Ramadan Hajdini v. Hyatt Regency St. Louis at the Arch

Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION

(Affirming Award and Decision of Administrative Law Judge with Supplemental Opinion)

**Injury No.:** 15-052459

**Employee:** Ramadan Hajdini

**Employer:** Hyatt Regency St. Louis at the Arch

**Insurer:** New Hampshire Insurance Company

This workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by § 287.480 RSMo. Having reviewed the evidence, read the parties' briefs, and considered the whole record, we find that the award of the administrative law judge allowing compensation is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Law. Pursuant to § 286.090 RSMo, we affirm the award and decision of the administrative law judge with this supplemental opinion.

The idiopathic conditions of thrombophilia and synovial chondromatosis are not causally connected to the work injury.

Section 287.020.3(1) RSMo provides a definition of a compensable injury:

> "Injury" is hereby defined to be an injury which has arisen out of an in the course of employment. An injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and the disability. "The prevailing factor" is defined to be the primary factor, in relation to any other factor, causing both the resulting medical condition and disability.

(Emphasis in original).

The resulting medical condition and disability from the July 19, 2015, work accident was a right knee contusion, as diagnosed by Dr. John Krause. We find Dr. Krause to be persuasive in his diagnosis and in his opinion that thrombophilia and synovial chondromatosis were not caused by the work injury. The work accident was the prevailing factor in causing only a right knee contusion.

Section 287.140 RSMo provides in relevant part:

> ...employer shall provide such medical, surgical, chiropractic, and hospital treatment ... as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury.

Employee suffered an isolated deep vein thrombosis (DVT) and pulmonary embolism (PE) in late 2015, which may have reasonably flowed from the surgery performed to address his knee symptoms after the work injury. It was therefore, appropriate to treat those incidents flowing from the surgery which was reasonably undertaken to address the suspected meniscus tear. However, there is no persuasive evidence that the work injury caused the idiopathic condition of thrombophilia, which resulted in the singular incident of DVT and PE. As of January 7, 2016, these conditions were not present as determined by objective evidence, a CT scan. Employee testified that he is no longer on anticoagulant medication, aside from a baby aspirin. Transcript,

Injury No.: 15-052459

Employee: Ramadan Hajdini

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page 15. We are not persuaded of the need for continuing or future medical treatment of these conditions resulting from the work injury.

We note the opinion of Dr. Anthony Shen, a pulmonologist, in his two paragraph letter of May 12, 2016, that the prevailing factor¹ of employee's lifetime need for anticoagulation for clot precaution was his work related knee injury. We are not persuaded by Dr. Shen's opinion.

As to the second condition, synovial chondromatosis (rice bodies), we adopt the opinion of Dr. Krause, as confirmed by Dr. Richard Lehman, that the synovial chondromatosis is an idiopathic condition. As such, any injury resulting directly or indirectly from idiopathic causes, is not compensable. § 287.020.3(3) RSMo. We are persuaded by Dr. Krause's opinion that rice bodies is not a condition caused by trauma and it is not causally connected to the work injury. Employer has borne the costs (and employee received the benefit) of the debridement, which was achieved during the surgery intended to repair the suspected meniscus tear. However, no further treatment for this idiopathic condition is reasonably required to cure and relieve the effects of the work injury.

**Conclusion**

We affirm and adopt the award of the administrative law judge as supplemented herein.

The award and decision of Administrative Law Judge Joseph P. Keaveny is attached and incorporated herein to the extent not inconsistent with this supplemental decision.

We approve and affirm the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law.

Given at Jefferson City, State of Missouri, this 10th day of January 2020.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

Robert Cornejo, Chairman

Reid K. Forrester, Member

SEPARATE OPINION FILED

Curtis E. Chick, Jr., Member

Attest:

Secretary

¹ While Dr. Shen and other doctors in this record use the term, "prevailing factor," it is not necessary to find the accident to be the prevailing factor in the need for treatment, once a compensable injury is found.

Injury No.: 15-052459

Employee: Ramadan Hajdini

The majority has voted to affirm the administrative law judge's award of 6 % permanent partial disability to the right knee and no future medical treatment. I agree that employee has suffered a permanent partial disability to his knee, but I disagree as to the nature and extent of the disability and the ruling regarding future medical treatment.

In line with employee's independent medical examiner, Dr. D. Wade Hammond, I would find employee suffered a 25 % permanent partial disability. Dr. Hammond noted the continuing problems and severity of disability that employee experiences with his right knee, and he opined that employee may very well require further medical and/or surgical intervention to alleviate his symptoms. I find Dr. Hammond to be more persuasive as to the extent of his disability flowing from the work injury to the right knee.

Likewise, employee provided persuasive evidence through the opinion of Dr. Richard Lehman, that the synovial chondromatosis (rice bodies), is causally connected to the work injury. I would adopt his opinion that the work injury aggravated the underlying synovial disease and resulted in further changes and post-traumatic issues in the knee. *Transcript*, pages 380, 381.

I also disagree with the majority and the administrative law judge on the need for future medical treatment which flows from the work injury.

The statute instructs us that: An injury is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability. (§ 287.020.3) It further states that the "prevailing factor" is the primary factor, in relation to any other factor, causing both the resulting medical condition and disability. However, in terms of future medical treatment the "prevailing factor" is not a necessary step in analysis.

*Tillotson* makes it clear that once it is established that there is a compensable injury, the issue of "prevailing factor" is no longer in question. The "prevailing factor" test need not be applied to the medical treatment that flows from the injury. *Tillotson v. St. Joseph Medical Center*, 347 S.W. 3d 511 (Mo. App. W.D. 2011). The deep vein thrombosis (DVT) and the pulmonary embolism experienced by employee are causally related to his work injury in that the reasonable treatment for the work injury brought on these conditions. Dr. Hammond notes the close proximity (15 days) between the surgery and the development of the DVT, which "suggests that this is directly related to the arthroscopic surgery." *Transcript*, page 379.

Employee has provided further support for his position through the opinion of Dr. Anthony Shen, the only pulmonologist reviewing the medical evidence, who unequivocally states employee will require lifetime anticoagulation¹ for clot precaution and that the need for this treatment flows from his work related knee injury with a reasonable degree of medical certainty.

In regard to future treatment for synovial chondromatosis, Dr. Lehman notes employee continues to suffer pain from that condition as a result of the work injury, and therefore it is reasonably probable that future medical treatment be required.

¹ I believe the fact that employee may have had his medication reduced to baby aspirin at a particular period in time is irrelevant. This still is indicative of the need to take precautions to monitor and address a blood clot problem.

Employee: Ramadan Hajdini

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Therefore, I respectfully dissent from the majority and would modify the award, as I have set forth.

Curtis E. Chick, Jr., Member

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law? Yes
4. Date of accident or onset of occupational disease: July 19, 2015
5. State location where accident occurred or occupational disease was contracted: St. Louis City
6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of the employment? Yes
9. Was claim for compensation filed within time required by Law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: While pulling a cart of tables, a table slipped off the cart and struck Employee on the knee.
12. Did accident or occupational disease cause death? No
13. Part(s) of body injured by accident or occupational disease: Right knee
14. Nature and extent of any permanent disability: 6% right knee
15. Compensation paid to-date for temporary disability: $5,302.40
16. Value necessary medical aid paid to date by employer/insurer? $46,987.60

Revised Form 31 (3/97)

Page 1

1. Value necessary medical aid not furnished by employer/insurer? N/A
2. Employee's average weekly wages: $\ 1,242.45
3. Weekly compensation rate: $\ 828.30 TTD/ $\ 464.58 PPD
4. Method wages computation: Stipulation

1. Amount of compensation payable:

$\ 4,459.97

1. Second Injury Fund liability: No

TOTAL:

$\ 4,459.97

1. Future requirements awarded:

N/A

Said payments to begin immediately and to be payable and be subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant: Scott L. Kolker

On May 7, 2019, the parties appeared for a hearing at the Missouri Division of Workers' Compensation, St. Louis Office ("Division"). Ramadan Hajdini ("Employee") appeared in person and with counsel (Scott L. Kolker). Hyatt Corporation ("Employer") and New Hampshire Insurance Company ("Insurer") were represented by Brian McBrearty.

1. The Employer, Hyatt Corporation, was operating subject to Missouri's Workers' Compensation Law on or about July 19, 2015.
2. Ramadan Hajdini was an employee at all times herein.
3. The Employer was provided notice of the Employee's alleged injury and the Report of Injury was timely filed.
4. St. Louis, Missouri is the proper venue.
5. Employee's average weekly wage is 1,242.45.
6. Applicable rates of compensation are 828.30 for TTD and 464.58 for PPD.
7. Employer paid 46,987.60 in medical expenses and $5,302.40 in TTD benefits.

Claimant introduced, and had admitted into evidence, the following Exhibits:

1. Concentra medical records
2. Cedar Imaging records
3. Medical records - John Krause, M.D.
4. Medical records - The St. Louis Spine and Orthopedic Surgery Center
5. Medical records - Missouri Baptist Medical Center
6. Medical records - St. Anthony's Medical Center
7. Medical records - Alexander Mammen, M.D.
8. Medical records - Anthony Shen, M.D.
9. Report from D. Wade Hammond, M.D.

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Injury No.: 15-052459

10) Medical records - The Work Center, Inc.

11) Deposition of Dr. Richard Lehman dated March 7, 2019

Employer/Insurer introduced, and had admitted into evidence, the following Exhibits:

1) Deposition of John Krause, M.D., dated November 9, 2018

2) Reports and treatment records of John Krause, M.D.

ISSUES

1) Medical causation.

2) Additional medical treatment.

FINDINGS OF FACT

At the time of the hearing, Employee was 51 years old. He does not speak English and had to depend on a translator during his interviews and at trial. He is Albanian and immigrated to the United States on April 7, 1997. He has been working as a server for Hyatt Corporation since 2007.

On July 19, 2015, after he had finished serving the breakfast buffet, he was breaking down tables and loading them onto a cart. He and his captain were moving the tables to a different location. It took two people to move the cart. The captain was pushing and Employee was pulling. A table came off the cart and struck Employee squarely on the front of the right knee. His captain filled out the Report of Injury.

On July 20, 2015, Employee was sent to Concentra by taxi. Concentra ordered an MRI. After the MRI was taken, Employee was referred to Dr. John Krause. On September 21, 2015, after review, Dr. Krause thought the MRI looked normal. He thought the menisci were intact with moderate effusion and he diagnosed him with a knee contusion with patellofemoral symptoms. Dr. Krause aspirated the fluid in his knee and administered a cortisone injection. Dr. Krause gave Employee a home exercise program.

On October 5, 2015, Dr. Krause examined Employee at a follow-up visit of his right knee pain. He noted that Employee got good relief from the injection, but not complete relief. Employee has been working full duty and still gets aching primarily around his patella. Dr. Krause noted: "Employee has satisfactory overall alignment. There is minimal effusion in his knee. He comes to full extension. He has full flexion. He has tenderness diffusely around his patellofemoral joint. He has no true medial joint line tenderness. He has significant laxity." Dr. Krause told Employee that there was nothing overly concerning about his exam or MRI. The MRI report indicated a possible medial meniscus tear. Dr. Krause noted no definite tear on the MRI and Employee does not have symptoms localized to his medial meniscus. Dr. Krause released him to full duty with no restrictions.

On October 30, 2015, after examining Employee, Dr. Krause noted that he had markedly increased swelling and continued to have pain with activities. Employee denied having a new

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injury. Dr. Krause concluded: "Given the patient's MRI and his symptoms today, I think he does have a meniscus tear and I recommend surgical treatment."

Dr. Krause took Employee to surgery on November 10, 2015. There was noted to be normal articular cartilage and the medial meniscus was probed. There was no identifiable tear and the meniscus was stable and the decision was made not to proceed with meniscal treatment. There were rice bodies in the articular spaces which were evacuated.

On November 25, 2015, Dr. Krause examined Employee for follow-up of his right knee. Dr. Krause noted: "Employee did not have a meniscus tear. He had some loose cartilaginous fragments in his knee. They were read as hypersynovial hyperplasia on pathology. Since the surgery he has developed deep vein thrombosis and has been on Xarelto. He noted that he has been having difficulty breathing and chest type pain." Dr. Krause recommended a CT scan to rule out a pulmonary embolism and a course of physical therapy.

At a January 13, 2016 examination, Dr. Krause noted that Employee was being evaluated by Anthony Shen, M.D., who diagnosed deep vein thrombosis and pulmonary embolism. It appeared that they were going to do a hypercoagulable workup. It was also noted that Employee had a history of diabetes mellitus, hypertension, and an anxiety disorder.

February 1, 2016 was Employee's last follow-up with Dr. Krause for his right knee. Dr. Krause reports that Employee has been doing physical therapy at the Work Center and has made satisfactory progress. He has been treating with Dr. Shen for his clotting disorder. Employee reports that he needs to be on Coumadin for the rest of his life. Dr. Krause reviewed patient's labs from Missouri Baptist dated January 13, 2016. Patient "was negative for the Lupus anticoagulant but was heterozygous for the Factor V Leiden mutation. He was negative for Cardiolipin Antibodies." Dr. Krause had no further recommendations for Employee's knee. He, again, noted that Employee continued to treat for his deep vein thrombosis and pulmonary embolism by Dr. Shen. He placed Employee at maximum medical improvement regarding his injury dated July 19, 2015. Dr. Krause opined: "Based on the patient being heterozygous for Factor V Leiden mutation, it is my opinion to a reasonable degree of medical certainty that the injury dated 7/19/15 is not the prevailing factor in the patient's deep vein thrombosis, pulmonary embolism or need for treatment. It is his inherited thrombophilia that is the prevailing factor in the patient's deep vein thrombosis, pulmonary embolism and need for treatment."

Opinion Evidence

Richard Lehman, M.D.

Claimant offered, and had admitted, the deposition and medical reports of Dr. Richard Lehman (Claimant's Exhibit 11). Dr. Lehman is a medical doctor specializing in orthopedics, subspecialty in sports medicine. He prepared a report dated November 11, 2017 (Claimant's Exhibit 11). After conducting an extensive record's review and physical examination, he opined that Employee continues to have problems in his knee.

He noted: "Patient did have a biopsy from his arthroscopic surgery, which shows fragmentation of the synovium with synovial cell hyperplasia as well as circumscribed fragments

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of hyaline cartilage with lobules of chondrocytes without atypia or activity. The appropriate clinical context are consistent with synovial chondromatosis. He reviewed a prior MRI and, it would be his opinion, that at this juncture, Employee is going to require a repeat MRI of his knee with contrast. He believes that Employee will need to be treated either with PRP injection and possible stem cell injection to resolve the breakdown of the patellofemoral joint or an arthroscopic evaluation with an articular cartilage reconstruction or BioCartilage reconstruction.

It is Dr. Lehman's opinion that the Employee's work-related injury of July 19, 2015 is the prevailing factor causing continued problems and the need for causing further workup and possibly further treatment. The large effusion is a problem and has continued to be unchanged over a long period of time, suggesting that there is still intraarticular damage with ongoing effusion.

In his deposition dated March 7, 2019 (Claimant's Exhibit 11), Dr. Lehman identifies three treatment options. One option would be biologic, which would be stem cell type injections. Another option would be to reconstruct the cartilage (BioCartilage) on the back surface of the kneecap. And the last option would be strengthening the knee, the quadriceps, hamstrings, and gluteal muscles, to take the pressure off the joint and see if he could "unload" the joint surfaces.

D. Wade Hammond, M.D.

Claimant offered, and had admitted, the Independent Medical Examination (IME) of D. Wade Hammond, M.D., (Claimant's Exhibit 9). He conducted the examination, summarized the medical records and issued the report on May 31, 2017. Dr. Hammond found Employee continues to have difficulties with his right knee, however, he is still working. He finds it difficult to walk more than a city block without some difficulty. He has problems walking downhill, and he finds it difficult to kneel or bend down. He is unable to run, and he has problems climbing and descending stairs. He says he sometimes has difficulty driving because he has problems applying the brakes. He said that initially following the knee surgery he made relatively satisfactory progress.

Dr. Hammond concluded that Employee sustained a significant contusion to his knee which, ultimately, led to an arthroscopic procedure and debridement. Employee developed deep vein thrombosis which resulted in pulmonary emboli. These latter problems have stabilized, and appear to be gradually clearing.

Dr. Hammond opined that Employee's initial knee injury, ultimately, accounted for a permanent partial disability of 25% of the function of his right lower extremity. Because of the ongoing problems that Employee continues to experience, it is his opinion that sometime in the future Employee might very well require further medical and/or surgical management to alleviate his ongoing symptoms.

John O. Krause M.D.

Employer/Insurer offered, and had admitted, the medical records (Employer's Exhibit 2) and deposition (Employer's Exhibit 1) of John O. Krause, M.D. Dr. Krause is a board certified orthopedic surgeon specializing in the lower extremity. Employee clearly suffered a right knee

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contusion on his injury dated July 19, 2015. Throughout the course of treatment he had patellofemoral symptoms. He had normal patellofemoral tracking arthroscopically and normal articular cartilage at his patellofemoral joint. On February 1, 2016, Dr. Krause placed Employee at MMI.

Dr. Krause further opined, the MRI/arthrogram that Dr. Lehman recommends is reasonable to evaluate for further synovial chondromatosis or rice bodies. The medical records are clear that the need for the MRI is unrelated to his injury of July 19, 2015. Synovial chondromatosis is not caused by trauma. The condition occurs spontaneously and is not inherited. The cause of synovial chondromatosis is unknown. Rice bodies in the knee are, typically, related to rheumatoid arthritis of tuberculous arthritis. Employee does not have a history of tuberculous or rheumatoid arthritis. Given Employee's history and pathology report, synovial chondromatosis may be the correct diagnosis. In any event, neither of these diagnoses are related to his injury of July 19, 2015. It is Dr. Krause's opinion to a reasonable degree of medical certainty that the injury dated July 19, 2015 is not the prevailing factor in Employee's synovial chondromatosis or rice body formation in the knee.

Dr. Krause does not believe that Employee's deep vein thrombosis and pulmonary embolism are primarily related to the arthroscopic procedure. Employee has a newly diagnosed hypercoagulable clotting mutation which is inherited. The medical literature is clear that Factor V Leiden mutation is the primary reason that patients develop deep vein thrombosis and pulmonary embolism following a procedure. It is Dr. Krause's opinion to a reasonable degree of medical certainty that the injury dated July 19, 2015 and the subsequent surgery are not the prevailing factor in Employee's deep vein thrombosis and pulmonary embolism. It is his opinion that Employee's inherited Factor V Leiden mutation is the prevailing factor in Employee's hypercoagulable state and his deep vein thrombosis and pulmonary embolism.

On May 4, 2017, Dr. Krause rated Employee at 2% permanent partial disability at the level of the knee (160) as a result of his right knee contusion with minimal objective findings.

RULINGS OF LAW

Medical Causation

Section 287.020 provides, in part:

1. (1) In this chapter the term "injury" is hereby defined to be an injury which has arisen out of and in the course of employment. An injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability. "The prevailing factor" is defined to be the primary factor, in relation to any other factor, causing both the resulting medical condition and disability.

(2) An injury shall be deemed to arise out of and in the course of the employment only if:

(a) It is reasonably apparent, upon consideration of all circumstances, that the accident is the prevailing factor in causing the injury; and

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(b) It does not come from a hazard or risk unrelated to the employment to which workers would have been equally exposed outside of and unrelated to the employment in normal non-employment life.

(3) An injury resulting directly or indirectly from idiopathic causes is not compensable. (Emphasis added.)

In the instant case, Employer's expert, Dr. Krause, initially, did not believe there was a meniscus tear and diagnosed a knee contusion. It was only after Employee's complaints and persistent swelling, did Dr. Krause perform surgery. The arthroscopic surgery revealed no meniscus tear but an idiopathic condition known as synovial chondromatosis. This manifests itself as small pieces of cartilage that float in the knee. Dr. Krause debrided the knee and, ultimately, released Employee to full duty with no restrictions.

Claimant argues that Employee did not have this condition before sustaining the knee contusion and, because he has it now, it must be as a result of the contusion. I find this argument unpersuasive. Both experts have testified that this condition is idiopathic. Synovial chondromatosis cannot be reasonably stated to "flow" from the reported injury. Employer's expert, Dr. Krause, testified further that it is not caused by trauma. Therefore, I find that Employee suffered a right knee contusion. It is reasonable, and I so find, that Employee suffered a 6% permanent partial disability to the right knee for the injury dated July 19, 2015.

Additional Medical Treatment

Section 287.140 provides, in part:

1. In addition to all other compensation paid to the employee under this section, the employee shall receive and the employer shall provide such medical, surgical, chiropractic, and hospital treatment, including nursing, custodial, ambulance and medicines, as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury.

In determining whether medical treatment is "reasonably required" to cure or relieve a compensable injury, it is immaterial that the treatment may have been required because of the complication or preexisting conditions, or that the treatment will benefit both the compensable injury and the preexisting condition *Tillotson v. St. Joseph Med Ctr., 347 S.W. 3d 511,519 (Mo.App.W.D.2011)*. Rather, once it is determined that there has been a compensable accident, Claimant need only prove the need for treatment and medication flow from the work injury.

It is uncontroverted that Employee suffered a direct trauma to the knee which resulted in an initial diagnosis of knee contusion with patellofemoral symptoms. It was only after continued swelling and persistent complaints did Dr. Krause perform surgery. The surgery revealed that there was no meniscus tear. The resultant treatment was an examination of the knee and debridement of the rice bodies that manifest from the synovial chondromatosis.

As, found above, synovial chondromatosis is an idiopathic condition. Employer's expert, Dr. Krause, testified that it was (Employer's Exhibit 1, page 11) and Claimant's expert, Dr.

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Lehman, confirmed it (Claimant's Exhibit 11, page 22). Dr. Krause debrided Employee's right knee during his arthroscopic examination. Therefore, it is reasonable, and I find, that Employer has fulfilled its obligation under Tillotson. There is insufficient evidence to impose liability on Employer for further treatment for the idiopathic condition.

On November 16, 2015, after the surgery on his knee, Employee developed deep vein thrombosis (DVT) and a pulmonary embolism (PE). He was prescribed Xarelto. On January 7, 2016, Employee underwent a CT scan of his chest. There was evidence of a fatty liver. There was no evidence of pulmonary embolism and no evidence of deep vein thrombosis. Therefore, it is reasonable, and I find, that Employee is not entitled to future medical care for this condition.

Employer is liable for 9.6 weeks of permanent partial disability and no future medical treatment.

I certify that on 6-18-19 I delivered a copy of the foregoing ewerd to the parties to the case. A complete record of the method of delivery and date of service upon each party is retained with the executed award in the Division's case file.


Made by:

Joseph P. Keaveny

Administrative Law Judge

Division of Workers' Compensation