WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20090066
OBJECTION BY: Worker
EMPLOYER: Not Participating
HEARING DATE: October 14, 2009
ATTENDEES: Worker, Worker Representative
ISSUE
This worker had total right knee replacement surgery on October 1, 2008. Entitlement to the surgery has been denied as outlined in the claims adjudicator’s letter of November 3, 2008.
HOW THE ISSUE AROSE
This claim was established when this worker twisted his right knee and sustained a hyperextension injury on September 1, 2006. A magnetic resonance imaging (MRI) scan on February 3, 2007 demonstrated severe degenerative changes with evidence of a medial meniscal tear. The case was first reviewed by a Workplace Safety and Insurance Board (WSIB) medical advisor on March 26, 2007. The medical advisor indicated that the meniscal tear would be reasonable given the hyperextension injury which would overload the meniscus and the medial compartment of the knee particularly noting the degenerative changes. Surgery took place on May 2, 2007. The pre-operative diagnosis was torn medial meniscus with osteoarthritis of the right knee.
In this case, the WSIB accepted the worker had a significant pre-existing condition and, in fact, 90 per cent cost relief under the Second Injury and Enhancement Fund (SIEF) has been applied in this case.
On October 1, 2008, the worker underwent surgery for a total knee replacement. This issue was reviewed by a WSIB medical advisor in Memo 20A. The medical advisor indicated the total knee replacement was done for the pre-existing condition and not for the meniscal damage. The surgery was therefore not considered to be claim-related.
This worker underwent a non-economic loss (NEL) award assessment on December 23, 2008. He was granted a 12 per cent NEL award with the diagnosis of chronic aggravation of osteoarthritis in the right knee. It is also noted that the claims adjudicator’s decision of November 3, 2008 indicated that, as a result of the injury, the worker sustained a permanent aggravation of an underlying arthritic condition. It was however accepted that maximum medical recovery (MMR) was reached on June 20, 2007.
It is the position of the worker and the worker representative that entitlement in the claim exists for a permanent aggravation of the underlying degenerative condition and therefore, the surgery on October 1, 2008 would be well within the scope of entitlement in the claim.
AUTHORITY
Secondary conditions resulting from a work-related disability are assessed in accordance to Operational Policy Manual Document, 15-05-01 - Resulting from Work-Related Disability, which states, in part:
“Workers sustaining secondary conditions that are causally linked to the work-related injury will derive benefits to compensate for the further aggravation of the work-related impairment or for new injuries.”
ASSESSMENT OF THE EVIDENCE AND SUBMISSIONS
In this claim, the worker had an x-ray of the right knee on September 1, 2006. The x-ray demonstrated a few minor degenerative changes that were scattered through the bony structures of the knee. The x-ray was otherwise unremarkable. This x-ray does not, in fact, demonstrate a significant pre-existing condition of osteoarthritis.
The worker went on to have an MRI on February 3, 2007. This demonstrated a large amount of effusion as well as a tear of the posterior horn of the medial meniscus extending to the superior surface. There also appeared to be a portion of the meniscus displaced into the intercondylar notch consistent with a bucket-handle tear. There was severe degenerative change involving the medial femoral condyle with subchondral change and severe loss of cartilage. There were similar changes involving the patellofemoral joint with subchondral change and loss of cartilage. The interpretation was severe degenerative change involving the medial and patellofemoral compartments with a bucket-handle tear of the posterior horn of the medial meniscus.
During the hearing, the worker representative argued that the significant changes noted in the MRI would be related to the injury process sustained from the accident and did not necessarily represent damage that existed before the accident noting the somewhat normal x-rays from September 1, 2006.
Medical documentation, as well as testimony from the worker also indicates the worker had no symptoms in the right knee before the accident. Subsequent to the accident the worker continued to have pain and swelling and ongoing difficulties. Symptoms typically occurred with prolonged weight-bearing activities and stairs and squatting as well as kneeling tasks were difficult. Depending on the worker’s activities, the knee would swell up.
One would expect that if the worker had a significant degenerative process in the knee prior to the accident, some of these symptoms would have been noted before the accident. It is also interesting to note that this worker has no difficulties with the left knee and the worker testified he has no other arthritic processes in his body that have been diagnosed.
A medical report from an orthopaedic surgeon, dated February 27, 2007, stated the following:
“I believe that some of his symptoms are secondary to patellofemoral overload but also secondary to a tear of the medial meniscus. At this stage, I have recommended surgery in the form of an arthroscopic debridement which I think will help him with most of his symptoms. However, I have advised him that he will likely have some ongoing discomfort due to the underlying arthritis.”
It would therefore appear that the worker did have an underlying arthritic condition; however, it would be extremely difficult to determine the extent of that condition given the fact that the worker was asymptomatic and early x-rays were somewhat normal.
An orthopaedic surgeon report of June 20, 2007 indicated that during the surgery it was noted that the worker had a significant synovitis, which was considered to be reactive. The report indicated he would possibly require further surgery in the future but agreed that his symptoms were not severe enough at the time to warrant further surgery.
According to the worker’s testimony, his symptoms continued to get worse subsequent to the first surgical procedure.
An orthopaedic surgeon report of August 14, 2008, indicated that the MRI done before the previous arthroscopy showed significant medial compartment osteoarthritis; however, x-rays had been normal. The worker had not responded well to the arthroscopic procedure and updated x-rays demonstrated more significant osteoarthritis than was noted previously. The only intervention to improve the worker’s symptoms was a total knee replacement.
This medical report would suggest that the osteoarthritic condition progressed post-accident and post-surgery.
As this worker has entitlement for a permanent aggravation for the osteoarthritis and the osteoarthritis progressed and worsened after the accident, it would be logical to include the October 1, 2008 surgical procedure as within the scope of entitlement in this claim. While this surgical procedure may be for the osteoarthritic condition, part of the entitlement in this claim is for the aggravation of that pre-existing condition and there is no objective medical documentation to substantiate this worker would have required a total knee replacement had the accident not occurred.
The Appeals Resolution Officer (ARO) therefore concludes that the surgical procedure of October 1, 2008 (the total knee replacement) falls within the scope of entitlement in this claim.
CONCLUSION
Entitlement is granted for the total knee replacement and any benefits associated with that surgical procedure.
The worker’s objection is therefore, granted.
DATED October 23, 2009
S.M. Elliot
Appeals Resolution Officer
Appeals Branch