1. The issue identified by the parties that requires determination is whether it is reasonably necessary for the applicant to receive left hip surgery.

1. The following documents were in evidence before the Commission and considered in making this determination:

(a) ARD and attached documents, and

(b) Reply with attachments from the respondent (Reply).

1. There was no application to call oral evidence or cross-examine any witness at the hearing.

1. Section 60 of the Workers Compensation Act 1987 (the 1987 Act) provides that if, as a result of an injury received by a worker, medical or related treatment is reasonably necessary, then the employer is liable to pay the related cost. The nature of the applicant's left hip condition is not the subject of dispute for resolution in these proceedings, whether treatment by way of hip replacement surgery is reasonably necessary is the issue to be resolved.

1. The applicant's statement evidence is that she has been "experiencing ongoing and significant pain" in her left hip that has "gradually worsened over time".[1] She believes the "worsening pain to be directly related to [her] original injury" to her "right hip and leg" on 26 April 2017 and the subsequent surgical procedures on 24 January 2018, 27 September 2018, 22 July 2019 and 15 January 2021.[2] Her statement continues that:[3]

"6. As a result of the surgical procedures to my right hip and knee, I placed increased weight on my left side during recovery. I walked with a limp, particularly after each surgery, to reduce pain and protect my right side while it recovered. Over time, this excessive loan on my left hip and leg has caused progressive pain in my left hip. This has had a significant impact on my overall mobility as my ability to favour my left hip and leg has diminished.

7. At the recommendation of my treating specialist, Professor Munjed Al Muderis, I attempted several non-operative treatments to improve these symptoms, including pain medications, corticosteroid injections, general rest, and weight management. These only provided temporary or minimal relief, and my left hip has continued to deteriorate.

8. On or about 30 April 2024, Prof. Muderis recommended I undergo a total left hip replacement to improve my left hip and increase mobility. I discussed with Prof. Muderis, and understand, the possible benefits and risks of the recommended surgery.

9. After considering the exhaustion of non-operative treatments, and the risk and benefits of surgery, I confirmed that I wish to undergo the total left hip replacement as recommended by Prof. Muderis. I Believe it's the most appropriate and definitive way to address my ongoing left hip pain and improve my long-term mobility."

1. The applicant received treatment from Professor Munjed Al Muderis, orthopaedic surgeon, for her right-side hip injury. He has more recently been consulted with respect to her left hip condition and his various reports are relied upon by the applicant in these proceedings.
2. Before continuing, a submission needs to be addressed that was made for the applicant that suggested a "team of doctors", consisting of four orthopaedic surgeons, assessed her at various times and agree upon the nature of her condition and need for surgery. It is evident from the reports in evidence from Professor Al Muderis,[4] that he supervises orthopaedic surgeons undergoing a period of further specialist training, when they are known as an 'orthopaedic fellow'.
3. Several reports in evidence were apparently prepared by orthopaedic fellows but "on behalf of Professor Munjed Al Muderis". It can reasonably be inferred those doctors were in specialist training with him. There can be little doubt that reports signed in that form were prepared at his direction or under his supervision and with his approval. In such circumstances, the reports are taken to be those of Professor Al Muderis. While specialists in training may have been involved in consultations with the applicant, and with the preparation of associated reports, Professor Al Muderis was the specialist orthopaedic surgeon ultimately responsible for the assessments, opinion and report content.
4. It was noted by Professor Al Muderis (then, Associate Professor Al Muderis) on 11 February 2020 that the applicant's hip pain was at that time "starting to affect her left side as well" that was "because of the compensation she is doing with the left side to avoid the painful right hip movement". A further consultation occurred on 24 March 2020 due to "some degree of irritability over her left hip" as well as right-side problems. The applicant had earlier been referred by the specialist for an MRI scan of both hips at the time, which was conducted on 16 March 2020. The imaging report of Dr Simon Dimmick, radiologist, identified a range of 10 different issues with the applicant's left hip, including various tears, bony spurring and tendinosis at several locations.[5]
5. It seems however that the right-side was immediately thereafter the priority for Dr Al Muderis during 2020 as there is no further reference to the left hip in his subsequent reports from that period. It is noted that the applicant's right gluteal tendon reconstruction surgery was performed in July 2020,[6] which seems to have been the focus and primary concern.
6. Dr Ajeya Ramesh, under the supervision of Professor Al Muderis, examined the applicant on 6 June 2023, and apparently prepared the report on his behalf. It was noted she had "severe pain in the left hip" where the right hip was "slowly settling" (which had been the subject of an earlier consultation on 21 March 2023). The applicant was diagnosed at that time with "mild to moderate degenerative arthritis in the left hip" where an MRI scan showed "features suggestive of degenerative changes ... along with hyperintensity and increased uptake at the gluteus medius insertion" that suggested a "gluteus medius insertional tear in the hip as well". It was considered that:[7]

"Her left hip does have features suggestive of arthritis with narrowing of joint space as well as degenerative changes to the chondral surface. The MRI has also picked up the gluteus medius insertional tendinopathy. It is very likely that [the applicant's] symptoms in the left hip have resulted as a result of overcompensation and bearing more weight and strain over the left hip joint to offload the right hip over the past few years following the work-related trauma and multiple surgeries to the right, lower limb.

At present we have advised for [the applicant] to have ultrasound guided injections to the left hip, as well as the left gluteus medius insertion with the space of two to three weeks, which would be both diagnostic and therapeutic and give us an understanding as to which of the two components is causing her more pain. We will review with her in six weeks' time and if [the applicant's] symptoms have progressively worsened, we have explained to her that she will likely require a left total hip replacement with the possible need for gluteus medius tendon reconstruction."

1. The applicant returned for further consultation on 31 October 2023 when Dr Mohamed Taher Ghaderi, under the supervision of Professor Al Muderis, conducted the examination and reported. The left hip joint was said to have been the "problem" for "several months". The previously arranged corticosteroid injection into the hip joint "helped her a lot but the pain recurred after a couple of months and we did the second injection into the left hip, but it did not help her". Physiotherapy, anti-inflammatory medication and hydrotherapy was also noted as having been tried by the applicant, "but the pain is constant and does not resolve with non-operative measures", according to the report.[8]
2. Professor Al Muderis suggested the applicant continue with "non-operative measures", but she replied that her pain had "not responded" to those, that it was constant and affected her sleep and interfered with "day-to-day activities and with walking". A total hip replacement was then suggested based upon those issues and the "mild to moderate arthritic changes in the hip" as well as "significant irritability". The applicant is reported to have been "happy to proceed" with a left total hip replacement.[9]
3. At their next consultation on 9 January 2024, Professor Al Muderis reported the applicant's right hip as the reason for the visit but also noted ongoing left hip pain with "severe irritability".[10] Her intentions regarding left hip replacement surgery were noted where that was "the main source of the pain" at the time.[11]
4. On 30 April 2024, the applicant was seen by Dr Dareen Rednah under the supervision of Professor Al Muderis. The applicant complained of "severe left hip pain 10/10". It was recorded that "severe left hip osteoarthritis" was one of her "problems" identified from MRI investigations. By the time of that report the applicant's right hip was said to be compensating for her left hip and she could "hardly walk". It was restated that the applicant was "a candidate of left total hip replacement", where her "right hip may suffer if the left hip is not treated" with that surgery.[12]
5. In a letter dated 30 July 2024, Professor Al Muderis responded to queries from the applicant's solicitor. When asked about the nature of the applicant's condition, he responded that she had:[13]

"...developed right hip pain, functional limitation, secondary to Osteoarthritis which was secondary to the work related injury back in April 2017. Secondary to the right hip pain and the overload the left hip had to bear secondary to the limitations of her right hip, she developed left hip osteoarthritis, which has as a definitive option of management a total hip replacement. She hasn't responded to non operative measures, and given the severity of the degenerative changes in the left hip, an arthroscopic procedure is not an option and will most likely worsen her symptoms."

1. On the issue of proposed hip replacement surgery, Professor Al Muderis considered that:[14]

"... the osteoarthritic changes and her symptoms warrant a definitive management with a total hip replacement. She hasn't responded to non operative measures, and given the severity of the degenerative changes in the left hip, an arthroscopic procedure is not an option and will most likely worsen her symptoms."

1. Professor Al Muderis opined in respect of the likely effectiveness of surgery that:[15]

"Given the extent of osteoarthritis and her symptoms on the left hip, and having a previous right total hip replacement that was successful, the chance of having good pain control and winning back her functionality is very high."

"All the non operative measures including corticosteroid injections, oral pain control, and lowering her physical activity + reducing her body weight, hasn't provided her relief in pain on her left hip. There are no more alternative treatment modalities, and an arthroscopic surgery will most likely worsen her symptoms."

1. The respondent qualified Dr Stephen Rimmer, orthopaedic surgeon, to conduct an independent medical examination of the applicant, which took place on 1 February 2024. In his 2 February 2024 report, when he noted there were no "radiological investigations present", Dr Rimmer referred to the applicant's "gradual onset of left groin/hip pain" about two and a half years before where there had been "no specific initiating event".[16] He identified that the applicant walked with a limp but had no "leg length discrepancy".[17]
2. In response to a question about whether the proposed left total hip replacement surgery for the applicant "has the capacity to relieve her current symptoms", Dr Rimmer responded that in "general terms, a total hip replacement has a very high success rate in resolving pain and restoring function". As to whether that surgery was reasonably necessary for the applicant's work-related condition, Dr Rimmer opined [emphasis in original]: "More than likely, it is NOT related to her work-related condition. However, to confirm this, I need to see the radiological investigations".[18]
3. A supplementary report was provided by Dr Rimmer dated 16 October 2024, wherein he refers to having reviewed a 2 May 2023 bone scan, that he thought "showed basically no abnormality in the left hip articulation", as well as a 30 April 2024 X-ray, he referred to as showing "at most very mild degenerative change in her left hip articulation consistent with her age group".[19]
4. By the time of his second report, in relation to whether the proposed left total hip replacement surgery was reasonably necessary for the applicant's work-related condition, Dr Rimmer responded:[20]

"Given the history, examination and review of investigations, the proposed left total hip replacement is not reasonable and/or necessary, i.e. there is no surgical pathology present in the left hip."

1. He commented later in the report that:[21]

"Now that I have reviewed the radiological investigations sighted above, there is no surgical pathology in the left hip, i.e. there is no surgical need for a left total hip replacement."

1. Dr Rimmer was of the firm view that although there "are no alternative treatments" the applicant "does not need surgery" as a preferred treatment option and that she "does not require a left total hip replacement" to relieve her current symptoms.[22]

1. Dr Eddie Price, occupational medicine and injury management consultant, referred to the applicant's left hip condition in his 18 December 2023 report following an independent medical examination on 12 December 2023. Although he was not specifically requested to comment on the proposed left hip replacement surgery, Dr Price noted at that time the applicant stated she had "most pain in the left hip and this can go up to 8-9/10 and she states she limps".[23] He diagnosed her a suffering "secondary compensatory pain in the left hip" from "chronic pain following a right total hip replacement and right total knee replacement".[24]
2. An independent medical examination arranged by the applicant's solicitor with Dr John Bentivoglio, orthopaedic surgeon, was the subject of a 16 February 2022 report about her right-side injuries. In that report, he referred to the applicant having "evidence of bilateral degenerative osteoarthritis involving her hips".[25] Having commented upon the applicant's right hip, right knee, back, shoulders and scarring, Dr Bentivoglio stated in that report there was "no other condition that [he] would consider that has developed as a result of the specific injury on 26 April 2017".

1. The applicant relies on the opinion of her treating orthopaedic surgeon, Dr Al Muderis, that she requires left total hip replacement surgery to treat the effect of the work-caused injury. She claims medical expenses pursuant to s 60 of the 1987 Act and that it is reasonably necessary to undertake that surgery, which results from her work injury.
2. The applicant has the onus to establish, on the balance of probabilities, the provision of surgery is reasonably necessary as treatment for her left hip condition. I must have a "a sense of actual persuasion" that the reasonable necessity exists and that it results from the injury as claimed: Nguyen v Cosmopolitan Homes Pty Ltd [2008] NSWCA 246 and Yucel v AAES Pty Ltd t/as Roadtrack [2015] NSWWCCPD 51.
3. The concept of reasonable necessity of a particular treatment was considered by Roche DP in Diab v NRMA Ltd [2014] NSWWCCPD 72 (Diab). The fundamental question: "is it better that the worker have the treatment or not?" That is, are there reasonable prospects that the worker's situation will be improved or ameliorated by the treatment.
4. It was made clear by Roche DP, citing various authority, in Murphy v Allity Management Services Pty Ltd [2015] NSWWCCPD 49 (Murphy) that in order to satisfy the test of causation implied by the expression "result of", it is not necessary to establish the work injury was the only, or even a substantial, contributing factor to the need for medical treatment. It is sufficient to establish only that the injury "materially contributed" to that need and "a condition can have multiple causes".
5. A commonsense examination of the causal chain is required to determine whether the need for the claimed treatment arises as a result of the work-related injury: Kooragang Cement Pty Ltd v Bates (Kooragang).[26] The applicant is not required to prove the requested surgery is absolutely necessary, only that it be reasonably so: Diab.
6. In summary, I must determine whether it is reasonable and preferable for the applicant to have the surgery requested. In making that determination, relevant considerations include the suitability of the treatment, availability of alternative treatment (and the potential effectiveness of those), cost of the proposed treatment, potential effectiveness of the proposed treatment and the acceptance by medical experts of the treatment as being appropriate and likely to be effective.[27]
7. The respondent relies on the report of Dr Rimmer and submitted the "mild" nature of the applicant's condition that he identified is insufficient basis for it to be accepted as reasonably necessary. It was contended the Commission could also not be satisfied of the reasonable need for the surgery due to work-related injury given the applicant had pre-existing osteoarthritis in her left hip, which was said to be the real basis for the treatment. According to the respondent, relying on Dr Rimmer's opinion that is argued to be "consistent with the radiological investigations, there is not sufficient pathology present for it to be liable for the applicant's proposed surgery.
8. I consider Dr Rimmer's opinion to be lacking in several respects. It seems that he did not have the benefit, at any time, of reviewing and considering the 16 March 2020 MRI scan report of Dr Dimmick. Although several years old by the time Dr Rimmer was qualified by the respondent, that report identified and listed 10 separate findings by Dr Dimmick associated with the applicant's left hip. It would have undoubtedly at least been important and relevant background information for consideration.
9. On 16 October 2024, Dr Rimmer referred to there being "basically no abnormality in the left hip articulation" in his review of the 2 May 2023 bone scan report, despite that investigation report identifying "mild to moderate degenerative arthritis in the left hip". It is unclear from Dr Rimmer's report the extent to which he took into account that radiological finding given a lack of explanation for his findings generally.
10. There is a dearth of reasoning contained in Dr Rimmer's reports. He did not provide any proper reasoning or explanation about why the left hip surgery recommended by Dr Al Muderis for the applicant was not reasonably necessary. His opinion that "there is no surgical pathology present in the left hip" is in stark contrast to the other medical evidence, specifically that of Professor Al Muderis. That opinion seems to also ignore the applicant's multiple reports of severe pain, including as recorded by Dr Price, arising from her left hip condition.
11. It is relevant that Dr Rimmer consdiered there were no other treatment options available for the applicant's condition and that the proposed surgery would generally have "a very high success rate in resolving pain and restoring function", referring to her condition. Further, he was of the view that the proposed surgery "has the capacity to relieve her current symptoms".
12. Dr Rimmer nonetheless considered the proposed left total hip replacement as "not reasonable and/or necessary" given "there is no surgical pathology present in the left hip" following his review of the bone scan and x-ray reports. That is however the extent of the explanation proffered by Dr Rimmer about why he considered surgery to not be reasonably necessary. When viewed overall his findings appear contradictory and inconsistent with the applicant's medical history, this is perhaps a result of a lack of adequate explanation and reasoning for those findings. I prefer the views of Professor Al Muderis in the circumstances.
13. While it must be taken into account that Professor Al Muderis is the applicant's treating surgeon, and therefore not independent of the treatment process, he provides cogent reasons for the applicant's need for surgery: other treatment had been tried and failed, the severity of the applicant's condition, that surgery was likely to relieve her ongoing pain and restore function, but also that her right hip has been compensating for the left and is at risk of damage (after having been surgically replaced during 2019).
14. It is also evident from the reports that his preference was for non-operative treatment of the applicant's condition, and it seems that it was only after she stressed all prior conservative treatment had failed that Professor Al Muderis considered surgery to be appropriate. There can be little doubt the applicant has exhausted non-operative options, which was confirmed by Dr Rimmer.
15. Professor Al Muderis gave detailed reasons about why the proposed treatment is reasonably necessary. Other modes of treatment have been used in the past have been tried but failed to fully and finally rectify the problem. It is apparent the applicant is unlikely to improve without the proposed surgical intervention. There seems to be a good chance of a successful outcome from the proposed surgery, according to both Professor Al Muderis and Dr Rimmer, which is an accepted form of treatment for the applicant's condition. There is no evidence of the requested procedure being cost prohibitive. On balance it would appear better for the applicant to have it than not: Diab
16. I consider that nothing of significance arises from the 16 February 2022 report of Dr Bentivoglio. The applicant's left hip was not identified as a work-related issue at that time and was not the subject of specific queries from the author of the referring letter. It was nonetheless a condition noted by Dr Bentivoglio as present at the time in the context of "bilateral degenerative osteoarthritis involving her hips". Notwithstanding his comment that he considered the applicant had no other conditions related to the 26 April 2017 injury, the issue of liability is not a subject for resolution in these proceedings, and in any case, the applicant only later presented to Professor Al Muderis (with Dr Ramesh) with her left hip condition as a primary concern on 6 June 2023.
17. The comments and observations of Dr Price in his 18 December 2023 are noted to be consistent with the reports of Professor Al Muderis around that time.
18. I am reasonably satisfied that even where the applicant's weight and any pre-existing or underlying osteoarthritis may be a factor, the work-related component of the applicant's condition has materially contributed to the need for surgery: Murphy. This is made clear in the various reports from Professor Al Muderis from which extracts have already been cited.[28]
19. I have weighed the matters identified in Rose and consider the evidence supports a finding the proposed treatment is reasonably necessary in the circumstances for the purposes of

s 60 of the 1987 Act. Accordingly, the respondent is liable to meet the cost of the surgical treatment as recommended by Professor Al Muderis in his Request for Approval of Surgery letter dated 31 October 2023,[29] that is, "HIP, total replacement arthroplasty of, including minor bone grafting".

1. The applicant's work-related left hip condition requires treatment by way of replacement surgery. The respondent is liable for the cost of that treatment.

[4] See for example, the report of consultation on 30 April 2024, ARD p 20.

[26] Kooragang Cement Pty Ltd v Bates (1994) 10 NSW CCR 796.

[27] Rose v Health Commission (NSW) [1986] NSWCC 2 (Rose).