CME

An update on primary care management of knee osteoarthritis Cody Sasek, MPAS, PA-C

ABSTRACT Primary care providers often make the initial diagnosis and play an important role in the effective management of knee osteoarthritis. This article reviews new treatment guidelines from the American Academy of Orthopedic Surgeons and discusses when to refer patients to specialists. Keywords: knee osteoarthritis, guidelines, orthopedic, musculoskeletal, total knee arthroplasty, hyaluronic acid injections

Learning objectives Discuss the primary care approach to evaluation of knee pain. Apply the American Academy of Orthopaedic Surgeons guidelines for treating knee osteoarthritis to patient care. Recognize indications for orthopedic referral of knee osteoarthritis.

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steoarthritis is a common condition, affecting 22% of adults in the United States, with knee osteoarthritis being most common.1 Nearly half of adults may develop symptomatic knee osteoarthritis by age 85 years.2 As the population ages, arthritic conditions are expected to affect an estimated 67 million adults in the United States by 2030.3 Already, the number of total knee arthroplasties has increased by 162% from 1991 to 2010.4 An analysis by the CDC showed direct and indirect costs attributable to osteoarthritis and other rheumatic conditions in the United States were about $128 billion in 2003, equivalent to 1.2% of the 2003 US gross domestic product.5 The cause of knee osteoarthritis is multifactorial and includes trauma, genetic factors, obesity, and participation in high-impact activities that result in wearing and loss of the protective hyaline cartilage joint surface. Cartilage loss is irreversible, so the goals of management Cody Sasek is an assistant professor at the University of Nebraska Medical Center in Omaha, Neb. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000458853.38655.02 Copyright © 2015 American Academy of Physician Assistants

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are symptom control and maintenance of appropriate function. Patients with knee osteoarthritis often present with inflammation, swelling, and mechanical catching symptoms, in addition to pain with either loading of the knee or in extremes of motion. Patients will report pain and stiffness that often worsen when the patient rises from a seated position. For patients with patellofemoral compartment osteoarthritis, a primary complaint is pain and difficulty with stairs, particularly when descending. As knee osteoarthritis progresses, patients may also develop night pain. www.JAAPA.com

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Key points Weight-bearing radiographs are essential for evaluating knee osteoarthritis. MRI is generally not indicated for knees that are osteoarthritic. Guidelines recommend against use of hyaluronic acid injections. Tramadol is indicated for treatment of knee osteoarthritis pain. Treatment with total knee arthroplasty is effective and shows good long-term results. Younger patients with osteoarthritis should be referred early to an orthopedist.

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Often, as a result of reflexive inhibition of the quadriceps secondary to pain, patients may have a sense of their legs giving way or buckling. Loss of range of motion also may occur as degenerative changes progress. Symptoms generally worsen with increases in activity and may result in significant loss of function and decreased quality of life. EVALUATION A thorough history and physical examination are essential. The physical examination should focus on assessing the patient’s gait, leg alignment, and knee range of motion; testing ligamentous stability; and performing provocative meniscal testing. Patients with osteoarthritic knees often have concomitant meniscal tears. These tears are rarely the primary source of pain and disability, except in the case of a torn and locking meniscal fragment. Examination of the hip is also important, as hip pathology can occasionally refer pain to the knee. If possible, the diagnosis of internal derangement of the knee should be avoided because it lacks specificity. IMAGING Radiographs are the primary means of diagnosis for knee osteoarthritis. Generally, radiographic views should include bilateral anteroposterior weight-bearing, 45-degree flexion posteroanterior (Rosenberg view), lateral, and patellofemoral (Merchant) views. Radiographic findings of osteoarthritis include decreased joint space caused by cartilage wear and thinning, marginal osteophyte formation, flattening of the femoral condyles, subchondral sclerosis, and cystic formation in the subchondral bone (Figure 1). Generally, MRI of the knee is unnecessary unless other pathology, such as osteonecrosis or mechanically locking meniscal tear, is suspected. TREATMENT OVERVIEW In 2013, the American Academy of Orthopaedic Surgeons (AAOS) revised its initial guidelines on treating knee osteoarthritis. These practice guidelines are derived from 38

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C FIGURE 1. Radiographs of the right knee with osteoarthritis.

Anteroposterior standing view (A), Rosenberg or notch view (B), and Merchant view (C). These radiographs show medial compartment joint space narrowing, marginal osteophyte formation, flattening of the medial femoral condyle, asymmetric varus alignment, and patellofemoral osteoarthritis, most significant at the medial facet.

evidence-based research and focus largely on treatment options short of knee replacement. As such, they provide a framework for management decisions not only in the orthopedist’s office, but also for primary care providers. Recommendations in the AAOS guidelines were based on the statistical and clinical significance of the supporting evidence. Volume 28 • Number 1 • January 2015

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An update on primary care management of knee osteoarthritis

• Strong recommendations were highly likely to be beneficial and had high-quality evidence to support them. • Moderate recommendations had lesser evidence of benefit in the medical literature. • Limited recommendations were those for which the quality of supporting evidence was unconvincing, or wellcontrolled studies showed little clear advantage to one approach over another. • Inconclusive recommendations are treatments that do not show significant benefit, but are unlikely to cause harm; providers should exercise clinical judgment in these instances, along with consideration of patient preference. Figure 2 summarizes the AAOS treatment recommendations. INITIAL TREATMENT Patient education and self-management are the initial treatments recommended by AAOS. Self-management programs in a primary care setting have been shown effective for knee osteoarthritis.6 These programs should focus on activity modifications including low-impact aerobics, careful strengthening, and avoidance of high-impact activities. Patients who participated in structured, guided programs including home exercise programs had improved pain and function scores.7 Water aerobics have been shown to improve patients’ pain scores, as has proprioceptive training.8,9 Several studies have found a significant improvement in patients who participate in a supervised walking program.10 Recent studies, including by Ebnezar and colleagues, show that a combination of yoga and physical therapy for strengthening was superior to strengthening alone.11 Patients should be cautioned to avoid extreme range of motion, particularly in flexion when strengthening, as this can increase forces dramatically at the knee, specifically through the patellofemoral joint. As always, these physical activity recommendations should be implemented as symptoms dictate, and patients should avoid activities that increase symptoms. Patients need to modify high-impact and other activities based on their symptoms. Educate patients about appropriate activity modifications and avoidances. Appropriate physical activity and diet leading to weight loss received moderate recommendation, particularly in patients with a body mass index of 25 or more.12,13 Weight reduction can be important because forces about the knee can be quite significant, particularly at the patellofemoral joint: contact pressures can reach about six times body weight when patients perform deep knee flexion. During weight lifting and jumping, the force through the patellofemoral joint can be as high as 20 to 25 times body weight.14 This multiplied effect should reinforce in both patient and provider the importance of appropriate weight loss and its effect on additional treatment. Additional conservative treatment may include the use of a cane, walker, or knee sleeve. The cane should be held JAAPA Journal of the American Academy of Physician Assistants

Self management

Nonoperative interventions

Orthopedic referral

• Activity modification/avoidance • Weight loss • Low-impact exercise • Knee sleeve • Cane/walker

• NSAIDs • Physical therapy for exercise programming • Corticosteroid injection • Acetaminophen • Tramadol

• Arthroscopy if indicated • Growth factor injection • Unloader bracing • Osteotomy • Unicompartmental knee arthroplasty • Total knee arthroplasty

FIGURE 2. Knee osteoarthritis treatment recommendations.

Bolded items showed strong evidence in the AAOS analysis and guidelines.

in the opposite hand of the most affected knee. Often a knee sleeve can provide subjective improvement in symptoms, which is likely related to compressive effect and improved neuromuscular feedback. Research by Berry and colleagues found the use of a simple neoprene knee sleeve decreased pain and was associated with short-term subjective improvement.15 Physical therapy referral is often recommended for management of knee osteoarthritis. Physical therapy programs focused on strengthening and proprioception have shown improvement in symptoms.12 The use of physical agent modalities, including electrical stimulation, shortwave diathermy, transcutaneous electrical nerve stimulation (TENS), and ultrasound have shown mixed results. Atamaz and colleagues compared these with sham procedures and found no significant improvement at 4, 12, or 26 weeks.16 Several studies have demonstrated evidence that ultrasound treatments provided improvements in both pain and function.17 Due to the available data, the AAOS guidelines did not recommend for or against the use of physical agent modalities in physical therapy.12 As noted, physical therapy referral is beneficial for development and monitoring exercise programming but not for physical agent modality care alone. Manual therapy, such as joint mobilization, chiropractic care, joint manipulation, and myofascial release, may occasionally provide symptom relief, but is not included www.JAAPA.com

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as part of the recommendations because none of the reviewed studies met the AAOS inclusion criteria.12 One study did find that Swedish massage therapy had statistically significant results at 8 weeks, but not at 16 weeks.18 Several studies indicated potential for clinical improvement in patients receiving acupuncture, but none of these studies showed evidence of statistically significant efficacy.19,20 Nonsurgical attempts to modify forces at the knee joint include bracing, specifically unloader bracing. Unloader braces transfer forces away from the involved compartment of the knee and to less-arthritic areas. In patients with medial osteoarthritis, a brace is applied to the knee that creates a valgus force and directs more of the force through the lateral compartment of the knee. Unloader bracing can address medial and lateral compartment osteoarthritis. Studies comparing unloader bracing to neoprene sleeve use and appropriate self-management programs, and to self-management alone were unable to show significant improvement in pain and function with unloader bracing across these groups.21,22 Studies evaluating the use of lateral wedge insoles versus neutral insoles in patients with medial osteoarthritis demonstrated no significant difference in pain or function.23 The alteration of foot alignment had no direct effect on the knee and the anticipated off-loading effect was not significant in improving symptoms.23 PHARMACOLOGIC TREATMENT Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of pharmacologic treatment for symptomatic knee osteoarthritis. NSAIDs are available in oral and topical forms, and one, ketorolac tromethamine, is available as a nasal spray. NSAIDs inhibit inflammatory pathways and cytokine production, reducing pain and swelling. Each of the nine classes of NSAIDs has a slightly different profile and pharmacology. Because of this, if one class of NSAIDs is ineffective in a patient, another class may provide relief. If an NSAID is indicated, consider cost, adherence, and adverse reaction profile before prescribing. Also consider the known risk of cardiovascular events and the gastrointestinal (GI) risk, specifically GI bleeding. Older adults may be at higher risk for these adverse reactions. Patients who are on long-term anticoagulation also warrant special consideration, as NSAIDs can increase patients’ bleeding risk. Topical NSAID ointments, which have low systemic absorption, may be an option in these patients. In developing the AAOS guidelines, no harms analysis was performed in regards to NSAIDs.12 Traditionally, providers have chosen to begin treatment with acetaminophen as needed for pain. The current systematic review showed a lack of clinically significant improvement with the use of oral acetaminophen when compared with placebo.24 At this time, the AAOS was unable to recommend the use of acetaminophen, although it may continue to be useful to treat breakthrough soreness.12 40

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Tramadol, another pharmacologic option, is a weak mu-opioid receptor agonist. Because of the weaker nature of its opioid action, tramadol has a more tolerable adverse reaction profile and somewhat less risk of dependency at lower dosages than more potent opioids. Research by Fishman and colleagues did not show significant difference in efficacy between 100 mg, 200 mg, and 300 mg doses of tramadol.25 Lower-dose tramadol should be used when indicated because improvement in pain with tramadol is not dose-dependent, and lower doses minimize the drug’s risks and adverse reactions. The literature review used in developing the AAOS guidelines did not uncover significantly relevant studies relating to the use of opioids or pain patches in the primary treatment of knee osteoarthritis.12 Because opioids can cause many adverse reactions (including constipation, respiratory depression, and death) and have an addictive potential, they should be reserved for breakthrough pain on a limited basis, as appropriate. Glucosamine and chondroitin formulations, either alone or in various combinations, often are used by patients with knee osteoarthritis. These formulations are classified as supplements, so formulations and quality can vary greatly. Study of glucosamine and chondroitin has not found evidence to indicate that these supplements significantly improve clinical outcomes.26,27 Because of this, the AAOS does not recommend use of glucosamine or chondroitin.12 INTRA-ARTICULAR TREATMENT OPTIONS Osteoarthritis is not only a physical wearing of the joint surface, but also a chemical and inflammatory process. Laboratory studies of joint aspirate of osteoarthritic knees show decreased synovial fluid viscosity and hyaluronic acid concentration. Hyaluronic acid is a major component of synovial fluid and one of the fluid’s main lubricating components. Additionally, patients with osteoarthritis have increased inflammatory cytokines and free radicals. Needle lavage has been attempted to improve these dynamics. A large-gauge needle is introduced intra-articularly, aspirating the joint fluid, and cycling sterile saline through the joint before final fluid aspiration. This procedure has not been shown to produce measurable benefit for patients in either pain or function.28 Routinely, knee osteoarthritis has been treated in both primary care and orthopedics offices with intra-articular corticosteroid injections aimed at reducing inflammation and pain and improving knee function. These improvements are often transitory. In a series of three studies used in the AAOS guidelines, corticosteroids were found to betterreduce pain than placebo at 4 weeks, but were inferior to hyaluronic acid injections.29,30 Additionally, intra-articular corticosteroids were found inferior to needle lavage.31 Due to these findings, the use of intra-articular corticosteroids was given an inconclusive recommendation by AAOS.12 Corticosteroid injections remain appropriate for use, with Volume 28 • Number 1 • January 2015

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An update on primary care management of knee osteoarthritis

an understanding of their indications and limitations. Perhaps the most significant change to the AAOS guidelines was the recommendation against the use of hyaluronic acid injections for osteoarthritis. Hyaluronic acid injections have become an integral part of the osteoarthritis treatment algorithm in both primary care and orthopedic offices. Research has been variable in terms of statistically significant effect of these injections. Not all hyaluronic acid injections are identical; they can vary significantly in molecular weight, with several formulations being much lower molecular weight than native hyaluronic acid. Higher weight (>750 kDa) and cross-linked formulations had statistically significant improvement, though not to the level of the minimal clinically significant improvement threshold used by the AAOS.12 The recommendation against the use of hyaluronic acid injections was based on this finding and not on potential harm.12 Another treatment under study is intra-articular injection of growth factors by platelet-rich plasma preparations. The plasma preparations are prepared in a variety of ways, but commonly use autologous blood drawn at the time of injection through venipuncture. The blood is spun in a centrifuge to separate the blood elements, with the top platelet layer being drawn off for injection. This layer of platelets is also high in growth factors, which play a key role in the control of inflammatory processes. No consensus exists on specific formulations and concentrations of platelet-rich plasma preparations.12 Data on the clinical application of growth factors or platelet-rich plasma are limited, although some basic science research has indicated promise.32,33 For these reasons, platelet-rich plasma injections remain generally outside the purview of the primary care provider. REFERRAL Patients who continue to have significant disability and symptoms despite appropriate treatment should be referred to an orthopedic surgeon for consideration for joint replacement surgery. Younger patients with significant osteoarthritis should be referred early to an orthopedic surgeon. Referral is also appropriate if the provider is not comfortable with intra-articular injections. Additional criteria for referral include increased varus or valgus deformities, as well as patients with chronic or increasing flexion contracture or loss of flexion to less than 110 degrees. These factors, specifically deformity, bone loss, and loss of range of motion, can affect eventual surgical outcomes. SURGICAL TREATMENT Routinely, patients present with pathology in addition to the primary osteoarthritis diagnosis, including torn menisci or loose bodies (fragments of bone or cartilage freefloating in the joint space). For these patients, surgical treatment with arthroscopy is not necessarily indicated, even in patients with a diagnosis and MRI findings of meniscal tear. JAAPA Journal of the American Academy of Physician Assistants

Surgical treatment may be helpful in a subset of patients with symptomatic osteoarthritis and primary signs and symptoms of meniscal tearing. Careful patient selection is key. Indications for surgery are either mechanical catchingtype symptoms from a loose body or new onset, sharper, stabbing pain consistent with primary meniscal tear. In patients who did not have these indications, Herrlin and colleagues demonstrated no significant benefit to treatment with arthroscopy at 8 weeks and 6 months postoperative.34 The potential benefit, both short- and long-term, should be weighed against the inherent risks of surgery and recovery, including anesthesia complications, venous thromboembolism, and infection. Study of less-invasive surgical treatment with arthroscopy for lavage and/or debridement has been examined in patients with significant, nonmechanical osteoarthritis symptoms with the goal of avoiding the lengthy recovery following total knee arthroplasty. Two studies examined arthroscopic treatment for patients whose primary diagnosis was osteoarthritis. These studies excluded patients with surgical meniscal tears, loose bodies, or other mechanical pathology. The resulting data did not demonstrate clinical benefit from either arthroscopic lavage or debridement to treat knee osteoarthritis.35,36 Historically, attempts have been made to surgically insert free-floating interpositional devices intra-articularly to act as a spacer between arthritic surfaces. These devices have had extremely high failure rates due to reoperation, revision to total knee arthroplasty, or from persistently poor pain scores postoperatively. The revision rate to total knee arthroplasty in these patients was 32% at 26 months postoperative.37 For these reasons, interpositional devices are not recommended.12 In a limited subset of younger patients with unicompartmental osteoarthritis, a valgus or varus producing osteotomy may be considered to permanently bring the knee into better alignment. An osteotomy is a significant procedure with associated perioperative and postoperative risks; careful patient selection is key. Bilateral long leg radiographs can be helpful in determining the degree of knee alignment abnormality. This procedure is generally reserved for patients age 50 years and younger who would benefit considerably from delaying total knee arthroplasty. Most patients are better treated definitively by prosthetic resurfacing with total knee arthroplasty or, in some cases, unicompartmental arthroplasty. Definitive treatment with total knee arthroplasty is effective and cost effective, providing patients with improved function and quality of life with reduced pain. This invasive surgery, however, is not without risk, so patient education and recommendation for surgery should be carefully considered, weighing the risks versus benefits. Recent long-term series show that after 10 years, more than 95% of total knee arthroplasty implants are still in place.38 Longer-term studies have shown near 80% implant survival at 20 years.39 www.JAAPA.com

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Concerned with the potential need for revision of total knee arthroplasty in younger patients, some patients and providers may recommend delaying surgical treatment. For patients who have failed to improve with other appropriate treatment options and who are significantly limited, total knee arthroplasty should still be considered regardless of age, on a case-by-case basis. CONCLUSION The updated AAOS guidelines provide specific recommendations for various treatment options; however, clinicians must determine which options are appropriate for each patient. An inconclusive recommendation in the guidelines does not preclude the provider from using these treatment options when appropriate. Specifically, the recommendation against the use of hyaluronic acid injections can create a treatment dilemma, especially for patients who cannot tolerate anti-inflammatory medications. Because hyaluronic acid injections vary in formulation and effect, ongoing evaluation of their effectiveness is important. The change in recommendation against acetaminophen and for the use of tramadol for pain control likely will affect treatment patterns in primary care and orthopedic offices, with increased reliance on NSAIDs. Primary care providers have much to offer in the team approach to the management of knee osteoarthritis. Understanding current treatment recommendations, along with appropriate imaging and experience evaluating painful knees, will help providers manage symptomatic knee osteoarthritis and know when to refer patients to orthopedic specialists. JAAPA Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa. org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of January 2015.

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6. Coleman S, Briffa NK, Carroll G, et al. A randomised controlled trial of a self-management education program for osteoarthritis of the knee delivered by health care professionals. Arthritis Res Ther. 2012;14(1):R21. 7. Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus. Rheumatology (Oxford). 2005;44(1):67-73. 8. Silva LE, Valim V, Pessanha AP, et al. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther. 2008;88(1):12-21. 9. Fitzgerald GK, Piva SR, Gil AB, et al. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther. 2011;91(4):452-469. 10. Kovar PA, Allegrante JP, MacKenzie CR, et al. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 1992;116(7):529-534. 11. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: a randomized controlled study. J Altern Complement Med. 2012;18(5):463-472. 12. American Academy of Orthopaedic Surgeons. The treatment of osteoarthritis of the knee—2nd edition clinical practice guideline. May 18, 2013. http://www.aaos.org/Research/ guidelines/GuidelineOAKnee.asp. Accessed October 3, 2014. 13. Muthuri SG, Hui M, Doherty M, Zhang W. What if we prevent obesity? Risk reduction in knee osteoarthritis estimated through a meta-analysis of observational studies. Arthritis Care Res. 2011;63(7):982-990. 14. Huberti HH, Hayes WC. Patellofemoral contact pressures. The influence of q-angle and tendofemoral contact. J Bone Joint Surg Am. 1984;66(5):715-724. 15. Berry H, Black C, Fernandes L, et al. Controlled trial of a knee support (Genutrain) in patients with osteoarthritis of the knee. Eur J Rheumatol Inflamm. 1992;12:30-34. 16. Atamaz FC, Durmaz B, Baydar M, et al. Comparison of the efficacy of transcutaneous electrical nerve stimulation, interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized, controlled, multicenter study. Arch Phys Med Rehabil. 2012;93(5):748-756. 17. Yang PF, Li D, Zhang SM, et al. Efficacy of ultrasound in the treatment of osteoarthritis of the knee. Orthop Surg. 2011;3(3): 181-187. 18. Perlman AI, Sabina A, Williams AL, et al. Massage therapy for osteoarthritis of the knee: a randomized controlled trial. Arch Intern Med. 2006;166(22):2533-2538. 19. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004;141(12): 901-910. 20. Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology (Oxford). 2007;46(9):1445-1449. 21. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. 1999;81 (4):539-548. 22. Brouwer RW, van Raaij TM, Verhaar JA, et al. Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage. 2006;14(8):777-783. 23. Bennell KL, Bowles KA, Payne C, et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. BMJ. 2011;342:d2912. Volume 28 • Number 1 • January 2015

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An update on primary care management of knee osteoarthritis 24. Miceli-Richard C, Le Bars M, Schmidely N, Dougados M. Paracetamol in osteoarthritis of the knee. Ann Rheum Dis. 2004;63(8):923-930. 25. Fishman RL, Kistler CJ, Ellerbusch MT, et al. Efficacy and safety of 12 weeks of osteoarthritic pain therapy with once-daily tramadol (Tramadol Contramid OAD). J Opioid Manag. 2007; 3(5):273-280. 26. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795-808. 27. Trč T, Bohmová J. Efficacy and tolerance of enzymatic hydrolysed collagen (EHC) vs. glucosamine sulphate (GS) in the treatment of knee osteoarthritis (KOA). Int Orthop. 2011;35 (3):341-348. 28. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum. 2002;46(1):100-108. 29. Chao J, Wu C, Sun B, et al. Inflammatory characteristics on ultrasound predict poorer longterm response to intraarticular corticosteroid injections in knee osteoarthritis. J Rheumatol. 2010;37(3):650-655. 30. Caborn D, Rush J, Lanzer W, et al. A randomized, single-blind comparison of the efficacy and tolerability of hylan G-F 20 and triamcinolone hexacetonide in patients with osteoarthritis of the knee. J Rheumatol. 2004;31(2):333-343. 31. Arden NK, Reading IC, Jordan KM, et al. A randomised controlled trial of tidal irrigation vs corticosteroid injection in knee osteoarthritis: the KIVIS Study. Osteoarthritis Cartilage. 2008;16(6):733-739.

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32. Sánchez M, Fiz N, Azofra J, et al. A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis. Arthroscopy. 2012;28(8): 1070-1078. 33. Sánchez M, Anitua E, Azofra J, et al. Intra-articular injection of an autologous preparation rich in growth factors for the treatment of knee OA: a retrospective cohort study. Clin Exp Rheumatol. 2008;26(5):910-913. 34. Herrlin SV, Wange PO, Lapidus G, et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):358-364. 35. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359(11):1097-1107. 36. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81-88. 37. Sisto DJ, Mitchell IL. UniSpacer arthroplasty of the knee. J Bone Joint Surg Am. 2005;87(8):1706-1711. 38. Lützner J, Hübel U, Kirschner S, et al. Long-term results in total knee arthroplasty. A meta-analysis of revision rates and functional outcome. Chirurg. 2011;82(7):618-624. 39. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am. 2003;85-A(2):259-265.

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An update on primary care management of knee osteoarthritis.

Primary care providers often make the initial diagnosis and play an important role in the effective management of knee osteoarthritis. This article re...
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