Diagnostic Assessment — Bilateral Knees - Osteoarthritis
Example 1 of 1 · fictitious patient (Veteran DX)
Diagnostic Assessment
Bilateral Knees - Osteoarthritis
BOP Code: 62 of 2017 (Osteoarthritis)
RH Code: 61 of 2017 (Osteoarthritis)
ADF History
Veteran DX, date of birth 11 March 1932, Australian Army, Rifleman (Infantry) from 1950 and Vehicle Mechanic (Royal Australian Electrical and Mechanical Engineers) from 1958, enlisted 02 February 1950, discharged 10 March 1984. Operational service: Korea, 28 September 1950 to 06 September 1953 (warlike; prisoner of war from 23 April 1951); Malaya, 01 October 1955 to 01 October 1957 (operational service); Vietnam, 12 May 1966 to 20 May 1967 and 10 March 1970 to 20 September 1970 (warlike; aeromedically evacuated).
Occupational History
As an infantryman the veteran marched and patrolled carrying packs and weapons of 25 to 40 kilograms over mountainous and jungle terrain. As a vehicle mechanic he knelt and squatted beside and under vehicles for hours a day, climbed ladders onto vehicle decks and cabs, lifted and carried wheels, gearboxes and batteries, and used spanners, wrenches and vibrating pneumatic tools for most of the working day.
Field workshops on operations worked long shifts on rough ground, with vehicle accidents, falls from vehicles and crush injuries common. Cold injury, malnutrition and infection were severe hazards for prisoners of war in Korea, where captives were made to kneel and labour on frozen ground.
History
Veteran DX, an infantryman and later a vehicle mechanic in the Australian Army, was a prisoner of war in Korea from 1951 to 1953, where he suffered frostbite of both knees and feet, septic arthritis of the left knee and beriberi. He went on to sustain intra-articular fractures and ligament and meniscal injuries of both knees, in Vietnam in 1970 and in Australia in 1976, after decades of kneeling, lifting and carrying, and developed osteoarthritis of both knees on 14 June 1994, which worsened to end-stage disease by 1999.
Timeline
- 06 Sep 1953 — Repatriation medical examination after 29 months as a prisoner of war in Korea. Recorded frostbite scarring over both patellae and gangrene of the second to fourth toes of the right foot, a stiff left knee after septic arthritis in captivity in February 1952, weight 52 kg, and sensory loss in both legs from beriberi. The gangrenous toes were amputated on 14 October 1953 and he walked with an asymmetric gait from then on. "frostbite knees, septic L knee"
- 14 Sep 1970 — During warlike service in Vietnam the truck he was driving rolled. He sustained a depressed fracture of the left lateral tibial plateau involving the joint surface, with a tense haemarthrosis, a lateral meniscal tear and an articular cartilage tear. The fracture was fixed at a field hospital and he was aeromedically evacuated. It healed with 8 degrees of valgus angulation. "L tibial plateau fracture, haemarthrosis"
- 17 May 1976 — Fell from the deck of a tank transporter onto his right knee during peacetime service. X-ray showed a fracture of the patella through its articular surface and 60 mL of blood was aspirated. The knee was immobilised in a cylinder cast for six weeks. Recurrent giving way followed. "R patella fracture, haemarthrosis"
- 26 Jul 1977 — Arthroscopy of the right knee showed rupture of the anterior cruciate ligament, a bucket-handle tear of the medial meniscus, a chondral flap tear of the medial femoral condyle and chondromalacia of the patella. Partial meniscectomy was performed. On 02 August 1977 he developed septic arthritis with Staphylococcus aureus, requiring washout and six weeks of antibiotics. "ACL rupture, septic arthritis R"
- 10 Mar 1984 — Discharge medical examination after 34 years of service, 26 of them as a vehicle mechanic. Weight 98 kg, height 1.76 m, BMI 31.6, waist 110 cm. Recorded acromegaly treated surgically in 1979, gout with urate crystals aspirated from the right knee in 1980, chondromalacia patellae since 1963, an unstable right knee and an asymmetric gait. The trade summary recorded daily kneeling, ladder climbing, lifting and carrying of heavy components and use of pneumatic tools. "BMI 31.6, unstable R knee"
- 22 Nov 1992 — Rheumatology review for rheumatoid arthritis diagnosed in 1985 and treated with prednisolone and methotrexate. Paget's disease of both distal femora and proximal tibiae (1988), bilateral femoroacetabular impingement (1989), increased bone density (1990), chondrocalcinosis (1990), sensory neuropathy (1990) and right medial femoral condyle osteonecrosis on MRI (1991) were recorded. Knee X-rays showed healed fractures and chondrocalcinosis but preserved joint spaces and no osteophytes. "knee joint spaces preserved"
- 20 Jun 1994 — Presented to his general practitioner with gradually increasing pain in both knees with walking, stairs and standing since about 14 June 1994, morning stiffness under 30 minutes and grating. Examination showed bilateral crepitus, bony enlargement, small effusions and loss of flexion. X-rays on 24 June 1994 showed osteoarthritis of both knees, Kellgren-Lawrence grade 2. He was referred to an orthopaedic surgeon and placed on a waiting list. "bilateral knee OA, KL 2"
- 21 Jul 1997 — Fell onto his left knee when it gave way, his gait unbalanced by the toe amputations. Haemarthrosis was aspirated in the emergency department. MRI showed an acute medial meniscal tear and a chondral flap tear, treated at arthroscopy on 04 August 1997, which also showed advanced osteoarthritis. "fall, L haemarthrosis, meniscal tear"
- 08 Jun 1999 — Orthopaedic review for constant knee pain, night pain and a walking tolerance under 200 metres. X-rays showed end-stage osteoarthritis of both knees, Kellgren-Lawrence grade 4, with bone-on-bone medial and patellofemoral compartments, valgus deformity on the left and varus on the right. He was still awaiting surgery. Bilateral total knee replacements were performed in 2002. "end-stage OA, KL 4 bilateral"
Symptoms
At onset the veteran had aching pain in both knees on walking, standing and climbing stairs, brief morning stiffness, grating and swelling after activity, and difficulty kneeling and squatting. After onset the pain became daily and his walking distance shortened.
By 1999 he had constant pain, night pain, a walking tolerance under 200 metres and visible deformity of both knees. Since bilateral knee replacements he reports reduced pain but persisting stiffness, limited kneeling and a walking tolerance of about one kilometre with a stick.
Imaging
- 14 Sep 1970 — X-ray left knee (field hospital): "Depressed fracture of the lateral tibial plateau extending into the joint, with lipohaemarthrosis."
- 17 May 1976 — X-ray right knee: "Transverse fracture of the patella involving the articular surface, with joint effusion."
- 05 Apr 1990 — Bone densitometry: "Femoral neck T-score plus 1.8, increased bone mineral density."
- 12 Mar 1991 — MRI right knee: "Subchondral osteonecrosis of the medial femoral condyle. Anterior cruciate ligament deficient. Chondrocalcinosis of the menisci."
- 22 Nov 1992 — X-ray both knees: "Healed left tibial plateau fracture with 8 degrees of valgus and healed right patellar fracture. Chondrocalcinosis. Joint spaces preserved, no osteophytes."
- 24 Jun 1994 — X-ray both knees, weight bearing: "Osteoarthritis of both knees, Kellgren-Lawrence grade 2, with definite osteophytes and early joint space narrowing in the medial and patellofemoral compartments, lateral on the left."
- 18 Nov 1998 — Bone densitometry: "Lumbar spine T-score minus 2.7, osteoporosis."
- 08 Jun 1999 — X-ray both knees, weight bearing: "End-stage osteoarthritis of both knees, Kellgren-Lawrence grade 4, with bone-on-bone contact, large osteophytes, subchondral sclerosis and cysts, left valgus and right varus deformity."
Onset Date
The most likely date of onset of this condition is 14 Jun 1994.
At that date the veteran had been discharged from the Army for ten years. He had the long-term effects of captivity as a prisoner of war after warlike service in Korea, intra-articular fractures and internal derangement of both knees from service injuries in Vietnam in 1970 and in Australia in 1976, decades of kneeling, lifting, carrying and ladder climbing as a service vehicle mechanic, and rheumatoid arthritis, crystal arthropathy, Paget's disease and osteonecrosis involving the knees.
This date is appropriate because knee X-rays on 22 November 1992 showed preserved joint spaces and no osteophytes, and he first presented with bilateral knee pain on 20 June 1994, describing a week of symptoms, with X-rays on 24 June 1994 showing osteoarthritis of both knees.
For the Balance of Probabilities factors with a 25-year window, the 25 years before onset run from 14 Jun 1969 to 14 Jun 1994 and contain the knee trauma, cartilage and meniscal tears of 1970 and 1976, the use of vibrating tools from 1970 to 1984 and the ladder climbing from 1975 to 1984. The ten-year lifting and carrying period from 1974 to 1984 ended within the 25 years before onset, as did the kneeling period from 1975 to 1984. He was overweight, with a waist above 102 cm, for more than ten years before onset, from 1975 and 1978. The asymmetric gait from 1953 and the disordered mechanics of the left knee from 1971 and the right knee from 1988 lasted more than five years before onset. For the Reasonable Hypothesis factors, his captivity, frostbite and septic arthritis of 1951 to 1953, his load carriage from 1950 to 1960, his lifting from 1962 to 1972, his ladder climbing from 1966 to 1968 and his year of kneeling in Vietnam from 1966 to 1967 all preceded onset.
For the worsening factors, the period after onset runs from 14 Jun 1994 to the documented worsening on 08 Jun 1999, when the osteoarthritis had progressed from Kellgren-Lawrence grade 2 to grade 4 in both knees. The 25 years before the worsening run from 08 Jun 1974 to 08 Jun 1999 and contain the right knee trauma of 1976 and the fall onto the left knee of 21 Jul 1997, with haemarthrosis and meniscal and cartilage tears, as well as ten years of vibrating tool use and nine years of ladder climbing and kneeling from 1974 to 1984. Osteoporosis was documented on 18 Nov 1998, before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Bilateral Knees - Osteoarthritis (ICD-10 M17.0, primary bilateral gonarthrosis, with post-traumatic contributions), under the Statements of Principles concerning osteoarthritis, Balance of Probabilities No. 62 of 2017 and Reasonable Hypothesis No. 61 of 2017.
Osteoarthritis is a degenerative joint disease characterised by focal loss of articular cartilage, subchondral bone sclerosis and cysts, osteophyte formation and synovial inflammation. In the knee it causes pain on weight bearing, stiffness, crepitus, swelling, deformity and loss of movement, and it progresses to end-stage disease requiring joint replacement. It is caused by joint injury, fractures and meniscal and ligament damage, abnormal joint loading and alignment, occupational kneeling, lifting and carrying, obesity, and inflammatory, crystal, infective, metabolic and neurological diseases of the joint.
The diagnosis followed captivity, frostbite and septic arthritis as a prisoner of war after warlike service in Korea, intra-articular fractures and internal derangement of both knees from service injuries, and 26 years of heavy mechanical work. It began on 14 June 1994, was confirmed on X-ray on 24 June 1994, and worsened to end-stage disease by 08 June 1999.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 June 1994.
When did the veteran first present to a health / medical provider for this condition?
20 June 1994.
When was the condition confirmed / formally diagnosed?
24 June 1994.
When did the veteran first present to you (or your practice) for this condition?
26 February 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by weight-bearing X-rays of both knees on 24 June 1994, which showed definite osteophytes and joint space narrowing in the medial and patellofemoral compartments, and laterally on the left, Kellgren-Lawrence grade 2. The clinical picture was consistent: activity-related pain, brief morning stiffness, crepitus, bony enlargement and loss of flexion in both knees, meeting the American College of Rheumatology clinical and radiographic criteria for osteoarthritis of the knee and the Statement of Principles definition.
The worsening was documented by X-rays on 08 June 1999 showing end-stage osteoarthritis, Kellgren-Lawrence grade 4, with bone-on-bone contact and deformity, after arthroscopy of the left knee on 04 August 1997 had shown advanced cartilage loss. Bilateral total knee replacement was performed in 2002 and the operation notes confirmed advanced osteoarthritis of both knees.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 14 June 1994, before 1 July 2004. The veteran rendered operational service under the Veterans' Entitlements Act 1986 (VEA) in Korea, Malaya and Vietnam, so this is a VEA claim and the Statements of Principles bind the decision maker. The Reasonable Hypothesis instrument applies to his operational service, including his captivity as a prisoner of war after warlike service in Korea and the knee injury in Vietnam. The Balance of Probabilities instrument applies to his peacetime defence service, including the 1976 knee injury and his years as a vehicle mechanic in Australia. Even where a particular period falls outside these instruments, every factor has been analysed.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Osteoarthritis, No. 62 of 2017
Causative factors
Factor 9(1): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- A rheumatologist diagnosed seropositive rheumatoid arthritis in 1985, with synovitis of both knees, hands and wrists, and it remained active, treated with prednisolone and methotrexate, until the onset of osteoarthritis in both knees on 14 June 1994.
Factor 9(2): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- The veteran had bacterial septic arthritis of the right knee in August 1977 after a Defence-arranged arthroscopy for his service knee injury, with Staphylococcus aureus cultured from the joint and surgical washout required. This was before onset on 14 June 1994.
Factor 9(3): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- On 17 May 1976, during peacetime service, the veteran fell from the deck of a tank transporter onto his right knee and fractured the patella through its articular surface, shown on X-ray. This intra-articular fracture preceded onset on 14 June 1994.
Factor 9(4): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The right patellar fracture on 17 May 1976 caused a tense haemarthrosis, and 60 mL of blood was aspirated from the knee. This preceded onset on 14 June 1994.
Factor 9(5): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Gout was diagnosed in 1980 with urate crystals aspirated from the right knee during service, and calcium pyrophosphate deposition disease was confirmed in 1990 by chondrocalcinosis of both knee menisci on X-ray. Both affected the knees before onset on 14 June 1994.
Factor 9(6): having trauma to the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- The 25 years before onset run from 14 June 1969 to 14 June 1994. Within that period the veteran sustained the left tibial plateau fracture on 14 September 1970 and the right patellar fracture and ligament injury on 17 May 1976, each a discrete event of significant force causing joint damage, pain and loss of movement and requiring surgery or splinting.
Factor 9(7): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- Arthroscopy of the right knee on 26 July 1977 showed an acute chondral flap tear of the medial femoral condyle from the injury of 17 May 1976, within the 25 years before onset.
Factor 9(8): having an acute meniscal tear of the affected knee within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- Arthroscopy on 26 July 1977 showed an acute bucket-handle tear of the right medial meniscus from the injury of 17 May 1976, and a left lateral meniscal tear was recorded with the tibial plateau fracture of 14 September 1970. Both were within the 25 years before onset.
Factor 9(9): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- During captivity in the winter of 1951 and 1952 the veteran was made to kneel for hours on frozen ground and suffered frostbite of both knees and both feet, with blistering and later scarring over both patellae recorded at his repatriation examination of 06 September 1953. The frostbite preceded onset by more than 40 years.
Factor 9(10): having disordered joint mechanics of the affected joint for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- The left tibial plateau fracture of 1970 healed with 8 degrees of valgus angulation, and Paget's disease from 1988 produced varus bowing of the right distal femur. The left knee had disordered mechanics from 1971 and the right from 1988, each for more than five years before onset on 14 June 1994.
Factor 9(11): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- MRI on 12 March 1991 showed osteonecrosis of the subchondral bone of the right medial femoral condyle, attributed to long-term prednisolone. This preceded onset on 14 June 1994.
Factor 9(12): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- From 1958 to 1984 the veteran worked as a vehicle mechanic in service, gripping spanners, wrenches and power tools and handling heavy components for more than 30 hours a week. This continued for 26 years, well over ten years within a continuous 15-year period before onset, and was the same work that loaded his knees.
Factor 9(13): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- From 1970 to 1984 the veteran used pneumatic impact wrenches, rattle guns and air chisels on most working days, a cumulative 14 years within the 25 years before onset, which run from 14 June 1969 to 14 June 1994.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical onset of osteoarthritis in that joint; — MET
- The second, third and fourth toes of the right foot were amputated on 14 October 1953 for frostbite gangrene sustained in captivity, and the veteran has walked with an asymmetric gait ever since, recorded in his service medical documents from 1954 to 1984. This was for 40 years before onset.
Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1974 to 1984 the veteran lifted truck wheels of 50 to 70 kilograms, gearboxes, batteries and components of 20 kilograms or more while standing, an estimated 22,000 kilograms a year and more than 200,000 kilograms in that ten-year period. Onset in 1994 was within the 25 years following that period.
Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; and (ii) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1974 to 1984 the veteran carried wheels, batteries, toolboxes and recovery chains of 20 kilograms or more for about two hours on most working days, more than 4,000 hours in that ten-year period. Onset in 1994 was within the 25 years following that period.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical onset of osteoarthritis in that joint; — MET
- From 1975 to 1984 the veteran climbed ladders to vehicle decks, cabs and workshop mezzanines more than 150 rungs and stairs a day on most working days, a continuous period of nine years, within the 25 years before onset.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- Bone densitometry on 05 April 1990 showed a femoral neck T-score of plus 1.8, more than one standard deviation above the young adult mean, attributed to acromegaly and Paget's disease. This preceded onset on 14 June 1994.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's BMI was 28.4 in 1975 and remained between 28 and 32 from then until onset, recorded at each periodic health examination, so he was overweight for more than ten years before onset on 14 June 1994.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran's waist circumference was 106 cm in 1978 and 110 cm at discharge in 1984, and remained above 102 cm to onset, more than ten years.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- The veteran is male. His waist circumference exceeded 88 cm continuously from 1975, when it was recorded as 98 cm, to onset, and exceeded 102 cm from 1978, so the threshold in this sub-factor was exceeded for more than ten years.
Factor 9(16): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; and (b) where the clinical onset of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- From 1975 to 1984, a continuous period of nine years, the veteran knelt and squatted beside and under vehicles for two to three hours on most working days, recorded in his trade summary. Onset in 1994 was within the 25 years following that period.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The right knee had internal derangement from 17 May 1976, with an anterior cruciate ligament rupture and a bucket-handle meniscal tear confirmed at arthroscopy in 1977, and the left knee from the meniscal tear of 1970, before onset.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of both knees was diagnosed by a medical officer on 03 June 1963 after anterior knee pain from kneeling in the workshop, and was confirmed at arthroscopy of the right knee in 1977. This preceded the patellofemoral osteoarthritis present at onset.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Nerve conduction studies on 19 September 1990 showed a length-dependent sensory peripheral neuropathy with loss of vibration and joint position sense to the knees, which a neurologist attributed to beriberi in captivity. This disorder preceded onset.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of bone affecting the distal femora and proximal tibiae of both knees was diagnosed in 1988 on a raised alkaline phosphatase and increased uptake on bone scan, before onset.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly from a growth hormone-secreting pituitary adenoma was diagnosed in 1979, during service, and treated by transsphenoidal surgery. It preceded onset on 14 June 1994.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The right knee was unstable from the anterior cruciate ligament rupture of 17 May 1976, with recurrent giving way recorded in 1978 and 1983, and the left patella dislocated in the workshop on 11 February 1962. Both were more than one year before onset.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- X-rays and CT of the hips on 14 November 1989 showed bilateral cam-type femoroacetabular impingement with hip pain and positive impingement tests, diagnosed by an orthopaedic surgeon. The resulting restriction of hip rotation increased torsional loading of both knees. This preceded onset.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Rheumatoid arthritis of both knees was present throughout the period before the worsening on 08 June 1999, with a flare and knee effusions documented in 1998.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis of the right knee in 1977 and of the left knee in 1952 both preceded the worsening on 08 June 1999.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The right patellar fracture of 1976 and the left tibial plateau fracture of 1970 both involved the articular surface and preceded the worsening on 08 June 1999.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The left knee haemarthrosis after a fall on 21 July 1997, aspirated in the emergency department, and the right knee haemarthrosis of 1976 preceded the worsening on 08 June 1999.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Calcium pyrophosphate deposition in both knees and gout persisted, with an acute pseudogout attack of the left knee in 1998, before the worsening on 08 June 1999.
Factor 9(29): having trauma to the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The 25 years before the worsening run from 08 June 1974 to 08 June 1999. Within that period he sustained the right knee injury of 17 May 1976 and, on 21 July 1997, a fall onto the left knee caused by his asymmetric gait, with haemarthrosis and a meniscal tear requiring arthroscopic surgery.
Factor 9(30): having an acute articular cartilage tear of the affected joint within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- Arthroscopy of the left knee on 04 August 1997 showed an acute chondral flap tear of the lateral femoral condyle from the fall of 21 July 1997, within the 25 years before the worsening.
Factor 9(31): having an acute meniscal tear of the affected knee within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The fall of 21 July 1997 caused an acute tear of the left medial meniscus, resected at arthroscopy on 04 August 1997, within the 25 years before the worsening. The right meniscal tear of 1976 was also within that window.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The frostbite of both knees in captivity in 1951 and 1952 preceded the worsening on 08 June 1999.
Factor 9(33): having disordered joint mechanics of the affected joint for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The valgus malunion of the left tibial plateau and the varus bowing of the right femur persisted for more than five years before the worsening on 08 June 1999.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- The osteonecrosis of the right medial femoral condyle, shown in 1991, progressed with subchondral collapse before the worsening on 08 June 1999.
Factor 9(35): for osteoarthritis of a joint of the upper limb only, performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The power grip work from 1958 to 1984 amounted to more than ten years within a continuous 15-year period before the worsening on 08 June 1999.
Factor 9(36): for osteoarthritis of a joint of the hand, wrist or elbow joint only, using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- His use of vibrating pneumatic tools on most working days from 1974 to 1984 amounted to ten years within the 25 years before the worsening, which run from 08 June 1974 to 08 June 1999.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least five years before the clinical worsening of osteoarthritis in that joint; — MET
- The amputation and asymmetric gait persisted for more than five years before the worsening on 08 June 1999, and the gait caused the fall of 21 July 1997.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 150 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The lifting of more than 200,000 kilograms from 1974 to 1984 was followed by the worsening on 08 June 1999, within the 25 years following that period.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint: (i) to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; and (ii) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The carrying of more than 4,000 hours from 1974 to 1984 was followed by the worsening on 08 June 1999, within the 25 years following that period.
Factor 9(37)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least five years, within the 25 years before the clinical worsening of osteoarthritis in that joint; — MET
- The nine years of ladder and stair climbing from 1975 to 1984 fell within the 25 years before the worsening on 08 June 1999.
Factor 9(38)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- His BMI remained above 25 throughout the ten years before the worsening on 08 June 1999.
Factor 9(38)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- His waist circumference exceeded 102 cm throughout the ten years before the worsening.
Factor 9(38)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- His waist circumference exceeded 88 cm throughout the ten years before the worsening.
Factor 9(39): for osteoarthritis of a hip or knee joint only: (a) kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at two years before the clinical worsening of osteoarthritis in that joint; and (b) where the clinical worsening of osteoarthritis in that joint occurs within the 25 years following that period; — MET
- The nine years of kneeling and squatting from 1975 to 1984 were followed by the worsening on 08 June 1999, within the 25 years following that period.
Factor 9(40): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Internal derangement of both knees, including the left medial meniscal tear of 1997, preceded the worsening on 08 June 1999.
Factor 9(41): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of both knees preceded the worsening on 08 June 1999.
Factor 9(42): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The sensory neuropathy with loss of proprioception at the knees persisted before the worsening on 08 June 1999.
Factor 9(43): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease around both knees remained active before the worsening on 08 June 1999.
Factor 9(44): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly preceded the worsening on 08 June 1999.
Factor 9(45): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- Right knee instability from 1976 persisted, and the left knee gave way causing the fall of 21 July 1997, more than one year before the worsening.
Factor 9(46): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- Bilateral femoroacetabular impingement syndrome preceded the worsening on 08 June 1999.
Factor 9(47): inability to obtain appropriate clinical management for osteoarthritis. — MET
- After the diagnosis on 24 June 1994 the veteran was referred to an orthopaedic surgeon but waited more than four years on a public waiting list, and his request for funding of treatment was not approved until 2001. No physiotherapy, bracing or weight management program was arranged in that time. The osteoarthritis progressed from Kellgren-Lawrence grade 2 to grade 4 before bilateral knee replacement in 2002. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Osteoarthritis, No. 61 of 2017
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of osteoarthritis; — MET
- The veteran was captured by enemy forces during warlike service in Korea on 23 April 1951 and held as a prisoner of war until his repatriation on 06 September 1953, more than 40 years before the onset of osteoarthritis in both knees on 14 June 1994. During captivity he endured forced labour, prolonged kneeling on frozen ground, frostbite, septic arthritis and severe malnutrition with beriberi.
Factor 9(2): having inflammatory joint disease as specified, of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Seropositive rheumatoid arthritis involving both knees was diagnosed in 1985 and was present before onset on 14 June 1994. The veteran's treating rheumatologist recorded that his years of captivity and operational stress had preceded the disease.
Factor 9(3): having an infection of the affected joint as specified before the clinical onset of osteoarthritis in that joint; — MET
- During captivity as a prisoner of war after warlike service in Korea, the veteran developed septic arthritis of the left knee in February 1952, with a hot, swollen knee and pus drained by a fellow prisoner, confirmed by the repatriation medical examination of 06 September 1953 and later X-ray changes. The right knee became infected with Staphylococcus aureus after arthroscopy in August 1977. Both infections preceded onset.
Factor 9(4): having an intra-articular fracture of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- On 14 September 1970, during warlike service in Vietnam, the truck he was driving rolled and he sustained a fracture of the lateral tibial plateau of the left knee, involving the articular surface, which was fixed surgically. The right patellar fracture of 1976 also involved the joint surface. Both preceded onset.
Factor 9(5): having haemarthrosis of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The left tibial plateau fracture on warlike service in Vietnam on 14 September 1970 caused a haemarthrosis aspirated at the field hospital, and the right knee haemarthrosis of 1976 followed. Both preceded onset.
Factor 9(6): having a depositional joint disease as specified, in the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Gout with urate crystals aspirated from the right knee in 1980, and calcium pyrophosphate deposition disease with chondrocalcinosis of both knees from 1990, were present before onset.
Factor 9(7): having trauma to the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- The veteran sustained trauma to the left knee in a vehicle rollover on warlike service in Vietnam on 14 September 1970, and to the right knee on 17 May 1976. Each caused fracture, pain and loss of movement and required surgery or immobilisation before onset.
Factor 9(8): having an acute articular cartilage tear of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- An acute articular cartilage tear of the left lateral tibial plateau was recorded at fixation of the fracture sustained on warlike service in Vietnam in September 1970, and a chondral flap tear of the right medial femoral condyle at arthroscopy in July 1977. Both preceded onset.
Factor 9(9): having an acute meniscal tear of the affected knee before the clinical onset of osteoarthritis in that joint; — MET
- A tear of the left lateral meniscus was found at fixation of the tibial plateau fracture sustained on warlike service in Vietnam on 14 September 1970, and the right medial meniscus tore in 1976. Both preceded onset.
Factor 9(10): having frostbite involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- As a prisoner of war after warlike service in Korea, the veteran suffered frostbite of both knees and feet in the winter of 1951 and 1952, kneeling for hours on frozen ground in punishment. Scarring over both patellae was recorded at repatriation on 06 September 1953, long before onset.
Factor 9(11): having disordered joint mechanics of the affected joint for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- The left tibial plateau fracture from warlike service in Vietnam healed with a valgus angulation deformity of 8 degrees, maldistributing load across the left knee from 1971, far more than three years before onset. The right knee had varus deformity from Paget's bowing from 1988.
Factor 9(12): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical onset of osteoarthritis in that joint; — MET
- Subchondral osteonecrosis of the right medial femoral condyle was shown on MRI on 12 March 1991, before onset. The veteran's treating physician also noted bone infarcts of both distal femora consistent with his malnutrition and cold injury in captivity after warlike service in Korea.
Factor 9(13)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical onset of osteoarthritis in that joint; — MET
- As a vehicle mechanic from 1958 to 1984, including in the field workshops on warlike service in Vietnam in 1966 and 1967 and in 1970, he performed sustained power grip tasks for more than 30 hours a week, for more than ten years within a continuous 15-year period before onset.
Factor 9(13)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical onset of osteoarthritis in that joint; — MET
- The veteran used pneumatic impact wrenches and air chisels on more days than not from 1958 to 1984, more than ten years in total, including in field workshops on warlike service in Vietnam.
Factor 9(14)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical onset of osteoarthritis in that joint; — MET
- Toe amputations of the right foot on 14 October 1953 for frostbite sustained as a prisoner of war after warlike service in Korea left the veteran with an amputation involving the leg and an asymmetric gait for more than 40 years before onset.
Factor 9(14)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical onset of osteoarthritis in that joint; — MET
- From 1962 to 1972, a period that included his warlike service in Vietnam in 1966 and 1967 and in 1970, the veteran lifted wheels, gearboxes and other loads of 20 kilograms or more while bearing weight, a cumulative total of more than 180,000 kilograms, before onset.
Factor 9(14)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical onset of osteoarthritis in that joint; — MET
- From 1950 to 1960 the veteran served as an infantryman, including warlike service in Korea in 1950 and 1951 and operational service in Malaya from 1955 to 1957, carrying packs and weapons of 25 to 40 kilograms for more than 3,800 hours in total.
Factor 9(14)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years before the clinical onset of osteoarthritis in that joint; — MET
- From May 1966 to May 1968, a continuous period that included warlike service in Vietnam, the veteran climbed more than 150 ladder rungs and stairs a day on vehicles and workshop structures, before onset.
Factor 9(14)(e): for osteoarthritis of a joint of the lower limb only: having increased bone mineral density before the clinical onset of osteoarthritis in that joint; — MET
- Bone densitometry on 05 April 1990 showed increased bone mineral density with a T-score of plus 1.8, before onset.
Factor 9(15)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- He was overweight, with a BMI of 28 to 32, from 1975 to onset, more than ten years. His weight gain began after the knee injury of 1970 on warlike service in Vietnam limited his activity.
Factor 9(15)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- His waist circumference exceeded 102 cm from 1978 to onset, more than ten years.
Factor 9(15)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical onset of osteoarthritis in that joint; — MET
- His waist circumference exceeded 88 cm from 1975 to onset, more than ten years.
Factor 9(16): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical onset of osteoarthritis in that joint; — MET
- Throughout his warlike service in Vietnam from 12 May 1966 to 20 May 1967, a continuous period of one year, he knelt and squatted beside and under vehicles in a field workshop for two to three hours a day, before onset.
Factor 9(17): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Internal derangement of the left knee from the meniscal tear on warlike service in Vietnam in 1970, and of the right knee from the cruciate and meniscal injuries of 1976, preceded onset.
Factor 9(18): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical onset of osteoarthritis in that joint; — MET
- Chondromalacia patellae of both knees, diagnosed in 1963 and aggravated by kneeling in field workshops on warlike service in Vietnam, preceded onset.
Factor 9(19): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Beriberi neuropathy from severe thiamine deficiency as a prisoner of war after warlike service in Korea left the veteran with loss of pain sensation and proprioception in both legs, documented in 1954 and confirmed on nerve conduction studies in 1990, before onset.
Factor 9(20): having Paget's disease of bone of the affected joint before the clinical onset of osteoarthritis in that joint; — MET
- Paget's disease of bone around both knees was diagnosed in 1988, before onset.
Factor 9(21): having acromegaly before the clinical onset of osteoarthritis in that joint; — MET
- Acromegaly was diagnosed in 1979 and treated surgically, before onset.
Factor 9(22): having joint instability or dislocation of the affected joint, at least one year before the clinical onset of osteoarthritis in that joint; — MET
- The left knee was unstable after the tibial plateau fracture and meniscal tear on warlike service in Vietnam in 1970, and the right knee after the cruciate rupture of 1976, each more than one year before onset.
Factor 9(23): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical onset of osteoarthritis in that joint; — MET
- Bilateral cam-type femoroacetabular impingement syndrome was diagnosed on 14 November 1989, before onset.
Worsening factors
Factor 9(24): having inflammatory joint disease as specified, of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Rheumatoid arthritis involving both knees was present before the worsening on 08 June 1999.
Factor 9(25): having an infection of the affected joint as specified before the clinical worsening of osteoarthritis in that joint; — MET
- The septic arthritis of the left knee in captivity after warlike service in Korea in 1952, and of the right knee in 1977, preceded the worsening on 08 June 1999.
Factor 9(26): having an intra-articular fracture of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The left tibial plateau fracture sustained on warlike service in Vietnam in 1970 involved the articular surface and preceded the worsening on 08 June 1999.
Factor 9(27): having haemarthrosis of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The left knee haemarthrosis from the fracture on warlike service in Vietnam in 1970, and a further haemarthrosis after a fall on 21 July 1997, preceded the worsening on 08 June 1999.
Factor 9(28): having a depositional joint disease as specified, in the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Calcium pyrophosphate deposition disease and gout affecting both knees were present before the worsening on 08 June 1999.
Factor 9(29): having trauma to the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The left knee trauma on warlike service in Vietnam in 1970, the right knee trauma of 1976 and the fall onto the left knee on 21 July 1997 all preceded the worsening on 08 June 1999.
Factor 9(30): having an acute articular cartilage tear of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The acute cartilage tears of the left knee in 1970 and 1997 and of the right knee in 1977 preceded the worsening on 08 June 1999.
Factor 9(31): having an acute meniscal tear of the affected knee before the clinical worsening of osteoarthritis in that joint; — MET
- The left lateral meniscal tear from warlike service in Vietnam in 1970 and the left medial meniscal tear of 1997 preceded the worsening on 08 June 1999.
Factor 9(32): having frostbite involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Frostbite of both knees sustained as a prisoner of war after warlike service in Korea preceded the worsening on 08 June 1999.
Factor 9(33): having disordered joint mechanics of the affected joint for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The valgus malunion from warlike service in Vietnam persisted for more than three years before the worsening on 08 June 1999.
Factor 9(34): having necrosis of the subchondral bone near the affected joint, including that from dysbaric osteonecrosis, before the clinical worsening of osteoarthritis in that joint; — MET
- Subchondral osteonecrosis of the right knee preceded the worsening on 08 June 1999.
Factor 9(35)(a): for osteoarthritis of a joint of the upper limb only: performing any combination of repetitive activities or tasks involving repeated or sustained pinch grip or hand/power grip, for an average of at least 30 hours per week, for a cumulative period of at least ten years within a continuous period of 15 years, before the clinical worsening of osteoarthritis in that joint; — MET
- The power grip work as a service vehicle mechanic, including on warlike service in Vietnam, preceded the worsening on 08 June 1999.
Factor 9(35)(b): for osteoarthritis of a joint of the upper limb only: using a hand-held, vibrating percussive tool or object on more days than not, for a cumulative period of at least ten years, before the clinical worsening of osteoarthritis in that joint; — MET
- The veteran's use of vibrating pneumatic tools for more than ten years, including on warlike service in Vietnam, preceded the worsening on 08 June 1999.
Factor 9(36)(a): for osteoarthritis of a joint of the lower limb only: having: (i) an amputation involving either leg; or (ii) an asymmetric gait; for at least three years before the clinical worsening of osteoarthritis in that joint; — MET
- The amputation and asymmetric gait from frostbite in captivity after warlike service in Korea persisted for more than three years before the worsening on 08 June 1999.
Factor 9(36)(b): for osteoarthritis of a joint of the lower limb only: lifting loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 100 000 kilograms within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET
- The lifting of more than 180,000 kilograms from 1962 to 1972, including on warlike service in Vietnam, preceded the worsening on 08 June 1999.
Factor 9(36)(c): for osteoarthritis of a joint of the lower limb only: carrying loads of at least 20 kilograms while bearing weight through the affected joint to a cumulative total of at least 3 800 hours within any ten year period before the clinical worsening of osteoarthritis in that joint; — MET
- The carrying of loads for more than 3,800 hours from 1950 to 1960, including on warlike service in Korea and operational service in Malaya, preceded the worsening on 08 June 1999.
Factor 9(36)(d): for osteoarthritis of a joint of the lower limb only: ascending or descending at least 150 stairs or rungs of a ladder per day, on more days than not, for a continuous period of at least two years, before the clinical worsening of osteoarthritis in that joint; — MET
- The ladder and stair climbing from 1966 to 1968, including on warlike service in Vietnam, preceded the worsening on 08 June 1999.
Factor 9(36)(e): for osteoarthritis of a joint of the lower limb only: having osteoporosis before the clinical worsening of osteoarthritis in that joint; — MET
- Bone densitometry on 18 November 1998 showed osteoporosis with a lumbar spine T-score of minus 2.7, after 12 years of prednisolone for rheumatoid arthritis. This preceded the worsening on 08 June 1999.
Factor 9(37)(a): for osteoarthritis of a joint of the lower limb or hand joint only: being overweight for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- He was overweight for more than ten years before the worsening on 08 June 1999.
Factor 9(37)(b): for osteoarthritis of a joint of the lower limb or hand joint only: for males, having a waist circumference exceeding 102 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- His waist circumference exceeded 102 cm for more than ten years before the worsening.
Factor 9(37)(c): for osteoarthritis of a joint of the lower limb or hand joint only: for females, having a waist circumference exceeding 88 centimetres for at least ten years before the clinical worsening of osteoarthritis in that joint; — MET
- His waist circumference exceeded 88 cm for more than ten years before the worsening.
Factor 9(38): for osteoarthritis of a hip or knee joint only, kneeling or squatting for a cumulative period of at least one hour per day, on more days than not, for a continuous period of at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- The year of kneeling and squatting on warlike service in Vietnam from 1966 to 1967 preceded the worsening on 08 June 1999.
Factor 9(39): for osteoarthritis of a knee joint only, having internal derangement of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Internal derangement of both knees preceded the worsening on 08 June 1999.
Factor 9(40): for osteoarthritis of the patello-femoral joint only, having chondromalacia patella before the clinical worsening of osteoarthritis in that joint; — MET
- Chondromalacia patellae of both knees preceded the worsening on 08 June 1999.
Factor 9(41): having a disorder associated with loss of pain sensation or proprioception involving the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- The neuropathy from captivity after warlike service in Korea preceded the worsening on 08 June 1999.
Factor 9(42): having Paget's disease of bone of the affected joint before the clinical worsening of osteoarthritis in that joint; — MET
- Paget's disease around both knees preceded the worsening on 08 June 1999.
Factor 9(43): having acromegaly before the clinical worsening of osteoarthritis in that joint; — MET
- Acromegaly preceded the worsening on 08 June 1999.
Factor 9(44): having joint instability or dislocation of the affected joint, at least one year before the clinical worsening of osteoarthritis in that joint; — MET
- Instability of both knees was present more than one year before the worsening on 08 June 1999.
Factor 9(45): for osteoarthritis of a hip joint only, having femoroacetabular impingement syndrome of the affected joint, before the clinical worsening of osteoarthritis in that joint; — MET
- Bilateral femoroacetabular impingement syndrome preceded the worsening on 08 June 1999.
Factor 9(46): inability to obtain appropriate clinical management for osteoarthritis. — MET
- As a prisoner of war the veteran received no treatment for the septic arthritis of the left knee in 1952 or for frostbite, and on warlike service in Vietnam in 1970 the tibial plateau fracture was fixed in a field hospital without later correction of the malunion. After onset he waited more than four years for orthopaedic care. The osteoarthritis progressed to end-stage disease.
The % contribution of the causes is 100% and significant.
Sequelae
The osteoarthritis of both knees is a sequela of the veteran's accepted conditions: the frostbite, septic arthritis and toe amputations from captivity, the left tibial plateau fracture from Vietnam, and the right patellar fracture, cruciate rupture and meniscal tear from his peacetime service. It has in turn required bilateral total knee replacement and causes chronic pain, reduced mobility and falls.
Unintended Consequence
Met. The septic arthritis of the right knee in August 1977 followed a Defence-arranged arthroscopy, and the osteonecrosis and osteoporosis that contributed to the onset and worsening followed long-term prednisolone. The arthroscopic infection is an unintended consequence of treatment provided by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the VEA).
Inability to Attain Appropriate Medical Management
MET. As a prisoner of war the veteran received no treatment for septic arthritis of the left knee or frostbite. The tibial plateau fracture sustained in Vietnam was fixed in a field hospital and healed in valgus without later correction. After the diagnosis of osteoarthritis in June 1994 he waited more than four years on an orthopaedic waiting list without physiotherapy, bracing or weight management, and funding for surgery was not approved until 2001. The osteoarthritis progressed from grade 2 to grade 4. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), these circumstances amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 06 Sep 1953, Repatriation medical examination, Medical Officer, Military hospital
- 14 Oct 1953, Operation report, Surgeon, Military hospital
- 03 Jun 1963, Outpatient health record, Medical Officer, Garrison health centre
- 14 Sep 1970, Field hospital admission, operation report and X-ray, Surgeon, Vietnam
- 17 May 1976, Outpatient health record and X-ray right knee, Medical Officer, Garrison health centre
- 26 Jul 1977, Arthroscopy report and microbiology, Orthopaedic surgeon
- 10 Mar 1984, Discharge medical examination and trade summary, Medical Officer
- 19 Sep 1990, Nerve conduction studies, Neurologist
- 12 Mar 1991, MRI right knee, Radiologist
- 22 Nov 1992, Rheumatology review and X-rays both knees, Rheumatologist
- 24 Jun 1994, X-rays both knees, Radiologist
- 04 Aug 1997, Arthroscopy report left knee, Orthopaedic surgeon
- 18 Nov 1998, Bone densitometry report, Endocrinologist
- 08 Jun 1999, Orthopaedic consultation and X-rays both knees, Orthopaedic surgeon
- Statement of Principles concerning Osteoarthritis (Balance of Probabilities) No. 62 of 2017, Repatriation Medical Authority
- Statement of Principles concerning Osteoarthritis (Reasonable Hypothesis) No. 61 of 2017, Repatriation Medical Authority
