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Accurate measurement of long limb alignment is an essential stage of the pre-operative planning of realignment surgery. This alignment is quantified according to the hip-knee-ankle (HKA) angle of the mechanical axis of the lower extremity and is measured based on a full-length weight-bearing X-ray or standard computed radiography (CR) image of the patient in standing position. Due to the limited field-of-view of the traditionally employed digital X-ray imaging systems, several sector images are required to capture the posture of a standing individual. These sector images need to then be stitched" together to reconstruct the standing posture. To eliminate user-induced variability and time constraints associated with the traditional manual "stitching" protocol, we have created an image processing application to automate the stitching process, when there are no reliable external markers available in the images, by only relying on the most reliable anatomical content of the image. The application starts with a rough segmentation of the tibia and the sector images are then registered by evaluating the DICE coefficient between the edges of these corresponding bones along the medial edge. The identified translations are then used to register the original sector images into the standing panorama image. To test the robustness of our method, we randomly selected 40 datasets from a variant database consisting of nearly 100 patient X-ray images acquired for patient screening as part of a multi-site clinical trial. The resulting horizontal and vertical translation values from the automated registration were compared to the homologous translations recorded during the manual panorama generation conducted by a knowledgeable X-ray imaging technician. The mean and standard deviation of the differences for the horizontal translation parameters was -0:27±1:14 mm and 0:31±1:86 mm for the left and right tibia, respectively. The vertical translation differences for the left and right tibia were 1:05±5:24 mm and 1:32±4:77 mm, respectively. For these differences, the expert radiologist reported no difference in the hip-knee-ankle angular assessment.
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