Although it is not common, I occasionally see patients who have had a work related injury to their knee where the underlying arthritic changes are so severe that the only appropriate treatment would be a knee replacement. The question then arises as to whether the workers’ compensation insurer is liable for the cost of a knee replacement.
The first issue to address is whether the symptoms are indeed bad enough to warrant a knee replacement, regardless of medicolegal issues.
In deciding whether a knee replacement is appropriate, we look at how prolonged the symptoms have been. Arthritic symptoms do fluctuate in severity and I make people aware of the concept of “flare ups”. A flare up of symptoms can last weeks or months and it is not appropriate to make a decision about knee replacement surgery during a flare up. We need a good idea of what the baseline symptoms are over time. As a ballpark figure, I would say that we should be looking back at symptoms over the last six months at least.
We would also expect that the patient had exhausted all non-operative treatment. That includes regular Panadol, anti-inflammatories, weight loss and low impact exercise. Often we will have tried cortisone or lubricant injections, supportive knee braces and orthotics. There are some alternative therapies that are applicable.
I tell people that they are ready for a knee replacement if they are at the point where they wake up thinking about their sore knee, they go to bed thinking about their sore knee, and it is a major factor in every decision that they make during the day. If you are thinking about doing something and you have to run it through the filter of “will my knee cope with this?” then you are approaching the point of knee replacement. Another assessment is to look at what we call activities of daily living. If you cannot go to the shop for groceries and push the trolley around for an hour without stopping to rest regularly and being exhausted at the end of it, then again you are approaching the point of knee replacement.
Bear in mind what activities are feasible following a knee replacement. It is appropriate for walking, bowls, golf, and social doubles tennis. It does not improve your activity level overall. Knee replacement is an operation for pain relief.
Getting back to the question of liability for a knee replacement through the workers’ compensation scheme, I would reiterate the point that doctors do not answer liability issues, insurance companies do. The legal terminology is that the work injury must be a “significant” contributing factor. It does not need to be the only contributing factor. If the arthritic symptoms prior to the work injury were non-existent or of a very low grade, then that would strongly support the case for a knee replacement arising from a work injury. Another factor that might constitute a significant contribution would be the force involved in the work injury. A “high energy” injury is more likely to be a significant contributor than a low grade twisting injury. An MRI scan done at the time of injury might show factors consistent with high force such as bone bruising or additional soft tissue injuries.
Knee replacement may be one of the treatment options for severe work related knee injuries, but it should definitely be seen as a last resort.
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Dr David Colvin consults at:
Western Orthopaedic Clinic Suite 213,
25 McCourt Street,
Subiaco WA 6008 (Perth)
- These rooms are part of St John of God Subiaco Hospital.
- Parking is available on site.
Dr David Colvin operates at:
St John of God Subiaco Hospital
Subiaco WA 6008 (Perth)