In vivo quantification of 3D displacement in sacral soft tissues under compression Relevance of 2D US -based measurements for pressure ulcer risk assessment

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In vivo quantification of 3D displacement in sacral soft tissues under

compression: Relevance of 2D US-based measurements for pressure ulcer risk

assessment

Authors:

Ekaterina Mukhina*

Univ. Grenoble Alpes, CNRS, TIMC, 38000 Grenoble, France.

ekaterina.mukhina@univ-grenoble-alpes.fr

Alessio Trebbi

Univ. Grenoble Alpes, CNRS, TIMC, 38000 Grenoble, France.

Alessio.Trebbi@univ-grenoble-alpes.fr

Pierre-Yves Rohan

Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, 151 bd de l'Hôpital,

75013. Paris, France

Pierre-Yves.ROHAN@ensam.eu

Nathanaël Connesson

Univ. Grenoble Alpes, CNRS, TIMC, 38000 Grenoble, France.

nathanael.connesson@univ-grenoble-alpes.fr

Yohan Payan

Univ. Grenoble Alpes, CNRS, TIMC, 38000 Grenoble, France

Yohan.Payan@univ-grenoble-alpes.fr

Keywords: Pressure Ulcer; Image Registration; Soft Tissue Damage; Ultrasound Evaluation; MRI

Experiment

To cite this paper:

Mukhina E., Trebbi A., Rohan P.Y., Connesson N. & Payan Y. (to appear). In vivo quantification of 3D

displacement in sacral soft tissues under compression: Relevance of 2D US-based measurements for

pressure ulcer risk assessment. Journal of Tissue Viability. https://doi.org/10.1016/j.jtv.2022.09.007

Abstract

Objective: 2D Ultrasound (US) imaging has been recently investigated as a more accessible

alternative to 3D Magnetic Resonance Imaging (MRI) for the estimation of soft issue motion

under external mechanical loading. In the context of pressure ulcer prevention, the aim of this

pilot MRI study was to design an experiment to characterize the sacral soft tissue motion under

a controlled mechanical loading. Such an experiment targeted the estimation of the discrepancy

between tissue motion assessed using a 2D imaging modality (echography) versus tissue motion

assessed using a (reference) 3D imaging modality (MRI).

Methods: One healthy male volunteer participated in the study. An MRI-compatible custom-

made setup was designed and used to load the top region of the sacrum with a 3D-printed copy

of the US transducer. Five MR images were collected, one in the unloaded and four in the

different loaded configurations (400-1200 [g]). Then, a 3D displacement field for each loading

configuration was extracted based on the results of digital volume correlation. Tissue motion was

separated into the X, Y, Z directions of the MRI coordinate system and the ratios between the

out-of-plane and in-plane components were assessed for each voxel of the selected region of

interest.

Results: Ratios between the out-of-plane and in-plane displacement components were higher

than 0.6 for more than half of the voxels in the region of interest for all load cases and higher

than 1 for at least quarter of the voxels when loads of 400-800 [g] were used.

Conclusion: The out-of-ultrasound-plane tissue displacement was not negligible, therefore 2D US

imaging should be used with caution for the evaluation of the tissue motion in the sacrum region.

The 3D US modality should be further investigated for this application.

Introduction

Internal soft tissue deformation has been shown to be one of the main factors responsible for

the onset of Pressure Ulcers (PU) and to be representative of the risk of the PU development.

Indeed, previous work in animal models have established that compression-induced damage and

internal tissue strains are correlated (Gawlitta et al. 2007; S. S. Loerakker et al. 2010; S. Loerakker

et al. 2011; Nelissen et al. 2019; Stekelenburg et al. 2006; Traa et al. 2018; 2019; van Nierop et

al. 2010). Based on the results obtained on N=11 female Brown-Norway rats, Ceelen et al.

established that tissue damage could be measured using T2-weighted MRI when the maximum

shear strain in the tissues and the compressive strain were in excess of 75% and 45 % respectively

(Ceelen et al. 2008). The experimental quantification of soft tissue displacements and associated

strain fields when tissues are compressed is therefore an important question. Monitoring strain

fields could potentially be used to provide a quantitative metric to assist in the clinical evaluation

of injury risk. However, the in vivo (and more challenging, in situ) monitoring of mechanical

strains represents a significant challenge for the community.

B-mode ultrasound (US) imaging has been shown to be promising for the quantification of soft

tissue motion in combination with Digital Image Correlation (DIC) (Gennisson et al. 2013). It has

been used to quantify soft tissue displacements in vitro, in tissue-mimicking phantom (Zhu et al.

2015), ex vivo, in porcine flexor tendon (Chernak Slane and Thelen 2014) and, in vivo, in the

human Achilles tendon (Chimenti et al. 2016) and in the quadriceps muscle (Affagard, Feissel,

and Bensamoun 2015). From the perspective of PU prevention, a recent study by Doridam et al.

(Doridam et al. 2018) investigated the feasibility of using B-mode ultrasound imaging combined

with DIC for the quantification of subdermal soft tissue strains in the buttock region in two

perpendicular planes (sagittal and frontal) during sitting. Results showed that, in both planes, the

muscle tissue motion in the second principal direction (perpendicular to the pelvis motion) was

important suggesting there was a non-negligible out-of-ultrasound-plane motion of the material

particles. As a result, tracking muscle features using image registration techniques in each plane

would introduce biases. This is a major limitation for the use of 2D US imaging for the in vivo

assessment of soft tissue motion under mechanical loading.

Other attempts have been made using Magnetic Resonance Imaging (MRI) associated with Digital

Image Correlation (DIC) to quantify tissue motion. MRI associated with cross correlation

techniques is actually considered the gold standard for the assessment of 3D tissue motion under

mechanical loading (Gilchrist et al. 2004; Bay 2008). From a PU prevention perspective, Solis et

al. assessed the internal displacements and the associated strain fields in vivo in healthy and

spinal cord injury (SCI) pigs using tagged MRI observing an increase in the values of shear and

tensile strains with an increase in the distance from the centre of ischial tuberosity ventrally (Solis

et al. 2012). In humans, Sonenblum et al. used 3D seated MRI to evaluate displacements in

buttock tissues during sitting in able-bodied and SCI subjects. Results showed that 5 out of 7

tested subjects did not have notable muscle tissue under the ischial tuberosity while sitting

suggesting the importance of using multi-planar imaging to assess subject-specific anatomy

(Sonenblum et al. 2015). Likewise, Trebbi et al. combined MRI of the foot in both deformed and

undeformed configurations with Digital Volume Correlation (DVC), to experimentally assess

internal tissue displacements in the heel pad region (Trebbi et al. 2021) under external shearing

load. However, although MRI is a potential tool for the quantitative evaluation of soft tissue

displacements, it has important drawbacks such as high costs, a confined environment and the

requirement for the patient to not move for long periods in positions that can be uncomfortable.

To summarize, ultrasound-based investigations represent a promising alternative to MRI-based

assessment of tissue motion in clinical environment because they improve on the shortcomings

of MRI for bedside imaging. However, current 2D ultrasound systems are limited in characterising

the soft tissue deformations under mechanical loading because they can only image in the 2D

US-plane. As far as the authors are aware of, no studies have quantified how much error results

from using a 2D imaging modality (echography) as a substitute for a 3D imaging modality (MRI)

for the assessment of soft tissue motion under mechanical loading to inform on injury risk.

Moreover, according to figures reported in a National Prevalence Study in French Hospital

patients, sacral and heel regions have been reported to be the two most common anatomical

sites for PU development (Barrois et al. 2008). Sacrum was therefore chosen in this study as

investigation location because of the high prevalence of PUs at this location (Bauer et al. 2016)

and ease of access for experimentation.

Because of the significant challenges associated with the in situ measurement of both loading

and tissue motion using medical imaging in clinical routine, the objective of this of this pilot MRI

study was to design an experiment to characterize the sacral soft tissue motion under a

controlled mechanical loading. Such an experiment targeted an estimation of the discrepancy

between tissue motion assessed using a 2D imaging modality (echography) versus tissue motion

assessed using a (reference) 3D imaging modality (Magnetic Resonance Imaging) to inform on

the relevance of 2D US-based measurements for pressure ulcer risk assessment. In this work it

was not assumed that the out-of-plane movement is negligible.

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Invivoquantificationof3Ddisplacementinsacralsofttissuesundercompression:Relevanceof2DUS-basedmeasurementsforpressureulcerriskassessmentAuthors:EkaterinaMukhina*Univ.GrenobleAlpes,CNRS,TIMC,38000Grenoble,France.ekaterina.mukhina@univ-grenoble-alpes.frAlessioTrebbiUniv.GrenobleAlpes,CNRS,TIMC,38000Gre...

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In vivo quantification of 3D displacement in sacral soft tissues under compression Relevance of 2D US -based measurements for pressure ulcer risk assessment

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