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Chapter 6116IntroductionSeveral factors are crucial for the success of ACL reconstruction. A surgical factor which is considered to be essential in influencing clinical outcomes is femoral tunnel placement.5,17 Malposition of the femoral tunnel is a risk factor for re-rupture of the graft.6 In current surgical techniques, the location of the femoral tunnel is estimated either with a direct measurement beginning on the posterior cortex of the femur or by ‘eyeballing’ anatomical landmarks through an accessory anteromedial portal. Both techniques are profoundly dependent on the experience and preference of the orthopedic surgeon. It is not always easy to accurately determine the exact location of the previously ruptured anterior cruciate ligament during ACL reconstruction surgery, even with the help of MR images. Artificial intelligence to aid in determination of this location is yet to be developed. A meta-analysis performed by Piefer et al showed a wide variability in describing the femoral origin of the ACL, on radiologic as well as on arthroscopic landmarks.13 The need for an individualized guide for optimized femoral tunnel placement seems apparent. When creating a patient specific instrument for ACL reconstruction, preoperatively a decision has to be made regarding the femoral origin of the ACL. Depending on the technique used, this point is either the starting (inside-out) or exit point (outside-in) of the drill. The aim of this study is to determine the intra- and interobserver reliability of identifying the femoral footprint of the torn anterior cruciate ligament on MRI. The influence of background (surgical or imaging) and experience of observers (surgeon or resident) is investigated.MethodsThe research protocol met the requirements to be considered Not Human Subjects Research. This study was a retrospective study in which 20 anonymized MRI scans of subjects with a confirmed rupture of the ACL were analyzed. Scans were selected at random from a cohort of 386 chart numbers corresponding to patients over the age of 16 years, diagnosed with ACL rupture in 2018 at a university hospital. In order to be used in this study, scans had to meet the following inclusion criteria: the scan was of a Mark Zee.indd 116 03-01-2024 08:56