Last month, I started a series of articles addressing post-traumatic arthritis and iatrogenic conditions. Last month’s article focused on the shoulder, with particular discussion regarding post-traumatic shoulder arthritis and a condition called chondrolysis that can appear in the shoulder after surgery.
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 January 6, 2010, edition titled "Rapid Chondrolysis of the Knee After Anterior Cruciate Ligament Reconstruction." The article, which was 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. The article 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 need to be able to 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, I think 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, The Journal of Arthroscopic and Related Surgery published an article titled "Idiopathic Chondrolysis of the Ankle." The article, written 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.
This series will continue next month with a continued focus on post-traumatic arthritis and iatrogenic conditions. •
Brandon Swartz is a founding partner of Swartz Culleton. His practice focuses on all types of personal injury cases, including wrongful death, medical malpractice, civil rights violations, motor vehicle, premises liability, products liability, trucking accidents and workers’ compensation.