BVA9504175 DOCKET NO. 91-14 908 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a right knee disability as being secondary to a service connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Susan S. Toth, Associate Counsel INTRODUCTION The veteran had active service from August 1968 to November 1971. This matter arises from a rating decision of August 1990, whereby the Regional Office (RO) denied the veteran's claim for entitlement to service connection for a right knee disability. The Board of Veterans' Appeals (Board) remanded the case in June 1991 for further development of the evidence. At this time, the case is ready for appellate disposition. In the veteran's substantive appeal of December 1990, he appeared to raise the issues of entitlement to increased evaluations for his service-connected disabilities. Since these issues were not certified for appeal and are not related to the certified issue, they are referred to the RO for appropriate consideration. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in effect, that a service-connected disability of the right femur caused a disability of the right knee. Specifically, he argues that the service-connected residuals of a compound comminuted fracture to the midshaft and neck of the right femur, to include shortening of the extremity and a varus deformity, eventually resulted in disability of the right knee. 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 evidence supports the veteran's claim for entitlement to service connection for a disability of the right knee. FINDINGS OF FACT 1. Attempts to obtain all relevant evidence necessary for an equitable disposition of the appeal have been made by the RO. 2. A disability of the right knee is etiologically related to a service-connected disability. CONCLUSION OF LAW Disability of the right knee is proximately due to or the result of a service-connected disability. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran satisfied the threshold requirement of presenting a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a). That is, he set forth a claim which was plausible. The Board is also satisfied that all relevant evidence has been properly developed, and that no further assistance is required to comply with the Department of Veterans Affairs' (VA) duty to assist as mandated by 38 U.S.C.A. § 5107(a). The facts which are relevant to the determination on appeal may be briefly summarized. In October 1970, while the veteran was in service, he was involved in a motorcycle accident. Injuries sustained included compound comminuted fractures of the right midshaft and femoral neck. An open reduction was performed on the right hip femoral neck fracture and skeletal traction was utilized to reduce the mid-femur fracture. X-ray results dated shortly thereafter revealed that there was considerable lateral displacement of the distal fractured part of the femoral shaft. In March 1971, measurements of the lower extremities revealed that the right leg was 1 3/4" shorter than the left. In April 1971, the surgical pin was removed from the right femoral neck and malunion of the femoral head in the varus position was noted. In September 1991, William J. Mullins, M.D., provided a statement wherein he indicated that the veteran's right leg felt weak and tended to give way when his weight was on the leg. He also observed that the veteran's right thigh was bowed and atrophied in comparison to the left thigh. The hip fracture was healed with malunion, a coxa vara deformity and a leg length discrepancy. The Physical Evaluation Board recommended that the veteran be permanently retired in September 1971, due to malunion of the right femur with marked hip disability and a left shoulder condition. VA examination report dated in May 1972 contained diagnoses of healed fracture with varus deformity of the right femur with no atrophy and shortening of the right leg. Gait was normal when utilizing the built up shoe on the right; however, without the built up shoe, the veteran was noted to limp. Upon VA examination of November 1984, the diagnosis was seven degree varus deformity of the right knee with stable ligaments. An operative report dated in September 1989 from Holston Valley Hospital contained a postoperative diagnosis of torn medial cartilage of the right knee with early erosion of the medial femoral condyle tibial plateau. An arthroscopy was performed. A VA orthopedic clinic note dated in December 1990 contained a medical doctor's opinion which clearly supports the veteran's secondary service-connection claim. This doctor opined that the problems in the veteran's right leg and knee were a direct consequence of the injuries he sustained while in the Army in 1972. He apparently based his opinion on the following notations which were contained in the progress notes. The right femur was noted to be healed status post surgery for hip and femoral neck fracture, however, the right leg was 1 1/2" shorter than the left. The veteran compensated through the use of a built up shoe. The veteran reported that he was injured in a motorcycle accident while he was in the Army in 1972. In February 1989, the veteran began to have pain in the right knee without antecedent trauma. A diagnosis of traumatic arthritis with degenerated meniscus was made. A right knee arthroscopy was performed in September 1989. The veteran reported considerable improvement in the right knee but the symptoms had not completely disappeared. Physical examination revealed a 1 1/2" shortening of the right leg, with marked impairment of right hip range of motion. Movement of the right knee caused pain and there was considerable crepitus in the joint. X-ray results indicated deformity of femoral neck and mild degenerative arthritis with some narrowing of the joint space with osteophyte formation. X-ray result of the right knee revealed a prominent tibial spine and flattening of the medial and lateral femoral condyles. A July 1971 deposition of Dr. Hess, who originally treated the veteran after the motorcycle accident, is of record. He indicated that the femur healed in malunion with bowing. He expected the atrophy of the muscles to improve but not correct itself, such that the veteran would have permanent weakness about the knee. The veteran had a waddling gait, bowlegged appearance, muscle atrophy and shortening of the leg which would definitely increase his fatigability. He also had a deformity which had the potential for causing him aggravating discomfort of the right lower extremity. Outpatient treatment records dated from August 1989 to March 1993 were received from R. T. Strang, Jr., M.D., who performed the 1989 arthroscopy. A note of August 1989 indicated that the veteran did not remember an acute injury occurring which would account for the recent discomfort in the right knee. Dr. Strang provided the following opinion in March 1993, "I do feel in all probability the changes we see in [the veteran's] right knee are directly related to the position of his right femur. Ultimately he will develop more and more arthritis in the knee secondary to the femoral position." Upon physical examination during the previous month, the diagnosis provided was status post fractured femur with mild varus deformity of the hip and femoral shaft. He indicated that the veteran had developed mild osteoarthritic changes in the medial compartment of the right knee which were directly related to his femoral position. He felt that the arthritic changes were accentuated and aggravated by the varus position. The applicable criteria provide that service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Two medical doctors have provided their uncontradicted opinions to the effect that the veteran's right knee disability is related to the service-connected disability. The VA doctor based his opinion upon the accurate history provided by the veteran, the physical examination conducted and X-ray reports. Accordingly, the physician's opinion is highly probative of the disputed issue. Also of record is the confirmatory opinion of Dr. Strang. He based his opinion on his own physical examination of the veteran's right lower extremity and on the veteran's statement that there was no injury which would otherwise account for the right knee disability. It should also be noted that Dr. Strang limits his practice to orthopedic surgery, therefore, he presumably possesses a certain amount of skill in determining the etiology of orthopedic disabilities. Since there is no evidence of record which would indicate that the veteran sustained an interceding injury to the right knee, Dr. Strang's opinion is uncontradicted. At this point, the Board notes that the probative value of medical opinion evidence is based upon the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet.App. 467, 471 (1993). These two medical opinions clearly constitute evidence which supports the veteran's claim for service connection for a right knee disability on a secondary basis. The other medical evidence of record does not contradict the supporting opinions, therefore, their probative value is undiminished. Accordingly, the Board finds that there is an etiological relationship between the service-connected disability of the right femur and the current disability of the right knee. ORDER Service connection for a right knee disability on a secondary basis is granted. C. W. SYMANSKI 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.