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Expert Systems with Applications

Expert Systems with Applications 36 (2009) 12081216 www.elsevier.com/locate/eswa

An automatic diagnosis method for the knee meniscus tears in MR images

lu b, Ug ur S Cemal Ko aliog se a,*, Okyay Genc evik a
a

Department of Computer Engineering, Faculty of Engineering, Karadeniz Technical University, 61080 Trabzon, Turkey b Department of Radiology, Faculty of Medicine, Karadeniz Technical University, 61080 Trabzon, Turkey

Abstract Everyday vast amount of information accumulated in medical databases. These databases include quite useful information that could be exploited to improve diagnosis of illnesses and their treatments. However, classication of this information is becoming more and more dicult. In this paper, an automatic method to diagnose the knee meniscus tears from MR medical images is presented. This proposed system uses histogram based method with edge detection ltering and statistical segmentation based methods to locate meniscus at knee joint. A template matching technique is also employed to extract the meniscus. Finally, the meniscus area is analyzed to detect the meniscus tears automatically. Accurate segmentation of the statistical pattern requires a technique that eliminates background eects. Hence, the density distributions of the statistical patterns on images with varying background are corrected. Here, the statistical segmentation method also extracts a representing image of the statistical patterns such as bone and uses the image to enhance the segmentation. Performance of this method is examined on MR images in varying qualities. The results show that our method is quite successful in segmentation of knee bones and diagnosis of the meniscus tears. This system has achieved accuracy about 93% in the diagnosis of meniscus tears on MR images. 2007 Elsevier Ltd. All rights reserved.
Keywords: Medical image processing; Statistical image processing; Bone Segmentation; Knee meniscus location; Meniscus tears; Automatic diagnosis

1. Introduction Medical databases contain vast amount of information relevant to illnesses and their cures. Users may spend a large portion of their time to extract useful information from the medical databases. In fact, many research projects have been launched on data mining to extract information from the medical databases. The developed systems are used to collect or classify the statistical information obtained from the databases. In this study, a sample medical mining system running on large medical databases to detect knee meniscus tears is presented. Manual processing of these databases is quite tedious, costly and time consuming, since obtaining information from nation-wide medical
Corresponding author. Tel.: +90 4623773167; fax: +90 4623257405. E-mail addresses: ckose@ktu.edu.tr (C. Ko se), okyaygenc@meds. lu), usevik@ktu.edu.tr (U. S ktu.edu.tr (O. Genc aliog evik). 0957-4174/$ - see front matter 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.eswa.2007.11.036
*

databases requires many users to spend excessive amount of time (Cicuttini, Wluka, Forbes, & Wolfe, 2003; Dam Erik, Folkesson, Pettersen Paola, & Christiansen, 2006; Inan, Firat, Uc man, & Necaattin, 2004; Martinez, Sucar, & Acosta, 2006; Stammberger, Eckstein, Michaelis, Englmeier, & Reiser, 1999). This proposed diagnosis system enable users to collect valuable information easily from these databases (Diaz, Fdez-Riverola, & Glez-Pena, 2006; Hung & Chen, 2006; Latifoglu, Sahan, & Kara, 2007; Moon, Bullitt, van Leemput, & Gerig, 2002; Ryzewicz, Peterson, & Siparsky, 2007). Then, the medical researchers may measure the eectiveness of the medical treatments considering the information in the databases and give some advices to the doctors if necessary (Guven & Kara, 2006; Kaumann, Gravel, & Godbout, 2003; Ko se, 2006). Meniscus tears are very common knee joint disease resulting in cartilage and bone degeneration that causes pain and loss of mobility. MR (magnetic resonance) imaging

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allows 2D and 3D knee visualization and detection of meniscus tears (Martinez et al., 2006; Tamez-Pena, Barbu-McInnsis, & Toterman, 2004). Processing many knee images manually is quite laborious and can take signicant amount of time. Obtaining accurate results is also subject to the judgment of the clinician and requires a signicant experience and training. Quantifying these problems will enable evaluation of therapies that may heal, slow down or stop degradation in a knee. Consequently, there is a high demand to automate the diagnosis and measurement processes (Erik et al., 2006; Pyridonos, Papageorgiou, & Groumpos, 2006; Stammberger et al., 1999; Tamez-Pena et al., 2004). Then, a diagnosis system is implemented to detect knee meniscus tears in a medical image. Even though medical images give a picture of the small details of the organs in the body, beneting from these images is quite dicult since data sets to be analyzed by the radiologist is increasing substantially. In this application, the scans obtained are grey scale images of knee consisting of 16 slices typically. All of these proton density weighted MR images are acquired in sagittal plane (Brix et al., 1990). Here, automatic organ segmentation and recognition approaches can be used to improve both the eciency and the quality of the diagnosis (Bruijne & Nielsen, 2004; Gamanya, De Maeyer, & De Dapper, 2007; Martinez et al., 2006; Pyridonos et al., 2006; Schilham, van Ginneken, & Loog, 2006; Tamez-Pena, Totterman, & Parker, 1999; Wu, Wang, & Ng, 2006). Hence, the automatic method using both statistical and template matching techniques is employed to analyze and diagnose knee meniscus tears. In this paper, several approaches are examined to locate meniscal region at knee joints in order to automatically diagnose knee meniscus tears from sagittal MR images (Folkesson, Dam, Olsen, Pettersen, & Christiansen, 2005). These are histogram based approaches with edge detection option, and bone segmentation based approaches. To locate meniscal regions, these approaches are examined on images in varying qualities. After locating the meniscal region, a triangular template matching method is employed to determine meniscuses at the knee joint (Alexander & Andriacchi, 2001). Then, the size of meniscus tears on each of the sagittal images is measured for the diagnosis. The system is also tested on images taken from dierent patients and the diagnosis performance of the system is measured for MR images in varying qualities. The rest of this paper is organized as follows. An overview and the implementation details of the developed system are given in Section 2. Histogram and segmentation based location approaches are also explained in the same section. A detailed description of the diagnosis system is presented in Section 3. The results are discussed in Section 4. The conclusion and future work are given in Section 5. 2. Methods for locating the meniscal region In this section, histogram and statistical segmentation based location methods are described in detail (Folkesson

et al., 2005; Letteboer et al., 2004; Prastawa, Bullitt, & Ho, 2004; Tamez-Pena et al., 1999). In the application, the system rst locates the meniscal region on sagittal MR images and then applies a triangular template matching technique to diagnose the meniscus tears. On the proton density sagital knee MR images, meniscal areas at knee joint are symmetrically formed triangular dark regions like horns so they are called anterior and posterior horns. In practice, physician rst concentrates on the knee joint and then searches the meniscus horns. Our system is mainly based on this simple idea. Mainly two approaches are employed to locate meniscal region. These are histogram based and statistical bone segmentation methods. Here, the correct determination of the location of the meniscal region depends on choosing the correct methods. In the literature, few other methods were also proposed to locate meniscus regions (zones) (Folkesson et al., 2005; Song, Chi, & Wang, 2005; Villeger, Ouchchane, & Lemaire, 2006). 2.1. The histogram based location methods In this section, several methods to locate knee meniscal regions are introduced. Histogram based methods exploit the morphology of the femur and the location of the femoral notch, so some knowledge of the knee anatomy is used in the determination of the meniscus regions. Histogram based methods generate vertical and horizontal histograms of the knee images from the original MR scan. Then, histograms are smoothed, normalized and scaled down to tolerate the rotations of the original image. Hence, vertical and horizontal histograms are generated from each image. The maximum and minimum or both values of the histograms are used to determine the approximate locations of the meniscus horns. Histogram based methods involve tree key steps that can be monitored by the user. In the rst step, vertical and horizontal histogram of the knee images are calculated. Then, these histograms are compared to the reference histograms to decide whether they are typical knee histograms or not. If there is no matching between the original histogram, scaled sequence of the original image with dierent rotations are examined to calculate the angle of current rotation. Hence, the extreme values of the histogram are used to locate the knee joints as given in Fig. 1. Here, the cartilage regions generally have higher intensity values compared to the surrounding bones/tissues at knee joints. Therefore, the cartilage regions can be chosen as reference and these high intensity regions can be used to determine the exact positions of the meniscal region. In the application, several histogram based methods are employed. These are histogram based method, and normalized histogram based method with edge detection or ltering. The histogram based method just generates the vertical and horizontal smoothed histograms of the images and then searches the extremes for locating the meniscal region as illustrated in Fig. 1. The second method rst lters the

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Fig. 1. Locating the meniscal region by using the histogram based method.

Fig. 2. Locating the meniscal region by using the normalized histogram based method with ltering.

image by using lters such as Sobel, Prewitt or Roberts lter, and then generates normalized histograms (Sonka et al., 1998). Here, the vertical and horizontal histograms are normalized by considering only the pixels accounted in the histogram calculation. Therefore, pixels under a certain threshold intensity values are not taken into consideration and the vertical and horizontal histograms are normalized related to the number of pixel used in the calculation. Finally, the extremes of the normalized histogram are used to localize the meniscal region as shown in Fig. 2. This gure shows that the horizontal location was found successfully but vertical location was not found that much precisely. 2.2. The segmentation based location method As it can be seen from previous results, the meniscal region can be located in large intervals vertically. This decreases the accuracy of the diagnosis and increases the computation time of the process. Thus, the anatomy of the knee and bones can be also be used in locating the meniscal region in order to reduce computation time and increase the accuracy. Then, a method, using knowledge of the knee anatomy, exploits the morphology of the femur and the location of the femoral notch and locates the region. Here, a statistical method is employed to perform segmentation of knee bones as presented in Fig. 3. The knee bone is rst segmented automatically, and then the histograms of the bones are used to localize the meniscus regions on each slice of knee images. In the application, vertical and horizontal histograms of the segmented bones are rst determined to locate the men-

Fig. 3. Locating the meniscal region by using the statistical segmentation method.

iscal regions. In the next step, the boundaries and the middle of the meniscus regions are detected. The basic idea is to exploit the characteristic shape of the knee bone slices and meniscus regions and the intensity values of the surrounding regions as shown in Fig. 3. The essential steps of this statistical method are determination of characteristic images (CIs), obtaining statistical properties of the statistical texture or bone, background toleration and

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of the current pixel, l represents the size of the CI, and k stands for intensity value index which is Inti; j. 2.2.3. The background eect toleration The background changes, given in Fig. 5, aect the intensity distribution and the segmentation negatively. Fig. 5 shows sample textures and their intensity distributions with and without background changes. The darkest distribution in the gure is the corrected distribution of the texture with background changes. Here, a simple background correction technique is used to minimize the background eects. This technique calculates an average intensity representing sample texture on the current pixel. Then, an average intensity is calculated for each pixel on the sample texture by using Eq. (2). Here, each pixel on the current sample texture and surrounding pixels are taken into account. The size of the sub area is set to the size of the minimum CI. Finally, to enhance the intensity distribution of the texture, intensity of each pixel is rearranged by considering the dierence between the representing average intensity and the average intensity of each pixel. Here, the background changes are tolerated in an expected interval rather than the calculated one. Therefore, intensity of each pixel on the texture is arranged in a limited interval. Int Pxli; j Int Pxli; j fAvrg Intl 1=mm nn mm X nn X Int Pxlii; jjg:
ii1 jj1

Fig. 4. Calculation of the characteristic images.

segmentation. These techniques are explained in detail in the following sections. 2.2.1. Determination of characteristic images Determination of the characteristic images of a statistical texture is important because the characteristic images are in certain sizes and help to minimize the error threshold during the segmentation process. The sizes of these images are related to the size of the patterns in various scales. Large images may include many of the basic images as shown in Fig. 4. Our system allows the user to choose the characteristic images automatically and manually. During the training process, the sizes of the characteristic images are calculated automatically. Here, a small seed image is rst randomly chosen in the interested texture. Then, many other images are selected in the same size at random positions in the interested texture. All of these images are compared to the seed image and then, average error threshold is determined for that size. Finally, all of these operations are carried out for many other seed images located at random positions. Then, the characteristic images with minimum average error values are determined and statistical properties of these images are used to segment the statistical pattern. 2.2.2. Obtaining the statistical properties Some statistical properties of the characteristic images of a texture are calculated during the training process. These are the average of average intensity of variation intervals, standard intensity of deviation interval, intensity distribution array, and the distribution arrays of the high and low extremes intensities of the texture. These properties are collected from the interested image chosen by the user during the training period. The intensity distributions of the CIs are calculated by using the Eq. (1) from the characteristic textures chosen by the user. These intensity distributions are registered as integer arrays and they are normalized for the comparison in the segmentation. Int Distk l
M X N X fInt DistInti; jl 1g: i0 j0

where mm and nn is the height and width of the sub areas, respectively. Int Pxli; j is the intensity of the current pixel, Int Pxlii; jj is the intensities of the pixel around the current pixel and Avrg Intl is the average intensity of the CI in size l. 2.2.4. The statistical segmentation method Localization of meniscus horns at knee is important and a simple statistical segmentation method is proposed to segment two main bones (femur and tibia) at the knee joint. This simple method segments grayscale images with varying intensities from 0 to 255. This method exploits the

where M, N is the height and width of the CI, respectively. Int Dist is the intensity distribution, (i, j) are coordinates

Fig. 5. Sample textures with and without background changes.

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Start

Obtain statistical properties Calculate histograms Segment knee bones

Knowledge base

Locate meniscal region

Apply histogram equalization, Generate binary image

Apply the template matching Detect meniscus horns

Fig. 6. Locating the meniscal region by the statistical segmentation method.

Measure tears

statistical properties of a texture and performs segmentation of bones in a knee slice. The method compares the statistical properties of the reference CI and sample image. If the dierence is under a certain threshold, the pixel is segmented as bone and this process carried out on all the other pixels on the image. After calculating the intensity distributions of each sample at the current pixel, they are normalized and compared with the chosen CIs distributions. Then, dierences between intensity distributions are calculated by using the Eq. (3). Finally, the segmented bones (femur and tibia) are enlarged by employing a simple adaptive region growing technique based on average intensity (Pohle & Toennies, 2001). A sample segmented image is given in Fig. 6. fDist Errgl
b X ia

Manual measurements

Evaluate results

Diagnose meniscus tears

Fig. 7. A ow chart of meniscus tears diagnosis.

1994), (4) applying the template matching method in order to determine meniscus horns areas, (5) measuring the meniscal tears, (6) evaluating the results, and nally (7) diagnosing the meniscus tears. 3.1. A template matching technique for detecting meniscuses The morphological and geometric structures of the meniscal regions are exploited to detect the meniscus horns. Several polygonal (triangular) templates in various sizes are used for detecting the regions. The optimum matching triangle is searched to estimate the meniscal area on each image slice with meniscus. Here, the triangle consists of a black triangle in the middle and this black triangle is surrounded by a thick white triangular polygon as shown in Fig. 8. The black area corresponds to the meniscus horn and the white area corresponds to the surrounding regions of the meniscus horns. Template matching is only done in the previously determined meniscal region. In our application, statistical information about the meniscuses are obtained by using a large number of samples and it is seen that the meniscus horns may be represented in triangular forms in various sizes. Then, the triangle matching is searched within the location limited vertically and horizontally based on the statistical information. Finally, the best matching triangle in terms of size and position is found to determine the size of the meniscus horns. Here, the relative position and sizes of the meniscus horns are also considered. A localized image of an original MR image is shown in Fig. 8a. The details of the localized image are exposed by using histogram equalization technique as given in Fig. 8b. Then, Otsu adaptive threshold

jfInt DistiCI l Int DistiSample l gj: 3

where fDist Errgl is the dierence between the intensity distributions of CI and current sample image in sizel, Int DistCI is the intensity distributions of CI and Int DistSample is the intensity distribution of the current sample image. Here, i is the intensity index and varies from a to b. a (a P 0) is the smallest and b (b 6 255) is the greatest common intensity index of both distributions. 3. Diagnosing meniscus tears The diagnosis system for meniscus tears is described in the following owchart in Fig. 7. The basic steps in this automatic diagnosis of meniscus tears are (1) calculating the histograms, or obtaining the statistical properties of the bone slices at knee and applying the statistical segmentation method to segment the bones, (2) locating the meniscal regions, (3) exposing details of the localized image by using histogram equalization technique and then generating the binary image by employing Otsu adaptive threshold algorithm (Otsu, 1979; Walker, Wolfart, Fisher, & Perkins,

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Fig. 8. Triangle matching and extraction of the meniscus horns.

algorithm is employed to generate the binary image as shown Fig. 8c. The determination of the meniscus regions is shown in Fig. 8d and e. Here, as it can be seen, the meniscus horns are clearly determined. In a large proportion of the MR scans, the meniscus horns are shaped as a triangular with low pixel intensity, surrounded by cartilage/tissues with high pixel intensity. The edges of the meniscus region are found by detecting rapidly changing areas in terms of intensity because the region is mostly surrounded by cartilage. Practical experiments also show that the intensity of the meniscal tears is lower than the intensity of the surrounding cartilages and this is quite useful in determination of the meniscus horn. Here, the template matching exploits the characteristic shape of the meniscal regions and the intensity values of the surrounding regions. The template matching technique using triangles in varying sizes is employed to determine the rough boundaries of the meniscus regions. Finally, the best matching triangle is used to detect exact location of the meniscuses. 3.2. Measuring the meniscus tears Automatic measurement of meniscus tears is preferable because it avoids inter/intra-observer variability and it is better for clinical studies and diagnosis. The areas of the meniscus tears are calculated by searching the high intensity pixels within the black triangle. Here, low intensity pixels surrounded by the high intensity cartilage/tissue pixel are considered in the determination of meniscus tear ratio. Areas of meniscus region of each slice are calculated by summing each corresponding pixel in all meniscus regions. The real corresponding dimensions of pixels (the width and height of real area) are obtained from the metadata in the MR images. Hence, the system calculates the area of the meniscuses and tears. If the area of the tears is larger than a threshold value (an experimentally determined value), meniscus tears are diagnosed as positive. Hence, medical

researchers may take the patient into further examination and applies proper medical treatment plan. 4. Results In this paper, an automatic system is presented to diagnose knee meniscus tears. This system uses a simple histogram based method and statistical segmentation based methods to locate meniscal region at a knee. Besides, the system employs a triangular template matching method to diagnose knee tears on MR images. In this study, about ve hundred images collected from 30 patients at the Department of Radiology at Faculty of Medicine at Karadeniz Technical University and processed for the diagnosis. The system was evaluated on these various quality medical images and results show that the system quite successfully locates the meniscal region. In order to examine the system, a hundred 8 bit greyscale test images taken from 24 dierent patients are chosen from our library of MR images. The diagnosis system was run on PC with P4-3.2 GHz CPU and 512 MB RAM. For the diagnosis, all of these test images are processed in 3.92 min on the system. This result proves that our system is quite promising for large-scale mining applications. A common problem encountered during segmentation is the non-uniformity of the bone textures. This is due to heterogeneous properties of bones and some abnormalities. In most cases, the segmentation method works well and locates the meniscal region correctly. The number of images where incorrect segmentation occurs for a patient knee also depends on the set up of the MR scanner. Evaluation of the results show that histogram based method achieves 39.0% performance in locating the meniscal region horizontally. On the other hand, if the minimum value between two maximums on the vertical histogram is chosen as the reference point, the method achieves about 95.0% of accuracy in locating the meniscal region vertically. Here, if the maximums are chosen as

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the reference points, the system achieves 99.0% of accuracy in locating the meniscal region vertically. In general, this histogram based method achieves 38.0% of accuracy in locating the knee meniscal regions. Another approach is applying an edge detection ltering to whole image, and then applying normalized histogram based method to the ltered image. This approach especially increases the performance of nding horizontal location signicantly. The horizontal performances of the system are given in Table 1. As illustrated in Fig. 9, with this improvement general performance of the system is enhanced 60.0% and it reached to 98.0% at locating meniscal area. On the other hand, these ltering approaches do not enhance the vertical performance of the system. On the contrary, they dramatically improve the horizontal performance of system. Experiments show that 11.0% of the vertical intervals are determined as expected. In others words, 89.0% of the vertical intervals are over estimated. Although the performance of the system at locating the regions is quite good, this over estimation increases the processing time about 20% during template matching and diagnosis, and decreases the accuracy in diagnosis. Therefore, more preTable 1 Horizontal localization performances after ltering Sobel Normal Normalized 98% 100% Prewitt 98% 100% Roberts 96.0% 96.0% Robinson 98% 99% Frei-Chen 98% 100%

cise locating technique is needed to reduce the processing time and to increase the accuracy of the system. The proposed statistical bone segmentation technique is employed to locate the medical regions more precisely because the most known invariant morphology is the structure of the bones (femur and tibia) at a knee. Therefore, bone segmentation may help to gure out the morphological structure of the knee joint more precisely so that it can be used to localize the meniscal region more accurately. After the segmentation, the circular ltering technique is used to remove small segmented fragments on the segmented image (Ko se, 2006). Then, the resulting image is rotated to tolerate the rotation and histograms of the rotated image are compared with the histograms of the reference images to determine exact orientation of the input image. Hence, the simple statistical bone segmentation technique with the region growing method is employed and the results show that 82.0% of meniscal regions are located accurately. On the other hand, if only the femur is considered, the performance goes further up to 94.0% and the rest 6.0% of meniscal regions is also located in large interval vertically. Finally, the diagnosis system is tested on various qualities of knee MR images. Here, the triangular template matching technique is used to detect the knee meniscus horns. Hence, 93.5% of the meniscus horns on two-dimensional images are detected by using template matching technique. Here, experimentally determined triangular templates are rst used to search the meniscus horns and then

Fig. 9. A typical location of meniscal region.

Fig. 10. Measuring the meniscus tears.

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an optimum triangular template is searched for each meniscal area. Results are also examined by medical researchers. These results show that 88.3% of 30 knee images with tears are successfully diagnosed. On the other hand, 95.7% of the 70 knee images without knee tears are diagnosed accurately. In other words, only thirteen out of two hundred meniscus horns are not correctly detected because of poor quality and noise. In addition to these, a quantitative method is also applied to measure the amount of tears with 10% tolerance. These results also show that over 90.0% of measurements are quite successful and other measurements are less precise than expected. The automatic meniscus tear measurements are compared with the manually measured results. These results show that the system successfully detects and diagnose about 90.0% of the meniscus tears from MR images. Fig. 10 shows a typical diagnosis and measurement of the meniscus tears. 5. Conclusion and future work In this study, our goal is to automatically diagnose the meniscus tears on knee MR images. In order to do this, we addressed simple histogram based, statistical segmentation methods and triangular template matching technique. Here, the histogram and statistical techniques are used to locate meniscal region and the triangular template matching technique is used to detect meniscus tears for diagnosis. The diagnosis system achieves accuracy over 93.0% in diagnosis of knee meniscus tears on various qualities of MR images. Although some satisfactory results are obtained, the diagnosis system still needs to be improved. The results of the experiments show that the methods proposed for knee meniscus tear diagnosis may also be applied to the other areas of medical image analysis. So, another future task is to apply this proposed method to other areas in medical image analysis. This automatic diagnosis method is developed to classify the images of large medical databases. Here, this simple and fast diagnosis method may be used to extract information from the large medical databases. An important future work would be measuring the performance of this method in mining medical databases. Acknowledgements We would like to thank to sta and faculty members in Faculty of Medicine at Karadeniz Technical University for providing the MR image data sets used in this study. The authors would also like to thank to Prof. Dr. Ahmet SARI for his contribution on the medical issues in this study. References
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