Citation Nr: 1340911 Decision Date: 12/11/13 Archive Date: 12/20/13 DOCKET NO. 09-34 669 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUE Entitlement to compensation under the provisions of 38 U.S.C.A § 1151 (West 2002) for residuals due to complications of a right hip replacement surgery. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1973 to May 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. Jurisdiction over this appeal was subsequently transferred to the RO in Wilmington, Delaware. In April 2013, the Veteran testified at a hearing held before the undersigned Veterans Law Judge (VLJ) sitting at the RO. A transcript of the hearing has been associated with the record. At the time of the April 2013 hearing, the Veteran submitted additional evidence directly to the Board, along with a waiver of initial RO consideration of the evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2013). This appeal was processed using the Virtual VA and VBMS paperless claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. FINDING OF FACT The probative, competent evidence does not demonstrate that the June 2007 VA medical treatment resulted in an additional disability that was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing this medical treatment, or an event not reasonably foreseeable. CONCLUSION OF LAW The criteria for compensation under 38 U.S.C.A. § 1151 for additional disability as a result of a June 2007 VA right hip replacement surgery have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 3.361 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman, 19 Vet. App. at 486. This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a July 2007 letter, prior to initial adjudication of the issue, the Veteran was notified of the evidence needed to substantiate the claim of entitlement to compensation under 38 U.S.C.A. § 1151, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. In general, when a claimant experiences additional disability as the result of hospital care, medical or surgical treatment, or examination furnished by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151. Although the Veteran was not apprised of the criteria for consideration in the assignment of a disability rating and effective date in the event of an award of the benefit sought, the Board finds that the Veteran is not prejudiced in this regard. As the appeal is denied herein, the benefit sought is not granted, and there is no disability rating or effective date for assignment. Duty to Assist VA has also satisfied its duty to assist the Veteran at every stage of this case. The Veteran's claims file contains his service treatment records, lay statements, VA treatment records, and identified private treatment records pertinent to the claim on appeal. The Veteran underwent a VA joints examination in March 2008. In addition, in September 2008, a VA orthopedic surgeon, Dr. J. Esterhai, provided an opinion in connection with the Veteran's claim. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). After reviewing the medical opinions, the Board found them inadequate and therefore remanded the Veteran's claim in July 2013 for additional development. Specifically, the Board requested that Dr. Esterhai, or a suitable substitute, determine whether any additional disability caused by complications of the right total hip arthroplasty was related to any deficiency in VA medical treatment. Accordingly, an independent medical opinion was provided in September 2013 by the Medical Officer at the VA Appeals Management Center (AMC). Upon review, the Board finds the September 2013 VA opinion adequate for the purpose of determining entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for residuals due to complications of a right hip replacement surgery. The VA examiner reviewed the Veteran's relevant medical history and lay statements and provided an opinion as to the clinical findings. In addition, the VA examiner provided an adequate rationale for the opinion, with citation to the records and current medical literature. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). As such, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). In addition, the Board finds the RO substantially complied with the Board's remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the elements of the claim that were lacking to substantiate the claim of entitlement to compensation under 38 U.S.C.A. § 1151. The VLJ asked questions to ascertain the surgical procedures performed and the extent of any post-surgery symptoms. The VLJ also solicited information to determine whether there existed pertinent evidence that might have been overlooked and that might substantiate the claim. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. The Veteran has not suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As all relevant facts have been properly and sufficiently developed in this appeal, no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria The law provides that compensation may be paid for a qualifying additional disability not the result of the veteran's willful misconduct, caused by hospital care, medical or surgical treatment, or examination furnished the veteran when the proximate cause of the disability was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not recently foreseeable. 38 U.S.C.A. § 1151. VA regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability due to hospital care, medical or surgical treatment, or examination, require actual causation not the result of continuance or natural progression of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361. If additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the veteran's additional disability. See 38 C.F.R. § 3.361(c)(1). In addition, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). It must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the informed consent of the veteran or the veteran's representative. Whether the proximate cause of a veteran's additional disability or death was an event not recently foreseeable is to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d). Analysis The Board has an obligation to provide adequate reasons and bases supporting its decision; however, there is no requirement that the evidence submitted by the veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the issue on appeal. Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran asserts that he is entitled to compensation under 38 U.S.C.A. § 1151 for residual disability due to complications of a June 2007 right hip replacement surgery at the VA Medical Center (VAMC) in Philadelphia, Pennsylvania. Specifically, he claims that while undergoing the right hip replacement surgery on June 14, 2007, his pelvis was fractured, and as a result, his right knee and leg have turned inward. During the April 2013 Board hearing, the Veteran testified that due to the tilting of his pelvis, which resulted from the fracture status-post right hip replacement surgery, two discs of his lower lumbar spine are out of place. He also contends that post-surgical treatments provided by VA were not appropriate in that physical therapy was not timely administered and as a result, he developed atrophy in his right leg that eventually caused nerve damage. The medical evidence shows the Veteran underwent right hip total replacement surgery on June 14, 2007 at the VAMC in Philadelphia, Pennsylvania and that the surgery was complicated by an intraoperative acetabular fracture. Subsequently, the Veteran was sent to the VAMC in Wilmington, Delaware for rehabilitation evaluation and placement. He was discharged in July 2007 to follow-up by the visiting nurse and the primary care physician. A June 14, 2007 operation report shows the Veteran was taken into the operating room and underwent placement of general endotracheal anesthesia. He was given 2 grams of Ancef for preoperative prophylaxis. He was placed in a right lateral decubitus position. The right lower extremity was prepped and draped in a sterile fashion. At this point, a 10 centimeter frayed incision was made from the tip of the greater trochanter posteriorly. Sharp dissection was taken down to the tensor fascia lata. The tensor fascia lata was incised with Metzenbaum scissors - this revealed the lateral aspect of the greater trochanter. The bursa of the greater trochanter was removed - this revealed the piriformis tendon. Using a Bovie, the piriformis tendon was taken down and two tagged stitches of No. 5 Tevdek were placed. The dissection was taken further down to the posterior aspect of the femoral neck, down to the capsular level. Tag sutures were also placed in the capsule. At this point, the femoral head was dislocated without difficulty - care was taken to avoid fracture of the femur while dislocating. At this point, using a reciprocating saw, the femoral neck was osteotomized. Attention was now turned to the acetabulum. An anterior double-angled Hohmann retractor, followed by an Antler retractor, was placed. This revealed excellent exposure of the acetabulum. Using a long Bovie, the pulvinar tissue was removed. Using a long-handled knife, the labral tissue was also removed. At this point, reaming commenced. A 44 size reamer was used to medialize the acetabular component. Sequential reaming was taken up to a size 54 reamer. A size 54 cup was then attempted to be placed. However, while the cup was being placed, it was noted that an acetabular fracture had been created by the force from placement of the cup. Therefore, a decision was made to ream up to a larger size and place a larger acetabular component. Therefore, a size 58 component was placed with a multihole configuration. Six acetabular screws from size 15 to 25 were placed in the face zones of the acetabular quadrants. This revealed excellent fixation of the acetabular component. At this point, an acetabular liner was placed with a 10 degree elevated lip. Attention was now turned to the proximal femur. Using a boxed osteotome, the lateral femoral neck was removed. Sequential broaching was taken up to a size 15 ML taper stem, which had excellent fit. A size 15 stem was placed. At this point, a trial was placed with a size 36 ball head with a +3.5 configuration. This revealed excellent stability of the configuration. Therefore, this component was removed and a size 15 Zimmer stem was placed. This was followed by the 36 size ball head with a +2.5 configuration. This again was taken through a range and had excellent stability. At this point, drill holes were placed in the lateral greater trochanter, and the tag sutures from the piriformis and capsular tissue were placed to reapproximate the posterior soft tissue repair of the proximal femur. The tensor fascia lata was then closed with a zero Vicryl suture, the deep fat was closed with a zero Vicryl suture, and the skin was closed with a 2-0 Vicryl suture and staples. The Veteran awoke from surgery without difficulty. He was neurovascularly intact. He was to be non-weight bearing on the right lower extremity for a period of six weeks to allow healing of his acetabular fracture. A June 26, 2007 discharge summary shows the Veteran's hemoglobin had remained stable after post-operative transfusion and that he had been medically stable while on the floor. He had a new set of X-rays of both his hip and knee, which were unchanged from the films taken immediately post-operation. He had skin staples in his right hip, which could be removed any day between June 28, 2007 and June 5, 2007 with steri-strips placed over the wound. He was to follow-up with orthopedics in Philadelphia with new X-rays and the possibility of advancing his weight bearing status at that time. X-ray examination in June 2007 revealed position and alignment of bony structures and surgical devices in satisfactory condition. The right gluteus maximus muscle was very enlarged and edematous with significantly increase in Housfield unit. The findings were compatible with hemorrhage in the right gluteus maximus muscle. A July 5, 2007 discharge summary indicates that on admission to the VAMC in Wilmington, Delaware, the Veteran complained of right hip pain secondary to operation, for which he had been getting dilaudid and valium, and recent onset right lower extremity swelling. Physical therapy was initiated and pain was treated. The Veteran was also seen by surgery, and staples were removed with steri-strips placed. During the admission, the Veteran exhibited many behavioral issues, was disruptive on the floor and to other patients, and was not accepted by the nursing home care unit because of behavior warning. The staff was concerned about the safety and well-being of other residents, as security and police were called on several occasions. As the Veteran did not have any need for acute care medical facility, arrangements were made for the Veteran to return home for physical therapy to be set up with a Community Nurse. The Veteran was provided a VA joints examination in March 2008. The Veteran complained of pain in the right hip and reported that he could not stand for more than 15 minutes due to pain and that he could only walk one block because of the pain. The diagnoses were right hip injury with degenerative joint disease and avascular necrosis status-post right hip replacement, complicated by intraoperative acetabular fracture, and claimed right leg condition secondary to right hip replacement. The examiner opined that there was disability caused by the intraoperative fracture of the acetabulum; the Veteran was not allowed to be weight bearing for several weeks. It was noted that attempts were made to enroll the Veteran in a nursing home, but due to his inability to cooperate, he was discharged to his home. The examiner noted that the intraoperative fracture increased the length of time the Veteran was homebound, with significant effects on him. In support of this opinion, the examiner further noted that an acetabular fracture is a significant liability and that the Veteran could not ambulate until the fracture had healed appropriately. An April 2008 private treatment record indicates that a private physician reviewed the imaging reports, surgical report, and the Veteran's history. The private physician believed that the pelvic tilt and leg length discrepancy may be related to the intraoperative trauma that created the reported acetabular fracture. The Veteran reported no prior history of a leg length discrepancy or pelvic tilt, and there was nothing in the records that showed findings of a pelvic tilt or leg length discrepancy. The records indicate the Veteran underwent curative physical therapy. In August 2008, the RO provided the Chief of Staff of the Philadelphia VAMC with the Veteran's VA and private medical records, as well as his statements, and requested that an investigation be conducted to determine whether the Veteran's intraoperative acetabular fracture resulted from carelessness, accident, negligence, lack of proper skill, error in judgment, or similar instances of fault on the part of the VA without informed consent, or an event not reasonably foreseeable. In a September 2008 statement, Dr. Esterhai stated that during the June 2007 surgery, a non-displaced fracture of the acetabulum was created. According to Dr. Esterhai, the fracture was noted immediately and addressed appropriately with multiple fixation screws through the acetabular shell. Dr. Esterhai noted that during admission the Veteran exhibited behavioral issues and was not accepted by the nursing home care unit because of his behavior warnings. Dr. Esterhai opined that "[b]oth the femur and the acetabulum can be fractured during a total hip arthroplasty. It is a recognized potential complication in the operating room. Both are specifically mentioned in our informed consent (12.5 attached). In this [V]eteran's surgery it occurred as an event not reasonably foreseen. It was treated appropriately and immediately." Dr. Esterhai further opined that there was no permanent residual deficit for the Veteran related to his June 2007 surgery because he was asked to be non-weight bearing on his hip for six weeks to allow for bone healing. In this regard, the record includes a June 2007 consent form from the Philadelphia VAMC signed by the Veteran, his physician, and a witness, which in pertinent part provides that the known risks of a total hip arthroplasty procedure include associated fractures secondary to the surgical procedure and sciatic nerve injury and its resulting consequences, among others. A March 2013 VA treatment record shows the Veteran reported that his pelvis was broken during surgery, which had left him with chronic pain in his hip, knee, back, and shoulders. A magnetic resonance imaging scan revealed mild, broad-based disc-bulge at the Ll-L2 level, and mild, right-sided neural foraminal narrowing at this level; diffuse broad-based disc bulgate at the L2-L3 and L3-L4 levels, causing mild to moderate bilateral neural foraminal narrowing; mild disc desiccation changes at L1/L2; and normal terminating conus. The diagnosis was chronic back pain from degenerative joint disease. In April 2013, a VA physician, Dr. D. Axon, found the Veteran had right low back pain and lower extremity symptoms that would appear to be predominantly due to neurologic injury. The VA physician stated that the Veteran's reported symptoms following surgery raised the likelihood of sciatic nerve injury during the course of surgery, which was a recognized complication of a posterior approach to the hip for hip replacement. In addition, the Veteran may have been at increased risk for this injury due to his intra-operative acetabular fracture and increased need for retraction during surgery. Additionally, leg lengthening resulting from hip replacement surgery could contribute to intra-operative sciatic nerve injury. Dr. Axon stated that the acetabular fracture was treated appropriately by placement of fixation screws and that radiographically, his acetabular fracture appeared to have gone on to uneventful healing in excellent alignment. Dr. Axon opined that he did not expect symptoms to be arising directly from this fracture. An April 2013 VA consultation note shows the Veteran reported that immediately after the right hip surgery he had pain in the right hip with radicular symptoms into the entire right lower extremity. He also reported numbness and tingling that extended into the lower leg and foot and attributed his ongoing right lower extremity symptoms to his pelvis fracture as a complication of the surgery. A VA orthopedic surgeon opined that based on the Veteran's reported history, it seemed likely that this sciatic nerve was injured during the course of the surgery, and this would account for his radicular symptoms as well as the numbness over the dorsum of his foot and lateral aspect of the leg; however, the surgeon stated that it would be very helpful to have better objective documentation from the medical record regarding the onset of the Veteran's complaints of radicular symptoms into the right lower extremity. Pursuant to the Board's remand, the Medical Officer at the VA AMC provided an opinion in September 2013. Dr. L. Terry-Choyke opined that it is less likely than not that compensation under 38 U.S.C.A. § 1151 is warranted for the Veteran's claimed pelvic fracture. Therefore, it is less likely than not that compensation under 38 U.S.C.A. § 1151 is warranted on the grounds that 'the disability must have been caused by hospital care, medical or surgical treatment, or examination furnished the veteran or the proximate cause of the veteran's disability must be carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA or an event not reasonable foreseeable'. Dr. Terry-Choyke stated that the comprehensive medical review of the clinical files, CAPRI, and current medical literature stood as the foundation for the independent medical opinion. The opinions and clinical recommendations were based on the following clinical evidence: The Veteran underwent elective right total hip replacement in June 2007. Intraoperative complications included an acetabular fracture during placement of the acetabular cup. Dr. Terry-Choke stated that although this was an unfortunate complication, an acetabular fracture is a known complication for this procedure. 'According to the Mayo Clinic Total Joint Registry, fractures occurred in 1% of primary total hip arthroplasties and in 4% of revision procedures... And according to Haidukewych et al. in a review of 7121 primary total hip arthroplasties found a 0.4% prevalence of intraoperative acetabular fracture... Most of the fractures were stable, and the original acetabular component was retained. Components that were thought to be unstable were converted to a different component that allowed supplemental screw fixation. All fractures united, and no revisions were necessary' (Canale & Beaty: Campbell's Operative Orthopaedics, 12th Ed, http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-323-07243-4..00003-7--s0420&isbn=978-0-323-07243-4&sid=1471727341&uniqId=423306329-5#4-u1.0-B978-0-323-07243-4..00003-7--s0420). The informed consent, dated June 14, 2007, properly informed the Veteran of the possible need for a blood transfusion, potentials for infection, fracture and other 'foreseeable' complications to include death. Therefore, the Veteran was given proper informed consent for elective right hip surgery and total joint replacement. In this case, the Veteran's post-operative course included acetabular fracture, additional radiographs, and the need for transfusion. The consent form mirrored the medical literature and confirms these types of intraoperative events and post-operative treatments as foreseeable and known complications of a total hip replacement. Therefore, it is not uncommon to require a blood transfusion and additional radiographic follow-up, and it is at least as likely as not supportive of the 'best practice of medicine' and appropriate treatment by the Philadelphia VA healthcare providers and staff. According to Dr. Terry-Choyke, the discharge summary, dated June 26, 2007, provided appropriate post-operative direction. The summary stated 'the patient's only recourse from the fracture is that he remain non-weight bearing (NWB) on the right lower extremity for a minimum of 6 weeks. His hemoglobin (HGB) has remained stable after post-operative transfusion and he has been medically stable while on the floor. He had a new set of x-rays today of both his hip and knee which were unchanged from the films taken immediately post-operative'. To the contrary, the Veteran chose to disregard these instructions. The July 5, 2007 Wilmington VAMC discharge summary indicated 'inappropriate behavior' on the part of the Veteran following his surgery. Dr. T. Martynowicz stated 'during his admission, patient exhibited many behavioral issues, was disruptive on the floor and to other patients and was not accepted by the NHCU because of behavioral warnings. Staff was concerned about the safety and well-being of other residents, security/policy called on several occasions. Patient had been refused for outside pass and when he was refused, left and returned from pass with UDS positive for marijuana. He went AWOL. Patient did not have any need for acute care medical facility and we attempted to find patient other NH/inpatient rehab but could not be placed, and arrangement were made for patient to return home, for physical therapy to be set up with community nurse.' Therefore, it is as least as likely as not that the hospital staff acted in accordance of and appropriate standards of the 'best practice of medicine'. The Veteran was sent to Wilmington for rehabilitation. Dr. Terry-Choyke found this was appropriate post-operative protocol. According to Dr. Terry-Choyke, although it could be argued that the intraoperative complication, to include an acetabular fracture, caused a prolonged rehabilitation period, additional immobilization, muscle weakness and atrophy, these were known residuals of surgery. Appropriate treatment and convalescence were administered. The residuals of surgery were not neglected. A proper level of skill and judgment in post-operative therapy were provided by the staff and physical therapy healthcare providers. To the contrary, the medical notes indicated that the Veteran missed appointments and was sometimes uncooperative (August 27, 2008 PT medical note of his problematic nature as written by Donald E. Potts, Delaware Curative Workshop's Outpatient Physical Therapy). Dr. Terry-Choyke noted the April 2013 operative note provided by Dr. Axon, and the July 10, 2007 lumbar spine radiograph, which indicated a normal lumbar spine configuration following right hip surgical. The impression was as follows: AP and Iateral view shows no acute fracture or subluxation. Disc space and vertebra body heights are preserved. No significant facet arthroplasty. Mild lumbar scoliosis convexed to the right centered on L3 and L4. To the contrary, Dr. Terry-Choyke opined that it is less likely than not that the Veteran's current sciatica, radiculopathy, and disc degenerative disease were residuals of the total right hip surgery and/or complication of an acetabular fracture. According to the record, Dr. Terry-Choyke was in total disagreement with Dr. Axon's opinion because anatomically an uncomplicated acetabular fracture would be less likely than not the cause for sciatic nerve compromise. The course of the nerve exits the sciatic notch and runs deep to the piriformis muscle, superficial to the obturator internus and continues posteriodistal within the thigh. Dr. Terry-Choyke also noted that the Veteran had a past medical history of HIV (1985), HCV, septic arthritis of the right ankle, osteomyelitis of the left foot and shoulder, and avascular necrosis of the hips, bilateral. In Dr. Terry-Choyke's opinion, the Veteran's past medical history was at least as likely a major risk factor for intraoperative complications secondary to underlying deficiencies and compromised metabolic bone disorders. Dr. Terry-Choyke found that overall, the comprehensive medical review of VBMS, CAPRI, and current medical literature supports the medical treatment of those healthcare providers throughout this Veteran's care. In Dr. Terry-Choyke's opinion, it is less likely than not that entitlement to compensation under 38 U.S.C.A. § 1151 is warranted on the grounds that 'the disability must have been caused by hospital care, medical or surgical treatment, or examination furnished the veteran or the proximate cause of the veteran's disability must be carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA or an event not reasonable foreseeable'. The Board finds that the September 2013 independent medical opinion constitutes highly probative evidence against the Veteran's claim. Dr. Terry-Choyke based the opinion on the Veteran's past medical history (which included a review of both VA and private medical records), the operative and post-operative reports, and records detailing the Veteran's post-operative symptoms, to which the opinion referred in detail. Dr. Terry-Choyke also explained the opinion by referring to medical principles and provided cites to medical texts. These facts are particularly important, in the Board's judgment, as the references make for a more convincing rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"); see Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). With respect to the other medical opinions of record, the September 2008 VA physician stated that the acetabulum fracture during the Veteran's total hip arthroplasty was a recognized potential complication in the operating room, which was specifically mentioned in the informed consent signed by the Veteran prior to the surgery. If any additional disability caused by intraoperative fracture was a recognized potential complication of operation, then it should have been foreseeable. However, the VA physician later made a conflicting statement that in the Veteran's surgery, the intraoperative fracture occurred as an event not reasonably foreseen. To that effect, in determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32 (2013). 38 C.F.R. § 3.361(d)(2). As noted above, the June 2007 consent form listed intraoperative fracture and sciatic nerve injury as the known risks of a total hip arthroplasty procedure. Therefore, due to the conflicting statements in the September 2008 VA medical opinion, the Board finds that this opinion is not adequate. In addition, the March 2008 VA medical opinion, April 2008 private physician's opinion, and April 2013 VA consultation note are also not adequate as they failed to address whether any additional disability resulted from carelessness, accident, negligence, lack of proper skill, error in judgment, or similar instances of fault on the part of the VA without informed consent, or was due to an event not reasonably foreseeable. The Board recognizes the Veteran's statements made in support of his claim. The Veteran is competent to provide testimony and statements about the symptoms he experiences. See Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). In this regard, the Board finds the Veteran credible. However, the Veteran is not competent to state that any symptoms or problems concerning his right knee, right leg, back, and shoulders are etiologically related to VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in the June 2007 VA surgery, or an event not reasonably foreseeable. A layperson is generally not deemed competent to express an opinion on a matter that requires medical knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). It is not shown that the Veteran or his representative is otherwise qualified through specialized education, training, or experience to offer a medical opinion in these circumstances. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Thus, the Board finds the Veteran's assertions are outweighed by the September 2013 Medical Officer's opinion. In sum, the probative, competent evidence does not demonstrate that the June 2007 VA medical treatment resulted in additional disability that was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing this medical treatment, or an event not reasonably foreseeable. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for residuals due to complications of a right hip replacement surgery is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs