Theoretical Accuracy of Model-Based Shape Matching for Measuring Natural Knee Kinematics with Single-Plane Fluoroscopy

Quantification of knee motion under dynamic, in vivo loaded conditions is necessary to understand how knee kinematics influence joint injury, disease, and rehabilitation. Though recent studies have measured three-dimensional knee kinematics by matching geometric bone models to single-plane fluoroscopic images, factors limiting the accuracy of this approach have not been thoroughly investigated. This study used a three-step computational approach to evaluate theoretical accuracy limitations due to the shape matching process alone. First, cortical bone models of the femur, tibia/fibula, and patella were created from CT data. Next, synthetic (i.e., computer generated) fluoroscopic images were created by ray tracing the bone models in known poses. Finally, an automated matching algorithm utilizing edge detection methods was developed to align flat-shaded bone models to the synthetic images. Accuracy of the recovered pose parameters was assessed in terms of measurement bias and precision. Under these ideal conditions where other sources of error were eliminated, tibiofemoral poses were within $2mm$ for sagittal plane translations and $1.5deg$ for all rotations while patellofemoral poses were within $2mm$ and $3deg$⁠. However, statistically significant bias was found in most relative pose parameters. Bias disappeared and precision improved by a factor of two when the synthetic images were regenerated using flat shading (i.e., sharp bone edges) instead of ray tracing (i.e., attenuated bone edges). Analysis of absolute pose parameter errors revealed that the automated matching algorithm systematically pushed the flat-shaded bone models too far into the image plane to match the attenuated edges of the synthetic ray-traced images. These results suggest that biased edge detection is the primary factor limiting the theoretical accuracy of this single-plane shape matching procedure.