Whole

Anthropometric study of the femur - an automated approach
Author:
Lau, Chi Bang Abe
Publication Date:
2009
DOI:
https://doi.org/10.26190/unsworks/20402
License:
https://creativecommons.org/licenses/by-nc-nd/3.0/au/
Link to license to see what you are allowed to do with this resource.
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Anthropometric Study of the Femur
An Automated Approach
Chi Bang Abe LAU
July 2009
A Thesis Submitted For The Degree Of

Doctor Of Philosophy
Surgical & Orthopaedic Research Laboratories

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Abstract
nowledge of anatomy is an elementary step towards the understanding

K of the human body. First used by Alphonse Bertillon as an identification
system, anthropometry refers to the measurements of human individuals. In
orthopaedics, comparative analysis is widely used in the understanding of
morphological variance due to races, sex and pathological conditions. The
characterization of bone and joint geometry has also been a foundation of
modern surgical implant design.
Traditional anthropometric studies rely on physical measurements by means of

osteometric table. Recent advancements of 3-D imaging modalities and image
processing techniques have empowered more fine-grained anthropometric
characterization. The inspiration for the study is:
• the understanding of anatomy originating from the clinical domain have

shown to contribute to undesirable inconsistency in the image processing
domain.
• the difficulty of existing automated anthropometric methodology in han-

dling pathological femur.
• the tedious amount of manual and subjective work involved with the
increasing amount of high resolution imaging data.
The aim of the study is to:
• develop a consistent and robust methodology in accurate extraction of

anthropometric parameters on the femur.
i
• increase the level of automation on the process of anthropometric pa-
rameter extraction.
With the bridging of anthropometry and the image processing disciplines, a

robust methodology of anthropometric parameter extraction with high level of
automation was developed, implemented and tested.
A dataset comprised of femoral CT scans of 19 healthy Australian, 10 healthy

Japanese, 15 Japanese diagnosed with primary or secondary hip osteoarthritis
and 20 adult sheep was utilized for testing. Intra-class correlation and
Cronbach’s α were extensively employed to evaluate the intra-rater, inter-
rater and repeated scans consistency of the proposed methodology. High
correlation values (mean > 0.95) were noted suggesting a high consistency
of the methodology. All healthy and osteoarthritis human datasets were
processed successfully. With the structural similarity between the sheep
and human femur, the robustness was further demonstrated by accurate
processing of the sheep dataset without the need of any modification of the
underlying methodology. The methodology proposed is highly automated and
requires very few user interactions in the parameter extraction stage.
ii
Acknowledgments
his work would not have been possible without the continue support of
T my supervisor, Prof. W.R. Walsh, and all fellow members of the Surgical
& Orthopaedic Research Laboratories.
I would like to express my sincere gratitude to Dr. Akira Maeyama for his
gracious help on acquiring patient data overseas.
I cannot say how grateful I am with my parents, for their values, their
character and their unfailing support throughout the years. To my lovely
sister Angela, for all her encouragements.
Last, I wish to thank my dear uncle Simon, aunt Mary, and my cousins Joyce,
Patrick and little Winnie for all the care and joy you bring during my stay in
Australia.
iii
iv
Contents
1. Introduction 1
2. Anatomy and Bone Histology 5

2.1. Histology of Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.1. Types of Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.2. Bone Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.3. Woven and Lamellar Bone . . . . . . . . . . . . . . . . . . . . 7
2.1.4. Cortical and Trabecular Bone . . . . . . . . . . . . . . . . . 8
2.1.5. Modelling and Remodelling . . . . . . . . . . . . . . . . . . . 9
2.2. Anatomy of the Human Femur . . . . . . . . . . . . . . . . . . . . . 10
2.2.1. Hip Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.2. Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.2.1. Upper End . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.2.2. Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.2.3. Lower End . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.2.4. Bone Structure . . . . . . . . . . . . . . . . . . . . . 15
2.2.3. Proximal Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2.4. Patella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. Medical Imaging 19
3.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.2. X-ray Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.2.1. Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.2. Measurement Units . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.3. Generation of X-rays . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.4. Applications in Radiology . . . . . . . . . . . . . . . . . . . . 24
v
Contents
3.2.5. Biological Hazards . . . . . . . . . . . . . . . . . . . . . . . . . 25

3.2.6. Strengths and Limitations . . . . . . . . . . . . . . . . . . . . 25
3.3. Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.1. Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.2. Hounsfield Unit Scale . . . . . . . . . . . . . . . . . . . . . . . 27
3.3.3. Quantitative Computed Tomography . . . . . . . . . . . . . 28
3.3.4. Applications in Radiology . . . . . . . . . . . . . . . . . . . . 28
3.3.6.1. Beam Hardening . . . . . . . . . . . . . . . . . . . . 29
3.3.6.2. Partial Volume Averaging . . . . . . . . . . . . . . 30
3.3.6.3. Photon Starvation . . . . . . . . . . . . . . . . . . . 30
3.3.6.4. Metal Objects . . . . . . . . . . . . . . . . . . . . . . 31
3.3.6.5. Ring Artifacts . . . . . . . . . . . . . . . . . . . . . . 32
3.3.6.6. Helical Artifacts . . . . . . . . . . . . . . . . . . . . 32
3.4. Dual Energy X-ray Absorptiometry . . . . . . . . . . . . . . . . . . 32
3.4.1. DXA Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.4.2. Biological Hazard . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.5. Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . 35
3.5.1. Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4. Image Analysis 39
4.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2. Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.1. The DICOM Format . . . . . . . . . . . . . . . . . . . . . . . . 40
4.3. Image Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.3.1. Thresholding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.3.1.1. Fixed Global Threshold . . . . . . . . . . . . . . . . 42
4.3.1.2. Adaptive Threshold . . . . . . . . . . . . . . . . . . 43
4.3.2. Region Growing . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.3. Edge Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.3.3.1. Gradient Operators . . . . . . . . . . . . . . . . . . 47
4.3.3.2. Laplacian Operator . . . . . . . . . . . . . . . . . . 51
4.3.3.3. Canny Edge Detector . . . . . . . . . . . . . . . . . 56
4.3.4. Model Based Techniques . . . . . . . . . . . . . . . . . . . . . 58
4.4. Image Geometric Transformation . . . . . . . . . . . . . . . . . . . . 59
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Contents
4.4.1. Affine Transformation . . . . . . . . . . . . . . . . . . . . . . 59

4.5. Morphological Processing . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.5.1. Preliminaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.5.2. Dilation and Erosion . . . . . . . . . . . . . . . . . . . . . . . 64
4.5.2.1. Dilation . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.5.2.2. Erosion . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.5.3. Opening and Closing . . . . . . . . . . . . . . . . . . . . . . . 66
4.5.4. The Hit-or-miss Operation . . . . . . . . . . . . . . . . . . . . 68
4.5.5. Thinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.5.6. Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.5.7. Convex Hull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.6. Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.6.1. The Hungarian Algorithm . . . . . . . . . . . . . . . . . . . . 77
5. Shape Analysis 79
5.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.2. Basic Geometrical Shape Parameters . . . . . . . . . . . . . . . . . 79
5.2.1. Region Based Parameters . . . . . . . . . . . . . . . . . . . . 80
5.2.1.1. Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
5.2.1.2. Centroid . . . . . . . . . . . . . . . . . . . . . . . . . 80
5.2.1.3. Eccentricity . . . . . . . . . . . . . . . . . . . . . . . 80
5.2.1.4. Area Moment of Inertia . . . . . . . . . . . . . . . . 81
5.2.1.5. Polar Moment of Inertia . . . . . . . . . . . . . . . 81
5.3. Object Description Techniques . . . . . . . . . . . . . . . . . . . . . 82
5.3.1. Chain Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.3.1.1. Principles . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.3.1.2. Applications . . . . . . . . . . . . . . . . . . . . . . . 85
5.3.2. Fourier Descriptors . . . . . . . . . . . . . . . . . . . . . . . . 85
5.3.2.1. Applications . . . . . . . . . . . . . . . . . . . . . . . 88
5.3.3. Hausdorff Distance . . . . . . . . . . . . . . . . . . . . . . . . 89
5.3.4. Corner Detector . . . . . . . . . . . . . . . . . . . . . . . . . . 90
5.3.4.1. Moravec Operator . . . . . . . . . . . . . . . . . . . 91
5.3.4.2. Plessey Operator . . . . . . . . . . . . . . . . . . . . 92
5.3.4.3. Curvature Scale Space Detector . . . . . . . . . . 94
6. Anthropometric Analysis of the Femur 97

6.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.2. Reference Positions and Axes . . . . . . . . . . . . . . . . . . . . . . 98
6.3. Anteversion Angle and Reference Axes . . . . . . . . . . . . . . . . 98
vii
Contents
6.3.1. Physical Measurements . . . . . . . . . . . . . . . . . . . . . 99

6.3.2. 2-D Imaging Techniques . . . . . . . . . . . . . . . . . . . . . 101
6.3.3. 3-D Imaging Techniques . . . . . . . . . . . . . . . . . . . . . 104
6.4. Proximal Measurements . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.4.1. Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.4.2. Femoral Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.4.3. Canal Flare Index . . . . . . . . . . . . . . . . . . . . . . . . . 114
6.5. Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.6. Distal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
7. Methods 123
7.1. Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.2. Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.3. Anthropometric Parameter Extraction . . . . . . . . . . . . . . . . 125
7.3.1. Model Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . 126
7.3.1.1. Lesser Trochanter . . . . . . . . . . . . . . . . . . . 127
7.3.1.2. Proximal Femoral Axis . . . . . . . . . . . . . . . . 130
7.3.1.3. Transepicondylar Axis . . . . . . . . . . . . . . . . 130
7.3.1.4. Affine Transformation . . . . . . . . . . . . . . . . . 133
7.3.2. Trochanters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.3.3. Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.3.4. Distal Posterior Condyles . . . . . . . . . . . . . . . . . . . . 139
7.3.4.1. Tangential Line Extraction . . . . . . . . . . . . . 139
7.3.4.2. Cylinder Fitting . . . . . . . . . . . . . . . . . . . . . 139
7.3.4.3. Posterior Condylar Axis . . . . . . . . . . . . . . . . 141
7.3.4.4. Knee Centre . . . . . . . . . . . . . . . . . . . . . . . 142
7.3.5. Neck Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
7.3.5.1. Reslice . . . . . . . . . . . . . . . . . . . . . . . . . . 142
7.3.5.2. Parameter Extraction . . . . . . . . . . . . . . . . . 147
7.3.6. Anteversion Angle . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.3.7. Trochlear Groove . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.3.8. Bow Curvature . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.3.9. Misc Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.3.9.1. Greater Trochanter Height . . . . . . . . . . . . . 153
7.3.9.2. Femoral Head Offset . . . . . . . . . . . . . . . . . . 153
7.3.9.3. Length . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.3.9.4. Canal Flare Index . . . . . . . . . . . . . . . . . . . 153
7.3.10. Section Properties . . . . . . . . . . . . . . . . . . . . . . . . . 154
viii
Contents
7.4. Verification & Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

7.4.1. Inter-rater Variation in Segmentation . . . . . . . . . . . . 155
7.4.2. Intra-rater Variation in Segmentation . . . . . . . . . . . . 155
7.4.3. Variation on CT Voxel Size . . . . . . . . . . . . . . . . . . . 155
7.4.4. Reference Axes . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.4.4.1. Femoral Axis . . . . . . . . . . . . . . . . . . . . . . 156
7.4.4.2. Epicondylar Axis . . . . . . . . . . . . . . . . . . . . 156
7.4.5. Effect on Posterior Condyles Range Variation . . . . . . . 156
7.4.6. Variation on Anteversion . . . . . . . . . . . . . . . . . . . . . 157
7.4.7. Verification using 3-D model . . . . . . . . . . . . . . . . . . 157
7.5. Anthropometric Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 158
7.5.1. Human Femoral CT . . . . . . . . . . . . . . . . . . . . . . . . 160
7.5.1.1. Australian CT Data . . . . . . . . . . . . . . . . . . 160
7.5.1.2. Japanese OA CT Data . . . . . . . . . . . . . . . . 160
7.5.2. Sheep Femoral CT . . . . . . . . . . . . . . . . . . . . . . . . . 161
8. Results 163
8.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.2. Consistency Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
8.2.1. Intra-rater Consistency . . . . . . . . . . . . . . . . . . . . . 167
8.2.2. Inter-rater Consistency . . . . . . . . . . . . . . . . . . . . . . 170
8.2.3. Repeated Scans . . . . . . . . . . . . . . . . . . . . . . . . . . 172
8.3. Parameter Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
8.3.1. Proximal Femoral Axis Variation . . . . . . . . . . . . . . . 174
8.3.2. Variation with Full Femoral Shaft . . . . . . . . . . . . . . 177
8.3.3. Posterior Condyles Slice Range . . . . . . . . . . . . . . . . . 179
8.4. Verification with 3-D Model . . . . . . . . . . . . . . . . . . . . . . . 181
8.5. Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
8.5.1. Condyles Radius . . . . . . . . . . . . . . . . . . . . . . . . . . 183
8.5.2. Optimal Flexion Axis . . . . . . . . . . . . . . . . . . . . . . . 183
8.5.3. Australian & Japanese . . . . . . . . . . . . . . . . . . . . . . 186
8.6. Sheep Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
9. Discussion 193
9.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
9.2. Software Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
9.3. Image Acquisition & Segmentation . . . . . . . . . . . . . . . . . . 196
9.3.1. Acquisition Parameters . . . . . . . . . . . . . . . . . . . . . . 196
9.3.2. Automated Segmentation . . . . . . . . . . . . . . . . . . . . 197
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9.3.3. Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

9.4. Performance of the Methodology . . . . . . . . . . . . . . . . . . . . 200
9.4.1. Automation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9.4.2. Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9.4.3. Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
9.5. Reference Axes Definition . . . . . . . . . . . . . . . . . . . . . . . . 202
9.5.1. Longitudinal Axis . . . . . . . . . . . . . . . . . . . . . . . . . 202
9.5.2. Distal Transverse Axis . . . . . . . . . . . . . . . . . . . . . . 204
9.6. General Parameter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.6.1. Head Centre . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.6.2. Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.6.3. Posterior Condyles & Knee Centre . . . . . . . . . . . . . . 212
9.6.4. Canal Flare Index . . . . . . . . . . . . . . . . . . . . . . . . . 216
9.7. Anteversion Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9.8. Sheep Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
10. Conclusions 223

10.1. Limitations and Future Directions . . . . . . . . . . . . . . . . . . . 224
A. Function Summary 225
B. Sample Output File 237
C. CT Acquisition Settings 247
D. Consistence Test Data 251

D.1. Intra-rater Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . 252
D.2. Inter-rater Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . 256
D.3. Repeated Scans Consistency . . . . . . . . . . . . . . . . . . . . . . . 260
E. Results of Parameter Variation 265

E.1. Variation with Full Femoral Shaft . . . . . . . . . . . . . . . . . . . 265
E.2. Posterior Condyles Slice Range . . . . . . . . . . . . . . . . . . . . . 265
x
List of Figures
2.1. Woven and lamellar bone. OC: osteocytes. HC: Haversian canal.
HL: Lamellae. IL: Interstitial lamellae. . . . . . . . . . . . . . . . 7
2.2. Osteons (Haversian systems) in cortical bone. . . . . . . . . . . . . 8
2.3. A BMU consisting of osteoblasts and osteoclasts in the resorption
and formation of bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.4. Lateral view of the hip bone showing the acetbulum formed by
the ilium, ischium and the pubis. . . . . . . . . . . . . . . . . . . . . 11
2.5. Femur (anterior and posterior view). . . . . . . . . . . . . . . . . . 12
2.6. Proximal femur in a posterio-medial view showing the trochanters
and femoral head region. . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.7. Angle of inclination (Anterior view) is defined as the angle span
between the femoral axis and the neck axis, and decrease over
active growth period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.8. The torsion angle is often defined as the angle spanned by the
femoral neck axis and the distal condylar axis. . . . . . . . . . . . 14
2.9. Medial view of a right femur, with anterior curvature on the
shaft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.10. Inferior view of the lower femoral epiphysis. . . . . . . . . . . . . . 15
2.11. Proximal tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.12. The Patella is a triangular-shared sesamoid bone with the pos-
terior surface articates with the patellar surface of the femur. . 17
3.1. Electromagnetic Spectrum . . . . . . . . . . . . . . . . . . . . . . . . 21

3.2. Photoelectric Absorption . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.3. Compton Scattering . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
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List of Figures
3.4. Pair Production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.5. The Coolidge X-ray Tube . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.6. CT schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.7. The Hounsfield Unit Scale . . . . . . . . . . . . . . . . . . . . . . . . 28
3.8. Change of X-ray energy spectrum as it passes through different
depth of water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.9. Attenuation profile of X-ray passing through a uniform cylindri-
cal phantom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.10. CT image with cupping artifacts on a uniform cylindrical phantom 31
3.11. Streaking artifacts caused by photon starvation on a shoulder
phantom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.12. Ring artifacts on a water-filled phantom . . . . . . . . . . . . . . . 33
3.13. Shape distortion in helical scan of a cone-shape phantom . . . . 33
3.14. Report of a DXA scan . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.1. Grey-level histograms with threshold. Left; Single threshold T .

Right: Multi-level threshold (T1 and T2 ). . . . . . . . . . . . . . . . 42
4.2. Left: A non-uniformly illuminated display. Right: Thresholded
image. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3. Intensity profile across ideal and ramp edge . . . . . . . . . . . . . 45
4.4. Effect of noise to ramp edge. Left column (top to bottom): Ramp
edge corrupted by random Gaussian noise of σ = 0.1, 1.0, 10.0
respectively with its profile line plotted. Middle column: First
derivatives of the corresponding ramp edges. Right column:
Second derivatives of the corresponding ramp edges. . . . . . . . 46
4.5. top: image demonstrating a ramp edge; middle: intensity profile;
bottom: first derivative . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.6. 3x3 image region with intensity values i x . . . . . . . . . . . . . . 48
4.7. The Roberts Cross operator kernel (left: vertical, right: horizontal) 48
4.8. Edges extracted from the Roberts (top right), Prewitt (bottom
left) and Sobel (bottom right) operators from the circuit (top
left) image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.9. Gradient operators under noise Top left: circuit with added
noise (Gaussian σ2 = 0.01). Top right: Roberts. Bottom left:
Prewitt. Bottom right: Sobel. . . . . . . . . . . . . . . . . . . . . . . 50
4.10. The Prewitt operator (left: vertical, right: horizontal) . . . . . . . 50
4.11. The Sobel operator (left: vertical, right: horizontal) . . . . . . . . 51
4.12. top: ramp edge; bottom: second order derivative of the horizontal
intensity profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
xii
List of Figures
4.13. Laplacian convolution kernels . . . . . . . . . . . . . . . . . . . . . . 52

4.14. 3-D plot of a two dimensional Gaussian filter kernel . . . . . . . 52
4.15. 5x5 Laplacian of Gaussian kernel . . . . . . . . . . . . . . . . . . . 53
4.16. 3-D plot of a two dimensional Laplacian of Gaussian filter kernel 53
4.17. Top left: noisy circuit image (Gaussian σ2 = 1). Top right: zero-
crossing threshold = 0, σ = 2. Bottom left: zero-crossing thresh-
old = 0.01, σ = 2. Bottom right: zero-crossing = 0, σ = 5. . . . . . 55
4.18. 3-D plot of a two dimensional Difference of Gaussian filter kernel 56
4.19. Left: noisy circuit image (Gaussian σ2 = 1). Right: Canny edge
detector (T = 0.1, T2 = 0.2, σ = 1.5]) . . . . . . . . . . . . . . . . . . . . . 57
4.20. Typical adaptation results with the use of deformable model.
Note that part of the model is attracted and settled on false
boundaries (white arrows). . . . . . . . . . . . . . . . . . . . . . . . . 58
4.21. Geometric interpretation of morphological opening . . . . . . . . 67
4.22. Geometric interpretation of morphological closing . . . . . . . . . 67
4.23. Left: Noisy fingerprint image. Middle: Opening of the image.
Right: Opening followed by closing. . . . . . . . . . . . . . . . . . . 68
4.24. left: Set A (gray). right: foreground template W and background
template (W − X ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
4.25. left: set A c (gray). right: A X (gray regions) . . . . . . . . . . . . 69
4.26. A c (W − X ) in gray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.27. Iterations of a thinning operation. B 1 to B 8 : structuring ele-
ments for thinning operation. Middle 3 rows: thinning opera-
tions using the 8 structuring elements incrementally. Bottom
left: Final result after convergence. Bottom right: Conversion
to m-connectivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.28. Thickening obtained by thinning operation. Top left: original
set A . Top right: Complement of set A . Middle row: iterations
of the thinning operation on set (A)c . Bottom: Final result after
removal of disconnected islands . . . . . . . . . . . . . . . . . . . . . 72
4.29. Principle of skeleton generation. Maximum-sized disks are
positioned with centres on the skeleton. . . . . . . . . . . . . . . . 73
4.30. Top left: original segmented human chromosome image. Top
right: Thresholded image. Bottom left: Skeleton of the image.
Bottom right: Skeleton followed by spur removal. . . . . . . . . . 74
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List of Figures
4.31. A morphological algorithm to compute the convex hull. X 01 : the

original set A . X 41 , X 22 , X 83 , X 24 : the set at convergence using the
structuring elements B 1 , B 2 , B 3 , B 4 respectively. C (A): The final
convex hull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.32. Convex hull with extra criteria to limit growth . . . . . . . . . . . 76
5.1. 8-th directional chain code . . . . . . . . . . . . . . . . . . . . . . . . 83

5.2. Steps in computing the shape number from chain code . . . . . . 84
5.3. Shape reconstruction with different number of Fourier coeffi-
cients. P is the number of Fourier coefficients used. . . . . . . . . 87
5.4. Typical corner detector workflow . . . . . . . . . . . . . . . . . . . . 91
5.5. Intensity variation cases, Moravec (1977) . . . . . . . . . . . . . . 92
5.6. Feature regions in eigenvalue space . . . . . . . . . . . . . . . . . . 94
5.7. Comparison of various corner detectors. Top left: The Moravec
operator. Top right: The Plessey operator. Bottom left: The CSS
operator. Bottom left: The modified CSS (He and Yung, 2004) . 96
6.1. Kingsley’s neck axis definition. Left: posterior point. Middle:

anterior point. Right: mid-point. . . . . . . . . . . . . . . . . . . . . 100
6.2. Kingsley’s anteversion measurement. . . . . . . . . . . . . . . . . . 100
6.3. Anteversion calculation based on the longitudinal functional
axis. C: head centre; N: mid-point of the anterior and posterior
surfaces of the neck region. . . . . . . . . . . . . . . . . . . . . . . . 101
6.4. Anteversion measured on fluoroscopic bed. . . . . . . . . . . . . . . 102
6.5. Relationship of true and projected anteversion under different
inclination angle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6.6. Effect of anterior bowing on anteversion angle determination.
Left: The long axis defined does not bisect but passes over the
anterior aspect of the greater trochanter, with an extra 12◦
flexion from the right angle. Right: the adjusted axis bisecting
the greater trochanter, and passing through the proximal one
fourth of the femur. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6.7. Neck axis determination from a single cross section. A: Head
centre; B: mid-point between the anterior and posterior surfaces
of the neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
6.8. Centroid (O) point at the base of the femoral neck. . . . . . . . . 106
6.9. Distal transverse axis definitions. Left: The tabletop method.
Right: The TEA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
xiv
List of Figures
6.10. Distal transverse axis definitions. Left: Area centres of the

condyles defined visually. Right: Bisector of angle between the
anterior and posterior tangential lines. . . . . . . . . . . . . . . . . 107
6.11. Determination of the trochlear line for rotational reference. Left:
The most anterior point of the lateral ridge was marked. Middle:
the most anterior point of the medial ridge was marked, and
the lateral point projected to the same slice. Right: the final
trochlear line (TL); surgical epicondylar axis (SEA); Whiteside’s
line (AP); posterior condylar axis (PCA). . . . . . . . . . . . . . . . 109
6.12. Number of hospital admission for hip fracture in New South
Wales, Australia, 1990–2000. . . . . . . . . . . . . . . . . . . . . . . 112
6.13. The Canal Flare Index is a geometric ratio to describe the shape
of the proximal femoral canal. . . . . . . . . . . . . . . . . . . . . . . 114
6.14. Distribution of the Canal Flare Index over the 3 categories, CFI
< 3.0: Stovepipe; 3.0<CFI<4.7: Normal; CFI > 4.7: Champagne-
fluted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.15. Algorithm proposed by Fessy et al. on the choice of femoral
implant based on CFI (C.M.I.) and cortical index (F.F.I.). . . . . 116
6.16. Datum points along the anterior and posterior wall of the
medullary canal for anterior bow curvature evaluation. . . . . . 117
6.17. Evaluation of anterior bowing with plain digital photography. . 118
6.18. Instant centre of rotation of the knee on the sagittal plane.

Two points A 1 and B 1 are displaced to A 1 and B 1 respectively.
The intersection of the perpendicular bisectors of the two lines

connecting A 1 A 1 and B 1 B 1 is defined as the centre of rotation. . 119
6.19. The optimal knee flexion axis. . . . . . . . . . . . . . . . . . . . . . . 120
6.20. The knee joint centre (filled circle) defined by projecting the mid-
point (circle) of the transepicondylar axis (dots) to the optimal
flexion axis (A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
7.1. Amira (Visage Imaging, Inc., Carlsbad, USA) is used for seg-
mentation of the CT stacks. . . . . . . . . . . . . . . . . . . . . . . . 124
7.2. Mimics (Materialize, Inc., Leuven, Belgium). . . . . . . . . . . . 125
7.3. Profile lines across the lesser trochanter region for base thresh-
old value evaluation. In cases where an optimal threshold cannot
be chosen, the reference is chosen to avoid over-segmentation
when possible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
7.4. The MATLAB development environment running on Gentoo
Linux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
xv
List of Figures
7.5. Extraction of PMC for initial lesser trochanter LT1 estimation. . 128
7.6. The initial estimation of the lesser trochanter LT1 (blue) from
the candidate list {PMC } (red). . . . . . . . . . . . . . . . . . . . . . . 129
7.7. Second estimation of the lesser trochanter based on LT1 . The
furthest coordinates of the image perimeter from the femoral
axis (F A LT ) of each cross-section was taken as the PMC2 in the
second estimation of the lesser trochanter position. . . . . . . . . 129
7.8. Shape outlines on the flattened image. Two sets of line segments
were constructed to estimate the shape outline. {L τ=3 (BWper i m )}
(red), {L N =6 (BWper i m )} (blue), and the final epicondylar point
(green). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
7.9. Shape template {L T } for orientation matching. . . . . . . . . . . . 132
7.10. Fallback TEA evaluation routine by corner (blue) detection.
The figure shows the result of the corner detection with high
sensitivity. The sensitivity of the corner sub-routine could be
lowered to eliminate false corners and to reduce the number of
candidates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
7.11. The reference coordinate system. The proximal femoral axis (FA )
is taken as the longitudinal reference axis and the epicondylar
) is taken as the transverse axis for rotational reference.134
axis (TEA
7.12. Axial view of the reference axes . . . . . . . . . . . . . . . . . . . . . 135
7.13. The trochanters (LT and GT ) re-evaluated after model alignment.136
7.14. Initial estimation of the femoral head centre. First best-fit
sphere (right) estimation of the femoral head based on the
proximal head region (blue). . . . . . . . . . . . . . . . . . . . . . . . 137
7.15. Final estimation of the best-fit sphere based on additional datum
points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
7.16. Extraction of the posterior condylar line by morphological oper-
ations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
7.17. The Lorentzian function. . . . . . . . . . . . . . . . . . . . . . . . . . 140
7.18. The Lorentzian minimization function estimated using a log
function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.19. Cylinder (PCCYL ) fitted to the posterior condyles using the
Lorentzian minimization function. . . . . . . . . . . . . . . . . . . . 142
7.20. The knee centre (KC ) is defined as the intersection between the
cylinder PCCYL and the distal femoral articular surface . . . . . 143
7.21. Initial estimation of the neck axis based on femoral head centre
HC and NB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
xvi
List of Figures
7.22. Flattened PA view of the femur. NB SK was evaluated by mor-

phological skeletonization followed by detection of intersections
(blue) in the skeleton. The intersection at the neck base (red
cross) superior to the lesser trochanter intersection was taken
as NB SK for the initial estimation of the neck axis. . . . . . . . . . 144
7.23. Thinning operation on the axial slice corresponding to NB SK .
The green dotted line shows the possible candidates of NB SK
described in figure 7.22 on page 144. The first intersection
between the dotted line and the thinned skeleton was taken as
NB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
7.24. First and final neck axis estimation with cylinder fit. . . . . . . . 146
. Note the appearance
7.25. Point cloud of the final NECK based on NA
the greater trochanter at the top of the reslice neck. This was
eliminated in the first estimation of the neck axis. . . . . . . . . . 147
7.26. Anthropometric measurements based on the neck axis NA and
femoral axis FA . NLGT is the neck length from NA st ar t to the
lateral aspect of the trochanter along the neck axis. NL F A is the
neck length measured from NA st ar t to the femoral axis. ∠NAF A
is the neck shaft angle. Note that the point NA st ar t lies on the
femoral neck axis but may not coincide with the femoral head
centre ( HC ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.27. Elevation of the neck axis (NAF A ) is defined as the anterior
displacement of the femoral neck axis with reference to the
femoral axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.28. Axes for anteversion angle measurements. . . . . . . . . . . . . . . 149
7.29. Trochlear groove extraction. . . . . . . . . . . . . . . . . . . . . . . . 151
7.30. A plane P TR was fitted to the trochlear groove. . . . . . . . . . . . 152
7.31. Anterior bow curvature. . . . . . . . . . . . . . . . . . . . . . . . . . . 152
7.32. The use of nearest site Voronoi diagram in the computation of
the greatest inscribed circle. . . . . . . . . . . . . . . . . . . . . . . . 154
7.33. Verification of the head neck region on 3-D models created with
Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
7.34. Verification of the femoral length on 3-D model created by
Mimics . The measurement in black is FLGT −KC , the distance
between the proximal tip of the greater trochanter and knee
centre. The measurement line in orange is an estimation of
FL HC −KC + HR , the sum of distance between the femoral head
centre and knee centre, plus the femoral head radius. . . . . . . 160
xvii
List of Figures
8.1. The Matlab routine showing the process of sectional properties

computation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
8.2. The dependency matrix. . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.3. Difference in anteversion angle with proximal and full femoral
shaft as the reference longitudinal axis. The error bars indicate
one standard deviation. This shows a substantial difference in
the measurements under the use of different reference longitu-
dinal axes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
8.4. Box-plot showing difference in anteversion with the proximal
and full femoral shaft as the longitudinal reference axis. Upper
and lower whisker (black), median (red) and the quartiles (blue)
are shown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
8.5. Neck axis elevation (NAF A ) relative to the femoral axis with
proximal and full femoral shaft as the reference longitudinal
axis. The error bars represent one standard deviation. . . . . . . 180
8.6. Canal flare indices with proximal femoral shaft and full femoral
shaft as reference longitudinal axis. Only the oblique index
shows a significant difference under the change of reference
longitudinal axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
8.7. Difference between direct measurements on the created 3-D
model and that using the proposed methodology. The error bars
represent one standard deviation of the measurements. Neck
length is the length from the start of the femoral neck to the
lateral aspect of the trochanter along the computed neck axis
(NLGT ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
8.8. Difference between the medial and lateral condyle radius. A
positive difference indicates the lateral radius is larger than
that of the medial and vice versa. . . . . . . . . . . . . . . . . . . . 184
8.9. Displacement of the medial epicondyle relative to the optimal
flexion axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.10. Displacement of the medial epicondyle relative to the optimal
flexion axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.11. Femoral head and neck measurements of the AU and JP datasets.187
8.12. Anteversion angles of the AU and JP datasets. Significant
difference was observed in ∠(NA, TEA) and ∠(NA, CA) (P<0.05)
in which the Japanese dataset has a larger angle than the
Australian dataset. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
xviii
List of Figures
8.13. Femoral length measurements of the AU and JP datasets. The

Japanese dataset has a smaller value in all femoral length
measurements (P<0.001). . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.14. Cross-sectional area of the bone section and the medullary canal
of the proximal femur. The error bars represent 1 standard
deviation of the measurements. . . . . . . . . . . . . . . . . . . . . . 190
8.15. Moment of inertia across the medio-lateral axis (Ixx) and antero-
posterior axis (Iyy) of the proximal femur. . . . . . . . . . . . . . . 190
8.16. Summary of measurements of proximal femur and posterior
condyles of sheep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
8.17. Summary of femoral length, neck shaft angle and anterior bow
of sheep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8.18. Summary of canal flare index of sheep. . . . . . . . . . . . . . . . . 192
9.1. Effect of anterior bowing on different definitions of the longitu-

dinal axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9.2. Posterior bow at the femoral metaphysis . . . . . . . . . . . . . . . 218
9.3. The helitorsion angle compared to the anteversion angle. . . . . 220
9.4. The use of full femoral shaft as the longitudinal reference axis
in determination of the anteversion angle. Under this reference
system, the long axis of the femur and the femoral neck axis are
in close proximity in the superior view and neck axis elevation
is virtually non-existent. . . . . . . . . . . . . . . . . . . . . . . . . . 220
E.1. Variation between the use of proximal femoral shaft and full
femoral shaft as reference longitudinal axis. . . . . . . . . . . . . . 267
xix
List of Figures
xx
List of Tables
3.1. Causes of X-ray attenuation in water at various photon energies 23

3.2. Man’s exposure to ionizing radiation . . . . . . . . . . . . . . . . . 25
3.3. Typical Effective Dose in CT (Shrimpton et al., 2003) . . . . . . . 29
4.1. The membership relation in set theory . . . . . . . . . . . . . . . . 62

4.2. Standard notations in set theory . . . . . . . . . . . . . . . . . . . . 63
4.3. Logical operations on binary images . . . . . . . . . . . . . . . . . . 64
4.4. Common properties of morphological opening and closing . . . . 67
5.1. Effect of transformation in Fourier descriptor . . . . . . . . . . . . 88
7.1. Verification measurements on 3-D model. . . . . . . . . . . . . . . 158
8.1. Types of ICC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

8.2. Femoral head intra-rater consistency. . . . . . . . . . . . . . . . . . 169
8.3. Femoral neck intra-rater consistency. . . . . . . . . . . . . . . . . . 169
8.4. Anteversion angles intra-rater consistency. . . . . . . . . . . . . . 170
8.5. Canal flare indices intra-rater consistency. . . . . . . . . . . . . . . 170
8.6. Shaft and distal femur intra-rater consistency. . . . . . . . . . . . 171
8.7. Femoral length intra-rater consistency. . . . . . . . . . . . . . . . . 171
8.8. Femoral head inter-rater consistency. . . . . . . . . . . . . . . . . . 172
8.9. Femoral neck inter-rater consistency. . . . . . . . . . . . . . . . . . 172
8.10. Anteversion angles inter-rater consistency. . . . . . . . . . . . . . . 173
8.11. Canal flare indices inter-rater consistency. . . . . . . . . . . . . . . 173
8.12. Shaft and distal femur inter-rater consistency. . . . . . . . . . . . 173
8.13. Femoral length inter-rater consistency. . . . . . . . . . . . . . . . . 174
8.14. Femoral head consistency on repeated scans. . . . . . . . . . . . . 174
xxi
List of Tables
8.15. Femoral neck consistency on repeated scans. . . . . . . . . . . . . 175

8.16. Anteversion angles consistency on repeated scans. . . . . . . . . . 175
8.17. Canal flare indices inter-rater consistency on repeated scans. . 175
8.18. Shaft and distal femur consistency on repeated scans. . . . . . . 176
8.19. Femoral length consistency on repeated scans. . . . . . . . . . . . 176
8.20. Variations of the proximal femoral axis due to inconsistent lesser
trochanter evaluation. A mean difference of 0.6◦ was observed
which is negligible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
8.21. Typical maximum error of the posterior condyles radius due to
variation in slice range selection by user. . . . . . . . . . . . . . . 182
8.22. Difference on the radius of curvature between medial and lateral
condyles in the Australian dataset. . . . . . . . . . . . . . . . . . . 183
8.23. Difference on the radius of curvature between medial and lateral
condyles in the healthy Japanese dataset. . . . . . . . . . . . . . . 183
8.24. Statistical comparison between AU and JP femoral head region. 186
8.25. Statistical comparison between AU and JP femoral neck regions.187
8.26. Statistical comparison between AU and JP anteversion angles. 187
8.27. Statistical comparison between AU and JP canal flare index. . . 188
8.28. Statistical comparison between AU and JP distal femur and
shaft regions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
8.29. Statistical comparison between AU and JP femoral length. . . . 189
A.1. Function summary of the Matlab subroutines. . . . . . . . . . . 226

A.2. External Matlab subroutines used in the study. They are
obtainable from the Mathworks File Exchange repository. . . . . 235
D.1. Intra-rater consistency data. . . . . . . . . . . . . . . . . . . . . . . . 252

D.2. Inter-rater consistency data. . . . . . . . . . . . . . . . . . . . . . . . 256
xxii
List of Tables

D.3. Repeated scans consistency data. . . . . . . . . . . . . . . . . . . . . 260
E.1. Effect of condyles radius on the fitting slice range. . . . . . . . . . 266
xxiii
List of Tables
xxiv
Nomenclature
BMC Bone Mineral Content
BMD Bone Mineral Density
CFI Canal Flare Index
CT Computed Tomography
DEXA/DXA Dual Energy X-ray Absorptiometry
DFT Discrete Fourier Transform
DICOM Digital Imaging and Communications in Medicine
DoG Difference of Gaussian
EM Electromagnetic
erg force of one dyne exerted for a distance of one centimetre, or 0.1 micro-
joule
GT Greater Trochanter
GUI Graphical User Interface
GUI Graphical User Interface
xxv
List of Tables
HC Head Centre
HSA Hip Strength Analysis
HU Hounsfield Unit
ICC Intra-Class Correlation
KC Knee Centre
LaTeX This thesis was typeset with LATEX, a document preparation system
for the TEX typesetting program.
LoG Laplacian of Gaussian
LT Lesser Trochanter
LyX LyX is the document processor in which this thesis was written on.
MRI Magnetic Resonance Imaging
OA Osteoarithis
PACS Picture Archiving and Communication System
PCL Posterior Cruciate Ligament
QCT Quantitative Computed Tomography
rad Radiation Absorbed Dose
rem Röntgen Equivalent in Man
SEA Surgical Epicondylar Axis
SI International System of Units
SNR Signal-to-noise Ratio
Sv Sievert
xxvi
Nomenclature
TEA Trans-epicondylar Axis
THR Total Hip Replacement
TKR Total Knee Replacement
xxvii
Nomenclature
xxviii
Introduction
1
uman anatomy is one of the fundamental aspects in the comprehension
H of the human body. Initially used by Alphonse Bertillon in 1882 as a
scientific system to identify and match arrested criminals who had previous
criminal records, anthropometry refers to the measurements of human in-
dividuals. Since then, human anthropometry has been incorporated more
extensively in other disciplines such as biomechanics, forensic analysis and
orthopaedics.
Particularly, human anthropometry played a key role in the field of or-

thopaedics. Most modern surgical prostheses are designed based on anthro-
pometric data. Traditionally, anthropometric data are gathered via physical
measurements, which often limit its scope to in vitro studies only. The ap-
plication of radiographic imaging with its minimal invasive nature allows a
wider range of in vivo anthropometry to be studied. Nonetheless, the two
dimensional nature of radiographic imaging poses a significant constraint
in describing more complex shapes such as those found in the epiphysis
of human bones. The simplification of a three dimensional entity into a
single radiographic image is likely to shield plenty useful information desir-
able for more detailed anthropometric analysis. Measurement error due to
dimension-reducing projection is another major concern that affects accuracy
and consistency.
The advancements of three-dimensional imaging modalities have brought an-

thropometry to another level, eliminating the dimension-reducing deficiency
in planar radiographic image, and allow more complex shapes to be measured
accurately. Coupled with the increasing adoption of digital image process-
ing techniques, more fine-grained anthropometric characterization could be
1
1. Introduction
realized.
Nonetheless, the context of human anatomy originating from the clinical

domain has shown to contribute to undesirable inconsistency in the context
of image processing. Many definitions of anatomical landmarks are based on
prominence of anatomical structure. While its accuracy in the clinical domain
proved sufficient, its consistency in the image processing domain may not be
satisfactory. In pathological cases, precise location of anatomical landmarks
could become too subjective. This adds extra difficulty in the image processing
domain for more precise analysis. The understanding and manipulation of
the anatomical definitions in the different perspectives is critical and is one
of the inspirations of the study.
As a starting point, the femur bone was chosen as the study object. Articulating
with the hip and knee joints, the femur provides weight support to the skeletal
structure at up-right position, and is of particular interest in the field of
orthopaedics due to being a common fracture site. With the femur playing
an important role in body support and gait cycle, the understanding of its
anthropometry is also of importance in bio-mechanics.
Acquisition of higher resolution image is getting more common. A typical

clinical computed tomography scanner could acquire images with spatial
resolution up to 0.2 mm. The increasing amount of image data makes manual
processing a tedious amount of work. The use of automated or semi-automated
analysis techniques is thus desirable.
The current study aims to develop a consistent and robust methodology in

accurate extraction of anthropometric parameters on the femur from clinical
computed tomography images. To avoid the need of manually process an
immense amount of work resulting from high resolution image stacks, another
objective is to increase the level of automation in the entire process.
Without being very application specific, the scope of the current study is
to present a general framework for anthropometric analysis of the femur.
The focus is towards the investigation of a more automated means at the
parameter extraction procedures in anthropometric analysis to eliminate the
massive amount of manual work required.
As a preliminary evaluation of the designed methodology, a dataset comprising

of femoral CT scans of 19 healthy Australian, 10 healthy Japanese was used.
2
Intra-class correlation and Cronbach’s α were employed to evaluate the intra-
rater, inter-rater and repeated scans consistency of the proposed methodology.
All scans were processed successfully, and high correlation values (mean > 0.95)
were observed, indicating a satisfactory consistency achieved.
As a further test of robustness of the proposed methodology towards slightly

malformed femoral geometry, an additional 15 CT scans of Japanese diagnosed
with primary or secondary hip osteoarthritis were tested. All 15 scans were
processed successfully. While a more comprehensive and extensive test would
be required to demonstrate its performance in various pathological types, the
preliminary test showed a potential of the proposed method.
As a sidetrack of the experiment, an additional 20 adult sheep were scanned

and processed successfully with the exact methodology. The inspiration of this
part of the study originates from the fact that sheep femora is a commonly
used animal model in prostheses testing due to its availability and structural
similarity to that of human femur. Despite its wide usage of sheep in the area,
implants for sheep experiments are mostly designed on a trial and error basis.
To the author’s knowledge, no previous study was noted in the literature in
an attempt to systematically extract and summarize anthropometric data
of sheep femur. As a start, 20 sheep femurs were included in the study to
initialize a database of anthropometric data on sheep femur. With more sheep
scans data being included in the future, it is anticipated that the database
would assist in providing a more systematic and accurate anthropometric
data for sheep experiments.
The following page gives an outline of the thesis, with the focus of each chapter.
Thesis Outline
• Chapter 1: An introduction of the overall aims, work undertaken and

scope of the study.
• Chapter 2: A review on bone histology and anatomy of the femur.
• Chapter 3: A summary on the basic principles on current imaging

modalities for clinical applications, with its strengths and weaknesses
discussed.
3
1. Introduction
• Chapter 4: A review on the basic principles on various image analysis

techniques employed in the study.
• Chapter 5: A descriptions on the definitions of various geometry mea-

surements employed in the study.
• Chapter 6: A review on previous works on anthropometric studies of the

femur.
• Chapter 7: A detailed protocol on the methodology proposed for the

extraction of anthropometric parameters
• Chapter 8: Test results of the proposed methodology with the focus in

consistency measures. Summary and comparison of the human and
sheep datasets are also presented.
• Chapter 9: Discussion on the performance and robustness of the proposed

methodology with focus on several parameters of interest.
• Chapter 10: Conclusion on the methodology proposed, it strengths and

limitations. Further directions are proposed.
4
Anatomy and Bone Histology
2
Contents
2.1. Histology of Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.1. Types of Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.2. Bone Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.3. Woven and Lamellar Bone . . . . . . . . . . . . . . . . . . . 7
2.1.4. Cortical and Trabecular Bone . . . . . . . . . . . . . . . . 8
2.1.5. Modelling and Remodelling . . . . . . . . . . . . . . . . . . 9
2.2. Anatomy of the Human Femur . . . . . . . . . . . . . . . . . . 10
2.2.1. Hip Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.2. Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.3. Proximal Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2.4. Patella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.1. Histology of Bone
onnective tissue is made up of an organic matrix comprising of three

C components, namely the cells, fibres or collagen and ground substance
with which the latter two predominate in general.
Bone is a kind of connective tissue that contains an extensive matrix of

intercellular materials. Unlike other types of connective tissues, the organic
matrix of bone tissue is calcified and is made up of 65% of minerals (Jee, 2001),
which contributes to the hardness of the bone and the radiopacity towards
many medical imaging modalities based on X-rays. Bone is specialized in
5
2. Anatomy and Bone Histology
providing a supportive framework for the body and continuously remodel

under the influence of hormonal and other external mechanical environment.
Bone remodeling is the ongoing process of the replacement of old or injured
bone tissue by new bone tissue.
2.1.1. Types of Cells
There are four types of cells in bone tissue, namely osteogenic cells, osteoblasts,
osteocytes and osteoclasts. Located at the endosteum and the inner portion of
the periosteum, osteogenic cells are capable of mitotic division and develop into
osteoblasts. Osteoblasts are not capable of mitotic division and are the cells
that form bone. Osteoblasts secrete collagen and other organic compounds
necessary for the formation of bone matrix and are found on the surface of
bones and at the margins of growing bone. In the process of bone formation,
osteoblasts are encased in the bone matrix they form and remain as osteocytes
(Hancox, 1972). Each osteocyte occupies its own cavity or lacunae in the bone
matrix and maintains its metabolism in exchanging nutrients and waste with
the blood. Osteocytes must be within 100-150μm of a blood vessel to prevent
necrosis (Martin and Burr, 1989). Osteoclasts are large multi-nucleated cells
that are formed by the fusion of as many as 50 monocytes, which is a type
of white blood cell. Osteoclasts resorb bone matrix by means of lysosomal
enzymes.
2.1.2. Bone Salt
Calcium hydroxyapatite is the primary bone salt present in bone tissue, with
the unit cell formula of 3Ca3 (PO4 )2 -Ca(OH)2 . Crystal of calcium hydroxyapatite
in bone has a thickness of few unit cells, with a rough dimensions of 5 × 5 × 40
nm.
With its major component being mineral salts, bone is a major reservoir of
calcium in which 99% of the total amount of calcium in the body is stored.
It serves as a vital component of the homeostatic mechanisms in regulating
concentrations of Ca2+ , H+ , and (HPO4 )2− .
6
(a) Bone is always initially deposited (b) Lamellar bone.

as woven bone.
Figure 2.1.: Woven and lamellar bone. OC: osteocytes. HC: Haversian canal.
HL: Lamellae. IL: Interstitial lamellae.
Reproduced from Hancox (1972).
2.1.3. Woven and Lamellar Bone
From a molecular view, bone is always deposited as woven bone as shown

in figure 2.1a. Woven bone serves as a temporary scaffold and is eventually
converted to lamellar bone. Woven bone is weaker with collagen fibres ori-
ented in all directions and large vascular channels. Osteocytes are scattered
throughout the bone matrix.
Lamellar bone is stronger and consists of fine collagen fibres lined in a parallel
manner. The fibres are grouped into layers called the lamellae. The central
canal of each functional unit is called a Haversian canal, named after Havers
(1691) and grouped with its concentric lamellae is named as an osteone or
Haversian system. Lamellar bone is replaced in trabeculae and cortical bone
at a rate of about 25% and 5% respectively (Martin R.B. and N.A., 1998). The
orientation of lamellar bone formation is known to be affected by external
machanical stimuli in which the collagen fibres tends to line with the direction
of stress (Martin and Burr, 1989).
7
Figure 2.2.: Osteons (Haversian systems) in cortical bone.

Reproduced from Taylor et al. (2007). Original images courtesy of Tortora
(2002); Colopy et al. (2004).
2.1.4. Cortical and Trabecular Bone
At a macroscopic view, bones can be categorized into cortical (compact) and

trabecular (cancellous) bone. Cortical bone is dense and contains only spares
vascular channels that form the external layers of all bones. Cortical bone
is hard and provides protection to other organs and support for the skeletal
system. Cortical bone has a concentric ring structure with which an extensive
network of canals are presented across the width of bone, named as the
perforating canals or the Volkmann’s canals. The blood vessels, lymphatic
vessels and nurves in the perforating canals inter-connect with those in the
medullary cavity, periosteum and the Haversian canals (Figure 2.2).
Trabecular bone, also known as cancellous bone or spongy bone are irregular
latticework constructed with thin columns of bone called trabeculae of about
8
Figure 2.3.: A BMU consisting of osteoblasts and osteoclasts in the resorption

and formation of bone.
Reproduced from Taylor et al. (2007).
200 μm in thickness. The space between the trabeculae is filled with marrow
or myeloid tissue.
Most short, flat and irregularly shaped bone is made up of trabecular bone.
It also exists in epiphyses and around the marrow cavity of the diaphyses
of long bones, which are areas that are not subject to enormous mechanical
stress. Trabecular bone is usually surrounded by a shell of cortical bone for
increased strength and rigidity. The distribution of the types of bone varies
depending on the need for strength or flexibility.
2.1.5. Modelling and Remodelling
Wolff (1892) published his seminal in 1892 documenting the observation of

bone remodelling, in which the bone undergoes reshaping in response to
stresses acting on it. Its classical findings are widely known as the Wolff’s law.
While the rationale for the existence of the Wolff’s law has been questioned or
challenged (Bertram and Swartz, 1991; Cowin, 1997; Lee and Taylor, 1999),
many still ascribe to the idea of Wolff’s law in which bone remodels in response
to mechanical stresses to produce an optimal structure adapted to the load.
Frost (1973) has compiled and analysed the bone remodeling phenomenant
and the principle summary are quoted as follows:
1. Remodeling is triggered not by principal stress but by “flexure”.
2. Repetitive dynamic loads on bone trigger remodeling.
3. Dynamic flexure causes all affected bone surfaces to drift towards the
concavity which arises during the act of dynamic flexure.
Remodelling is accomplished by actions of osteoclasts and osteblasts that form

a basic multi-cellular unit (BMU), consisting of around 10 osteoclasts and
9
hundreds of osteoblasts. The process could be summarized into activation,

resorption and formation stages. The activation stage involves the fusion
of monocytes in the formation of osteoclasts. In the resorption stage, the
osteoclasts tunnels into cortical bone with the formation of tunnels of about
200 μm is diameter. The excavated tunnel wall is then lined with osteoblasts
which the formation of secondary osteon occurs. The central portion or the
core of the tunnel are not completely filled, and is left for the Haversian canal.
2.2. Anatomy of the Human Femur
The femur, also commonly known as the thigh bone, is the longest and heaviest
bone in the human skeletal system. The femur comprises of a shaft section
with two ends, where the proximal end articulates with the hip bone forming
the hip joint, and the distal end articulates with the tibia and the patella
forming the knee joint.
2.2.1. Hip Bone
The hip bone is a bony structure at the base of the spine, articulating behind
the proximal part of the sacrum forming the sacroiliac joint and to the proximal
end of the femur forming the hip joint. This results in a connection between
the trunk and the lower limbs. The hip bones form the pelvic girdle that meet
at the pubic symphysis, and forms the anterior and lateral walls of the pelvis.
Each hip bone is made up of the ilium, ischium and pubis, with which they
meet at the acetabulum as shown in figure 2.4 on the next page. The hip
bones are initially separated in the acetabulum by the Y-shaped triradiate
cartilage and begin to fuse during adolescence.
The acetabulum is a cup-shaped cavity facing laterally downwards, and is

formed by roughly one-fifth of the pubis, two-fifths of the ilium and ischium
each. The articular surface covered by hyaline cartilage forms a horse-shoe-
shaped region.
10
Figure 2.4.: Lateral view of the hip bone showing the acetbulum formed by
the ilium, ischium and the pubis.
Reproduced from Gray (1918).
2.2.2. Femur
The femur is the longest and heaviest bone in the human skeletal system
transferring the entire body weight between the trunk and the lower limb,
with its length being roughly one-fourth to one-third of the human body
length. It consists of two ends and a mid-shaft section. With its proximal
end, it articulates with the hip bone forming the hip joint, which is a synovial
ball-and-socket joint and with its distal end, it articulates with the tibia and
patellar forming the knee joint.
2.2.2.1. Upper End
The head of the femur is a partial two-third sphere that faces upward, forward
and medial. The fovea capitis, located slightly below and behind the centre, is
a pit in which the ligament of the head of femur is attached. Apart from the
fovea capitis, the entire femoral head region is covered with articular surface
and in many cases, the articular surface extends upon the anterosuperior
region of the neck.
The neck region is a bar of bone connecting the head to the trochanter region.
In front, the neck and the trochanter region is separated with a relatively
11
Figure 2.5.: Femur (anterior and posterior view).

Reproduced from Moore (2007).
Figure 2.6.: Proximal femur in a posterio-medial view showing the trochanters

and femoral head region.
12
Figure 2.7.: Angle of inclination (Anterior view) is defined as the angle span
between the femoral axis and the neck axis, and decrease over
active growth period.
prominent trochanteric line that runs downwards and medially. The line
becomes more indistinguishable near the lesser trochanter and the neck-
trochanter ridge, the intertrochanteric crest, is relatively smooth at the back
of the femur.
The greater trochanter projects superomedially to where the neck-shaft region

joins, and is located above the junction of the shaft laterally, about 10 cm
below the iliac crest. The lesser trochanter is a round palpable conical region
which extends medially from the posteromedial part of the junction between
the neck and the shaft.
The intertrochanteric crest is the ridge that connects the greater trochanter
with the lesser trochanter posterially. Compared to the intertrochanteric
line which connects the greater trochanter with the lesser trochanter at the
anterior side of the femur, the intertrochanteric crest is relatively smoother
and more indistinguishable.
The angle of inclination (Figure 2.7) is the angle between the superomedially
projected neck and head axis and the shaft-axis and has a typical value of
between 110◦ − 145◦ , with an average of about 126◦ . It is usually smaller in
female and decreases during the active growth period (Harty, 1957). The
angle of inclination of the femur allows the long axis of the neck and head
to intersect with the acetabulum cup in a more perpendicular manner, and
allows for a large range of motion in the hip joint.
13
Figure 2.8.: The torsion angle is often defined as the angle spanned by the
femoral neck axis and the distal condylar axis.
Figure 2.9.: Medial view of a right femur, with anterior curvature on the
shaft.
Reproduced from Gardner et al. (1969).
The angle of torsion (Figure 2.8) of the head of the femur, also known as
the anteversion angle, is the angle between the long axis of the head and
neck region and the transverse axis of the femoral condyles when viewed
superiorly along the shaft axis. It is reported the average anteversion angle is
around 12◦ −15◦ (Breathnach, 1965). If the angle is larger than the range, it is
called anteverted, and if the angle is less than the normal range, it is called
retroverted. The effect of an anteverted and retroverted torsion angle could
be noted by external and internal rotation of the femur, causing out-toeing
and in-toeing (pigeon toe) respectively (Norkin C., 1992).
2.2.2.2. Shaft
The femoral shaft connects between the proximal and distal femur. A sig-
nificant characteristic of the shaft is its anterior curvature (Figure 2.9) in a
medial view. The functional role of the anterior curvature is unknown and
no correlations have yet been found on the curvature and other functional
parameters such as body mass or size.
14
Figure 2.10.: Inferior view of the lower femoral epiphysis.

2.2.2.3. Lower End
The distal end of the femur is characterized by two spirally curved condyles,
continuous in front, and separated below and behind the intercondylar fossa
(Figure 2.10). The two condyles articulate with the tibial condyles to form
the knee joint. The front of the condyles characterizes a vertical groove and
divides the patellar surface into two unequal parts.
The lateral side of the groove is wider, extends further and articulates with
the lateral articular facet of the patella. The medial groove is narrower
and articulates with the medial articular facet of the patella. Below the
intercondylar fossa, the lateral condyle is broad and straight compare with
that of the medial condyle which is relatively curved and narrow. The posterior
part of the condyles articulates with the tibial condyles only in knee flexion.
The medial surface is convex and rough, and features a prominence named
the medial epicondyle. Likewise, the lateral epicondylar is a prominence on
the lateral surface of the lateral condyle, but is not as convex as that of the
medial epicondyle. A pit immediately above the lateral epicondyle marks the
lateral head of the gastrocnemius. Often, a groove that lodges the tendon of
the popliteus in knee flexion runs upward and backward of the pit. When the
leg extends, a notch in the articular margin lodges the tendon.
2.2.2.4. Bone Structure
Two regional structures of bone masses could be noted from the proximal end
of the femur. The calcar femorale is the bar of cortical bone that extends into
the neck from the lesser trochanter region on the medial side. The cervical
torus is a thickened band of cortical bone on the upper region of the neck
15
Figure 2.11.: Proximal tibia.

between the femoral head and the greater trochanter region on the upper
neck.
2.2.3. Proximal Tibia
The tibia (Figure 2.11), also known as the shin bone has a length roughly
one-fourth to one-fifth of the body length, and is located on the anterior and
medial side of the leg. It transmits body weight from the femur to the ankle
and foot. The tibia has an upper and lower end, separated by a shaft, with
the upper end rotated more medially than the lower in superior axial view.
The upper end of the tibia is large, expanded and bent slightly backward. The
upper surface comprises of the medial and lateral condyles, a large ovoid and
smooth surface that articulates with the femoral condyles. Laterally, the tibia
articulates with the fibula.
2.2.4. Patella
The patella (Figure 2.12 on the next page), also known as the knee cap, is a
triangular-shaped sesamoid bone of roughly 5cm in diameter and is located
anterior to the knee joint. It articulates with the patellar surface of the femur.
The anterior surface is convex and contains vertical ridges and many small
openings for nutrient vessels. The two lateral and medial borders converge
to form the apex. The posterior surface is a smooth and oval area divided
into two articular facet; a larger lateral articular facet and a smaller medial
articular facet, separated by a vertical ridge. Part of the posterior aspect is
not articulated and gives the attachment point of the ligamentum patellae.
16
Figure 2.12.: The Patella is a triangular-shared sesamoid bone with the pos-
terior surface articates with the patellar surface of the femur.
Reproduced from Gardner et al. (1969).
17
18
Medical Imaging
3
Contents
3.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.2. X-ray Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.2.1. Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.2. Measurement Units . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.3. Generation of X-rays . . . . . . . . . . . . . . . . . . . . . . 23
3.2.4. Applications in Radiology . . . . . . . . . . . . . . . . . . . 24
3.2.5. Biological Hazards . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2.6. Strengths and Limitations . . . . . . . . . . . . . . . . . . . 25
3.3. Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.1. Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.2. Hounsfield Unit Scale . . . . . . . . . . . . . . . . . . . . . . 27
3.3.3. Quantitative Computed Tomography . . . . . . . . . . . . 28
3.3.4. Applications in Radiology . . . . . . . . . . . . . . . . . . . 28
3.4. Dual Energy X-ray Absorptiometry . . . . . . . . . . . . . . . 32
3.4.1. DXA Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.4.2. Biological Hazard . . . . . . . . . . . . . . . . . . . . . . . . 35
3.5. Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . 35
3.5.1. Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
19
3. Medical Imaging
3.1. Overview
edical imaging in general, refers to the techniques of obtaining images of

M the human body, mainly for diagnostic purpose in clinical use. It is also
considered as a subset of the very widely spanned biological imaging category,
which consists of an even larger range of techniques of visualizing different
aspects of biological specimens. Medical imaging can be briefly categorized
into photography (medical), microscopy, endoscopy imaging, thermography,
and radiology. Medical imaging plays a key role in the first step in the image
processing process - Image Acquisition. A more detailed description of several
commonly used medical imaging techniques in Orthopaedics within the clinical
context are discussed below. Focus is placed on X-ray based modalities, which
is more commonly used in the field of orthopaedics.
3.2. X-ray Imaging
Discovered in 1895, X-rays are one of the oldest and most widely used source of
electromagnetic (EM) radiation in medical imaging. It is also called Röntgen
ray, named after the discoverer, Professor Wilhelm Conrad Röntgen, (1845-
1923) from the University of Wurburg.
X-rays are high energy, ionizing EM radiation that lies between ultraviolet
light and gamma rays with wavelengths roughly between 10 nanometers
(10 ∗ 10−9 ) and 10 picometers (10 ∗ 10−12 ), equivalent to a frequency of 30
petahertz (30 ∗ 1015 ) to 30 exahertz (30 ∗ 1018 ). It can further be divided into
hard X-rays and soft X-rays, with soft X-rays having longer wavelengths and
thus lower energy. The cutoff wavelength between soft and hard X-rays is
around 100 picometers. Note that the soft X-rays spectrum overlaps with
extreme ultraviolet, while hard X-rays spectrum overlaps partially with gamma
(γ) rays, in their shorter and longer wavelengths ranges respectively. The
distinction between gamma (γ) rays and hard X-rays are thus often referred to
the source of the radiation instead of a cutoff wavelength, with X-ray generated
by the emission of X-ray photons by energetic electron bombardment, and
gamma (γ) rays by energy state transition in the nuclei level.
20
3.2. X-ray Imaging
Figure 3.1.: Electromagnetic Spectrum

Reproduced from radiology.med.sc.edu
Figure 3.2.: Photoelectric Absorption

Reproduced from Dresser Atlas
3.2.1. Principles
Projection X-rays imaging makes use of the fact that different body tissues
have different X-ray attenuation. Below are the three main processes that
contribute the most towards X-ray attenuation:
• Photoelectric Absorption
Photoelectric absorption occurs when a photon collides with an atom, ejecting

one of the orbital electrons from the inner shell of the atom, resulting in atom
ionization. In general, photoelectric absorption contributes the most to the
total attenuation for low energy X-rays up to 500 keV.
• Compton Scattering
Compton refers to the inelastic photon scattering, which results from a collision
with orbital electrons. Some energy is transferred to the electron, which is
knocked out of the atom. The frequency of the photon is lowered due to energy
losses and direction change. The Compton effect occurs mostly in photons
with an energy range of around 2 keV to 2 meV.
• Pair Production
Pair production refers to the effect of the conversion of a photon into an

electron and a positron. The process occurs when the incident photon has
21
3. Medical Imaging
Figure 3.3.: Compton Scattering

Figure 3.4.: Pair Production

at least twice the rest mass energy of two electrons (1.022 MeV). It was first
observed by Patrick Blackett, the winner of Nobel Prize in Physics in 1948.
Table 3.1 shows the probability of each of the above processes in water at
various X-ray photon energies.
The attenuation of a mono-energetic beam passing through a homogeneous

material can be expressed by the Beer’s Law.
I = I 0e −μd (3.1)
where I0 is the intensity of the incident radiation, I is the intensity of the

transmitted radiation, d is the tissue thickness, and μ is the attenuation
coefficient which depends on the electron density and the atomic number of
the tissues.
The attenuation is visualized by means of a detector medium such as radio-

graphic film. Photostimulable phosphors plates are increasingly adopted in
radiography with the advancements of computer technology. It is reusable
and the resulting images can be digitized and stored directly into a computer
system.
22
3.2. X-ray Imaging
Photoelectric Compton Pair

X-ray Photon Energy
Absorption Scatter Production
10 keV 95% 5% 0
25 keV (Mammography) 50% 50% 0
60keV (Diagnostic) 7% 93% 0
150 keV 0 100% 0
4 MeV 0 94% 6%
10 MeV (Therapy) 0 77% 23%
24 MeV 0 50% 50%
Table 3.1.: Causes of X-ray attenuation in water at various photon energies

Reproduced from e-radiography.net
3.2.2. Measurement Units
Röntgen(R) is a unit used to define the radiation field in air. Due to the fact
that attenuation of X-rays when passing through different matters vary, a unit
called rad(radiation absorbed dose) is defined in the measurement of absorbed
dose. 1 rad is equal to the dose of radiation resulting in the absorption of
100 ergs (10−7 Joules) per gram in any material.
rem, abbreviated from röntgen equivalent in man, is the traditional unit for
radiation dose measurement, defined as the product of the dose absorbed in
R(röntgen) and the biological efficiency. It defines the estimated dose of any
radiation that would produce the same biological effect delivered by x or γ
radiation.
The SI (International System of Units) unit is sievert (Sv) and is equivalent

to 100 rem.
3.2.3. Generation of X-rays
The Coolidge tube, designed by Willian Collidge in 1913, is based on the

Crookes tube design. It is one of the most widely used yet simplistic design to
produce X-rays. It works as follows: The tungsten cathode filament is heated.
Electrons are emitted by the thermionic effect and accelerated due to the high
voltage potential set up between the cathode and the anode. The bombardment
of high speed electrons to the positively charged, angled anode causes the
23
3. Medical Imaging
Figure 3.5.: The Coolidge X-ray Tube

Reproduced from orau.org
emission of bremsstrahlung. Bremsstrahlung is the electromagnetic radiation

with a continuous spectrum resulting from EM radiation produced by the
deceleration of a charged particle when deflected by another charged particle.
A window is designed to allow the escape of the generated X-ray photons from
the focal spot of the anode.
X-ray generation by the above process is very inefficient and an estimated

99% of energy is wasted as heat. Overheating at the focal spot on the anode
thus becomes a severe limitation on the power of X-ray tube. A rotating anode
tube is designed to overcome the limitation by sweeping the anode on a rotary
disc, thus spreading the heat generated over a larger area.
3.2.4. Applications in Radiology
X-rays visualize the target by measuring the X-rays attenuation after passing
though the exposed structure. It is especially effective in the visualization
of the pathology of the skeletal system, which has an excellent attenuation
coefficient towards X-rays. It is also commonly used in identifying lung
diseases. Soft tissues, however, have a lower attenuation coefficient towards
X-rays and in general produce less contrast in an X-ray image, which makes
discerning fine details more difficult. Phase-sensitive X-ray imaging (Pfeiffer
et al., 2006; Schneider et al., 2008) is a new concept in recent years to generate
higher contrast from detection of the phase shift of X-rays passing through
the sample in addition to X-ray attenuation detection.
24
3.2. X-ray Imaging
Source of Exposure Exposure

Seven Hour Aeroplane Flight 0.05 mSv
Chest X-ray 0.04 mSv
Nuclear Fallout (From atmospheric tests in
0.02 mSv per year
50’s & 60’s)
Chernobyl (People living in Control Zones
10 mSv per year
near Chernobyl)
Cosmic Radiation Exposure of Domestic
2 mSv per year
Airline Pilot
Table 3.2.: Man’s exposure to ionizing radiation

Reproduced from Australian Radiation Protection and Nuclear Safety Agency
3.2.5. Biological Hazards
Due to the high energy, penetrability and ionizing nature of X-rays, they
interact with living tissue resulting in damage to healthy living cells. Under
substantial exposure, more serious damage to, for instance the DNA of the
cell could occur and may lead to a higher risk of heritable defects and cancer.
According to the ARPANSA Radiation Protection Series No. 1 (Republished
2002) published by the Australian Government. The effective dose limit for
general public is 1mSv per year, while an occupational dose limit of 20 mSv per
year applies. Table 3.2 lists some examples on the radiation dosage received
in various events.
3.2.6. Strengths and Limitations
Being one of the oldest modalities in medical imaging, X-ray imaging is a

mature technology that provides a very safe, non-invasive and economical
diagnostic method in medicine. It is also one of the most commonly and
widely used modalities in medical imaging for diagnosis purpose. Nonetheless,
studies (Ardran, 1979; Veip, 2005; Pfeiffer et al., 2006; Schneider et al., 2008)
have pointed out that conventional X-ray imaging often suffers from lower
contrast or dynamic range, especially in cases where different forms of tissue
with similar attenuation coefficients are under investigation within the same
cross-section. Materials with relatively low X-ray attenuation such as polymers,
fiber composites pose another limitation on the application of X-rays because
of the low signal-to-noise ratio.
25
3. Medical Imaging
Veip (2005) pointed out that the use of digital X-ray receiver could deliver
twice the contrast compared to conventional X-ray film. Still, the upper limit
of the dynamic range is bounded by the allowable radiation dosage, while the
lower limit of the dynamic range is restrained by the noise floor.
Phase-sensitive X-ray (Pfeiffer et al., 2006) is another new concept that aims
to deliver a better contrast by detecting phase changes in addition to X-ray
attenuation.
3.3. Computed Tomography
Computed tomography (CT), also known as computed axial tomography (CAT),

is one of the most common tomography techniques in medical imaging. An es-
timate of 1.06 million CT scans were done in Australia in 1995 (Thompson and
Tingey, 1997) and the trend is growing. The concept of tomography was first
proposed by an Italian radiologist Alessandro Vallebona in early 1930s based
on the concept of projective geometry, to represent a single cross-sectional
slice. The first CT system was invented in 1972 by Sir Godfrey Newbold
Hounsfield at the EMI Central Research Laboratories (Hayes, the United
Kingdom). Allan McLeod Cormack from the Tufts University independently
invented a similar process and both were awarded the Nobel Prize in Medicine
in 1979.
3.3.1. Principle
CT is another imaging technique utilizing X-rays and is also based upon the
fact that different tissues express a different degree of X-ray attenuation. In
CT, a thin fan shaped beam of X-rays is emitted from the tube perpendicular to
the long axis of the body. An array of detectors are positioned on the opposite
side of the X-ray source as shown in Figure 3.6 to convert X-ray intensity into
electrical signals. The resulting images are then combined to form the final
cross-sectional slice by a method called tomographic reconstruction.
26
Figure 3.6.: CT schematic

Reproduced from Medcyclopaedia
3.3.2. Hounsfield Unit Scale
The Hounsfield unit (HU) scale is used in CT, named after Sir Godfrey Newbold
Hounsfield, the inventor of the first CT machine. It represents the linear
transformation based on the original linear attenuation coefficient μ where
adjustments are made such that water and air have values of 0 and -1000
respectively, given in expression 3.2.
μx − μ H2 O
X 1000 (3.2)
μH2O − μai r
where μx , μH2O and μai r are the attenuation coefficients of the scanned tissue,
water and air respectively. A change of 1 HU corresponds to around 0.1% of
the attenuation coefficient, given the fact that μai r 0.
With the large range of values defined in the HU scale, difficulties exist in
visualizing the entire spectrum in modern display devices, which can commonly
resolve only 256 (8-bit) gray levels. Windowing and contrast compression
techniques are often applied to visualize the HU range of interest only. Window
centre or window level is the centre value of the visualizing range, while
window width is the maximum HU deviation from the window centre in which
the shades of gray will be distributed over. For instance, a window center of
1000 and a window width of 100 will effectively display the HU range between
(1000±100)HU on screen. Values above 1100 HU or below 900 HU would be
displayed as pure white and black respectively.
27
3. Medical Imaging
Figure 3.7.: The Hounsfield Unit Scale

Reproduced from Medcyclopaedia
3.3.3. Quantitative Computed Tomography
Quantitative computed tomography (QCT) utilizes a special calibration phan-

tom and additional softwares on top of a CT system to achieve more accurate
measurements. In orthopaedics, QCT allows a more accurate three dimen-
sional volumetric bone mineral measurement. Diagnosis of pathological
conditions can be done quantitatively with QCT. As most commercial CT
system could be upgraded to perform QCT with minor modifications, QCT
may have higher availability and wider acceptance.
3.3.4. Applications in Radiology
CT has become a valuable tool in medical imaging since its introduction, and is
used in the diagnosis of a large range of diseases. Examples include diagnostic
of complex fractures at extremities and joints; abdominal diseases such as
urinary stones and appendicitis; fractures and organ injury due to trauma.
Contrast agents such as barium sulfate can be used to further enhance the
attenuation difference for more specific diagnosis.
While improvements in CT technology have led to a lower overall radiation

dose per examination, CT is still considered a high dose diagnostic procedure
in radiology. Table 3.3 shows some figures on the average effective radiation
dose on several types of CT examinations.
28
Examination Type Typical Effective Dose (mSv)

Adult Head CT 1.5
Adult Abdomen CT 5.3
Adult Chest CT 5.8
10-year-old Head CT 1.6
10-year-old Chest CT 3.9
Table 3.3.: Typical Effective Dose in CT (Shrimpton et al., 2003)
Figure 3.8.: Change of X-ray energy spectrum as it passes through different

depth of water
Reproduced from Barrett and Keat (2004)
This section below aims to provide an overview on some of the most common
artifacts in CT imaging, with focus in the field of orthopaedics.
3.3.6.1. Beam Hardening
When X-ray beams with photons of different energies pass through the exami-
nation object, photons with lower energy has a higher attenuation compared
to the high energy photons, as shown in figure 3.8. This effect is known as
beam hardening.
Beam hardening often shows up in images as cupping artifacts where X-

ray beams that pass through the middle portion of a cylindrical object are
29
3. Medical Imaging
Figure 3.9.: Attenuation profile of X-ray passing through a uniform cylindrical

phantom
hardened more than that those through the edges (Figure 3.9), resulting in
lower HU values towards the centre of the cylinder, as shown in Figure 3.10.
Filtration with metallic material to pre-harden the X-ray beam before passing
through the examination object is often used to reduce the effect of beam-
hardening. Scanners can be calibrated for different pre-defined types of
examinations, and specific correction algorithms could be applied during the
reconstruction stage to compensate or minimize the effect of beam hardening.
3.3.6.2. Partial Volume Averaging
The partial volume averaging effect occurs on slices across structure edges,
due to the effect of averaging the output Hounsfield values across tissues
with very different attenuation properties within the same voxel. It is usually
observed across the z-axis of the CT volume with anisotropic voxel size, where
slice thickness is larger than the spatial resolutions. A smaller slice thickness
could minimize the effect of partial volume averaging.
3.3.6.3. Photon Starvation
Photon starvation occurs when insufficient photons reach the detector because
of high attenuating region, resulting in a noisy projection and often results
in serious streaking artifacts. Figure 3.11 shows a CT cross-section of a
30
Figure 3.10.: CT image with cupping artifacts on a uniform cylindrical phan-

tom
shoulder phantom where photon starvation occurs when the X-ray beam
projects through horizontally.
Photon starvation can be reduced by increasing the tube current, but with a
drawback of a higher radiation dose to patient. An alternative solution is to
vary the tube current automatically at different angular orientation, a process
known as milli-amperage modulation, such that a sufficient tube current is
achieved when needed.
3.3.6.4. Metal Objects
Metal objects possess high density and attenuation coefficient that is out of the
handling range of normal CT system and can cause serious streaking artifacts.
The presence of metal objects in CT examinations are not uncommon in the
field of Orthopaedics, where surgical nails and prosthesis are commonly used
metal devices.
Metal objects are generally removed from patient’s body before scanning
commences. For unremovable metal objects, reduction of streaking artifacts
could be achieved with special software correction algorithms by replacing the
out-of-range values. Additional measures to reduce artifacts resulting from
beam-hardening are always applied, as mentioned in section 3.3.6.1.
31
3. Medical Imaging
Figure 3.11.: Streaking artifacts caused by photon starvation on a shoulder

phantom
3.3.6.5. Ring Artifacts
Ring artifacts occurs when one of the detectors among the detector array is
out of calibration, as shown in figure 3.12.
3.3.6.6. Helical Artifacts
Helical or spiral CT was introduced in the early 1990s and is commonly

used in CT examinations today with the major advantage of speed but with
the drawback of shape distortion due to the need of helical interpolation.
Figure 3.13 shows a helical scan on a cone-shaped phantom with the shape of
the circular cross-section distorted.
3.4. Dual Energy X-ray Absorptiometry
Dual Energy X-ray Absorptiometry (DEXA/DXA) makes use of X-rays to

measure bone mineral content (BMC) and also bone mineral density (BMD)
indirectly. The principle behind DXA is very similar to traditional X-ray
imaging as described in section 3.2.1 on page 21, except that it relies on two
distinct energy levels of X-rays with which each has different attenuation
coefficient for soft tissues and bone. This allows elimination of the attenuation
effect of soft tissue for a more accurate BMD calculation. In orthopaedics,
32
3.4. Dual Energy X-ray Absorptiometry
Figure 3.12.: Ring artifacts on a water-filled phantom

Figure 3.13.: Shape distortion in helical scan of a cone-shape phantom

Reproduced from Wilting and Timmer (1999)
33
3. Medical Imaging
Figure 3.14.: Report of a DXA scan

Reproduced from www.ammom.com.mx
DXA is currently the “gold standard” for diagnosing osteoporosis. Another

use of DXA is body fat content assessment.
DXA for bone densitometry is often performed on lower spine and hips. Mar-
shall et al. (1996) have shown that DXA results performed on hip may be a
good indicator on relative hip fracture risk.
While most DXA devices use dual-energy X-rays for BMD measurements,
newer and more economical portable DXA devices make use of ultrasound on
peripheral sites such as heels and forearm. However, its use are currently
limited to screening purposes (Kirk et al., 2002) while studies (Barr et al.,
2005) show that peripheral DXA could be effective in predicting fracture risk
of older women who are at increased risk of future fracture.
3.4.1. DXA Scores
A typical DXA examination results in two primary values reflecting a patient’s

bone material density, the T-score and the Z-score. T-score is the bone density
compared with what is expected of a young normal patient in the same sex,
while Z-score is the bone density compared with a normal individual of the
same sex, weight and race as the patient. According to the World Health
Organization, a T-score of higher than -1 is considered normal, while a value
of between -1 and -2.5 is considered osteopenia, and a value lower than -2.5 is
considered osteoporosis.
34
3.5. Magnetic Resonance Imaging
3.4.2. Biological Hazard
DXA employs a very low dose X-ray and it is estimated that the effective dose
received by patient per examination on conventional pencil-beam DXA machine
is around 0.08 - 4.6 μSv (Njeh et al., 1999). The effective dose received by
patient on newer and higher resolution fan-beam DXA examination is reported
to be around 6.7 - 31 μSv . It is generally considered that the very low dose of
X-ray used in a DXA examination does not pose any biological hazard to the
general public.
DXA is still currently the most widely used method for BMD measurements.
It is economical, easily accessible and use very low dose ionizing radiation,
which pose negligible biological hazard to the patient.
However, due to the two dimensional nature of DXA scans, Kolta et al. (2005)
pointed out that DXA-derived BMD are not true bone mineral density, but,
more appropriately, an areal density only. Various studies (Goh et al., 1995;
Cheng et al., 1997b; Lekamwasam and Lenora, 2003) have shown that anatom-
ical variations and different hip positioning could lead to as much as 50%
variations on the resulting BMD values. While the extreme variations re-
ported should not happen from a well-trained professional radiologist with
proper patient hip positioning, the effect of anatomical variations such as the
anteversion angle is still unlikely to be eliminated.
Magnetic resonance imaging (MRI), originally known as nuclear magnetic

resonance imaging, could be used in medical imaging to create images of any
part of the body in any plane. MRI has a higher contrast on soft tissue com-
paring to CT and thus a very suitable candidate for distinguishing pathologic
tissue, and imaging in the cardiovascular, and oncological disciplines.
35
3. Medical Imaging
3.5.1. Principles
This section serves only as a brief explanation on the basic principles of MRI.
The detail physics involved in MRI is beyond the scope of discussion here.
MRI makes use of the nuclear resonance of an elementary subatomic particle
with an odd atomic number, such as 1 H , 31 P or 13C , which acts like a magnetic
dipoles. Under strong magnetic field, usually generated by an electromagnet
in an MRI machine, the atoms start to align with the axis of the external
magnetic field with a resonance frequency known as the Larmor frequency,
named after a French physicist. The Larmor equation is
w0 = g B0 (3.3)
where w 0 is the Larmor frequency, B 0 is the magnetic field and g is the constant
gyromagnetic ratio, specific to each type of atomic nucleus mentioned above.
However, only a slight majority of atoms are aligned (parallel protons) in the
direction of the magnetic field and the remainings are aligned in an opposite
fashion (anti-parallel protons). This creates a slight net magnetic moment in
the tissues under the strong magnetic field. When a radio wave pulse exactly
the same as the Larmor frequency is applied, some of the already aligned
protons will be pushed out of their alignment under the original magnetic
field. A tiny but detectable change in the magnetic field when the protons
relax back to their original states can be detected by a receiver coil.
The realignment of the nuclei relaxation after short pulse in the Larmor
frequency is called longitudinal relaxation. The time required for the tissue
magnetism to reach back to 63% of the value before the pulse is applied, is
termed T1. A common value of T1 is 500ms to 1s. The transverse relaxation
time, which is the local de-phasing of the spins after a transverse pulse, is
named T2. A common value of T2 is 50ms to 100ms.
By using different time period between the radio pulses, echo time and other
parameters, images with very different contrast can be achieved.
No ionizing radiation is involved in an MRI examination. MRI thus does not

pose the same potential biological hazards as other imaging modalities that
36
make use of ionization radiation such as X-rays. The hazards involved in

MRI are mainly due to its use of strong magnetic field, which could impose
life-threatening danger when any ferromagnetic objects are attracted towards
to the magnetic bore.
The strong magnetic strengths may cause potential hazard to electronic

circuitry, such as patients with pacemakers installed. Energy transfer via
radio frequency may cause heating effect in tissues of the body. The Safety
Guidelines for Magnetic Resonance Diagnostic Facilities published by the
National Health and Medical Research Council contains details of the safety
limit of the average specific absorption rate in different type of scans, such
as 4 W/kg over the head region, and 8 W/kg over the trunk. Other countries
such as the United States has further recommendations towards maximum
acoustic noise level during the use of MRI.
37
3. Medical Imaging
38
Image Analysis
4
Contents
4.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2. Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.1. The DICOM Format . . . . . . . . . . . . . . . . . . . . . . . 40
4.3. Image Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.3.1. Thresholding . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.3.2. Region Growing . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.3. Edge Detection . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.3.4. Model Based Techniques . . . . . . . . . . . . . . . . . . . . 58
4.4. Image Geometric Transformation . . . . . . . . . . . . . . . . 59
4.4.1. Affine Transformation . . . . . . . . . . . . . . . . . . . . . 59
4.5. Morphological Processing . . . . . . . . . . . . . . . . . . . . . 62
4.5.1. Preliminaries . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4.5.2. Dilation and Erosion . . . . . . . . . . . . . . . . . . . . . . 64
4.5.3. Opening and Closing . . . . . . . . . . . . . . . . . . . . . . 66
4.5.4. The Hit-or-miss Operation . . . . . . . . . . . . . . . . . . . 68
4.5.5. Thinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.5.6. Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.5.7. Convex Hull . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.6. Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.6.1. The Hungarian Algorithm . . . . . . . . . . . . . . . . . . . 77
39
4. Image Analysis
4.1. Overview
s one of the subdivisions of digital signal processing, digital image pro-

A cessing focuses on the analysis of images in digital form. Contrary to
traditional analog image printouts such as traditional X-rays films, digital
images allow the application of much wider analysis and manipulation tech-
niques, not limited by the many physical constraints. The more widespread
use of digital images in medical imaging such as digital X-rays, CT, MRI imag-
ing, and the advancement of micro-computer, makes digital image processing a
powerful yet feasible and economical analysis choice. With the comprehensive
use of the digital Hospital Information System and picture archiving and
communication systems (PACS) throughout Australia (Caffery and Manthey,
2004; Crowe and Sim, 2004), digital images can be transferred easily across
hospitals, fascinating collaborations as well as information sharing.
This section aims to provide an overview of image processing techniques, with

more focus in the field of biomedical imaging. With the fact that the majority
of medical imaging techniques only output grayscale images, the discussion
below assumes images are single-channel if not specified.
4.2. Image Acquisition
Image acquisition is the first step of image analysis. Being the initial source
of all imaging analysis, the image acquisition step has a profound effect on all
the subsequent steps down the analysis pathway. An overview of commonly
used clinical medical imaging techniques and their comparison, strengths and
artifacts are discussed in section 3 on page 19.
Output of the image acquisition step is often stored in a digital form for
further processing. In clinical medical imaging; the DICOM (Digital Imaging
and Communications in Medicine) format is the most commonly used.
4.2.1. The DICOM Format
Introduced by the American College of Radiology and the National Electrical

Manufacturers Association in 1983, The Digital Imaging and Communications
40
4.3. Image Segmentation
in Medicine (DICOM, originally known as ACR/NEMA) standard aimed to

standardize an image format across different brands of CT and MRI imaging
devices. To tailor the use of DICOM in the medical field, the DICOM format
is designed to contain multiple data objects, known as attributes, to enable
the storage of extra information such as patient information, and modality
specific scanning parameters. With the conformance of most major vendors,
and the increasing use of PACS within health care network, DICOM is now
the de facto digital format for most medical imaging modalities. The DICOM
standard is updated four to five times every year according to the standards
committee to incorporate new technology and as of this writing, the most
current version is the “Base Standard - 2008”.
Image segmentation refers to the process of dividing or separating the image

into structural units or to distinguish objects of interest. Specifically in the
case of a single object of interest, segmentation is often referred to as a
foreground background separation procedure. The section below outlines
various commonly used segmentation techniques on gray-scale images. It
has to be noted that while image segmentation has always been a major
focus in image processing, and large amount of algorithms are available,
segmentation are in general, image type-specific, and none are considered
close to universally perfect.
4.3.1. Thresholding
Because of its implementation simplicity, thresholding has always been one

of the popular segmentation methods. The technique is based on a straight-
forward concept on group separation. Given an intensity image I (x, y) with
light objects on a dark background, and a level threshold T , the thresholding
process is defined as follows:
⎧
⎨1 i f I (x, y) > T
I (x, y) = (4.1)
⎩0 i f I (x, y) ≤ T
41
4. Image Analysis
Figure 4.1.: Grey-level histograms with threshold. Left; Single threshold T .

Right: Multi-level threshold (T1 and T2 ).
Reproduced from Gonzalez and Woods (2002)
The output of the segmentation is a binary image with regions of interest or

objects with a value of 1. An extension to the single thresholding method is
to utilize two threshold values T1 and T2 where
⎧
⎨1 i f T1 ≤ I (x, y) < T2
I (x, y) = (4.2)
⎩0 i f I (x, y) < T1 or I (x, y) ≥ T2
Figure 4.1 on page 42 shows a histogram representation of the two thresholding

techniques. The concept can further be extended to multi-channel images.
With the thresholding segmentation technique, the central question lies upon
the method of choosing an optimal threshold T .
4.3.1.1. Fixed Global Threshold
The simplest form of a fixed global threshold is to apply a predefined threshold

value T to the entire image. This method depends on a priori knowledge on
the intensity range of the region of interest.
Various techniques are designed to obtain an optimal global threshold based

on the analysis on the intensity histogram. An iterative method for threshold
selection is proposed by Ridler and Calvard in 1978 (Ridler and Calvard, 1978),
also known as the intermeans algorithm, and is defined as
f gˆk−1 + bgˆk−1
Tk = unt i l Tk = Tk−1 (4.3)
2
where f gˆk−1 and bg k−1 are the sample mean of the gray values on all foreground
and background pixels respectively, with Tk−1 as the threshold value. The
42
initial threshold for foreground background separation, T0 is usually defined

as the median value of the image dynamic range. For images with comparable
area of foreground and background, the average gray level of the image
could be chosen as T0 . The average number of iteration needed to reach an
unchanged T is reported to be 4. For performance reason, the iteration could
be set to stop when the change between Tk−1 and Tk is small.
Another widely used method, the Otsu’s method (Otsu, 1979) aims to search
for a threshold to minimize the weighted within-class variance, or equiva-
lently to maximize the between-class variance, under the assumption of a
bimodal histogram with uniform illumination. In the case of single foreground
background separation, the weighted within-class variance is defined as
σ2P (T ) = P f g (T )σ2f g (T ) + P bg (T )σ2bg (T ) (4.4)
where P f g and P bg are the probabilities of the foreground and background

classes under threshold T respectively, and σ2 is the class variance. Practi-
cally, an exhaustive search across the grayscale dynamic range is done by
maximizing the between-class variance, which is functionally equivalent to
minimizing the function in equation 4.4.
While being one of the oldest histogram-based threshold selection algorithms,

it is still one of the widely adopted methods (Seo et al., 2004; Yadollahi
and Moussavi, 2006). Various extensions and derivatives exist, with Yerly
et al. (2007) extending the Otsu method to three dimensional space, and Liao
et al. (2001) proposing a multilevel threshold derivative with performance
improvement.
4.3.1.2. Adaptive Threshold
Discussion on algorithms in selecting an optimal threshold for global thresh-

olding are built on the assumption of constant illumination with acceptable
signal-to-noise ratio (SNR). Under uneven illumination, picking a constant
global threshold for the entire image will likely under-segment and or over-
segment different parts of the image (Figure 4.2 on the following page). One
solution to the issue is to divide the image into smaller sub-images and select
an optimal threshold value for each child image.
43
4. Image Analysis
Figure 4.2.: Left: A non-uniformly illuminated display. Right: Thresholded

image.
Reproduced from the NI Developer Zone, National Instruments
4.3.2. Region Growing
One fundamental limitation of histogram-based segmentation techniques is

that spatial information is totally discarded in the process. On the contrary,
segmentation based on region growing techniques focus on the spatial location
of pixels, in the aim of grouping pixels into regions of interest. The grouping
criteria are often based on the similarity assumption, in which neighborhood
pixels have similar intensity values.
The basic idea is to start with a set of predefined points in the image called
“seed” points and regions are grown by iteratively grouping neighborhood
pixels which satisfy certain similarity criteria. The procedures of seed points
selection is image specific, and often require a prior knowledge of the image
type. Without extra prior information, an alternative method of seed point
selection is to apply the defined similarity criteria on all pixels across the
image, and assign seed points based on the resulting seeded regions.
Additional stopping rules may be imposed on top of the similarity growing

criteria. Properties such as total region size, intensity limit, or even limitations
on the region shape can be used as stopping criteria for the iterative growing
process. Lee et al. (2005) suggested an automated region growing algorithm
for tumor segmentation on PET images with low spatial resolution and high
variations of intensity by making use of gradient magnitude difference. The
authors further suggested that the use of gradient magnitude difference as
the growing criteria prevented the problem of over-segmentation commonly
observed in traditional region growing techniques with intensity criteria.
Alakuijala et al. (1995) proposed a region growing technique that employs seed
regions for initialization and expansion limited by natural borders, designed
44

Figure 4.3.: Intensity profile across ideal and ramp edge
to give optimal results for interactive and knowledge-based segmentation of

volumetric medical images.
Region growing and its derivatives are also commonly used for more automated
segmentation in areas where manual segmentation is tedious (Tuduki et al.,
2000; Dehmeshki et al., 2008) or in ultrasound imaging (Hao et al., 2000).
4.3.3. Edge Detection
An edge is a set of connected pixels that separates two regions. Note that an
edge is in general a more local measure when compared to an ROI boundary.
Ideally, the intensity values across an edge is distinct with its intensity profile
line perpendicular to the edge being a step function as shown in figure 4.3.
Nonetheless, edges are always presented as a more gradual transition of
intensity level in practice, due to imperfections introduced in the image
acquisition stage. Noise is another major factor in edge detection. This raises
the question on the actual location of a blurred or noisy edge and hence
various techniques were developed. Figure 4.4 on the following page shows
the effects of random Gaussian noise towards a ramp edge and its first and
second derivatives. Note that while the ramp edge is still distinguishable
when σ = 10.0, the magnification effect of the noise in its first and second
derivatives makes the use of derivatives alone in edge detection not very
feasible in noisy cases.
From a viewpoint in the frequency domain, edges are considered local regions
with high frequency components. Theoretically, edge extraction could be
achieved by applying a high-pass filter in, for instance the Fourier domain,
45
4. Image Analysis
Figure 4.4.: Effect of noise to ramp edge. Left column (top to bottom): Ramp
edge corrupted by random Gaussian noise of σ = 0.1, 1.0, 10.0 re-
spectively with its profile line plotted. Middle column: First
derivatives of the corresponding ramp edges. Right column: Sec-
ond derivatives of the corresponding ramp edges.
46
Figure 4.5.: top: image demonstrating a ramp edge; middle: intensity profile;
bottom: first derivative
which is a commonly used frequency representation. However, edge detec-

tion performed in the frequency domain is hardly used because of its extra
computation complexity.
4.3.3.1. Gradient Operators
As discussed above, edges in real world images are always presented as

intensity gradients, and that the first-derivative of an edge gives a good
highlight of it. Figure 4.5 shows an exaggerated ramp edge. Its grayscale
intensity profile across the horizontal axis and the first derivative, which
consist of two distinguish step changes.
The gradient of a certain pixel f (x, y) of an image could be defined as a vector
⎡ ⎤
∂f
−→ Gx ∂x
∇f = ⎣
= ∂f ⎦ (4.5)
Gy
∂y
with direction of the maximum gradient change
Gy
α(x, y) = arctan( ) (4.6)
Gx
47
4. Image Analysis
⎡ ⎤
i1 i2 i3
A = ⎣ i4 i5 i6 ⎦
i7 i8 i9
Figure 4.6.: 3x3 image region with intensity values i x

+1 0 0 +1
0 −1 −1 0
Figure 4.7.: The Roberts Cross operator kernel (left: vertical, right: horizontal)
and magnitude

−→ ∂f 2 ∂f 2
∇ f = |∇ f | = ( ) +( ) (4.7)
∂x ∂y
Note that for performance reason, an approximation on the magnitude ∇ f

may be used
∇ f ≈ |G x | + |G y | (4.8)
The partial derivatives can be calculated by considering the difference between

a pixel and its neighborhood. Figure 4.6 shows a 3 by 3 image region A
The Roberts Cross (Roberts, 1965) operator is a simple and computationally

quick gradient operator, defined as a 2x2 convolution kernel as shown in
figure 4.7.
The first derivative at point i 5 in figure 4.6 using the Roberts cross operator is
Gx = i9 − i5 (4.9)
G y = i8 − i6 (4.10)
with the approximate magnitude
∇ f ≈ |i 9 − i 5 | + |i 8 − i 6 | (4.11)
48
Figure 4.8.: Edges extracted from the Roberts (top right), Prewitt (bottom
left) and Sobel (bottom right) operators from the circuit (top left)
image
Original image courtesy of Steve Decker and Shujaat Nadeem, MIT, 1993.
The approximation reduces the computational complexity to simple arithmetic

operations. However, one drawback for this simplification is the loss of isotropic
property, but is usually acceptable because the three gradient operators in
this section only give isotropic results on vertical and horizontal edges.
The Roberts cross operator has an advantage of simplicity and thus quick
to compute. However, because of its small kernel size, the method is very
sensitive to noise (Figure 4.9 on the next page, top right), and its performance
in blurred edge is poor.
A slight variation of the Robert cross operator is called the Prewitt operator
(Prewitt, 1970) (Figure 4.10 on the following page), which is a 3 by 3 kernel
with a clear centre compared to the 2 by 2 Robert cross operator.
Another variations based on the Prewitt operator is called the Sobel operator
49
4. Image Analysis
Figure 4.9.: Gradient operators under noise Top left: circuit with added noise
(Gaussian σ2 = 0.01). Top right: Roberts. Bottom left: Prewitt.
Bottom right: Sobel.
⎡ ⎤⎡ ⎤
+1 +1 +1 −1 0 +1
⎣ 0 0 0 ⎦ ⎣ −1 0 +1 ⎦
−1 −1 −1 −1 0 +1
Figure 4.10.: The Prewitt operator (left: vertical, right: horizontal)
50
⎡ ⎤⎡ ⎤
+1 +2 +1 −1 0 +1
⎣ 0 0 0 ⎦ ⎣ −2 0 +2 ⎦
−1 −2 −1 −1 0 +1
Figure 4.11.: The Sobel operator (left: vertical, right: horizontal)
Figure 4.12.: top: ramp edge; bottom: second order derivative of the horizontal
intensity profile
(Sobel, 1970), with a weighting of 2 instead of unit weighting applied to the

centre coefficients, as shown in figure 4.11. Higher emphasis is placed on
pixels that are closer to the centre pixel and this leads to a smoothing effect
which attribute to a slightly less noise sensitive characteristic compared to
the Prewitt and Robert cross operators.
4.3.3.2. Laplacian Operator
Despite using first-order derivatives for edge detection, edge points can be
detected by searching for zero crossings of the second-derivative. A second
order derivative of an exaggerated ramp edge is shown in figure 4.12.
The Laplacian operator is a second-order differential operator. For a twice

differentiable real function f , the Laplacian is defined as
∂2 f ∂2 f
∇2 f = ∇ • ∇ f = + (4.12)
∂x 2 ∂y 2
51
4. Image Analysis
⎡ ⎤⎡ ⎤
0 −1 0 −1 −1 −1
⎣ −1 +4 −1 ⎦ ⎣ −1 +8 −1 ⎦
0 −1 0 −1 −1 −1
Figure 4.13.: Laplacian convolution kernels
0.02
0.015
0.01
0.005
0
30
30
20
20
10
10
0 0
Figure 4.14.: 3-D plot of a two dimensional Gaussian filter kernel
For digital images, two commonly used discrete convolution kernel for ap-
proximation is shown in figure 4.13. Similar to the Sobel edge operator, the
left kernel on figure 4.13 is isotropic only on the horizontal and vertical edge,
while the kernel on the right is isotropic on multiples of 45◦ rotation.
However, the second-order derivative nature of the Laplacian is very sensitive

to noise (Figure 4.4 on page 46). To counter this, the image is often smoothed
with a Gaussian filter before the Laplacian is applied. The Gaussian filter
has the form
1 x 2 +y 2
−
G(x, y) = e 2σ2 (4.13)
2πσ2
where σ is the standard deviation. Figure 4.14 shows a 3-D plot of a two
dimensional (30x30) gaussian kernel with σ = 3.
Since convolution operation is associative, the smoothing Gaussian filter and

the Laplacian operator could be combined into a single convolution kernel,
52
⎡ ⎤
0 0 1 0 0
⎢ ⎥
⎢ 0 1 2 1 0 ⎥
⎢ ⎥
⎢ 1 2 −16 2 1 ⎥
⎢ ⎥
⎣ 0 1 2 1 0 ⎦
0 0 1 0 0
Figure 4.15.: 5x5 Laplacian of Gaussian kernel
−3
x 10
−1
−2
−3
−4
30
30
20
20
10
10
0 0
Figure 4.16.: 3-D plot of a two dimensional Laplacian of Gaussian filter kernel
which is more computationally efficient.

1 x 2 + y 2 − x 2 +y2 2
LoG(x, y) = − 4 1 − e 2σ (4.14)
πσ 2σ2
The resulting kernel is commonly named the Laplacian of Gaussian (LoG,

Marr and Hildreth (1980)), and also known as the Mexican hat function,
inspired by the three-dimensional shape as shown in figure 4.16. Figure 4.15
shows a 3-D plot of a 5 by 5 Laplacian of Gaussian convolution kernel.
As discussed above, edge points will give rise to zero-crossings in the resulting
Laplacian output. Nevertheless, zero-crossings may also occur at any region
with changes in the intensity gradient, not necessarily edges. A straightfor-
ward approach for zero-crossing detection is to apply a threshold that sets
53
4. Image Analysis
all positive pixels to logical 1 and all negative pixels to logical 0, resulting in
a binary image. Zero-crossing points can then be retrieved by searching for
all foreground pixels that has a background neighbor. One drawback of this
technique is the bias of the edge towards either the foreground or background.
An alternative is to consider both the foreground and background edge, and
choose the one with a lower magnitude of the Laplacian output.
One characteristic of zero-crossing Laplacian output is that all edges are

presented in closed curves (Figure 4.17 on the next page) except edges that
go off the image boundary. Because of the second-derivative nature of the
filter, the LoG is susceptible to noise under insufficient Gaussian smoothing
(Figure 4.17 on the facing page), resulting in lots of spurious edges. Apart
from increasing the Gaussian smoothing, threshold on the gradients of zeros-
crossings could also be applied, having a drawback of amplifying high frequency
noise due to the third derivative nature of the operation.
The level of detail of the LoG output is governed by the standard deviation
used in the Gaussian smoothing kernel. The higher σ is set, the less level of
detail will be retrieved. Also note that while the 3 by 3 convolution kernel
in figure 4.13 on page 52 is only isotropic in 45◦ rotational increment, LoG
kernel used in practice is an isotropic filter, thus it is not possible to extract
edge orientation directly from the transformation output.
Computationally, the LoG kernel could easily give rise to extremely positive
or negative values which lies out of bound of the original pixel data type. It
is important to ensure the output data type is able to handle the larger range
of values from the operation.
Several variants of the LoG exist, with the most common one named the
Difference of Gaussian (DoG) filter, which is an approximation of the LoG
using just the difference of two Gaussians of different size, defined as
−(x 2 +y 2 ) −(x 2 +y 2 )

1 1 2σ2
1 2σ2
DoG(x, y) = e 1 − 2e 2 (4.15)
2π σ21 σ2
Figure 4.18 on page 56 shows the plot of a DoG function (σ1 = 3 , σ2 = 2), which
is very similar to the LoG filter. Another even coarser approximation is the
Difference of Boxes filter, which is the difference of two different-sized mean
filter. It has an advantage of being much faster than the LoG operator.
54
Figure 4.17.: Top left: noisy circuit image (Gaussian σ2 = 1). Top right: zero-
crossing threshold = 0, σ = 2. Bottom left: zero-crossing threshold
= 0.01, σ = 2. Bottom right: zero-crossing = 0, σ = 5.
55
4. Image Analysis
0.005
−0.005
−0.01
−0.015
−0.02
−0.025
30
30
20
20
10
10
0 0
Figure 4.18.: 3-D plot of a two dimensional Difference of Gaussian filter kernel
4.3.3.3. Canny Edge Detector
The Canny edge detector was proposed (Canny, 1986) aiming to construct the
optimal edge detection with the criteria of marking as many real edges as
possible, marking as close to the real edge as possible, and avoid duplicate
marking of edges. Unlike previously discussed gradient operators and the
Laplacian operator, the Canny edge detector is a multi-step procedure.
The image is first smoothed using a Gaussian filter for noise reduction using
the kernel as described in equation 4.13 on page 52. The gradient is then
computed using any gradient operator described in section 4.3.3.1 on page 47
to obtain

G(x, y) = G x2 +G 2y (4.16)
and with gradient orientation

G y (x, y)
θ(x, y) = arctan (4.17)
G x (x, y)
A threshold T is applied to suppress most of the noise while try to keep all
edge candidates.
56
Figure 4.19.: Left: noisy circuit image (Gaussian σ2 = 1). Right: Canny edge
detector (T = 0.1, T2 = 0.2, σ = 1.5])
⎧
⎨G(x, y) i f G(x, y) > T
G T (x, y) = (4.18)
⎩0 ot her wi se
Edge ridge thinning to G T (x, y) is performed by suppressing all non-maxima

pixels. Each non-zero pixel in G T (x, y) is checked and if it is greatest among
its two neighbors along the gradient direction, the pixel is kept. If it is not,
the pixel is set to zero.
Two binary images G T1 and G T2 are generated using two thresholds T1 and
T2 respectively where T2 > T1 . Comparatively, the binary image G T1 is more
noisy and contains more false positives. The final step involves applying edge
linking on image G T2 with the use of pixels in G T1 as bridging purpose only.
The output of the Canny edge detector (Figure 4.19) depends on three ad-
justable parameters. The width of the Gaussian smoothing kernel affects the
balance point between noise sensitivity and sensitivity towards finer object
details. The higher the upper threshold T2 , the less edge fragments; and the
higher the lower threshold T1 ,the higher the chance of having edges broken
up especially in noisy situation.
One drawback of the Canny edge detector is the defect on Y-junctions, where
three edges connect at the same point. Application of the Canny detector will
result in having two of the edges linked, with the remaining edge approaching
the centre point, but not connecting.
57
4. Image Analysis
Figure 4.20.: Typical adaptation results with the use of deformable model.
Note that part of the model is attracted and settled on false
boundaries (white arrows).
4.3.4. Model Based Techniques
Recent developments in image segmentation have taken into account more

prior information of the object of interest, in order to produce more accurate
and robust automatic segmentation outcome. Shapes are one of the commonly
used priori information, in which a predefined shape is iterated and refined to
a better matched state. Criteria such as strong edges could be used to define
the degree of match.
Active shape models (Cootes et al., 1995; Kelemen et al., 1998) a commonly
employed refinement approach, which is analogous to that employed by Active
Contour Models (commonly known as snakes, Kass et al., 1988). Statistically
based techniques are employed for constructing deformable shape templates
with the deformation constrained by the statistical parameterization. It is a
fast and robust automatic segmentation method, but its segmentation accuracy
could be limited due to its restriction to a model with a few parameters (Weese
et al., 2001).
Elastically deformable models (McInerney and Terzopoulos, 1996; Staib and

Duncan, 1996) is another promising technique in effectively segmenting types
of medical images. It has a relatively higher flexibility and is capable of
accommodating a higher level of structural variability commonly encountered
in anatomical objects. Nonetheless, in non-interactive applications, the ini-
tialization template has to be close to the actual object of interest for good
performance, making it a major drawback. This is mainly due to the presence
of other surrounding features which could incorrectly attract the deformable
model towards false boundaries as shown in figure 4.20.
58
4.4. Image Geometric Transformation
Several authors (Kaus et al., 1999; Weese et al., 2001) proposed the use of
shape constrained deformable model, in an attempt to combine the benefits
of active shape and elastically deformable models. It involves adaptation
to the image by means of an external energy from local surface detection,
combined with an internal energy constraining the deformable surface to stay
close to the predefined shape model. Kaus et al. (1999) reported success in
applying the method to MRI images of grade 1-3 brain tumors (meningiomas
and astrocytomas) in various locations. Nevertheless, it was pointed out
an intrinsic limitation exists; the pre-defined template cannot account for
any pathological structures. While successful segmentation was achieved in
simple tumors, the authors called for additional investigations in improving
the elastic matching technique to explicitly handle pathological structures.
Image output from the acquisition stage may contain irregularities, distortion
or other unwanted artifacts. While many modern equipments have sophisti-
cated calibration procedures to minimize its effect to the final image quality,
image pre-processing is often required to tailor to special analysis need. In
medical imaging, extra processing steps for artifact reduction, calibrations as
described in section 3 on page 19 are often done within the image acquisition
system, resulting in usually acceptable image quality provided that optimal
imaging parameters are employed. However, one uncontrollable factor in real
world medical imaging, precise patient or specimen positioning, often exist
in practice. While patients are often positioned in a standardized position
before any medical imaging procedures commences, the consistence is often
not sufficient, or the positioning may not be suitable for analysis purpose. A
transformation on the coordinate system may be necessary or desired for ease
of analysis.
4.4.1. Affine Transformation
Affine transformation is a type of linear geometric transformation converting

between two affine spaces, and can be expressed as a linear transformation
plus a translation operation. An affine transformation has the following
properties:
59
4. Image Analysis
• Preservation of collinearity: all points on a line still lie on a line after

transformation
• Preservation of distance ratio: ratio of two collinear line segments

remains the same after transformation
Note that although affine transformation preserves collinearity and distance

ratio, it may not necessarily conserves angles or actual length.
An affine transformation can be generally expressed as

x = Ax + B (4.19)
where x is a n by 1 vector in n-dimensional space, A is the transformation

matrix and B is an n by 1 translation matrix.
Affine transformation is useful in conversions between coordinate systems

with a combination of translation, rotation, scaling and shear procedures.
Intuitively, only translation, rotation are employed in most coordinate system
conversion because of the goal to preserve geometric or actual length consis-
tence. Scaling may be used in coordinate system conversion when anisotropic
voxels or pixels are being used. For a two dimensional matrix, the affine
transformation for translation is defined as

x 1 0 x tx
= + (4.20)
y 0 1 y ty
where t x and t y are the x and y translation respectively. Rotation is defined

as

x cos θ − sin θ x
= (4.21)
y sin θ cos θ y
where θ is the angle of rotation counterclockwise about the origin. The

transformation for scaling

x sx 0 x
= (4.22)
y 0 sy y
60
where s x and s y is the scaling factor of x and y respectively. The shearing

transformation has two forms

x 1 mx x
= (4.23)
y 0 1 y

x 1 0 x
= (4.24)
y my 1 y
where equation 4.23 is for shearing operation parallel to the x axis and
equation 4.24 is for shear parallel to the y axis. m x and m y are the shearing
factor correspondingly.
Multiple affine transformations could be combined into a single operation

using matrix multiplication. Given an affine transform defined by matrix A 1
followed by another affine transformation defined by matrix A 2 , the resultant
procedure is equivalent to performing an affine transformation with matrix A

x x
=A (4.25)
y y
where A = A 2 ∗ A 1 . Note that the matrix multiplication is not commutative,

meaning the operation is order dependent.
Homogeneous coordinates are often used as an alternative representation,

to combine the transformation matrix A and the translation matrix B . This
is done by incorporating the translation matrix using an n+1 by n+1 affine
transformation matrix as follows:
⎡ ⎤ ⎡ ⎤
x x
⎢ ⎥ A B ⎢ ⎥
⎢ y ⎥ = ⎢ y ⎥ (4.26)
⎣ ⎦ ⎣ ⎦
0 0 1
1 1
where A and B are the matrices defined in equation 4.19 on the facing page.
This representation simplifies the transformation parameter into a single
homogeneous matrix and is often used in software packages like Matlab .
61
4. Image Analysis
Representation Explanation
a∈A a is an element of A
a∉A a is not an element of A
Table 4.1.: The membership relation in set theory
4.5. Morphological Processing
The term morphology refers to mathematical morphology which in image

processing, denotes the representation and operation of regional shapes or
structures. Though originally developed for binary images only, it has been
extended to operate on grayscale images and multi-channel images.
Mathematical morphology is built based on the set theory, in which in a

binary image, the set of all black pixels could be represented as a set of 2-D
vectors in Z2 where each pixel coordinates (x, y) symbolized a 2-D vector. In
grayscale images, an extra dimension is added to incorporate the grayscale
values, resulting in a set representation in the Z3 . The concept can be further
extended to multi-channel colour images by set representation in higher
dimension. The sections below focuses on morphological operations in binary
images with brief mention of operations on single-channel grayscale images.
4.5.1. Preliminaries
The basic relationship between objects in the set theory is the membership
relation. Let A be a set in Z2 , which is a general representation of a binary
image as mentioned above and for any a in Z2 , the membership relations are
listed in table 4.1.
The content of a set is denoted by two braces, with A = {a} meaning the set A
contains an element a ,. Furthermore, the expression B = {b|b = −a, f or a ∈ A}
means the set B contains element b in which b is composed by multiplying
every element in the set A by −1. Another common notation is the empty set,
denoted by Ø. Table 4.2 on the facing page shows a set of commonly used
notations in set manipulation.
Logical operations on binary images are often involved in many morphological

operations. Unlike the set operations mentioned above, logical operations
62
Relationship Representation Explanation

Subset A⊆B every element of set A is an
element of set B
Proper Subset AB set A is a subset of set B but
A = B
Union C = A ∪B set C contains all elements in
either set A or B
Intersection C = A ∩B set C contains all elements in
A and B
Complement A or A c the set A contains the set of
elements not in set A
Difference C = A − B or A\B set C contains elements which
are member of set A but not
set B
Cartesian Product C = AxB set C contains all the ordered
pairs (a, b) where a ∈ A and
b∈B
Reflection Â defined as
Â = {c|c = −a, f or a ∈ A},
equivalent to flipping an object
along the x-axis followed by
the y-axis in a 2-D image.
Translation (A)z defined as
(A)z = {c|c = a + z, f or a ∈ A},
equivalent to moving an object
in the x-y plane in a 2-D
image.
Table 4.2.: Standard notations in set theory
63
4. Image Analysis
Operation Notation Explanation Equivalent Set Operation

AND a •b Logical AND operation Intersection
between a and b
OR a +b Logical OR operation Union
between a and b
NOT ā Logical NOT operation Complement
on a
Table 4.3.: Logical operations on binary images
are performed on a pixel by pixel basis, and on images or image windows of

exactly the same dimension. Table 4.3 lists the notations of binary logical
operations and its equivalent set operations.
4.5.2. Dilation and Erosion
Image dilation and erosion are one of the most fundamental and commonly
employed morphological techniques and serve as a basis of a wide range of
morphological operations.
4.5.2.1. Dilation
Named after Hermann Minkowski, the dilation operation (Minkowski, 1900)

is also known as the Minkowski sum. Dilation of two sets A and B in Z2 ,
denoted by the symbol ⊕, and is defined as
A ⊕ B = {z|(B )z ∩ A = Ø} (4.27)
where B is often referred to as the structuring element of the operation. The

dilation result of set A and B is the union set of A and set B with all translation
z , with which the translated set, (B )z has at least one overlapping element
with set A .
On a binary image, dilation could be achieved by superimposing the structuring

element on top of each background pixel. If at least one pixel of the structuring
element coincides with a foreground pixel, all pixels covered by the structuring
64
element are set to the foreground value, or else the pixel values are left
unchanged.
Dilation on grayscale images are similar, in which the maximum pixel inten-
sity level of the superimposed structuring element window is taken as the
output pixel value. This operation in general results in a brightened image,
with bright regions surrounded by dark regions enlarged, and dark regions
surrounded by bright regions shrank.
Structuring elements are often symmetrical, with square or disk topology.

The use of non-symmetrical structuring element will result in a directional
operation. Dilation using a 10 pixels vertical structuring element on a binary
image could be performed to link only vertical gaps but not horizontal gaps.
4.5.2.2. Erosion
Erosion is another basic morphological operation denoted by the symbol ,

and is defined as
A B = {z|(B )z ⊆ A} (4.28)
The erosion result of a set A using a structuring element B is the set B with
all translation combination z in which (B )z is completely contained in set A .
Erosion of a binary image can be done by superimposing the structuring

element over each of the foreground pixels. If for all the pixels in the structur-
ing element, the underlying pixels are foreground pixels, the pixels are left
unchanged, or else the corresponding pixels in the structuring elements are
set to the background value.
Erosion on grayscale images is similar. The minimum pixel intensity level of

the superimposed structuring element window is taken as the output pixel
value. This operation in general results in a darkened image, with dark
regions surrounded by bright regions enlarged, and bright regions surrounded
by dark regions shrunk.
Similar to dilation, structuring element are often symmetrical, with square

or disc shape. The use of non-symmetrical structuring element will result in
a directional erosion operation.
65
4. Image Analysis
4.5.3. Opening and Closing
Morphological dilation and erosion described in previous sections are fre-

quently combined to provide more robust operations, namely image opening
and closing.
Morphological opening of a set A with a structuring element B is denoted by

the symbol ◦ and is defined as
A ◦ B = (A B ) ⊕ B (4.29)
Similarly, morphological closing of a set A with a structuring element B is

denoted by the symbol • and is defined as
A • B = (A ⊕ B ) B (4.30)
From its definition, morphological opening is an erosion followed by a dilation

operation, and morphological closing is a dilation followed by an erosion oper-
ation. While the usefulness of the two operators may not be straightforward
from a set theory interpretation, the geometric interpretation of the two
operators give a more direct understanding of the usefulness in morphological
image processing. Assuming a ball or disc shaped structuring element B is
being used, the resulting boundary of an opening operation could be viewed
as the coverage of a rolling ball inside an object along its inner boundary. Fig-
ure 4.21 on the facing page shows the morphological opening of a rectangular
foreground object using a disc-shaped structuring element. The resulting set
is the coverage of the rolling ball inside the object bounded by its boundary.
Similarly, figure 4.22 on the next page shows the geometric interpretation of
the morphological closing operation. Instead of tracing the structuring element
along the inner boundary, the rolling disc is traced outside the foreground
object following the outer object boundary. Note that while we use the term
“rolling” in the above description, the structuring element only undergoes
translation but not rotation, and this interpretation extends similarly to other
non-symmetrical structuring element.
The opening and closing operation are often considered duals of each other.
Table 4.4 on the facing page shows some common properties of the opening
and closing operations.
66

Figure 4.21.: Geometric interpretation of morphological opening

Figure 4.22.: Geometric interpretation of morphological closing
Property Equation
Duality A ◦ B = A c • B and A • B = A c ◦ B
Translation (A)z ◦ B = (A ◦ B )z and (A)z • B = (A • B )z
Idempotence (A ◦ B ) ◦ B = A ◦ B and (A • B ) • B = A • B
Extensivity A ⊆ (A • B )
Antiextensivity (A ◦ B ) ⊆ A
Table 4.4.: Common properties of morphological opening and closing
67
4. Image Analysis
Figure 4.23.: Left: Noisy fingerprint image. Middle: Opening of the image.
Right: Opening followed by closing.
Reproduced from Gonzalez et al. (2003), original image courtesy of the
National Institute of Standards and Technology.
In general, the opening operation separates slightly connected object while

closing fill up small holes within the object. Both operations give a smoothed
contours, with which the opening and closing operations smooth the contour
through the tracing of the inner and outer object boundary respectively, as
demonstrated in figure 4.21 on the previous page and figure 4.22 on the
preceding page. Figure 4.23 shows the use of opening operation to remove
small islands as a result of noise in a fingerprint image using a 3 × 3 square
structuring element. Numerous gaps along the ridges of the fingerprint is
introduced due to pepper noise on the original ridges, and the closing operator
is applied to bridge the gaps.
4.5.4. The Hit-or-miss Operation
Originally defined by Serra (1982), and sometimes known as the hit-and-

miss operation, the transformation is one of the basic techniques for shape
matching. Denoted by the symbol , the hit-or-miss transformation is defined
as
A B = (A X ) ∩ [A c (W − X )] (4.31)
where W is a small window with X enclosed, and X is the shape to be

matched. Without loss of generality, a set B = (B 1 , B 2 ) is always defined in
which B 1 represents the object template X while B 2 represents the background
template (W − X ) to aid the geometric illustration. Thus equation 4.31 can be
expressed as
68

Figure 4.24.: left: Set A (gray). right: foreground template W and background
template (W − X )

Figure 4.25.: left: set A c (gray). right: A X (gray regions)
A B = (A B 1 ) ∩ [(A B 2 ) (4.32)
The geometric interpretation of the transformation is as follows. A binary

image A containing 3 foreground objects, A = X ∪ Y ∪ Z , with background
template B 2 are shown in figure 4.24.
Figure 4.25 shows the complement or set A and the erosion of set A using X
as the structuring element. Geometrically speaking, the result represents a
possible match of the template X within set A .
The next step is to compute the erosion of set A c with the background template
(W − X ), as shown in figure 4.26 on the next page.
The final step is to compute the intersection of the two erosion results, giving
the final match as shown in figure 4.26 on the following page. While the
erosion step shown in figure 4.25 is already a matching operation, the beauty
69
4. Image Analysis

Figure 4.26.: A c (W − X ) in gray
of the hit-or-miss transformation is the additional matching of the background

template (W − X ), eliminating objects that contain X .
4.5.5. Thinning
Object representation using line segments are often useful in describing

the topology in a simplistic way. Thinning is a commonly used procedure
(Elmoutaouakkil et al., 2002; Qiang et al., 2004) to generate topological
representation and is based on the hit-or-miss transformation discussed in
previous section. Denoted by the symbol ⊗, the thinning transformation is
defined as
A ⊗ B = A − (A B ) (4.33)
The thinning operation could be treated as a erosion to reduce the thickness

of an object while not vanishing it. A more practical interpretation could
be made by descriptions using conditional statements using a simple 3 by 3
structuring element with 8-th connectivity. The operation could be interpreted
as an erosion operation of zeroing the centre origin pixel if any of the following
conditions are not met, or equivalently it is not zeroed only if all the conditions
are met:
• it is an isolated pixel
• connectivity will be broken
70
Figure 4.27.: Iterations of a thinning operation. B 1 to B 8 : structuring elements

for thinning operation. Middle 3 rows: thinning operations
using the 8 structuring elements incrementally. Bottom left:
Final result after convergence. Bottom right: Conversion to
m-connectivity.
• line will be shortened
The operation is repeated until no further change is observed in the subsequent

step and the final image will be a set of connected paths with unity width
giving an approximation of the topology of the object. From the nature of the
operation, it could be considered as a conditional recursive erosion operation.
In the above case utilizing a 3 by 3 structuring element, having 29 = 512
possible window combination, a look-up table is often pre-calculated to speed
up computation. Figure 4.27 shows an example of the thinning operation using
a common set of structuring elements (B 1 to B 8 ). The thinning operation is
applied incrementally using each of the structuring elements until convergence
and the final output is converted to m-connectivity.
71
4. Image Analysis
Figure 4.28.: Thickening obtained by thinning operation. Top left: original

set A . Top right: Complement of set A . Middle row: iterations
of the thinning operation on set (A)c . Bottom: Final result after
removal of disconnected islands
Another useful application of the thinning operation is to reduce the output of

the Sobel edge detector described in section 4.3.3.1 on page 47. The operation
is useful in reducing the edge to unity width while preserving connectivity
and avoiding the path shortening effect.
The dual of morphological thinning is the thickening operation, which is not

a commonly used morphological processing technique. Denoted by the symbol
, it is defined as
A B = A ∪ (A B ) (4.34)
In practice, thickening is usually achieved by thinning the background set

A c followed by a complement operation (Figure 4.28). An extra procedure of
removing disconnected islands is always applied to eliminate the side effect
of the operation.
4.5.6. Skeleton
Similar to the morphological thinning operation described in previous section,

the skeleton of an object is another topological representation. Based on the
work of Lantuejoul and Serra (Lantuéjoul, 1978; Serra, 1982), the skeleton of
A with structuring element B is defined as
72
Figure 4.29.: Principle of skeleton generation. Maximum-sized disks are

positioned with centres on the skeleton.

K
S(A) = S k (A) (4.35)
k=0
where
S k (A) = (A kB ) − (A kB ) ◦ B (4.36)
and
K = max{k|(A kB ) = ∅} (4.37)
K is chosen such that it is the step before the set A turns into an empty set.
The structuring element B is chosen to be an approximation of a disc. Given
K and the structuring element B , reconstruction could be done using the
equation

K
A= (S k (A) ⊕ kB ) (4.38)
k=0
Figure 4.29 shows the use of maximum-sized disks in the construction of

a skeleton outline. Compared to the morphological thinning operation, the
skeleton operation does not guarantee connectivity nor path of unity width.
73
4. Image Analysis
Figure 4.30.: Top left: original segmented human chromosome image. Top
right: Thresholded image. Bottom left: Skeleton of the image.
Bottom right: Skeleton followed by spur removal.
Original image courtesy of Gonzalez et al. (2003)
Figure 4.30 shows the skeleton of a human chromosome, delivering a good rep-
resentation on the structural shape of the object. Spur removal is repeatedly
applied to remove tiny spurs which is common in a skeleton image.
4.5.7. Convex Hull
A set {A} is said to be convex if all points lying between the line segment
constructed between any two points in {A} lies in {A}. The convex hull C (B ) of
a set {B } is defined as the smallest convex set containing {B }. The term convex
deficiency is often used to denote the set difference {C (B ) − B }.
The simplified implementation of computing C (B ) can be described as follows:
74
Let B 1 , B 2 , B 3 , B 4 be 4 structuring elements as shown in figure 4.32 on the next

page, and define
X ki = (X k−1 B i ) ∪ A f or i = 1, 2, 3, 4 and k = 1, 2, 3, 4 . . . wi t h X 0i = A (4.39)
now define D i to be the convergence of above equation,
D i = X i when X ki = X k−1
i
(4.40)
The convex hull of A, can be denoted as

4
C (A) = Di (4.41)
i =1
The above procedures are equivalent to applying the hit-or-miss transformation

(Section 4.5.4 on page 68) iteratively. The hit-or-miss transformation is applied
to A using the structuring element B 1 until it converges and the union with A
is computed (D 1 ). The same operation is performed with structuring element
B 2 , B 3 , B 4 resulting in D 2 , D 3 , D 4 respectively. The final convex hull C (A) can be
obtained by computing the union of D i . Note that the implementation described
above does not necessary produce a smallest convex set containing {A}, as
illustrated in (Figure 4.32 on the next page). To limit the growth, addition
criterion to the above algorithm could be added by imposing limitations to the
maximum vertical and horizontal dimensions of C (A) to that of {A} (Figure 4.32
on page 76), or in an even more detailed approach, limitation upon diagonal
directions could be applied. The cost of the additional criteria is a higher
complexity, thus computational complexity and time.
Various algorithms for computing the convex hull have been proposed. Being
one of the simplest while comparatively not very efficient, Jarvis (1973)
proposed a 2-D case named the Jarvis march, also known as the gift wrapping
algorithm, having a complexity of O(nh) where n is the number of points in
{A} and h is the number of points in the final convex hull. A more efficient
algorithm was proposed by Graham (1972) reducing the complexity to O(n log n).
Other even more efficient methods (Kirkpatrick and Seidel, 1986; Chan, 1996)
based on output-sensitive algorithms were proposed, further reducing the
complexity down to O(n log h).
75
4. Image Analysis
Figure 4.31.: A morphological algorithm to compute the convex hull. X 01 : the

original set A . X 41 , X 22 , X 83 , X 24 : the set at convergence using the
structuring elements B 1 , B 2 , B 3 , B 4 respectively. C (A): The final
convex hull
Figure 4.32.: Convex hull with extra criteria to limit growth

76
4.6. Miscellaneous
4.6. Miscellaneous
4.6.1. The Hungarian Algorithm
The Hungarian algorithm, proposed by Kuhn (1955), is a combinatorial opti-

mization algorithm for solving assignment problem minimizing or maximizing
the total cost associated. A typical example of the method is to find an optimal
assignment of worker to job so as to minimize the total cost in which one
worker could be assigned to one and only one job.
Starting with an n ×n cost matrix c where c i j denotes the cost associated with
assigning the i -the worker to the j -th job, the algorithm could be summarized
into the following steps:
1. Subtract each row by the row minimum
2. Subtract each column by the column minimum
3. Use the minimum number of lines to cover all zeros in the resulting cost
matrix. If k lines are used, and k < n , compute m which is the minimum
uncovered number in the cost matrix. Subtract m from all uncovered
number, and add m to all number covered with two lines (one horizontal
and one vertical) and restart step 3. If k = n , go on to step 4.
4. Start from the top row to make assignments. Unique assignment can
be made when there is exactly 1 zero in the row. Delete the row and
column associated with the assigned element. In the case with which all
remaining rows containing more than 1 zero, where unique assignment
could not be made, iterate in columns starting from the left-most column.
Similar to the row assignment, unique assignment can be made when
there is exactly 1 zero in the column. Delete the row and column
associated with the assigned element. Switch between row and column
assignment until all unique assignments can be made.
5. If there are still unassigned rows in which unique assignment could

not be made in step 4, make one arbitrary assignment by selecting an
element with a zero, and try step 4 to make further unique row or column
assignment.
77
4. Image Analysis
78
Shape Analysis
5
Contents
5.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.2. Basic Geometrical Shape Parameters . . . . . . . . . . . . . 79
5.2.1. Region Based Parameters . . . . . . . . . . . . . . . . . . . 80
5.3. Object Description Techniques . . . . . . . . . . . . . . . . . . 82
5.3.1. Chain Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.3.2. Fourier Descriptors . . . . . . . . . . . . . . . . . . . . . . . 85
5.3.3. Hausdorff Distance . . . . . . . . . . . . . . . . . . . . . . . 89
5.3.4. Corner Detector . . . . . . . . . . . . . . . . . . . . . . . . . 90
5.1. Overview
hape is one of the fundamental factors in anthropometry. While shape

S cognition is an instinct nature of human being, its perception in the
digital world remains a difficult task. Numerous methods were suggested
in characterizing object shape, but their performance and versatility is far
from satisfactory. The section below summarized several commonly employed
object description techniques.
5.2. Basic Geometrical Shape Parameters
Direct geometrical measurements are one of the most common ways of struc-
turally describing an object. This section aims to provide descriptions on some
79
5. Shape Analysis
geometric measurement parameters.
5.2.1. Region Based Parameters
5.2.1.1. Area
A 2-D quantity representing the extent of a surface. In digital images where

objects are quantized to pixel level, the area is defined as the number of pixels
times the individual pixel area.
5.2.1.2. Centroid
The centroid of a geometric shape is defined as

xd A yd A
Cx = , Cy = (5.1)
A A

where A is the area of the shape defined as A = f (x)d x . The centroid on a
digital image could be simplified, and denoted as
n n
1 x 1 y
Cx = , Cy = (5.2)
n n
where n is the number of pixels in the shape. In a homogeneous object, the

centroid equals to its centre of mass.
5.2.1.3. Eccentricity
The eccentricity (ε) of a two dimensional region is defined as the eccentricity

of the ellipse that has the same second-moments as the shape region. The
eccentricity of an ellipse with semi-major axis a and distance from the centre
to either focus c is defined as ε = ac . Eccentricity is a scale between 0 and 1,
in which an ellipse is a circle when ε = 0 and a line segment when ε = 1.
80
5.2. Basic Geometrical Shape Parameters
5.2.1.4. Area Moment of Inertia
The area moment of inertia, also known as the second moment of inertia, or
just moment of inertia, measures the resistance of an object towards bending.
The area moment of inertia about an x-axis is defined as

I xx = y 2d A (5.3)
where y is the perpendicular distance from the axis to the area element, and
A is the element area. Equation 5.3 is valid for sections that are symmetrical
about the x-axis. For other cases, equation 5.4 applies.

Ix y = x yd A (5.4)
where A is the element area, x and y are the perpendicular distance to the
element A from the x-axis and y-axis respectively. The parallel axis theorem
also states that given the area moment of inertia of an object about the centre
of mass, the area moment of inertia of any arbitrary parallel axis I cm is
defined as
I cm = I cm + Ad 2 (5.5)
where I cm is the area moment of inertia through the centroid, A is the shape
area, I cm is the moment of inertia through an axis parallel to that of I cm , d is
the perpendicular distance between the axes of I cm and I cm .
5.2.1.5. Polar Moment of Inertia
The polar moment of inertia measures the resistance of an object towards

torsion. Analogous to the area moment of inertia, the polar moment of inertia
is used in calculation of the twist of an object under torque, and is defined as

Jx = r 2d A (5.6)
where J x is the polar moment of inertia (m 4 ), r is the radial distance from the
element to the axis of rotation, A is the infinitely small element area.
81
5. Shape Analysis
5.3. Object Description Techniques
Shape description techniques are widely used in many disciplines in image

analysis, from object recognition in computer vision, biological classification,
character recognition in optical character recognition (Kuhl and Kuhl, 1963),
to visual perception in cognitive science. This section aims to provide a
brief outlook in several shape representation techniques and specifically its
applications in the field of biomedical engineering which form the bases of
various techniques employed in the discussion in following sections.
Shape description usually refers to methods that generate a numerical de-

scriptor of a shape and its goal to uniquely characterize a shape based on
certain features.
Several properties are considered desirable properties of a good shape descrip-

tor:
• Uniqueness: Having a unique representation of shapes is fundamentally

critical to allow any shape comparison or retrieval.
• Completeness: This generally refers to obtaining an unambiguous repre-

sentation towards a shape.
• Invariance: Shape representation that is invariant under different geo-

metrical transformations is generally a desired property especially in
real-world applications. This includes translation, rotation and scale
invariance.
• Sensitivity: A particularly important aspect in shape representation

in shape similarity analysis, where similar shape objects can be distin-
guished.
• Efficiency: With the increasingly popular real-time or online shape

retrieval applications, shape descriptor with high efficiency or low com-
putational complexity is desired.
82
Figure 5.1.: 8-th directional chain code
5.3.1. Chain Coding
5.3.1.1. Principles
Chain code (Freeman, 1961; Freeman and Saaghri, 1978) was first introduced
by Freeman in 1961, by describing a method in encoding any arbitrary curve
into a piecewise linear sequence using a pre-defined set of 8 vectors. Figure 5.1
shows the 8 direction of the vectors, and each is represented with an integer
from 0 - 7.
The chain code of an arbitrary curve is generated by finding the closest

directional approximation when the vector grid is superimposed on points
along the curve. The grid is transversed along the entire curve and the
resulting sequence generated is the chain code. Other variations exist, using
an N-directional vector (N = 2k where N > 8 and k
Z ) and is called the general
chain code (Freeman and Saaghri, 1978).
Freeman stated that the coding schemes must satisfy the following three
objectives:
1. It must faithfully preserve the information of interest.
2. It must permit compact storage and be convenient for display
3. It must facilitate any required processing.
While the above three objectives could be mutually exclusive to a certain level,
most of the derivatives were proposed based on different levels of compromising
the three ideal goals.
The chain coding scheme of a boundary is dependent on its starting point,

which makes it not very suitable in the context of shape matching. One simple
normalization method is to treat the chain code as a circular sequence of
integers. The starting point is redefined such that the resulting redistributed
83
5. Shape Analysis
Figure 5.2.: Steps in computing the shape number from chain code
Reproduced from Gonzalez et al. (2003).
code obtains a minimum magnitude when the code is treated as an integer.

To achieve rotational invariance, derivative notation could be used in which
an integer is assigned for each change in directions (Figure 5.2). The resulting
derivative notation is then normalized by cyclic permutation until a minimum
integer value is obtained. The resulting normalized code is called shape
number as described by Bribiesca and Guzman (1980). Bribiesca (1999)
proposed another derivative chain code based on the shape number, called
vertex chain code. The vertex chain code indicates the number of cell vertices
that are in touch with the bounding contour of the shape. In 2000, Bribiesca
(2000) proposed a chain code representation of three dimensional curves,
by computing the relative directional derivatives on a digitalized 3-D curve.
Kui Liu and Zalik (2005) applied Huffman coding (Huffman and Huffman,
1952) on top of chain coding, resulting in a shorter code, though considerations
towards handling holes within an object is absent. Various other related
derivatives (Merrill, 1973; Huo and Chen, 2005) of chain coding were proposed
and summarized (Sanchez-Cruz et al., 2007). Chain coding is translation
invariant because only the relative directional information on the transversal
of the curve is stored, but is not scale invariance.
84
5.3.1.2. Applications
Chain code and its derivatives are widely used as a base in shape representa-
tion because of its information preservation property while having substantial
reduction of data size. Martín-Landrove et al. (2007) reported successful
use of chain code based analysis in brain tumoral lesions diagnosis on T-2
weighted MRI images. Min and Choi (2006) employs a modified chain code
algorithm based on the vertex chain code (Bribiesca, 1999) in connecting
intersection points for contour extraction from 3D ultrasound volume of pipe-
shaped human organs. Shi and Mao (1995) suggested the use of chain code
in the classification of direction and curvature features on movement tracks
in frontal chewing patterns.
5.3.2. Fourier Descriptors
Fourier descriptors and its derivatives have been widely used to generate
unique shape signatures. Fourier descriptors are based on the discrete Fourier
transform (DFT), a specific form of Fourier analysis designed for discrete-time
signal in a finite domain. DFT is based on the Fourier transform which
transform a function x(t ) from the time domain to the frequency domain
defined as follows:

∞
F (w) = f (t )e −2πwi t d t (5.7)

−∞
where F (w) is the spectrum and w representing the frequency, f (t ) is the

signal over time t . The original signal f (t ) can be reconstructed from F (w) by
the inverse Fourier transform:

∞
f (t ) = F (w)e 2πw t d w (5.8)

−∞
With the inherent discrete-time nature of digital images or signals, DFT is

instead more widely employed in the field of digital signal processing. DFT
is a transformation of a function from the spatial domain to the frequency
domain.
85
5. Shape Analysis
Figure 5.2 on page 84 shows a K-point digital boundary in xy-plane. A full

transversal of the boundary yield a list of coordinate pair (x 0, y 0 ), (x 1 , y 1 ), (x 2 , y 2 ), . . . , (x K , y K ).
The coordinate pairs could be expressed in complex form as:
s(k) = x(k) + i y(k) x(k) = x k , y(k) = y k , k = 0, 1, 2, . . . , K − 1 (5.9)
The Discrete Fourier Transform of equation 5.9 is:
1 K−1
X (n) = s(k)e −i 2πnk/K n = 0, 1, 2, . . . , K − 1 (5.10)
K K =0
The complex coefficients X (n) are called the Fourier descriptors. The inverse
discrete Fourier transform is given by equation 5.11
K
−1
x(k) = X (n)e i 2πnk/K k = 0, 1, 2, . . . , K − 1 (5.11)
K =0
The inverse Fourier transform of equation 5.9 gives back the original s(k)
coefficients, as shown in equation 5.12.
K
−1
s(k) = a(n)e i 2πnk/K (5.12)
n=0
If only the first P coefficients instead of all K coefficients are used in the
inverse Fourier transform in equation 5.12, this will yield an approximation
of s(k), ŝ(k).
P
−1
ŝ(k) = a(n)e i 2πnk/K (5.13)
n=0
This approximation still contains the same number of coordinate points as the
original boundary, with the high frequency component filtered out. With higher
frequency components representing finer details of a shape, the procedure is
equivalent to filtering out the level of fine details defined by P . Figure 5.3 on
the facing page shows the increase in detail levels of the reconstructed shapes
using an increasing number of Fourier coefficients.
One of the desired properties of shape signature is to be as insensitive as

possible to various transformations that does not affect the shape boundary.
86
Figure 5.3.: Shape reconstruction with different number of Fourier coefficients.

P is the number of Fourier coefficients used.
Reproduced from Gonzalez and Woods (2002).
87
5. Shape Analysis
Transformation Shape boundary Fourier descriptor

Identity s(k) X (n)
Translation s(k) + x y X (n) + x y δ(n)
Rotation s(k)e i θ X (n)e i θ
Scaling αs(k) X (n)α
Table 5.1.: Effect of transformation in Fourier descriptor
However, the Fourier descriptors are not directly invariant to scale, rotation
and translation, but with the properties of Fourier transform, the changes of
the descriptor coefficients could be summarized in table 5.1. Rotation scale
all the Fourier coefficients by a constant term e i θ while scaling affects the
Fourier coefficients by a multiplicative factor of α. Translation of the shape
affects only the first coefficient X (0).
5.3.2.1. Applications
Fourier descriptors are a very versatile shape representation technique. Its

ability to represent a coarse to fine level of shape detail from the number of
Fourier coefficients makes it a very suitable candidate for content-based image
retrieval systems, where high efficiency can be achieved by eliminating large
amount of dissimilar candidates at coarse level, while finer level of details
could be matched with more Fourier coefficients taken into account. Fourier
descriptors and its derivatives are widely used in shape representation. In
the field of computer vision, Fourier descriptors hold an important role in
object recognition (Blumenkrans, 1991), due to its invariance under various
transformations. The use of Fourier descriptors combined with other disci-
plines, such as multi-resolution or multi-scale representations (Kunttu et al.,
2003), is designed, to better anticipate the human vision and recognition
ability. Widespread use (Antani et al., 2004; Palmer et al., 2004; Gregory
et al., 2004) of Fourier shape representation techniques are also noted in
the biomedical field. Younker and Ehrlich (1977) in 1977 has pointed out
the potential advantages of utilizing Fourier analysis for efficient measure-
ment in morphological variation within biological specimens. Schmittbuhl
et al. (2001) reported the use of elliptical Fourier analysis in demonstrating a
significant sexual dimorphism on the outline of the human mandible. Schmit-
tbuhl et al. further pointed out that the use of elliptical Fourier analysis
88
in shape representation delivers a higher discrimination power compared to

traditional metrical approaches. Ostermeier et al. (2001) employed a modified
Fourier function for the nuclei shape description of bovine sperm, reporting
0-5 harmonics are sufficient to define and distinguish the nuclei shape for
classification purpose. With many complex anatomic outlines not being able
to be effectively described by conventional anthropometric measurements,
the introduction of Fourier methods is often proven to be more functional
and powerful alternatives. Procedures in potential effective representation of
the morphological features in distal femur using elliptical Fourier methods
has been suggested by Minor and Schmittbuhl (1999) as a more accurate
mean for characterization purpose. The number of harmonics necessary for
sufficient shape representation varies depending on the outline complexity,
with a number of less than 10 generally considered sufficient to incorporate all
shape information, as in all above-mentioned studies. Considering in general
the number of shape vertices necessary in capturing a simple curved biological
shape is likely to be an order of magnitude higher, Fourier descriptors provide
shape representation and storage in a more efficient manner.
5.3.3. Hausdorff Distance
Hausdorff distance, named after Felix Hausdorff, is a classical correspondence

based technique to measure similarity between shapes by point-to-point match-
ing. Given two sets of boundary points A = {a1 , a 2 , . . . , a m } and B = {b1 , b 2 , . . . , bn },
the Hausdorff distance is defined as
H (A, B ) = max(h(A, B ), h(B, A)) (5.14)
where
h(A, B ) = max min ||a − b|| (5.15)

a
A b
B
where h(A, B ) is called the Hausdorff distance from A to B , and ||∗|| is the norm,
which is usually taken as the Euclidean distance. The Hausdorff distance is
thus the distance from a point a
A to its nearest neighboring point in B , in
which a is the point in A that is furthest away from any point in B. One major
drawback for the Hausdorff distance described above is its over-sensitivity to
89
5. Shape Analysis
noise, with which a single outlier point within the point sets of two similar
shapes will result in a large Hausdorff distance. To circumvent this, Rucklidge
(1997) proposed a modified Hausdorff distance
h f (A, B ) = f a
A
th
min ||a − b|| (5.16)
b
B
where instead of the maximum value, the f-th quantile value is chosen.
Comparing to most other shape representation techniques, the Hausdorff

distance has a relatively distinct advantage in which partial shape matching
could be achieved. However, it is in general not translation, rotation or scale
invariant, thus an exhaustive search of all Hausdorff distances with full
combination of positions, orientations or scales may be needed in the shape
matching procedures. This incurs very high computational requirements.
Rucklidge (1997) proposed a modified Hausdorff distance with higher efficiency
and is affine invariant, though the computational requirements are still
considerably high.
5.3.4. Corner Detector
Corner detection serves as a very important role in feature extraction (Koch

and Kashyap, 1985; Sun et al., 2004; Qin et al., 2006) in object description
and classification and various corner detectors(Harris, 1987; Kitchen and
Rosenfeld, 1982; Smith and Brady, 1997) have been proposed.
In general, most corners detectors (Harris, 1987; Kitchen and Rosenfeld, 1982;
Smith and Brady, 1997) works as follows (Figure 5.4 on the next page):
1. Application of a corner operator: With the input image as the source,

a corner operator with possibly several other pre-defined parameters is
applied to compute a cornerness measure of all pixels in the image. The
resulting output is a cornerness map having the same size as the image,
representing the likelihood of each pixel being a true corner based on
the corner operator defined.
2. Threshold of the cornerness map: Upon the computation of the cor-

nerness of every pixel, a threshold is always applied to filter out local
90
Figure 5.4.: Typical corner detector workflow

Reproduced from McGill Centre for Intelligent Machines.
maximas in the cornerness map. The goal is to eliminate all false cor-
ners which are shown as local maxima in the cornerness map, while
preserving as many true corners as possible. Nonetheless, the dilemma
is always present in the selection of an optimal threshold, to balance
between the number of false-positive fake corners and the number of
true corners detected.
3. Suppression of non-maxima: Upon the threshold on the cornerness map,

the final stage involves the marking of the corner points. Non-maximal
suppression is applied for all pixels, in which if the cornerness level is
not larger than that of its neighborhood, the pixel is discarded. The final
set of the resulting suppression is marked as corners.
5.3.4.1. Moravec Operator
Moravec (1977, 1979) proposed the concept of “points of interest”, defined as the
occurrence where intensity variations are large in all directions, by computing
the local auto-correlation in four directions and taking the lowest of the four.
91
5. Shape Analysis
Figure 5.5.: Intensity variation cases, Moravec (1977)

Reproduced from McGill Centre for Intelligent Machines.
A threshold was applied and any local non-maxima were suppressed. However,
because the goal of Moravec research was not in accurate identification of
corner position, but only to distinct regions in an image that enable registration
of consecutive image frames in order to navigate a Standford Cart through a
clustered environment. The proposed method is in general considered as a
more generalized one. Figure 5.5 shows the general idea of how the algorithm
is able to extract regions where the corners reside, where there is only a
small minimum intensity variation by shifting the window position (in red)
upon 4 directions at positions in cases A or B, while both positions in cases C
and D give a large intensity variations for all shifting directions, and thus
considered a “point of interest”.
5.3.4.2. Plessey Operator
Harris (1987) pointed out that the proposed algorithm is anisotropic because
only four auto-correlation directions were used, or in general only over a
discrete set of principle directions, and that the response could be noisy
and sensitive to strong edges due to the fact that the minimum of the auto-
correlation measurements were taken, but not truly the intensity variations as
originally proposed. A new operator was proposed (Harris and Stephens, 1988)
as an enhancement to address the limitations and it is commonly referenced
as the Harris operator or the Plessey operator.
The general idea of the Plessey operator is that the sum of difference between
two neighborhood Moravec windows can be a rough approximation of the
gradient and Harris and Stephens proposed the use of a simplified Prewitt
92
operator (Section 4.3.3.1 on page 47) to approximate the intensity variations

as shown in equation 5.17.
⎡ ⎤
−1 0 0 +1
⎢ ⎥
X : [ −1 0 +1 ]; Y : [ 0 ]; Di ag onal : ⎢
⎣ 0 0 0 ⎥
⎦ (5.17)
+1 −1 0 0
The intensity variations is then defined as
2
δI i δI i
Vu,v (x, y) = u +v (5.18)
∀i d e f i ned wi t h (x,y) cent r e δx δy
where δIδx
i
and δI
δy
i
are calculated with the simplified Prewitt operator in equa-
tion 5.17, and different u and v could be selected to denote intensity variations
along different directions. To further eliminate noise and to impose empha-
sis based on the Euclidean distance from the pixel to the window centre, a
Gaussian window w is additionally convoluted with V , and the results could
be simplified and expressed as

u
Vu,v (x, y) = u v M (5.19)
v

A C 2 2
δI δI δI δI
where M = , A= δx
⊗ w, B = δy
⊗ w, C = δx δy
⊗w
C B
The authors further pointed out that the eigenvalues of M , denoted by λ1 , λ2

can be categorized as shown in figure 5.6 on the following page.
To extract the final cornerness of each pixels, Harris and Stephens proposed
the following cornerness measure:
C (x, y) = d et (M ) − k(t r ace(M ))2 (5.20)
where d et (M ) = λ1 λ2 , t r ace(M ) = λ1 + λ2 and k is a constant.
Threshold and non-maximal suppression are then applied and the resulting
non-zero points are marked as final corners.
93
5. Shape Analysis
Figure 5.6.: Feature regions in eigenvalue space

Reproduced from McGill Centre for Intelligent Machines
5.3.4.3. Curvature Scale Space Detector
Mokhtarian and Suomela (1998a,b) proposed a corner detection method based

on the curvature scale space (CSS) which is more immune to noise and is
especially useful in retrieving invariant geometric features at multiple scales.
The CSS technique on a curve Γ parametrized by the arc length parameter u

could be expressed as
Γ(u) = (x(u), y(u)) (5.21)
Γσ , the evolved version of Γ is
Γσ = (X (u, σ), Y (u, σ)) (5.22)
where X (u, σ) = x(u)⊗ g (u, σ) and Y (u, σ) = y(u)⊗ g (u, σ), g (u, σ) denotes a Gaus-
sian with width σ (the scale parameter). The evolution of Γ gradually smooths
the curve with increasing simplification of the shape.
To obtain the zero-crossings of the curvature from different evolved versions

of Γ, the curvature could be expressed as:
Xu (u, σ)Yuu (u, σ) − Xuu (u, σ)Yu (u, σ)

K (u, σ) = (5.23)
(Xu (u, σ)2 + Yu (u, σ)2 )1.5
94
where
δ
Xu (u, σ) = δu (x(u) ⊗ g (u, σ)) = x(u) ⊗ g u (u, σ) and
2
δ
Xuu (u, σ) = δu 2 (x(u) ⊗ g (u, σ)) = x(u) ⊗ g uu (u, σ), and similarly
Yu (u, σ) = y(u) ⊗ g u (u, σ) and
Yuu (u, σ) = y(u) ⊗ g uu (u, σ).
The CSS corner detection could be briefly summarized as follows:
1. Apply the Canny edge detector to extract edges from input image.
2. Extract edge contours (gaps filling, T-junctions marking).
3. Compute curvature at σhi g h (highest scale) and mark corner candidates

(maxima above a predefined threshold).
4. Localize corner candidates via corners tracking in lowest scale.
5. Remove very close corners by comparing with the T-corners marked in

step 2.
While the CSS detector is robust with respect to image noise, He and Yung
(2004) pointed out the CSS fails to detect true corners when σhi g h is large and
prone to false-positives if σhi g h is small. An improved algorithm based on the
CSS was proposed, introducing an adaptive local threshold in the process of
local-maxima identification. This could eliminate points that are detected as
local maximum while having a small curvature difference within the region
of support, such as rounded corners. Another improvement suggested is the
additional criterion on the angle of corner. With the fact that a well-defined
corner should have a relatively sharp angle, false corners could be further
eliminated by computing the corner angle over its region of support, which is
defined as the corner candidate and its two adjacent corner candidates. The
process is iterated such that all corners fell under the criterion are eliminated.
Figure 5.7 on the next page shows a comparison of various corner detectors
on the table test image.
95
5. Shape Analysis
Figure 5.7.: Comparison of various corner detectors. Top left: The Moravec
operator. Top right: The Plessey operator. Bottom left: The CSS
operator. Bottom left: The modified CSS (He and Yung, 2004)
Reproduced from McGill Centre for Intelligent Machines, and He and Yung
(2004).
96
Anthropometric Analysis of the Femur
6
Contents
6.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.2. Reference Positions and Axes . . . . . . . . . . . . . . . . . . . 98
6.3. Anteversion Angle and Reference Axes . . . . . . . . . . . . 98
6.3.1. Physical Measurements . . . . . . . . . . . . . . . . . . . . 99
6.3.2. 2-D Imaging Techniques . . . . . . . . . . . . . . . . . . . . 101
6.3.3. 3-D Imaging Techniques . . . . . . . . . . . . . . . . . . . . 104
6.4. Proximal Measurements . . . . . . . . . . . . . . . . . . . . . . . 110
6.4.1. Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.4.2. Femoral Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.4.3. Canal Flare Index . . . . . . . . . . . . . . . . . . . . . . . . 114
6.5. Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.6. Distal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.1. Overview
nthropometric analysis of the femur involves gathering of geometric

A measurements based on a predefined set of reference landmarks. It is
an undeniable fact that the complex shape of the femur with variations, give
rise to many different interpretations on the reference landmark definitions
and analysis techniques.
Traditionally, anthropometric studies only involved physical measurements,

and osteometric tables were often employed with the femur being fitted to
97
6. Anthropometric Analysis of the Femur
a predefined reference position. Not surprisingly, anthropometric reference

landmarks were solely based on anatomical landmarks, which were mostly
surface landmarks, and estimations were often employed in cases where virtual
axes were involved. The introduction and widespread application of various
3-D imaging techniques (Section 3 on page 19) empower an improved revisit
utilizing various imaging techniques in the area, allowing many previously
impossible measurements as well as studies in vivo.
The following chapter summarizes various methods in the literature in an-

thropometric analysis of the femur, their design inspirations, strengths and
limitations.
6.2. Reference Positions and Axes
Axes or reference position definition plays a crucial role being the factor that
could significantly affect subsequent measurements. Traditional anthropo-
metric studies on femur (Kingsley and Olmsted, 1948; Dunlap et al., 1953;
Ryder and Crane, 1953), dating back to early 1900s (Parsons, 1914), used
osteometric table and similar devices as a physical platform for anthropometric
studies extensively. Their physical devices and specific reference positioning
of the femur were often defined to facilitate the measurement of a few specific
parameters. Kingsley and Olmsted, 1948 defined the reference position of the
bone as that of resting on a smooth horizontal surface, touching the posterior
aspect of the two condyles and the posterior aspect of the greater trochanter.
6.3. Anteversion Angle and Reference Axes
The version angle, or anteversion angle is one of the most studied parameters
in anthropometric studies of the femur in all time (Croce et al., 1999). From
a reference position definition point of view, the parameter provides a very
good ground for discussion with the fact that this single parameter involves
the definition of the three major axes in the femur, namely the longitudinal
or long axis, the neck axis and the distal transverse axis.
98
6.3.1. Physical Measurements
Traditional anthropometric studies (Parsons, 1914; Kingsley and Olmsted,

1948) utilizing osteometric table or similar devices often make use of the
fact that the posterior aspect of a femur lies on a horizontal surface in a
stable equilibrium position with 3 points in contact: the medial and lateral
posterior condyles, and the posterior aspect of the greater trochanter. Initially
mentioned by Parsons (1914), the femur was laid on a flat surface on its
posterior surface with 3 points contact; a hole was drilled and knitting needle
was placed in the internal condyle of the femur parallel to the lying surface.
The neck axis was defined by drilling with a bradawl from the fovea capitis
along the neck axis such that it would come out of the shaft just below the
greater trochanter, midway between anterior and posterior aspect of the
trochanter.
The concept was better documented and refined by Kingsley and Olmsted
(1948), with which the reference position, axes definitions and its derivatives
became one of the most widely used bases in anthropometric studies where
physical measurements were made (Lausten et al., 1989; Kim et al., 2000a;
Jain et al., 2003).
While Kingsley and Olmsted (1948) did not state the exact distal transverse
axis definition, its method of anteversion determination implied the use of
the posterior condyle axis as the distal transverse axis, which is defined as
the posterior tangential line touching the posterior aspect of the two condyles.
With the femur lying at its reference position, the long axis being employed
is parallel to the horizontal surface, and aligned with the direction of the
shaft in an AP view. Kingsley and Olmsted further defined the neck axis
based on two points, which is the two mid-points between two sets of points
extracted from the anterior and posterior surfaces along the neck axis, under
a superior transversal view (Figure 6.1 on the next page). The anteversion
angle was measured as the angle between the neck axis and the posterior
condyles axis, in the transversal plane along the long axis of the femur
(Figure 6.2 on the following page). However, the authors pointed out this
method may not be able to accurate measure retroverted femur samples, with
which the proximal supporting points with the flat horizontal surface shifted
from the greater trochanter region to the head region. To cater the problem,
small smooth blocks were placed beneath the supporting points to elevate the
entire platform, but it was noted that the natural supporting point could still
99
Figure 6.1.: Kingsley’s neck axis definition. Left: posterior point. Middle:
anterior point. Right: mid-point.
Reproduced from Kingsley and Olmsted (1948).
Figure 6.2.: Kingsley’s anteversion measurement.

Reproduced from Kingsley and Olmsted (1948).
occasionally be shifted to the lesser trochanter.
Yoshioka et al. (1987) reported the use of different axes on an osteometric

table. Instead of taking the femoral shaft as the long axis, the long axis
was constructed by joining the head centre and the attachment point of the
posterior cruciate ligament (PCL). The longitudinal axis definition is one of the
commonly used mechanical axes (Walmsley, 1933) of the femur in a vertical
standing posture. The transverse functional axis was defined as a line through
the landmark of the PCL passing through the condyles and parallel to the two
epicondylar points. Though different from the commonly employed transverse
axis based on the posterior articulated surface, the authors reasoned that the
suggested definition would permit a separate analysis on the axial rotation of
the distal and proximal aspect of the femur. With the transverse axis defined
based on the posterior articulated surface of the distal femur, the two angles
100
Figure 6.3.: Anteversion calculation based on the longitudinal functional axis.

C: head centre; N: mid-point of the anterior and posterior surfaces
of the neck region.
Reproduced from Yoshioka et al. (1987).
would be aggregated into a single measurement.
With the reference coordinate system based on functional axes, Yoshioka et al.
further reported the discrepancy in anteversion definition (Figure 6.3) and
the measurements obtained. In another study (Yoshioka and Cooke, 1987),
the authors pointed out the transepicondylar axis (TEA) has in general less
geometric variations when compared to the posterior condylar axis, and thus
would serve as a better alternative definition of the transverse axis.
6.3.2. 2-D Imaging Techniques
Rogers (1931) is one of the first researchers in utilizing fluoroscopy in deter-

mining the anteversion angle in vivo. He stated that the angle of version
could be measured under a PA fluoroscopic view by externally rotating the
femur until the shadow of the femoral head aligns to the shaft axis. The
proposed orientation ensures the neck axis is in the direction of the rays,
pointing downwards under a superior transversal view and the anteversion
is the angle between the tibia and the fluoroscopic bed (Figure 6.4 on the
following page).
Ryder and Crane (1953) pointed out the abduction of the femur could sig-
nificantly magnify the measured anteversion. Ryder and Crane proposed
a method based on two X-ray projections in two orientations. The angle of
inclination was calculated based on an AP X-ray while the projected antever-
sion was measured on an X-ray with the hip and knee under 90◦ flexion and
the femur under 30◦ abduction. To obtain the true anteversion, Ryder and
101
Figure 6.4.: Anteversion measured on fluoroscopic bed.

Reproduced from Rogers (1931).
Crane pre-computed a set of graphs (Figure 6.5 on the next page) mapping
the projected anteversion angle to the real anteversion angle under different
angles of inclination.
Dunlap et al. (1953) proposed an anteversion discovery technique similar

to Ryder and Crane (1953), with which one AP X-ray and one lateral X-ray
were taken after aligning the patient with 90◦ flexion of the hip and knee.
A set of graphs similar to figure 6.5 on the facing page was pre-computed
based on trigonometric formula to map the measured torsion angle to the
real anteversion angle. One of the significances in Dunlap et al. study is the
analysis on the anterior bowing effect towards the anteversion measurement.
The authors pointed out that the ignorance of anterior bowing of the femur
would lead to under-estimation of the anteversion angle with extra flexion on
the hip joint. A 12◦ under-estimation in anteversion angle was observed in a
case with extreme anterior bowing. The authors further suggested the need
of adjustments such that the long axis bisects the greater trochanter and
passes through the proximal one fourth of the femur for correct evaluation of
the anteversion angle, as illustrated in figure 6.6 on page 104.
While the method compensates for the anteversion magnification due to

femoral abduction, Ryder and Crane (1953) pointed out the method is still
subject to two main sources of error: an inaccurate patient positioning when
the X-rays are performed; and inaccurate location of the axes on the X-rays
102
Figure 6.5.: Relationship of true and projected anteversion under different

inclination angle.
Reproduced from Ryder and Crane (1953).
films. The authors made an estimation of a maximum of ±10o of error from

the true anteversion angle, but stated that the occurrence of this worse case
scenario should be rare.
Evaluation of rotational alignment from the epicondylar axis during knee

arthroplasty was also studied (Berger et al., 1993). Berger et al. suggested
the use of epicondylar axis as an alternative anatomic axis for rotational
measurement of the femoral component when the posterior condylar axis
cannot be used, and reported high consistence of ±1.2◦ when compared to that
with the posterior condyle axis. It was reported that the mean angle between
the posterior condyle axis and the suggested epicondylar axis is 3.5◦ for male
and 0.3◦ for female. There is one discrepancy between the epicondylar axis
definition and that defined by Yoshioka et al. (1987). Berger et al. defined the
surgical epicondylar axis (SEA) as the vector connecting the lateral epicondylar
prominence and the medial sulcus below the medial epicondyle while Yoshioka
et al. employed the definition with which the medial and lateral prominence
of the epicondyles were selected.
Nevertheless, Kinzel et al. (2005) reported the surgical identification of the

SEA to be error prone. Stout pins were inserted to the entry points of the
SEA on 74 knees and only 70% were found to be within 3◦ of the true SEA
determined by post-operative CT scans. It was suggested that the error could
be attributed to the visual mis-perception by the overall directional alignment
103
Figure 6.6.: Effect of anterior bowing on anteversion angle determination.

Left: The long axis defined does not bisect but passes over the
anterior aspect of the greater trochanter, with an extra 12◦ flexion
from the right angle. Right: the adjusted axis bisecting the
greater trochanter, and passing through the proximal one fourth
of the femur.
Reproduced from Dunlap et al. (1953).
of the intra-operative epicondylar pins, while only the entry point should be
considered theoretically.
6.3.3. 3-D Imaging Techniques
The above-mentioned studies are either based on physical measurements on

cadavers or 2-D imaging techniques. With the availability of 3-D imaging
techniques, anthropometric studies are more often performed in 3-D digital
images, which not only provide a better flexibility, but permit more sophisti-
cated and possibly accurate analysis to be performed. Kim and Kim (1997)
pointed out the accuracy of using 2-D imaging techniques such as X-rays in
anteversion determination had always been adversely affected by the mal-
positioning of patients with inexact abduction. Inaccurate hip flexion and
rotation would lead to additional error in inclination angle determination.
The difficulties in selecting reproducible anatomical landmarks on 2-D images
introduce further error in the process. Høiseth et al. (1988) reported the
radially asymmetric property of the femoral neck, and further concluded the
impossibility to precisely evaluate the neck centre by any combination of
bi-plane projections of the neck.
104
Figure 6.7.: Neck axis determination from a single cross section. A: Head
centre; B: mid-point between the anterior and posterior surfaces
of the neck.
Reproduced from Murphy et al. (1987).
Weiner et al. (1978) documented the application of CT in anthropometric

study and reported the use of CT allowed a visual portrayal of the neck axis
to be superimposed on the distal transverse axis for direct measurement of
the anteversion angle. Comparison to previous 2-D imaging techniques with
special and complicated positioning devices also reviewed the simplicity of the
method.
Hernandez et al. (1981) reported similar findings on the advantages of utilizing

CT for anteversion determination. Distal fixation on the ankle was achieved
by a foot-board with the patient in a supine position. The longitudinal
axis is effectively the functional axis though the authors did not define it
specifically. The commonly employed posterior condyle axis was defined as the
transverse axis. With the fact that the axial CT scans intersected the neck
region in an oblique way, the neck axis was evaluated on a single CT section
(Figure 6.7). Similarly, Weiner et al. (1978) employed a similar method in
neck axis definition.
Murphy et al. (1987) compared various methods in axes definition and pointed
out the deficiency of the neck axis definition on a single cross-section (Weiner
et al., 1978; Hernandez et al., 1981). A two dimensional cross-section should
not be used in determination of the neck axis, which is a three dimensional
attribute. It is reported that the above method underestimated the anteversion
angle by about 10◦ when compared to their physical measurement method
(Billing, 1954). The author suggested an improvement of incorporating an
extra CT cross-section. The head centre was determined on one cross-section,
and the other endpoint was selected as the centroid of the femoral diaphysis
105
Figure 6.8.: Centroid (O) point at the base of the femoral neck.
on a cross-section at the base of the neck (Figure 6.8).
Murphy et al. (1987) further compared 4 commonly employed definitions on

the transverse axis; the traditional tabletop method, the TEA (Figure 6.9 on
the facing page), area centres determined by estimation of the centres of the
medial and lateral condyles visually, and a angle bisector line constructed
based on the anterior and posterior tangential lines (Figure 6.10 on the
next page). It was reported that all four methods described introduce small
errors into the determination of the anteversion angle when compared to
the physical measurements, with which the centroid method (method C in
figure 6.10 on the facing page) produced highest consistence, seconded by the
tabletop method. With clinical relevance added into considerations, it was
suggested the tabletop method delivered the best combinations of simplicity
and reproducibility.
Construction of 3-D models based on the acquired CT scan for anthropometric

analysis was also noted (Abel et al., 1994; Miura et al., 1998). Abel et al. (1994)
reported the use of reconstructed model based on CT images in quantitative
assessment on the femoral and acetabular anteversion. The authors pointed
out the construction of a 3-D model allowed visual rotation in all three
reference planes, and thus could minimize positional error.
Kim and Kim (1997) documented a more well-defined and systematic approach
in extracting anthropometric data from CT data. The longitudinal axis was
defined as a 3-D least-square best-fit line on centroids computed from the
axial CT images over the entire shaft portion of the femur. The centre of the
neck was determined by selection of an arbitrary point N0 on the neck surface
and creation of a variable 3-D plane passing through N0 . Iterations were
performed to minimize the cross-sectional area of the 3-D plane under free
rotation under the constraint of passing through N0 . The femoral neck centre
was defined as the centroid point of the resulting 3-D plane and the the neck
axis was constructed as a vector passing though the head and neck centre
106
Figure 6.9.: Distal transverse axis definitions. Left: The tabletop method.
Right: The TEA.
Figure 6.10.: Distal transverse axis definitions. Left: Area centres of the
condyles defined visually. Right: Bisector of angle between the
anterior and posterior tangential lines.
107
coordinates. The posterior condyle axis was selected as the transverse axis.
An iterative procedure was designed to adjust the position of the medial and
lateral condylar contact points until a tangential line contacting the condyles
were achieved.
Similar studies to the above mentioned were performed (Kim et al., 2000a,b).
Extra comparisons were done between the proposed method and the 2-D CT
method used by previous studies (Hernandez et al., 1981; Murphy et al., 1987;
Weiner et al., 1978) in axes and anteversion angle determination. While the
simplified method based on some cross-sectional CT images was proven to
have acceptable accuracy, the proposed 3-D processing would give even closer
figures compared to the physical measurements.
Mahaisavariya et al. (2002) further enhanced the use of CT images and utilized
various reverse engineering software to reconstruct a point cloud model of
the femur for anthropometric analysis. Best-fit functions were applied in
determination of the femoral head centre, and the neck axis was defined
based on an iterative approach in minimizing cross-sectional area of the neck
isthmus. Various additional parameters were measured, including the femoral
head height, mid-shaft isthmus location. One significance of this study is the
measurement of the level of anterior bowing of the femoral shaft in terms
of a bow angle across the shaft isthmus. Various researches (Egol et al.,
2004; Harma et al., 2005) reported the mismatch between the anterior bow
curvature and that of the intramedullary nails, which could lead to iatrogenic
fractures (Gausepohl et al., 2002), or anterior distal femoral cortex penetration
(Ostrum and Levy, 2005).
Apart from the abovementioned transverse axis definitions in the determina-

tion of distal femoral rotation and anteversion angle, other studies (Whiteside
and Arima, 1995; Won et al., 2007) have suggested the use of additional distal
axes as a secondary rotational reference.
With an increasing focus on the precision in TKR with computer-assisted

surgery, reference distal femoral axes are constantly being employed for
accurate rotational alignment of the femoral prosthesis. This is important
for correct patella tracking and ensures a correct varus-valgus positioning
in knee flexion. While the SEA were often used, its inaccuracy in knee
with valgus deformity was observed (Anouchi et al., 1993). Whiteside and
Arima (1995) evaluated the use of the anteroposterior axis (Figure 6.11 on the
next page) of the distal femur as the reference axis for rotational alignment
108
Figure 6.11.: Determination of the trochlear line for rotational reference. Left:
The most anterior point of the lateral ridge was marked. Middle:
the most anterior point of the medial ridge was marked, and
the lateral point projected to the same slice. Right: the final
trochlear line (TL); surgical epicondylar axis (SEA); Whiteside’s
line (AP); posterior condylar axis (PCA).
Reproduced from Won et al. (2007).
of the femoral component in valgus knees and reported less occurrence of

patella tracking problem when compared to that using the traditional posterior
condyle axis clinically. Arima et al. (1995) reported a similar findings in which
the Whiteside line served as a more accurate axis for rotational evaluation
in valgus knee. However, various studies (Middleton and Palmer, 2007;
Won et al., 2007) have pointed out that while the Whiteside line performed
better in a valgus knee, its variations would be too large to be employed as
the principle rotational reference. Middleton and Palmer (2007) observed a
variation of Whiteside line measurements having a standard deviation of 4.7◦
when compared to SEA, and suggested the Whiteside line alone should not
be used alone as the axis for rotational alignment.
Won et al. (2007) examined the possibility of utilizing the trochlear line as an
alternative reference axis for femoral rotation in total knee replacement (TKR).
While the use of the SEA in anthropometric studies was well-studied and
proved to be robust, the authors pointed out the need to establish other axes
because of the reported difficulty in precisely locating the sulcus of the medial
epicondylar during surgery (Griffin et al., 2000). The use of the trochlear line
(Figure 6.11) to reference the SEA was shown to have similar variability when
compared to that of the Whiteside’s line (Whiteside and Arima, 1995) or the
posterior condylar axis (Figure 6.11). It was suggested that the trochlear line
may be considered as an additional reference axis for evaluation of femoral
rotational alignment in TKR apart from the posterior condylar line.
109
While X-rays and CT images are still one of the most common imaging
techniques in 3-D anthropometric analysis, other imaging modalities such as
ultrasound were also being used. Moulton and Upadhyay (1982) reported the
use of ultrasound for anteversion determination and the authors concluded
that ultrasound was not able to deliver a very clear picture for accurate
anteversion computation. However, it was further suggested that the ionizing
radiation involved in CT scans may be too invasive for general anthropometric
analysis. Lausten et al. (1989) reported similar findings, further adding
that ultrasound did not correspond well with the physical measurements of
anteversion angle, but CT showed a good correlation with measurements on
cadavers.
6.4. Proximal Measurements
This section aims to give a brief summary on the methodology and findings
of previous anthropometric studies. Note, however, that because of a wide
variation of the definitions of some anthropometric parameters, caution should
be taken in direct comparison on the measured results across different studies.
6.4.1. Femoral Head
The femoral head is generally considered a sphere-like structure and its radius
is used comprehensively for parametrization. Its measurement method could
be categorized into two groups, physical measurements using calipers; and
digital measurement on X-rays or 3-D imaging modalities such as CT.
With the use of caliper, Dwight (1905) reported a mean head diameter of 43.84
mm female, 49.68 mm over 200 American Caucasian sample each, spotting
a gender difference of 5.84 mm. Parsons (1914) reported similar figures on
the English femurs, with a mean of 49 mm for male and 43.4 mm for female,
with the slightly lower values possibly due to absence of cartilage in the
measurements. The authors further reported the right side has an average
radius of 2 mm higher than that of the left in female. Noble et al. (1988)
reported an average head diameter of 46.1 mm on 200 American cadavers, in
which the figure agrees with the averages mentioned above.
110
Mahaisavariya et al. (2002) performed 108 head diameter measurements on

the Thai population head by means of a 3 dimensional sphere fitting function
on segmented CT point cloud, reporting an average diameter of 43.98 mm,
2.08 mm lower then Caucasian figures reported by Noble et al. (1988).
Noble et al. (1988) also reported an average femoral offset to the femoral axis
to be 43 mm ranging between 23.6 mm to 61.0 mm with a standard deviation
of 6.8 mm, indicating possibly a wide variation of proximal femoral geometry
even within the Caucasian population.
6.4.2. Femoral Neck
The femoral neck has always been a popular area of interest in anthropometric
studies, mainly associated with a large number of femoral neck fracture.
Boufous et al. (2004) reported a total of more than 5000 neck fracture incident
in New South Wales (Australia) in 2000, based on the Inpatient Statistics
Collection covering all inpatient separations from acute-care hospitals aged
50 and above. Comparison of the data with previous years further revealed
41.2% and 31.2% incident increase in male and female population (Figure 6.12
on the following page), though the age-adjusted data remained practically
unchanged.
The femoral neck shaft angle of a healthy individual has a range from around
100◦ to 150◦ . Noble et al. (1988) reported an average angle of 124.7◦ and most
other studies (Yoshioka et al., 1987; Rubin et al., 1992; Leung et al., 1996;
Mahaisavariya et al., 2002; Gnudi et al., 2002; Zebaze et al., 2005) have
reported a similar average ranged between 122◦ − 130◦ .
El-Kaissi et al. (2005) analyzed DXA output of 62 post-menopause Canadian

Caucasian women with hip fracture, with 608 age-matched controls, and
concluded that the fracture group has a wider neck width and a reduced
cortical thickness, further pointing out the fracture risk is influenced by BMC,
neck width, medial cortical thickness of the femoral shaft. Similar studies
(Gómez Alonso et al., 2000; Gnudi et al., 2002; Bergot et al., 2002) based on
DXA, or its derivative hip structural analysis, also confirmed BMD, and in
general, proximal femoral geometry are closely associated with neck fracture
risk.
111
Figure 6.12.: Number of hospital admission for hip fracture in New South
Wales, Australia, 1990–2000.
Reproduced from Boufous et al. (2004).
While DXA is still the gold-standard in evaluation of BMD, together with hip
strength analysis (HSA, Martin and Burr, 1984) procedures delivering addi-
tional geometric parameters, the evaluation of 3-D geometric measurements
from a 2-D DXA are prone to unavoidable rotational, magnification errors
Beck (2003); Gregory et al. (2004). BMD measurements are also reported
(Goh et al., 1995) to vary significantly in rotational misalignment.
In a study (Noble et al., 2003) to quantify the anthropometric difference be-

tween dysplastic and healthy individuals among Japanese population using
CT, it was pointed out rotational orientation could severely affect anteversion,
and canal width under standard AP X-rays examination. In dysplastic femur,
the anteversion and minimum canal width over the isthmus would be overes-
timated, in which the authors reasoned this as the cause why surgeons tend
to favor the use of undersized cemented prosthesis, which allows a greater
flexibility intraoperatively.
Kolta et al. (2005) evaluated the feasibility of potentially employing stereo-

radiographic 3-D reconstruction algorithm (Bras et al., 2004) from two planner
DXA images with a generic proximal femur model. The authors reported a
very high degree of precision (mean error = 0.8 mm, 95% of errors < 2.1 mm)
112
to the CT-based reconstructed model in vitro. While the proposed technique

has great potential given its low radiographic dosage and cost comparing to
other 3-D modalities, parameters extracted from the DXA-derived model, and
its robustness in vivo are yet to be examined.
Similar analysis has also been studied using other imaging modalities. Manske
et al. (2006) evaluated the use of MRI in correlating cortical bone in the femoral
neck region with failure load on simulated sideways fall, reporting association
between failure load and cortical cross-sectional area as well as second area
moment of inertia.
QCT is also an emerging technology due to its ability to deliver true volumetric
BMD instead of areal BMD as in DXA. The correlation between DXA and QCT
has been found to be highly significant (Masala et al., 2003; Link et al., 2004).
Significant correlation has also been reported (Link et al., 2004) between QCT
and conventional spiral CT, allowing the possibility of BMD evaluation with
routine spiral CT with the application of a conversion factor. The additional
3-D information from QCT has also allowed finite element analysis to be
performed Faulkner et al. (1991a). However, it has to be noted that the
effective radiation dosage of a QCT examination is significant higher when
compared to that of DXA Faulkner et al. (1991b).
Cheng et al. (1997a) reported QCT and DXA had a similar ability to predict
femoral strength in vitro, though several small-scaled studies (Cheng et al.,
1997a; Bousson et al., 2006) showed that the combination of the QCT and
DXA model did not deliver significantly improved prediction accuracy towards
hip fracture risk and densitometric parameters remained the most significant
individual parameter. Large-scale comparison on the effectiveness of QCT in
fracture prediction is still to be examined.
Notwithstanding, conclusion in the application of ultrasound in the prediction

of proximal femoral strength and fracture risk varies. It is known that
relationship exists between density and ultrasound propagation through bone
(Kang and Speller, 1998; McCloskey et al., 1990; Agren et al., 1991; Tavakoli
and Evans, 1991). It has been hypothesized that ultrasound measurements
may deliver additional information towards the trabecular orientation and
micro-structure (Glüer et al., 1993; Nicholson et al., 1994). Most studies (Glüer
et al., 1993; Schott et al., 1995; Turner et al., 1995; Lochmüller et al., 1998)
have reported ultrasound has comparable as well as independent predictive
ability towards hip fracture risk. Nevertheless, numerous studies (Baran
113
Figure 6.13.: The Canal Flare Index is a geometric ratio to describe the shape
of the proximal femoral canal.
Reproduced from Noble et al. (1988).
et al., 1991; Faulkner et al., 1994; Nicholson et al., 1997) also suggested only
low to moderate correlation exists between ultrasound measurements and
BMD.
Various studies (Tian et al., 2003; Gregory et al., 2004; Chen et al., 2005) have
attempted to automate part of the parameter extraction process. Tian et al.
(2003) developed an automated method in neck shaft angle computation from
planar X-rays images for osteoporotic fracture screening. The authors reported
a 94% accuracy of fracture classification based on the neck shaft angle among
their testing dataset. (Gregory et al., 2004; Chen et al., 2005) also reported
success in automatic proximal femoral contour extraction based on active
shape contour (the snake algorithm, Kass et al., 1988), while limitations of
the algorithms on pathological and odd cases exist.
6.4.3. Canal Flare Index
The Canal Flare Index (CFI), defined by Noble et al. (1988) as a single
geometric index in categorizing the proximal femoral canal shape. The CFI is
defined as the ratio of the intra-cortical width of the femur, at the section 20
mm proximal to the lesser trochanter and at the section of the canal isthmus
as shown in figure 6.13. Three categories were defined, with CFI less than
3.0 defined as stovepipe canals, CFI between 3.0 and 4.7 as normal canals,
114
Figure 6.14.: Distribution of the Canal Flare Index over the 3 categories, CFI
< 3.0: Stovepipe; 3.0<CFI<4.7: Normal; CFI > 4.7: Champagne-
fluted.
and CFI of 4.7 or above as champagne-fluted canals. Figure 6.14 shows the
CFI distribution reported by Noble et al. (1988).
Several derivatives of the CFI exist. Laine et al. (2000) suggested the meta-
physeal canal flare index, defined as the ratio between the medio-lateral
width of the femoral canal at the level 20 mm proximal and 20 mm distal
to the lesser trochanter. It was proposed that the metaphyseal CFI would
deliver a more specific description on the metaphyseal dimension, and thus
enable a closer fit to especially newer generations of cementless femoral stem
for better osseo-integration and stress transfer at the metaphyseal region.
Similar indices were proposed by Husmann et al. (1997) to measure the flare
at the metaphyseal region and a similar distribution was observed between
the two studies.
Another derivative of the CFI suggested by Laine et al. (2000) is the neck-
oriented CFI, which is defined as the ratio between the longest oblique dimen-
sion at the level 20 mm proximal to the lesser trochanter and the isthmus
width.
The cortical index was proposed by Dorr et al. (1990) based on the femoral
score in an osteoporosis study (Barnett and Nordin, 1960). It is defined as
the ratio between the sum of medial and lateral cortical thickness and the
femoral endosteal diameter, at 100 mm below the lesser trochanter. A high
115
Figure 6.15.: Algorithm proposed by Fessy et al. on the choice of femoral

implant based on CFI (C.M.I.) and cortical index (F.F.I.).
Reproduced from Fessy et al. (1997).
cortical index implies thick cortices. Gruen (1997) measured the cortical index
on pre-operative radiographs of 110 THR patients and reported a moderate
correlation between the index and body mass index, age, weight, in which
significant higher indices were observed in the degenerative group than the
fracture group, leading to a conclusion that the cortical index provides an
indication of bone quality.
Fessy et al. (1997) reported the anatomical basis for the choice of femoral
implant in THR and reported both the CFI and cortical index serves an impor-
tant role in the determination if a custom implant is preferable (Figure 6.15).
The authors further pointed out the benefits of the utilizing ratio instead of
absolute measurements as a effective solution to the inherent deficiency of
undesirable magnification in radiographic films.
116
6.5. Femoral Shaft
Figure 6.16.: Datum points along the anterior and posterior wall of the
medullary canal for anterior bow curvature evaluation.
Reproduced from Harper and Carson (1987).
6.5. Femoral Shaft
One of the most distinguish features on the femoral shaft is its anterior
bowing. With the use of intramedullary nails being the current gold standard
(Harper and Carson, 1987; Harma et al., 2005) in diaphyseal femoral fracture,
many studies have been surrounding the goodness of fit between nails design
and actual femoral shaft morphology.
Harper and Carson (1987) evaluated the anterior curvature of 14 adult cadaver
femora on lateral radiograph by fitting a curve to 20 datum points defined
along the anterior and posterior wall of the medullary canal. The authors
reported an average radius of curvature of 111.4 cm with a range from 68.9
cm to 188.5 cm. Comparison were made with 4 brands of intramedullary
rods and it was noted that the radius of curvature of 3 out of 4 rods (2 with
Kuntscher design and one with Grosse-Kempf design) fell above the observed
curvature in the femora. Similar findings were reported by other researchers
(Egol et al., 2004; Harma et al., 2005; Ostrum and Levy, 2005).
The authors pointed out the curvature mismatch between intramedullary

rods and the medullary canal could possibly lead to iatrogenic comminution
(Christie and Court-Brown, 1988; Simonian et al., 1994; Apivatthakakul and
Arpornchayanon, 2001) during insertion. Rod deformation during insertion
would result in inaccuracy in alignment devices for distal interlocking screws
117
Figure 6.17.: Evaluation of anterior bowing with plain digital photography.

Reproduced from Egol et al. (2004).
placement. Impingement of the nail into medial and anterior cortices has
also been reported in the Chinese population Leung et al. (1996).
It was also suggested that the most appropriate site for proximal access of
the intramedullary rod is the junction of the femoral neck and the greater
trochanter slightly anterior to or in the pyriformis recess, which is easily
identifiable clinically. This could prevent additional stress on superior femoral
neck. Similar entry point suggestion was also made by Gausepohl et al. (2002).
Numerous studies (Egol et al., 2004; Ostrum and Levy, 2005) confirmed the
curvature mismatch between medullary canal and current intramedullary
rods. Complications such as anterior distal femoral cortex penetration (Ostrum
and Levy, 2005) were also reported.
Mahaisavariya et al. (2002) quantified the bowing by fitting circle over the
femoral canal cross-sections, with the shaft isthmus defined as the section
with the smallest circle diameter. Two straight lines were fitted to the derived
circle centres proximal and distal to the shaft isthmus respectively and the
the acute angle between the two constructed lines was defined as the bow
angle. The average bow angle reported by the method over 108 Thai cadaveric
femora is 5.75◦ .
Egol et al. (2004) studied 892 femurs from two museums in New York and
118
6.6. Distal
Figure 6.18.: Instant centre of rotation of the knee on the sagittal plane.

Two points A 1 and B 1 are displaced to A 1 and B 1 respectively.
The intersection of the perpendicular bisectors of the two lines

connecting A 1 A 1 and B 1 B 1 is defined as the centre of rotation.
Reproduced from Frankel et al. (1971).
Ohio (USA) by means of plain digital photography. Three lines were drawn,
with the first immediately below the lesser trochanter, the second immediately
above the flare of the of the distal condyles and the third one defined as the
mid-point between the former two (Figure 6.17 on the facing page). Circle
fitting was performed based on the 3 extracted coordinates to evaluate the
anterior curvature. An average radius of curvature of 120 cm was reported,
with a range from 56 cm to 326 cm. While no relationship between anterior
curvature and age was found, it was found that blacks had a larger radius
of curvature than whites, which confirms with other literature (Ballard and
Trudell, 1999). Contrary to Egol et al. findings, Harma et al. (2005) reported
high correlation (r = −0.234, p < 0.017) between age and anterior medullary
curvature in female Anatolia population only, which was not reported by other
similar studies.
6.6. Distal
The major structure of the distal femur is the medial and lateral condyles
that articulate with the tibia, and analysis of the distal femur is often linked
to kinematics study of the knee joint.
Traditional analysis of knee kinematics on the sagittal plane uses the method
of instantaneous centres of rotation (Frankel et al., 1971; Walker et al., 1972;
Blankevoort et al., 1990), in which the centres are reported to move within
the knee flexion cycle. This implies that there is no single axis of rotation of
119
Figure 6.19.: The optimal knee flexion axis.

Reproduced from Churchill et al. (1998).
the knee. However, the above model does not take into account any out of
plane motion during the knee flexion cycle and is reported to introduce error
in out of plane movements Panjabi et al. (1982).
More recent studies (Jonsson and Kärrholm, 1994; Sheehan, 2007) employed
the helical axis method, an extension to the instantaneous centre of rotation
to three dimensions. It was reported that the knee undergoes translations
during flexion cycle, and was concluded that the knee does not rotate about
any fixed axis. However, Elias et al. (1990) pointed out the fact that the
posterior aspect of the femoral condyles are circular in shape in the sagittal
view. It was also reported that from 10◦ to 150◦ knee flexion, the tibia rotates
around the circular posterior condyles with a radius of curvature of 21mm.
The centre line of rotation was observed to pass through the attachment
region of the medial and lateral collateral ligaments, suggesting the existence
of a fixed centre of rotation.
Hollister et al. (1993) further suggested the kinematics of the knee can be
modeled as rotations across two fixed axes, where the flexion-extension axis
passes through the medial and lateral collateral ligaments and superior to
the crossing points between the anterior and posterior cruciate ligaments.
The longitudinal axis is roughly parallel to the long axis of the tibia. It was
concluded that motion due to each of the two axes contributes to varus-valgus,
internal and external rotation as neither they are mutually orthogonal, nor
they align to the coronal or sagittal plane.
Further investigation was performed by Churchill et al. (1998) in an attempt

to confirm the model proposed by Hollister et al. (1993) and to search for
120
6.6. Distal
Figure 6.20.: The knee joint centre (filled circle) defined by projecting the mid-
point (circle) of the transepicondylar axis (dots) to the optimal
flexion axis (A).
Reproduced from Hagemeister et al. (2005).
the optimal flexion axis of the knee. 15 cadaveric knees were studied in a
simulated load-bearing environment and the optimal flexion and longitudinal
rotational axes were identified successfully in all specimens. Additional
analysis revealed the optimal flexion axes of all specimens coincide with the
centre of best-fit circles (Figure 6.19 on the preceding page) of the posterior
condyles when viewed along the evaluated optimal flexion axis. The mean
distance on the medial and lateral side is 2.8 mm (±1.2 mm) and 3.1 mm
(±1.8 mm). It was also reported the location and orientation of the anatomical
transepicondylar axis closely matches the optimal flexion axis. In the medial
plane, the epicondylar point was in average 0.2 mm (std dev = 2.4 mm) and
0.14 mm (std dev = 2.7 mm) posterior and distal to the optimal flexion axis
respectively. The lateral epicondyle point to flexion axis is similar but slightly
more distal. An average of 2.9◦ of angular difference between the TEA and
the optimal flexion axis was observed.
Churchill et al. (1998) study further confirmed a close relationship between

morphology of the distal femur and knee kinematics, in which functional
geometric measurements provide an accurate mean of evaluating bone mor-
phology.
Various definitions of the knee joint centre has also been proposed (Holden
and Stanhope, 1998; Hagemeister et al., 2005). The mid-point of the femoral
epicondyles were one of the simplest and common way of knee joint centre
definition (Li et al., 2004; Holmberg and Lanshammar, 2006; Stefanyshyn
et al., 2006).
Hagemeister et al. (2005) defined the knee joint centre based on the optimal
flexion axis method (Churchill et al., 1998). The mid point of the transepi-
121
condylar axis was evaluated and projected on the computed optimal flexion
axis as shown in figure 6.20 on the preceding page. The authors further
pointed out that the definition of the knee joint centre on the optimal flex-
ion axis is more repeatable when compared to taking the mid-point of the
transepicondylar axis.
The use of functional methods (Croce et al., 1999; Stagni et al., 2000; Besier
et al., 2003; Hagemeister et al., 2005) instead of pure anatomical landmarks
in determination of joint centres have been praised. Initially employed by
Cappozzo (1984) in the use of femoral head centre as a functional landmark,
various researchers (Croce et al., 1999; Besier et al., 2003) have suggested
the use of functional methods as an effective way to reduce variability and
dependency on the accurate location of anatomical landmarks. Croce et al.
(1999) further addressed the difficulties associated with accurate location
of anatomical landmarks with the fact most anatomical landmarks are not
discrete points but relatively large and curved areas and thus their determi-
nation by means of palpation or other means is more susceptible to intra and
inter-rater variability.
122
Methods
7
Contents
7.1. Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.2. Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.3. Anthropometric Parameter Extraction . . . . . . . . . . . . 125
7.3.1. Model Alignment . . . . . . . . . . . . . . . . . . . . . . . . . 126
7.3.2. Trochanters . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.3.3. Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.3.4. Distal Posterior Condyles . . . . . . . . . . . . . . . . . . . 139
7.3.5. Neck Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
7.3.6. Anteversion Angle . . . . . . . . . . . . . . . . . . . . . . . . 149
7.3.7. Trochlear Groove . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.3.8. Bow Curvature . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.3.9. Misc Parameters . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.3.10. Section Properties . . . . . . . . . . . . . . . . . . . . . . . . 154
7.4. Verification & Testing . . . . . . . . . . . . . . . . . . . . . . . . 155
7.4.1. Inter-rater Variation in Segmentation . . . . . . . . . . . 155
7.4.2. Intra-rater Variation in Segmentation . . . . . . . . . . . 155
7.4.3. Variation on CT Voxel Size . . . . . . . . . . . . . . . . . . 155
7.4.4. Reference Axes . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.4.5. Effect on Posterior Condyles Range Variation . . . . . . 156
7.4.6. Variation on Anteversion . . . . . . . . . . . . . . . . . . . . 157
7.4.7. Verification using 3-D model . . . . . . . . . . . . . . . . . 157
7.5. Anthropometric Studies . . . . . . . . . . . . . . . . . . . . . . . 158
7.5.1. Human Femoral CT . . . . . . . . . . . . . . . . . . . . . . . 160
7.5.2. Sheep Femoral CT . . . . . . . . . . . . . . . . . . . . . . . . 161
123
7. Methods
Figure 7.1.: Amira (Visage Imaging, Inc., Carlsbad, USA) is used for seg-
mentation of the CT stacks.
7.1. Acquisition
T images were acquired following the default acquisition settings sug-

C gested by the radiologist. Details on the settings are included in ap-
pendix C on page 247.
7.2. Segmentation
Amira (Visage Imaging, Inc., Carlsbad, USA, figure 7.1) was used as the
primary software for the image segmentation process. CT images in DICOM
format were imported into Amira. Two label fields were created for the
segmentation of all bone, and cancellous bone region respectively. Primary and
secondary thresholds were chosen depending on several criteria: histogram
analysis of several cross-sections around the lesser trochanter region and bone
type. Several samples of each bone type with similar scanning parameters
were imported to Mimics (Materialize, Inc., Leuven, Belgium, figure 7.2 on
the next page) and profile lines (Figure 7.3 on page 126) were drawn across the
cross-sectional slices around the lesser trochanter and femoral neck regions
for evaluation of a suitable base threshold that includes the cortical region but
not under-segmenting its neighborhood. The determined base thresholds were
124
7.3. Anthropometric Parameter Extraction
Figure 7.2.: Mimics (Materialize, Inc., Leuven, Belgium).
used as a reference for the particular bone and scan type. Minor adjustments
to the base threshold values were applied to several samples due to a lower
average of HU values.
While the base threshold values usually suffice in segmenting a large portion
of the femur, the femoral head, neck and the regions distal to the epicondylar
axis are prone to over-segmentation due to the relatively lower HU values
compared to the rest of the femur. Extra region growing procedure was applied
locally in Amira to ensure the inclusion of the entire femur. The fovia capitis,
which is the attachment point of the ligament teres, is mostly cartilaginous
and thus has a relatively lower contrast with surrounding tissues under
CT. Thus, the fovia capitis was included as part of the bone region with as
estimated convex hull applied on the local region. Volume smoothing with
a 3 × 3 × 3 cubic window was applied to the label fields. The two segmented
label fields were then exported, resulting in two stacks of binary image mask
stored in DICOM format. Note that both the in-plane spatial resolution and
the slice thickness were preserved.
This section aims to provide the detailed procedure of the methodology of the
parameter extraction stage. One of the main design goals of the methodology
is to eliminate as much subjective user interactions as possible, delivering
consistent and accurate anthropometric parameters. For verification, testing
125
7. Methods
Figure 7.3.: Profile lines across the lesser trochanter region for base threshold
value evaluation. In cases where an optimal threshold cannot be
chosen, the reference is chosen to avoid over-segmentation when
possible.
and application, the proposed methodology was implemented in MATLAB

(Mathworks Inc., MA, USA), a numerical processing environment for algorithm
development.
Minimal user interactions exist mostly in confirmations during the initial

estimation phase to ensure a sensible automatic initial estimation is fed
into the programme for further fine-tuning. Minor user interactions were
introduced in some steps designed as a fall-back procedure when the auto-
mated subroutines fail. For user interactions which involve higher level of
subjectivity, extra measures were taken to minimize the effect of intra-rater
and inter-rater subjectivity on the final outcome.
For simplicity reason, the procedure discussed in subsequent subsections is

fully-automated routines, unless otherwise specified.
7.3.1. Model Alignment
The two exported DICOM binary image stacks from the preceding step were
loaded into the program. Bone orientation was detected and confirmed by
users and the image stacks were cropped to the minimum bounding box
containing the entire femur, and were flipped to a proximal starting position
along the z-axis and anterior-posterior along the y-axis.
126
Figure 7.4.: The MATLAB development environment running on Gentoo

Linux .
7.3.1.1. Lesser Trochanter
The lesser trochanter, defined as the pyramidal prominence at the proximal

and posterioral-medial aspect of the femur was identified in two stages. The
first stage computes an estimation of the rough lesser trochanter position
while the second computes a more accurate estimation based on the former
result.
The distal posterior condylar axis was first estimated to provide a rough
rotational reference of the femur with the method as described in figure 7.16
on page 140. The angular orientation of the posterio-medial direction was
defined based on the estimated condylar axis by externally rotating the axis
by 45◦ . A mask M having a gradient towards the posterio-medial direction
was generated (Figure 7.5a on the following page) and applied to each cross-
section. The posterioral-medial coordinates (PMC ) of each cross-section BW
were extracted starting from the mid-shaft slice transversing proximally. The
red cross on figure 7.5b on the next page shows the the position of PMC on a
single cross-section. The procedure on a single slice could be denoted by
PMC = {(x, y)|M (x, y) = max(M ⊗ BW )} (7.1)
127
7. Methods
PMC
(a) An example of the image mask(b) The most posterio-medial coordi-

M for the extraction of the most nates of a slice (PMC ) with its value
posterio-medial coordinates of each taken as the pixel value of the
cross-section. masked cross-section.
Figure 7.5.: Extraction of PMC for initial lesser trochanter LT1 estimation.
LT1 = {(x, y)|M (x, y) = max(M (PMC ))} (7.2)

l ocal
where PMC is the coordinates values, M is the generated mask, and BW is

the original cross-sectional binary image. For simplicity reason, only the first
coordinates were chosen for each slice if more than one point satisfied the
above criterion. The pixel values of the PMC coordinates were then analyzed
starting from the mid-shaft as a series, with the first local maximum chosen
to be the first lesser trochanter estimation (LT1 ).
Note from figure 7.6 on the facing page that the initial estimation LT1 may
not be sufficiently accurate due to the position variations during the image
acquisition stage. With variations in patient positioning and anthropometric
variations, the true lesser trochanter position is likely to be deviated from the
local maximum of the posterioral-medial coordinates. Refinement of LT1 was
achieved by calculating the distance from the femoral axis to the perimeter of
the slices. A temporary femoral axis (F A LT ) was constructed by computing a
least-square best fit line to the centroids extracted from 10mm distal of LT1 to
30mm distal of LT1 . Slice range ±5mm of the LT1 was selected and perimeter
points ({PMC2}) furthest away from the F A LT for each slice was computed as
shown in figure 7.7 on the next page. An extra criterion is set up such that
PMC 2 is limited to the posterioral-medial quadrant of each slice to further
128
Figure 7.6.: The initial estimation of the lesser trochanter LT1 (blue) from the
candidate list {PMC } (red).
FALT
PMC2
Figure 7.7.: Second estimation of the lesser trochanter based on LT1 . The
furthest coordinates of the image perimeter from the femoral axis
(F A LT ) of each cross-section was taken as the PMC2 in the second
estimation of the lesser trochanter position.
129
7. Methods
ensure the selected candidates would be in a close proximity to LT1 . The

operation on a single cross-section could be expressed as
PMC2 = {(x, y)| BW (x, y) = max(|perim(BW ) − femoral axis|)} (7.3)
where perim(M ) is the perimeter of the image. The datum point with the
maximum distance; LT0 = max({PMC2}) to the femoral axis was picked as the
final lesser trochanter point.
7.3.1.2. Proximal Femoral Axis
Centroid coordinates of cross-sections slices from 20mm proximal to 80mm

distal to LT0 were computed. The proximal femoral axis (FA 0 ) is defined as the
least-square best-fit line of the centroid coordinates computed in the preceding
step. Singular value decomposition was employed in determining the best-fit
line. The decomposition of an m × 3 matrix A containing the list of centroid
coordinates of the proximal cross-sections could be decomposed to the form
below:
A = U SV T (7.4)
where the columns of U contains the eigenvectors of A A T . U is an m × m

matrix, S is an m × 3 matrix containing the singular values of A , and the rows
of V T contains the eigenvectors of A T A . The matrix U and V are called the
left and right singular vectors of A . The best fit vector is the right singular
vector of A with the smallest singular value.
7.3.1.3. Transepicondylar Axis
The anatomical transepicondylar axis (TEA , also commonly known as the

epicondylar axis) is defined as the two most prominent points medially and
laterally in the epicondylar region. The axis definition requires perfect posi-
tioning of the patient, which is practically unachievable. To determine the
epicondylar axis without a perfect positioning, slices around the epicondylar
region were flattened to produce a binary image BWE A as shown in figure 7.8 on
130
{Lτ =3(BWEA )}
{LN =6(BWEA)}
EL
Figure 7.8.: Shape outlines on the flattened image. Two sets of line segments
were constructed to estimate the shape outline. {L τ=3 (BWper i m )}
(red), {L N =6 (BWper i m )} (blue), and the final epicondylar point
(green).
the facing page. Coordinates of the image perimeter BWper i m were extracted,
connected straight line segments were fitted to provide an estimation of the
shape outline with the procedure as follows:
• Starting from an arbitrary perimeter coordinates, the endpoint of a

straight line segment are transversed along the perimeter points cov-
ering as many coordinates points as possible, limited by the maximum
deviation off the covered perimeter segment, defined by the tolerance τ.
• A new line segment is created from the endpoint of the preceding line
segment and the process repeats until the entire list of perimeter coordi-
nates are transversed.
Two sets of line segments were created (Figure 7.8 on page 131), {L τ=3 (BWper i m )}
with tolerance of 3 pixels, and {L N =6 (BWper i m )} with number of line segments
equal to 6. L N =6 (BWper i m ) was generated with tolerance parameter τ increased
until the shape could be estimated by 6 segments.
Figure 7.9 on page 132 shows the predefined template {L T } comprising 6

points. {L T } was scaled and translated to approximately match the size of the
131
7. Methods
{LT }
Figure 7.9.: Shape template {L T } for orientation matching.
foreground object in BWE A . The Hungarian method (Section 4.6.1 on page 77)
was then applied to map coordinates points between {L T } and {L N =6 (BWper i m )}
(blue line segments in figure 7.8 on the preceding page) minimizing the
allocation resources, defined as the Euclidean distance between the allocation
pairs. The template prevents mis-identification of the epicondylar points in
cases of severe rotation of the femur during image acquisition.
Automated identification of the epicondylar points {E M , E L } in {L N =6 (BWper i m )}

was achieved by retrieving the mapped coordinates corresponding to the
template coordinates. The epicondylar points {E M , E L } were then further refined
by determining the closest datum points within {L τ=3 (BWper i m )} (Figure 7.8 on
the previous page). The relevant z-coordinates of {E M , E L } were also retrieved.
While the abovementioned method is robust in identifying the correct epi-

condylar points, minor errors were encountered in some cases where the local
epicondylar region is edgy. A dialog was used to confirm the selection accuracy
and a fallback selection method was employed if insufficient accuracy was
indicated by the user. List of corners datum points of BWper i m were identified
(Figure 7.10 on the facing page) based on the method proposed by He and
Yung (2004) explained as follows:
1. A binary edge map is obtained using the Canny edge detector and the
edge contours are extracted with gaps filled. In our case where the
binary image BWE A comprises of a single region with no holes (Euler
number equals to one) is used, this is equivalent to taking the perimeter
of the image.
2. The curvature of the contour is computed at a low scale such that all
true corners are retained.
132
Figure 7.10.: Fallback TEA evaluation routine by corner (blue) detection. The
figure shows the result of the corner detection with high sensitiv-
ity. The sensitivity of the corner sub-routine could be lowered to
eliminate false corners and to reduce the number of candidates.
3. All local maxima of the curvature are taken as initial corner candidates,
and rounded corners and false corners resulting from boundary noise
are excluded from the candidate list.
7.3.1.4. Affine Transformation
The standardized coordinates system is defined as follows:
• The proximal femoral axis FA 0 defined in section 7.3.1.2 on page 130 is
aligned such that it is parallel to the new z-axis, which is the long axis
of the new model
0 defined
• The model is rotated axially such that the epicondylar axis TEA
in section 7.3.1.3 on page 130 is parallel to the x-axis
Figure 7.11 on the next page shows an illustration of the 3 reference axes in
the standardized coordinates system. The direction of the 3 reference axes
Vx , Vy , Vz of the coordinates system could be denoted by
133
7. Methods
Figure 7.11.: The reference coordinate system. The proximal femoral axis (FA )
is taken as the longitudinal reference axis and the epicondylar
) is taken as the transverse axis for rotational reference.
axis (TEA
⎧
⎪
⎪Vx : 0 − n ∗ FA 0
⎪
⎪ TEA
⎨
Vy : −(Vx × Vz ) (7.5)
⎪
⎪
⎪
⎪
⎩Vz : FA 0
where n is the scaling factor such that Vx is orthogonal to FA 0 and passes
0 , denoted by
through TEA
0 FA 0
TEA
n= (7.6)
|FA 0 |2
Vy is defined as the vector cross product of Vx and Vz and negatively signed to
conform to the right-handed Cartesian coordinates system, as illustrated in
figure 7.12 on the facing page.
The transformation matrix of the scaling operation on CT with anisotropic

voxels is given by
⎡ ⎤
pixel width 0 0 0
⎢ ⎥
⎢ pixel height 0 ⎥
⎢ 0 0 ⎥
Ts = ⎢ ⎥ (7.7)
⎢ 0 0 slice thickness 0 ⎥
⎣ ⎦
0 0 0 1
134
Figure 7.12.: Axial view of the reference axes
The rotational transformation matrix could be expressed as
⎡ ⎤
[ Vx ] 0
⎢ ⎥
⎢ [ V 0 ⎥
⎢ y ]⎥
T = inv(T s ) ∗ ⎢ ⎥ ∗ Ts (7.8)
⎢ [ Vz ] 0 ⎥
⎣ ⎦
0 0 0 1
where inv(T s ) is the matrix inverse of T s . In practice the transformation matrix

T is transposed in MATLAB because column vectors instead of row vectors
were used. Additional translation and cropping were applied to the rotated
model such that the entire femur is contained in the smallest bounding box.
Upon aligning the model to the standardized coordinates system, the same
transformation was applied to the lesser trochanter, proximal femoral axis,
and the epicondylar axis.
LT = T ∗ LT0 (7.9)
FA = T ∗ FA 0 (7.10)
= T ∗ TEA
TEA 0 (7.11)
where LT , FA , TEA

are the transformed lesser trochanter, femoral axis and
trans-epicondylar axis respectively.
135
7. Methods
Figure 7.13.: The trochanters (LT and GT ) re-evaluated after model alignment.
For simplicity reasons, the notation BW (n)|n ∈ Z+ is used to denote the n-

th cross-sectional slice of the transformed binary image stack beginning
proximally and BW is used to denote the entire image stack onwards in the
discussion below.
7.3.2. Trochanters
The lesser trochanter point LT was re-evaluated after transformation to the

new coordinates system to further eliminate errors introduced due to the
arbitrary positioning of the femur in the original CT scans. Same algorithms
were applied as described in section 7.3.1.1 on page 127.
Coordinates of the most proximal point of the greater trochanter region were
automatically extracted by analyzing the proximal regions of the femur. The
greater trochanter region was identified by region growing techniques from
BW (0) to BW (k) where k is chosen as the most distal slice in BW just before
the greater trochanter and the head region merge. The head region was
identified as the medial region and the proximal tip of the greater trochanter
region was extracted and denoted by GT as shown in figure 7.13.
7.3.3. Femoral Head
To automate the process, the femoral head centre (HC ) was evaluated in two
stages. The first stage involves a coarse estimation of the head centre based
136
(a) Datum points used for initial estimation (b) Initial estimation of the fitted sphere.
(blue).
Figure 7.14.: Initial estimation of the femoral head centre. First best-fit sphere
(right) estimation of the femoral head based on the proximal
head region (blue).
on the partial contours of the proximal femoral head region. With the greater
trochanter region eliminated based on 3-D region growing from the datum
point GT , edge points of the proximal head region were extracted as shown
in figure 7.14 where h is the height of the head measured from the trough
point between the head and greater trochanter region. The base level of the
trough point was measured by searching for the first slice where the greater
trochanter and the head region merged. A sphere was fitted to the partial
contours in a least-square sense resulting in the first estimation of the femoral
head centre HC 0 and head radius HR 0 .
Based on the HC 0 and HR 0 , additional surface points were extracted as shown

in figure 7.15 on the following page, with extra medial part of the head included.
The least-square best-fit sphere to the refined point set was computed and its
radius HR and centre coordinates HC were taken as the final estimation of
the femoral head radius and centre respectively. Two offsets measurements
of the head centre were made; the femoral axis offset measures the distance
between the head centre to the femoral axis on the transverse plane; and the
vertical offset to the lesser trochanter.
137
7. Methods
(a) Inclusion of additional datum points for(b) The second estimation of the fitted sphere.
the second estimation of the femoral head
centre.
Figure 7.15.: Final estimation of the best-fit sphere based on additional datum
points.
138
7.3.4. Distal Posterior Condyles
Manual selections were made by the user specifying the starting and ending
slices. The slice range was selected such that the femoral condyles below or
posterior to the intercondylar fossa were included.
7.3.4.1. Tangential Line Extraction
For each slice k , the posterior tangential line touching the medial and lateral
condyles were computed and the two touching coordinates were extracted
as the datum points which represents the most prominent points of the two
condyles.
To extract the two datum points (CO med (k) & CO l at (k)) for slice k , a convex hull
C onvex(BW (k)) and the difference BW (k) − C onvex(BW (k)) was computed as
shown in figure 7.16 on the next page. Centroid of the posterior notch region
C not ch (k) (Figure 7.16b on the following page) around the intercondylar fossa
was calculated and used as a reference datum point. CO med (k) and CO l at (k)
were defined as the closest convex hull polygon coordinates to C not ch (k) medially
and laterally respectively (Figure 7.16c on the next page).
7.3.4.2. Cylinder Fitting
A cylinder was then fitted to the set of datum points {CO}.
{CO} = {CO med ,CO l at }
The Lorentzian minimization function was employed as the error function.

The original Lorentzian function (Figure 7.17 on the following page) is given
by:
1
1 2Γ
L(x) = (7.12)
π (x − x 0 )2 + ( 12 Γ)2
where x 0 is the centre and Γ specifies the width at its half maximum. The
Lorentzian minimization function can be simplified as:
error = ln(1 + x 2 ) (7.13)
139
7. Methods
BW (k) BW (k) ∩ Convex(BW (k))
Cnotch(k)
(a) Convex hull C onvex(BW (k)) of BW (k). (b) BW (k) − C onvex(BW (k)). C not ch (k) is
taken as the centroid point of the pos-
terior notch region.
C Olat(k)
C Omed(k)
(c) Final posterior condylar line of BW (k)

(green). This is equivalent to the tan-
gential line touching the medial and
lateral condyles.
Figure 7.16.: Extraction of the posterior condylar line by morphological opera-

tions.
1
1
1
0.8 y= Γ
π (x−x0 )2 +( Γ 2
2)
0.6
y
0.4
Γ=2,x0=0
0.2
0
−5 0 5
x
Figure 7.17.: The Lorentzian function.
140
y=log(1+x2)
4
y
1
0
−6 −4 −2 0 2 4 6
x
Figure 7.18.: The Lorentzian minimization function estimated using a log

function.
which is symmetric and is zero when x = 0, as shown in figure 7.18. The

Lorentzian function is robust in rejecting outliers with minimal effect on the
final fit, and is thus very effective in minimizing error due to datum points
at the posterior extreme of the condyle edges. . Figure 7.19 on the following
page shows the final cylinder fit with axis PCCYL vec and radius PCCYL r .
7.3.4.3. Posterior Condylar Axis
) is defined as the the two datum points on the

The posterior condylar axis (CA
posterior lateral and medial condyles touching the tangential plane parallel
to FA . With the use of CA
being only a determination of the axial rotation,
simplification is made to ignore the evaluation of the z-coordinates of the axis.
The method employed is similar to that shown in figure 7.16 on the preceding
page. Slices in the distal femur region were flattened producing an inferior
view and a convex hull was fitted. The posterior condylar axis is the closest
posterior medial and lateral convex hull coordinates to the inter-condylar notch
(Figure 7.16 on the facing page). This is equivalent to the anatomical posterior
condylar axis. Note that the term posterior is not necessarily equivalent to the
most posterior coordinates of the two condyles under the current coordinates
system where TEA is taken as the transverse axis. The TEA is usually not
and thus the most posterior points of the medial and lateral
parallel to the CA
condyles may not necessarily coincide with the condylar axis. Instead, the
posterior condylar axis should more clearly be expressed as the tangential
line touching the two condyles posteriorly in an inferior view of the femur.
141
7. Methods
Figure 7.19.: Cylinder (PCCYL ) fitted to the posterior condyles using the
Lorentzian minimization function.
7.3.4.4. Knee Centre
A plane orthogonal to PCCYL vec was created with equal mean distance to the
lateral (CO l at ) and medial (CO med ) datum points on the condyles. The knee
centre KC is defined as the point of the distal intersection between the plane
and the distal articular surface as shown in figure 7.20 on the next page.
7.3.5. Neck Region
Analysis in the neck region was done in two stages, reslice of the image stack
and extraction of parameters.
7.3.5.1. Reslice
The neck region was resliced such that the cross-sections intersect the long
axis of the neck orthogonally, or equivalently aligning the true neck axis with
the z-axis. Neck axis evaluation can be divided into two steps, an initial
estimation of the neck axis based on existing landmarks, and optimization of
the first estimation based on the neck surface point cloud extracted from the
first step.
142
Figure 7.20.: The knee centre (KC ) is defined as the intersection between the
cylinder PCCYL and the distal femoral articular surface
Figure 7.21.: Initial estimation of the neck axis based on femoral head centre
HC and NB .
143
7. Methods
NBS K
Figure 7.22.: Flattened PA view of the femur. NB SK was evaluated by mor-

phological skeletonization followed by detection of intersections
(blue) in the skeleton. The intersection at the neck base (red
cross) superior to the lesser trochanter intersection was taken
as NB SK for the initial estimation of the neck axis.
Two coordinates were chosen as the initial neck axis vector (Figure 7.21 on
the preceding page), the femoral head centre ( HC ) and virtual datum point
NB (NB x , N B y , N B z ) at the base of the femoral neck, as defined below.
A posterior-anterior view (x-z plane) was generated as shown in figure 7.22.

The reason for adopting a posterior-anterior (PA) view instead of a more
commonly used anterior-posterior (AP) view is to avoid extra flipping of
the existing coordinates system and has no effect on the final outcome. A
morphological skeletonization described in section 4.30 on page 74 was applied
to create a skeleton image as shown in figure 7.22 in white. All proximal
intersections (blue dots in figure 7.22), defined as pixels connected to more
than 2 skeletal paths, were identified. The intersection coordinates NB SK at
the neck base was extracted, denoted by the second intersection tracing the
144
(NBx , NBy )
Figure 7.23.: Thinning operation on the axial slice corresponding to NB SK . The

green dotted line shows the possible candidates of NB SK described
in figure 7.22 on the preceding page. The first intersection
between the dotted line and the thinned skeleton was taken as
NB .
skeletal path proximally from the mid-shaft section, or equivalently the first
intersection tracing the skeletal path proximally after the lesser trochanter
region. The extracted point NB SK is shown in red in figure 7.22 on the
preceding page and (N B x , N B z ) was taken as the x-y coordinates of NB SK .
To obtain the y-coordinate NB y of NB , morphological thinning, as explained in

section 4.5.5 on page 70 , was applied to the axial slice corresponding to NB SK ,
as illustrated in figure 7.23. The coordinates of the first intersection between
the thinned path and the NB SK locus and was computed and the datum point
is taken as NB .
The vector N B − HC was selected as the initial estimation of the neck axis
0 ). NECK 0 (Figure 7.24 on the following page) was resliced and cropped
(NA
from BW as follows:
NECK 0 = T N 1 ∗ BW (7.14)
where T N 1 is the affine transformation matrix based on the initial neck axis
145
7. Methods
(a) The neck region NECK 0 after first esti- (b) The final neck axis NA is defined as the
mation. Evaluation of the final neck long axis of the fitted cylinder.
) with cylindrical fitting. NA
axis (NA 0
is the initial neck axis estimation.
Figure 7.24.: First and final neck axis estimation with cylinder fit.
0.
estimation NA
Two methods were designed in the second estimation of the neck axis. The
first method involved a cylinder fitting routine to represent the resliced neck
region with a cylinder under optimal orientation and dimensions. Figure 7.24
shows the rotated and cropped neck region with a cylinder fitted to the neck
region in a least-square sense, and the axis of the fitted cylinder is shown in
blue. An alternative second method involved computing the geometric centre
points (centroid) of all cross-sections in NECK 0 and fitting a 3-D line to all the
centroids in a least square sense by the use of singular value decomposition
as described in section 7.3.1.2 on page 130. The axis evaluated was defined as
the final neck axis (NA ). An affine transformation matrix T N 2 was constructed
for the conversion from NA 0 to NA
.
Upon defining the final neck axis, BW was rotated and cropped by applying
the transformation matrix T N 2 ∗ T N 1 ,
NECK = T N 2 ∗ T N 1 ∗ BW (7.15)
resulting in the final resliced neck region as shown in figure 7.25. With the
146
40
30
20
10
0 140
100 120
80
60 100
. Note the appearance

Figure 7.25.: Point cloud of the final NECK based on NA
the greater trochanter at the top of the reslice neck. This was
eliminated in the first estimation of the neck axis.
fact that the final neck axis may not necessary coincide with the head centre

( HC ), an extra datum point NA st ar t was constructed as the point on the NA
which is closest to HC .
7.3.5.2. Parameter Extraction
,
Measurements in the neck region were based on the defined neck axis NA
and are summarized as follows (Figure 7.26 on the following page):
• Neck length to femoral axis (NL F A )
• Neck length to greater trochanter (NLGT )
• Neck angle (∠NAF A )
to HC (NAHC )
• Distance from NA
on F A (NAF A , figure 7.27 on the next page)

• Elevation of the NA
The resliced stack (NECK ) now provides a true cross-sectional geometry of the
neck region. A list of parameters were extracted for each of the cross-sectional
slice, namely
• Cross-sectional Area
• Eccentricity ε = ac
147
7. Methods
Figure 7.26.: Anthropometric measurements based on the neck axis NA and

femoral axis FA . NLGT is the neck length from NA st ar t to the
lateral aspect of the trochanter along the neck axis. NL F A is the
neck length measured from NA st ar t to the femoral axis. ∠NAF A
is the neck shaft angle. Note that the point NA st ar t lies on the
femoral neck axis but may not coincide with the femoral head
centre (HC ).
Figure 7.27.: Elevation of the neck axis (NAF A ) is defined as the anterior
displacement of the femoral neck axis with reference to the
femoral axis.
148
(a) Anteversion angles based on the femoral

.
neck axis NA
(b) Anteversion angles based on the axis

A defined by the femoral head cen-
HCF
tre (HC ) and the femoral axis (FA ).
Figure 7.28.: Axes for anteversion angle measurements.

• Area moment of inertia I x y = x yd A

• Polar moment of inertia J x = r 2 d A
Details of the definition and representation of the above properties are dis-
cussed in section 5.2 on page 79.
7.3.6. Anteversion Angle
With the model already aligned with the epicondylar axis and the proximal
femoral axis, the anteversion angle, defined as the internal axial rotation
of the femoral neck relative to distal transverse axis was computed. Under
various definitions of anteversion across different axes combinations, the
angles measured could be summarized as follows:
149
7. Methods
TEA)
• ∠(NA,
CA)
• ∠(NA,
A joining the femoral head centre ( HC ) to the proximal

An additional axis HCF
femoral axis FA was constructed, and the torsion angles between HCF A and
the distal transverse axes (epicondylar axis TEA , condylar axis CA ) were
calculated.
A, TEA)
• ∠(HCF
A, CA)
• ∠(HCF
CA)
2 extra angles between the distal transverse axes (∠(TEA, ) and proximal
A, NA)
axes (∠(HCF ) were also measured for later comparison.
7.3.7. Trochlear Groove
Located at the distal femur, the trochlear groove is a depression on the

patellar surface and articulates with the two posteriorly articulated facets of
the patellar. The following analysis is to extract the position of the groove,
which is the saddle and the coordinates of the medial and lateral ridges on
the edge of patella surface.
Manual selections were made by the user on the slice range in which the
trochlear groove region located.
Each image within the selected region was analyzed and the groove and ridges
coordinates extracted. A convex hull C (BW ) was fitted and the coordinates
of the convex hull were identified as shown in figure 7.29a on the next page
in blue. The original image was then subtracted from the convex image,
denoted by BW − C (BW ), as shown in figure . Upon removal of small islands,
the centroid coordinates C not ch (k) of the top-most region were identified. A
vertical offset was added to shift C not ch (k) to C not ch (k) for more reliable ridge
points evaluation. The two coordinates of the ridges (RI med & RI l at ) were
defined as the closest convex hull points on the medial and lateral side of
C not ch (k) (Figure 7.29a on the facing page). This is equivalent to the contact
points of the tangential line over the trochlear groove.
Upon identification of the ridges on the trochlear groove, a tangential line

was computed passing through the datum points RI med and RI l at . The trough
150
Cnotch(k)
RIlat(k) RIlat(k)
RImed(k) RImed(k)
Cnotch(k)
TR(k)
C onvex(BW (k))
(a) Extraction of the tangential line touch-(b) Groove point on the cross-section
ing the medial (RI l at (k)) and lateral BW (k).
(RI med (k)) trochlear ridges from the
convex hull (C onvex(BW (k))).
Figure 7.29.: Trochlear groove extraction.
point TR(k) was defined as the coordinates on the trough perimeter furthest
from the tangential line (Figure 7.29b).
Three datum points were extracted from each image within the user-selected
range, resulting in three sets of datum points, {RI med }, {RI l at }, {TR}.
A plane P TR was then constructed fitting on the set {TR} as shown in figure 7.30
on the following page. The angle between the plane and the femoral axis (FA )
on the coronal plane was measured as the trochlear groove angle (∠TR ).
7.3.8. Bow Curvature
The anterior bow is defined as the anterior curvature of the medullary canal
along the femoral shaft (Section 6.5 on page 117). Centroid coordinates of the
each femoral canal cross-sections were computed from the lesser trochanter
to 100mm proximal to the distal femur. The centroid points could roughly be
estimated as an arc in the sagittal view. A circle was fitted to the centroid
coordinates (Figure 7.31 on the following page) in a least-square manner and
the centre coordinates and the radius of curvature were used as an estimation
on the anterior bow curvature in later analysis.
151
7. Methods
Figure 7.30.: A plane P TR was fitted to the trochlear groove.
Figure 7.31.: Anterior bow curvature.
152
7.3.9. Misc Parameters
A list of extra geometric properties or anthropometric parameters was ex-

tracted based on the landmarks coordinates obtained in previous sections.
7.3.9.1. Greater Trochanter Height
The greater trochanter height (GTH ) is defined as the vertical distance between
the most proximal point (GT ) of the greater trochanter and the trough between
the greater trochanter and the neck base region as shown in figure 7.14a on
page 137 denoted by the label h .
7.3.9.2. Femoral Head Offset
The femoral head offset is defined as the antero-medial shift of the femoral
head centre (HC ) from the proximal femoral axis on the transverse plane.
7.3.9.3. Length
A number of length measurements were recorded. The FLGT −KC is the distance
in millimeter between the proximal tip of the greater trochanter (GT ) to the
knee centre (KC ). FL HC −KC is the distance in millimeter between the femoral
head centre ( HC ) to the knee centre (KC ).
An additional 2 measurements were made based on the mechanical axis.

Di st HC −T E A and Di st LT −T E A measure the perpendicular distance from the epi-
condylar axis TEA to head centre ( HC ) and lesser trochanter (LT ) respectively.
7.3.9.4. Canal Flare Index
The classic canal flare index (CFI ml ) is defined as the ratio between the medio-
lateral width of the femoral canal at the level 20mm proximal to the lesser
trochanter to that of the femoral isthmus. Likewise, the anterio-posterior
canal flare index (CFI ap ) is defined as the anterio-posterior width of the femoral
canal at the above femoral sites.
153
7. Methods
Figure 7.32.: The use of nearest site Voronoi diagram in the computation of
the greatest inscribed circle.
Two derivatives of the original canal flare index were computed (Laine et al.,
2000). The metaphyseal canal flare index (CFI met aph y seal ) which is defined as
the ratio between the medio-lateral width of the femoral canal at the level 20
mm proximal and 20 mm distal to the lesser trochanter. The neck-oriented
canal flare index (CFI obl i que ) is defined as the ratio between the longest oblique
dimension at the level 20 mm proximal to the lesser trochanter and the width
at the isthmus level.
7.3.10. Section Properties
A list of properties was extracted for each cross-section for both the entire
bone section and the cancellous bone region. A more detailed description of
individual parameters are stated in section 5.2 on page 79.
• Area.
• Moment of inertia: I xx , I y y , J x (polar moment of inertia), I x y , principle

angle.
• Radius of the greatest inscribed circle in the cancellous bone region only
with the use of Voronoi diagram.
• Cortical thickness (medial, lateral, anterior, posterior).
154
7.4. Verification & Testing
7.4.1. Inter-rater Variation in Segmentation
With the majority of manual user-interactive work involved in the image

segmentation stage, a test is conducted to evaluate the inter-rater error
towards the final anthropometric parameters. 5 human femoral CT stacks
were selected at random and were segmented using Amira by two different
users according to the reference protocol described in previous sections. The
segmented CTs were then processed by a single user for parameter extraction
and the output pairs were compared to measure the inter-rater variations.
7.4.2. Intra-rater Variation in Segmentation
Intra-rater variations in image segmentation were determined by segmenting

the same set of CT multiple times followed by parameters extraction. Re-
segmentation of the same CT dataset was done on different day to minimize
possible memory effect. The list of extracted parameters was then compared
and the correlation coefficient and Cronbach’s alpha were computed to examine
the level of variation.
7.4.3. Variation on CT Voxel Size
The proposed methodology was designed to handle any voxel dimension,

including isotropic voxel, bounded by the resource limitation of the processing
workstation. To test against the feasibility of direct comparison between CT
stacks of different voxel size, the variation due to different CT voxel size was
studied. 4 sets of CT stacks comprising of 2 repeated scans of 2 human femurs
having different in-plane resolution as well as slice thickness were retrieved
from the laboratories CT database. The CTs were segmented and processed
and output parameters compared to evaluate the variation due to different
voxel size.
155
7. Methods
7.4.4. Reference Axes
7.4.4.1. Femoral Axis
Accuracy of FA evaluation (Figure 7.3.1.2 on page 130) depends upon the
detection accuracy of the lesser trochanter datum point (LT ). 5 stacks of
human femoral CT were selected randomly and comparison was done on the
effects on FA resulting from shifting the automatically detected LT datum
point by ±3mm along the z-axis.
7.4.4.2. Epicondylar Axis
The primary purpose of the epicondylar axis (TEA ) is to provide a rotational

reference in the model alignment stage. While the epicondylar points may

not be perfectly and accurately located at times, it is desirable for any TEA
deviation to have a minimal effect on other anthropometric parameters. 3
sets of human femoral CTs were segmented and processed according to the
proposed protocol. Each TEA of the sets were manually altered by ∼ +5◦
and ∼ −5◦ via the fallback manual corners selection interface as described in
section 7.3.1.3 on page 130 and a list of general anthropometric parameters
were extracted and variations compared.
7.4.5. Effect on Posterior Condyles Range Variation
While one of the main targets of the design is to automate the anthropometric
parameter extraction stage, manual user interaction was still required to
select the starting and ending slice of the posterior condyles. Comparison
on the extracted parameters (PCCYL vec , PCCYL r , KC ) were done on 5 human
femur CT stacks to study the consistency of the method and the variations
due to user subjectivity.
Each CT stack was processed following the procedure described in above

sections. The reference posterior condyles starting slice BW (r e f st ar t ) was
selected as the most proximal slice possible in which both the lateral and
medial condyles were visible. The reference ending slice BW (r e f end ) is defined
as the most distal slice before the medial and lateral condyles divide into two
separate regions on the axial slice. The reference slice range ([r e f st ar t , r e f end ])
156
represents the largest range in which the user could select according to the
protocol. The slice range was processed and the extracted parameters were
taken as the reference values.
Slice range of [r e f st ar t +3, r e f end −3] was taken as the normal range of subjective
error due to intra-rater variation and analysis was applied and compared
with the reference values.
Additional morphological analysis and comparison with the reference values

were done on slice ranges of [r e f st ar t − 5, r e f end ], [r e f st ar t , r e f end − 5], [r e f st ar t +
5, r e f end − 5], to further evaluate the performance of the methodology with
extreme user input.
7.4.6. Variation on Anteversion
Dunlap et al. (1953) pointed out ignoring the anterior bowing effect would
lead to an under-estimation of the anteversion by as much as 12◦ due to the
extra flexion of the hip joint, while most other previous studies (Ryder and
Crane, 1953; Kim and Kim, 1997) take the approach of utilizing the entire
femoral shaft when defining the femoral long axis. Our proposed methodology
by default utilizes the proximal femoral shaft for evaluation of the FA , and
allows user to alter the slice range if desired.
10 sets of human femoral CT data (5 random healthy Australian and 5 healthy

Japanese) were segmented and processed with the proposed methodology and
TEA),
their anteversion angles (∠(NA, CA),
∠(NA, ∠( HCF A, TEA),
A, CA)
∠(HCF ), sec-
tion 7.3.6 on page 149 recorded and taken as the reference. Each dataset was
then re-processed with the femoral axis (FA ) incorporating the full femoral
shaft from the lesser trochanter to the start of the distal metaphyseal flare.
The resulting anteversion angles were compared against the additional femoral
flexion with respect to the reference FA to study its effect due to anterior
bowing.
7.4.7. Verification using 3-D model
To verify the parameters extracted in our proposed procedure using 3-D

models, 5 sets of segmented human femoral CT were processed with Mimics .
157
7. Methods
Parameter Equivalent Estimation from 3-D model created in

Mimics
HR The femoral head radius was measured by taking average
of 4 diameter measurements (Figure 7.33a on the facing
page).
NLGT The neck length measured from the femoral head centre
to the lateral aspect of the trochanter along an estimated
neck axis (Figure 7.33b on the next page).
∠NAF A An estimated neck shaft angle was measured on the
anterior and posterior aspect of the femoral surface and
the average was taken (Figure 7.33c on the facing page).
FL HC −KC The femoral length measured from the femoral head
centre (HC ) to the knee centre (KC ). The actual
measurement will overestimate the value by roughly 1×
head radius (Figure 7.34 on page 160).
FL GT −KC The femoral length measured from the proximal tip of the
greater trochanter (GT ) to the estimated knee centre (KC )
(Figure 7.34 on page 160).
Table 7.1.: Verification measurements on 3-D model.
Segmented CT was used throughout the verification step to eliminate the

effect of possible variation in segmentation. The aim of the test is not to
compare the relatively accuracy, but to provide an external assurance using a
third party application.
3-D models were generated and a list of parameters were measured as shown
in table 7.1. Note that majority of the anthropometric parameters involve
the use of virtual axes and datum points defined throughout the proposed
procedure and thus direct verification by means of 3-D model generated
from the same stack of segmented CT would only be able to give a minor
subset of the entire parameter set with unavoidable subjective estimation.
The procedure aims to provide an external assurance independent on the
automated subroutines, to ensure the implemented procedure coincide with
the proposed methodology.
7.5. Anthropometric Studies
The proposed methodology was concurrently being applied and refined during
its development stage in several studies. While the studies are still ongoing
at the time of this writing, its inclusion mainly aims at demonstrating the
158
(a) Femoral head radius (HR ) was evaluated by(b) An estimation of the parameter NLGT , the
taking the average of four diameter measure- femoral neck length defined from the head
ments to minimize the effect of centre to the lateral aspect of the trochanter
along the direction of the neck axis. The
actual measurement shown in orange is
NLGT + HR .
(c) Neck shaft angle (∠NAF A ).
Figure 7.33.: Verification of the head neck region on 3-D models created with
Mimics .
159
7. Methods
Figure 7.34.: Verification of the femoral length on 3-D model created by

Mimics . The measurement in black is FLGT −KC , the distance
between the proximal tip of the greater trochanter and knee
centre. The measurement line in orange is an estimation of
FL HC −KC + HR , the sum of distance between the femoral head
centre and knee centre, plus the femoral head radius.
versatility of the future application of the proposed methodology, and to provide

a source of broad-ranged femoral CT data for on-the-go testing purpose.
7.5.1. Human Femoral CT
7.5.1.1. Australian CT Data
15 sets of healthy femoral CT data were retrieved from the laboratories CT

database and were extensively used as the primary testing samples during
the development of the methodology.
7.5.1.2. Japanese OA CT Data
CT data was collected and processed from an ongoing study with the Fukuoka
University Hospital (Japan) aiming to study the anthropometric properties of
patients with hip joint osteoarthritis (OA) that require total hip arthroplasty.
Two categories of data were being acquired, CT data from healthy Japanese
patients, and patients with OA. The CT acquired from OA patients are pre-
operative CT for surgical planning purpose; while the CT dataset of healthy
Japanese patient was acquired from the hospital radiology database. All
scans were done with 1mm spatial resolution and slice thickness and stored
in DICOM format.
160
Additional comparison was planned between the acquired healthy Japanese

CT dataset, with the Australian CT dataset described in previous subsection.
A total of 15 sets of OA data and 10 sets of healthy CT data were collected
and processed at the time of this writing.
7.5.2. Sheep Femoral CT
The sheep femur has, in general, a similar structure when compared to that
of human and the proposed methodology could be applied directly to sheep
femoral CT data without any need of modification, further allowing a more
direct comparison between the morphology of human and sheep femur.
20 sets of sheep femoral CT data were collected at the time of this writing
and processed with the proposed methodology aiming to construct a database
of sheep femoral anthropometric data. The data aims to provide valuable and
precise anthropometric information for prosthesis design and testing done on
sheep, which is a commonly used animal model.
161
7. Methods
162
Results
8
Contents
8.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.2. Consistency Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
8.2.1. Intra-rater Consistency . . . . . . . . . . . . . . . . . . . . 167
8.2.2. Inter-rater Consistency . . . . . . . . . . . . . . . . . . . . . 170
8.2.3. Repeated Scans . . . . . . . . . . . . . . . . . . . . . . . . . 172
8.3. Parameter Variation . . . . . . . . . . . . . . . . . . . . . . . . . 174
8.3.1. Proximal Femoral Axis Variation . . . . . . . . . . . . . . 174
8.3.2. Variation with Full Femoral Shaft . . . . . . . . . . . . . 177
8.3.3. Posterior Condyles Slice Range . . . . . . . . . . . . . . . . 179
8.4. Verification with 3-D Model . . . . . . . . . . . . . . . . . . . . 181
8.5. Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
8.5.1. Condyles Radius . . . . . . . . . . . . . . . . . . . . . . . . . 183
8.5.2. Optimal Flexion Axis . . . . . . . . . . . . . . . . . . . . . . 183
8.5.3. Australian & Japanese . . . . . . . . . . . . . . . . . . . . . 186
8.6. Sheep Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.1. Overview
he proposed methodology was implemented and tested in Matlab (Mathworks

T Inc., MA, USA) with a graphical user interface (GUI) for illustration
and user interaction (Figure 8.1 on the following page). As described in the
previous section, most part of the routine are fully automated. The final
routine comprises of around 10000 lines of code (including comments) and
163
8. Results
Figure 8.1.: The Matlab routine showing the process of sectional properties
computation.
with 2000 lines of code incorporated from external sources as listed in the
appendix A, table A.2 on page 235. A brief summary of the dependencies
of the core functions is listed in figure 8.2 on page 166. A more detailed
descriptions of individual sub-routines are listed in appendix A on page 225.
A total of 44 human femoral CT and 20 sheep femoral CT stacks were processed.

All anthropometric parameters were successfully extracted using our proposed
methodology. Of all 44 human femoral CT, 23 scans were acquired from 19
healthy adult Australian (sex and age unknown) cadavers retrieved from the
laboratories CT database (Appendix C on page 247). Within the 23 scans, 3
were repeated scans on the same femur, and 2 were paired femur from the same
donor. 19 scans of unique individuals were used as the Australian dataset after
removal of the duplicates and paires which were utilized for later verification
steps. 25 stacks of CTs were acquired from Fukuoka University Hospital
(Fukuoka, Japan) radiology database, in which 10 were healthy individual
and 15 were diagnosed with either primary or secondary hip osteoarthritis. 10
pairs of sheep femora (adult crossbred wethers, 15–24 months) were studied.
The sheep femurs were previously used in another animal study where a small
6 mm drill hole was created at the distal end of the femoral shaft. The drill
hole did not fall within our region of interest in any of our anthropometric
parameters and thus has no effect on the processed outcome. All CT datasets
were processed and results exported to a tab-delimited text format. A sample
164
8.1. Overview
output file was included in appendix B on page 237.
165
8. Results
Figure 8.2.: The dependency matrix.
find_lesser_tro_epicondylar_dist
find_greater_trochanter_height
bone_orientation_detection
find_head_epicondylar_dist
trochlear_groove_analysis
find_shaft_section_props
find_greater_trochanter
find_post_condylar_axis
find_anteversion_angle
find_canal_flare_index
find_lesser_trochanter
find_skel_intersection
est_lesser_trochanter
find_condylar_cyl_fit
find_epicondylar_axis
fix_bone_orientation
find_section_props
find_anterior_bow
find_femoral_axis
find_femur_length
femur_anthro_gui
align_model_axis
find_head_centre
find_head_offset
recrop_bone_mask
find_neck_props
crop_bone_mask
export_to_file
load_bone_mask
sim_xray_dexa
reslice_neck
uigetfiles
get_files
gui_disp
lineseg
waitbar
femur_anthro_gui + 0
align_model_axis + 1
E: calls f/eval..]
bone_orientation_detection + 1
corner > 1
crop_bone_mask + 1
cvoronoi E > 1
cylinder_fit > 1
deleteoutliers > 1
drawedgelist > 1
est_lesser_trochanter + 1
euclidean_distance > 1
export_to_file + 1
export_to_mat E > 1
export_workspace E > 1
extrema > 2
find_anterior_bow + 1
find_anteversion_angle + 1
find_best_fit_circle > 2
find_best_fit_plane > 1
>: not a caller S: a script (red)

find_best_fit_sphere > 1
find_canal_flare_index + 1
find_condylar_cyl_fit + 1
find_condylar_tangential_line > 2
find_epicondylar_axis + 1
find_femoral_axis + 2
find_femur_length + 1
61 module(s)
find_greater_trochanter + 1
find_greater_trochanter_height + 2
find_head_centre + 1
find_head_epicondylar_dist + 1
find_head_offset + 1
find_lesser_tro_epicondylar_dist + 1
find_lesser_trochanter + 1
find_neck_props + 1
find_post_condylar_axis + 1
find_section_props + 1
find_shaft_section_props + 1
find_skel_intersection + 1
findn > 1
fix_bone_orientation + 2
gen_circle > 1
get_files + 1
gui_disp E + 27
gui_msg > 2
hungarian > 1
import_workspace E > 1
lineseg + 1
load_bone_mask + 1
maxlinedev > 1
1
[+: a caller
recrop_bone_mask +
reslice_neck + 1
sim_xray_dexa + 1
sortclasses > 1
split > 1
tomm > 16
topixel > 11
trochlear_groove_analysis E + 1
uiGetFiles > 0
uigetfiles + 0
waitbar + 9
write > 1
333 2 1 5 2 5 1 2 8 6 4 1 3 3 5 1 1 1 2 4 3 5 3 2 1 0 1 1 1 2 7 1 3 0 1
36 caller(s)
[+: link ο: recursive ♦: caller=module]
166
8.2. Consistency Test
With one of the main goals of this study is to present a consistent and reliable
methodology as a platform for future larger-scaled anthropometric studies, it
is necessary to ensure the proposed techniques do not suffer from unacceptable
variations under normal usage.
The intra-class correlation coefficient (ICC) is a variation decomposition

method to evaluate the overall variance due to between-subject variability.
Ranged from 0 to 1, the ICC will approach 1.0 when there is no variance
between targets. The theoretical ICC formula could be expressed as follows:
σ2B
ICC = (8.1)
σ2B + σW
2
where σ2B is the between-subject variance, σW

2
is the variance between cases.
A summary of the types of ICC and a brief description is provided in table 8.1
on the following page.
The Cronbach’s α is another commonly used index to evaluate internal consis-

tency reliability, defined by the formula below.

N N c̄
α= (8.2)
N − 1 v̄ + (N − 1) c̄
where N is the total number of items, c̄ is the mean of all inter-item covariance,
and v̄ is the average variance.
With a range from negative infinity to 1, Cronbach’s α increase when the av-
erage inter-item correlation increases. A general rule of thumb of a minimum
alpha of 0.7 is required to reach good consistency.
All ICC and Cronbach’s α test in this section was undertaken using SPSS
(SPSS Inc., Chicago, Illinois, USA) version 15.
8.2.1. Intra-rater Consistency
The aim for the intra-rater consistency test is to evaluate the effect of variations
in repeated segmentation by the same user towards the anthropometric
167
8. Results
ICC type SPSS equivalent Description

model
ICC(1,1) One-way random Each judge is considered a random
effects, single selection among all possible judges
measure. and rate all subject of interest.
ICC(1,k) One-way random Same as ICC(1,1) but the unit of
effects, average measures is an average of k judges
measure. instead of results from an individ-
ual judge.
ICC(2,1) Two-way random Both judges and subject of interest
effects, single are considered a random selection
measure. among all possible judges and sub-
jects.
ICC(2,k) Two-way random Same as ICC(2,1), but he unit of
effects, average measures is an average of k judges
ual judge.
ICC(3,1) Two-way mixed All judges of interest rate all sub-
model, single ject of interest. Here judges are
measure. considered a fixed effect and the
subject of interest is a random se-
lection from all possible subjects.
ICC(3,k) Two-way mixed Same as ICC(3,1), but the unit of
model, average measures is an average of k judges
ual judge.
Table 8.1.: Types of ICC.
168
ICC 95% C.I.

Parameter ICC Cronbach’s α
Upper Lower
Radius (HR ) 0.999 0.991 1.000 0.999
Femoral axis offset 0.999 0.983 1.000 1.000
Vertical offset to lesser 0.980 0.809 0.998 0.993
trochanter
Table 8.2.: Femoral head intra-rater consistency.
ICC 95% C.I.

Upper Lower
Neck length to femoral 0.999 0.994 1.000 1.000
axis (NL F A )
Neck length to lateral 0.995 0.956 1.000 0.997
greater trochanter (NLGT )
Neck shaft angle (∠NAF A ) 0.926 0.429 0.992 0.953
Neck axis elevation (NAF A ) 0.972 0.000 0.999 0.998
Neck axis to head centre 0.975 0.760 0.997 0.983
distance (NAHC )
Table 8.3.: Femoral neck intra-rater consistency.
parameters extracted. The segmentation was performed according to the

same protocol and each tested subject was segmented and re-segmented on a
different day to minimize possible memory effect.
Two consistency tests were conducted, namely the ICC and the Cronbach’s α.
ICC was evaluated using the ICC(2,1) model, a two-way random effects model
of single measure with a 95% confidence interval (C.I.). The Cronbach’s α
was computed in additional to the ICC. While each of the listed parameters
below were tested as independent variables, it was grouped and presented in
6 tables for clarity purpose.
With the femoral head radius evaluated based on a two staged sphere-fit
estimation and the proximal femoral axis being a function axis not depending
solely on an individual anatomical landmark, the effect of variations in seg-
mentation was found to be minimal having an excellent ICC and Cronbach’s
α (Table 8.2).
Parameters in the neck region (Table 8.3) showed a varying ICC. ICC of
169
8. Results
ICC 95% C.I.

Upper Lower
CA)
∠(TEA, 0.566 -0.229 0.940 0.759
A, TEA)
∠(HCF 0.984 0.888 0.998 0.992
A, CA)
∠(HCF 0.983 0.809 0.998 0.994
TEA)
∠(NA, 0.978 0.842 0.998 0.990
CA)
∠(NA, 1.000 0.997 1.000 1.000
Table 8.4.: Anteversion angles intra-rater consistency.
ICC 95% C.I.

Upper Lower
Distance from LT to 0.965 0.668 0.996 0.988
isthmus
CFI ml 0.990 0.908 0.999 0.994
CFI ap 0.965 0.751 0.996 0.980
CFI obl i que 0.950 0.494 0.995 0.985
CFI met aph y seal 0.994 0.959 0.999 0.997
Table 8.5.: Canal flare indices intra-rater consistency.
the neck shaft angle, while still satisfactory, is relatively lower. This could
possibly be attributed to the low inter-subject variance within our sample set,
in which the errors were magnified. A low ICC on the distance between neck
axis to head centre was under expectation due to the low average magnitude
(~ 1 mm), which is around the sensitivity limit of the scan resolution.
Similarly, the angle between the transepicondylar axis and the posterior
condyles axis (Table 8.4) has an expected lower ICC and confidence interval
due to the sensitivity limit being reached. Quantization error in CT and
very minor segmentation variations would induce a significant within-subject
variance, leading to a lower correlation value.
8.2.2. Inter-rater Consistency
To further evaluate the possible variations due to subjectivity in the segmenta-

tion stage to the final outcomes, 5 CT stacks were segmented by two different
users with the same protocol. The ICC and Cronbach’s α were computed.
170
ICC 95% C.I.

Upper Lower
Posterior condyles radius 0.998 0.899 0.999 0.993
(PCCYL r )
Trochlear groove angle 0.965 0.766 0.996 0.983
(∠TR )
Anterior bow radius 0.998 0.980 1.000 0.999
(BOWr )
Table 8.6.: Shaft and distal femur intra-rater consistency.
ICC 95% C.I.

Upper Lower
FL GT −KC 1.000 0.999 1.000 1.000
FL HC −KC 1.000 1.000 1.000 1.000
Head centre to epicondylar 0.999 0.995 1.000 0.999
(Di st HC −T E A )
Lesser trochanter to 0.999 0.989 1.000 0.999
epicondylar (Di st LT −T E A )
Greater trochanter height 0.925 0.469 0.992 0.954
(GTH )
Table 8.7.: Femoral length intra-rater consistency.
171
8. Results
ICC 95% C.I.

Upper Lower
Radius ( HR ) 0.998 0.985 1.000 0.999
trochanter
Table 8.8.: Femoral head inter-rater consistency.
ICC 95% C.I.

Upper Lower
axis (NL F A )
Neck axis to head centre 0.865 0.279 0.985 0.944
distance (NAHC )
Table 8.9.: Femoral neck inter-rater consistency.
Similarly, a two-way random effects model of single measure was employed in

the calculation of the ICC.
The inter-rater ICC values and Cronbach’s α has a very similar range when
compared to the intra-rater consistency with the inter-rater consistency
marginally lower in some cases. This could possibly be a result from a
greater variation in user subjectivity in the segmentation stage.
8.2.3. Repeated Scans
To allow direct comparison between a larger range of CT, a consistency test

over repeated scans of the same subject was conducted. All repeated scans
were conducted on different day, and it was observed that all pairs experienced
slight orientation variations. 4 out of 5 pairs of the CT were scanned with
different spatial resolution and slice thickness.
A one-way random effect model of the ICC was employed in this case because
172
ICC 95% C.I.

Upper Lower
CA)
∠(TEA, 0.873 0.255 0.986 0.923
A, TEA)
∠(HCF 0.992 0.937 0.999 0.995
A, CA)
∠(HCF 0.997 0.864 1.000 0.999
TEA)
∠(NA, 0.983 0.863 0.998 0.993
CA)
∠(NA, 0.993 0.941 0.999 0.997
Table 8.10.: Anteversion angles inter-rater consistency.
ICC 95% C.I.

Upper Lower
isthmus
CFI ml 0.986 0.899 0.998 0.993
CFI ap 0.976 0.806 0.997 0.985
CFI obl i que 0.995 0.963 0.999 0.997
CFI met aph y seal 0.979 0.846 0.998 0.991
Table 8.11.: Canal flare indices inter-rater consistency.
ICC 95% C.I.

Upper Lower
(PCCYL r )
(∠TR )
(BOWr )
Table 8.12.: Shaft and distal femur inter-rater consistency.
173
8. Results
ICC 95% C.I.

Upper Lower
FL GT −KC 1.000 0.997 1.000 1.000
FL HC −KC 1.000 1.000 1.000 1.000
(GTH )
Table 8.13.: Femoral length inter-rater consistency.
ICC 95% C.I.

Upper Lower
Radius ( HR ) 0.972 0.799 0.997 0.984
trochanter
Table 8.14.: Femoral head consistency on repeated scans.
of the fact that the 5 pairs of CT were acquired from different scanners.
Consistency of the extracted parameters in repeated scans were in general

slightly lower compared to that of the intra and inter-rater test. This is within
expectation with the fact that variations in repeated scans could be considered
as a combined effect of intra-rater variations, patient orientation variations
and scanning parameter variations.
8.3. Parameter Variation
8.3.1. Proximal Femoral Axis Variation
The proximal femoral axis was used as the reference longitudinal axis through-
out the study. While the axis was defined in a functional manner which
minimized the direct reliance on a precise location of a single anatomical
landmark, the slice range employed in the evaluation of the femoral axis is
174
ICC 95% C.I.

Upper Lower
axis (NL F A )
Neck axis to head centre 0.781 -0.023 0.975 0.867
distance (NAHC )
Table 8.15.: Femoral neck consistency on repeated scans.
ICC 95% C.I.

Upper Lower
CA)
∠(TEA, 0.158 -0.309 0.811 0.383
A, TEA)
∠(HCF 0.955 0.648 0.995 0.983
A, CA)
∠(HCF 0.997 0.974 1.000 0.999
TEA)
∠(NA, 0.973 0.785 0.997 0.989
CA)
∠(NA, 0.991 0.919 0.999 0.996
Table 8.16.: Anteversion angles consistency on repeated scans.
ICC 95% C.I.

Upper Lower
isthmus
CFI ml 0.968 0.711 0.997 0.989
CFI ap 0.969 0.783 0.997 0.983
CFI obl i que 0.971 0.677 0.997 0.991
CFI met aph y seal 0.778 -0.243 0.975 0.848
Table 8.17.: Canal flare indices inter-rater consistency on repeated scans.
175
8. Results
ICC 95% C.I.

Upper Lower
(PCCYL r )
(∠TR )
(BOWr )
Table 8.18.: Shaft and distal femur consistency on repeated scans.
ICC 95% C.I.

Upper Lower
FL GT −KC 0.999 0.991 1.000 0.999
FL HC −KC 0.999 0.994 1.000 1.000
(GTH )
Table 8.19.: Femoral length consistency on repeated scans.
176
governed by the accurate location of the lesser trochanter. It was estimated

that a possible variation of 1–3 mm may exist in the evaluation of the lesser
trochanter, mainly due to possible quantization error in the CT scans.
Our use of only the proximal femoral axis as the longitudinal axis is relatively
prone to this error when comparing to most other similar studies that adopted
the full femoral shaft axis. A simple test was performed to compare the
angular variations of the proximal femoral axis by a shifting of the lesser
trochanter position superoinferiorly by ±3 mm. 5 subjects were chosen at
random and the reference proximal femoral axis (FA ) was computed based
on the default automatic procedures. The position of the lesser trochanter
was then shifted superoinferiorly by ±3 mm and the proximal femoral axis

re-calculated (FA ). Table 8.20 on the following page shows the angular
difference between the reference proximal femoral axis and that with altered
lesser trochanter positions. A mean difference of 0.60◦ was observed which is
negligible.
8.3.2. Variation with Full Femoral Shaft
To study the effect of using the proximal femoral shaft as longitudinal axis to
the anteversion angles, 10 (5 healthy Australian and 5 healthy Japanese) CT
datasets were randomly selected and processed using the proximal femoral
axis and full femoral shaft axis as the longitudinal. It was noted that there is
a very significant difference in all anteversion angles, and neck axis elevation
relative to the longitudinal femoral axis.
As shown in figure 8.3 on page 179, a huge reduction of the anteversion angles
is shown when the full femoral shaft is used as the reference longitudinal axis.
Note that the large standard deviation as presented in the error bars are the
result of the population variance, not the variance of the difference. To further
illustrate the huge changes in anteversion angles, a box-and-whisker plot
was constructed as shown in figure 8.4 on page 180. The red line indicates
the median difference, blue box denotes the interquartile range. The range
bounded by black is the upper and lower whisker, which is equal to the range
in this case, because no outlier was present.
The anterior elevation of the neck axis relative to the longitudinal femoral axis
has shown a significant change of 11 mm with the switch of the longitudinal
177
8. Results

ID FA [
xy
z] Lesser FA [
xy
z] Angular
trochanter difference
z-shift (mm) (degree)
[-0.052 -0.194
10R [-0.042 -0.201 +3 0.980] 0.67
0.979]
[-0.033 -0.207
−3 0.978] 0.63
[0.089 -0.177
29L [0.083 -0.178 +3 0.980] 0.33
0.980]
[0.079 -0.179
−3 0.981] 0.26
[-0.063 -0.176
71L [-0.079 -0.180 +3 0.982] 0.90
0.981]
[-0.085 -0.181
−3 0.980] 0.40
[0.008 -0.156
67L [-0.009 -0.167 +3 0.988] 1.17
0.986]
[0.000 -0.162
−3 0.987] 0.58
[-0.059 -0.153
03R [-0.051 -0.158 +3 0.987] 0.53
0.986]
[-0.043 -0.162
−3 0.986] 0.50
Mean 0.60
Table 8.20.: Variations of the proximal femoral axis due to inconsistent lesser
trochanter evaluation. A mean difference of 0.6◦ was observed
which is negligible.
178

! $
! "# ! "# !
$
Figure 8.3.: Difference in anteversion angle with proximal and full femoral
shaft as the reference longitudinal axis. The error bars indicate
one standard deviation. This shows a substantial difference in the
measurements under the use of different reference longitudinal
axes.
reference axis as shown in figure 8.5 on the next page. The canal flare index
based on the longest oblique dimension, C F I obl i que , has shown to have a larger
variation between the two reference longitudinal axis while the other 3 CFI
are very consistent. Other parameters involving measurements with respect
to the femoral reference axis have shown to be highly consistent between the
two settings (Appendix E.1 on page 265).
8.3.3. Posterior Condyles Slice Range
The reference slice range was defined as the maximum possible slice range.
The proximal limit is chosen with which the condyles start visible to the
image cross-section and the distal limit is chosen in which the condyles are
no longer inter-connected via the anterior aspect of the femur.
The typical maximum erroneous selection range is defined as 3 slices inferior

to the proximal limit to 3 slices superior to the distal limit. This is equivalent
to a 6mm of total range reduction for the first 3 samples with slice thickness
of 1mm and 12 mm of total range reduction for the last 2 samples with
slice thickness of 2 mm. It was observed that the variation in radius is
very minimal with a mean of 0.72 mm (Table 8.21 on page 182). A number
179
8. Results
30
Difference (degree)
25
20
15
10

(HCFA,
(HCFA,
TEA) (NA,
CA) TEA)
CA)
(NA,
Figure 8.4.: Box-plot showing difference in anteversion with the proximal and
full femoral shaft as the longitudinal reference axis. Upper and
lower whisker (black), median (red) and the quartiles (blue) are
shown.

Figure 8.5.: Neck axis elevation (NAF A ) relative to the femoral axis with
proximal and full femoral shaft as the reference longitudinal axis.
The error bars represent one standard deviation.
180
8.4. Verification with 3-D Model

Figure 8.6.: Canal flare indices with proximal femoral shaft and full femoral
shaft as reference longitudinal axis. Only the oblique index shows
a significant difference under the change of reference longitudinal
axis.
of additional erroneous range with more extreme limits were tested and is
included in appendix E.2 on page 265 for reference.
8.4. Verification with 3-D Model
Verification was done in Mimics on 5 sets of CT. 3-D model was created and
measurements were made on the surface mesh. The aim of the test is to
provide an assurance on the measurements using our proposed methodology
with the application of a more direct method using a third party tool. All
measurements on the 3-D surface meshes were done manually and visually.
Figure 8.7 on the next page shows the mean difference of the 5 parameters
measured with reference to the parameters measured using our proposed
methodology. The mean difference was small, while a larger deviation on the
percentage difference on femoral neck length, femoral head radius and the
neck shaft angle was observed.
181
8. Results
ID Slice Reference Radius with typical Difference (mm)

thickness radius max selection error
(mm) (mm) (mm)
67L 1 22.5 22.0 -0.5
03R 1 21.0 22.0 1.0
14L 1 17.8 17.9 0.1
71L 2 22.2 24.9 2.7
OBL 2 18.5 18.8 0.3
Mean 0.72
Table 8.21.: Typical maximum error of the posterior condyles radius due to
variation in slice range selection by user.

(a) Mean difference. (b) Percentage difference.
Figure 8.7.: Difference between direct measurements on the created 3-D model
and that using the proposed methodology. The error bars repre-
sent one standard deviation of the measurements. Neck length is
the length from the start of the femoral neck to the lateral aspect
of the trochanter along the computed neck axis (NLGT ).
182
8.5. Comparison
Min Max Mean

Medial condyle (mm) 17.3 26.0 21.5
Lateral condyle (mm) 18.8 29.5 22.6
Difference (mm) -2.9 4.5 1.2
Table 8.22.: Difference on the radius of curvature between medial and lateral
condyles in the Australian dataset.
Min Max Mean

Medial condyle (mm) 16.4 20.3 18.3
Lateral condyle (mm) 15.1 23.2 18.3
Difference (mm) -3.0 2.9 0.0
Table 8.23.: Difference on the radius of curvature between medial and lateral
condyles in the healthy Japanese dataset.
8.5. Comparison
8.5.1. Condyles Radius
The posterior condyles has a circular shape profile in the sagittal view. To
study the difference of the radius of curvature between the two condyles,
circle-fitting was applied to the extracted medial and lateral posterior condyles
datum points to evaluate the radius of curvature of the Australian dataset.
Contrary to previous findings, we observed a 1.2 mm larger average radius

of curvature of the lateral condyle in our Australian dataset (Table 8.22).
The healthy Japanese dataset showed roughly the same radius of curvature
between the condyles (Table 8.23).
8.5.2. Optimal Flexion Axis
Recent studies (Hollister et al., 1993; Churchill et al., 1998) have suggested
knee kinematics could reliably be represented using 2 non-orthogonal axes;
a flexion axis and a longitudinal rotational axis on the tibia. The optimal
knee flexion axis, or sometimes known as the geometric centre axis, is usually
determined by fitting two separate circles to the medial and lateral condyles
183
8. Results

Figure 8.8.: Difference between the medial and lateral condyle radius. A
positive difference indicates the lateral radius is larger than that
of the medial and vice versa.
in the sagittal plane and connect the centres of the circles. It was discovered
the fitting of 2-D circles to the condyles may be error prone due to undesirable
rotational variations. Thus a cylinder fitting procedures were employed in the
evaluate of the optimal flexion axis.
To verify whether the optimal femoral axis coincide with the transepicondylar
axis, comparison was conducted on our Australian dataset to quantify the
difference between the optimal flexion axis and the transepicondylar axis.
The optimal knee flexion axis was evaluated using the fit cylinder method and
the anteroposterior and superoinferior distance between the axis and the two
epicondylar points were computed. The angle between the transepicondylar
axis and the optimal flexion axis was also calculated.
As shown in figure 8.9 on the facing page, the medial epicondyle is in general
anterior and superior to the optimal flexion axis. The mean anterior and
superior displacement is 13.1 mm and 8.2 mm respectively. The lateral
epicondyle is of a closer proximity to the optimal flexion axis relatively, with
an average of 4.4 mm anterior and 2.7 mm superior displacement (Figure 8.10
on the next page). The mean angle between the transepicondylar axis and the
optimal flexion axis is 7.3◦ with a standard deviation of 1.9◦ . It is concluded
that the epicondyles are in general not in close proximity to the optimal flexion
axis.
184
8.5. Comparison

Figure 8.9.: Displacement of the medial epicondyle relative to the optimal

flexion axis.

!

!
Figure 8.10.: Displacement of the medial epicondyle relative to the optimal

flexion axis.
185
8. Results
Parameter P-value Mean difference

Radius (HR ) 0.001∗ 2.5
Femoral axis offset 0.028∗ 5.9
Vertical offset to lesser trochanter 0.001∗ 9.8
Table 8.24.: Statistical comparison between AU and JP femoral head region.
8.5.3. Australian & Japanese
To evaluate if there is any observable difference using our methodology between

the healthy Australian and Japanese datasets, a comparison was made to the
processed parameter set.
Independent two-tailed Student t-test was computed using SPSS . The

Levene’s test was performed for each variables to determine if equal variance
of the two datasets could be assumed. With the significance level of the
Levene’s test taken to be 0.05, only two variables showed that equal variance
could not be assumed. For the two variables, non-parametric Mann-Whitney
test was performed in which equal variance is not assumed with a slight
penalty of the degree of freedom. Entries with which non-parametric tests
were performed are marked by a superscript hash sign (# ) in table 8.26 on
the facing page and table 8.27 on page 188.
A significance level of 0.05 was selected in the test to reject the null hypothesis,
and the mean difference is the mean value of the Japanese dataset subtracted
from that of the Australian dataset. Variables that are statistically significant
is marked by an asterisk (∗ ).
The Japanese tends to have a smaller femur in general. A smaller femoral

head, shorter femoral length, shorter neck, and smaller posterior condyles
were observed. It was however noted that the Japanese dataset has a larger
anterior bowing of the femoral shaft and a larger anteversion.
8.6. Sheep Summary
The inclusion of ovine data is to systematically gather anthropometric data for

sheep femur,which is a commonly used animal model in prosthesis testing in
186
8.6. Sheep Summary

Neck length to femoral axis (NL F A ) 0.026∗ 6.0
Neck length to lateral greater <0.001∗ 11.8
trochanter (NLGT )
Neck shaft angle (∠NAF A ) 0.686 -0.8
Neck axis elevation (NAF A ) 0.004∗ 2.2
Neck axis to head centre distance 0.589 -0.1
(NAHC )
Greater trochanter height (GTH ) 0.223 1.5
Table 8.25.: Statistical comparison between AU and JP femoral neck regions.

!"#

(a) Femoral head. (b) Femoral neck.
Figure 8.11.: Femoral head and neck measurements of the AU and JP datasets.

CA)
∠(TEA, 0.735# -0.3
A, TEA)
∠(HCF 0.584 -1.6
A, CA)
∠(HCF 0.525 -1.9
TEA)
∠(NA, 0.044∗ -5.8
CA)
∠(NA, 0.044∗ -6.1
Table 8.26.: Statistical comparison between AU and JP anteversion angles.
187
8. Results

"

Figure 8.12.: Anteversion angles of the AU and JP datasets. Significant

TEA)
difference was observed in ∠(NA, CA)
and ∠(NA, (P<0.05)
in which the Japanese dataset has a larger angle than the
Australian dataset.

Distance from LT to isthmus 0.213 11.1
CFI ml 0.946 0.0
CFI ap 0.793 0.0
CFI obl i que 0.299 0.1
CFI met aph y seal 0.016#∗ -0.1
Table 8.27.: Statistical comparison between AU and JP canal flare index.

Posterior condyles radius (PCCYL r ) <0.001∗ 3.8
Trochlear groove angle (∠TR ) 0.604 2.1
Anterior bow radius (BOWr ) 0.011∗ 235.3
Table 8.28.: Statistical comparison between AU and JP distal femur and shaft
regions.
188
8.6. Sheep Summary

FL GT −KC <0.001∗ 64.7
FL HC −KC <0.001∗ 63.4
Head centre to epicondylar <0.001∗ 58.5
Lesser trochanter to epicondylar <0.001∗ 49.4
(Di st LT −T E A )
Table 8.29.: Statistical comparison between AU and JP femoral length.

Figure 8.13.: Femoral length measurements of the AU and JP datasets. The

Japanese dataset has a smaller value in all femoral length
measurements (P<0.001).
189
8. Results

Figure 8.14.: Cross-sectional area of the bone section and the medullary canal
of the proximal femur. The error bars represent 1 standard
deviation of the measurements.

Figure 8.15.: Moment of inertia across the medio-lateral axis (Ixx) and antero-
posterior axis (Iyy) of the proximal femur.
190
8.6. Sheep Summary

!

Figure 8.16.: Summary of measurements of proximal femur and posterior

condyles of sheep.
the field of Orthopaedics. It also demonstrates the robustness of the proposed

methodology in handling datasets with similar structure. 19 sheep femur
were successfully processed without the need of core methodology modification.
The data is sorted according to the average magnitude and plotted below.
191
8. Results

!&&%

!

"

Figure 8.17.: Summary of femoral length, neck shaft angle and anterior bow
of sheep.

#

#$ "#$ #
"

Figure 8.18.: Summary of canal flare index of sheep.
192
Discussion
9
Contents
9.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
9.2. Software Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
9.3. Image Acquisition & Segmentation . . . . . . . . . . . . . . . 196
9.3.1. Acquisition Parameters . . . . . . . . . . . . . . . . . . . . . 196
9.3.2. Automated Segmentation . . . . . . . . . . . . . . . . . . . 197
9.3.3. Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
9.4. Performance of the Methodology . . . . . . . . . . . . . . . . 200
9.4.1. Automation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9.4.2. Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9.4.3. Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
9.5. Reference Axes Definition . . . . . . . . . . . . . . . . . . . . . 202
9.5.1. Longitudinal Axis . . . . . . . . . . . . . . . . . . . . . . . . 202
9.5.2. Distal Transverse Axis . . . . . . . . . . . . . . . . . . . . . 204
9.6. General Parameter . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.6.1. Head Centre . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.6.2. Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.6.3. Posterior Condyles & Knee Centre . . . . . . . . . . . . . 212
9.6.4. Canal Flare Index . . . . . . . . . . . . . . . . . . . . . . . . 216
9.7. Anteversion Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9.8. Sheep Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
193
9. Discussion
9.1. Overview
he main goal of the project is to develop a methodology for the extraction

T of anthropometric parameters of the femur, to serve as a platform for
further analysis. Numerous anthropometric studies (Section 6 on page 97)
have been conducted in literature, from physical measurements on osteometric
table (Parsons, 1914; Kingsley and Olmsted, 1948; Yoshioka and Cooke, 1987),
to the utilization of modern medical imaging techniques including X-rays
(Rogers, 1931; Dunlap et al., 1953; Ryder and Crane, 1953), MRI (Iwaki et al.,
2000; Manske et al., 2006; Sheehan, 2007) and CT (Weiner et al., 1978; Høiseth
et al., 1988; Kim and Kim, 1997; Kim et al., 2000a). The studies span a wide
range of applications, such as analysis of racial difference, categorizing data
for prosthesis design, comparison of anthropometric difference or changes in
pathological cases, evaluation of fracture risk. The accurate understanding of
the geometric properties of the bone is vital and fundamental for many of the
analysis abovementioned.
During the initial stage of the study, it was noticed that while most of
the anthropometric parameters are well-defined in the anatomical aspect,
many definitions remain ambiguous in the image processing domain. It is
understandable that as most of the anthropometric measurements evolved
from the clinical domain, human anatomy plays a major role towards their
definitions. Nonetheless, with the increasing application of image processing
techniques in the medical field, the problem of ambiguity in anatomical
definitions surfaced.
Several studies (Croce et al., 1999; Besier et al., 2003; Hagemeister et al.,
2005) have pointed out the difficulty in precise and consistent location of
anatomical landmarks. Croce et al. (1999) have pointed out the intrinsic
reason for the positional inconsistency in the use of anatomical landmarks
due to the fact that anatomical landmarks are generally defined as relatively
large and curved region instead of discrete points. This could possibly incur
undesirable inter and intra-rater inconsistency in the process of locating
anatomical landmarks for anthropometric study. An effective way to overcome
the inherent limitation is to incorporate function methods in the evaluation
of anthropometric parameters (Croce et al., 1999; Stagni et al., 2000; Besier
et al., 2003; Hagemeister et al., 2005).
The deficiency of the anatomical definitions in the image processing aspect

inspired the investigation of the proposed methodology, in which the definition
194
9.2. Software Selection
is more consistent and reproducible, reducing as much subjective judgment of

landmarks identification as possible.
One derived advantage of a consistent and well-defined anatomical definitions

is the possibility of higher level of automation with the methodology not
dependent on subjective user input which could significantly increase inter
and intra-rater consistency.
The robustness of the methodology was another major concern. It was noted
that while many methodologies documented in literature (Section 6 on page 97)
are robust in terms of processing healthy femur, the outcomes on pathological
samples are far from satisfactory. This could possibly due to the use of
geometric assumptions no longer being valid when the structure is deformed.
It was thus one of the criteria to try to develop a methodology that allows
pathological samples to be processed.
The sections below discusses various aspects of the proposed methodology, the
performance and robustness, the consistency observed, the reason for various
measurements, a brief summary and comparison on the datasets acquired,
the limitations and future directions.
9.2. Software Selection
Several software packages were used in this study. Amira (Visage Imaging,
Inc., Carlsbad, USA) was used due to its extensive image segmentation
capabilities. Morphological functions and other semi-automatic functions
such as edge tracing and local region growing provided a good tool-set for an
efficient and consistent segmentation process.
Matlab (Mathworks Inc., MA, USA) was used extensively in the imple-
mentation of the proposed methodology. While the proposed methodology is
language independent, the Matlab package provided a very comprehensive
set of functions for image and signal processing and thus served as a very
good platform for prototyping.
Nevertheless, it was noted that the use of Matlab in the prototype had
resulted in significant performance penalty in several occasions. The applica-
tion of affine transformation (Section 7.3.1.4 on page 133) to large CT dataset
in the model alignment stage has suffered from low performance and could
195
9. Discussion
take up to several minutes to complete on an Intel Pentium 4 personal

computer. Similar operation using the Amira software package, for instance
is in general a few times faster. Even so, with the fact that the processing
in our Matlab routine is mostly automated, the impact of the performance
drawback is considered minimal.
Mimics (Materialize, Inc., Leuven, Belgium) was used as the reverse engi-
neering software package in the creation of 3-D model for verification purpose.
While it was noticed that Mimics may not be as fine-grained and robust as
other functional-specific software packages in model creation, the functionality
is sufficient for our verification purpose. The intuitive interface allows direct
measurements on the generated model, eliminating the need of additional
software packages for this purpose.
9.3. Image Acquisition & Segmentation
Computing tomography was employed as the primary acquisition technique

due to its high availability and good reflection on bone structure. While
the ideal CT number, the Hounsfield unit, theoretically represents only the
average X-rays attenuation of the corresponding voxel, artifacts such as beam
hardening or photon starvation have been shown to have a profound effect on
the final Hounsfield value. Various findings (Levi et al., 1982; Groell et al.,
2000) have suggested extra caution should be taken in the adoption of direct
Hounsfield values for clinical diagnostics due to the variations observed on
intra-scanner and inter-scanner output. Specifically, unacceptable variations
in soft tissues and similar low attenuation masses have been confirmed
(Boland et al., 1998; Maki et al., 1999) in various studies.
9.3.1. Acquisition Parameters
Nonetheless, it was noted within our datasets from various scanners that the
Hounsfield value of bone are relatively consistent, possibly due to a higher
attenuation coefficient leading to a higher signal to noise ratio, and thus
less prone to the varying effect of background attenuation. Our observation
confirms with Groell et al. (2000) study in quantifying CT number variations
under different image acquisition parameters and across two different scanners.
196
Still, extra caution has been taken in the process of base threshold value
selection in the study. Manual examinations were performed on several
image stacks from each of the scanners/parameter group, with analysis on
the histogram and profile line. It was discovered that a value of 200 HU
served as a good base reference for thresholding the periosteal boundary from
the surrounding soft tissue; and 500 HU being a good base reference for
thresholding cancellous bone from cortical bone in our datasets as a result of
the analysis on the profile lines as shown in figure 7.3 on page 126. The use
of 200 HU for reference in segmentation of the periosteal boundary in femur
for CT-based computer navigation system in THR was reported (Sugano et al.,
2001). In the analysis, Sugano et al. further reported that the accuracy of
surface registration of the periosteal boundary of the femur does not vary
significant within the range of 110–320 HU. Other studies have documented
the optimal Hounsfield value for segmentation of trabecular bone to be within
the range of 300–600 HU (Aamodt et al., 1999; Hua J, 1993). In our study,
the reference base threshold values were chosen in favor to the avoidance
of under-segmentation, and slight amount of manual work were required
especially in the proximal and distal extremes.
9.3.2. Automated Segmentation
With image segmentation being one of the key steps in image processing,
attempts have been made in automating the segmentation process without
much success. One of the major difficulties encountered was achieving a
precise and consistent segmentation between the acetabulum and the femoral
head, especially in the osteoarthritis patient where the joint space are not
well defined.
Active contour models (Kass et al., 1988), also commonly known as snakes,
defined as an energy minimizing spline or deformable template matching,
are often employed in tackling the above-described problem. Gregory et al.
(2004) developed a technique based on active shape modeling in measuring
the morphometry of proximal femur in AP radiography and reported an
accuracy of 2.2 mm of median point-to-point error could be achieved. Chen
et al. (2005) employed a similar algorithm with additional shape constraints
to automatically extract femoral contours from X-rays images whilst pointing
out the deficiency in handling odd or pathological cases.
197
9. Discussion
More complex techniques have been proposed by Zoroofi et al. (2003) in

automatic segmentation of the femur from CT, delivering a 54% success rate
within a dataset of 60 patients. Challenges remains in the complexity and
variations of the CT, particularly in pathological cases with bone deformation,
when coupled with the possible artifacts from the image acquisition stage.
The inconsistency and low robustness of automatic segmentation (Zoroofi et al.,

2003; Chen et al., 2005) has led to the decision of adopting a more conservative
approach in current study. Amira was chosen as the primary segmentation
tool with its versatile set of image segmentation tool including region growing
and edge tracing, which extensively accelerated the segmentation process
upon applying a base threshold.
Extra investigations were performed in designing the segmentation protocol

as discussed in previous section (Section 9.3.1 on page 196). The amount
of extra manual work involved depends upon the bone quality of individual
patient, and more work is usually involved in pathological dataset.
9.3.3. Consistency
With the manual segmentation involving significant amount of user interaction,

individual subjectivity is expected to be one of the main sources of error in the
entire study. Additional testing was performed to quantify the effect of user
subjectivity towards the final outcome. Intra-rater and inter-rater variability
were conducted to evaluate the consistency among users (Section 8.2 on
page 167).
The Intra-class Correlation Coefficient (ICC) has been extensively employed

(Ginja et al., 2007; Tannast et al., 2007; Delgado-Martínez et al., 2000) as
a consistency test in evaluating inter and intra-rater variability. An ICC
value of 0.7 or higher (Baumgartner and Chung, 2001) is generally consid-
ered good consistency. Intra-rater variability evaluated using ICC on most
general parameters resulted in a correlation coefficient of 0.95 (mean 0.96) or
CA)
above (Section 8.2.1 on page 167). ICC of ∠(TEA, , the angle between the
transepicondylar and posterior axis, was lower than the generally required
0.7 threshold to be considered consistent (Table 8.4 on page 170). Further
investigations revealed the low correlation is attributed to other causes. The
angle was found to have a very low value (mean 6.3◦ ) in which any variation
198
involved would affect the measurement relatively significantly. Removing the

parameter ∠(TEA, CA)
resulted in a mean ICC of 0.98 and Cronbach’s alpha
of 0.99, a strong evidence of high intra-rater consistency.
Inter-rater variability evaluated using ICC resulted in similar ranges, with

mean ICC of 0.974 and Cronbach’s alpha of 0.987, concluding the effect of
segmentation variations is minimal with our proposed methodology.
All previous anthropometric studies in the literature reviewed were based

on a single preset image acquisition protocol. To be able to utilize a wider
range of input source, the ability to process and compare datasets obtained
from different scanner sources is desirable. With different scanning protocols
adopted in our sources, the validity of direct comparison between scans of
different resolutions aroused. The question further extended to the consis-
tency between repeated scans where patient positioning would vary. Another
significant factor is the influence of partial volume averaging (Section 3.3.6.2
on page 30) especially in lower resolution scans with anisotropic voxels.
A promising mean correlation coefficient of 0.921 was obtained in our repeated

scan test, with a mean Cronbach’s alpha of 0.953. It should safely be concluded
that direct comparison between scans of different resolution is feasible and a
slice thickness of 2 mm could still deliver accurate results.
While the inter and intra-rater ICC segmentation tests were designed to
evaluate the reliability of a single variable (segmentation) per test, the results
represented an aggregated consistency measures, including possible variations
due to the methodology design. With consistency being one of the fundamental
properties in anthropometric study, it was noted that the ICC could serve
as an additional selection criterion to distinguish the robustness between
different extracted parameters.
It was observed, in general, that measurements that are derived from a func-
tional method such as various fitting procedures acquire a higher consistency
in both inter and intra-rater tests when compared to those that measures
directly upon anatomical landmarks. This confirms with various studies
(Croce et al., 1999; Besier et al., 2003; Hagemeister et al., 2005) and could be
explained by the fact that anatomical landmarks are usually small distinctive
regions instead of discrete points. More detailed discussion on the use of
functional methods in the study are discussed in the following sections.
199
9. Discussion
9.4. Performance of the Methodology
9.4.1. Automation
The implication of the methodology is two-folded. It provides a consistent

method in extracting anthropometric parameters with minimal subjective
user judgments involved. The consistent and well-defined methodology allows
comprehensive automation, delivering a good platform for further comparison
and analysis.
The procedure implemented in Matlab is mostly automated, with several

minor user interactions, mostly for confirmation and initialization purposes.
Upon loading the segmented CT stacks and confirming a few orientation
parameters, steps that require user interaction could be summarized as
follows:
• Confirmation of the automatically evaluated transepicondylar axis with

the option of a semi-automatic fall-back method.
• Selection of the starting and ending slice range of the posterior condyles
for cylinder fitting.
• Selection of the starting slice range of the distal trochlear groove.
Extra care and tests were taken in the automatic procedure to minimize the
effect of subjective user input in the above steps. A corner detection procedure
was added in the semi-automatic fall-back method (Figure 7.10 on page 133)
in the case when automatic discovery of the transepicondylar axis failed. The
effect of shifting the slice range in posterior condyles fitting was recorded
(Section 8.3.3 on page 179). The resulting procedure in Matlab could easily
be performed by users without specific knowledge in anthropometric studies.
9.4.2. Accuracy
Accuracy of measurements based on CT is well-established. Numerous studies

(Laine et al., 1997; Kim et al., 2000b; Prevrhal et al., 2003) have confirmed
a high accuracy on measurements taken from CT images, having additional
benefits of obtaining three dimensional measurements which is not possible
200
9.4. Performance of the Methodology
with traditional radiography. Prevrhal et al. (2003) investigated the accuracy

of CT in thickness measurements over thin structure under various scan
resolutions and reported that the sensitivity highly correlates with the slice
thickness, which is usually the largest singleton dimension, and the intersec-
tion angle of the measurements with the scanner axis. With the majority of
our measurements significantly above the sensitivity of current CT systems,
it is safe to assume sufficient accuracy is delivered in our CT datasets.
3-D models were generated using Mimics to provide an assurance on the

correctness of the Matlab implementation based on a third-party tool. 5
parameters including length measurements, neck shaft angle, head diameter
and neck length were measured and compared with values extracted using our
methodology (Section 8.4 on page 181). Differences of up to 3 mm and 3 degrees
were observed. Taking into account the fact that all measurements were
taken in Mimics by visual inspection, which would undoubtedly incorporate
a small amount of error, the difference was considered acceptable, and that
the correctness of our implementation could be assumed.
9.4.3. Consistency
Traditional Pearson’s correlation coefficient (r) suffers from the limitation

of only providing a measurement on the correlation between variables, but
does not provide an indication on the level of absolute agreement (Müller and
Büttner, 1994). For instance, a measurement which is always a double of the
reference one will give a perfect Pearson’s correlation coefficient of 1, while
their absolute agreement is poor. ICC provides a more robust evaluation
of concordance, which is more suitable in the evaluation of intra and inter-
rater consistency and was thus used extensively in testing of consistence and
concordance in the study.
Several variations of ICC were described by Shrout and Fleiss (1979). Based
on a detailed explanation by McGraw and Wong (1996) on the specific ICC
class to use, ICC(2,1) (Table 8.1 on page 168) was selected in our intra and
inter-rater consistency test with which both the judge and subject of interest
are assumed to be a random selection, while ICC(1,1) was employed in our
repeated scans test with which each scanner (judge) did not scan all the tested
samples (subject of interest). Another commonly used reliability test using
Cronbach’s α (Cronbach, 1951) was performed in additional to the ICC. In
201
9. Discussion
both cases, excellent intra and inter-rater consistency were observed and it is
concluded that the proposed methodology achieve the goal of being internally
consistent.
9.5. Reference Axes Definition
There are several reference axes schemes generally being adopted in anthro-
pometric studies (Dunlap et al., 1953; Yoshioka and Cooke, 1987; Noble et al.,
1988; Whiteside and Arima, 1995) of the femur as discussed in section 6.2
on page 98. Several aspects were considered in the definition of reference
axes. With variation in patient positioning during the image acquisition
stage, anatomical landmarks employed in the computation of reference axes
should be independent on patient position or orientation, well-defined and
reproducible for high consistency and accuracy. The ease of initial estima-
tion without an accurate reference frame is highly preferred, especially in
automation of the entire process. The robustness of the reference axes, as its
applicability towards different type of femur including pathological type, was
also considered.
9.5.1. Longitudinal Axis
Traditional anthropometric studies utilizing osteometric table often employ the

natural stable sitting position as its reference frame. Most studies (Parsons,
1914; Kingsley and Olmsted, 1948; Lausten et al., 1989; Jain et al., 2003)
rely on the fact that most femurs sit on the flat osteometric table on its
posterior surface with 3 supporting points (the distal posterior condyles, and
the posterior aspect of the greater trochanter), and defined the reference frame
based on the stable sitting position. One inherent drawback (Kingsley and
Olmsted, 1948) of the definition is the inability to handle retroverted femur,
where the proximal supporting point would shift to the posterior surface of
the femoral head.
Anthropometric studies based on CT and other 3-D imaging modalities have

higher flexibility to allow definition of virtual axes not based on anatomical
landmarks. Most studies (Lee et al., 1992; Kim and Kim, 1997; Mahaisavariya
et al., 2002) adopted a more functional approach with the longitudinal axis
202
(a) The use of full femoral shaft axis as (b) The use of proximal femoral axis as the longitudi-
the longitudinal axis. Note that the nal axis. The axis bisects the greater trochanter
axis no longer bisect the proximal independent on the amount of anterior bowing.
femur, but passes through the proxi-
mal aspect of the greater trochanter.
Figure 9.1.: Effect of anterior bowing on different definitions of the longitudinal

axis.
Reproduced from Dunlap et al. (1953).
defined as an estimation of the femoral shaft in a best-fit sense which is highly

consistent.
Anteversion angle is a measurement that is significantly affected (Dunlap

et al., 1953; Ryder and Crane, 1953) by the definition of the longitudinal
axis. Dunlap et al. further pointed out the ignorance of anterior bowing of
the femoral shaft would under-estimate the anteversion angle by as much
as 12◦ . In cases of moderate anterior bowing, the full femoral axis no longer
bisect the proximal femur but passes over the anterior aspect of the greater
trochanter. Taking into account the anterior bowing, the proximal femoral
axis was chosen as the default longitudinal axis in this study and singular
value decomposition was employed to obtain the 3-D best-fit estimation of the
long axis based on cross-sectional centroid coordinates. It was observed that
the use of proximal femoral axis as the reference longitudinal axis has an
additional benefit of closely aligning with the long axis of femoral prosthesis in
THR, thus may provide a more clinically-related measurement in the proximal
regions such as neck shaft angle and neck length. To provide extra flexibility,
extra options were incorporated into the user interface to allow the use of
entire femoral shaft as the longitudinal axis.
203
9. Discussion
One possible drawback of our modified long axis definition is the higher vari-
ability due to less cross-sections used. The lesser trochanter was selected as
the anatomical landmark to locate the proximal and distal limits in longitu-
dinal axis evaluation. It was noted that the conical eminence of the lesser
trochanter is easily identifiable, but CT artifacts, due to partial volume aver-
aging could adversely affect the accuracy, especially in the case of anisotropic
voxels with large slice thickness. Nevertheless, our consistency tests showed
that the deviation is minimal (mean 0.60◦ , σ=0.27◦ ) in misjudgment of the
lesser trochanter by ±3 mm superoinferiorly from the automatic evaluated
location.
The use of mechanical axis as the reference longitudinal axis was also studied.
Yoshioka and Cooke (1987) reasoned that the axes of motion maybe a more
appropriate approach to evaluate angular geometry of the hip and knee, and
thus employed the mechanical axis as the principal reference longitudinal
axis. The mechanical axis (Walmsley, 1933) was defined as the femoral head
centre to the attachment point of the posterior cruciate ligaments (PCL).
While the author agreed with the arguments suggested, various practical
difficulties were observed. The attachment point of the PCL is well-defined
anatomically but could be hardly distinguishable in CT. Second, the PCL-
femoral interface is a region rather than a discrete point, the representation
of the PCL attachment region with a discrete point would be inconsistent.
The adoption of mechanical axis as reference would potentially be feasible in
other imaging modalities such as MRI, but not in the case of CT.
9.5.2. Distal Transverse Axis
The transverse axis provides a rotational reference in additional to the longi-

tudinal axis. Most anthropometric studies based on osteometric table have
employed the posterior medial and lateral condyles as the rotational reference
evaluated with the tabletop method as described by Murphy et al. (1987).
The posterior condyles supporting points depend upon other factors such as
the amount of anterior bowing of the femoral shaft, and thus are not very
well-defined anatomical landmarks. Murphy et al. (1987) further pointed
out that the condylar axis suffers from rotational variations if excessively
proximal or distal cross-sections are used in axis evaluation. Nonetheless, its
locations are trivial in cadaveric studies, and are clinically correlated to the
horizontal plane when knee flexion is 90◦ .
204
We adopted the use of transepicondylar axis (TEA) as a rotational reference,

as first proposed by Weiner et al. (1978). The TEA is simple and, in general,
well-defined in CT. From a technical point of view, the epicondylar promi-
nences are not affected by the orientation of the femur. The TEA may serve
as a rotational reference for comparative study in total knee arthroplasty.
Additionally, the epicondyles could be the only reliable anatomical landmarks
left in some revision TKR (Griffin et al., 2000). Numerous studies (Berger
et al., 1993; Stiehl and Abbott, 1995; Poilvache et al., 1996; Olcott and Scott,
1999) have reported the importance of the TEA in the role as a rotational
reference of the femoral component in TKR. However, thick soft tissue and
the inconspicuous morphology of the medial epicondyle (Griffin et al., 2000)
have shown to introduce extra error (Jenny and Boeri, 2004; Siston et al.,
2005; Yau et al., 2005) in the accurate location of the TEA in clinical settings.
Under appropriate segmentation, the adverse effect of soft tissue could be
eliminated while the obscure structure of the medial epicondyle was found to
adversely affect the accurate location of the TEA in our CT datasets.
The proposed automatic TEA evaluation subroutine failed to identify several

cases, where the semi-automatic fall-back procedures were applied. The
reason was a lack of distinguishable prominence on the medial epicondyle
(Griffin et al., 2000).
Unlike the longitudinal axis which is a functionally derived axis from a large
set of datum points, the TEA could be significantly affected by inaccurate
evaluation of any one of the epicondylar points. The intra and inter-rater
consistency test (Section 8.2.1 on page 167) showed the TEA has a slightly
lower correlation coefficient, implying the posterior condylar axis may have
an edge for consistent rotational reference purpose. Note however that the
posterior condylar axis was evaluated after the reference system was set up,
in which possible variations due to the use of superior or inferior extremes of
the condyles described by Murphy et al. (1987) were minimized or eliminated.
While it has to be admitted the transverse axis has a larger variation than
anticipated, the extra rotational variance were tested to have minimal and
negligible effect on other parameters being extracted. More discussion on the
variations of the TEA observed in our study is discussed on section 9.7 on
page 217.
The use of surgical epicondylar axis (SEA) suggested by Berger et al. (1993)
has also been studied. It is defined as the the line connecting the lateral
205
9. Discussion
epicondylar prominence to the sulcus inferior to the medial epicondylar, the

attachment point of the medial collateral ligament. However, similar to the
location of PCL attachment point, the SEA is deemed not suitable in CT
images because of the location difficulty of the medial epicondylar sulcus.
This has also been reflected in studies (Kinzel et al., 2005; Lustig et al., 2008)
involving the use of SEA with CT, in which radio-oblique objects needed to be
inserted as landmarks prior to scanning.
Whiteside and Arima (1995) suggested the use of the anteroposterior axis (also
known as the Whiteside line) as a rotational reference instead of the TEA or
the posterior condylar axis. It was reported that the use of the anteroposterior
axis as a rotational reference of the femoral component reduced significantly
the number of patellar tracking problem that required realignment in valgus
knee. Nevertheless, other studies (Middleton and Palmer, 2007; Won et al.,
2007) have reported the anteroposterior axis alone has too large variation
to be employed as the rotational reference. It was noticed from our datasets
that the anteroposterior axis were hard to be well-defined because of the
variation observed down the patellar groove superoinferiorly which would
affect the anterior reference point of the axis. In cases of osteoarthritis in the
knee, it was not uncommon to observe large osteophytes in the intercondylar
notch or around the trochlear groove region, leading to extra difficulty in the
determination of the Whiteside line (Yau et al., 2008).
9.6. General Parameter
9.6.1. Head Centre
The femoral head offset, defined as the distance between the head centre and
the proximal femoral shaft, is one of the important factors being studied in
THR (Abraham and Dimon, 1992; Davey et al., 1993).
Optimal femoral head offset in THR could minimize the chance of hip dislo-
cation (Bourne and Mehin, 2004) and maximize range of motion (McGrory
et al., 1995). Austin et al. (2003) have pointed out that femoral offset is a
powerful tool for increasing THR stability without affecting the leg length.
This could reduce the chance of leg length inequality, which could contribute
to ipsilateral knee pain, low back pain, sciatic nerve palsy and even aseptic
206
loosening (Friberg, 1983; Edeen et al., 1995; Bose, 2000; Gurney et al., 2001).
A lateral offset is reported to have an effect of increase stability, decrease wear
and reduction of joint reactive force if used appropriately (Davey et al., 1993)
while the decrease of femoral offset could lead to an increase of polyethylene
wear in THR (Sakalkale et al., 2001).
Femoral head offset also serves a significant role in hip resurfacing (Beaulé
et al., 2007). Silva et al. (2004); Loughead et al. (2005) both reported the
decrease in femoral offset after hip resurfacing when compared to stemmed
implant. While the effect of femoral offset has been studied more extensively
in traditional THR, the actual effect of an decrease in femoral offset in hip
resurfacing is not well-defined (Girard et al., 2006).
Accurate femoral head centre evaluation serves as an important basis to

understand the morphology of proximal femur and correct measurement of
the head offset. The modeling of the femoral head by sphere fitting has
been a well-established and accurate technique in the determination of the
head centre and diameter (Kim et al., 2000a,b; Mahaisavariya et al., 2002;
MacLatchy and Bossert, 1996). Kim et al. (2000a) proposed an automatic
routine in obtaining a sphere estimate of the femoral head from CT. This
involved extracting contours of the head region proximal to the femoral neck
and fitting circle to every contour line. Pairs of circles were then used to
generate several fitted sphere, in which they were averaged resulting in the
final sphere estimate.
A two phase evaluation was adopted in our sphere fitting procedures. The
initial phase provided estimation from a set of datum points obtained at
the proximal aspect of the femoral head. However, under-estimation of the
femoral head diameter was observed in numerous cases. In the several cases
of pathologically deformed femur, the measured diameter is erroneous because
the femoral head was far from perfectly spherical. Cases with small femoral
neck-shaft-angle would lead to insufficient datum point and result in erroneous
outcome.
To circumvent this, a second phase was designed to capture further surface

datum points for a more robust fitting. The medial aspect of the head was
included into the fitting algorithm and the outcome is satisfactory and highly
consistent. The close fitting was confirmed by the close match of the outcome
with manual measurements (Figure 8.7 on page 182). The infero-medial aspect
of the femoral head was not included in the estimation because the capital
207
9. Discussion
drop osteophytes observed in numerous cases would introduce unnecessary

error in our fitting procedures.
The use of other fitting methods by means of reverse engineering from 3-D
model was also investigated. Numerous studies have (Mahaisavariya et al.,
2002; Song et al., 2007) presented accurate and reproducible femoral head
fitting routines based on 3-D surface model created from CT. While accurate
and consistent, the 3-D modeling approach suffers from the need of immense
amount of manual work. Even so, improvements have been seen in newer
software packages such as Mimics in the lengthy model creation procedures
with more encapsulation of technical details.
9.6.2. Neck
Apart from the previously discussed (Section 9.6.1 on page 206) femoral head
offset, which is primarily caused by the orientation of the femoral neck, the
neck region is another main focus in anthropometric studies.
With 5000 neck fracture recorded in New South Wales (Australia) alone in
2000, and a still increasing trend as reported by Boufous et al. (2004), fracture
risk prediction has always been an area of focus.
While it is widely accepted that BMD serves as a good prediction factor of

hip fracture (Cummings et al., 1993; Nicholson et al., 1997; Lochmüller et al.,
1998; Barr et al., 2005), an increasing amount of studies have reported neck
geometry being an additional prediction factor (Gómez Alonso et al., 2000;
Pulkkinen et al., 2004; El-Kaissi et al., 2005). El-Kaissi et al. (2005) reported
the observation of a wider neck width and reduction of cortical thickness in
fracture patients and Pulkkinen et al. (2004) confirms the combination of
BMD with geometric measures improved the assessment of fracture risk.
Relationship with BMD and neck geometry during aging has been suggested
by Kaptoge et al. (2003). Based on the fact that the cross-sectional modulus,
a measurement of bending resistance, does not decrease at the same rate
as BMD during aging, it was suggested that part of the effect of aging in
BMD could be a result from the expansion of the bone envelope. While no
quantitative relationship between the two has been documented, this gives
an insight on the possible role neck geometry could bear.
208
Racial difference has also been investigated. Nakamura et al. (1994) reported
that Japanese women have a substantially lower incidence of hip fracture
than North American whites due to different geometric characteristics of the
femoral neck. Despite lower femoral neck bone mass, it was shown that the
lower risk of structural failure in the femoral neck of Japanese women is
attributed primarily to a shorter femoral neck and a smaller neck shaft angle.
Other studies (Bergot et al., 2002; Pulkkinen et al., 2004) have also confirmed
the use of femoral neck length and upper femoral geometry in improving the
assessment of hip fracture.
While various studies abovementioned have suggested relations between

fracture risk and femoral neck geometry exist, there is not yet a widely
accepted conclusion. Bouxsein and Karasik (2006) suggested the limited
knowledge could, in part, be attributed to the predominant use of 2-D imaging
techniques to estimate bone geometry. The adoption of 3-D imaging would
be needed to better characterize the relationship between bone geometry and
skeletal fragility. While the use of hip strength analysis (Martin and Burr,
1984; Lou Bonnick, 2007) based on DXA may deliver an estimation of 3-D
geometry, various studies (Beck, 2003; Gregory et al., 2004) have pointed out
its use suffers from unavoidable rotational and magnification errors. This
further strengthens the significance of our proposed methodology to deliver a
consistent and accurate 3-D geometric understanding of the proximal femur.
Based on existing 2-D DXA, the application of stereo-radiographic 3-D recon-

struction from standard biplanar DXA images has also been reported (Kolta
et al., 2005), though its robustness is yet to be confirmed. Still, this indicates
the increasing focus of three dimensional structure which could deliver a more
accurate representation of anatomy.
Accurate evaluation of the neck axis is essential for the calculation of the
anteversion angle, which is one of the most important geometric parameters
determining the relative rotational orientation between the proximal and
distal femur. Details of the anteversion angle will be discussed in later section
(Section 9.7 on page 217).
Accurate and robust evaluation of the neck axis has always been a challenging
task in anthropometric studies. Commonly described as a tapered cylinder
in shape, analysis of the femoral neck poses great challenges because of its
variability and the lack of distinguishable anatomical landmarks. Kingsley
209
9. Discussion
and Olmsted (1948) commented on the determination of the true longitudinal

neck axis as the most difficult part of his anthropometric study.
Numerous methods of neck axis identification on cadaveric studies were

documented (Section 6.4.2 on page 111). The method of evaluating two mid-
points between the anterior and posterior neck surfaces in superior view
(Kingsley and Olmsted, 1948) was most commonly employed. The inherent
restriction of the method and its derivatives is the inability to take into
consideration the cross-sectional shape in the evaluation of the neck axis.
The use of 3-D imaging methods in general allows a more fine-grained evalua-
tion of the neck axis Hernandez et al. (1981). However, most scanning protocols
produce an oblique view of the neck region by default. This introduces extra
difficulty in the identification of the neck axis without further post-processing.
The use of a single oblique cross-section in the evaluation of the true neck
axis (Weiner et al., 1978; Hoaglund and Low, 1980; Hernandez et al., 1981)
has been criticized Murphy et al. (1987). More robust techniques involving
the use of optimization techniques to obtain a orthogonal cross-section with
minimized area has also been suggested (Kim et al., 2000b; Mahaisavariya
et al., 2002).
In a study of the morphometry of the hip in developmental dysplasia patient,

Sugano et al. (1998) utilized the centroids of a wider range of neck region
(21 mm) in the evaluation of the neck axis from a reconstructed 3-D model.
However, no details were provided on the actual methodology and the reason
of why 21 mm of neck region was chosen was not documented.
One inherit limitation of the methods reviewed above is the use of only a fixed
partial or localized region in the evaluation of the neck axis. Høiseth et al.
(1988) reported the radially asymmetric property of the femoral neck, and
further pointed out the impossibility to precisely evaluate the neck centre by
any combination of bi-planar projections. We have observed that the reliance
on such a localized region could be error prone especially in pathological
cases where the neck shape is deformed. To overcome this shortcoming, our
proposed technique tried to take into account a larger region of the neck in
the estimation of the true neck axis.
Morphological skeletonization (Section 4.5.6 on page 72) on flattened AP image

was found to provide a automatic yet reliable initial estimation of the neck
base within all our CT datasets, allowing the entire neck axis evaluation to
210
be fully automatic. Skeleton intersections (Figure 7.22 on page 144) were

incorrectly identified in several cases when an extra skeleton branch was
generated proximal to the lesser trochanter, leading to a less accurate initial
estimate. Even so, subsequent steps in the optimization procedures were
able to rectify the minor deviation. The proposed method with the use of
morphological skeletonization (Section 7.3.5.1 on page 142) delivered a robust
approach for bootstrapping the initial neck axis by automatically adapting
to the morphology of individual femur, and is independent on the neck shaft
angle and neck length.
The second phase of neck axis evaluation was based on the initial estimation
obtained above. Two different algorithms were proposed and tested in our
final design. The cylinder fitting optimization procedures (Figure 7.24 on
page 146) were initially conceptualized with the thought of modeling the neck
as a cylindrical shape. This has an advantage of taking into account the shape
of the entire neck region rather than limiting the definition to a selective
localized neck region. With the optimization procedures proposed, the need for
using the head centre as one of the reference points is avoided. The cylinder
fitting procedures identified the neck axis in all our human CT dataset except
one case where severe deformation of the head neck region was observed with
a shortened neck. The insufficient cross-sections of the neck region resulted
in a bad cylinder fitting. Despite this extreme pathological case, the cylinder
fitting algorithm was found to be very robust in the evaluation of human
femoral neck axis.
The main drawback of modeling the neck region as a cylindrical shape is the
inaccuracy encountered when applying the algorithm to our sheep dataset.
It was noted that the morphology of sheep femoral neck has considerable
difference when compared to the human. The sheep neck is more cylindrical
at the femoral head end and gets more fanned out and more flattened in the
coronal plane at the neck base than that of the human. Further investigations
suggested that the use of areal centroids on the cross-sections delivered a
more reliable outcome and is able to handle all our human and sheep datasets.
One additional difficulty was encountered at the definition of the neck base.
The femoral neck extends from the femoral head till the intertrochanteric line.
However, it was noticed that the inclusion of the neck region approaching
the intertrochanteric line would over-estimate the neck shaft angle due to
the asymmetric fanning inferiorly to the lesser trochanter region. A more
conservative approach was adopted in which the extreme end of the neck base
211
9. Discussion
was excluded in our calculation but whether the approach is optimal is yet to
be concluded.
The proposed algorithm does not rely on the femoral head centre as a reference
point of the neck axis. Kingsley and Olmsted (1948) cited the term “capit-
o-collar” axis documented by Pearson and Bell (1919) who implied the head
may not be centred on the femoral neck. Thus the femoral head centre should
not be considered in the evaluation of the neck axis. Measurements on our
human dataset showed that a mean distance of 1.21mm (range: 0.22–2.88mm)
exists between the computed femoral head centre and neck axis. While this
maybe considered a confirmation with observation by Kingsley and Olmsted,
the difference could be originated from errors involved in the process.
A lower intra, inter-rater consistency of the distance from neck axis to head
centre was observed. A possible reason is the low value (mean 1.21mm) of
the attribute, in which the sensitivity limit of our CT datasets is reached.
With the slice thickness of our human CT dataset ranging from 1mm to 2mm,
a lower consistency on the measurement due to quantization error is not
surprising.
Consistency test of intra and inter rater resulted in high correlation for neck
shaft angle (ICC > 0.9) and neck length (ICC > 0.99). The largest neck shaft
angle variation of 2.5◦ was observed under repeated CT scan of the same
femur under different resolution. To our knowledge, no previous studies have
documented their neck axis evaluation consistency on intra, inter-rater and
on repeated scans.
It was observed that the neck axis, when extended laterally, lies anterior to
the proximal femoral axis by an average of 10.7mm in our Australian dataset.
The neck axis elevation was noted to have a slightly lower consistency in
our intra, inter-rater and repeated scan test. It was suspected the lower
consistency is attributed to the pivoting effect of the neck axis where the error
of measurement is being magnified.
9.6.3. Posterior Condyles & Knee Centre
Traditional studies have demonstrated the use of instantaneous centre of

rotation (Frankel et al., 1971; Walker et al., 1972; Blankevoort et al., 1990)
and helical axis (Jonsson and Kärrholm, 1994; Sheehan, 2007) to represent
212
knee kinematics. This implies the rotation of knee does not have a fixed
axis of rotation. Recent studies (Hollister et al., 1993; Churchill et al., 1998)
however have confirmed that knee kinematics could be modeled with two fixed
non-orthogonal axes. Churchill et al. (1998) concluded that the optimal knee
flexion axis agreed with the rotational centre of the posterior femoral condyles,
which has a circular shape profile. This has shown that knee kinematics
could be closely associated and modeled with the functional morphology of
bone. While the accurate determination of the rotational centre of the femoral
condyles may not be straight forward in clinical environment, the use of
imaging techniques based on 3-D data would allow the optimal flexion axis to
be evaluated consistently and accurately.
Motion of knee is constrained by the articular geometry of the articular

surfaces and the muscle forces acting on it and various studies have reported
the representation of the knee or distal femoral geometry by various means,
including the use of digitizer Zoghi et al. (1992) ,3-D imaging techniques (Siu
et al., 1996) and mathematical model (Imran and O’Connor, 1997). Li et al.
(2006) have pointed out the importance of the understanding of the condyles
geometry in analyzing reaction force in the cruciate ligaments. Added the
fact that the posterior condylar axis have been reported to be in use as an
rotational alignment in TKR (Matsuda et al., 1998, 2004), the study of the
geometry of the posterior condyles would provide additional information in
the understanding of knee kinematics.
Churchill et al. (1998) utilized electro-magnetic position sensors in the deter-

mination of the optimal knee flexion axis and obtain the best-fit circles of the
medial and lateral condyles on the 2-D plane orthogonal to the evaluated opti-
mal flexion axis. Without prior knowledge to the experimental optimal flexion
axis, the entire fitting procedures were not constrained to two dimensional. It
was observed that without the extra planar constrain, the fittings of individual
circle to each posterior condyles could be error prone. To circumvent this,
cylinder fitting procedures were employed to model the medial and lateral
condyles as a single entity to provide additional rotational constrain.
The proposed cylinder fitting subroutines to model the posterior condyles

resulted in negligible fitting error in all our datasets. Over an average of 40
condyles datum points used for fitting on each femur, the average sum of error
is 3.8 across our Australian dataset. Note that the Lorentzian minimization
(Figure 7.18 on page 141) was applied to minimize impact of possible outliers
due to the inclusion of datum points at the superior extreme. Thus the sum
213
9. Discussion
of error calculated does not correspond directly to the sum of fitting error in
millimeter.
Additional tests were done to evaluate the effect of subjective user slice
range selection towards the cylinder radius (Section 8.3.3 on page 179 and
appendix E.2 on page 265). It was concluded that the effect of subjective user
range selection was minimal under normal conditions. Larger errors were
observed in samples with a larger slice thickness and it was found that a
minimum of around 15 slices are necessary to give an accurate and consistent
cylinder fitting. This pose a limitation on the maximum slice thickness that
could be used in the image acquisition stage.
Based on the optimized cylinder fit, the knee joint centre could easily be
obtained by taking the mid-point on the cylinder axis. While the mid point of
the epicondyles were often used (Stagni et al., 2000; Li et al., 2004; Coventry
et al., 2006; Stefanyshyn et al., 2006; Holmberg and Lanshammar, 2006),
Hagemeister et al. (2005) reported a higher repeatability in the the definition
of knee joint centre by the circle fitting procedure rather than adopting the
transepicondylar axis. This conforms to our findings in which the location of
the epicondyles exhibit a larger variation in our consistency tests compared
to the cylinder fitting procedure.
However, our definition of knee joint centre was slightly different to that
proposed by Churchill et al. (1998). The main reason for the modification
is the need for an undergoing study to identify a consistent and repeatable
reference datum point on the knee surface for a patella tracking experiment
Bertollo (2007) and the fact that the knee joint centre proposed by Churchill
et al. is not positioned on bone surface. Based on the joint centre defined by
Churchill et al., the joint centre was deliberately projected back to the most
inferior point on the knee joint surface as shown in figure 6.20 on page 121.
It was noted that the defined joint centre is of close proximity to the posterior
cruciate ligaments attachment point in the intercondylar notch, in which it
was sometimes being used as a anatomical landmark to define the mechanical
axis of the femur (Yoshioka et al., 1987; Croce et al., 1999).
Excellent consistency of the cylinder evaluation was obtained in all intra,

inter-rater and repeated scan test. A maximum radius discrepancy of merely
0.91 mm was observed in a pair of repeated scan test, where the slice thickness
of one of the scans was 2 mm. The high repeatability could be attributed to
the fact that the cylinder is evaluated based on a functional method and not
214
relying on the accurate location of a particular anatomic landmark. Numerous

studies (Croce et al., 1999; Besier et al., 2003; Hagemeister et al., 2005) have
confirmed the use of functional methods in defining joint centre and axis
as an effective way to reduce variability when compared to pure anatomical
landmarks definition.
One drawback of our cylinder fitting method is the inability to quantify the
radii of curvature of the medial and lateral condyles individually. Most studies
(Churchill et al., 1998; Iwaki et al., 2000; Besier et al., 2003) reported a slightly
larger (~2 mm) radius of curvature on the medial condyle relative to the lateral
condyle, while fewer studies (Lustig et al., 2008) reported no difference in the
radii of curvature of the condyles. Additional test were done to evaluate the
radius of curvature of the individual condyle. Contrary to previous studies,
we observed that the lateral condyles of our Australian dataset have a slight
1.2 mm larger radius of curvature than the medial condyle. The healthy
Japanese dataset, however, showed no significant difference between the two
condyles. Further investigation was performed by constructing 3-D models
using Mimics and confirmed the findings.
One possible explanation for the discrepancy observed when compared to

previous findings is the absence of an experimental optimal knee flexion
axis in the study. Without the prior definition of the experimental optimal
flexion axis, our circle fitting procedures are not constrained to the plane that
is orthogonal to a particular axis. While the fitted circles to the condyles
are theoretically more optimal with the extra 2 degrees of freedom in the
optimization process, the medial and lateral circles are likely to be not parallel.
It was observed from the 3-D models generated in Mimics that the judgment
of the radius of curvature depends highly upon the orientation of the bone
and thus a priori definition of the experimental flexion axis may explain the
difference observed.
Churchill et al. (1998) pointed out that the medial and lateral epicondyles
coincide with the optimal flexion axis of the knee. Nonetheless, various
studies (Elias et al., 1990; Hollister et al., 1993; Lustig et al., 2008) reported
the condyles centre does not coincide with the mid-point of the epicondyles.
Comparison within the Australian (Section 8.5.2 on page 183) dataset showed
a significant difference between the best-fit cylindrical condyle axis and the
epicondylar points. The medial epicondylar point has an average of 13.1 mm
anterior to and 8.2 mm superior to the cylinder axis. The lateral epicondylar
point is however of a closer proximity to the cylinder axis, with an average
215
9. Discussion
anterior and superior displacement of 4.4 mm and 2.7 mm respectively. Even

so, the average angular discrepancy of 7.3◦ between the two axes would be too
large to conclude the two axes coincide.
9.6.4. Canal Flare Index
The canal flare index (CFI), initially defined by (Noble et al., 1988), is an
effective index to describe the flare shape of the proximal medullary canal.
The classical CFI is defined as the ratio of the intra-cortical width of the
femur, at the section 200 proximal to the lesser trochanter and that of the
canal isthmus. Three categories were defined, namely stovepipe, normal
and champagne-fluted canals. Other derivatives of the CFI exists, aiming
to provide additional information on the medullary flare (Section 6.4.3 on
page 114).
Relationship between CFI and pathological conditions in various population

groups have been reported (Yang et al., 2005, 2006; Liu et al., 2007; Kawate
et al., 2008). Other studies have pointed out the CFI variation in different
races (Khang et al., 2003) and age groups (Noble et al., 1995).
Fessy et al. (1997) reported that CFI is one of the important factors in the
implant choice in THR
3 derivatives of the classical flare index proposed by previous studies (Sec-

tion 6.4.3 on page 114) have also been measured.
Attempts have been made in the usage of Fourier descriptors in the represen-
tation of the proximal medullary shape (Section 5.3.2 on page 85). Based on
the methods suggested by Kuhl and Giardina (1982), a preliminary study was
done in which multiple measurements of the canal width were made and an
elliptical Fourier descriptors were applied to construct a shape representation
of the canal flare. Instead of using only a ratio of two measurements to
quantify the flare, the use of Fourier descriptor takes into consideration of
the entire flare shape. It was noted that the Fourier harmonics were able to
distinguish a more fine-grained difference such as the concavity of the canal
and would be a plausible tool to describe the full canal shape when extended
to three dimensional. Nonetheless, even the difference of shapes pair could
be quantified by computing the sum of difference between the two harmonics
sets, we were unable to conglomerate the harmonics outcome to sort into a
specific shape category.
216
9.7. Anteversion Angle
The anteversion angle is one of the most studied anthropometric parameter

and is closely related to total hip replacement. Excessive or insufficient antev-
ersion in hip arthroplasty may lead to component impingement, dislocation,
subluxation, limited range or motion or aseptic loosening (Masaoka et al.,
2006; Kessler et al., 2008; Kleemann et al., 2003).
The anteversion angle involves the definition of two axes, namely the distal
transverse axis and the femoral neck axis. With both of the axes not being
very well-defined, numerous definitions and methodology exists in the deter-
mination of the anteversion angle. The distal posterior condylar axis (Parsons,
1914; Kingsley and Olmsted, 1948) obtained by the tabletop method is by far
the most commonly used distal transverse axis. The use of a height gauge
(Figure 6.1 on page 100) in the determination of the neck axis Kingsley and
Olmsted (1948) has also been extensively applied (Lausten et al., 1989; Kim
et al., 2000a; Jain et al., 2003) in anthropometric studies based on osteometric
table.
Yoshioka and Cooke (1987) recommended the use of the transepicondylar

line as the transverse axis because of less geometric variation involved when
compared to the posterior condyles. However, consistency test of our proposed
methodology slightly favor the use of the posterior condylar axis especially in
the case of repeated scan test with different scanning resolution (Table 8.10
on page 173).
While both the use of the posterior condylar axis and transepicondylar axis in
anteversion calculation were statistically consistent in our intra, inter-rater
and repeated scan test (ICC > 0.9), it was noted that anteversion angles based
on the transepicondylar axis resulted in a slightly larger discrepancy.
The anteversion angle is not a direct angle between any two axes, but a
projected angle on the transverse plane, and thus highly dependent on the
viewing perspective. Dunlap et al. (1953) pointed out the influence of the
anteversion angle due to the anterior bowing of the femoral shaft. It was
suggested that the proximal one fourth of the femur should be used as the
longitudinal axis such that the axis bisects the greater trochanter. This forms
the basis as to why the proximal femoral shaft was chosen as the longitudinal
axis as discussed in section 9.5.1 on page 202.
217
9. Discussion
Figure 9.2.: Posterior bow at the femoral metaphysis

Notwithstanding, most anthropometric studies (Kingsley and Olmsted, 1948;

Lausten et al., 1989; Kim et al., 2000a; Jain et al., 2003) have chosen to adopt
the full femoral shaft as the longitudinal axis implicitly or explicitly. We
anticipate that it could be due to the simple and well-defined tabletop method
proposed by Kingsley and Olmsted (1948), in which the longitudinal axis is
implicitly close to the full femoral shaft axis. The difficulty in defining the
proximal femoral axis on an osteometric table would possibly limit the use of
the proximal femoral axis for practicability reason.
One interesting and less documented parameter measured is the proximal

metaphysis posterior bowing. Noble et al. (1988) documented the observation
of a compensating posterior bow at the proximal femoral metaphysis that leads
to an average anteroposterior displacement of 8 mm between the medullary
axis and the cross-sectional centroid at the site of conventional neck osteotomy.
An angle α was defined as the angle between the anterior and posterior
bow intersection (Figure 9.2). Nishihara et al. (2003) followed the method
suggested and reported a larger α angle in dysplastic femora while both
authors did not present a precise definition of how the posterior bow is being
measured. Most other studies (Barsoum et al., 2007) briefly documented the
existence of a proximal posterior bowing in femoral stem design without much
quantitative information given.
In an attempt to evaluate the angle α, it was discovered that a clear and

consistent definition could not be made. There was no anatomical landmark
with which a reference datum point could be defined, and the angle is highly
218
dependent on the viewing perspective or the rotational alignment of the femur.

Instead, the anteroposterior elevation of the neck axis based on the proximal
femoral axis delivers a more consistent and well-defined measurement.
A mean neck axis elevation of 10.7 mm (Range: 7.6–15.0 mm) was observed
in our Australian dataset while a mean of 8.6 mm (Range: 6.0–9.9 mm) was
recorded in our Japanese dataset and is statistically different (P=0.002).
From a geometric point of view, the elevation of the femoral neck may sig-
nificantly affect the anteroposterior offset of the femoral head. With an
average anteversion angle of 10◦ with reference to the transepicondylar axis
TEA)
(∠(NA, ) and an average neck length of 50 mm observed, the anterior
femoral head offset due to femoral neck anteversion alone is 8.7 mm (50×sin 10◦ ).
Compare with an average neck axis elevation of 10.7 mm, it is deduced that
the anterior femoral head offset with reference to the proximal femoral axis is
a resultant effect of both the femoral neck anteversion and the neck anterior
offset.
With the assumption of our longitudinal axis being closely aligned to the
long axis of the femoral component in THR, it may imply the need to apply
additional anteversion on the femoral component that has none or insufficient
anterior neck offset, to achieve the necessary anterior offset of the femoral head
to mimic the original hip morphology. A comparison between the commonly
used neck anteversion angle and the anteversion computed using the femoral
axis (∠(HCF A, TEA)
, ∠( HCF A, CA)
) revealed a mean difference of 15◦ and 10◦
in our Australian and Japanese datasets respectively. This implies if the
same anterior femoral head offset is to be obtained, an additional 10◦ –15◦ of
anteversion would need to be applied to the femoral component in THR. It
was noted that some hip arthroplasty systems (e.g. the Zimmer APR Hip
System) incorporate a 10◦ of anteversion into their femoral stem design. Several
clinical studies (Gill et al., 2002; Barsoum et al., 2007) have pointed out that
an increase in the anteversion by 10◦ –20◦ on the femoral component increases
stability and possibly reduce the chance of impingement or dislocation. From
a morphological point of view, It is felt that one of the reasons of the act may
be back-traced to the basic principle in the attempt to restore a closer original
morphological structure of the femur.
A few studies (Husmann et al., 1997; Argenson et al., 2002) documented

measurements of the helitorsion angle which is the torsion angle between the
posterior condyle axis and the cross-sectional plane 20 mm proximal to the
219
9. Discussion
Figure 9.3.: The helitorsion angle compared to the anteversion angle.

Reproduced from Husmann et al. (1997).
Figure 9.4.: The use of full femoral shaft as the longitudinal reference axis
in determination of the anteversion angle. Under this reference
system, the long axis of the femur and the femoral neck axis are
in close proximity in the superior view and neck axis elevation is
virtually non-existent.
lesser trochanter. Husmann et al. (1997) pointed out 25% of his dataset has
an anteversion helitorsion difference of larger than 10◦ . While the definition
of helitorsion is different from our definition of the neck axis elevation, it
was observed that the angular difference could possibly be affected by the
elevation of the neck axis over the proximal femoral axis.
With reference to the comparison done using a different longitudinal reference

axis (Section 8.3.2 on page 177), it was noted that the anterior displacement
of the neck axis changed significantly from an average of 9 mm (proximal
femoral shaft as reference) to -2.6 mm (full femoral shaft as reference), which
lead to a reasonable general assumption that the neck axis crosses the femoral
axis as shown in figure 9.4. The negligible neck axis displacement when
adopting the full femoral shaft as the reference longitudinal axis may explain
why the parameter is seldom studied in literature.
220
9.8. Sheep Femur
9.8. Sheep Femur
19 adult crossbred wethers femur were processed successfully without the need
of modification of the core methodology proposed. Several parameters were
scaled down due to a smaller-sized femur in sheep in the process of evaluating
the reference axes, and were all adjustable in the GUI. The main aim of the
inclusion of sheep femur is to demonstrate the robustness of the methodology
and also to initialize a database to systematically record anthropometric
parameters in sheep femur, which is a common animal model being used in
the field of Orthopaedics.
It was noted that while the sheep femur may have distinct difference when
compared to that of healthy human, structural similarity exist. The same
applies to human femur with pathological conditions. This explains the robust-
ness of relying on a structural method in the measurement of anthropometric
parameters. For instance, the use of morphological skeletonization in the
initial estimation of the neck axis offers a more adaptive approach to accom-
modate variations observed in sheep, and human with pathological conditions
without the need of manual tuning.
While the sheep and human femur share a similar coarse structure, several
distinguishable differences were observed. The femoral neck of sheep tends
to fan out asymmetrically to a larger extent and is relatively more flattened
in the coronal plane. This implies the reliance on a single cross-section in the
determination of the neck axis could be error prone. The use of a cylindrical
representation of the region were also discovered not optimal for the case, as
discussed previously (Section 9.6.2 on page 208).
The use of transepicondylar axis (TEA) as a rotational reference may not be

optimal in the case of sheep because of the relatively large indistinguishable
prominence of the epicondyles. Manual selection based on the fallback TEA
estimation was always necessary, and even so, it was observed that the
inconspicuous epicondyles caused extra difficulty in the selection. The use of
the posterior condylar axis in the evaluation of the anteversion angle would
be more accurate.
The spherical surface of the femoral head in sheep is less than that of human.
This may explain the more restricted range of motion in hip joint of sheep
when comparing to that of human. The use of optimization procedures in the
sphere fitting procedure in the representation of sheep femoral head would
221
9. Discussion
be an advantage here due to the fact that direct measurements on the partial
sphere surface may not be feasible.
Another major difference apart from the general size is the canal flare index.
The mean value of CFI ml is between 3 to 4 in our human dataset, and coincides
with the literature (Noble et al., 1988; Laine et al., 2000) while the value
observed in our sheep dataset is of a much lower value of 1.84, which is
categorized as stovepipe. This may have an influence on the selection or
design in the use of sheep model for study involving femoral stem.
Apart from a demonstration on the robustness of the proposed methodology,

the future application of the methodology on sheep femur would enable a
more detailed and quantitative summary on its morphology, which would
possibly deliver valuable information in future experimental design in the use
of sheep as an animal model in orthopaedic studies.
222
10
Conclusions
methodology has been developed and implemented in the extraction of

A anthropometric parameters of the femur. This provides a robust platform
for future anthropometric analysis (Section 7.5 on page 158).
The method was tested to have a very high intra, inter and repeated scan
consistency. This could be attributed to several causes. The extensive use
of functional methods instead of direct reliance on anatomical landmarks
significantly reduce the effect of possible variations in anatomical landmarks
location. Parameters evaluated based on a functional method such as the
cylindrical fitting of the posterior condyles has shown to have, in general, a
higher ICC and Cronbach’s α when compared to other parameters such as
the CFI.
The use of functional methods together with the structural approach further
allowed the proposed methodology to process the osteoarthritis datasets, in
which deformation of the proximal femoral geometry is common. It was
observed that in processing femurs with pathological conditions, assumptions
on the absolute locations of anatomical features may no longer hold true, and
more adaptive techniques were necessary. For instance, the application of
morphological skeletonization in the first estimation of the neck axis have
proven to deliver an adaptive technique catering a diverse range of femoral
geometry.
The robustness of the proposed method was further demonstrated by the

application to the sheep femoral datasets. With sheep being used as a common
animal model in orthopaedics in, for instance, femoral implant testing, a
comprehensive understanding of the femoral geometry of sheep would be
advantageous.
223
10. Conclusions
Automation in the anthropometric parameter extraction stage has also be

achieved. While the proposed methodology is not fully automated, very few
user interactions were necessary.
10.1. Limitations and Future Directions
While the consistency tests conducted resulted in very high consistency within
our intra-rater, inter-rater test settings in segmentation, the image segmenta-
tion stage was expected to be still the main source of inconsistency. Attempts
have been made to automate the image segmentation step without much suc-
cess. Further investigation on the improvements towards a more automated
segmentation algorithm would be desirable.
It was noted that the use of CT in the study may not be optimal. CT is
inherently poor in imaging articular cartilages, posing a limitation in which
the cartilage structure would be ignored in anthropometric studies. MRI has
been another emerging image modality with which articular cartilages could be
imaged. Quantitative CT has also proven to provide accurate BMD information
in additional to bone geometry. The combination of bone morphology and
accurate 3-D BMD figures may be a new ground in areas such as fracture
risk prediction. Further investigation on the incorporation of other imaging
modalities in the study would be desirable.
As a proof of concept, the primary use of the CT datasets in this study is to

demonstrate the robustness of the proposed methodology. It has to be admitted
that the small sample size, and the lack of detailed biological information
on part of the datasets are limitations of the work. Due to this limitation,
direct anthropometric comparison between literature and our datasets was
not performed. Even though many of our measurement results fall within the
coarse range of that reported in the literature, further conclusions shall not
be made at this stage because of a lack of statistical power.
Likewise, the number of sheep samples may not be sufficient to quantify the
morphological properties and its variations in the present study. A larger
dataset would be necessary to further unleash the full potential of the proposed
methodology in anthropometric analysis.
224
A
Function Summary
225
226
Table A.1.: Function summary of the Matlab subroutines.
Name (m-file) Description Lines Calls Calls Calls in Sub-
to from file functions
femur_anthro_gui The main function initiating the 1326 33 0 154 66

GUI and callback functions
A. Function Summary
align_model_axis Apply affine transformation based 211 3 1 19 1

on the longitudinal and transverse
reference axes
bone_orientation_detection Detect whether the CT stack is 173 2 1 19 1

proximal or distal starting
corner Identify corners of an image 407 0 1 51 6
crop_bone_mask Resize the CT volume to the small- 93 1 1 15 1

est bounding box
cvoronoi Compute the Voronoi diagram, and 1263 0 1 155 10

the largest inscribed circle
cylinder_fit Cylinder fitting based on the 94 0 1 16 1

Lorentzian minimization function
deleteoutliers Remove outliers of a series based 103 0 1 17 2

on their deviation from the mean
drawedgelist Draw lines connecting consecutive 89 0 1 14 1

2-D coordinates
est_lesser_trochanter Second estimation of the lesser 119 5 1 20 1

trochanter by locating the most
prominent point away from the
proximal femoral axis
euclidean_distance Compute the euclidean distance be- 35 0 1 4 1

tween points
export_to_file Export results to delimited text file 244 2 1 7 1
export_to_mat Export results to mat file format 46 0 1 5 1
export_workspace Export entire Matlab workspace 50 0 1 6 1

to file
extrema Compute the global maxima points 146 0 2 14 1

from a time series
find_anterior_bow Compute the radius of curvature of 100 5 1 10 1

the anterior bow
227
find_anteversion_angle Calculate the anteversion angles 54 1 1 4 1
228
find_best_fit_circle Estimate the best-fit 2-D circle 115 0 2 7 1

based on a list of input 3-D coor-
A. Function Summary
dinates
find_best_fit_plane Estimate the best-fit 3-D plane on 135 0 1 9 1

a set of 3-D coordinates
find_best_fit_sphere Estimate the best-fit sphere based 89 0 1 8 1

on a list of input 3-D coordinates
find_canal_flare_index Compute the canal flare indices of 70 2 1 14 1
the proximal femoral shaft
find_condylar_cyl_fit Cylinder fitting to the posterior 227 8 1 33 1

condyles
find_condylar_tangential_line Compute the posterior tangential 59 0 2 13 1

line touching the medial and lat-
eral condyles
find_epicondylar_axis Construct the epicondylar axis 317 6 1 44 1

based on the medial and lateral epi-
condyles
find_femoral_axis Evaluate the femoral axis by fitting 119 4 2 21 1

a best-fit line using singular value
decomposition
find_femur_length Compute various measures of the 28 1 1 3 1

femoral length
find_greater_trochanter Locate the superior tip of the 61 3 1 13 1

greater trochanter
find_greater_trochanter_height Compute the height of the supe- 79 3 2 25 1

rior tip of the greater trochanter
to the trough between the femoral
head and the proximal aspect of the
trochanter
find_head_centre Evaluate the femoral head centre 200 5 1 26 1
find_head_epicondylar_dist Measure the perpendicular dis- 29 1 1 3 1

tance from the femoral head to the
epicondylar axis
229
230
find_head_offset Compute the offset between the 20 1 1 3 1

fermoal head and the lesser
A. Function Summary
trochanter and femoral axis
find_lesser_tro_epicondylar_dist Measure the distance between the 31 1 1 3 1

lesser trochanter and the epicondy-
lar axis
find_lesser_trochanter First estimation of the lesser 191 2 1 15 1

trochanter by locating the most
posterio-medial coordinates along
the femoral shaft
find_neck_props Compute cross-sectional properties 241 4 1 34 1

of the resliced femoral neck binary
images
find_post_condylar_axis Evaluate the posterior condylar 47 3 1 9 1

axis
find_section_props Compute cross-sectional properties 399 5 1 33 1

of the femoral shaft
find_shaft_section_props Compute cross-sectional properties 173 3 1 16 1

of the proximal femoral shaft
find_skel_intersection Determine the locations of the in- 97 2 1 19 1

tersection points on a morphologi-
cal skeleton
findn A helper function to find the index 33 0 1 6 1

in an 3-D matrix satisfying certain
criteria
fix_bone_orientation Flip the imported CT to a proximal- 37 1 2 5 1

starting and anterior-top position
gen_circle Generate coordinates of a circle 20 0 1 6 1

with a given centre coordinates and
radius
get_files Dialog box for selection of input 47 0 1 7 1

files
gui_disp Print message to the output pane 45 1 27 15 1

on the GUI
231
232
gui_msg Print message to the message pane 26 0 2 7 1

on the GUI
A. Function Summary
hungarian Compute the optimal assignment 280 0 1 34 8

with the Hungarian method.
import_workspace Import Matlab workspace 25 0 1 7 1
lineseg Compute an estimation of an edge 78 1 1 3 1

by means of connecting straight
line segments
load_bone_mask Load the binary bone mask in DI- 104 1 1 10 1

COM format
maxlinedev Helper function to find the point 84 0 1 9 1

of maximum deviation from a line
joining the endpoints of an edge
recrop_bone_mask Crop the bone matrix to the small- 92 2 1 13 1

est bounding box
reslice_neck Reslice the neck region such that 587 7 1 51 1

the cross-sections are perpendicu-
lar to the long axis of the neck
sim_xray_dexa Illustration a flattened image of dif- 175 1 1 27 6

ferent orientation
sortclasses Group list of coordinates based on 137 0 1 6 1

its connectivity
split Split a string into smaller strings 18 0 1 2 1

based on the locations of delimiter
tomm Convert coordinates unit from pixel 29 0 16 5 1

to millimeter
topixel Convert coordinates unit from mil- 25 0 11 5 1

limeter to pixel
trochlear_groove_analysis Compute the best-fit plane on the 209 3 1 36 1

trochlear groove region
233
234
uiGetFiles Alternative dialog box for mulit- 48 0 0 4 1

ple input files selection with a
A. Function Summary
Java interface
uigetfiles Dialog box for multiple input files 48 0 0 4 1

selection
waitbar Display a progress bar for lengthy 449 0 8 70 6

process
write Helper function to write text to file 81 0 1 24 3

Subroutine name Author Company/Affiliation Date
arrowPlot.m Emmanuel P. Dinna 2005
corner.m He Xiaochen HKU EEE Dept. ITSR 2005
cvoronoi.m Novaski & Barczak 1997
deleteoutliers.m Brett Shoelson 2003
drawedgelist.m, Peter Kovesi School of Computer 2006
lineseg.m, Science & Software
maxlinedev.m Engineering. The
University of Western
Australia
extrema.m Carlos Adrián Vargas Universidad De 2004
Aguilera Guadalajara, Mexico
fEfourier.m, David Thomas 2006
rEfourier.m
hungarian.m Alex Melin 2006
lmin.m, lmax.m Serge Koptenko Guigne International 1997
Ltd.
MagnetGInput.m Michael Robbins 2003
save2pdf.m Gabe Hoffmann 2007
split.m Gerald Dalley 2004
uiGetFiles.m Shanrong Zhang Department of 2004
Radiology, University
of Texas Southwestern
Medical Center
uipickfiles.m Douglas M. Schwarz 2006
waitbar.m Peder Axensten 2006
euclidean_distance.m Alister Fong 2003
sortclasses.m Siew Teng Lee 2003
Table A.2.: External Matlab subroutines used in the study. They are obtain-
able from the Mathworks File Exchange repository.
235
A. Function Summary
236
Sample Output File
B
Listed below is a sample output file generated by the subroutines. The file
contains results of the anthropometric parameters extracted, exact coordinates
of various landmarks and error of fitting functions. It is saved in a tab-
delimited plain text format and could be imported to various spreadsheet
or statistical analysis software packages for further processing. For clarity
purpose, the file output is splitted into various tables.
File /file_path/anonymous
Pixel Spacing (mm)
xy 0.27
z 2
Orientation
ap anterior
lr right
start proximal
Femoral axis ref point 60.49,41.38,124.12
Lesser trochanter 35.11,54.26,70.00
Greater trochanter
coords 70.21,36.60,14.00
height 12
237
B. Sample Output File
base_coords 63.00,21.21,26.00
Head
centre 21.82,22.72,21.34
radius 20.52
error 0.73
fa_offset 42.94
lt_offset 48.66
Posterior Condyles
cylinder
vector 0.99,-0.12,-0.02
pt 49.37,101.88,411.86
radius 19.45
err 1.2
knee_centre 46.02,89.64,426.00
axis
mpt 28.73,123.96
lpt 70.22,118.90
Neck axis start coords 21.70,22.27,21.66
Neck length to FA 48.99
Neck length to lateral GT 71.71
Neck shaft angle 125.12
Neck axis elevation 8.79
Neck axis to head centre distance 0.57
Anteversion angles
TEA_CA 6.94
238
HC_FA_TEA 25.77
HC_FA_CA 32.71
NA_TEA 14.93
NA_CA 21.87
Trochlear groove plane 1.00,-0.19,-0.08,0.00
Trochlear groove angle -3.39
Anterior bow centre 53.60,1188.41,95.31
Anterior bow radius 1149.61
Femoral length
GTKC 416.1
HCKC 410.87
Head centre epicondylar distance 391.75
Lesser trochanter epicondylar distance 338.83
Canal flare indices
isthmus_LT_dist 104
ml 3.55
ap 2.26
oblique 1.21
metaphyseal_ml 0.41
239
240
Neck section properties
slice_no 1 2 3 4 5 6 7 8 9 10
mm_from_head 1 2 3 4 5 6 7 8 9 10
Area 1435 1427 1425 1409 1385 1340 1296 1226 1171 1101
Centroid 30.4 30.4 30.4 30.59 30.68 30.83 31.03 31.29 31.43 31.43
39.21 39.19 39.17 39.26 39.37 39.32 39.34 39.25 39.32 39.17
MajorAxisLength 43.8 43.63 43.35 43.14 42.75 42.36 42.01 41.53 40.75 39.96
MinorAxisLength 41.87 41.74 41.95 41.73 41.42 40.44 39.5 37.85 36.84 35.3
Eccentricity 0.29 0.29 0.25 0.25 0.25 0.3 0.34 0.41 0.43 0.47
Orientation 87.59 87.75 80.72 81.47 84.47 -87.72 -81.07 -81.07 -82.18 -81.27
moi
Ixx 157127 155262 156870 153480 148485 136900 126670 110205 99633 86212
Iyy 171904 169651 166965 163529 157997 150122 142442 131527 120995 109222
polar_moi 329032 324913 323835 317009 306482 287022 269112 241731 220628 195434
Ixy -623 -565 -1694 -1543 -930 527 2542 3436 2992 3618
princ_angle -0.04 -0.04 -0.16 -0.15 -0.1 0.04 0.16 0.16 0.14 0.15
Ip1 171931 169673 167242 163760 158087 150143 142842 132067 121406 109777
Ip2 157101 155240 156593 153248 148395 136879 126270 109665 99222 85657
241
242
Proximal shaft section properties
slice_no 25 27 29 31 33 35 37 39 41
mm_proximal 50 54 58 62 66 70 74 78 82
centroid 61.3 60.1 59.1 57.7 56.6 56.3 56.6 57.8 59.3
36.0 37.0 38.2 39.6 40.8 41.6 42.0 41.6 40.7
can_centroid 62.3 61.2 60.3 59.1 57.5 56.6 57.2 58.6 60.5
36.6 37.8 39.0 40.4 41.9 43.0 42.8 42.4 41.0
area 1348 1202 1120 1098 1090 1058 985 881 769
can_area 927 833 762 708 685 644 539 438 333
moi
Ixx 242228 175159 137537 128804 128174 121060 104923 78164 55507
Iyy 97403 81887 75642 76340 79439 78988 70761 57660 42630
polar_moi 339631 257046 213179 205145 207613 200048 175685 135824 98137
Ixy 30747 19284 7210 -8574 -20899 -26554 -24671 -13048 -1485
princ_angle -0.2 -0.2 -0.11 0.16 0.35 0.45 0.48 0.45 0.11
Ip1 248486 178988 138366 130170 135909 133901 117849 84505 55676
Ip2 91146 78058 74813 74975 71704 66147 57836 51319 42460
can_moi
Ixx 243651 176747 139278 130947 129023 121112 105329 78686 56722
Iyy 97938 82754 76493 77031 80826 80835 71417 58323 42682
polar_moi 341590 259501 215771 207978 209849 201948 176747 137009 99404
Ixy 31620 20457 8427 -7358 -19814 -26244 -24155 -12459 -1234
princ_angle -0.2 -0.21 -0.13 0.13 0.34 0.46 0.48 0.44 0.09
Ip1 250217 181006 140389 131933 136123 134054 117885 84595 56830
Ip2 91373 78495 75382 76045 73726 67893 58861 52414 42574
gic
x 64.3 62.7 60.4 54.3 55.5 56.9 57.4 58.3 59.0
y 38.8 39.1 39.7 40.1 40.4 40.6 40.6 40.2 39.8
r 16.1 15.6 15.2 15.0 14.6 14.3 13.9 13.6 13.2
gic_can_centroid
r 14.2 14.5 14.6 14.2 12.7 12.0 11.7 11.3 12.0
shaft_curve
medial 35.9 38.6 41.8 43.6 47.1 48.4 49.2 51.6 51.9
lateral 77.1 76.6 75.3 74.2 73.4 72.1 71.8 71.6 71.0
243
244
Shaft section properties
slice_no 25 30 35 40 45 50 55 60 65 70
mm_proximal 50 60 70 80 90 100 110 120 130 140
centroid 61.3 58.4 56.3 58.7 60.2 60.7 60.9 60.9 60.7 60.4
36.0 38.9 41.6 41.1 40.1 39.9 39.9 40.1 40.3 40.5
moi
Ixx 242228 131272 121060 64982 38709 30522 27740 26824 26456 25408
Iyy 97403 75344 78988 49833 30121 24502 22915 22742 23825 24168
polar_moi 339631 206616 200048 114815 68830 55024 50655 49566 50280 49576
Ixy 30747 -589 -26554 -6067 1697 3048 3512 3720 3855 3838
princ_angle -0.2 0.01 0.45 0.34 -0.19 -0.4 -0.48 -0.53 -0.62 -0.71
Ip1 248486 131278 133901 67112 39033 31795 29588 29026 29214 28675
Ip2 91146 75338 66147 47703 29798 23229 21067 20540 21067 20900
cortical_thickness
medial 4.52 3.19 3.99 4.52 5.05 6.12 7.18 7.71 8.25 7.45
lateral 7.71 6.65 5.32 5.32 6.38 8.51 7.45 8.51 7.98 8.51
anterior 2.93 2.66 3.19 3.99 4.79 5.59 5.59 5.85 5.85 6.12
posterior 1.33 2.13 2.13 3.19 3.46 5.05 5.32 6.12 6.92 6.65
area 1348 1106 1058 823 652 583 559 553 557 553
can_area 927 733 644 386 227 171 149 135 120 118
can_eccentricity 0.74 0.63 0.85 0.75 0.37 0.39 0.57 0.61 0.58 0.58
can_orientation -12.6 9.5 31.6 36.2 23.9 -67.5 -56.4 -59.7 -63.3 -65.5
245
246
C
CT Acquisition Settings
247
248
ID Scanner Exposure Pixel Slice KVP (Peak X-ray Tube
Time (ms) Spacing Thickness KV) Current
(mm) (mm) (mA)
All Japanese dataset Toshiba Aquilion 500 0.63 1 120 auto

modulation
C. CT Acquisition Settings
Australian dataset
71L Toshiba Asteion 750 0.36 2 120 150
71R Toshiba Asteion 750 0.36 2 120 150
67L-2 Toshiba Asteion 750 0.26 2 120 180
67R-2 Toshiba Asteion 750 0.29 2 120 150

OBL Toshiba Asteion 750 0.25 2 120 150
22L-2 Toshiba Asteion 750 0.25 1 120 80
EDR Toshiba Asteion 750 0.27 2 120 150
TTR Toshiba Asteion 750 0.25 2 120 150
W5L Toshiba Asteion 750 0.44 1 120 180
W4R Toshiba Asteion 750 0.34 1 120 180
All sheep dataset Toshiba Asteion 750 0.24 0.5 120 80
249
C. CT Acquisition Settings
250
D
Consistence Test Data
251
D.1. Intra-rater Consistency
252
Table D.1.: Intra-rater consistency data.
ID 53R 53R-2 28R 28R-2 67L 67L-2 67R 67R-2 TTR TTR-2
Greater 9 9 9 9 13 12 12 12 14 16
trochanter
D. Consistence Test Data
height
Head
radius 19.8 19.8 20.4 20.3 26.3 26.3 26.4 26.0 22.3 22.6
fa_offset 38.8 38.8 36.2 36.2 50.4 50.2 49.8 51.2 40.1 39.9
lt_offset 39.6 39.6 56.5 54.7 55.0 55.0 52.2 53.2 50.0 49.7
Condyles 17.8 17.8 17.9 18.0 22.6 22.1 22.0 23.0 19.9 20.6
radius
Neck length to 40.3 40.3 42.5 42.2 58.6 58.6 52.2 53.9 48.4 46.3
FA
Neck length to 62.7 62.8 67.8 68.2 88.9 88.5 86.0 86.6 73.7 71.5
lateral GT
Neck shaft 120.9 120.9 127.8 127.2 124.7 123.2 121.9 122.6 127.5 123.2
angle
Neck axis 7.7 7.6 7.8 7.6 9.5 9.7 10.8 10.5 9.2 9.1
elevation
Neck axis to 0.5 0.5 0.6 0.9 1.9 1.7 1.5 2.2 0.9 1.6
head centre
distance
Anteversion
angles
TEA_CA 10.2 10.2 9.9 9.9 4.9 9.9 5.8 5.7 4.5 4.1
HC_FA_TEA 40.5 40.5 28.3 28.0 16.9 12.7 33.9 34.9 17.6 16.4
HC_FA_CA 50.6 50.6 38.1 37.9 21.7 22.6 39.8 40.7 22.1 20.5
NA_TEA 31.4 31.5 17.1 17.8 8.2 3.6 24.2 26.6 2.3 5.3
NA_CA 41.6 41.6 27.0 27.7 13.1 13.5 30.1 32.3 6.8 9.4
Trochlear -1.2 -7.1 1.1 1.0 12.2 12.9 -13.8 -12.7 -10.0 -9.6
groove angle
253
254
Anterior bow 774 775 738 747 967 953 854 1235 968 978
radius
Femoral length
GTKC 376.7 376.7 382.2 382.1 455.9 456.8 454.8 453.2 412.4 412.5
HCKC 371.9 371.9 381.2 381.3 448.0 448.1 445.5 445.1 402.5 401.9
Head centre 355.5 355.5 362.2 363.3 423.6 421.5 423.3 419.0 383.2 382.5
epicondylar
distance
Lesser 311.0 311.0 301.1 303.6 365.6 365.3 365.1 360.5 328.1 328.1
trochanter
epicondylar
distance
Canal flare
indices
isthmus_LT_dist 111 111 109 108 130 129 125 132 110 108
ml 5.10 5.10 3.00 3.27 2.97 2.89 3.19 3.18 3.02 2.96
ap 2.23 2.23 2.35 2.35 2.39 2.60 1.78 1.78 2.84 2.77
oblique 1.11 1.11 1.18 1.20 1.23 1.29 1.11 1.09 1.31 1.32
metaphyseal_ml 0.57 0.57 0.36 0.38 0.40 0.40 0.41 0.41 0.37 0.37
255
D.2. Inter-rater Consistency
256
Table D.2.: Inter-rater consistency data.
ID 28R 28R-2 53R 53R-2 TTL TTL-2 67L 67L-2 67R 67R-2
Greater 9 9 10 11 14 14 14 14 12 12
trochanter
height
Head
radius 20.4 20.4 19.5 19.8 22.3 22.5 26.4 26.2 26.4 26.3
fa_offset 36.2 36.3 38.9 39.2 40.1 39.8 49.9 50.7 49.8 49.8
lt_offset 56.5 55.2 40.8 40.3 50.0 49.7 56.1 55.8 52.2 50.2
Posterior
Condyles
Cylinder radius 17.94 17.99 17.18 18.07 19.91 20.58 22.84 21.24 21.98 22.01
Neck length to 42.47 41.85 39.94 40.85 48.38 48.55 57.9 58.7 52.24 51.44
FA
Neck length to 67.78 67.66 63.05 63.22 73.66 73.88 88.55 89 85.98 85.35
lateral GT
Neck shaft 127.81 126.56 120.77 120.65 127.46 128.82 124.99 123.97 121.85 120.39
angle
Neck axis 7.82 7.55 7.86 7.37 9.15 8.68 11.01 9.35 10.79 10.88
elevation
Neck axis to 0.6 0.8 0.6 0.5 0.9 1.5 1.9 2.2 1.5 1.6
head centre
distance
Anteversion
angles
TEA_CA 9.9 9.9 8.8 10.4 4.5 4.1 8.4 7.6 5.8 3.3
HC_FA_TEA 28.3 28.1 42.0 39.8 17.6 16.4 15.9 15.2 33.9 35.9
HC_FA_CA 38.1 38.0 50.7 50.2 22.1 20.5 24.3 22.8 39.8 39.2
NA_TEA 17.1 17.8 32.9 31.1 2.3 5.9 5.0 7.1 24.2 26.4
NA_CA 27.0 27.6 41.7 41.5 6.8 10.0 13.4 14.7 30.1 29.8
Trochlear 1.1 0.3 -2.8 -3.5 -10.0 -9.0 12.6 13.6 -13.8 -8.0
groove angle
257
258
Anterior bow 738 747 775 764 968 977 1843 1823 854 884
radius
Femoral length
GTKC 382.2 382.2 377.5 378.4 412.4 410.5 455.0 455.1 454.8 454.6
HCKC 381.2 380.8 372.1 372.6 402.5 402.0 446.4 446.1 445.5 445.4
Head centre 362.2 362.9 356.8 356.4 383.2 382.5 421.7 421.9 423.3 423.4
epicondylar
distance
Lesser 301.1 302.9 310.9 311.0 328.1 328.1 362.6 363.2 365.1 367.1
trochanter
epicondylar
distance
Canal flare
indices
isthmus_LT_dist 109 110 111 106 110 108 128 130 125 127
ml 3.00 3.06 5.27 5.67 3.02 2.92 2.84 2.84 3.19 3.23
ap 2.35 2.35 2.46 2.64 2.84 2.77 2.57 2.59 1.78 1.75
oblique 1.18 1.18 1.12 1.13 1.31 1.32 1.25 1.26 1.11 1.10
metaphyseal_ml 0.36 0.37 0.52 0.55 0.37 0.37 0.40 0.40 0.41 0.41
259
D.3. Repeated Scans Consistency
260
Table D.3.: Repeated scans consistency data.
ID 10R 10R-2 14L 14L-2 22L 22L-2 67L 67L-2 67R 67R-2
Pixel Spacing
(mm)
xy 0.63 0.63 0.36 0.26 0.34 0.25 0.38 0.26 0.38 0.29
z 1 1 1 2 2 1 1 2 1 2
height 8 8 10 12 16 15 13 14 12 12
Head
radius 22.89 22.85 22.03 21.94 24.72 25.11 26.34 26.21 26.38 25.46
fa_offset 38.19 38.37 35.75 36.19 52.88 53.28 50.44 50.71 49.78 51.73
lt_offset 50.67 50.01 52.13 53.17 53.18 53.23 54.95 55.77 52.15 51.93
radius 18.95 19.09 18.15 17.78 23.59 22.68 22.6 21.24 21.98 22.71
Neck length to 48.58 48.42 44.34 44.94 60.76 61.25 58.62 58.7 52.24 56.01
FA
ID 10R 10R-2 14L 14L-2 22L 22L-2 67L 67L-2 67R 67R-2
Neck length to 71.68 71.56 73.13 71.9 91.55 91.53 88.87 89 85.98 88.17
lateral GT
Neck shaft 131.23 130.75 133.14 132.31 123.1 122.95 124.71 123.97 121.85 123.67
angle
Neck axis 9.16 9.59 11.02 10.8 9.24 8.67 9.53 9.35 10.79 10.04
elevation
Neck axis to 1.67 1.3 0.89 0.8 1.38 1.72 1.9 2.24 1.53 1.85
head centre
distance
Anteversion
angles
TEA_CA 6.95 5.91 7.23 12.12 6.06 6.97 4.89 7.61 5.83 8.66
HC_FA_TEA 13.29 14.77 27.12 22.49 14.64 13.16 16.85 15.2 33.94 32.04
HC_FA_CA 20.24 20.68 34.35 34.6 20.7 20.13 21.74 22.81 39.77 40.7
NA_TEA 1.44 2.08 6.28 1.92 4.59 3.64 8.22 7.07 24.24 23.59
NA_CA 8.39 7.98 13.51 14.03 10.65 10.61 13.11 14.68 30.07 32.25
261
262
ID 10R 10R-2 14L 14L-2 22L 22L-2 67L 67L-2 67R 67R-2
Trochlear -7.7 -9.12 7.37 12.66 12.87 13.43 12.2 13.55 -13.75 -8.17
groove angle
Anterior bow 579.79 589.01 1036.56 916.38 1361.75 950.69 966.91 1822.87 853.68 1176.23
radius
Femoral length
GTKC 392.76 392.33 443.84 446.18 483.95 485.18 455.85 455.11 454.77 453
HCKC 388.88 389 442.94 442.04 475.17 476.56 447.95 446.06 445.52 445.62
Head centre 369.55 367.82 424.68 418.01 450.87 451.89 423.62 421.85 423.33 420.02
epicondylar
distance
Lesser 316.23 315.33 369.22 363.07 392.37 394.12 365.64 363.15 365.12 362.1
trochanter
epicondylar
distance
Canal flare
indices
ID 10R 10R-2 14L 14L-2 22L 22L-2 67L 67L-2 67R 67R-2
isthmus_LT_dist 117 118 121 116 130 128 130 130 125 126
ml 4.2 4.27 3.22 2.98 3.23 3.17 2.97 2.84 3.19 3.1
ap 2.4 2.3 1.51 1.57 2.36 2.36 2.39 2.59 1.78 1.8
oblique 1.2 1.2 1.09 1.11 1.24 1.24 1.23 1.26 1.11 1.12
metaphyseal_ml 0.39 0.39 0.41 0.42 0.4 0.4 0.4 0.4 0.41 0.4
263
264
Results of Parameter Variation
E
E.1. Variation with Full Femoral Shaft
E.2. Posterior Condyles Slice Range
The first and second slice range of each sample is the reference slice range
and the typical maximum erroneous range respectively. The last row of each
sample are more extreme slice ranges. Entries marked with an asterisks (*)
are ranges that are insufficient to produce an accurate fitting, and are not
included in the table.
265
E. Results of Parameter Variation
Slice
Condyles
ID thickness Slice range Knee centre
radius
(mm)
2667L 1 430–469 22.5 (46.5, 93, 468)
1 433–466 22.1 (46.9, 93.8, 468)
1 435–469 22.1 (46.5, 96.75, 467)
C003R 1 422–453 21.0 (56.2, 96.4, 453)
1 425–450 22.0 (56.6, 94.1, 454)
1 427–453 22.7 (56.6, 94.1, 454)
C014L 1 433–461 17.8 (42.5, 98.2, 459)
1 436–458 17.9 (42.5, 97.8, 460)
1 438–461 17.9 (42.8, 97.8, 460)
71cm 2 218–236 22.2 (49.1, 114.6, 470)
2 221–233 24.9 (50.2, 104.0, 472)
2 223–231 na* na*
BOB 2 225–240 18.5 (47.0, 41.6, 476)
2 228–237 18.8 (47.2, 41.6, 476)
2 220–235 na* na*
Table E.1.: Effect of condyles radius on the fitting slice range.
266
E.2. Posterior Condyles Slice Range

!

!

(a) Proximal femur and posterior condyles ra- (b) Femoral length and anterior bow radius.
dius.
Figure E.1.: Variation between the use of proximal femoral shaft and full
femoral shaft as reference longitudinal axis.
267
E. Results of Parameter Variation
268
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Anthropometric study of the femur - an automated approach

Downloaded from http://hdl.handle.net/1959.4/43647 in https://

Chi Bang Abe LAU

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Surgical & Orthopaedic Research Laboratories

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nowledge of anatomy is an elementary step towards the understanding

Traditional anthropometric studies rely on physical measurements by means of

• the understanding of anatomy originating from the clinical domain have

• the diﬃculty of existing automated anthropometric methodology in han-

The aim of the study is to:

• develop a consistent and robust methodology in accurate extraction of

With the bridging of anthropometry and the image processing disciplines, a

A dataset comprised of femoral CT scans of 19 healthy Australian, 10 healthy

2. Anatomy and Bone Histology 5

3.2.5. Biological Hazards . . . . . . . . . . . . . . . . . . . . . . . . . 25

4.4.1. Aﬃne Transformation . . . . . . . . . . . . . . . . . . . . . . 59

6. Anthropometric Analysis of the Femur 97

6.3.1. Physical Measurements . . . . . . . . . . . . . . . . . . . . . 99

7.4. Veriﬁcation & Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

9.3.3. Consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

10. Conclusions 223

A. Function Summary 225

B. Sample Output File 237

C. CT Acquisition Settings 247

D. Consistence Test Data 251

E. Results of Parameter Variation 265

3.1. Electromagnetic Spectrum . . . . . . . . . . . . . . . . . . . . . . . . 21

3.4. Pair Production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

4.1. Grey-level histograms with threshold. Left; Single threshold T .

4.13. Laplacian convolution kernels . . . . . . . . . . . . . . . . . . . . . . 52

4.31. A morphological algorithm to compute the convex hull. X 01 : the

5.1. 8-th directional chain code . . . . . . . . . . . . . . . . . . . . . . . . 83

6.1. Kingsley’s neck axis deﬁnition. Left: posterior point. Middle:

6.10. Distal transverse axis deﬁnitions. Left: Area centres of the

7.22. Flattened PA view of the femur. NB SK was evaluated by mor-

8.1. The Matlab routine showing the process of sectional properties

8.13. Femoral length measurements of the AU and JP datasets. The

9.1. Effect of anterior bowing on different definitions of the longitu-

3.1. Causes of X-ray attenuation in water at various photon energies 23

4.1. The membership relation in set theory . . . . . . . . . . . . . . . . 62

5.1. Eﬀect of transformation in Fourier descriptor . . . . . . . . . . . . 88

7.1. Veriﬁcation measurements on 3-D model. . . . . . . . . . . . . . . 158

8.1. Types of ICC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

8.15. Femoral neck consistency on repeated scans. . . . . . . . . . . . . 175

A.1. Function summary of the Matlab subroutines. . . . . . . . . . . 226

D.1. Intra-rater consistency data. . . . . . . . . . . . . . . . . . . . . . . . 252

D.2. Inter-rater consistency data. . . . . . . . . . . . . . . . . . . . . . . . 257

E.1. Eﬀect of condyles radius on the ﬁtting slice range. . . . . . . . . . 266

BMC Bone Mineral Content

BMD Bone Mineral Density

CFI Canal Flare Index

DEXA/DXA Dual Energy X-ray Absorptiometry

DFT Discrete Fourier Transform

DICOM Digital Imaging and Communications in Medicine

DoG Diﬀerence of Gaussian

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