Background In computed tomography (CT) scans, artifacts caused by metallic orthopedic implants still hamper the visualization of important, periprosthetic tissues. Smart MAR metal artifact reduction tool is a promising three-stage, projection-based, post-processing algorithm. Purpose To determine whether the Smart MAR tool improves subjective and objective image quality and diagnostic confidence in patients with orthopedic implants of the hip, spine, and shoulder. Material and Methods Seventy-two patients with orthopedic screws, hip/shoulder replacement, or spine spondylodesis were included. CT scans were performed on a single-source multislice CT scanner, raw data were post-processed using Smart MAR. Image quality was evaluated both quantitatively (ROI-based) and qualitatively (rater-based) and compared to iterative reconstructions (ASIR V). As comparative standard for artificial prosthetic breaks or loosening, follow-up examinations were used. Results Smart MAR reconstructions of the hip (n = 23), spine (n = 26), and shoulder (n = 23) showed a significantly reduced attenuation and noise of regions adjacent to metallic implants ( P<0.002). Subjective image quality ( P<0.005, shoulder P = 0.038/ P = 0.046) and overall diagnostic confidence were higher in Smart MAR (all regions P<0.002). Signal-to-noise ratio (SNR; P = 0.72/ P = 0.96) was not improved. Compared to standard ASIR V new, artificial metal extinctions (up to 50%) or periprosthetic hem lines (48%–73%) were introduced by Smart MAR. Conclusion Smart MAR improved image quality of the hip, spine, and shoulder CT scans resulting in higher diagnostic confidence in evaluation of periprosthetic soft tissues. As shown for spine implants, it should be used with caution and as a complementary tool for evaluation of periprosthetic loosening or integrity of metal implant, as in many cases it introduced new artifacts.
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