Metal Artifact Reduction Algorithm Research Articles

Quantitative CT assessment of a novel direction-modulated brachytherapy tandem applicator

PurposeThe purpose of this study was to quantitatively assess the CT metal-induced artifacts from a novel direction-modulated brachytherapy (DMBT) tandem applicator prototype, recently designed for cervical cancer treatments. Methods and materialsA water-based pelvic phantom was constructed for CT scanning. The DMBT applicator was imaged using our institutional protocol, one with higher kVp and mAs settings, and repetition of these protocols using 3-mm slices. A conventional stainless steel applicator was also scanned. In addition to the standard reconstructed images, applicator images were reconstructed using a commercial metal artifact-reduction (MAR) algorithm and an in-house–developed research algorithm. Subsequently, image quality and artifact severity were evaluated. ResultsArtifact severity, measured in terms of SDs in CT numbers, decreased asymptotically to background water levels with the distance away from the applicator. Artifact-reduction algorithms lead to significant and visible improvements in image quality, with >50% and >20% decrease in artifact severity achieved at a 10-mm distance for the DMBT and stainless steel applicators, respectively. Differences in artifact severity were minimal between the four imaging protocols. DMBT dimensions were the same on images with and without the commercial MAR algorithm, within <1 mm of the theoretical value. Both the commercial and in-house algorithms restored the CT numbers outside the applicator, albeit a better performance was achieved by the in-house algorithm. ConclusionsThe artifacts produced by both applicators were minimized with the use of MAR algorithms. Adoption of the DMBT and stainless steel applicators for CT-guided brachytherapy is anticipated as MAR algorithms are widely available on CT scanners.

Metal artefact reduction for accurate tumour delineation in radiotherapy

Background and purposeTwo techniques for metal artefact reduction for computed tomography were studied in order to identify their impact on tumour delineation in radiotherapy. Materials and methodsUsing specially designed phantoms containing metal implants (dental, spine and hip) as well as patient images, we investigated the impact of two methods for metal artefact reduction on (A) the size and severity of metal artefacts and the accuracy of Hounsfield Unit (HU) representation, (B) the visual impact of metal artefacts on image quality and (C) delineation accuracy. A metal artefact reduction algorithm (MAR) and two types of dual energy virtual monochromatic (DECT VM) reconstructions were used separately and in combination to identify the optimal technique for each implant site. ResultsThe artefact area and severity was reduced (by 48–76% and 58–79%, MAR and DECT VM respectively) and accurate Hounsfield-value representation was increased by 22–82%. For each energy, the observers preferred MAR over non-MAR reconstructions (p < 0.01 for dental and hip cases, p < 0.05 for the spine case). In addition, DECT VM was preferred for spine implants (p < 0.01). In all cases, techniques that improved target delineation significantly (p < 0.05) were identified. ConclusionsDECT VM and MAR techniques improve delineation accuracy and the optimal of reconstruction technique depends on the type of metal implant.

Metal artifact reduction for dental implants in kilovoltage computed tomography using megavoltage cone-beam computer tomography

This paper proposes a novel metal artifact reduction (MAR) algorithm for dental implants in kilovoltage computed tomography (kVCT) using megavoltage cone-beam computer tomography (MVCBCT). Firstly, two CT images were derived by scanning patient with dental implants using kVCT and MVCBCT. Metal image was derived by thresholding segmentation in kVCT. MVCBCT and kVCT images were fused to generate prior image which was forward projected to get surrogate sinogram of metal trace. The corrected image was generated by filtered backprojection (FBP) reconstruction in corrected sinogram. The results of proposed algorithm were compared with other frequently-used metal artifact reduction algorithm, such as normalized MAR (NMAR), normalized MAR using MVCBCT prior images (NMAR-MV), and linear interpolation MAR (LIMAR). The normalized root mean square deviation (NRMSD) and mean absolute deviation (MAD) were computed. The experiment showed that the proposed method removed serious metal artifacts without introducing new artifacts. The values of NRMSD and MAD for proposed method were the minimum in all methods. The values of NRMSD for NMAR, NMAR-MV, LIMAR and the proposed method were 21.0%, 22.1%, 41.9% and 17.0% respectively. And MAD values of them were 232, 235, 553, 205 HU, respectively. In conclusion, the proposed metal artifact reduction algorithm can successfully suppress metal artifacts for dental implants, and greatly improve the quality of CT image.

Advancements in Dual-Energy CT Applications for Musculoskeletal Imaging

Dual-energy computed tomography (DECT) has become a unique highly useful imaging modality in musculoskeletal (MSK) radiology practice. In this article, we provide a concise overview of the four main applications for DECT in (MSK) imaging: monosodium urate (Gout) detection, metal artifact reduction, bone marrow edema detection, and collagen imaging. We also highlight the recent studies published in radiology and rheumatology literature. Virtual monoenergetic images performed by utilizing DECT, particularly with the use of metal artifact reduction algorithm software, deliver superior image quality and have an impact on the assessment of the bone–metal interface. Regarding gout detection, DECT is a reliable, non-invasive diagnostic method to establish the diagnosis of gout that has been validated in the recent years. DECT has been incorporated into ACR/EULAR 2015 Gout Classification Criteria. DECT continues to play an important role in musculoskeletal radiology practice. Further research is required to validate some of the more recent and novel applications, for example, the collagen imaging application to compare its sensitivity and specificity in detecting tears and other tendon- and ligament-related pathologies as compared to MRI.

Metal Artifact Reduction for Orthopedic Implants (O-MAR): Usefulness in CT Evaluation of Reverse Total Shoulder Arthroplasty

The objective of this study is to evaluate the effect of the metal artifact reduction algorithm for orthopedic implants (O-MAR) on CT image quality for patients with reverse total shoulder arthroplasty (RTSA), with emphasis placed on the evaluation of bone in the vicinity of prostheses. Sixty-five patients who underwent CT scanning after RTSA were enrolled in the study. Two radiologists analyzed the images reconstructed with filtered back projection (FBP) with or without O-MAR processing. Images were evaluated to determine the degree of streaking artifacts, the confidence in depicting various structures around the prosthesis, and the presence of pseudolesions. The mean CT number and SD of the selected ROIs placed in the greater tuberosity, glenoid bone, and deltoid muscle were recorded. For measurements from the greater tuberosity and glenoid bone, the frequency with which the measurement met the typical CT number of bone was calculated. O-MAR images showed less metal streak artifact and noise and provided better visualization of the axillary neurovascular bundle compared with FBP images, with a statistically significant difference (p < 0.001 for all). FBP images were found to be statistically significantly better than O-MAR images, offering better visualization of bone cortex, bone trabeculae, and the bone-prosthesis interface (p < 0.001 for all). Scapular pseudonotching was observed on 4.6% of FBP images and 36.9% of O-MAR images. The pseudocemented appearance was noted on 47.7% of O-MAR images but was not seen on FBP images. The use of O-MAR improved CT image quality for patients with RTSA in the aspect of metal artifact reduction and soft-tissue profile. However, O-MAR tends to degrade depiction of the bone trabeculae and bone cortex and generate new artifacts, including a pseudocemented appearance and scapular pseudonotching.

Prototype metal artefact reduction algorithm in flat panel computed tomography - evaluation in patients undergoing transarterial hepatic radioembolisation.

To investigate the effect of an on-site prototype metal artefact reduction (MAR) algorithm in cone-beam CT-catheter-arteriography (CBCT-CA) in patients undergoing transarterial radioembolisation (RE) of hepatic masses. Ethical board approved retrospective study of 29 patients (mean 63.7±13.7 years, 11 female), including 16 patients with arterial metallic coils, undergoing CBCT-CA (8s scan, 200 degrees rotation, 397 projections). Image reconstructions with and without prototype MAR algorithm were evaluated quantitatively (streak-artefact attenuation changes) and qualitatively (visibility of hepatic parenchyma and vessels) in near- (<1cm) and far-field (>3cm) of artefact sources (metallic coils and catheters). Quantitative and qualitative measurements of uncorrected and MAR corrected images and different artefact sources were compared RESULTS: Quantitative evaluation showed significant reduction of near- and far-field streak-artefacts with MAR for both artefact sources (p<0.001), while remaining stable for unaffected organs (all p>0.05). Inhomogeneities of attenuation values were significantly higher for metallic coils compared to catheters (p<0.001) and decreased significantly for both after MAR (p<0.001). Qualitative image scores were significantly improved after MAR (all p<0.003) with by trend higher artefact degrees for metallic coils compared to catheters. In patients undergoing CBCT-CA for transarterial RE, prototype MAR algorithm improves image quality in proximity of metallic coil and catheter artefacts. • Metal objects cause artefacts in cone-beam computed tomography (CBCT) imaging. • These artefacts can be corrected by metal artefact reduction (MAR) algorithms. • Corrected images show significantly better visibility of nearby hepatic vessels and tissue. • Better visibility may facilitate image interpretation, save time and radiation exposure.

Single energy metal artifact reduction technique in the evaluation of postoperative tumor endoprostheses in the knee joint

Objective To evaluate the effect of the single energy metal artifact reduction (SEMAR) algorithm with a 320 multi-slice computed tomography (MSCT) volume scanner in patients with knee tumor prostheses. Methods From November 2015 to March 2016, 23 consecutive patients with knee tumor prostheses who underwent a 320-MSCT scan were collected. And the raw data were reconstructed using two different methods: conventional iterative reconstruction (IR) alone and IR associated with SEMAR. The ROI were objectively and subjectively assessed at osteotomy level and articular level, and the Wilcoxon signed rank test was used for them. Results Compared with IR, objectively, artifact index (AI) values of the osteotomy level decreased 44.8% to 74.1% and that of the articular level decreased 73.2% to 93.2%; subjectively, the scores of image quality of two levels were increased 0.5 to 2.0 scores and 1.0 to 4.0 scores by SEMAR respectively. The objective and subject image quality of periprosthetic structures were all significantly improved by the SEMAR algorithm (P<0.05). Conclusion The SEMAR algorithm significantly reduced the metal artifact of knee tumor prostheses, improved the image quality of periprosthetic structures and may increase diagnostic confidence of prosthetic complications in patients with modular knee tumor prostheses, especially at the osteotomy level. Key words: Knee prosthesis; Tomography,X-ray computed

A metal artifact reduction algorithm in CT using multiple prior images by recursive active contour segmentation.

We propose a novel metal artifact reduction (MAR) algorithm for CT images that completes a corrupted sinogram along the metal trace region. When metal implants are located inside a field of view, they create a barrier to the transmitted X-ray beam due to the high attenuation of metals, which significantly degrades the image quality. To fill in the metal trace region efficiently, the proposed algorithm uses multiple prior images with residual error compensation in sinogram space. Multiple prior images are generated by applying a recursive active contour (RAC) segmentation algorithm to the pre-corrected image acquired by MAR with linear interpolation, where the number of prior image is controlled by RAC depending on the object complexity. A sinogram basis is then acquired by forward projection of the prior images. The metal trace region of the original sinogram is replaced by the linearly combined sinogram of the prior images. Then, the additional correction in the metal trace region is performed to compensate the residual errors occurred by non-ideal data acquisition condition. The performance of the proposed MAR algorithm is compared with MAR with linear interpolation and the normalized MAR algorithm using simulated and experimental data. The results show that the proposed algorithm outperforms other MAR algorithms, especially when the object is complex with multiple bone objects.

Follow-up CT and CT angiography after intracranial aneurysm clipping and coiling-improved image quality by iterative metal artifact reduction.

This paper aims to evaluate a new iterative metal artifact reduction algorithm for post-interventional evaluation of brain tissue and intracranial arteries. The data of 20 patients that underwent follow-up cranial CT and cranial CT angiography after clipping or coiling of an intracranial aneurysm was retrospectively analyzed. After the images were processed using a novel iterative metal artifact reduction algorithm, images with and without metal artifact reduction were qualitatively evaluated by two readers, using a five-point Likert scale. Moreover, artifact strength was quantitatively assessed in terms of CT attenuation and standard deviation alterations. The qualitative analysis yielded a significant increase in image quality (p=0.0057) in iteratively processed images with substantial inter-observer agreement (ĸ=0.72), while the CTA image quality did not differ (p=0.864) and even showed vessel contrast reduction in six cases (30%). The mean relative attenuation difference was 27% without metal artifact reduction vs. 11% for iterative metal artifact reduction images (p=0.0003). The new iterative metal artifact reduction algorithm enhances non-enhanced CT image quality after clipping or coiling, but in CT-angiography images, the contrast of adjacent vessels can be compromised.

Proceedings to the 56th Annual Meeting of the Particle Therapy Cooperative Group (PTCOG), 8-13 May 2017: Hosted by the Kanagawa Cancer Center and the National Institute of Radiological Sciences, Japan.

Purpose: To evaluate for proton therapy treatment planning the feasibility of two commercial metal artifact reduction (MAR) algorithms in CT-imaging.Materials and Methods: A head phantom with remov ...

Evaluation of metal artefact reduction in cone-beam computed tomography images of different dental materials.

The aim of this study is to evaluate the efficacy of metal artefact reduction (MAR) in different dental materials with Picasso Trio cone-beam computed tomography (CBCT) scanner. Three imaging phantoms were custom-made of acrylic resin. Each phantom presented three cylinders of the same material: dental amalgam alloy, gutta-percha or aluminium-copper alloy. CBCT scans were performed on Picasso Trio unit with and without MAR, and artefact expression (standard deviation of grey values) was obtained and compared by Kruskal-Wallis and Student-Newman-Keuls (post hoc) (α=0.05). Significant reduction of artefact expression (p<0.05) was observed with MAR on areas around dental alloys. No significant difference (p>0.05) was observed with or without MAR when gutta-percha was scanned. MAR was effective in reducing artefacts arising from dental alloys on CBCT images. Dental materials of high atomic number and density are widely used in dentistry and can produce artefact that compromise CBCT image. The present study demonstrated that metal artefact reduction algorithm is an effective tool to improve image quality.

The impact of smart metal artefact reduction algorithm for use in radiotherapy treatment planning.

The presence of metal artefacts in computed tomography (CT) create issues in radiation oncology. The loss of anatomical information and incorrect Hounsfield unit (HU) values produce inaccuracies in dose calculations, providing suboptimal patient treatment. Metal artefact reduction (MAR) algorithms were developed to combat these problems. This study provides a qualitative and quantitative analysis of the "Smart MAR" software (General Electric Healthcare, Chicago, IL, USA), determining its usefulness in a clinical setting. A detailed analysis was conducted using both patient and phantom data, noting any improvements in HU values and dosimetry with the GE-MAR enabled. This study indicates qualitative improvements in severity of the streak artefacts produced by metals, allowing for easier patient contouring. Furthermore, the GE-MAR managed to recover previously lost anatomical information. Additionally, phantom data showed an improvement in HU value with GE-MAR correction, producing more accurate point dose calculations in the treatment planning system. Overall, the GE-MAR is a useful tool and is suitable for clinical environments.

Evaluation of the efficacy of a metal artifact reduction algorithm in different cone beam computed tomography scanning parameters

The aim of this study was to evaluate the efficacy of a metal artifact reduction (MAR) algorithm in cone beam computed tomography (CBCT) images of dental materials obtained with different field-of-view (FOV) and voxel sizes. Two imaging phantoms were custom-made of acrylic resin. Each phantom had 3 cylinders made of the same dental material: dental amalgam or copper-aluminum alloy. CBCT scans were obtained separately for each of the imaging phantoms using the Picasso-Trio CBCT (Vatech, Hwaseong, Republic of Korea) unit at 4 FOV sizes and 2 voxel sizes. Each imaging phantom was scanned with and without MAR. All images were evaluated in the OnDemand3D software (Cybermed, Seoul, Republic of Korea) and image noise (gray value variability) was calculated as the standard deviation (SD) of the gray values of regions of interest around the dental material cylinders. Data were compared by the Friedman test and Dunn test (α=0.05). Intraclass correlation coefficient (ICC) was calculated to assess intraobserver reliability. MAR significantly reduced (P<.05) image noise around the dental materials, irrespective of FOV and voxel sizes, with an ICC of 0.997. The efficacy of MAR was similar for the different FOV and voxel sizes studied. Hence, imaging protocols and the use of MAR algorithm should be based on the selection criteria.

Clinical evaluation of the iterative metal artefact reduction algorithm for post-operative CT examination after maxillofacial surgery.

Metal artefacts present challenges to both radiologists and clinicians during post-operative imaging. Such artefacts reduce the diagnostic effectiveness of CT scans and mask findings that could be vital for patient management. Thus, a powerful artefact reduction tool is necessary when imaging patients with metal implants. Our aim was to test the recently introduced iterative metal artefact reduction (iMAR) algorithm in patients with maxillofacial implants. Images from 17 patients with diverse maxillofacial metal implants who had undergone CT scans were qualitatively and quantitatively analyzed before and after metal artefact reduction with iMAR. After iMAR application, images exhibited decreased artefacts and improved image quality, leading to detection of lesions that were previously masked by artefacts. The application of iMAR did not affect image quality in regions distant from the metal implants. The application of iMAR to CT examinations of patients with maxillofacial metal implants leads to artefact reduction, improvement of image quality and increased diagnostic utility. Routine implementation of iMAR during imaging of patients with metal hardware implants could add diagnostic value to their CT examinations.

Implementation of iterative metal artifact reduction in the pre-planning-procedure of three-dimensional physical modeling

BackgroundTo assess the impact of metal artifact reduction techniques in 3D printing by evaluating image quality and segmentation time in both phantom and patient studies with dental restorations and/or other metal implants. An acrylic denture apparatus (Kilgore Typodent, Kilgore International, Coldwater, MI) was set in a 20 cm water phantom and scanned on a single-source CT scanner with gantry tilting capacity (SOMATOM Edge, Siemens Healthcare, Forchheim, Germany) under 5 scenerios: (1) Baseline acquisition at 120 kV with no gantry tilt, no jaw spacer, (2) acquisition at 140 kV, (3) acquisition with a gantry tilt at 15°, (4) acquisition with a non-radiopaque jaw spacer and (5) acquisition with a jaw spacer and a gantry tilt at 15°. All acquisitions were reconstructed both with and without a dedicated iterative metal artifact reduction algorithm (MAR). Patients referred for a head-and-neck exam were included into the study. Acquisitions were performed on the same scanner with 120 kV and the images were reconstructed with and without iterative MAR. Segmentation was performed on a dedicated workstation (Materialise Interactive Medical Image Control Systems; Materialise NV, Leuven, Belgium) to quantify volume of metal artifact and segmentation time.ResultsIn the phantom study, the use of gantry tilt, jaw spacer and increased tube voltage showed no benefit in time or artifact volume reduction. However the jaw spacer allowed easier separation of the upper and lower jaw and a better display of the teeth. The use of dedicated iterative MAR significantly reduced the metal artifact volume and processing time. Same observations were made for the four patients included into the study.ConclusionThe use of dedicated iterative MAR and jaw spacer substantially reduced metal artifacts in the head-and-neck CT acquisitions, hence allowing a faster 3D segmentation workflow.

CT venography after knee replacement surgery: comparison of dual-energy CT-based monochromatic imaging and single-energy metal artifact reduction techniques on a 320-row CT scanner.

BackgroundAn optimal metal artifact reduction (MAR) technique is needed for a reliable and accurate image-based diagnosis.PurposeUsing a 320-row scanner, we compared the dual-energy computed tomography (CT)-based monochromatic and the single-energy metal artifact reduction (SEMAR) techniques for CT venography (CTV) to identify the better imaging method for diagnosing deep vein thrombosis (DVT) in patients who had undergone knee replacement surgery.Material and MethodsTwenty-three consecutive patients with suspected DVT after unilateral knee replacement surgery underwent dual-energy CT (135/80 kVp). Monochromatic images of 35–135 keV were generated; the monochromatic image with the best signal-to-noise ratio (SNR) of the popliteal vein near the metal prosthesis were selected. The projection data of 80 kVp were reconstructed using MAR algorithm. The mean SNR ON MAR and the best SNR ON monochromatic images were compared. Two radiologists evaluated visualization of the metal artifacts on a four-point scale where 1 = extensive artifacts, 2 = strong artifacts, 3 = mild artifacts, and 4 = minimal artifacts.ResultsThe mean SNR was significantly higher on the MAR than the monochromatic images (12.8 ± 4.7 versus 7.7 ± 5.1, P < 0.01) and the visual scores were significantly higher for MAR than monochromatic images (2.6 ± 0.8 versus 1.3 ± 0.4, P < 0.01).ConclusionFor CTV after knee replacement surgery, the MAR technique is superior to the monochromatic imaging technique.

Gaussian diffusion sinogram inpainting for X-ray CT metal artifact reduction

BackgroundMetal objects implanted in the bodies of patients usually generate severe streaking artifacts in reconstructed images of X-ray computed tomography, which degrade the image quality and affect the diagnosis of disease. Therefore, it is essential to reduce these artifacts to meet the clinical demands.MethodsIn this work, we propose a Gaussian diffusion sinogram inpainting metal artifact reduction algorithm based on prior images to reduce these artifacts for fan-beam computed tomography reconstruction. In this algorithm, prior information that originated from a tissue-classified prior image is used for the inpainting of metal-corrupted projections, and it is incorporated into a Gaussian diffusion function. The prior knowledge is particularly designed to locate the diffusion position and improve the sparsity of the subtraction sinogram, which is obtained by subtracting the prior sinogram of the metal regions from the original sinogram. The sinogram inpainting algorithm is implemented through an approach of diffusing prior energy and is then solved by gradient descent. The performance of the proposed metal artifact reduction algorithm is compared with two conventional metal artifact reduction algorithms, namely the interpolation metal artifact reduction algorithm and normalized metal artifact reduction algorithm. The experimental datasets used included both simulated and clinical datasets.ResultsBy evaluating the results subjectively, the proposed metal artifact reduction algorithm causes fewer secondary artifacts than the two conventional metal artifact reduction algorithms, which lead to severe secondary artifacts resulting from impertinent interpolation and normalization. Additionally, the objective evaluation shows the proposed approach has the smallest normalized mean absolute deviation and the highest signal-to-noise ratio, indicating that the proposed method has produced the image with the best quality.ConclusionsNo matter for the simulated datasets or the clinical datasets, the proposed algorithm has reduced the metal artifacts apparently.

Iterative metal artefact reduction in CT: can dedicated algorithms improve image quality after spinal instrumentation?

To investigate the value of dedicated computed tomography (CT) iterative metal artefact reduction (iMAR) algorithms in patients after spinal instrumentation. Post-surgical spinal CT images of 24 patients performed between March 2015 and July 2016 were retrospectively included. Images were reconstructed with standard weighted filtered back projection (WFBP) and with two dedicated iMAR algorithms (iMAR-Algo1, adjusted to spinal instrumentations and iMAR-Algo2, adjusted to large metallic hip implants) using a medium smooth kernel (B30f) and a sharp kernel (B70f). Frequencies of density changes were quantified to assess objective image quality. Image quality was rated subjectively by evaluating the visibility of critical anatomical structures including the central canal, the spinal cord, neural foramina, and vertebral bone. Both iMAR algorithms significantly reduced artefacts from metal compared with WFBP (p<0.0001). Results of subjective image analysis showed that both iMAR algorithms led to an improvement in visualisation of soft-tissue structures (median iMAR-Algo1=3; interquartile range [IQR]:1.5-3; iMAR-Algo2=4; IQR: 3.5-4) and bone structures (iMAR-Algo1=3; IQR:3-4; iMAR-Algo2=4; IQR:4-5) compared to WFBP (soft tissue: median 2; IQR: 0.5-2 and bone structures: median 2; IQR: 1-3; p<0.0001). Compared with iMAR-Algo1, objective artefact reduction and subjective visualisation of soft-tissue and bone structures were improved with iMAR-Algo2 (p<0.0001). Both iMAR algorithms reduced artefacts compared with WFBP, however, the iMAR algorithm with dedicated settings for large metallic implants was superior to the algorithm specifically adjusted to spinal implants.

Evaluation of New Commercially Available Metal Artifact Reduction (MAR) Algorithm on Both Image Quality and Relative Dosimetry for Patients with Hip Prosthesis or Dental Fillings

Streaking artifacts on computed tomography (CT) images are caused by high density materials such as hip prosthesis, surgical clips and dental fillings. The artifacts can lead to compromised clinical outcome due to the inability to differentiate tumor volume and the uncertainties in dose calculation. The goals of our study are to evaluate how GE’s smart metal artifact reduction (MAR) algorithm impacts image quality on phantoms and dosimetry on head and neck patients with dental fillings and pelvic patients with hip prosthesis. Treatment plans calculated on the MAR and non-MAR datasets with the same beam arrangements and fluence are compared. Dose differences between the MAR and non-MAR datasets are not significant. However, substantial reductions of metal artifacts are observed when MAR algorithm is applied. Planning on the MAR dataset is recommended since it improves image quality and CT number accuracy. It also negates the need to contour the artifacts and override the density which can be time consuming.

Secure Screw Placement in Management of Acetabular Fractures Using the Suprapectineal Quadrilateral Buttress Plate.

Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30–45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014.