Investigating the Benefits of Using 3D Camera Technology to Improve Wound Measurements in a Tissue Viability Service: Outcomes of a Pilot Implementation Study

Research Article

Phys Med Rehabil Int. 2021; 8(4): 1188.

Investigating the Benefits of Using 3D Camera Technology to Improve Wound Measurements in a Tissue Viability Service: Outcomes of a Pilot Implementation Study

King BM1#, Doyle K1#, Kelley J2#, Taylor C1# and Davis SF2#*

1Tissue Viability Nurse Consultant, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, England, UK

2Research Fellow, Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, England, UK

#Contributed Equally to this Work

*Corresponding author: Sally Fowler Davis, Work address; 32 Collegiate Crescent, Sheffield S10 2HP tel 0114 225 2439. Home Address; 46 Button Hill Sheffield S11 9HH, England, UK

Received: July 08, 2021; Accepted: August 31, 2021; Published: September 07, 2021


Sub-optimal experience and outcomes for people with stalled wounds is common. Clinicians have limited methods for reliably and accurately measure wounds. Depth measurement is an important indicator of healing, and digital methods of imaging the wound may offer increased accuracy and enable clinical decision-making.

This study aimed to implement a Panasonic FZ-M1 toughpad with WoundCareLite software version, to enable three-dimensional measurements in Tissue Viability (TV) service. Length, width, and depth measurement were compared with usual manual measurement using a paper ruler alongside a 2D photographic image. Statistical analysis included the comparison of wound dimension measures and a presentation of visual healing trajectories over 4 weeks using run-charts.

30 patients were recruited over five weeks (13 female and 17 male), representing 4% of the usual caseload. Manual measurement and 3D software automatic method demonstrated that the width and depth 3D auto measures were more accurate than manual measures but depth measures were often wrong thus making volumetric measures inaccurate. Consistent wound size measurement was feasible, and healing trajectories provide a useful means of continuous assessment.

Technology guided measurement has potential benefits over manual measurement as a means of more accurately monitoring healing. In this case, depth measurement could not be accurately assessed in practice and further software innovation is indicated to enable outcome measurement in tissue viability services.

Keywords: Tissue Viability; WoundCareLite; 3D


Chronic wound management was estimated to cost the NHS around 3% of the healthcare budget [1,2], an estimate based predominantly on health care professionals’ time used to manage wounds and associated comorbidities [3]. With increase in demand estimated to be at 11%, an estimated 3.7 million patients with a chronic wound in 2017-18, will cost in the order of £8 to £9 billion per annum. Technology implementation associated with personcentered care in policy guidelines, suggests the needs for improved methods for wound assessment [4-6]. A Minimum Data Set (MDS) for wound assessment is recommended [7] with the inclusion of general health assessment, wound assessment parameters, i.e. wound size; the length, width and depth of a wound. Wound photography has been recommended as part of the MDS [8] with images taken on assessment and at a minimum of monthly dressing changes, to monitor progress. This is to enable the clinician to use an objective measure of the size of the wound as indication of healing. In several studies, a reduction of over 30% in wound size in a four-week period was a predictive indicator of wound healing [9,10]. Wound surface area measurement is important as therapeutic decisions may depend on the change of wound surface area over time [11].

Tissue Viability (TV) services in the UK offer specialist advice and care to patients with complex wounds, including pressure ulcers, surgical wounds, and chronic non-healing or so-called stalled wounds. Evidence pertaining to the impact of wound-care teams, on the prevention and management of chronic and non-healing wounds or stalled wounds, does not currently exist [12]. This is in part due to the inability to reliably measure wound dimensions for the purpose of demonstrating a clinical outcome [13].

Measurement of wounds in practice is traditionally undertaken manually with a paper ruler to capture the longest and widest measurements. Depth information is routinely missing from a wound assessment or is estimated and prone to inaccuracy. Subjective assessment also applies to size of wound, and Schultz et al. [14] argued that simple ruler methods could overestimate the surface area by 44%. This is in part because the wound is often measured by different nurses at each visit. Previous studies have demonstrated that variation between wound measurements is largely due to differences in subjective identification of the wound edge by clinicians [15]. In some tissue viability services, electronic record keeping includes the use of a standard template with manually collected data, along with a photographic 2D image. Whilst measurement techniques have been refined [16], using a range of technological methods, there remains a significant problem with the accurate measurement for the purpose of recording wound-healing dimensions, and National Institute of Care Excellence (NICE) guidance suggests that improved outcome measurement come with the addition of depth measurement [17,18].

The aim of the study was to pilot the implementation of a 3D digital method of measuring stalled wounds using the WoundCareLite software (GPC solutions) and to investigate the potential benefits over manual measurement as a means of more accurately monitoring healing within a tissue viability services. The comparison of manual and digital methods was compared to establish whether improved accuracy could be achieved.


The pilot implementation study design used a non-randomised purposive sampling of 30 patients over a five-week recruitment period that allowed all patients’ wounds to be monitored for up to 12 weeks. Sponsored by Sheffield Teaching Hospitals NHS Foundation Trust in Sheffield UK, the nurses within the Sheffield Tissue Viability Service were trained in the use of the camera equipment and in patient recruitment and consenting good practice via ‘Good Clinical Practice’ (GCP). Funding was obtained from National Institute for Health Research (NIHR) Wound Management Co-Operative, based on free access to loaned PC and software the Panasonic FZ-M1 toughpad with WoundCareLite software version supplied by GPC woundcare ( html#woundcare). NHS Ethics (IRAS approval NIHR 225761) was granted for the study, based on patients’ verbal informed consent at treatment that was then recorded in the patient’s notes. The electronic health record SystmOne was used to maintain patient records, which has the functionality to collate both 2 D images and TV assessment data. And so additional camera images were collected and stored within usual electronic database; SystmOne.


Tissue viability patients were referred to the service from community nursing and General Practice or other referral agency and were identified as potential participants if they had a non-healing wound that was of more than 4 weeks duration. Wounds of any size were included and the aetiology of the wound was not limited to any one type and adult patients’ ages (<18) and genders were not exclusion criteria. Following referral, existing triage methods included the use of a 2-D photo image with paper ruler and a standard wound template assessment, both of which were uploaded to an existing electronic health record (SystmOne). All referrals to tissue viability were triaged and treatment planning was then undertaken with the patient and the community nursing team as per usual care; with advice on dressing and specialist wound management.

Patients were identified, recruited, and consented on referral; provided with an information leaflet and the study was explained. All patients were seen either at a wound clinic or in their own home by the specialist TV research nurse using the digital camera and software and with a community nurse using standard ruler-based measurement. Patients’ wounds were measured every four weeks +/- 2 days during a routine dressing change. All patients’ wounds were imaged at 0, 4, 8 and 12 weeks or until the wound healed. Each timepoint data collection included:

• Manual measurement of length and width of their wound (known as ‘manual measurement’) and a 2D photographic image.

• A 3D image taken using the Panasonic FZ-M1 toughpad and WoundCareLite software detected the length, width, depth, surface area and volume of the wound. The 3D modelling and data analytics training to use the camera and software was provided to the research nurse by the company (

All 3D images were stored on a single Panasonic laptop and deleted at the end of the study. 2D images were transferred to SystmOne, thus assuring that no images were held by the company.

Images were first taken with the traditional 2D camera by the attending community nurse, along with measurements using a paper ruler. The camera was positioned 50cm above the wound at right angles and 2D images of the wound were taken. The paper ruler was placed to the side of the wound to indicate length then a second image using the paper ruler to indicate width. Immediately after the rulerbased measurements, a 3D image was taken by the tissue viability research nurse. As with the 2D camera, the touchpad device was held 50cms from the wound at right angles and an image taken. The WoundCareLite software indicates when it is at the correct distance from the subject and automatically takes the image when the camera is held still. The 3D images included measurement and these data were stored on the touchpad device. Stored images could be re-measured by the research nurse at any point. In the case of the software failing to differentiate tissue at a wound edge, it was also possible to manually outline the wound edge on the image in the WoundCareLite software to guide the detection of the edge of the wound (3D guided). This was to reduce the occurrence of the software incorrectly identifying the edge of the wound.

Data analysis

Wound dimensions were automatically provided by the WoundCareLite software on ‘auto’ mode; to obtain wound measurements of length, width, depth, surface area, and volume. The software automatically detected the wound edge on the image. All wound measurements were collated on SystmOne, manually uploaded alongside usual wound monitoring information. This included 3D images and data and the 2D image and ruler-based measurements for all 30 patients and all the available time points.

Data analysis was undertaken by a statistician who initially collated the data and undertook a review of the demographic spread of recruitment and the range of wounds included in the study. Both the 3D auto measurements and the 3D guided were compared to the manual measurements using Bland-Altman plots, scatter plots and R2 correlation coefficients. Comparisons (ruler-based vs 3D auto and ruler-based vs 3D guided) assumed a limit of agreement are between ±10mm and ±30mm for wounds measurements that are typically around 50mm. Limits of agreement demonstrate how far apart measurements from the two different methods are likely to be for most individuals. Where the difference is not clinically important, the two methods can be used interchangeably.


The normal (mean) rate of referral to tissue viability is 150 patients per week. Over a five-week period, a sample group of 30 participants was identified and recruited allowing the service to report that recruitment achieved 4% (30 x100/750) of the population of all patients with non-healing wounds referred to tissue viability. Of all potential participants eligible, two were screened out at the point of consent. One candidate’s wound differed from the referral description and another candidate decided not to participate but was the only patient approached who declined to take part.

The most frequent wound by anatomical location was on the lower leg (n=20) and the leg ulcer clinic was the most frequently reported location where wound management was provided (14). 11 participants were seen in their own home by community nurses, 4 self-managed their wound after an initial period, and 1 participant was seen by a practice nurse. Postcodes of the patients represented over half the postcodes in Sheffield and, therefore, a representative sample of a city wide demographic (see table 1) and that proportionally the spread of referrals and recruitment represented a representative sample of patients/wounds who were usually referred to the service.