Metal artifact reduction in patients with total hip replacements: evaluation of clinical photon counting CT using virtual monoenergetic images

OBJECTIVES: To investigate photon-counting CT (PCCT)–derived virtual monoenergetic images (VMI) for artifact reduction in patients with unilateral total hip replacements (THR). METHODS: Forty-two patients with THR and portal-venous phase PCCT of the abdomen and pelvis were retrospectively included. For the quantitative analysis, region of interest (ROI)–based measurements of hypodense and hyperdense artifacts, as well as of artifact-impaired bone and the urinary bladder, were conducted, and corrected attenuation and image noise were calculated as the difference of attenuation and noise between artifact-impaired and normal tissue. Two radiologists qualitatively evaluated artifact extent, bone assessment, organ assessment, and iliac vessel assessment using 5-point Likert scales. RESULTS: VMI(110keV) yielded a significant reduction of hypo- and hyperdense artifacts compared to conventional polyenergetic images (CI) and the corrected attenuation closest to 0, indicating best possible artifact reduction (hypodense artifacts: CI: 237.8 ± 71.4 HU, VMI(110keV): 8.5 ± 122.5 HU; p < 0.05; hyperdense artifacts: CI: 240.6 ± 40.8 HU vs. VMI(110keV): 13.0 ± 110.4 HU; p < 0.05). VMI(110keV) concordantly provided best artifact reduction in the bone and bladder as well as the lowest corrected image noise. In the qualitative assessment, VMI(110keV) received the best ratings for artifact extent (CI: 2 (1–3), VMI(110keV): 3 (2–4); p < 0.05) and bone assessment (CI: 3 (1–4), VMI(110keV): 4 (2–5); p < 0.05), whereas organ and iliac vessel assessments were rated highest in CI and VMI(70keV). CONCLUSIONS: PCCT-derived VMI effectively reduce artifacts from THR and thereby improve assessability of circumjacent bone tissue. VMI(110keV) yielded optimal artifact reduction without overcorrection, yet organ and vessel assessments at that energy level and higher were impaired by loss of contrast. CLINICAL RELEVANCE STATEMENT: PCCT-enabled artifact reduction is a feasible method for improving assessability of the pelvis in patients with total hip replacements at clinical routine imaging. KEY POINTS: • Photon-counting CT-derived virtual monoenergetic images at 110 keV yielded best reduction of hyper- and hypodense artifacts, whereas higher energy levels resulted in artifact overcorrection. • The qualitative artifact extent was reduced best in virtual monoenergetic images at 110 keV, facilitating an improved assessment of the circumjacent bone. • Despite significant artifact reduction, assessment of pelvic organs as well as vessels did not profit from energy levels higher than 70 keV, due to the decline in image contrast.