A 70 years old patient sought orthopaedic care due to progressively increasing pain in the bilateral knee joints anddifficulty to sit cross-legged and squat since the past three months. The patient also complained of low back pain with no radicular symptoms. The pain was insidious in onset with no history of trauma. The patient had right ankle pain and difficulty in range of motion the symptoms of which started at the age of 48 years. The right ankle joint was subjected to arthrodesis by an orthopaedic surgeon at the age of 50 years. On examination the patient had signs and symptoms suggestive of bilateral knee osteoarthritis and lumbar canal stenosis. The ankle examination revealed the healed surgical scar on the anterolateral aspect of the right ankle joint. Clinically the ankle joint was arthrodesed with no residual tenderness. The patient had features suggestive of severe tri-compartmental osteoarthritis in bilateral knee joints but the degenerative changes and osteophytes were more significant on the left side. The radiographs of the right ankle confirmed sound bony ankylosis (Fig. 1). Spine radiographs and MRI scan revealed lumbar degenerative left sided scoliosis, peridiscal osteophytes, endplate degenerative changes, facet joint arthropathy, lumbar canal stenosis from L3 to S1 levels and degenerative cervical spine with C3-C7 posterior disc protrusion compromising the spinal canal but no neurological compression. Bilateral hip and sacroiliac joints were normal on MRI screening.
The patient also had conspicuous bilateral elbow deformities but he had no functional limitations due to elbow affection. The patient had a history of fever with rash at the age of eight years. The patient had affection of bilateral elbow joints during the febrile episode in the form of pain and swelling and no treatment was taken. There was no history of trauma, osteoarticular tuberculosis, or any history suggestive of congenital affection. The patient did not get vaccinated to the best of his knowledge. Currently, on clinical examination the bilateral elbow joints were dislocated postero-medially with prominence of distal end of the humerus laterally and that of the proximal radio-ulnar complex medially. There was no joint line tenderness. Healed puckered scars were presented on the posteromedial aspect of bilateral elbows. There was no ulnar nerve thickening. Wasting of muscles could not be commented upon due to bilateral affection. The fourth and fifth ray were shortened on the left hand. On the right side the arc of motion was 140 degrees from 30 degree of hyperextension to 110 degree of flexion. On the left side, there was flexion deformity of 30 degree with further flexion up to 110 degree. The pronation was restricted to 20 degree on the right side and 30 degree on the left side with the full range supination bilaterally up to 90 degree (Figs. 2, 3). All movements were pain-free throughout the possible range of motion. There was no distal neurovascular deficit. The bilateral shoulder, wrist and hand joints were normal on clinical examination. On clinical examination of the face, we observed deep pitted scars anterior to the pinna which could be due to the healing of the smallpox lesions. On radiographs bilateral postero-medial dislocation of elbow joints was observed. The articular surfaces were deformed and incongruent. There was fusion of the proximal radius and ulna bilaterally. Heterotopic calcification was observed in bilateral elbow joints. There was marked hypoplasia of the right ulna and short fourth and fifth metacarpals were observed in the left hand. The patient also had hypoplasia of right fourth metacarpal with cortical thickening (Fig. 4). The complete hemogram, erythrocyte sedimentation rate, serum levels of calcium, phosphorus, alkaline phosphatase & uric acid were within normal limits. Rheumatoid factor was negative. Screening renal and liver function tests were normal.
The patient was right hand dominant and was an automobile mechanic by occupation. Despite the striking clinical deformity and the radiological abnormalities, the patient had no complaints with respect to the bilateral elbow joints. The patient had minimal disability of the elbows despite the striking radiological appearance and was functionally independent. The patient was an automobile mechanic by occupation and was able to lift heavy weights until retirement from occupation.