Clinical evaluation
Generally, no cutaneous signs of ochronosis in the form of skin discoloration were noted at the time of presentation; however, spots of sclera blackish discoloration bilaterally were detected (Osler sign) (Fig. 1). The patient denied any history of urine discoloration or darkening. On local examination, the patient was walking with an antalgic gait, having a flexion attitude of the spine and knee bilaterally. The left hip motion was painful and limited with flexion, abduction, and internal and external rotation degrees of 60, 30, 10, and 10 degrees. The left knee showed varus and flexion deformity on inspection. Tenderness over the knee medial joint line and the patellofemoral joint. The range of motion ranged from 10 to 100 degrees with painful last degrees of flexion, and a positive grinding test for the patellofemoral joint.
Radiological evaluation
Plain radiograph of the pelvis showing the hip joint bilaterally revealed an advanced osteoarthritis of the left hip joint with a partial collapse of the femoral head (Fig. 2A). Bilateral knee plain radiographs (anteroposterior and lateral views) showed bilateral knee osteoarthritis more on the left side with subchondral sclerosis and reduced medial joint space (Fig. 2B and C). The plain radiographs of the dorsal and lumbar spine showed osteopenia and calcifications of the intervertebral discs (Fig. 3) (Wu et al. 2018).
Surgical management
We decided to perform a cemented total hip replacement (THR) for the left hip first, then a total knee replacement (TKR) for the left knee in another session. THR was performed through a direct lateral approach to the hip, blackish discoloration of the tissues (iliotibial band, hip abductor muscles, and the femoral head articular surface) was noted while performing the surgery (Fig. 4A). For the TKR, the surgery was performed through a medial parapatellar approach; blackish discoloration was noted on the quadriceps tendon, the patellar surface, the tibial articular surface, the femoral articular surface, and within the substance of the medial meniscus. There was knee synovium hypertrophy with tiny black dots embedded within the synovium (Fig. 4B).
Both surgeries were 11 months apart; the surgeries went smoothly without any reported complications or the need for blood transfusion postoperatively. The postoperative period went uneventful; no wound healing problems or infection was reported, postoperative radiographs showed a stable position of the implants (Fig. 5).