anterior cruciate ligament (ACL) of the knee is a commonly occurring injury in the athletic population. Associated meniscal and chondral injury is well recognised. This occurs both at the time of index injury and also secondarily over time in the ACL-deficient knee as a result of several related pathways culminating in osteoarthritis. ACL reconstruction is a well established surgical technique for treatment of symptomatic instability in ACL-deficient knees but the role of ACL reconstruction in the prevention of osteoarthritis remains unclear. This article reviews the contemporary literature on the pathophysiology of chondral and meniscal loss in ACL-injured knees and the role of current treatment techniques, including surgical reconstruction of ligamentous, meniscal and chondral pathology, in altering the natural history of the ACL-deficient knee.