WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20150067
DECISION DATE: May 6, 2015
OBJECTING PARTY: Worker
REPRESENTED by: Worker Representative
RESPONDENT: Employer (not participating)
HEARING: Hearing in Writing
HEARD by: J. Cantwell, Appeals Resolution Officer
ISSUES
Entitlement for right total knee replacement surgery and the associated health care benefits.
Entitlement for temporary total disability benefits during the recovery from this surgery.
BACKGROUND
On August 18, 1979, the worker, a 22 year old bartender was involved in an altercation and injured his right knee. He was diagnosed with an anterior cruciate ligament (ACL) tear. This was treated arthroscopically in September 1979.
In July 1993, a high tibial valgus osteotomy was performed. On May 23, 1996, a permanent disability of 10 percent was granted for the right knee disability.
After the worker recovered from the osteotomy in 1997, there was no further medical reporting in the claim until May 2013 when a Form 8 was submitted to the claim. This indicated the worker underwent a total knee arthroplasty with osteotomy revision in May 2013.
On June 11, 2013, entitlement for total knee replacement surgery, and the associated health care and temporary total disability benefits, was denied. The surgical procedure was determined to have arisen out of degenerative changes in the knee and not the work injury. On September 24, 2013, the decision was confirmed on reconsideration.
AUTHORITY
15-03-01 Recurrences
18-06-03 Definitions for Adjudicating Pre-1998 Claims
A worker is entitled to benefits for a recurrence of a work-related injury or disease. To identify a recurrence, the WSIB must confirm that there is clinical compatibility between the original injury or disease and the current condition, or a combination of clinical compatibility and continuity.
ANALYSIS
I find entitlement for the right total knee replacement surgery is the responsibility of the claim. I accept the opinion of the treating surgeon over the opinion of the Physician Consultant, who reviewed the claim. I conclude there is clinical compatibility between the original injury and post-traumatic osteoarthritis.
On May 31, 2013, the Physician Consultant indicated total knee replacement surgery is used to treat advanced and progressive osteoarthritis. He noted the accepted diagnosis in the claim was ACL tear and that early degenerative changes were not accepted as part of the entitlement. He explained it was the progressive degenerative changes that required the high osteotomy and the knee replacement surgery. The Case Manager concluded the surgery was required for progressive degenerative changes in the right knee which did not arise out of the work injury.
The osteotomy done in 1995 was accepted as the responsibility of the claim. Memo 18A documented the opinion of the unit medical advisor in 1995. The doctor noted the worker’s arthroscopy revealed a torn ACL. He indicated the high tibial osteotomy was compatible with the ACL repair despite the lack of medical continuity.
I have carefully reviewed the medical evidence and the accepted entitlement in the claim. The September 27, 1995 letter to the worker granted entitlement for the osteotomy. I conclude entitlement for post-traumatic osteoarthritis was implicitly accepted when entitlement was extended to include the tibial osteotomy.
The question that must be addressed is whether the degenerative changes since the tibial osteotomy, done in 1995, are also attributable to the work injury. The treating surgeon explicitly indicated the total knee replacement surgery arose out of the work injury. I accept his opinion.
I found the following documents pertinent to the issue of whether the right total knee replacement surgery performed in May 2013 is the responsibility of the claim:
- On June 8, 1993 Dr. ‘L’, orthopedic surgeon indicated the worker had ACL deficiency of the right knee, chronic in nature with probable internal derangement.
- On July 12, 1993, the worker had arthroscopic debridement of the medial femoral condyle with partial arthroscopic medial meniscectomy of the right knee. The doctor prescribed a brace for ACL deficiency causing rotational instability.
- In September 1993, Dr. L identified two problems: a torn anterior cruciate ligament and medial chondromalacia. He recommended a high tibial osteotomy to shift the worker’s leg into valgus and take the weight off the medial joint space. He indicated an ACL augmentation could be considered if this procedure did not address the looseness of the knee.
- In November 1993, Dr. ‘Mc’, orthopedic surgeon noted wasting of the quadriceps muscle. He recommended the worker strengthen his quadriceps before considering any procedure.
- In April 1994, Dr. ‘M’, orthopedic surgeon also diagnosed ACL insufficiency and medial degenerative joint disease.
- In June 1994, the worker had a bone scan which showed degenerative changes in the medial compartment of both knees, right more than left, and in the right patella.
- In April 1995, Dr. ‘Ma’, orthopedic surgeon recommended a high tibial valgus osteotomy to relieve the medial compartment and prolong the life of the worker’s knee.
- The worker had a high tibial osteotomy, in May 1995, for medial compartment osteoarthritis of the right knee.
- In June 1995, Dr. ‘O’, family doctor noted the worker had been seen by a number of orthopedic surgeons who were in agreement regarding the diagnosis. He added these medical reports supported the osteoarthritis in the worker’s right knee was directly related to the ACL tear. Dr. O indicated there was no other reason for the worker to have such advanced findings in one knee and a normal left knee. He related the osteoarthritis in the right knee to the work injury.
- The worker was seen for a pension rating in May 1996. The diagnoses were:
- Remote injury to the right knee in August 1979 with tear of the ACL.
- Subsequent arthroscopic surgery, culminating with high tibial osteotomy in May 1995.
- Ongoing instability and post-traumatic arthritis.
- On May 3, 2013, the worker was treated with removal of hardware from the decompensated right tibial osteotomy and a right total knee replacement for osteoarthritis.
- On April 22, 2013, Dr. O reviewed the history of right knee problems. He indicated the ACL tear and other soft tissue injuries that occurred at the time of the work injury resulted in the development of significant osteoarthritis over time. The July 11, 2013 letter from Dr. O added that it would be unusual to see such severe osteoarthritis at the worker’s age due to aging alone.
- On June 27, 2013, Dr. ‘C’, the treating surgeon indicated that an ACL deficient knee will, in the vast majority of cases, develop osteoarthritis. He explained the high tibial osteotomy was done because the knee was arthritic and the medial compartment was wearing out. Osteotomies usually last seven years. The worker did very well. His knee lasted much longer than this. Dr. C indicated the worker required a total knee replacement and there was no question in his mind the right knee replacement in 2013 was occasioned by the injury in 1979.
The ACL tear and post-traumatic arthritis of the right knee were treated by arthroscopies, brace, high tibial osteotomy and finally, total knee replacement surgery. I find the evidence overwhelming supports the total knee replacement surgery arose out of the work injury. The medical reporting documented instability of the right knee due to the ACL tear. This instability caused post-traumatic arthritis which progressed and required the total knee replacement surgery in May 2013.
CONCLUSION
Entitlement is accepted for the right total knee replacement surgery and the associated health care benefits.
The worker is entitled to temporary total disability benefits until December 2, 2013 when Dr. C indicated he was capable of modified work. He is entitled to temporary partial benefits from December 3, 2013 until his return to work.
The worker’s objection is allowed.
DATED May 6, 2015
J. Cantwell Appeals Resolution Officer Appeals Services Division