Subsequent medical and allied assessments
23In the paragraphs that follow, as an aide to analysis, including for the assessment of damages for non-economic loss, I have set out a chronological history summarising the plaintiff's post-accident medical examinations and assessments.
2008
24On 14 July 2008, after the plaintiff returned from his trip overseas, at the referral of his local doctor, he underwent a CT scan of his right foot by the Illawarra Radiology Group. This scan revealed a rupture or fracture dislocation of the Lisfranc ligament of the right foot with lateral subluxation of the bone of the metatarsal region. The scan also revealed multiple small fracture fragments and an ossific fragment suggestive of trauma to the third tarso-metatarso-phalangeal joint with slight subluxation of the fourth and fifth metatarsal bases. Advanced osteoarthritis in the first meta-tarso-phalangeal joint was also noted.
25On 22 July 2008, the plaintiff attended the fracture clinic at Wollongong Hospital and was then referred to and examined by Dr Yiu-Key Ho, an orthopaedic surgeon. Dr Ho diagnosed a Lisfranc fracture dislocation in the right foot that occurred 8 weeks earlier and which had been missed when the plaintiff was first x-rayed. Dr Ho referred the plaintiff to a foot and ankle specialist for further management.
26On 25 July 2008, at the referral of Dr Ho, the plaintiff saw Dr David Lunz, an orthopaedic surgeon specialising in foot and ankle problems. Dr Lunz confirmed a missed fracture of the Lisfranc joint complex of the right foot. Dr Lunz recommended fusion surgery to treat that injury as 2 months had passed since the injury and there was minimal chance of a successful reduction and restoration of normal joint alignment without surgery at that time.
27On 29 August 2008, at the Prince of Wales Private Hospital, the plaintiff underwent the surgery recommended by Dr Lunz. The first, second and third TMT joints and the first MTP joint were fused as had been planned. He subsequently wore a non-weight bearing cam boot. Orthotics, physiotherapy, podiatry and custom footwear were recommended. Dr Lunz was of the view that the need for the plaintiff to wear orthotics and modified footwear would be lifelong. He also thought the plaintiff was at risk of developing arthritis in the other joints of his right foot because the fusion placed increased stress on adjacent joints.
28On 16 September and on 13 October 2008, at the referral of Dr Lunz, the plaintiff saw Mr Bruce Overton, a physiotherapist for the fitting of a protective short leg cast, and later for the fitting of a post-surgical boot by an orthotist. At that time the plaintiff was mobilising using a single left crutch.
29On 19 November 2008, at the request of Dr Lunz, the plaintiff underwent further radiological scanning of his right foot. The report described the surgical arthrodesis and indwelling hardware, and confirmed that the fusion had been successful.
2009
30On 24 November 2008 the plaintiff was reviewed by Dr Lunz, who suggested that the plaintiff begin using normal footwear without the cam boot. He was advised to use spacers to keep his right toes apart and to obtain special shoes.
31On 9 February 2009 Dr Lunz noted that the plaintiff reported difficulty walking long distances and that his foot was swollen. Orthotics were then suggested when Dr Lunz saw the plaintiff again on 21 May 2009, stiff-soled rocker shoes were recommended to assist the plaintiff to walk. At this time Dr Lunz discharged the plaintiff from his care.
32On 26 October 2009, at the request of his solicitor, the plaintiff was examined by Dr James Bodel, an orthopaedic surgeon. Dr Bodel noted a history from the plaintiff of an absence of right foot problems apart from an awareness of an arthritic process in the metatarsophanlangeal joint of the right great toe. Dr Bodel noted a restricted range of right ankle movements in the plaintiff's arthrodesed right great toe. He expressed the view that the prognosis was guarded, and that the plaintiff will have indefinite pain, weakness and stiffness in his right foot and that his ability to lead a normal life has been significantly impaired by the effects of the injury in question.
33On 27 October 2009, at the request of the Motor Accidents Authority, the plaintiff was examined by Dr Julien Ginsberg, an orthopaedic surgeon. He was of the opinion that the plaintiff's injury had been complicated by weight bearing and the non-reduction of the fracture dislocation that had not been reported in the initial x-ray taken on 30 May 2008. Dr Ginsberg stated:
"12. Work status: In your opinion as a result of the injuries sustained in the subject MVA does the claimant had [sic] an incapacity with respect to his earning capacity/gaining employment, in particular is the claimant fit for full time work duties compatible with his relevant education and training without restriction? Please comment on same.
It is certainly not (sic) to be expected that following his Lisfranc fracture dislocation and surgery that he is not able to walk for long distances nor is he able to stand for long periods, in view of the tendency for the foot to swell he should take the necessary precautions when flying and travelling for long periods, that is he should be wearing surgical hose, he should always wear the appropriate surgical footwear and orthotics."
34On 26 November 2009, at the request of his solicitor, the plaintiff was examined by Dr Peter Conrad, a consultant surgeon. Dr Conrad described the plaintiff's fracture dislocation as a substantial one, which had left him with ongoing pain and stiffness and a valgus deformity in the fused mid-metatarsal region of the right foot. Dr Conrad identified a range of treatments and assistance, and said that the plaintiff had an uncertain prognosis.
2010
35On 8 January 2010, Dr Lunz provided a report to the plaintiff's solicitor. At that time he thought the plaintiff's prognosis was good but he had not seen the plaintiff since 21 May 2009. He noted the risk of the plaintiff developing arthritis in the adjacent joints in the years to come.
36On 23 February 2010, the plaintiff was examined by Dr John Carmody, a consultant Neurologist. The focus of the consultation was the plaintiff's slowly worsening distal bilateral paraesthesia involving the soles of his feet. This was diagnosed as being mild distal sensory peripheral neuropathy, an unrelated condition. No active treatment was recommended.
2011
37On 11 January 2011, at the request of his solicitors, the plaintiff was re-examined by Dr Bodel, who confirmed his earlier findings on examination He recorded that the plaintiff still complained of pain, stiffness and swelling in the right foot and difficulty standing and walking because of aggravation of the pain. He also observed that the plaintiff's fourth toe was now crossing underneath the third toe, which was causing him some extra difficulty. He expressed a guarded prognosis because of the nature of the injuries.
38On 16 February 2011, at the request of his solicitor, the plaintiff was re-examined by Dr Conrad. Dr Conrad reported that the plaintiff's condition had remained unchanged since the previous examination in 2009, and he noted the plaintiff's ongoing complaints of pain and stiffness in the right foot, with a tendency for the foot to swell. He reported difficulty with activities such as walking, standing, negotiating stairs, sitting and driving. Dr Conrad reported that his examination of the plaintiff revealed him to have very little movement in the toes of his right foot.
39On 1 March 2011 the plaintiff underwent radiological examination of his lumbar spine, his pelvis and left hip. This was at the request of Mr Michael Ward, a chiropractor. The findings on that examination revealed a minor lumbo-sacral scoliosis, some minor spondylosis and facet joint arthrosis. Minor osteoarthritis was noted to be present in the left hip.
40On 15 March 2011, Dr Turner referred the plaintiff to Dr Horsley, an orthopaedic surgeon. Dr Horsley saw the plaintiff on 28 March 2011 and noted the plaintiff had moderate arthritis in the left hip. Dr Horsley did not recommend left hip replacement surgery at that time. He had replaced the plaintiff's right hip some 5 years earlier.
41On 21 June 2011, at the request of his solicitor, the plaintiff was examined by Mr Stewart Hayes, a podiatrist, for the purpose of biomechanical gait analysis. Bilateral rigid foot function was diagnosed, the right foot being worse than the left. Orthotics and a plan of management was identified.
42In July 2011, at the request of the solicitor for the defendant, Dr Ginsberg provided a commentary on the plaintiff's "current" problems. He did so in answer to a letter which was not in evidence. Dr Ginsberg said he found it difficult to concede that the plaintiff's left hip problems had occurred due to increased usage following the right foot injury. Dr Ginsberg's opinion was not supported by detailed reasons, and there was no acknowledgment of the Expert Witness Code.
43Dr Turner saw the plaintiff again on 25 November 2011, 17 and 24 January 2012, and 8 February 2012. A referral was made to Dr Cadden, at Wollongong, concerning the ongoing problems the plaintiff was experiencing with his feet.
2012
44On 8 February 2012, the plaintiff underwent further radiological scanning. The surgical hardware in the right foot was described as being intact and the fusions were described as being solid. Various sites of degenerative change in the foot were identified, as well as partial fusion between the bases of the second and third toes was described. Significantly, there was mild anterior subluxation of the proximal phalanges of the second, third, fourth and fifth toes. Some degenerative changes were also noted in the left foot. There was no indication that the x-ray changes seen in the left foot were symptomatic.
45On 15 February 2012, at the request of Dr Turner, the plaintiff consulted Dr Anthony Cadden, an orthopaedic foot and ankle surgeon. This consultation was a follow up consultation. Dr Cadden had apparently seen the plaintiff some two years earlier. There were no reports from Dr Cadden tendered in evidence concerning those earlier consultations. Dr Cadden noted the plaintiff had continuing swelling in the right foot, with decreased sensation in the foot, and the presence of solid fusion. He also noted a likely area of incomplete fusion between the bases of the first and second metatarsal region. Dr Cadden stated that the plaintiff's ongoing right foot pain was not an unexpected consequence. He also noted that the plaintiff's underlying neuropathy was confounding some of his other symptoms of pain and swelling in the right foot.
46On 15 February 2012 at the request of his solicitor, the plaintiff was examined by Dr Conrad for a third time. On this occasion Dr Conrad stated that the plaintiff's condition had deteriorated. In addition to the ongoing complaints of pain and stiffness in the right foot and ankle due to his hindfoot fusion, and irregular gait, the plaintiff had developed pain and stiffness in his left hip. X-rays of that hip revealed prominent degenerative changes. Dr Conrad also stated that the changes in the plaintiff's gait have produced a secondary right knee strain and substantial activation of symptoms in the plaintiff's arthritic left hip.
47Dr Conrad noted that the plaintiff had seen Dr Horsley, an orthopaedic surgeon, who had foreshadowed an eventual hip replacement procedure.
48On 1 March 2012 Dr Horsley saw the plaintiff, again at the request of Dr Turner, 6 years post right hip replacement surgery. Dr Horsley noted the plaintiff reported intermittent symptoms of osteoarthritis in the left hip but thought the pain was manageable at that time. He noted that the plaintiff had gained weight in the previous 12 months and suggested weight loss and regular exercise.
49On 2 April 2012, the plaintiff was assessed by Mr Donald Scott, a podiatrist, who confirmed the ongoing need for podiatry treatment as well as for orthopaedic footwear to accommodate his maligned foot.
50On 15 November 2012, at the request of his solicitor, the plaintiff was seen by Dr Conrad for a fourth time. On this occasion the plaintiff's earlier complaints were noted to have continued, but the plaintiff had by this time also developed pain and stiffness in his right knee. Dr Conrad's recommendations for future treatment and other assistance will be examined in the context of the assessment of the claimed heads of damage.
51On 18 December 2012 the plaintiff was re-examined by Dr Ginsberg, this time at the request of the defendant's solicitor. In his report of the same date, which was not objected to despite the absence of an acknowledgment of the Expert Witness Code, Dr Ginsberg commented on the claimed connection between the plaintiff's right foot injury and the deteriorated condition of the left hip. He cast doubt upon such a connection, in the following terms:
"In essence, this claimant has suffered a severe injury to his right foot which has caused him a lot of grief, but once again I must opine that there is no medical evidence at all to endorse the fact that his left hip arthritic condition is as a result of his motor vehicle accident.
I do opine that his left hip condition would have progressed, as it is progressing, had he not had the accident. His last hip x-ray, which was performed on 8/2/12 at Corrimal at the Illawarra Radiology Group, demonstrated that there were moderately prominent degenerative changes in the hip joint with some generalised narrowing, more prominent superolaterally
.
No other abnormalities are seen in the left hip.
A total hip replacement prosthesis is present on the right. The prosthesis appears to sit well in the acetabulum and abnormal lucency is seen around the visualised aspects of the prosthesis.
No focal lesions are seen in the bony pelvic girdle and the girdle appears fairly symmetrical. It is pertinent to note that examination of his left hip today revealed almost symmetrical ranges of movement, ie both hips demonstrated 110° of flexion, he had no internal rotation in the right hip whereas he had 15° in the left, external rotation to 30° right and 40° left, abduction 30° both hips, and adduction 25° right and 30° left.
From this examination today, my clinical impression is that, with an almost normal gait and with his ability to rise from a seated position and also not experiencing severe discomfort during examination of his left hip, his left hip does not require surgical intervention at this stage.
Once again, I need to emphasise the fact that I do not believe that the deterioration in the left hip is related in any way to the fracture dislocation of his right foot. He shows a normal predilection for arthritic hips and I therefore stand by my original statement that his left hip arthritis would have occurred anyway whether he had a injury to his right foot or not."