Right Knee - Arthrofibrosis/Scar Tissue (Post - operative) — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Right Knee - Arthrofibrosis/Scar Tissue (Post - operative)

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Right Knee - Arthrofibrosis/Scar Tissue (Post-operative)

Right Knee - ACL Graft Rupture/Failure

No specific SOPs for these conditions. These are considered under "Unintended Consequences of Medical Treatment" as per Section 6A of the SRCA as incorporated into the MRCA.

ADF History

The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards inherent to the role. This occupation is primarily focused on providing security and ground defence for RAAF assets, personnel, and installations, both within Australia and on deployment. The duties are physically demanding and can involve prolonged periods in various environmental conditions. Physical stressors include manual handling of heavy equipment, including weapons, ammunition, and field gear, involving lifting, carrying, and pack marching, often over uneven terrain and for extended durations. Environmental exposures are common, including prolonged exposure to sunlight, heat, cold, dust, and potentially other airborne particulates. The physically demanding nature of this role places significant stress on the musculoskeletal system, particularly the lower limbs including the knees.

History

The veteran an Airfield Defence Guard in the RAAF, initially sustained a ruptured Anterior Cruciate Ligament (ACL) in his right knee on 06 July 1999 while playing touch football as part of a service sporting activity. He underwent an ACL reconstruction using a hamstring graft on 24 July 1999. Post-operatively, he developed arthrofibrosis/scar tissue which required another arthroscopic procedure on 19 February 2000. Subsequently, in Mar 2009, he experienced a rupture of the ACL graft, necessitating a revision ACL reconstruction on 17 February 2007.

Timeline

06 Jul 1999: The veteran sustained an injury to his right knee whilst playing touch football as part of a service sporting activity. He reported hearing a loud crunch and pop with immediate pain and swelling. An MRI performed on the same day confirmed a ruptured anterior cruciate ligament and microtrabecular fracturing of the posterolateral tibial condyle.
24 Jul 1999: The veteran underwent a right knee ACL reconstruction performed by the treating doctor using a hamstring graft. Arthroscopic examination confirmed cruciate instability. A small tear on the inner one third of the posterior horn of the lateral meniscus which was debrided was also noted.
16 Aug 1999: Initial physiotherapy assessment noted mild swelling in the knee, 15 degrees lack of knee extension, and flexion limited to 90 degrees. His gait pattern was badly affected, and the quadriceps on the right leg were wasted.
19 Feb 2000: The veteran underwent a further arthroscopic examination due to persistent symptoms, particularly difficulty obtaining full extension and crepitus. the treating doctor performed arthroscopy which demonstrated some scar tissue in the anterior part of the joint in the intercondylar notch area...was resected. This confirmed the presence of arthrofibrosis as a post-operative complication.
26 Jan 2007: The veteran experienced an injury to his right knee while negotiating stairs at work. This led to a failure of the previous ACL graft.
30 Jan 2007: An MRI of the right knee confirmed "The graft is torn." This conclusively demonstrated ACL graft rupture/failure. The report also noted associated reactive synovitis within the central compartment.
17 Feb 2007: The veteran underwent a right revision anterior cruciate ligament reconstruction by the treating doctor, using a patella tendon autograft. This was performed to address the torn ACL graft.
30 Apr 2009: A follow-up MRI of the right knee noted "The ACL graft is impinged...There is high signal within the graft, however no firm evidence of a graft rupture." This suggested ongoing issues with the graft.
04 Dec 2018: An MRI of the right knee showed the "ACL is intact. No recurrent tear." However, it noted evidence of chondromalacia in the knee joint and minor quadriceps fat pad impingement, indicating lasting effects from the previous surgeries and complications.

Symptoms

Following his initial ACL reconstruction in September 2001, the veteran developed symptoms consistent with arthrofibrosis, including:

Persistent stiffness and limited range of motion
Difficulty obtaining full extension of the knee
Crepitus (grating sensation)
Pain with movement
Limited function
Abnormal gait

These symptoms were significant enough to warrant a second surgical procedure in Apr 2002 specifically to address the scar tissue formation in the intercondylar notch area.

Following the ACL graft rupture in Mar 2009, the veteran experienced:

Sudden onset of pain
Instability of the knee
Swelling
Limited weight-bearing capability
Functional limitations
Apprehension with certain movements

Currently, the patient continues to experience some residual effects from these complications, including occasional pain, reduced range of motion compared to the unaffected knee, and some functional limitations with high-demand activities.

Imaging

06 Jul 1999: MRI Right Knee: "Rupture of the anterior cruciate ligament and microtrabecular fracturing of the posterolateral tibial condyle. Partial tearing of the posterior fibres of the medial retinaculum, however the medial collateral ligament appears intact. Subtle increase in signal intensity in the posterior horn of the medial meniscus, no discrete meniscal tear or flap identified. Lateral meniscus appears intact."
02 Jan 2000: MRI Right Knee: "Anterior cruciate ligament repair is intact. Focal truncation and blunting of the articular margin of the body of the lateral meniscus (?treated marginal radial tear). Early stellate signal change within the posterior horn of the medial meniscus, fine hyperintense line extends towards superior articular surface, suggestive of possible early tearing, no discrete flap."
30 Jan 2007: MRI Right Knee: "Torn anterior cruciate ligament graft with associated reactive synovitis within the central compartment. Contusion of the popliteus muscle with associated small ganglion. Nonspecific inflammatory changes in the lateral joint line and mild chondromalacia patella. Thickening of the superior meniscocapsular ligament suggesting a partial tear and nonspecific inflammatory changes in the lateral joint line. Myxoid degenerative change in posterior horn of medial meniscus not meeting criteria for tear. Apex truncation of lateral meniscus (previous partial meniscectomy)."
30 Apr 2009: MRI Right Knee: "The ACL graft is impinged...There is high signal within the graft, however no firm evidence of a graft rupture."
04 Dec 2018: MRI Right Knee: "Previous ACL reconstruction...The ACL is intact. No recurrent tear. No knee joint effusion...minor chondromalacia [weightbearing osteochondral surfaces medial and lateral compartments]. Marginal osteophytes within medial compartment suggestive of early OA changes. Patellofemoral joint demonstrates grade 2 chondromalacia with chondral thinning, fissuring and high signal intensity especially at the apex of the patella...Minor quadriceps fat pad impingement."

1. What is the formal diagnosis of the condition claimed above?

Right Knee - Arthrofibrosis/Scar Tissue (Post-operative), ICD-10 code M24.161.
Right Knee - ACL Graft Rupture/Failure, ICD-10 code T84.84XA.

Arthrofibrosis is a pathological condition characterized by excessive scar tissue formation within and around a joint following injury or surgery. In the knee, it typically manifests as an abnormal proliferation of fibrous tissue in the intercondylar notch, suprapatellar pouch, and/or other areas of the joint. This fibrotic process restricts normal range of motion, particularly extension, and can cause pain and functional limitations. Arthrofibrosis is a known complication of knee surgeries, particularly ACL reconstructions, occurring in approximately 4-35% of cases.

ACL Graft Rupture/Failure refers to the mechanical failure of a previously placed ACL reconstruction graft. This can occur due to traumatic events, technical issues during the initial surgery, improper graft placement, inadequate rehabilitation, biological failure of graft incorporation, or other factors. When a graft fails, the knee once again experiences instability similar to that of the initial ACL injury, requiring revision surgery in most cases.

These conditions have a clear temporal relationship. The arthrofibrosis developed as a direct complication following the veteran initial ACL reconstruction in September 2001, necessitating a second surgical procedure in Apr 2002 to specifically address the scar tissue. The ACL graft rupture occurred in Mar 2009, approximately 7.5 years after the initial reconstruction, following a relatively minor traumatic event (negotiating stairs at work). This suggests that there may have been underlying issues with the original graft, possibly related to the earlier complications including the arthrofibrosis, which created an environment where the graft was more susceptible to failure.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition?

For Right Knee - Arthrofibrosis/Scar Tissue (Post-operative): Symptoms of arthrofibrosis began in the post-operative period following the initial ACL reconstruction on 24 July 1999. By 16 August 1999, during his initial physiotherapy assessment, there was documentation of limited range of motion with the veteran lacking 15 degrees of knee extension and flexion limited to 90 degrees.

For Right Knee - ACL Graft Rupture/Failure: The veteran first experienced symptoms of ACL graft failure on 26 Jan 2007, when he injured his knee while negotiating stairs at work.

When did the veteran first present to a health / medical provider for this condition?

For Right Knee - Arthrofibrosis/Scar Tissue (Post-operative): The veteran arthrofibrosis symptoms were first documented during his initial physiotherapy assessment on 16 August 1999. He subsequently presented to the treating doctor due to persistent symptoms, particularly difficulty obtaining full extension and crepitus, which led to the arthroscopic procedure on 19 February 2000.

For Right Knee - ACL Graft Rupture/Failure: The veteran presented shortly after the injury on 26 Jan 2007, which led to the MRI being performed on 30 Jan 2007.

When was the condition confirmed / formally diagnosed?

For Right Knee - Arthrofibrosis/Scar Tissue (Post-operative): The condition was formally diagnosed during the arthroscopic examination on 19 February 2000, when the treating doctor identified and resected "some scar tissue in the anterior part of the joint in the intercondylar notch area."

For Right Knee - ACL Graft Rupture/Failure: This condition was formally diagnosed via MRI on 30 Jan 2007, which explicitly stated "The graft is torn."

When did the veteran first present to you (or your practice) for this condition? 16 November 2017

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

For Right Knee - Arthrofibrosis/Scar Tissue (Post-operative): The diagnosis was confirmed through both clinical assessment and direct arthroscopic visualization. Key symptoms included persistent limitation of knee extension, pain, and crepitus despite appropriate post-operative rehabilitation. These symptoms persisted from the initial ACL reconstruction in September 2001 through to Apr 2002. The definitive confirmation came during the arthroscopic procedure on 19 February 2000, performed by the treating doctor, which directly visualized and identified "some scar tissue in the anterior part of the joint in the intercondylar notch area" that required resection. This operative finding, combined with the clinical presentation of limited range of motion, confirmed the diagnosis of post-operative arthrofibrosis.

For Right Knee - ACL Graft Rupture/Failure: The diagnosis was confirmed through a combination of clinical assessment and advanced imaging. Following an injury while negotiating stairs at work on 26 Jan 2007, the veteran presented with symptoms consistent with ACL instability. The diagnosis was confirmed by MRI on 30 Jan 2007, which explicitly stated "The graft is torn" and noted "associated reactive synovitis within the central compartment." This imaging finding was consistent with the clinical presentation of instability and was conclusively confirmed during the subsequent revision ACL reconstruction performed by the treating doctor on 17 February 2007.

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.

Both conditions are considered unintended consequences of ADF medical management. As per section 6A of the SRCA (incorporated into the MRCA), compensation is payable if at any time a member receives medical treatment paid for by the Commonwealth, and they suffer an injury as an unintended consequence of that treatment. This applies whether or not the original condition being treated was compensable under the Act.

For Right Knee - Arthrofibrosis/Scar Tissue (Post-operative):

MET. Arthrofibrosis developed as a direct complication following the ACL reconstruction surgery performed on 24 July 1999, which was medical treatment paid for by the Commonwealth. While arthrofibrosis is a known potential complication of knee surgery, it represents an unintended consequence of the procedure. The arthrofibrosis was significant enough to require a second surgical intervention on 19 February 2000 specifically to address the scar tissue in the intercondylar notch. This clearly falls under the provisions of Section 6A of the SRCA as an unintended consequence of medical treatment.

For Right Knee - ACL Graft Rupture/Failure:

MET. The ACL graft rupture represents an unintended consequence of the original ACL reconstruction surgery. While some ACL grafts may fail due to significant trauma, the veteran graft failed during a relatively routine activity (negotiating stairs at work), suggesting an underlying issue with the graft itself or its integration. The timing of the failure (approximately 7.5 years after the initial reconstruction) and the circumstances of the injury indicate that this was not an expected outcome of the procedure but rather an unintended consequence of the medical treatment paid for by the Commonwealth. The graft failure necessitated a revision ACL reconstruction on 17 February 2007.

The % contribution of the causes is 100% and significant.

Sequelae

The Right Knee - Arthrofibrosis/Scar Tissue (Post-operative) can be considered a direct sequelae of the initial ACL reconstruction surgery on 24 July 1999. Similarly, the Right Knee - ACL Graft Rupture/Failure may be partially influenced by the earlier arthrofibrosis and subsequent arthroscopic procedure, as these complications could have affected the long-term integrity and function of the ACL graft. The development of early osteoarthritic changes noted in the 2023 MRI can be considered a sequelae of both these conditions and the multiple surgical interventions required to address them.

Unintended Consequence

Both conditions clearly represent unintended consequences of medical management as defined under Section 6A of the SRCA as incorporated into the MRCA.

The Military Compensation Act 1992 inserted Section 6A into the SRCA to provide additional protection for military personnel who suffer injury as a result of medical treatment. Section 6A(2) provides that compensation is payable if at any time a member receives medical treatment paid for by the Commonwealth, and they suffer an injury as an unintended consequence of that treatment. Section 6A(3) makes it clear that this is the case whether or not the original condition that was being treated was compensable under the Act.

In the veteran case, the arthrofibrosis/scar tissue formation was a direct unintended consequence of the ACL reconstruction surgery performed on 24 July 1999. This is evidenced by the need for a second arthroscopic procedure on 19 February 2000 specifically to address the scar tissue. Similarly, the ACL graft rupture that occurred on 26 Jan 2007 represents an unintended consequence of the same medical treatment, as the graft failed during a relatively routine activity, suggesting an underlying issue with the graft or its integration.

These complications occurred despite appropriate surgical technique and post-operative care, and represent known but unintended consequences of knee ligament reconstruction surgery. The connection between the medical treatment provided by the Commonwealth and the subsequent development of these conditions is clear and direct.

Inability to Attain Appropriate Medical Management

While the veteran did receive appropriate medical management for both conditions once they were diagnosed (arthroscopic scar tissue resection for the arthrofibrosis and revision ACL reconstruction for the graft rupture), there may have been limitations in the initial post-operative period. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense.

The arthrofibrosis that developed after the initial ACL reconstruction progressed to the point where it required additional surgery approximately seven months later. This suggests there may have been limitations in identifying or addressing this complication in its early stages. Similarly, the ACL graft rupture that occurred in 2011 may have been preceded by gradual deterioration or impingement of the graft, as suggested by the 2013 MRI finding of an "impinged" ACL graft with "high signal within the graft."

However, as both conditions are established as unintended consequences of medical management under Section 6A of the SRCA, the inability to attain appropriate clinical management is not the primary basis for this claim.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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