Knee positioning systems for X-ray environment: a literature review

Abstract

The knee is one of the most stressed joints of the human body, being susceptible to ligament injuries and degenerative diseases. Due to the rising incidence of knee pathologies, the number of knee X-rays acquired is also increasing. Such X-rays are obtained for the diagnosis of knee injuries, the evaluation of the knee before and after surgery, and the monitoring of the knee joint's stability. These types of diagnosis and monitoring of the knee usually involve radiography under physical stress. This widely used medical tool provides a more objective analysis of the measurement of the knee laxity than a physical examination does, involving knee stress tests, such as valgus, varus, and Lachman. Despite being an improvement to physical examination regarding the physician's bias, stress radiography is still performed manually in a lot of healthcare facilities. To avoid exposing the physician to radiation and to decrease the number of X-ray images rejected due to inadequate positioning of the patient or the presence of artefacts, positioning systems for stress radiography of the knee have been developed. This review analyses knee positioning systems for X-ray environment, concluding that they have improved the objectivity and reproducibility during stress radiographs, but have failed to either be radiolucent or versatile with a simple ergonomic set-up.

Keywords: Knee joint; Lachman test; Positioning system; Stress radiography; Valgus stress; Varus stress.

Fig. 1

X-ray equipment

Fig. 2

Left knee X-rays, where “E” is an indicator for “Left”: a normal anteroposterior view, and b lateral view

Fig. 3

Valgus stress test performed manually by a physician. The arrow indicates the movement of the hand on the tibia whilst the other hand fixes the femur

Fig. 4

Varus stress test performed manually by a physician. The arrow indicates the movement of the hand on the tibia whilst the other hand fixes the femur

Fig. 5

Lachman test performed manually by a physician. The arrow indicates the movement of the hand on the tibia whilst the other hand fixes the femur

Fig. 6

X-ray image with hands of a physician whilst performing the varus stress on the left knee (“E” is an indicator for “Left”).

Fig. 7

X-ray image with artefact left by the table of examination during the performance of the varus stress test on the left knee (“E” is an indicator for “Left”)

Fig. 8

Schematic valgus stress test performed on the knee with the Telos Stress Device, Adapted from [26]