The medical model of history, examination and investigation forms the bedrock of diagnosis and management of all patients. The essence is the recognition of patterns of symptoms and signs. In the modern era there are an increasing number of non-medical resources ranging from web-based information, computer diagnostic aids and non-specialist healthcare professionals to provide a diagnosis and commence management of a wide range of conditions, including knee problems. We analysed the quality and patterns of clinical presentation in order to answer the question how closely clinical symptoms and examination findings correlate to diagnosis based on MRI scan and/or arthroscopic findings. The analysis was a dataset of a consecutive series of patients, aged 18 to 45, with no past history of knee problems or end stage arthritis, presenting to a single specialist triage physiotherapist, working within an integrated knee service, who fully completed a standardised knee assessment proforma of presenting symptoms and signs at a large district general hospital. The study comprises 86 patients and 98 knees. We analysed this data based on diagnostic findings of MRI scan or arthroscopy to provide definitive intra-articular diagnosis. Based on standard textbook descriptions of common presentations, we went on to define the patients' presentation history and examination as typical or atypical, with typical meaning the symptoms and signs correlated with the diagnosis. The null hypothesis is that patients have a high chance of typical presentations for common knee conditions. In the 75% of patients with a significant intra-articular pathology we found the majority had chondral rather than meniscal tears 1.7 to 1. Forty four percent of patients had atypical symptoms and 71% had atypical clinical signs, 30% and only 26% of the cohort had both typical symptoms and signs together, reflecting a surprisingly low positive predictive probability of symptoms and signs in this group of patients, particularly those with chondral lesions which was 44%. In this cohort, 57% of the cohort has 3 or more multiple diagnoses. In the diagnostically normal group, 43% had symptoms and signs typical for a meniscal tear. We conclude that clinical symptoms and signs surprisingly inaccurate in guiding intra-articular pathology within the knee, even in a sub-set considered the easy and accurate to assess. The number of multiple diagnoses and the incidence of false positive results also means that simplistic interpretations of non-definitive diagnoses and linear causation of pain pathways should be treated cautiously

Introduction. Cauda equina syndrome represents the constellation of symptoms and signs resulting from compression of lumbosacral nerve routes. Combined with subjective neurological findings, a reduction in anal tone is an important sign deeming further imaging necessary. Our main objective was to investigate the validity of DRE for assessment of anal tone. Method. 75 doctors completed a questionnaire documenting their grade, speciality and experience in performing DRE. A model anus, using a pressure transducer surrounding an artificial canal, was assembled and calibrated. Participants performed 4 DREs on the model and predicted tone as ‘reduced’ or ‘normal’ (35 and 60 mmHg respectively), followed by a ‘squeeze’ test. 30 healthcare assistants (HCAs) with no training in DRE partook as a control group. Results. In each attempt 60%, 61%, 63% and 72% of doctors correctly identified the anal tone respectively (average accuracy 64%). HCAs had an identical average accuracy of 64%. 100% of participants correctly felt the squeeze test. For doctors no correlation was found between confidence in assessing anal tone using DRE and a correct result. 71% had received previous training in DRE with 64% of these taught how to assess anal tone. Conclusion. The results demonstrate that accuracy in assessing anal tone using DRE is limited with overall correctness of 64%. Poor correlation exists between perceived level of skill and study result. Doctors were not significantly more able than HCAs to detect correct tone. Therefore, DRE for the assessment of anal tone is not a wholly accurate tool. No conflicts of interest. No funding obtained. This work was presented at BritSpine

The Exeter Stem (Howmedica, UK) has been in use for over 35 years. Over the years it has undergone several modifications with the most recent being a highly polished, tapered stem in 1986. The manufacturers quote a rate of 0.0006%. In the current literature there are 16 (or less) instances of fractures of the Orthinox stem. We present a case of fracture of an Orthinox Exeter Stem 9 years after insertion. Our patient, BB, presented, aged 62, with symptoms & signs consistent with OA right hip. THR was performed through a lateral approach utilising a trochanteric osteotomy. A size 0 37.5 stem was inserted. Radiographs were very satisfactory. She suffered a post operative DVT/PTE from which she recovered uneventfully. She was independently mobile at 6 month review and was discharged at the 2 year stage pain free. Aged 71, BB presented to outpatient clinic with a several month history of generalised groin pain. She had a Trendelenberg gait. Considerable pain was experienced on axial compression of the limb. Radiographs revealed a midstem fracture with cement loosening proximally. No trauma was reported. She underwent revision surgery through a posterior approach. Acetabular component was rigidly fixed. This was revised to a pressfit Trident (Zimmer, UK) cup with screws & polyethylene liner. An extended trochanteric osteotomy was used to remove the broken stem. An uncemented Restoration (Stryker, UK) stem was inserted with a 28mm head. Post-operative recovery was unremarkable and at 6 months osteotomy has healed. The stem was sent to Stryker UK Laboratories for analysis. They reported the stem broke in fatigue with the origin on the antero-lateral surface. No material or manufacturing defects seen. Dimensionally correct. Fracture may be due to abnormal bending stresses secondary to proximal loosening and firm distal fixation. Our case demonstrates a set of circumstances that led to inevitable fatigue and stem fracture. The method of failure should reinforce the radiograph appearances that may cause concern or be acted upon

Objectives

In this study, we compared the pain behaviour and osteoarthritis (OA) progression between anterior cruciate ligament transection (ACLT) and osteochondral injury in surgically-induced OA rat models.