Pathophysiology 17 (2010) 1 8. Received 24 February 2009; received in revised form 16 March 2009; accepted 28 April 2009

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1 Pathophysiology 17 (2010) 1 8 Detection and evaluation of initial cartilage pathology in man: A comparison between MRT, arthroscopy and near-infrared spectroscopy (NIR) in their relation to initial knee pain Gunther O. Hofmann a,b,, Julia Marticke a, Ralph Grossstück b, M. Hoffmann d, Matthias Lange d, Holger K.W. Plettenberg d, Rainer Braunschweig c, Oliver Schilling c, Ingmar Kaden c, Gunter Spahn a,e a Department of Traumatology, Friedrich Schiller University of Jena, Germany b Department of Traumatology and Orthopaedic Surgery, Trauma Center Halle (Saale), Germany c Institute for Diagnostic and Interventional Radiology, Trauma Center Halle (Saale), Germany d Research Center for Medical Technology and Biotechnology, Bad Langensalza, Germany e Center of Trauma and Orthopaedic Surgery Eisenach, Germany Received 24 February 2009; received in revised form 16 March 2009; accepted 28 April 2009 Abstract Background and aims: MRI and arthroscopy are important methods in the evaluation of cartilage pathology. But frequently initial changes of cartilage in combination with chronic knee pain cannot be detected by employing these two methods. Better diagnostic tools for the detection of the early stages of osteoarthritis (OA) are required. The objective of this study was to show that near-infrared spectroscopy (NIRS) can be incorporated into routine arthroscopy to improve detection and assessment of the initial cartilage pathology. Furthermore correlations between findings in MRI, arthroscopy and NIRS in patients with initial symptoms of OA have studied. Methods: Patients (n = 21, 12 women, 9 men, age: years, mean years) with knee pain lasting for at least half a year without any trauma of the knee in their history were interviewed (body weight, smoking behaviour) and clinically evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Also serum parameters (cholesterol, lipids) were analysed, conventional X-rays in three directions (evaluated according to Kellgren and Lawrence) and MRI (evaluation of cartilage damage according to the ICRS-score) were performed preoperatively in all patients. During subsequent arthroscopy cartilage damage was evaluated according to the ICRS-score. In addition the spectral reflection of cartilage was investigated in all knees using a special micro-glass-fiber probe in the near-infrared light region (spectral range between 1150 and 1475 nm). To characterize relations between the investigated parameters the Spearman s rank correlation coefficient was used. Inter-observer variance was calculated employing the Cohens Kappa-test. Results: MRI demonstrated a strong inter-observer variance with no significant correlations to other parameters. The same was observed for arthroscopic findings. Only NIRS showed significant correlations with three out of five KOOS subscores. Within the general parameters only smoking behaviour showed a significant correlation with two of the KOOS-scores. NIRS therefore seemed to be a sensitive diagnostic tool in detection of initial pathology in human cartilage. The additional necessary time for the spectroscopic investigation as part of the routine arthroscopy ranged between 3 and 7 min (mean: 4 min 18 s). Conclusion: Particularly for early-stage cartilage lesions (ICRS 0/I) MRI and arthroscopy have rather low predictive value. The inter-observer variance is very high (Cohens Kappa < 0.4). Correlations found between NIRS and KOOS suggest that NIRS potentially can be used for detection of initial cartilage Abbreviations: OA, osteoarthritis; MFT, medial femoral tibial; LFT, lateral femoral tibial; G, femoropatellar (groove); KOOS, Knee Injury and Osteoarthritis Outcome Score; ADL, activity of daily life; ICRS, International Cartilage Repair Society; KL, Kellgren Lawrence; MRI, magnetic resonance imaging; FFE, fast field echo; FOV, field of view; RFOV, rectangular field of view; TR, time of repetition; TE, time of echo; TSE, turbo spin echo; PD SPAIR, proton density (sequence with fat suppression); NIRS, near-infrared spectroscopy. Corresponding author at: Klinik für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Kliniken Bergmannstrost, D Halle (Saale), Merseburgerstrasse 165, Germany. Tel.: ; fax: address: (G.O. Hofmann) /$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved. doi: /j.pathophys

2 2 G.O. Hofmann et al. / Pathophysiology 17 (2010) 1 8 pathology and may be helpful in the evaluation of the benefit of different medical or surgical interventions at early-stage of articular cartilage damage Elsevier Ireland Ltd. All rights reserved. Keywords: Knee pain; Cartilage; Osteoarthritis; Imaging; MRI; Arthroscopy; NIRS 1. Introduction Osteoarthritis (OA) is one of the most prevalent diseases of cartilage in large joints with painful burden for the patients and enormous social end economic impact for society. A non-destructive quantitative evaluation method for extent and localization of early cartilage pathology (stage ICRS-I) is not available up to now [1]. Arthroscopy is still the golden standard for in vivo cartilage diagnosis employing visual impression and the mechanical feedback by palpation [2 4]. The consistency of articular cartilage is evaluated using mechanical tools, especially different hooks for distinct indentation of the cartilage surface. OA chances the biochemical and biomechanical properties of articular cartilage [5]. These changes manifest themselves in a breakup of the collagen glucosamine matrix of cartilage [6] with consequent changes in water-binding properties and a shift in the ratio of the main cartilage components, collagen II and water. Infrared light interacts with vibrational modes in molecules through a change in the dipole moment, producing a useful frequency range for the study of molecular properties of matter. Water, water-binding, CH- and NH-groups can be detected by near-infrared light, suggesting that even early changes in cartilage on the way to OA can be detected with this method [7,8]. Intra-articular NIR-devices can be manufactured as reflection probes with optical fibers and may be employed similar in size, shape and utility compared to classical palpating hooks. sum of all compartments were included in this study. The exclusion criteria made certain that only patients with very early stages of OA were included in this study. A total of 21 patients were recruited between 03/2007 and 09/2007. The study was open-label, prospective and performed in one centre. The mean age of the patients (12 woman and 9 men) was years (ranging from 15 to 59 years, SD years). Informed consent was obtained from all patients after the nature of all examinations had been fully explained. All patients were interviewed (body weight, smoking behaviour) and examined clinically and by serum analysis (cholesterol, lipids). The Knee Injury and Osteoarthritis Outcome Score (KOOS) first described by Roos et al. [11,12] and modified by Kessler et al. [13] was determined. This score is a well-established clinical grading system which quantifies the degree of pain (9 items), symptoms (7 items), activity of daily life (ADL) function (17 items), sport and recreation function (5 items) and quality of life (4 items). The different areas of articular cartilage in the knee joint were divided into 15 defined areas of interest (AOI) (Fig. 1). Mapping of the articular areas in the knee joint makes it easier to describe lesion location and enables a direct comparison between clinical, radiological, MRI, arthroscopic and spectroscopic evaluation. MRI of all knee joints was performed with the 1.5T Achiva (Philips, Eindhoven) by using an 8 channels dual phasedarray coil (Philips, Eindhoven) for signal reception. The sequences employed were: 2. Patients and methods All patients reported in this paper were operated due to clinically relevant knee pain lasting for at least half a year. Patients with a history of trauma, previous surgery or inflammatory arthritis were excluded. Preoperative conventional X-rays were taken of all knees in three planes: a.p., lateral and tangential view of the patellofemoral joint. The a.p.-view was performed in standing and weight-bearing position. The degree of osteoarthrosis was classified due to a modified Kellgren Lawrence(KL)- knee score [9,10] (Table 1), estimating the degree of pathological changes (A: osteophytes, B: subchondral sclerosis, C: joint space narrowing, D: joint deformation) between 0 and 8 points. The three compartments (medial femorotibial (MFT), lateral femorotibial (LFT), femoropatellar (G: groove) of each knee joint were evaluated separately. Only patients with a maximum of 2 points or less in Table 1 Modified Kellgren Lawrence-score [25,26] of OA in conventional X-ray diagnosis. Osteophytes (A) 0 = none or beginning 1 = definitive Subchondral sclerosis (B) 0 = none 1 = slight 2 = significant 3 = significant with bone cysts in femur, tibia, patella Joint space (C) 0 = normal 1 = half of normal 2 = no joint space visible Joint deformation (D) 0 = no deformation 1 = femur condyles not spherical 2 = significant destruction and deformations Kellgren Lawrence-score 3 (0...8)= for each compartment separately (MFT: medial femorotibial; LFT: lateral femorotibial; FP: femoropatellar).

3 G.O. Hofmann et al. / Pathophysiology 17 (2010) Fig. 1. Regions of interest. 15 areas of interest: mapping of the articular cartilage in femur, tibia and patella of the knee joints for a defined and consistent localization and evaluation of the cartilage in MRI, arthroscopy and NIRS. Footnotes: F: femoral, M: medial, T: tibial, L: lateral, P: patellar, V: ventral, G: groove, D: dorsal, N: notch, C: central. T2 FFE sagittal and coronal (FOV 200, RFOV 80%, thickness 2 mm, TR 796 ms, TE 10 ms, 2:40 min). T1 TSE sagittal (FOV 200, RVOV 90%, thickness 3 mm, TR 420 ms, TE 8.6 ms, 2:24 min). PD SPAIR sagittal, coronal and axial (FOV 170, RFOV 90%, thickness 3 mm, TR 2051 ms, TE 7 ms, 3:08 min). During the preoperative MRI all 15 AOI were evaluated according to the ICRS recommended magnetic resonance imaging acquisition protocols for articular cartilage [14] by three experienced radiologists as independent readers (R.B., O.S., I.K.). To compare both arthroscopic and MRI-findings and to evaluate the inner structures of the knee joint cartilage the following graduation was used: normal surface lesions defects in less than 50% of the cartilage thickness defects in more than 50% of the cartilage thickness total defect All operations were carried out by only two surgeons (G.O.H., R.G.). Evaluation of cartilage followed a standardized protocol for the clinical ICRS-based and the NIRS application. During arthroscopy the grade of cartilage pathology within the 15 AOI was determined and classified as four stages according to the ICRS protocol [14] (Table 2). Stage 2, 3 and 4 defects are easily detectable by visualization with bare eyes. However, the differentiation between early-stage cartilage defects (stage 1) and intact cartilage (stage 0) is rather difficult. Depth and areal extension of any lesions were analyzed with use of a graduated hook. One AOI could not be explored by arthroscopy and 15 AOIs were not to investigate with the NIRS probe due to a very narrow joint space. For NIRS a fiber optic diode micro-spectrometer (microparts 1.7, Dortmund, Germany) with a spectral range Table 2 Arthroscopy evaluation of articular cartilage according to the ICRS-score [11]. Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Normal, macroscopically intact cartilage, no notable defects Softening of cartilage with intact surface, 1a: with fibrillation; 1b: with additional superficial lacerations and fissures Clefts within the superficial layer (less than 50% of cartilage thickness) Clefts down to the subchondral bone (more than 50% of cartilage thickness), 3a: depth not extending to the calcified layer, 3b: depth extending to the calcified layer, 3c: depth extending down to but not through the subchondral bone plate, 3d: with blisters Complete defects of nm and a spectral resolution of 10 mm was used. The NIRS probe has nearly the same geometry as a standard hook probe usually employed during arthroscopy (Fig. 2). Light from a stabilized light source (LQ2NIR, JETI Technische Instrumente GmbH, Jena, Germany) was coupled into six optical fibers (silica glass, diameter: 200 m). The collection fiber (silica glass, diameter: 200 m) was connected to the spectrometer. The fibers were combined in a reflection probe (Loptec, Berlin, Germany) with the light delivering fibers surrounding the collection fiber (Fig. 3). Fig. 2. Arthroscopic NIRS probe compared to a standard hook probe.

4 4 G.O. Hofmann et al. / Pathophysiology 17 (2010) 1 8 Table 3 Recorded parameters in knee pain patients, part 1. N Min Max Mean SD BMI Age Cholesterol Lipids Koos-symptoms Koos-pain Koos-ADL Koos-sports Koos-quality of life Kellgreen MRI range ICRS NIRS ADL: activity of daily life. Fig. 3. Tip of the NIRS-probe. The collection fiber is placed in the center with the six light delivering fibers surrounding it in the periphery Prior to each measurement the reflectance of Ringer solution was recorded as reference. Then the tip of the probe was directly placed on the surface of each AOI (Fig. 4) and approximately 10 reflection spectra were recorded with 10 ms integration time. The absorption spectra were calculated from the reference and measurement spectra (absorption [AU] = log 10(reflectance [counts]/reference [counts]). The spectra were mean-centred to compensate for baseline shifts. For analysis the ratio of the peak absorptions of two bands, the 1st OH and CH combination overtones ( nm) and the 2nd CH overtone ( nm) was calculated for statistical evaluation. The additional necessary time for the spectroscopy during the routine arthroscopy ranged between 3 and 7 min (mean: 4 min 18 s). Statistical analysis was performed on a personal computer using SPSS (SPSS 11.0, SPSS Inc., USA). Since all Fig. 4. NIRS-probe in situ. NIRS-probe directly placed on the surface of articular cartilage in the medial groove of a knee joint with ICRS I during arthroscopy parameters showed no normal or linear distribution, the Spearman s rank correlation coefficient ρ was used to characterize links between parameters. The significance level p was set at 0.01 and for multiple tests was corrected by the number of variables involved. This resulted in a significance level of for the six general parameters (age, sex, BMI, smoking behaviour, cholesterol, lipids) and the five KOOS subscores. The AOIs were analyzed in three groups (femur, tibia, patella). Each imaging technique (X-ray, MRI, arthroscopy) and NIRS was tested against the 5 KOOS subscores with a corrected significance level of p = Cohens Kappa was used to test for inter-observer reliability between the three MRI readers. The study and all employed devices have been approved by the Ethic Commission for Clinical Trials of the Friedrich Schiller-University of Jena ( /06). Informed consent of all patients to the procedure was obtained. 3. Results All 21 patients underwent arthroscopic surgery because of chronic knee pain without any trauma. Range and distribution of all recorded parameters are shown in Tables 3 and 4. No patient had diabetes. In accordance with the exclusion criteria (KL 2) the radiological X-ray score showed no significant correlations with any other parameters. The matrix of significant correlation of general parameters with KOOS subscores is shown in Table 5. Only smoking behaviour correlated with two KOOS-scores (symptoms and pain). Table 4 Recorded parameters in knee pain patients, part 2. N Sex 21 Female 11 Male 10 Smoker 21 Non-smoker 5 Smoker 16 Polyarticular 21 No 13 Yes 8 Diabetes 21 No 21 Yes 0

5 G.O. Hofmann et al. / Pathophysiology 17 (2010) Table 5 Significant correlation of general parameters with KOOS subscores of knee pain patients. Age BMI Smoker Polyarticular Cholesterine Lipids KOOSsymp. KOOSpain KOOS- ADL Age BMI n.s. Smoker n.s. n.s. Poly-articular n.s. n.s. n.s. Cholesterine 0.65 n.s. n.s. n.s. Lipids n.s. n.s. n.s. n.s KOOS-symptoms n.s. n.s n.s. n.s. n.s. KOOS-pain n.s. n.s n.s. n.s. n.s KOOS-ADL n.s. n.s. n.s. n.s. n.s. n.s KOOS-sports n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s KOOS-quality of life n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s Corrected significance level at ADL: activity of daily life. KOOSsports KOOS-quality of life Table 6 Significant correlations between MRI, arthroscopy and NIRS. MRI Arthroscopy NIRS MRI Arthroscopy NIRS n.s. n.s. Corrected significance level at There is no correlation between radiological and MRIfindings, but MRI matched significantly (p < 0.1) with arthroscopy with a correlation coefficient ρ = 0.6 (Table 6). Moreover we found strong inter-observer differences for the MRI with a Cohens Kappa not extending 0.36 (low agreement [15]). There is no predictive value for KOOS parameters using MRI-findings with a maximal ρ of 0.51 (Table 7). Also the arthroscopic score showed no significant correlation with any KOOS subscore with a maximum of ρ of 0.41 (Table 7). Significant (p > 0.007) correlations with three KOOS subscores (symptoms, sports, quality of life) only were found with the NIRS (Table 7). The correlation coefficients ρ ranged between 0.68 and Discussion The main functions of articular cartilage are smooth gliding of articular surfaces and the withstanding of high loads. Therefore structural integrity of the articular cartilage is the most essential requirement for the performance of load bearing and motion. Clinical evaluation of early cartilage pathology is very difficult. Pain, the restriction of movement, joint effusion or crepitation are rather unspecific symptoms and may also occur in other joint diseases. Sensitivity, specificity and interobserver variations in clinical evaluation of cartilage pathology are very bad. Based on the experiences with the WOMAC-score, Roos et al. [11,12] developed the KOOSscore in This specific score for osteoarthritis patients was adapted to German-speaking patients by Kessler et al. [13]. With this a multidimensional instrument is available to measure health status in patients with knee problems. Five patient relevant subscales are scored separately. In order to analyse and interpret the five dimensions separately an aggregated score of the subscales must not be calculated. Therefore all subscales were checked separately against all other parameters of radiography, MRI, arthroscopy and NIRS Conventional radiography and CT The radiological examination of a joint by radiography or CT still remains parts of a standardized evaluation procedure. Both techniques have axial resolutions in excess of 500 m, which is insufficient for the detection of most microstructural changes and is not capable of depicting articular cartilage. Chondral lesions are not visible, except in cases of chondrocalcinosis or significant osteoarthrosis [9,10,16]. In early stages of osteoarthrosis changes in conventional radiology are not visible. Initial visibility is possible in stage II according to Kellgren and Lawrence (KL) in only 30% of cases [10]. Our study did not show any correlation between the KL-score and any clinical parameters or any technical diagnostic devices (MRI, arthroscopy, NIRS). Table 7 Significant correlations of MRI, arthroscopy and NIRS with KOOS subscores of knee pain patients. KOOS-sympt. KOOS-pain KOOS-ADL KOOS-sports KOOS-quality of life MRI n.s. n.s. n.s. n.s. n.s. Arthroscopy n.s. n.s. n.s. n.s. n.s. NIRS n.s. n.s. 0,269 0,3 Corrected significance level at

6 6 G.O. Hofmann et al. / Pathophysiology 17 (2010) MRI Magnetic resonance imaging (MRI) is a non-invasive method. During the last years MRI has become the leading diagnostic tool for the detection of intra-articular joint pathologies such as ligament or meniscal injuries with optical resolutions better than 100 m. With appropriate pulse sequences it is now feasible to quantify the volume and thickness of the cartilage non-invasively. Recent MRI techniques are able to detect focal abnormities with a high sensitivity (0.95) [17 22]. Up to now it is in discussion what abnormalities are to be expected in MRI at different stages of cartilage disease and whether MRI may be useful as an additional diagnostic tool in specific grades of osteoarthritis. Recently no standardized MRI classification system for articular cartilage lesions has been accepted. Previous studies have shown only a very poor correlation between arthroscopic grading of cartilage lesions according to Outerbridge and lesions detected by MRI [18 20]. Especially low-grade cartilage lesions are hardly detected by MRI employing magnetic fields between 0.5 and 2 T. At least superficial fissuring, fibrillation or shallow ulceration must be present before a lesion is detectable. Johnson et al. [1] found, that geographic bone bruise found on magnetic resonance imaging indicates substantial damage to normal articular cartilage homeostasis. Only in one study employing fat-suppressed fast-spin-echo imaging, ICRS-1 areas were detected as regions of cartilage signal abnormality without visually detectable morphologic changes [17]. MRI sensitive to the concentration of glycosaminoglycans within the cartilage matrix may detect ICRS-1a lesions in future [23]. Nevertheless the differentiation of ICRS-1a, - 1b or -2 lesions remains difficult in the MRI. For low-grade cartilage lesions the contemporary MRI technique is insufficient to provide reliable predictive values. Using a better gray scale exploration and high resolution matrix there may be some improvement in the future. Furthermore objective measurements as far as T2 relaxation time is concerned are hopefully able to improve the predictive value too. Whether advanced MRI technology mentioned above will correlate with the findings of NIRS during arthroscopy will be topic of further investigations. Up to now it remains open whether MRI will become the non-invasive golden standard for the detection of low-grade cartilage lesions Arthroscopy Evaluation of cartilage defects or disease under direct visualisation during arthroscopy still is the most reliable diagnostic tool. The most common used arthroscopic cartilage lesion classification system was developed by Outerbridge [24]. Chondral lesions are subdivided into four grades. The classification is easy to handle with, but some aspects are not implemented adequately, e.g. depth of the lesion. Other arthroscopic classification systems are based on various variables (articular surface appearance, lesion depth, lesion diameter, location) but are not in general use [4,25,26]. The problem unsolved is still the classification of low-grade chondral lesions, the transmission corridor from intact cartilage to first-degree lesions. In this field the classification is very subjective, based on the individual experience of the investigator and sometimes hardly reproducible [2,3,25 29]. Also in our study the two surgeons had difficulties to discern intact cartilage (ICRS-0) from early stages of chondral pathology (ICRS-1) in a reproducible manner without inter-observer differences NIRS Electromagnetic radiation (e.g. visible light or NIR-light) interacts with material in form of scattering, reflexion, absorption and transmission. These interactions depend on the physical and chemical properties of the specific material and the necessary energy level for these interactions, determined by the defined wavelength of the radiation. Some years ago another applications of IR light have been introduced with the intention of assessment of osteoarthritic articular cartilage microstructure. In optical coherence tomography (OCT), a high resolution micron scale imaging technology, the intensity of backreflected infrared light is measured [30 32]. The microstructural material resolution ranges between 4 and 30 m and the imaging penetration is limited to roughly 4 mm. OCT defined microstructural abnormalities in cartilage as fibrillation, fibrosis and abnormalities in the subchondral bone plate and therefore was thought to be a promising new technology for early diagnosis of cartilage abnormalities and osteoarthritis. In addition, the polarization sensitivity of imaging suggested a diagnostic role of polarization spectroscopy [30,31]. Normal cartilage yielded polarization sensitive imaging (birefringence), while osteoarthritic cartilage did not (loss of birefringence). Up to now only in vitro studies or those with relative small and inconsistent patient groups have been performed [7,8]. The detection of the intensity of reflected light at different wavelengths is called spectroscopy. Different methods of spectroscopy are available for different regions of electromagnetic radiation. In the infrared region (λ = ,000 nm) the underlying effect of absorption is the stimulation of interatomic bond vibrations. This is used, e.g. in biochemistry, to analyse the type of bonds present in a sample. In the NIR region (λ = nm) mostly the overtones of vibrations (especially of water and CH-, NH- SH- and OH-groups) can be observed. Therefore organic substances show a strong signal, which led to multiple applications of NIRS in many fields during the last decades [33 53]. Due to its relative high penetrations depth of 1 10 mm into organic samples it gives a good insight into the composition of material. NIRS is used in many clinical applications today. It is possible to measure water content, oxygen hemoglobin [38,47], glucose [42,46,49,53], lipids [41] and proteins and other substances in tissues, diet, blood or urine [40,50,52].

7 G.O. Hofmann et al. / Pathophysiology 17 (2010) Usually, NIRS is performed in the determination of brain [33,44,45,48], liver[33,43,51], skin [37] and muscle oxygenation [35,36]. In oncology the method is used for the differentiation of normal and pathological tissues in breast [39] and prostate cancer patients [34]. It is also possible to determine blood glucose levels percutaneously [42,46,49,53]. Further applications have been described in pharmacology and toxicology [41]. Arthritis diagnosis based upon the near-infrared spectrum of synovial fluid was first introduced by Shaw et al. [52]. Normal hyaline cartilage contains about 70 80% water, which is mainly bound to proteoglycans. During the initial stage of degeneration cartilage undergoes complex changes in matrix composition (water, proteoglycans, collagens) [54]. ICRS grade 1 cartilage shows significantly lower mechanical stiffness and more plastic deformation than ICRS grade 0 cartilage [5] and most interestingly these complex alterations within the matrix composition and the biomechanical sequelae correlate with its optical properties in the NIR region. The findings in NIRS significantly correlate with loss of mechanical hardness, increased water content and an increased Mankin-score in cartilage [8]. There are significant biochemical differences between weight-bearing and non-weight-bearing cartilage. Weightbearing regions of articular cartilage show a significantly higher concentration of glycosaminoglycans compared with non-weight-bearing areas [6]. Therefore intrapatient and interpatient variation of NIRS- and MRT-results and their correlation have to be discussed before the background of the specific articular region they have been evaluated. NIRS may be helpful for diagnosis and monitoring the progress of osteoarthritis in the future. Detection of low-grade cartilage lesions is of tremendous importance for different therapeutic approaches. The progression of articular damage may be modified at early stages either by medical or surgical interventions, when intervention is likely to have the greatest benefit. NIRS potentially can be used for the evaluation of successful cartilage repair or regeneration employing different therapeutical approaches like abrasion, drilling, microfracturing, OATS and autologous chondrocyte transplantation. Further challenge is to find out specific wavelength to receive better correlation between NIR findings and water, glycosaminoglycans and collagen content of the cartilage. Also a possible combination with polarization spectroscopy may provide more detailed biochemical and structural information to be obtained from the tissue. NIRS systems are optical fiber-based and therefore may be integrated into all kinds of arthroscopes, even very small ones. The spectroscopy as part of routine arthroscopy burdens no risk to the patient and leads to an only very low prolongation of the surgical procedure with the prospect of real-time analysis in the near future. We hope that NIRS probably will provide such a diagnostic tool to patients, therapist and scientist in the future. Acknowledgement This work has been supported by parts of the German Working Compensation (Berufsgenossenschaft für Bauwirtschaft) in Berlin. References [1] D.L. Johnson, W.P. Urban Jr., D.N. Caborn, W.J. Vanarthos, C.S. Carlson, Articular cartilage changes seen with magnetic resonance imaging-detected bone bruises associated with acute anterior cruciate ligament rupture, Am. J. Sports Med. 26 (1998) [2] A. Javed, M. Siddique, M. Vaghela, A.C. Hui, Interobserver variations in intra-articular evaluation during arthroscopy of the knee, J. Bone Joint Surg. Br. 84 (2002) [3] J. Jerosch, W.H. Castro, M.C. de Waal Malefijt, M. 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