3D Reconstruction of ATFL Ligament using Ultrasound Images *Vedpal Singh, *I. Elamvazuthi, *Varun Jeoti, **J George Centre for Intelligent Signal and Imaging Research (CISIR), Dept. of Electrical and Electronics Engineering Universiti Teknologi PETRONAS, Malaysia,
[email protected] ** Research Imaging Centre, University of Malaya, Kuala Lumpur, Malaysia Abstract- Among all existing medical imaging modalities such Ankle ligaments are prone to injury during sports. The most as MRI, CT, PET and SPECT, ultrasound (US) imaging is one common injury in ankle ligaments is due to the foot inversion of the most widely used in various applications such as ligament [3]. Foot inversion mostly affects the anterior talofibular injuries, tendon injuries, bone injuries, cardiac imaging, blood ligament [5] but Calcaneofibular and the posterior talofibular *
flow estimation and obstetrics. Although Three-Dimensional Ultrasound (3D-US) has many benefits such as non-invasive, low cost, portable, real-time and non-ionizing, however, it is limited in diagnosis and management of obstetrics and atherosclerosis, thus far. Since the current Two-Dimensional Ultrasound (2D-US) has many limitations in the diagnosis of ligament injuries and abnormalities. This study represents the 3D Ultrasound Reconstruction of Anterior talofibular Ligament (ATL) for obtaining the fruitful information for disease diagnosis and progression. Keywords – 3D musculoskeletal ultrasound, 3D reconstruction, Anterior talofibular Ligament
Your Human beings are increasingly besieged by injuries and abnormalities in various anatomical parts; specifically, ligament. Ligament is a short band of tough fibrous connective tissue composed mainly of long, strongly collagen fibers. Ligament connects bones to the other bones for making a joint [1]. Although ligaments by nature are very strong and rigid, sometimes strains and sudden forces may be the cause of injuries such as tear, bruise and rupture etc. [2]. Ligament injuries and abnormalities were frequently seen in association with joint debris and diffuse bone marrow edema. This combination is not so often. So, sometimes, it is difficult to determine the exact broken part [3]. Figure 1, shows the various ligament of body regarding elbow, wrist and knee. Ankle is a collection of four types of ligaments such as anterior talofibular (ATFL), posterior talofibular (PTFL), and calcaneofibular (CL) and deltoid ligament (DL) [3]. Figure 2 shows the structure of ankle ligaments in lateral and medial view.
Fig. 1. Ligament structure of Elbow, wrist and Knee Ligaments
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Fig. 2. Anatomy of Ankle Ligaments [4]
ligaments can also damage [6]. Due to eversion may be the main cause damage of deltoid ligament [7], while a hyper dorsiflexion trauma might cause an injury to the syndesmotic ligaments [3]. Some ankle ligament abnormalities are inflammation, tear, bruise etc. In lateral pattern, only ligaments such as anterior talofibular (ATFL), posterior talofibular (PTFL), and calcaneofibular (CL) are visualized but deltoid ligament can be seen in medial pattern and they can roughly be divided into a superficial and deep group of fibres [8]. It is adequately imaged with routine axial and coronal images. Hyalinization of tissue in the terolateral recess, a meniscoid lesion, may result from injury of the anterior talofibular ligament and can contribute to anterolateral impingement [9]. Several studies have shown that ultrasound imaging is capable of depicting injuries of the lateral collateral and medial ligaments [10] as shown in figure 3, represents common injuries causes. Sports are the important recreational and professional activities that are increasing worldwide. Increasingly, this type of activities results in injuries. In recent studies concerning sports injuries, it is estimated; about 20% of all registered
Fi 3 Li
tI j
t
such as high cost, low patient acceptability, time consuming etc. Table I represents comparative analysis of various imaging modalities in terms of their limitations. Figure 6, depicts the complete process for ATL 3D reconstruction using 2D ultrasound frames. Figure 6, provides the process flow for the 3D ultrasound reconstruction. First, collect the database, and then apply some image processing to enhance the database. Perform segmentation manually and arrange all the segmented images in a particular way for 3D reconstruction. Fig 4 Ankle Injuries per day [4 5]
professional sportsmen sustain injuries every year. Ankle was found to be the most prevalent injury body part. It was reported that 14-20% of the sports injuries are related to ankle and normally ligaments are affected [3]. Ankle and ligament injuries are among the most frequent of all injuries. The prevalence in general population is estimated at 1 ankle injury per 10,000 people / day [4, 17, 18]. Figure 4, represents the ankle injuries per day country wise. Critical ankle injuries are frequent of all injuries among athletes. Rapid variation in the direction of jumps and contact with opposing players may be the main cause of injuries. Sports with high incidence of acute ankle injuries include football, 20-25%, basketball and volleyball, 25-30%, of all injuries [19, 20]. Figure 5, shows ankle injury per 1000 hours during training and competitions. Researchers [11, 12, 13 14, 15] have investigated the abnormalities such as Spring Ligament Abnormalities, Ligament Laxity, Ligament Damage, Inflammation, Calcification related to the ligament in ankle using 2D-US.
From Table I, it can be seen that various imaging modalities have limitations in terms of time, cost, patient acceptability, agitation, harmfulness, painfulness, and it can be concluded that US is more flexible, less expensive, harmless
Fig 6 Processing Steps for 3D Ultrasound Reconstruction
and painless with high patient acceptability than other imaging methods. The 2D-US uses 1-D array of transducer for 2D-US image in two modes; freehand and mechanical. Therefore, today, with advances in technology across all imaging modalities, clinicians are demanding more from their 2D-US images. However, the 2D-US is unable to meet this demand. To improve the interpretability of the US images while maintaining US as a flexible anatomical and functional realtime imaging modality, there is a need for a multidimensional TABLE I COMPARATIVE ANALYSES OF MODALITIES XRay [31, 47]
MRI [20, 46]
CT [18, 47]
US [19, 22]
PET [17 ,47]
Time
M
L1
L1
S
L1
L
Cost Accessibility Agitation Real Time Easy Availability Histologic evidence Harmful
M M N N Y
H L Y N N
M L Y Y N
A H N Y Y
H L Y Y N
H L Y Y N
N
N
N
Y
N
N
Y
Y
Y
N
Y
Y
Limitation Fig 5 Ankle injuries per 1000 hours [19]
Despite the fact that the ankle ligaments are prone to injuries and abnormalities, proper anatomical knowledge of the different ligaments is still lacking due limitations of the existing 2D-US system. Therefore, this makes the diagnosis of these injuries and abnormalities more challenging. MATERIAL AND METHODS Ultrasound (US) has emerged as a popular medical imaging modality in a number of medical imaging applications because of its lower cost, wide reach, flexibility, lack of radiation, and intra-operability [21]. Currently, few imaging methods are available for ligament diagnosis but have critical limitations
SPECT [18, 47]
Where, H=high, L=low, M=medium, A=affordable, Yes=Y, No=N, Short=S, Affordable=A,
(specifically, 3D-US) imaging system [22, 23, 24, 25]. 3D-US imaging is being increasingly used for characterizing diseases such as carotid atherosclerosis, requiring a 3D volume to be
3D-US methods, the sensorless freehand 3D-US is widely used. The literature review shows the use of this system for MSK related problems is limited mainly because of its cost and the technology is immature for MSK. Research is continuing for alternative method such as 3D Reconstruction. Conversion of 2D-US frames into 3D-US image is called 3D-US Reconstruction. Figure 8 represents the traditional method for 3D-US Reconstruction. The freehand 3D-US Reconstruction falls into two categories, Volume and Surface Reconstruction. The 3D-US Reconstruction methods are shown in Figure 9.
Fi 7 3D US i
i
h
[22]
reconstructed from a series of 2D B-scans [21]. One of the best advancement is development of 3D-US that has real time capability to build a volumetric data and easy interpretability [26, 28, 47]. Figure 7 graphically represents 3D-US imaging methods where it is divided into mechanical devices, sensor based and sensor less freehand 3D-US that all are real time in nature. Mechanical device uses a motor for probe rotation which is already defined (speed, direction and rotation angle). Freehand
Volume Reconstruction method interpolate the data to a regular 3D array (voxel array). Surface Reconstruction method reconstructs the volume of interest (VOI) directly from contours (cross-sections) segmented from the original ultrasound B-scans in a prerequisite step. These B-scans do not contain processing artefact, hence the clinician has a better chance of outlining the contours of the organ accurately [29, 30]. RESULTS AND DISCUSSION Figure 10 represents the segmentation approach of every frame from input to segmented image. This segmented part used for 3D modeling.
Fig 8 The General process of 3D reconstruction model [28]
Fig. 10. Input image with their manual segmentation
Figure 11, shows the reconstructed 3D model from the segmented frames and also provide the valuable information regarding number of pixels, area, perimeter, and centroid.
Fig 9 3D US Reconstruction methods
system is of two types, sensor based, where sensor collects the information regarding co-ordinate, and sensorless system uses optical tracking system for location. Amongst the three types of Fig 11 3D stack of images with information
Figure 10-13 represents the 3D reconstruction results designed through Matlab ver. 2012b. This study represents the 3D reconstruction of ATL ligaments for better diagnosis. It is using the freehand process for manual segmentation and designs a 3D model of segmented frames. This 3D model is processed and applies rendering process for better visualization of 3D model. Reconstructed 3D model can provide the information regarding volume and area of ATL ligament. It can
evaluate injury size and healing rate for better treatment. CONCLUSION Human beings are increasingly surrounded by injuries and abnormalities in various anatomical parts; specifically, ankle ligament. Ankle ligaments are prone to injury during sports. The most common injury to the ankle ligaments is due inversion of the foot. On the basis of our literature, 3D-US is a better option for proper diagnosis of ligament injuries and abnormalities because 3D-US is relatively less expensive, portable, safe, volume measurement, easy interpretation and real time in nature. The objective of this study is to design the 3D-US from 2D ATL frames for the detection of ligaments injuries and abnormalities such as tears, bruise, torn, inflammation, and calcifications, for obtaining fruitful information of disease diagnosis and progression and to accelerate with real time nature. ACKNOWLEDGMENT The authors would like to thank UTP for their assistance and Ministry of Education (MOE) for sponsoring the project
under grant entitled ‘Formulation of Mathematical Model for 3-D Reconstruction of Ultrasound Images of MSK Disorders’.
REFERENCES [1]
[2] [3]
Tomáš Trč & Milan Handl & Vojtech Havlas “The anterior talo-fibular ligament reconstruction in surgical treatment of chronic lateral ankle instability” International Orthopaedics (SICOT) 34:991–996 Springer 2010. First Aid4 Sport “Ligaments v Tendon Injuries”, 2013. Dr Tim Kenny, Dr Michelle Wright “Knee injury and Ligament Injury” 2010.
[4]
[5] [6] [7] [8] [9] [10]
[11]
[12] [13] [14] [15]
[16]
[17] [18] [19]
[20] [21] [22] [23]
[24]
Matthias Muschol, Ingo Mu¨ller, Wolf Petersen, Joachim Hassenpflug “Symptomatic calcification of the medial collateral ligament of the knee joint: a report about five cases” Knee Surg Sports Traumatol Arthrosc, 2005. “Common Ankle Sprains” ACE Phyical therapy and Sports Medicine Institute. Van Dijk CN On diagnostic strategies in patient with severe ankle sprain. Thesis, University of Amsterdam, The Netherlands, 1994. Brostro¨m L Sprained ankles V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550, 1996. Anderson KJ, Lecoq JF Operative treatment of injury to the fibular collateral ligament of the ankle. J Bone Joint Surg Am 36:825–832, 1954. Boss AP, Hintermann B Anatomical study of the medial ankle ligament complex. Foot Ankle Int 23:547–553, 2002. Kiley D. Perrich, Douglas W. Goodwin, Paul J. Hecht, Yvonne Cheung “Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments” American Roentgen Ray Society, AJR:193, September 2009. Michael S. Bahk, MD and Andrew J. Cosgarea “Physical Examination and Imaging of the Lateral Collateral Ligament and Posterolateral Corner of the Knee” Sports Med Arthrosc Rev. Volume 14, Number 1, March 2006. Patrick S. Duffy, Ryan G. Miyamoto “management of Medical Collateral Ligament Injuries in the Knee: An Update and Review” The Physician and Sports Medicine, 2010. Ligaments Synovitis “ligaments Synovitis” West Virginia University School Of Medicine, 1993. Dr Ben Benjamin “Knee Ligaments” Collateral Damage to knee ligaments, 2005. Susan A. Mulligan, Martin L. Schwartz, Marc F. Broussard, James R. Andrews “Heterotopic Calcification and Tears of the Ulnar Collateral Ligament: Radiographic and MR Imaging Findings” American Roentgen Ray Society, 2000. Pau Golano´, Jordi Vega, Peter A. J. de Leeuw , Francesc Malagelada , M. Cristina Manzanares , Vı´ctor Go¨tzens, C. Niek van Dijk “Anatomy of the ankle ligaments: a pictorial essay” Knee Surg Sports Traumatol Arthrosc 18:557–569, 2010. Trevino SG, Davis P, Hecht PJ: Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am, 25: 1-16, 1994. Kannus P, Renström P: Treatment for acute tears of the lateral ligaments of the ankle J Bone Joint Surg Am, 73: 3015-312, 1991. Van Rijn RM, van Os AG, Bernsen RMD, Luijsterburg PA, Koes BA, Bierma-zeinstra SMA. What is the Clinical Course of Acute Ankle Sprains? A Systematic Literature Review. Am J Med, 121: 324-331, 2008. Fong DTP, Hong Y, Chan LK, Yung PSH, Chan KM: A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007, 37 (1): 73-94. Schneck CD, Mesgarzadeh M, Bonakdarpour A. MR imaging of the most commonly injured ankle ligaments. II. Ligament injuries. Radiology; 184:507–512, 1992. Manya V. Afonso_ and Jo˜ao M.R. Sanches “A Total Variation Based Reconstruction Algorithm for 3D Ultrasound” LNCS, Springer-Verlag Berlin Heidelberg 2013. Muhammad Adil Hayat Khan “3D Reconstruction of Ultrasound Images” University of Burgundy, University of Girona and University of Heriot Watt, MSc Erasmus Mundus in Vision and Robotics (VIBOT) 13th June 2008. Paula Gould “MRI and ultrasound reveal early signs of rheumatoid arthritis” Diagnostic imaging, 2009.
[25] Joseph G. Craig “Ultrasound of Ligaments and Bone” Ultrasound Clinics Volume 2, Issue 4, Pages 617–637 Musculoskeletal Ultrasound, October 2007. [26] Cheryl Jane Bass and Peter John Marriott “Ultrasound of the ankle” Australasian Journal of Ultrasound in Medicine November 2009. [27] Thomas R. Nelson “Three-dimensional Ultrasound Imaging” NELSON 3D/4D Ultrasound Imaging - Uia Annual Meeting, University of California, California, 2006. [28] Robert Nicholas Rohling “3D Freehand Ultrasound: Reconstruction and Spatial Compounding” Churchill College, 1998. [29] Tao Qiu, Tiexiang Wen, WenJian Qin, Jia Gu, Lei Wang, “Freehand 3D Ultrasound Reconstruction for Image-Guided surgery” Chinese Academy of Science, 1068 Xueyuan Avenue, Shenzhen University Town, Shenzhen, P.R.China, June 30, 2011. [30] Shuangcheng Deng, Yunhua Li, Lipei Jiang, Yingyu Cao and Junwen Zhang “Surface Reconstruction from Sparse and Arbitrarily Oriented Contours in Freehand 3D Ultrasound” Research Journal of Applied Sciences, Engineering and Technology 5(11): 3219-3225, 2013. [31] Sheridan C. Mayo, Andrew W. Stevenson and Stephen W. Wilkins “InLine Phase-Contrast X-ray Imaging and Tomography for Materials Science” Materials, 5, 937-965; doi: 10.3390/ma5050937, 2012. [32] Taeyoung Kang, Laura Horton, Paul Emery, Richard J. Wakefield “Value of Ultrasound in Rheumatologic Diseases” Immunology, Allergic Disorders & Rheumatology, JKMS, The Korean Academy of Medical Sciences, 2013. [33] Jacquelyn Rudis “Juvenile Rheumatoid Arthritis” 2013. [34] “Ankle Ligament Tear, Ankle Instability” 2012. [35] Naredo, E., Moller, I., Acebes, C., Batlle-Gualda, E., Brito, E., De Agustin, J. et al. “Three dimensional volumetric ultrasonography. Does it improve reliability of musculoskeletal ultrasound?” Clin Exp Rheumatol 28: 79–82, 2010. [36] C Zöch, V Fialka-Moser and M Quittan “Rehabilitation of ligamentous ankle injuries: a review of recent studies” British Journal of Sports Medicine, 2003. [37] “Ankle injury: A guide to prevention and management” Sports Medicine Australia, 2010. [38] Jeffrey S. Beitler “Knee Ligament Injuries: PCL, LCL, MCL, and ACL Injury” WebMD, 2012. [39] Døhn UM, Ejbjerg BJ, Court-Payen M, et al. Are bone erosions detected by magnetic resonance imaging and ultrasonography true erosions? A comparison with computed tomography in rheumatoid arthritis metatarsophalangeal joints. Arthritis Res Ther. 2006. [40] H.A. Abela “3D ultrasound breaks through to adult indications” Diagnostic Imaging October 2004. [41] “Collateral Ligament Injury (Knee)” Roland Jeffery Physiotherapy 2011. [42] “Physical Therapy in Bloomfield Hills, Milford, Novi, Suttons Bay, Traverse City, Waterford for Elbow” Ulnar Collateral Ligament Reconstruction (Tommy John Surgery). [43] Jmaes Sullvan, Anna Vines “Helping your knee to recover after a ligament sprain or rupture” Oxford Radcliffe Hospitals, 2010. [44] Victor Ibrahim, Zinovy Meyler, and Andre Panagos “Ankle Sprains and the Athlete” American College of sports Medicine. [45] G. K. SEFTON. J. GEORGE, J. M. FITFON, H. McMULLEN “Reconstruction of the Anterior Talofibular Ligament for The Treatment Of The Unstable Ankle” THE JOURNAL OF BONE AND JOINT SURGERY, 1979. [46] Ben Benjamin, Wrist Pain “Radial and Ulnar Collateral Ligament Injuries” 2005. [47] Shauna Sherker, Erin Cassell “In line Skating Injury: A review of the Literature” MONASH University, Accident Research Centre, 2002.
