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Background Metal artefact reduction (MAR) techniques still are in limited use in positron emission tomography/computed tomography (PET/CT). This study aimed to investigate the effect of Smart MAR on quantitative PET analysis in the vicinity of hip prostheses. Materials and methods Activities were measured on PET/CT images in 6 sources with tenfold activity concentration contrast to background, attached to the head, neck and the major trochanter of a human cadaveric femur, and in the same sources in similar locations after a hip prosthesis (titanium cup, ceramic head, chrome-cobalt stem) had been inserted into the femur. Measurements were compared between PET attenuation corrected using either conventional or MAR CT. In 38 patients harbouring 49 hip prostheses, standardized uptake values (SUV) in 6 periprosthetic regions and the bladder were compared between PET attenuation corrected with either conventional or MAR CT. Results Using conventional CT, measured activity decreased with 2 to 13% when the prosthesis was inserted. Use of MAR CT increased measured activity by up to 11% compared with conventional CT and reduced the relative difference with the reference values to under 5% in all sources. In all regions, to the exception of the prosthesis shaft, SUVmean increased significantly (p < 0.001) by use of MAR CT. Median (interquartile range) percentual increases of SUVmean were 1.4 (0.0–4.2), 4.0 (1.8–7.8), 7.8 (4.1–12.4), 1.5 (0.0–3.2), 1.4 (0.8–2.8) in acetabulum, lateral neck, medial neck, lateral diaphysis and medial diaphysis, respectively. Except for the shaft, the coefficient of variation did not increase significantly. Except for the erratic changes in the prosthesis shaft, decreases in SUVmean were rare and small. Bladder SUVmean increased by 0.9% in patients with unilateral prosthesis and by 4.1% in patients with bilateral prosthesis. Conclusions In a realistic hip prosthesis phantom, Smart MAR restores quantitative accuracy by recovering counts in underestimated sources. In patient studies, Smart MAR increases SUV in all areas surrounding the prosthesis, most markedly in the femoral neck region. This proves that underestimation of activity in the PET image is the most prevalent effect due to metal artefacts in the CT image in patients with hip prostheses. Smart MAR increases SUV in the urinary bladder, indicating effects at a distance from the prosthesis.

Background Metal artefact reduction (MAR) techniques still are in limited use in positron emission tomography / computed tomography (PET/CT). This study aimed to investigate the effect of Smart MAR on quantitative PET analysis in the vicinity of hip prostheses.Material and methods Activities were measured on PET/CT images in 6 sources with 10-fold activity concentration contrast to background, attached to the head, neck and the major trochanter of a human cadaveric femur, and in the same sources in similar locations after a hip prosthesis (titanium cup, ceramic head, chrome-cobalt stem) had been inserted into the femur. Measurements were compared between PET attenuation corrected using either conventional or MAR CT. In 46 patients harbouring 61 hip prostheses, standardized uptake values (SUV) in 6 periprosthetic regions and the bladder, were compared between PET attenuation corrected with either conventional or MAR CT. Results Using conventional CT, measured activity decreased from 2 to 13% when the prosthesis was inserted. Use of MAR CT increased measured activity by up to 11 12% compared with conventional CT and reduced the relative difference with the reference values to under 5% in all sources.In all regions, to the exception of the prosthesis shaft, SUVmean increased significantly (p<0.001) by use of MAR CT. Median (interquartile range) percentual increases of SUVmean were 1.9 (0.0-4.5), 3.9 (1.8-7.8), 7.0 (3.4-11.1), 1.7 (0.9-3.7), 1.5 (0.8-3.3) in acetabulum, lateral neck, medial neck, lateral diaphysis and medial diaphysis, respectively. Except for the shaft, the coefficient of variation did not increase significantly. Except for the erratic changes in the prosthesis shaft, decreases of SUVmean were rare and small. Bladder SUVmean increased by 1% in patients with unilateral and by 4% in patients with bilateral prosthesis. Conclusions In a realistic hip prosthesis phantom, Smart MAR restores quantitative accuracy by recovering counts in underestimated sources. In patient studies, Smart MAR increases SUV in all areas surrounding the prosthesis, most markedly in the femoral neck region. This proves that underestimation of activity is the most prevalent metal artefact in hip prostheses. Smart MAR increases SUV in the urinary bladder, indicating effects at a distance from the prosthesis.