BVA9501266 DOCKET NO. 92-55 180 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased evaluation for total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee), currently assigned a 30 percent disability rating. 2. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. L. Kennedy, Counsel INTRODUCTION The veteran served on active duty from May 1942 to September 1945. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 1990 rating decision of the Philadelphia, Pennsylvania, Department of Veterans Affairs (VA) Regional Office (RO). The notice of disagreement was received in August 1990. A statement of the case was issued in January 1991. The substantive appeal was received in March 1991. The Board remanded the case to the RO in February 1993 for additional development. It appears from the record that the veteran is raising the issue of a total rating based on individual unemployability. That issue is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that an increased evaluation of 100 percent is warranted for his service-connected right knee disorder. He maintains that the evidence reflects an altered gait for many years due to pain, swelling, instability, and degeneration of the right knee joint, and also reflects increasing problems with ambulation over the years due solely to his service-connected disorder. He contends that not only has he been wheelchair bound due to the severity of his right knee disorder, but he has been in receipt of special monthly aid and attendance benefits for many years, also due solely to that disability. He argues that the evidence shows a severe right knee disability for years requiring ongoing medical treatment including a total right knee replacement, and the use of a wheelchair, chair glide, and knee brace for years preceding his recent cerebral vascular accident. The veteran argues that the evidence recently presented in support of reopening his claim of entitlement to service connection for a left knee disability is not only new and material, but also sufficient to grant that benefit sought on appeal particularly when that evidence is considered in light of the entire record. He maintains that he developed a left knee disability as a direct result of his service-connected right knee disorder. He asserts that the severity of the joint degeneration associated with the service-connected right knee disorder required him to compensate by altering his gait which resulted in an imbalance in the left knee and resulting disability in that joint, which should be service connected. 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 a 60 percent evaluation for total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee) is warranted; and that new and material evidence has been submitted to reopen the claim of entitlement to service connection for a left knee disorder, and to establish entitlement to service connection for a left knee disorder. FINDINGS OF FACT 1. Service connection is in effect for total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee). 2. The veteran's service-connected total right knee replacement for arthritis is manifested by chronic residuals consisting of weakness in that extremity. 3. The disability picture presented is not so unusual as to render impractical the regular schedular standards. 4. A decision of the Board in May 1963, which is the last final denial based on the entire record in this case, denied service connection for a left knee disorder. 5. In support of the request to reopen the claim for service connection for a left knee disorder, the Board has considered private and VA medical records including a private medical statement indicating that the premature degeneration of the left knee was the direct result of the veteran's service-connected right knee disorder. 6. Some of the recently presented evidence reviewed and submitted since May 1963 is not redundant and cumulative, is relevant and probative, and presents a reasonable possibility that the outcome could be changed based on a review of all of the evidence of record. 7. All of the evidence of record, both old and new, establishes a direct causal relationship between the veteran's left knee disability and his service-connected right knee disorder. CONCLUSION OF LAW 1. The schedular criteria for a 60 percent evaluation for a total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee) are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.7, 4.71a, Diagnostic Code 5055 (1993). 2. The criteria for a rating in excess of 60 percent for total right knee replacement on an extraschedular basis are not met. 38 C.F.R. § 3.321(b)(1) (1993). 3. The May 1963 decision of the Board which denied service connection for a left knee disorder is final. 38 U.S.C.A. § 7104(b) (West 1991). 4. New and material evidence has been submitted and the claim for service connection for a left knee disorder is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1993). 5. All of the evidence of record, both new and old, establishes that a left knee disorder is proximately due to or the result of the veteran's service-connected right knee disorder. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Right Knee Disorder The issues currently under appellate consideration include the veteran's claim for an increased evaluation for service-connected total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee), and the request to reopen his claim of entitlement to service connection for a left knee disability as secondary to the service-connected right knee disorder. As both issues require consideration of the history of the veteran's service-connected right knee disorder, a somewhat detailed discussion applicable to both issues follows. Service medical records reflect that the veteran sustained a perforating gunshot wound of the right popliteal space from enemy machine gun fire in November 1943. The point of entry was described as on the lateral posterior aspect just below the right knee and the point of exit on the medical posterior, also just below the right knee. Following the injury, the veteran was taken to an evacuation hospital where the wound was debrided. Service medical records describe his wounds as practically healed in December 1943 and healed in January 1944; however, January 1944 entries also reflect complaints of difficulties with his right knee including, inability to bear weight, and the inability to fully extend that joint, and it was opined that internal derangement of the right knee joint was present. On further treatment in March 1944, it was noted that the veteran's wounds had healed approximately three months prior, but that he had developed an unstable right knee. During this time, the veteran was noted to walk with a moderate limp of the right leg, and snapping of the right external ligament on movement of the knee joint was documented. It was subsequently determined that the veteran also had an incomplete traumatic rupture of the right knee external longitudinal ligament which was incurred when he sustained the November 1943 gunshot wound. It was noted that his disability precluded his being assigned to duties in active combat areas, and prevented him from doing duties which involved arduous use of the legs. On separation examination in August 1945, examination of the skin revealed a small scar on the posterior aspect of the right knee which was described as healed, and nonsymptomatic and nondisabling. No musculoskeletal defects were noted. Service medical records are entirely negative for an injury to the left knee and no complaints referable to that joint are contained therein. The veteran did not file a claim for VA benefits related to the gunshot wound of the right knee until 1961. Although in his initial application, he did not make reference to a left knee disability, on subsequent VA examination related to his claim, in October 1961, the veteran indicated to the examiner that he had also injured his left knee at the time he sustained the injury to his right knee in November 1943. His complaints at the time included, in pertinent part, pain, weakness, and swelling of both the right and left legs. On examination, his gait was described as an occasional limp of the right leg. Neurologic examination at the time revealed no pertinent abnormalities. On general medical examination of the musculoskeletal system, a scar on the lateral aspect of the right popliteal space, 2 inches in length and 1/2 inch wide was reported. The exit wound was noted to be on the medial aspect of the popliteal area, 1/2 inch wide. There was some depression of the scar, but no fixation. Grating and clicking were present on extension and flexion of the right knee. There was no pain or compression of the patella. The circumference of the right knee at the patella was 15 inches. No limitation of motion was appreciated. The circumference of the left knee was described as 16 inches at the mid-patella level. There was some swelling of the left lower joint area, but no fluid noted in the joint. Full range of motion of the left knee was reported. There were no scars. X-rays of both knees were reportedly negative. The assessment was residuals of gunshot wound of the right knee area, popliteal fossa area. Based on the veteran's service medical records, and on the October 1961 VA examination, the RO, in a November 1961 rating decision, determined that service connection was in order for residuals of gunshot wound of the right knee, popliteal. A 10 percent disability evaluation was assigned at the time. In this rating decision, the RO also denied service connection for a left knee disorder. The veteran appealed the RO assignment of a 10 percent disability evaluation, and the denial of service connection for a left knee disability to the Board. At that time, the Board not only considered the medical evidence as described above, but also considered an October 1962 statement from a private physician who noted the veteran's gunshot wound of the right knee, and reported that the veteran had pain and swelling in both knees. He indicated that braces had been supplied by the VA, and that the pain and swelling was recurrent. A report of a VA examination conducted in January 1963 was also of record. At that time, the veteran continued to complain of pain, swelling, and limitation of motion of both legs. The veteran was noted to wear a right knee cage for support. He was also noted to be wearing a support on the left knee which had been recently bothering him. On examination, two scars similar to those described previously were reported. No related impairment of muscle function was reported. There was no evidence of atrophy of the thighs or calves. No discrepancy in thigh musculature or calve musculature was reported. Motion of the right knee joint was reported to be from 0 degrees extension to 100 degrees flexion, and from 0 degrees extension to 125 degrees flexion of the left knee. Marked crepitation was present with active motion, and the veteran complained of considerable discomfort when the right knee was taken passively through range of flexion and extension. There was no instability of either knee joint. Crepitation was also noted when the left knee was taken through range of flexion and extension. There was no evidence of synovial fluid accumulation within either joint, and no evidence of loose bodies or torn cartilages. X rays revealed arthritic changes of both knees consistent with hypertrophic changes. There was no evidence of recent injury. The diagnoses included residual scar of the right knee, secondary to gunshot wound; traumatic arthritis of the right knee joint; and osteoarthritis of the left knee. Based on the evidence of record as described above, the Board in a May 1963 decision determined that service connection for a left knee disorder, and an evaluation in excess of 10 percent for impairment of the right knee was not warranted; however, the Board also determined that a separate evaluation of 10 percent for damage of the muscles of the right leg was warranted. The RO effectuated that Board decision in a May 1963 rating decision. In a statement of a private physician received in November 1963, it was noted that the veteran had been complaining about an increased amount of pain in both knee areas which radiated to his thighs and hips. There was evidence of atrophy in the right leg causing a limp. Medication taken daily was noted to provide no benefit. Diathermy and heat therapy given to the veteran was noted to be of some benefit. On VA examination in March 1964, the examiner confirmed that there was atrophy of the right thigh musculature, just above the patella of about 3/4 inch. The examiner noted that it was of interest that the area of atrophy corresponded to the area covered by the knee support which the veteran wore. Range of motion of the right knee joint was the same as that recorded on VA examination in 1963, but range of motion of the left knee was now recorded as from 0 degrees extension to 115 flexion. Additional findings, including arthritis of both knees, were similar to those recorded in 1963. In a May 1964 rating decision, the disability evaluation assigned the veteran's residuals of a gunshot wound of the right knee was increased to 20 percent, based on outpatient treatment records which demonstrated that the veteran had received physiotherapy treatment for his right knee, and based on reports from a fee basis physician for the months October 1963 through February 1964 which detailed evidence of muscular atrophy of the right leg with muscular spasm of the ligamentous support of the right knee. It was noted that a January 1964 examination revealed mild crepitation of the knees with some swelling of the lower extremity. The March 1964 VA examination noted above was considered. In an August 1968 rating decision the disability evaluation for the veteran's right knee disability was increased to 30 percent, based primarily on a July 1968 VA examination. At the time of the examination, the veteran continued to complain of pain and swelling in both legs. On examination, the veteran was noted to wear braces on both legs. Marked swelling of the right knee was noted as well as instability of the medial collateral ligament. Cruciates were intact. Flexion was to 100 degrees, and extension was 10 degrees short of full motion. The 30 percent disability evaluation has essentially been in effect since 1968; however, based on medical evidence regarding treatment received by the veteran in 1984 and 1985, the RO, in a September 1985 rating decision, determined that it was not possible to disassociate the veteran's right knee replacement from his service-connected gunshot wound of the right knee. The service-connected disability was recharacterized as total right knee replacement (formerly residuals of gunshot wound of the right knee) and a 100 percent disability evaluation was assigned pursuant to Diagnostic Code 5055 of the VA's Schedule for Rating Disabilities, which provides for such a rating for one year following such prosthetic replacement, with the 30 percent disability evaluation reinstated in this case following the 1- year prescribed period. In connection with the current claim for an evaluation in excess of 30 percent for total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee), the veteran asserts that an increased evaluation of 100 percent is warranted for his service-connected right knee disorder. He maintains that the evidence reflects an altered gait for many years due to pain, swelling, instability, and degeneration of the right knee joint, and also reflects increasing problems with ambulation over the year due solely to his service-connected disorder. He contends that not only has he been wheelchair bound due to the severity of his right knee disorder, but he has been in receipt of special monthly aid and attendance benefits for many years, also due solely to that disability. Disability evaluations are determined by the application of a schedule of rating which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Under the VA's Schedule for Rating Disabilities, when there is a question of which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1993). Pertinent regulations do not require that all cases show all the findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (1993). Under the VA's Rating Schedule prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. Thereafter, with chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation is warranted. With intermediate degrees of residual weakness, pain, or limitation of motion, the disability is rated by analogy to diagnostic codes concerning the limitation of knee extension, ankylosis or impairment of the tibia and fibula. The minimum rating is 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Under Diagnostic Code 5256, a 40 percent rating is warranted where there is ankylosis of the knee in flexion between 10 degrees, and 20 degrees. Pursuant to Diagnostic Code 5261, a 40 percent rating would be in order where limitation of leg extension was limited to 30 degrees. Diagnostic Code 5262 contemplates nonunion of the tibia and fibula with loose motion, requiring a brace. The maximum rating for limitation of flexion of the knee where flexion us limited to 15 degrees is 30 percent. The Board has carefully considered not only the remote history of the right knee disability at issue in this case, but also the more recent history along with the current medical findings, and particularly in light of the veteran's contentions in this case as outlined above. Essentially, the Board concurs with the assessment of the veteran's representative that an evaluation of the current nature and extent of the disability in question is complicated by the fact that the veteran has apparently had several cerebral vascular accidents, which the record reflects has affected his ability to ambulate; however, the record also contains evidence as documented by medical professionals of the symptomatology which may be ascribed to the service-connected disability at issue such that an adequate evaluation could be made by the Board. The Board has particularly focused on those records describing the veteran's right knee disability following the total right knee replacement surgery which was performed in September 1984. Numerous private medical records of record reflect that the veteran underwent a total left knee replacement arthroplasty in July 1984 and a total right knee replacement arthroplasty several months later in September 1984 for osteoarthritis of both knees with severe varus deformity. In an April 1985 entry, the veteran's private physician indicated that approximately 6 months postoperative, x-rays revealed excellent position and alignment of all prosthetic components. In an August 1985 entry, he noted that it was now 1-year postoperative for the bilateral knee replacements, and that there were moderate good results on the right and good results on the left. However, he also noted that the veteran had unsteadiness of gait, and he was referred to another physician for evaluation. An extensive statement from this second physician dated in November 1985 is of record. He noted the veteran's history of injury to the right leg as described above as well as increasing difficulty with ambulation and the use of a cane for many years. He reported that since the veteran's bilateral knee replacements, his ambulatory status had deteriorated despite progressive ambulatory training. He indicated that he had evaluated the veteran for his ambulatory problems, and it was his impression that the veteran's ambulatory problems were not solely due to his osteoarthritis, and bilateral knee replacements, but, however, from a combination of decreased sensory input and loss of proprioception along with the problems with his knees. He noted that a computerized tomography scan revealed cerebral and cerebellar atrophy and a lacunar infarction of the left basal ganglion and an external capsule. Basic laboratory and EMG nerve conduction studies were reportedly unremarkable. The conclusions of the above physician have essentially been mirrored in subsequent and more recent medical findings and reports. In a VA examination for purposes of aid and attendance in October 1985, the examiner found bilateral proximal and distal muscle weakness. Range of motion of the right knee was to 90 degrees. He was unable to raise from the chair without assistance. Poor weight bearing was noted, right greater than left. He was noted to be status post operative bilateral knees prosthetic devices and to have had a cerebral vascular accident with residual neurologic weakness. The veteran was noted to be housebound with minimal self-care ability. A short term and long term memory loss due to old possible cerebral vascular accident was noted. He was noted to require a walker and assistance for locomotion. The examiner concluded that the veteran had mild organic brain syndrome in addition to osteoarthritis, hypertension, and old cerebral vascular accident. Despite the veteran's assertions that he had been in receipt of special monthly compensation for his knees, the RO in a February 1986 rating decision determined that the veteran was in need of aid and attendance because of resulting disability due to an old cerebral vascular accident, and such benefits were awarded from November 1985. More recent records VA and private medical records, particularly those dated in 1989 clearly reflect that some of the veteran's impaired physical mobility is related to his service-connected right knee replacement, and the record reflects that it was recommended that he utilize an electric seat lift chair in 1987 due to severe arthritis of the knees and that he had utilized a wheelchair since 1989 due to an inability to ambulate. In a VA January 1989 entry, it was noted that the veteran had had both knees replaced and wanted to reopen his claim. Although the veteran reportedly arrived in a wheelchair and it was noted that he used a stair glide to go up and down stairs, he was described as ambulatory. No acute problems were noted on examination. On VA outpatient treatment in June 1989, he was reportedly unable to ambulate. In a July 1989 letter, a private doctor noted that the veteran was nonambulatory without assistance, and that he was totally disabled due primarily to war-related injuries, although specific findings were not reported by him. None of these records comment on the problems with ambulation unrelated to his knees as recorded by medical records of the mid-1980's. The Board has considered the more recent medical findings in light of the veteran's long history of pain and swelling in the right knee, and even the continued problems following the 1984 total knee replacement. On VA examination in April 1993, the veteran was noted to be a resident of a nursing home. It was noted that he had had a cerebral vascular accident which had left him weak with multiple contractures on the left side of his body. It was also noted that since that time, he had been unable to ambulate. His past orthopedic history was noted to include a bilateral knee replacement secondary to post-traumatic arthritis of the right knee, and it was noted that he apparently had had improvement after both knee replacements. He was reported to be ambulatory without assertive devices until the cerebral vascular accident the previous year, although the Board does note that the record reflects that the veteran had been using assistive devices after his total knee replacements and had been using a wheelchair in 1989. The examiner reported that the veteran's right knee had a minimal flexion contracture and a healed surgical incision. Range of motion was to 90 degrees with no pain on motion. The diagnostic impression was that the veteran was nonambulatory because of the stoke he had experienced 1-year prior which left him with left-sided weakness and multiple left upper and left lower extremity contractures. He was described as status post operative knee replacements for arthritis of both knees with minimal pain with range of motion of both knees. On VA reexamination in December 1993, the examiner indicated that it was his impression that the veteran had arthritis of both knees, but that his main disability was his status following the stroke with left hemiparesis and flexed contractures of the left upper and left lower extremities. He opined that the veteran was unable to walk at this point because of the stroke and the hemiparesis, and not necessarily the arthritis in either knee. Although recent VA examiners have opined that the veteran's inability to ambulate is primarily due to the residuals of a recent stroke, it is clear that several medical examiners have found chronic residuals at least in the form of weakness in that extremity prior to this time, despite recent findings of minimal pain with motion. Given numerous statements of record of the veteran and of his sister attesting to the veteran's long history of problems with weight bearing and ambulation even after the total knee replacement and in light of the totality of the pertinent medical evidence, the Board finds it reasonable to conclude that the symptomatology associated with the veteran's service-connected total right knee replacement more nearly approximates that of a 60 percent rating under Diagnostic Code 5055 requiring chronic residuals following a total knee replacement. As such, the provisions requiring rating by analogy for other diagnostic codes where there is intermediate degrees of residual symptomatology is not for application. Moreover, a 100 percent evaluation is not in order as that schedular evaluation is only in order for one year following knee replacement. The Board finds that the provision of 38 C.F.R. § 4.40 (1993) and 38 U.S.C.A. § 5107(b) (West 1991) would not provide for an evaluation in excess of 60 percent in this case. Pursuant to 38 C.F.R. § 3.321(b)(1) (1993), an extraschedular rating is in order where there exists such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization such as to render impractical the application of the regular schedular standards. Clearly due to the long- standing severity of the veteran's right knee disability, interference with the veteran's employment as a grocer is foreseeable. However, the Board finds that the record does not reflect frequent periods of hospitalization because of service- connected disability, nor interference with employment to a degree greater than that contemplated by the regular schedular standards which are based on the average impairment of employment. Accordingly, an evaluation in excess of 60 percent on this basis is not warranted. II. Left Knee Disorder The issue of service connection for a left knee disability on either a direct or secondary basis was previously before the Board 1963. In a May 1963 decision, the Board denied, in pertinent part, the veteran's claim of entitlement to service connection for that disorder, finding that service records showed no evidence of injury to the left knee during service and that arthritis of the left knee, which had been shown on official examination in January 1963, was not demonstrated in service or within one year after separation therefrom. The Board further found that a left knee disorder was not shown to be causally related to service-connected disability. Although the veteran attempted to reopen his claim of entitlement to service connection for a left knee disability in 1964, the RO in a May 1964 rating decision determined that no new and material evidence had been submitted since the Board's final May 1963 decision sufficient to warrant such reopening of the veteran's claim. The United States Court of Veterans Appeals (Court), in a case unrelated to the present appeal, has stated that in determining whether new and material evidence has been submitted, it is necessary to consider all evidence added to the record since the last final denial based on the entire record, not merely the evidence added to the record subsequent to the last refusal to reopen the claim. Glynn v. Brown, 6 Vet.App. 523 (1994). In this regard, the last final denial based on the entire record was the decision rendered by the Board in May 1963, and thus, the Board's inquiry regarding the submission of new and material evidence will commence from that date. The current appeal stems from the RO denial of the veteran's most recent request to reopen his claim of entitlement to service connection for a left knee disability. Under the applicable legal criteria, the May 1963 decision of the Board is final, and it cannot be modified unless evidence presented in support of the claim is both "new and material" and warrants revision of the previous decision. 38 U.S.C.A. §§ 5108, 7104(b) (West 1991). "New and material" evidence means evidence not previously submitted to the RO which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant and which, by itself, or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1993). Moreover, the Court, in another unrelated case, has established a two-step analysis which must be applied in cases in which a claimant seeks to reopen a claim which has become final. First, there must be a determination as to whether there is new and material evidence to reopen the claim. If there is such evidence, the claim must be reviewed on the basis of all of the evidence, both new and old. A decision regarding either step is appealable. Manio v. Derwinski, 1 Vet.App. 140 (1991). Further, "new" evidence must be more than merely cumulative of other evidence of record, and "material" evidence must be relevant and probative of the issue under consideration, and present a reasonable possibility that the new evidence when viewed in the context of all of the evidence, new and old, would change the outcome. Colvin v. Derwinski, 1 Vet.App. 171 (1991). Finally, the Court has also stated that in determining whether evidence is new and material, the credibility of the new evidence is, preliminarily, to be presumed. If the additional evidence considered presents a reasonable possibility of changing the outcome, then the claim is reopened. Then, the ultimate credibility or weight to be accorded such evidence must be determined as a question of fact. Justus v. Principi, 3 Vet.App. 510 (1992). The evidence of record and considered by the Board at the time of the May 1963 decision consisted of service medical records, post service and VA medical records, and testimony provided by the veteran at a personal hearing held at the RO. At that time, the veteran contended that he had initially injured his left knee at the same time that he sustained the right knee wound, and he alleged that he had experienced residuals of that injury since that time; however, the objective evidence of record at the time documented no such inservice injury to the veteran's left knee. Moreover, although the post service medical evidence of record showed osteoarthritis of the left knee beginning in 1963, none of the medical evidence of record at the time demonstrated a causal relationship between the veteran's service-connected right knee disability and a left knee disorder. In connection with the veteran's recent request to reopen the claim of entitlement to service connection for a left knee disability, the Board has considered numerous private and VA medical records. The Board has considered these records in light of the veteran's current contention that the evidence shows that the severity of joint degeneration associated with his service- connected residuals of a gunshot wound to the right knee, requiring him to compensate by altering his gait which has resulted in an imbalance in the left knee, resulting in premature degeneration in that joint for which service connection is in order. While the vast majority of the recently considered evidence may be considered "new" in that it is not cumulative or redundant of evidence previously considered, most of the evidence is, however, not "material" to the issue of secondary service connection under consideration, as the evidence of record considered by the Board in 1963 clearly showed pathology in both the veteran's service- connected and nonservice-connected knees. However, a recently submitted statement from a private doctor of osteopathic medicine, dated in March 1991, clearly describes direct causal relationship between the disabilities of both knees, and more importantly, essentially relates both disabilities to the veteran's military service. The Board finds this statement not only to be new, but material to the issue of secondary service connection in that it necessarily presents a reasonable possibility of changing the outcome of this case. As such, the veteran's claim for service connection for a left knee disability is reopened. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service, or where arthritis was manifested to a degree of 10 percent within one year following the veteran's release from active duty. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). Pertinent regulations also provide that 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) (1993). As noted above, the veteran's current claim is predicated on a theory of secondary service connection. Although in numerous early statements or record made by the veteran in 1960's it was asserted that a direct injury to his left knee had been sustained at the time that he sustained a gunshot wound to the right knee, none of his more recent statement include a claim for service connection on a direct statement. Indeed, as noted in the detailed history as outlined in subpart I. of this decision, the medical evidence of record does not reflect injury to the left knee in service, chronic residuals of a left knee injury in service nor is the evidence of record reflective of arthritis of that joint manifest to a compensable degree within one year of service discharge. However, the Board does find that a preponderance of the evidence in this case does relate the veteran's left knee disability to his service-connected right knee disorder. The veteran's history of complaints of pain and swelling as they relate to his left knee and as documented in the above section essentially is documented in records beginning in the 1960's. At that time, the veteran clearly indicated that problems with his right knee were causing difficulties with his left knee. The record also reflects that he has had to utilize braces on both knees for many years. Traumatic arthritis of the right knee and osteoarthritis of the left knee has clearly been documented also since the 1960's. More importantly, the record contains a statement from one of the veteran's physicians who in a March 1991 letter stated that the veteran inservice injury to the right knee caused severe joint degeneration which in turn caused a gait abnormality, and who opined that the veteran's compensating for this gait abnormality caused premature degeneration, necessitating that knee also to be replaced with a mechanical knee. He reported that the veteran had had constant pain and difficulty ambulating since his bilateral total knee replacement. This medical statement has been considered in light of the remaining evidence of record. While the record does not show severe degeneration of the right knee preceded the finding of osteoarthritis in the left knee (on VA examination in July 1968, the arthritic changes in the right knee was described as minimal), there is clear evidence of a long-standing gait abnormality due to the veteran's service-connected right knee disorder as well as other positive findings as described above which clearly indicate that the veteran's right knee has been symptomatic to a significant degree for many years eventually resulting in a total right knee replacement which is now service connected. The Board finds the totality of the medical evidence to be persuasive in documenting a causal relationship between the veteran's service-connected right knee disability, and a left knee disability. Moreover, the Board finds that the total left knee replacement due to osteoarthritis cannot similarly be disassociated from the veteran's service connected disability. Accordingly, service connection for a left knee disability on a secondary basis is warranted. ORDER A 60 percent evaluation for total right knee replacement (formerly characterized as residuals of gunshot wound of the right knee) is granted subject to the laws and regulations governing the payment of monetary benefits. The claim for service connection for a left knee disorder is reopened and the evidence of record, both old and new, establishes a grant for service connection for a total left knee replacement. EUGENE A. O'NEILL 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.