Medical literature defines arthritis as inflammation of a joint. While the most common cause of arthritis is wearing out of joint surface cartilage (osteoarthritis), plaintiffs attorneys need to be aware that arthritis can be a post-traumatic condition and the most valuable, complicated and disputed part of a claim.
Post-traumatic arthritis is caused by the wearing out of a joint that has had any kind of physical injury. The injury could be from a motor-vehicle accident, a fall or any other source of physical trauma, such as repetitive stresses at work. Such injuries can damage the cartilage and/or the bone, changing the mechanics of the joint and making it wear out more quickly. In other words, the arthritic process is accelerated or hastened by the injury.
In addition, it may not just be the injury itself that causes the acceleration or hastening of the arthritic process — it could be the treatment required for the injury. In the setting of post-traumatic arthritis, iatrogenesis is an inadvertent adverse side effect or complication resulting from medical treatment.
We will start with post-traumatic shoulder arthritis. Shoulder arthritis is a clinical condition in which the joint that connects the ball of the arm bone (humeral head) to the shoulder blade socket (glenoid) has damaged or worn out cartilage. Normally, the ends of the bone are covered with articular cartilage, a surface so smooth that the friction at the joint is less than that of a rollerblade to laminated hardwood. In arthritis, this cartilage is progressively lost, exposing the bone beneath.
Shoulder arthritis is characterized by pain, stiffness and loss of function and often by a grinding on shoulder motion. From a personal injury standpoint, shoulder arthritis is important to establish because it is accompanied by lifelong pain and medical treatment and may ultimately require a shoulder replacement.
Post-traumatic shoulder arthritis often happens after a significant trauma is sustained by the shoulder joint, ruining the cartilage. As indicated earlier, this could be the result of a car accident, a fall or repeated trauma. A plaintiffs attorney can help establish the existence of post-traumatic shoulder arthritis by showing a lack of prior medical care, a lack of existence of the arthritis in early X-rays, a lack of existence of the arthritis in early MRI studies and, maybe most obviously, the lack of shoulder arthritis in intraoperative photographs and intraoperative observation by the shoulder surgeon.
If any of these tests does not show arthritis at the time of the injury and then it is detectable during the process, we know it was post-traumatic. This is necessarily true because arthritis that is degenerative would not appear that quickly. In a separate argument that can be made, some arthritis may have been present at the beginning, but it was worsened at an abnormal or accelerated rate, the plaintiffs attorney can argue, which tells us it is related to the trauma.
In looking for valid opportunities to make either of these arguments, plaintiffs attorneys also need to be aware not to confuse AC joint arthritis and glenohumeral joint arthritis. These are distinct conditions and the presence of one does not mean the other is present. Therefore, just because someone had AC joint arthritis prior to the injury does not mean he or she had glenohumeral joint arthritis. If that glenohumeral joint arthritis appears after the trauma, it is accident-related and vice versa.
Plaintiffs attorneys need to be aware that it is not just the trauma itself that can cause post-traumatic shoulder arthritis, but also the treatment. As all plaintiffs attorneys know, shoulder injuries often require surgery. That surgery itself is a separate and distinct trauma. On cross-examination of a defense medical witness, plaintiffs attorneys should also emphasize this point.
With respect to iatrogenic shoulder arthritis, shoulder specialists are currently studying a condition called chondrolysis, rapid destruction of cartilage. Chondrolysis is an unavoidable iatrogenic condition. Chondrolysis is a catastrophic injury that has only been studied extensively in the shoulder since the 1990s. The early theory of those medical experts studying the condition is that new procedures that have been developed have been accompanied by certain side effects.
In any instance where a plaintiffs attorney has a client with persistent complaints of pain after a shoulder surgery, the attorney needs to be aware of the possibility of this condition. The condition is wonderfully explained at www.chondrolysis.com. The website emphasizes that chondrolysis is a devastating condition because the articular cartilage does not repair itself well, and there are presently only two alternatives for a person with chondrolysis in the shoulder: a lifetime of pain and pain medications, or a shoulder replacement.
Chondrolysis is not limited to the shoulder — it can exist in any joint. The Journal of Bone and Joint Surgery published an article in its Jan. 6, 2010, edition titled “Rapid Chondrolysis of the Knee After Anterior Cruciate Ligament Reconstruction.” The article, written by Dr. Mark A. Slabaugh, has obvious implications in the personal injury setting. The name of the article alone should trigger the relationship to personal injuries, as anterior cruciate ligament (ACL) reconstruction is common post-trauma.
The article describes chondrolysis as a devastating complication of ACL reconstruction where the patient experiences “rapid and extensive destruction of the articular cartilage” in the knee, usually within six months of the surgical reconstruction. Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Dr. Slabaugh stresses that “associated with this destruction is an equally large inflammatory response that causes adhesions in the knee.” There is no known cause for the chondrolysis, though it is accepted that something happens to the joint during the surgical process that causes the condition.
It is critical that plaintiffs attorneys be aware of this condition. Many times, personal injury defendants will defend claims on the grounds that there is an unrelated arthritic condition that existed coincidental to the trauma. Plaintiffs attorneys must understand the terminology to combat this assertion. Terms that may be used by the physicians to describe this condition include arthrofibrosis and osteoarthritis.
In fact, rarely will the term chondrolysis actually appear in the medical notes, partially because of the surgeon’s fear of documenting a condition that came about as a result of the treatment and may even be caused by the surgeon’s unfamiliarity with the current medical literature. Plaintiffs attorneys need to understand that the timing of the onset of these conditions is crucial and that if the timing is after ACL reconstruction or any other type of knee surgery, including meniscus surgery, it is a direct result of the surgery and therefore a direct result of the original injury.
In order to form an effective cross-examination on the issue, plaintiffs attorneys should also be aware of the symptoms of chondrolysis after surgery. According to the medical literature, the patient will usually present with a clicking in the knee and associated swelling, as well as unusually high levels of pain. It is critical when your client makes these complaints that you have the client insist on a post-surgical MRI.
Chondrolysis of the knee adds a significant component to any personal injury claim and many times will result in additional surgeries. According to the American Academy of Orthopedic Surgeons’ website, the most common procedures for cartilage restoration include microfracture surgery, drilling, abrasion arthroplasty, autologous chondrocyte implantation, osteochondral autograft transplantation and osteochondral allograft transplantation.
Aside from the article discussed above, plaintiffs attorneys need to be aware that other orthopedic surgeons have published similar articles concerning the ankle and hip joint in other peer-reviewed journals.
For instance, in February 2005, TheJournal of Arthroscopic and Related Surgery published an article titled “Idiopathic Chondrolysis of the Ankle.” The article, by Dr. J.A. Bojescul, chronicles the rapid appearance of chondrolysis after a routine arthroscopic procedure and after reconstructive ankle surgery. The article stresses the progression of pain over time and the worsening of symptoms over time. This is very important for plaintiffs attorneys to understand. Many times, even the treating physician will discount increased complaints of pain by a plaintiff after a surgery, commonly stating, “I cannot account for the patient’s complaint of pain.”
Plaintiffs attorneys need to understand the potential biases of the treating surgeon and be ready to refer their clients for a qualified second opinion in the event they have persistent credible complaints of pain after surgery.
Plaintiffs attorneys also need to understand that it is not just surgical procedures that can bring about the condition of chondrolysis.
As recently as February, Tel Aviv University’s medical school reported a case study where chondrolysis came about as a result of an MR arthrography of the hip. The recent nature of this case report illustrates that orthopedic medicine is just now coming to really recognize and study the existence of chondrolysis. It is crucial that plaintiffs attorneys follow the development of this medical literature in order to effectively represent injured clients.
According to statistics published by the Cleveland Clinic, post-traumatic knee, wrist, hip and ankle arthritis affect more than 6 million people per year in the United States. According to the American Academy of Osteopathic Surgeons, at least 10 to 15 percent of all traumatic joint injuries will result in post-traumatic arthritis.
Understanding how injuries can lead to arthritis is critical to litigating personal injury claims, not only because of the pain and suffering caused by post-traumatic arthritis, but also because the treatment required for post-traumatic arthritis can be expensive and lifelong and is many times the most significant component of a claim for money damages. For instance, treatment for osteoarthritis includes massage therapy, physical therapy, prescription medication, injection therapy, arthroscopic surgery (surgical debridement), arthrodesis (joint fusion) and even arthroplasty (joint replacement).
It is well accepted in medical literature that arthritis can develop within months after a traumatic injury or could take years to develop. It can develop either through improper healing of a fractured bone or a fracture that healed properly but just over a prolonged period of time, causing atrophy and loss of function.
It can also develop because of a ligament injury that allows the bone to shift abnormally, causing undue stress on the cartilage of the adjacent joint. And, of course, it can develop because of direct trauma to the cartilage. While most defense medical examiners will concede that post-traumatic arthritis can develop after a trauma, many will refuse to acknowledge either the presence or significance of the post-traumatic arthritis. In other words, they will assert the arthritis has developed coincidental to the trauma or it doesn’t exist.
In terms of the diagnosis, post-traumatic arthritis is generally diagnosed through X-ray testing, CT testing, MRI testing and sometimes blood testing. However, when cross-examining a defense medical examiner on this subject, the plaintiff’s attorney needs to be aware that the diagnostic testing that demonstrates the arthritis will usually not specify whether it is post-traumatic arthritis, osteoarthritis or rheumatoid arthritis. The characterization of the particular type of arthritis is a clinical characterization based on the history of the injury and past medical records.•