In vivo mechanical response of thigh soft tissues under compression: A two-layer model allows an improved representation of the local tissue kinematics.

Biomechanical parameters have the potential to be used as physical markers for prevention and diagnosis. Finite Element Analysis (FEA) is a widely used tool to evaluate these parameters in vivo. However, the development of clinically relevant FEA requires personalisation of the geometry, boundary conditions, and constitutive parameters. This contribution focuses on the characterisation of mechanical properties in vivo which remains a significant challenge for the community. The aim of this retrospective study is to evaluate the sensitivity of the computed elastic parameters (shear modulus of fat and muscle tissues) derived by inverse analysis as a function of the geometrical modelling assumption (homogenised monolayer vs bilayer) and the formulation of the cost function. The methodology presented here proposes to extract the experimental force-displacement response for each tissue layer (muscle and fat) and construct the associated Finite Element Model for each volunteer, based on data previously collected in our group (N = 7 volunteers) as reported in (Fougeron et al., 2020). The sensitivity analysis indicates that the choice of the cost function has minimal impact on the topology of the response surface in the parametric space. Each surface displays a valley of parameters that minimises the cost function. The constitutive properties of the thigh (reported as median ± interquartile range) were determined to be (µ=198±322Pa,α=37) for the monolayer and (µmuscle=1675±1127Pa,αmuscle=22±14,µfat=537±1131Pa,αfat=32±7) for the bilayer. A comparison of the homogenised monolayer and bilayer models showed that adding a layer reduces the error on the local force displacement curves, increasing the accuracy of the local kinematics of soft tissues during indentation. This allows for an increased understanding of load transmission in soft tissue. The comparison of the two models in terms of strains indicates that the modelling choice significantly influences the localization of maximal compressive strains. These results support the idea that the biomechanical community should conduct further work to develop reliable methodologies for estimating in vivo strain in soft tissue.

Effect of the ischial support on muscle force estimation during transfemoral walking.

BACKGROUND: Transmission of loads between the prosthetic socket and the residual limb is critical for the comfort and walking ability of people with transfemoral amputation. This transmission is mainly determined by the socket tightening, muscle forces, and socket ischial support. However, numerical investigations of the amputated gait, using modeling approaches such as MusculoSkeletal (MSK) modeling, ignore the weight-bearing role of the ischial support. This simplification may lead to errors in the muscle force estimation. OBJECTIVE: This study aims to propose a MSK model of the amputated gait that accounts for the interaction between the body and the ischial support for the estimation of the muscle forces of 13 subjects with unilateral transfemoral amputation. METHODS: Contrary to previous studies on the amputated gait which ignored the interaction with the ischial support, here, the contact on the ischial support was included in the external loads acting on the pelvis in a MSK model of the amputated gait. RESULTS: Including the ischial support induced an increase in the activity of the main abductor muscles, while adductor muscles' activity was reduced. These results suggest that neglecting the interaction with the ischial support leads to erroneous muscle force distribution considering the gait of people with transfemoral amputation. Although subjects with various bone geometries, particularly femur lengths, were included in the study, similar results were obtained for all subjects. CONCLUSIONS: Eventually, the estimation of muscle forces from MSK models could be used in combination with finite element models to provide quantitative data for the design of prosthetic sockets.

The effect of breathing on the in vivo mechanical characterization of linea alba by ultrasound shearwave elastography.

The most common surgical repair of abdominal wall hernia consists in implanting a mesh to reinforce hernia defects during the healing phase. Ultrasound shearwave elastography (SWE) is a promising non-invasive method to estimate soft tissue mechanical properties at bedside through shear wave speed (SWS) measurement. Combined with conventional ultrasonography, it could help the clinician plan surgery. In this work, a novel protocol is proposed to reliably assess the stiffness of the linea alba, and to evaluate the effect of breathing and of inflating the abdomen on SWS. Fifteen healthy adults were included. SWS was measured in the linea alba, in the longitudinal and transverse direction, during several breathing cycle and during active abdominal inflation. SWS during normal breathing was 2.3 [2.0; 2.5] m/s in longitudinal direction and 2.2 [1.9; 2.7] m/s in the transversal. Inflating the abdomen increased SWS both in longitudinal and transversal direction (3.5 [2.8; 5.8] m/s and 5.2 [3.0; 6.0] m/s, respectively). The novel protocol significantly improved the reproducibility relative to the literature (8% in the longitudinal direction and 14% in the transverse one). Breathing had a mild effect on SWS, and accounting for it only marginally improved the reproducibility. This study proved the feasibility of the method, and its potential clinical interest. Further studies on larger cohort should focus on improving our understanding of the relationship between abdominal wall properties and clinical outcomes, but also provide a cartography of the abdominal wall, beyond the linea alba.

Single and bi-compartment poro-elastic model of perfused biological soft tissues: FEniCSx implementation and tutorial.

Soft biological tissues demonstrate strong time-dependent and strain-rate mechanical behavior, arising from their intrinsic visco-elasticity and fluid-solid interactions. The time-dependent mechanical properties of soft tissues influence their physiological functions and are related to several pathological processes. Poro-elastic modeling represents a promising approach because it allows the integration of multiscale/multiphysics data to probe biologically relevant phenomena at a smaller scale and embeds the relevant mechanisms at the larger scale. The implementation of multiphase flow poro-elastic models however is a complex undertaking, requiring extensive knowledge. The open-source software FEniCSx Project provides a novel tool for the automated solution of partial differential equations by the finite element method. This paper aims to provide the required tools to model the mixed formulation of poro-elasticity, from the theory to the implementation, within FEniCSx. Several benchmark cases are studied. A column under confined compression conditions is compared to the Terzaghi analytical solution, using the L2-norm. An implementation of poro-hyper-elasticity is proposed. A bi-compartment column is compared to previously published results (Cast3m implementation). For all cases, accurate results are obtained in terms of a normalized Root Mean Square Error (RMSE). Furthermore, the FEniCSx computation is found three times faster than the legacy FEniCS one. The benefits of parallel computation are also highlighted.

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

OBJECTIVE: 2D Ultrasound (US) imaging has been recently investigated as a more accessible alternative to 3D Magnetic Resonance Imaging (MRI) for the estimation of soft issue motion under external mechanical loading. In the context of pressure ulcer prevention, the aim of this pilot MRI study was to design an experiment to characterize the sacral soft tissue motion under a controlled mechanical loading. Such an experiment targeted the estimation of the discrepancy between tissue motion assessed using a 2D imaging modality (echography) versus tissue motion assessed using a (reference) 3D imaging modality (MRI). METHODS: One healthy male volunteer participated in the study. An MRI-compatible custom-made setup was designed and used to load the top region of the sacrum with a 3D-printed copy of the US transducer. Five MR images were collected, one in the unloaded and four in the different loaded configurations (400-1200 [g]). Then, a 3D displacement field for each loading configuration was extracted based on the results of digital volume correlation. Tissue motion was separated into the X, Y, Z directions of the MRI coordinate system and the ratios between the out-of-plane and in-plane components were assessed for each voxel of the selected region of interest. RESULTS: Ratios between the out-of-plane and in-plane displacement components were higher than 0.6 for more than half of the voxels in the region of interest for all load cases and higher than 1 for at least quarter of the voxels when loads of 400-800 [g] were used. CONCLUSION: The out-of-ultrasound-plane tissue displacement was not negligible, therefore 2D US imaging should be used with caution for the evaluation of the tissue motion in the sacrum region. The 3D US modality should be further investigated for this application.

A wear model to predict damage of reconstructed ACL.

Impingement with surrounding tissues is a major cause of failure of anterior cruciate ligament reconstruction. However, the complexity of the knee kinematics and anatomical variations make it difficult to predict the occurrence of contact and the extent of the resulting damage. Here we hypothesise that a description of wear between the reconstructed ligament and adjacent structures captures the in vivo damage produced with physiological loadings. To test this, we performed an in vivo study on a sheep model and investigated the role of different sources of damage: overstretching, excessive twist, excessive compression, and wear. Seven sheep underwent cranial cruciate ligament reconstruction using a tendon autograft. Necropsy observations and pull-out force measurements performed postoperatively at three months showed high variability across specimens of the extent and location of graft damage. Using 3D digital models of each stifle based on X-ray imaging and kinematics measurements, we determined the relative displacements between the graft and the surrounding bones and computed a wear index describing the work of friction forces underwent by the graft during a full flexion-extension movement. While tensile strain, angle of twist and impingement volume showed no correlation with pull-out force (ρ = -0.321, p = 0.498), the wear index showed a strong negative correlation (r = -0.902, p = 0.006). Moreover, contour maps showing the distribution of wear on the graft were consistent with the observations of damage during the necropsy. These results demonstrate that wear is a good proxy of graft damage. The proposed wear index could be used in implant design and surgery planning to minimise the risk of implant failure. Its application to sheep can provide a way to increase preclinical testing efficiency.

MR-based quantitative measurement of human soft tissue internal strains for pressure ulcer prevention.

Pressure ulcers are a severe disease affecting patients that are bedridden or in a wheelchair bound for long periods of time. These wounds can develop in the deep layers of the skin of specific parts of the body, mostly on heels or sacrum, making them hard to detect in their early stages. Strain levels have been identified as a direct danger indicator for triggering pressure ulcers. Prevention could be possible with the implementation of subject-specific Finite Element (FE) models. However, generation and validation of such FE models is a complex task, and the current implemented techniques offer only a partial solution of the entire problem considering only external displacements and pressures, or cadaveric samples. In this paper, we propose an in vivo solution based on the 3D non-rigid registration between two Magnetic Resonance (MR) images, one in an unloaded configuration and the other deformed by means of a plate or an indenter. From the results of the image registration, the displacement field and subsequent strain maps for the soft tissues were computed. An extensive study, considering different cases (on heel pad and sacrum regions) was performed to evaluate the reproducibility and accuracy of the results obtained with this methodology. The implemented technique can give insight for several applications. It adds a useful tool for better understanding the propagation of deformations in the heel soft tissues that could generate pressure ulcers. This methodology can be used to obtain data on the material properties of the soft tissues to define constitutive laws for FE simulations and finally it offers a promising technique for validating FE models.

Finite element analysis of the stump-ischial containment socket interaction: a technical note.

The role of the above-knee socket is to ensure the load transfer via the coupling of residual limb-prosthesis with minimal discomfort and without damaging the soft tissues. Modelling is a potential tool to predict socket fit prior to manufacture. However, state-of-the-art models only include the femur in soft tissues submitted to static loads neglecting the contribution of the hip joint. The hip joint is particularly challenging to model because it requires to compute the forces of muscles inserting on the residual limb. This work proposes a modelling of the hip joint including the estimation of muscular forces using a combined MusculoSKeletal (MSK)/Finite Element (FE) framework. An experimental-numerical approach was conducted on one femoral amputee subject. This allowed to i) model the hip joint and personalise muscular forces, ii) study the impact of the ischial support, and iii) evaluate the interface pressure. A reduction of the gluteus medius force from the MSK modelling was noticed when considering the ischial support. Interface pressure, predicted between 63 to 71 kPa, agreed with experimental literature data. The contribution of the hip joint is a key element of the modelling approach for the prediction of the socket interface pressure with the residual limb soft tissues.

Reliability of B-mode ultrasound and shear wave elastography in evaluating sacral bone and soft tissue characteristics in young adults with clinical feasibility in elderly.

BACKGROUND: Physiologic aging is associated with loss of mobility, sarcopenia, skin atrophy and loss of elasticity. These factors contribute, in the elderly, to the occurrence of a pressure ulcer (PU). Brightness mode ultrasound (US) and shear wave elastography (SWE) have been proposed as a patient-specific, bedside, and predictive tool for PU. However, reliability and clinical feasibility in application to the sacral region have not been clearly established. METHOD: The current study aimed to propose a simple bedside protocol combining US and SWE. The protocol was first tested on a group of 19 healthy young subjects by two operators. The measurements were repeated three times. Eight parameters were evaluated at the medial sacral crest. Intraclass Correlation Coefficient (ICC) was used for reliability assessment and the modified Bland Altman plot analysis for agreement assessment. The protocol was then evaluated for clinical feasibility on a healthy older group of 11 subjects with a mean age of 65 ± 2.4 yrs. FINDINGS: ICC showed poor to good reliability except for skin SWE and hypodermis thickness with an ICC (reported as: mean (95%CI)) of 0.78 (0.50-0.91) and 0.98 (0.95-0.99) respectively. No significant differences were observed between the young and older group except for the muscle Shear Wave Speed (SWS) (respectively 2.11 ± 0.27 m/s vs 1.70 ± 0.17 m/s). INTERPRETATION: This is the first protocol combining US and SWE that can be proposed on a large scale in nursing homes. Reliability, however, was unsatisfactory for most parameters despite efforts to standardize the protocol and measurement definitions. Further studies are needed to improve reliability.

Cortex tissue relaxation and slow to medium load rates dependency can be captured by a two-phase flow poroelastic model.

This paper investigates the complex time-dependent behavior of cortex tissue, under adiabatic condition, using a two-phase flow poroelastic model. Motivated by experiments and Biot's consolidation theory, we tackle time-dependent uniaxial loading, confined and unconfined, with various geometries and loading rates from 1µm/s to 100µm/s. The cortex tissue is modeled as the porous solid saturated by two immiscible fluids, with dynamic viscosities separated by four orders, resulting in two different characteristic times. These are respectively associated to interstitial fluid and glial cells. The partial differential equations system is discretized in space by the finite element method and in time by Euler-implicit scheme. The solution is computed using a monolithic scheme within the open-source computational framework FEniCS. The parameters calibration is based on Sobol sensitivity analysis, which divides them into two groups: the tissue specific group, whose parameters represent general properties, and sample specific group, whose parameters have greater variations. Our results show that the experimental curves can be reproduced without the need to resort to viscous solid effects, by adding an additional fluid phase. Through this process, we aim to present multiphase poromechanics as a promising way to a unified brain tissue modeling framework in a variety of settings.

Digital twinning of Cellular Capsule Technology: Emerging outcomes from the perspective of porous media mechanics.

Spheroids encapsulated within alginate capsules are emerging as suitable in vitro tools to investigate the impact of mechanical forces on tumor growth since the internal tumor pressure can be retrieved from the deformation of the capsule. Here we focus on the particular case of Cellular Capsule Technology (CCT). We show in this contribution that a modeling approach accounting for the triphasic nature of the spheroid (extracellular matrix, tumor cells and interstitial fluid) offers a new perspective of analysis revealing that the pressure retrieved experimentally cannot be interpreted as a direct picture of the pressure sustained by the tumor cells and, as such, cannot therefore be used to quantify the critical pressure which induces stress-induced phenotype switch in tumor cells. The proposed multiphase reactive poro-mechanical model was cross-validated. Parameter sensitivity analyses on the digital twin revealed that the main parameters determining the encapsulated growth configuration are different from those driving growth in free condition, confirming that radically different phenomena are at play. Results reported in this contribution support the idea that multiphase reactive poro-mechanics is an exceptional theoretical framework to attain an in-depth understanding of CCT experiments, to confirm their hypotheses and to further improve their design.

Development and evaluation of a new methodology for Soft Tissue Artifact compensation in the lower limb.

Skin Marker (SM) based motion capture is the most widespread technique used for motion analysis. Yet, the accuracy is often hindered by Soft Tissue Artifact (STA). This is a major issue in clinical gait analysis where kinematic results are used for decision-making. It also has a considerable influence on the results of rigid body and Finite Element (FE) musculoskeletal models that rely on SM-based kinematics to estimate muscle, contact and ligament forces. Current techniques devised to compensate for STA, in particular multi-body optimization methods, often consider simplified joint models. Although joint personalization with anatomical constraints has improved kinematic estimation, these models yet don't represent a fully reliable solution to the STA problem, thus allowing us to envisage an alternative approach. In this perspective, we propose to develop a conceptual FE-based model of the lower limb for STA compensation and evaluate it for 66 healthy subjects under level walking motor task. Both hip and knee joint kinematics were analyzed, considering both rotational and translational joint motion. Results showed that STA caused underestimation of the hip joint kinematics (up to 2.2°) for all rotational DoF, and overestimation of knee joint kinematics (up to 12°) except in flexion/extension. Joint kinematics, in particular the knee joint, appeared to be sensitive to soft tissue stiffness parameters (rotational and translational mean difference up to 1.5° and 3.4 mm). Analysis of the results using alternative joint representations highlighted the versatility of the proposed modeling approach. This work paves the way for using personalized models to compensate for STA in healthy subjects and different activities.

Development and evaluation of a new procedure for subject-specific tensioning of finite element knee ligaments.

Subject-specific tensioning of ligaments is essential for the stability of the knee joint and represents a challenging aspect in the development of finite element models. We aimed to introduce and evaluate a new procedure for the quantification of ligament prestrains from biplanar X-ray and CT data. Subject-specific model evaluation was performed by comparing predicted femorotibial kinematics with the in vitro response of six cadaveric specimens. The differences obtained using personalized models were comparable to those reported in similar studies in the literature. This study is the first step toward the use of simplified, personalized knee FE models in clinical context such as ligament balancing.

Combined 3D analysis of lower-limb morphology and function in children with idiopathic equinovarus clubfoot: A preliminary study.

INTRODUCTION: In children treated for idiopathic equinovarus clubfoot (EVCF), the relation between morphologic defects on clinical examination and standard X-ray on the one hand and functional abnormalities on the other is difficult to objectify. The aim of the present study was to demonstrate the feasibility of combined 3D analysis of the foot and lower limb based on biplanar EOS radiographs and gait analysis. The study hypothesis was that this provides better understanding of abnormalities in form and function. METHODS: Ten children with unilateral EVCF and "very good" clinical results were included. They underwent gait analysis on the Rizzoli Institute multisegment foot model. Kinematic data were collected for the hip, knee, ankle and foot (hindfoot/midfoot, midfoot/forefoot and hindfoot/forefoot). Biplanar EOS radiographs were taken to determine anatomic landmarks and radiological parameters. RESULTS: Complete acquisition time was around 2hours per patient. No significant differences were found between EVCF and healthy feet except for calcaneal incidence, tibiocalcaneal angle and hindfoot/midfoot and hindfoot/forefoot inversion. DISCUSSION: The feasibility of the combined analysis was confirmed. There were no differences in range of motion, moment or power between EVCF and healthy feet in this series of patients with very good results. The functional results are related to radiological results within the normal range. The protocol provided anatomic and kinematic reference data. A larger-scale study could more objectively assess the contribution of EOS radiography using optoelectronic markers. LEVEL OF EVIDENCE: II, low-power prospective study.

Combining Freehand Ultrasound-Based Indentation and Inverse Finite Element Modeling for the Identification of Hyperelastic Material Properties of Thigh Soft Tissues.

Finite element analysis (FEA) is a numerical modeling tool vastly employed in research facilities to analyze and predict load transmission between the human body and a medical device, such as a prosthesis or an exoskeleton. Yet, the use of finite element modeling (FEM) in a framework compatible with clinical constraints is hindered by, among others, heavy and time-consuming assessments of material properties. Ultrasound (U.S.) imaging opens new and unique opportunities for the assessment of in vivo material properties of soft tissues. Confident of these advances, a method combining a freehand U.S. probe and a force sensor was developed in order to compute the hyperelastic constitutive parameters of the soft tissues of the thigh in both relaxed (R) and contracted (C) muscles' configurations. Seven asymptomatic subjects were included for the experiment. Two operators in each configuration performed the acquisitions. Inverse FEM allowed for the optimization of an Ogden's hyperelastic constitutive model of soft tissues of the thigh in large displacement. The mean shear modulus identified for configurations R and C was, respectively, 3.2 ± 1.3 kPa and 13.7 ± 6.5 kPa. The mean alpha parameter identified for configurations R and C was, respectively, 10 ± 1 and 9 ± 4. An analysis of variance showed that the configuration had an effect on constitutive parameters but not on the operator.

Is a simplified Finite Element model of the gluteus region able to capture the mechanical response of the internal soft tissues under compression?

BACKGROUND: Internal soft tissue strains have been shown to be one of the main factors responsible for the onset of Pressure Ulcers and to be representative of its risk of development. However, the estimation of this parameter using Finite Element (FE) analysis in clinical setups is currently hindered by costly acquisition, reconstruction and computation times. Ultrasound (US) imaging is a promising candidate for the clinical assessment of both morphological and material parameters. METHOD: The aim of this study was to investigate the ability of a local FE model of the region beneath the ischium with a limited number of parameters to capture the internal response of the gluteus region predicted by a complete 3D FE model. 26 local FE models were developed, and their predictions were compared to those of the patient-specific reference FE models in sitting position. FINDINGS: A high correlation was observed (R = 0.90, p-value < 0.01). A sensitivity analysis showed that the most influent parameters were the mechanical behaviour of the muscle tissues, the ischium morphology and the external mechanical loading. INTERPRETATION: Given the progress of US for capturing both morphological and material parameters, these results are promising because they open up the possibility to use personalised simplified FE models for risk estimation in daily clinical routine.

Microstructural characterization of annulus fibrosus by ultrasonography: a feasibility study with an in vivo and in vitro approach.

The main function of the intervertebral disc is biomechanical function, since it must resist repetitive high loadings, while giving the spine its flexibility and protecting the spinal cord from over-straining. It partially owes its mechanical characteristics to the lamellar architecture of its outer layer, the annulus fibrosus. Today, no non-invasive means exist to characterize annulus lamellar structure in vivo. The aim of this work was to test the feasibility of imaging annulus fibrosus microstructure in vivo with ultrasonography. Twenty-nine healthy adolescents were included. Ultrasonographies of L3-L4 disc were acquired with a frontal approach. Annulus fibrosus was segmented in the images to measure the thickness of the lamellae. To validate lamellar appearance in ultrasonographies, multimodality images of two cow tail discs were compared: ultrasonography, magnetic resonance and optical microscopy. In vivo average lamellar thickness was 229.7 ± 91.5 µm, and it correlated with patient body mass index and age. Lamellar appearance in the three imaging modalities in vitro was consistent. Lamellar measurement uncertainty was 7%, with good agreement between two operators. Feasibility of ultrasonography for the analysis of lumbar annulus fibrosus structure was confirmed. Further work should aim at validating measurement reliability, and to assess the relevance of the method to characterize annulus alterations, for instance in disc degeneration or scoliosis.

Development and evaluation of a new methodology for the fast generation of patient-specific Finite Element models of the buttock for sitting-acquired deep tissue injury prevention.

The occurrence and management of Pressure Ulcers remain a major issue for patients with reduced mobility and neurosensory loss despite significant improvement in the prevention methods. These injuries are caused by biological cascades leading from a given mechanical loading state in tissues to irreversible tissue damage. Estimating the internal mechanical conditions within loaded soft tissues has the potential of improving the management and prevention of PU. Several Finite Element models of the buttock have therefore been proposed based on either MRI or CT-Scan data. However, because of the limited availability of MRI or CT-Scan systems and of the long segmentation time, all studies in the literature include the data of only one individual. Yet the inter-individual variability can't be overlooked when dealing with patient specific estimation of internal tissue loading. As an alternative, this contribution focuses on the combined use of low-dose biplanar X-ray images, B-mode ultrasound images and optical scanner acquisitions in a non-weight-bearing sitting posture for the fast generation of patient-specific FE models of the buttock. Model calibration was performed based on Ischial Tuberosity sagging. Model evaluation was performed by comparing the simulated contact pressure with experimental observations on a population of 6 healthy subjects. Analysis of the models confirmed the high inter-individual variability of soft tissue response (maximum Green Lagrange shear strains of 213 ±â€¯101% in the muscle). This methodology opens the way for investigating inter-individual factors influencing the soft tissue response during sitting and for providing tools to assess PU risk.

Assessing 3D paediatric foot morphology using low-dose biplanar radiography: Parameter reproducibility and preliminary values.

BACKGROUND: The physical examination and weight-bearing radiography are the two main available methods for assessing the feet and lower limbs. The anatomy and function of these two structures interact with each other. These two assessment methods are affected by subjectivity and projection bias. Low-dose biplanar radiography (LDBR) is now a promising alternative for evaluating the lower limbs in children. At present, however, the foot cannot be assessed using LDBR. The objective of this study was to work towards developing a new method for 3D radiographic analysis of the paediatric foot during weight-bearing, first by determining the reproducibility of landmarks defined by LDBR then by reporting the values of the calculated radiographic parameters. HYPOTHESIS: A new radiographic method based on LDBR can be used to obtain a 3D evaluation of the foot in paediatric patients. PATIENTS AND METHODS: Two biplanar radiographs in perpendicular planes were obtained simultaneously in a standardised position using the EOS system (EOS® Imaging, Paris, France) in each of 10 healthy children. To assess measurement uncertainty, two observers performed 3D reconstructions of each of the 10 feet three times (60 reconstructions). The standard error of reproducibility of the anatomic landmarks and clinical parameters was computed. Measurement uncertainty was then estimated based on the 95% confidence interval (95%CI). To obtain reference values, the mean±SD of each variable was computed after checking that the data were normally distributed. RESULTS: Reproducibility was high for the anatomical landmarks of interest, calcaneal pitch angle, tibio-calcaneal angle on the lateral view, and first metatarsal pitch angle (95%CI<5%). The values of these angles in the study population are reported. DISCUSSION AND CONCLUSION: The data reported here pave the way towards developing new parameters for describing 3D foot morphology and for simultaneously assessing the lower limb and foot in the standing position. LEVEL OF EVIDENCE: I.