Comparative evaluation of generative artificial intelligence models for synthetic knee radiograph augmentation in clinical research

In this study, the capability of state-of-the-art generative models to synthesize realistic knee radiographs was evaluated to address dataset scarcity in osteoarthritis (OA) research. Three generative frameworks—Style Generative Adversarial Network3 (StyleGAN3), a stable diffusion + Cycle-consistent Generative Adversarial Network (CycleGAN) pipeline, and Deep Convolutional Generative Adversarial Network (DCGAN)—were trained on 10,042 real knee X-rays. Image quality was assessed using Fréchet Inception Distance (FID) while visual fidelity was evaluated via a Visual Turing Test conducted by two orthopedic surgeons and a musculoskeletal radiologist. Joint Line Convergence Angle (JLCA) was compared between real and synthetic images for anatomical fidelity. Inter- and intra-observer reliability for JLCA was measured using intraclass correlation coefficients (ICC). StyleGAN3 achieved the best performance (FID 10.84), showing high visual and anatomical fidelity. Integrating Stable Diffusion with CycleGAN showed a moderate FID of 39.79, suggesting that adversarial enhancements improved the diffusion-based synthesis. DCGAN showed lower quality, achieving an FID of 74.15. Expert accuracy in distinguishing real from synthetic images ranged between 36% and 88%, confirming difficulty in visual differentiation. Furthermore, JLCA measurements showed no significant difference between real (4.19 ± 3.07°) and synthetic (3.36 ± 2.19°) images generated by DCGAN (p = 0.12). Similarly, Diffusion + CycleGAN (3.91 ± 2.59° vs. 3.72 ± 2.52°, p = 1.00) and StyleGAN3 (4.27 ± 3.01° vs. 3.60 ± 2.37°, p = 0.25) showed no statistically significant differences. These results indicate that all elevated generative models maintained high anatomical fidelity relative to real radiographs. Inter-observer agreement was strong, with ICC values ranging between 0.83 and 0.97. Intra-observer reliability was also excellent. StyleGAN3 generated the most realistic knee radiographs. Diffusion-based pipelines showed promising results when enhanced with adversarial networks. These findings underscore the potential of generative AI to mitigate data limitations in orthopedic research.