ACL reconstruction using autogenous semitendinosus and gracilis tendons has become more popular in the past, mainly because of less frequent donor site morbidity and a high level of patient acceptance. Numerous tibial and femoral fixation techniques have been described, which differ considerably with respect to the site of fixation (cortical, tunnel, near the joint line) and biomechanical parameters. Most commonly used femoral fixation techniques include fixation buttons (EndoButton), interference screws (titanium or biodegradable), or transfixation techniques. For tibial fixation, biodegradable interference screws, often in combination with a tibial fixation button or a suture over a bone bridge, are used most commonly. Each fixation technique has specific disadvantages, which cannot be completely overcome even with a precise operative procedure. Therefore, combined fixation techniques (hybrid fixation) have been developed to enhance biological healing of the graft while simultaneously providing sufficient initial mechanical strength. Furthermore, an atraumatic graft harvest and preparation depending on the desired fixation technique is essential. Most fixation techniques exhibit less initial mechanical strength compared to bone-tendon-bone grafts, which should be considered in a moderate rehabilitation program.