BVA9500859 DOCKET NO. 93-05 619 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for post operative residuals of avascular necrosis of the left hip. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from September 1970 until May 1976. This appeal comes before the Board of Veterans' Appeals (the Board) from rating decisions of the St. Louis, Missouri Regional Office (RO) denying service connection for postoperative residuals of a left hip disorder. CONTENTIONS OF APPELLANT ON APPEAL The appellant asserts that he now has left hip avascular necrosis on account of his military service. He contends that he either sustained direct trauma to his left hip as the result of being thrown from a jeep during active duty, or that left hip disability is due to biomechanical deficiency occasioned by the multiple surgeries he has required for his service-connected left knee disorder. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against avascular necrosis of the left hip on either a direct or secondary basis. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the RO. 2. Trauma to the left hip was not demonstrated in service; a left hip disability was not indicated until many years after service discharge. 3. Avascular necrosis of the left hip is not causally related to the service-connected post operative residuals of left knee meniscectomy. CONCLUSION OF LAW 1. Avascular necrosis of the left hip was not incurred in or aggravated by service and is not proximately due to or the result of the service-connected post operative residuals of left knee meniscectomy. 38 U.S.C.A. § § 1110, 1131, 5107 (West 1991); 38 C.F.R. § § 3.303, 3.310, 4.58 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim has been determined to be well-grounded within the meaning of 38 U.S.C.A. 5107(a). That is, he is found to have presented a claim which is plausible if the Board considers 38 C.F.R. § 4.58 as applicable to the veteran's case. We are also satisfied that all relevant facts have been properly developed. No further assistance to the appellant is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The service medical records show that the veteran entered service with a history of chondromalacia patella and developed internal derangement of the left knee during basic training in 1970. It was recorded that knee symptomatology recurred in 1971 during the course of his duties as a heavy vehicle driver while in Vietnam, and that he was treated for continuing symptoms of pain and instability. A medical board report dated in December 1975 detailing the history of the left knee disorder noted that the veteran himself reported a history of knee trauma in 1971 as the result of being thrown from his vehicle after it was blown up in Vietnam. It was indicated that he underwent left medial meniscectomy in February 1972, followed by medial collateral ligament reconstruction in October 1972 and reconstruction of the posterolateral ligament complex in September 1975. He was subsequently discharged from service for disabilities which included posterolateral instability, mild, with complete laxity of the anterior cruciate ligament of the left knee. On initial post service Department of Veterans Affairs (VA) examination in October 1976, the veteran had complaints of locking, swelling and instability of the left knee. He was observed to walk with a limp, and some anterior cruciate laxity was elicited upon examination. By rating action dated in October 1976, service connection for post operative residuals of medial meniscectomy, left knee, was granted and a 20 percent disability evaluation was assigned. The veteran sought medical attention from a private physician in February 1977 who found good anterior, posterior and lateral stability and no evidence of blocking or locking. It was, however, reported that there was evidence of hypertrophic arthritic changes of the left knee on X-ray. Significant activity restrictions were delineated at that time. The clinical record reflects no further treatment for the left knee until June 1987 when the veteran was admitted to a VA facility after a twisting injury with subsequent development of a large effusion. Left knee pain and instability persisted and he underwent arthroscopic examination in September 1987 which showed a deficient anterior cruciate. Examination under anesthesia disclosed a grossly unstable left knee with grossly positive lateral pivot shift, Lachman's and anterior drawer signs. The veteran underwent left anterior cruciate ligament reconstruction using patellar tendon, bone-tendon-bone, in October 1987. Upon orthopedic consultation in November 1987, he complained of spontaneous spasm of the lower left extremity from the mid thigh to the foot and indicated that he had had increased numbness following the surgical procedure. Examination findings on that occasion disclosed active flexion/extension of the hip of 12º/5º as well as left knee flexion/extension of 30º/60º. The left ankle jerk was absent. When he was seen in physical therapy consultation in 12/87, hip motions were noted to be poor to fair. The veteran was subsequently admitted to VA nursing home care for continued rehabilitative therapy. In January 1988, it was felt that a Don-Joy device for permanent bracing was indicated for an "ACL" deficient knee secondary to reconstruction. The veteran continued to complain of instability affecting the left knee and was noted to be ambulatory only with the aid of a wheel chair and crutches. In March 1988, it was recorded that there had been only slow progress during the 5 months post ACL reconstruction. In June 1988, it was observed that there was marked left thigh atrophy with 3+ Lachman's and 2+ drawer signs. X-rays revealed that his surgical screws were in place and that there were early degenerative changes. The veteran was admitted to a VA hospital in August 1989 with complaints of leg pain and dislocation. He underwent arthroscopy and repair via bone-tendon-bone allograft of the left anterior cruciate ligament. It was reported that he was discharged in good condition and was independent with ambulation. Subsequent VA clinical records in October 1989 indicate that he fell down 5 steps and twisted the left knee with resultant swelling. On subsequent follow-up that same month, an assessment of "failed ACL reconstruction" was recorded. The veteran was afforded a VA orthopedic examination in September 1990 where it was noted that he had been on crutches for the past 3 to 4 years. He indicated on that occasion that magnetic resonance imaging (MRI) had been performed two weeks before showing deterioration of the left hip for which total hip replacement had been recommended. He stated that at the same time that he had injured his knee in service as the result of being thrown from his vehicle in Vietnam, his hip had also been dislocated and had been reset, but that it had continued to give him problems throughout the ensuing years. MRI study of the left hip in November 1990 confirmed a diagnosis of left femoral head avascular necrosis. The veteran was admitted to a VA hospital in January 1991 and underwent left total hip replacement. He related at that time that he had been experiencing severe pain in the left hip for the past 5 years. The veteran testified upon personal hearing in March 1992 that he had dislocated his left hip at the same time that he had injured his left knee in service and was treated and had had X-rays taken at that time. He related that he was air evacuated from Vietnam to Japan where the hip was reset. It was reported that following his return to the continental United States, he was told by an orthopedic surgeon that he would eventually require surgery. The appellant stated that he continued to have problems throughout the years with the left hip but that doctors kept telling him that he was too young to have an operation. He also indicated that an altered gait occasioned by the service-connected left knee disability caused his left hip to shift to the left and that this had also been the case since the initial injury. Additional testimony was elicited to the effect that the veteran believed his service medical records to be incomplete because no hip injury or treatment in Japan was shown in the clinical data from that time frame. The veteran was afforded a VA compensation and pension examination in July 1992 where he reiterated a history of injury and treatment of the left hip after being thrown from a vehicle in 1971 in Vietnam. Upon examination, it was observed that there was exaggerated angulation in walking with his knee brace and crutch, causing the left hip to go out laterally. It was noted that an X-ray of the left hip disclosed a total hip replacement which was in the normal position without evidence of fracture, loosening or infection. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may legitimately be questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303. The Board has carefully considered the veteran's contentions, statements presented by his representative on his behalf, as well as his testimony on appeal as to trauma to the left hip in service. While it is now claimed that active duty medical data are incomplete and do not show treatment relating to injury or treatment for a dislocated left hip, it should be pointed out that the current service record does consist of substantial clinical entries and encompasses a span of time from service entrance until discharge in 1975. Consequently, if the veteran had sustained injury to his hip in 1972 and had sought treatment for persistent complaints, as claimed, the post trauma record would in all likelihood refer to and be reflective of continuing residuals. However, it is demonstrated that the service medical records are completely silent for any reference to any hip injury, complaints or treatment during the period of active duty. The veteran has testified that he hurt both his left hip and left knee in the same incident in Vietnam. It is shown that the service medical record is replete with notations with respect to the left knee but no mention whatever is made of his left hip. It should be added that when the appellant initially filed a claim for service connection in 1976, he only indicated that he had injured the left leg and had had surgery therefor in service. The postservice record also does not reflect evidence of a left hip injury in service or history of a left hip problem until recently. This is inconsistent with the veteran's testimony that he had a hip problem for as long as he had had left knee disability. The first clinical documentation of any left hip symptomatology appears in the record in 1987. This is 11 years or so after his discharge from service. Without a showing that he actually sustained trauma to the left hip in service and no evidence of continuing residuals, there is no tenable basis to find that the veteran's current left hip impairment began in service. 38 U.S.C.A. § § 110, 1131. The appellant argues in the alternative that an altered gait pattern occasioned by his service-connected left knee disorder imposed biomechanical defects of the left lower extremity that engendered left hip avascular necrosis. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § § 3.310(a). 38 C.F.R. § § 4.58 permits service connection of arthritis a joint directly subject to strain as a result of a service connected disability. The VA examiner who saw the veteran for compensation and pension purposes in July 1992 was specifically requested to provide an opinion as to any etiological relationship between the service- connected postoperative left knee and the subsequent development of avascular necrosis. In an addendum dated in August 1992 to her initial report of the previous month, she stated that she had reviewed the record with the chief resident of the orthopedic department and had not found any notation in the service clinical data regarding a hip dislocation. It was added that there had been radiological study of the left hip in 1988 which revealed minimal arthritic changes but no evidence of reset fracture or bone destruction. She also stated that there had been an examination in March 1988 at which the veteran reported he was able to perform straight leg raising. The VA examiner wrote that with the findings obtained it could be concluded that the veteran did not develop aseptic necrosis secondary to trauma in 1971. She unequivocally stated that his knee problem could not cause the avascular necrosis and that the origins of such were as yet unknown. She noted that the arthritic changes could have been due to the altered biomechanics incident to the knee problem and she opined that they might have "aggravated" the symptoms of avascular necrosis. However, the examiner did not suggest, either expressly or impliedly, that the minimal arthritic changes caused avascular necrosis or was the cause for the hip replacement procedure. It is well-established that the appellant as a layperson is untrained in the field of medicine and is not competent to provide a medical opinion. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The record contains no medical support that his avascular necrosis is causally related to a service-connected disorder or disorder associated with service. The Board must find under these circumstances that there is no probative evidence of record to find that the veteran's aseptic or avascular necrosis is directly or secondarily related to service and service connection for such must be denied. The Board has also considered the doctrine of benefit of the doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, we are unable to identify a reasonable basis for a grant of the benefit sought on appeal. ORDER Service connection for avascular necrosis of the left hip is denied. BRUCE KANNEE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.