Dual-layer spectral computerized tomography for metal artifact reduction: small versus large orthopedic devices

Introduction Metal artifacts limit the diagnostic utility of computerized tomography (CT) for implant-related complications. Dual-layer spectral detector CT imaging has been suggested for artifact reduction. Our objective was to evaluate the utility of spectral CT in artifact reduction in patients with small and large metal implants. Methods In this prospective study, patients with metallic orthopedic implants underwent CT imaging using a prototype spectral detector CT scanner. Conventional images were generated with iterative reconstruction at 120 kVp, and virtual monochromatic images were generated at 20-keV intervals between 40 to 200 keV. Conventional and monochromatic images were compared quantitatively using signal-to-noise ratio (SNR) and artifact improvement. Qualitative analysis was performed independently by two musculoskeletal radiologists and included six image quality indicators. Results A total of 12 patients were scanned. In monochromatic images, as the energy level increased, the artifact size decreased progressively (p < 0.01). When conventional and monochromatic images were compared, maximum reduction was seen at 200 keV. Using qualitative assessments, 160 and 180 keV levels had the best overall diagnostic image quality. With increased energy level, there was improvement in qualitative ratings of bone-metal interface conspicuity (p = 0.002), degree of streak artifact (p = 0.010) and trabecular bone definition at 1 cm from implant (p = 0.023), and a trend towards significance for bone definition at 5 cm, soft tissue detail and overall diagnostic quality. Subgroup analysis revealed superior artifact reduction in small implants compared to large hardware. Discussion Our results support the utility of dual-layer spectral CT in metal artifact reduction. Virtual monochromatic images were diagnostically superior, especially for smaller implants. Virtual monoenergetic images at 160-180 keV are ideal for reducing artifacts.