Comparison of fixed-flexion positioning with fluoroscopic semi-flexed positioning for quantifying radiographic joint-space width in the knee: test-retest reproducibility

Objective: To compare fixed-flexion radiography of the knee with fluoroscopic semi-flexed radiography in terms of the reproducibility of measurements of minimum joint-space width (JSW) in the medial femorotibial joint. Methods: Posteroanterior radiographs of the right knees of 18 normal volunteers were acquired with the patients standing on an upright fluoroscopy table, the feet externally rotated 10degrees and the toes touching the vertical table. Knees were positioned and radiographed with two different techniques: (1) semi-flexed positioning under fluoroscopic guidance using a horizontal X-ray beam; and (2) fixed-flexion positioning, with the knees and thighs touching the vertical table, using 10degrees caudal beam angulation without fluoroscopy. Foot maps were drawn in each case. Subjects were repositioned and radiographed twice using each technique. The posteroanterior beam angle that optimally projected the medial tibia plateau with the patient in the fixed-flexion position was also determined for each subject in a separate examination using fluoroscopy. Ten patients with osteoarthritis were also examined with the fixed-flexion technique using a conventional radiographic unit. Minimum medial joint-space width (JSW) in the medial femorotibial joint was measured manually with a graduated lens and also with a semi-automated computer algorithm. Results: Reproducibility errors (root-mean-square SD) for manual and automated JSW measurement were 0.2 mm and 0.1 mm, respectively, for fluoroscopic semi-flexed positioning in volunteers; 0.3 mm and 0.1 mm, respectively, for fixed-flexion positioning in volunteers; and 0.2 mm and 0.1 mm, respectively, for fixed-flexion positioning in osteoarthritic patients. The optimal beam angle for visualizing the joint space was 9.0degrees+/-3.6degrees. Conclusion: Fixed-flexion, non-fluoroscopic radiography of the knee can provide reproducible JSW measurement using widely available X-ray equipment. This technique is more feasible for multicenter clinical studies and routine clinical use than are methods that rely on fluoroscopic alignment of the tibial plateau.