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Transcripts

November 17, 2004

Host: Michael Grant
Topics:
· Medical Breakthroughs "Ceramic Hip Joint Replacement;"
· Legal opinion regarding state programs covered by Proposition 200
In-Studio Guests:
· Terry Goddard, Arizona Attorney General;
· Jim Bonnell, patient;
· Dr. Brett Smith;
· Dr. Paul Howard, former chair, Arthritis Foundation Board of Directors
Important Links and Resources
Arthritis Foundation
Arizona Orthopedic Education Foundation

>> Michael Grant:
Tonight on "HORIZON," a new type of prosthetic hip is helping osteoarthritis patients. See one Arizona man's surgery. And we'll talk about other arthritis issues.

>>> Plus, the state attorney general has released a legal opinion making clear what state programs are covered by Proposition 200, which was passed by Arizona voters on November 2. That's next on "HORIZON."

> Announcer:
"HORIZON" is made possible by the Friends of Channel 8, members who provide financial support to this Arizona PBS station. Thank you.

>> Michael Grant:
Good evening, welcome to "HORIZON." I'm Michael Grant. Governor Janet Napolitano is hospitalized tonight after undergoing surgery to have an ovarian cyst and her right ovary removed. Napolitano had the operation last night here in Phoenix, after feeling uncomfortable during a trip to Flagstaff. The Governor's office says the cyst appears benign. The Governor, who battled breast cancer four years ago, is recovering well and is expected to be back at work within a few days.

>>> Proposition 200, passed by voters this month, requires proof of immigration status when applying for public benefits. It also requires public employees to report suspected illegal immigrants who try to obtain benefits. The state's Medicaid healthcare program for poor people, the Arizona Healthcare Cost Containment System, asked our state attorney general Terry Goddard for an opinion to clarify what state and local public benefits are under proposition 200. The opinion provides guidance to state employees who will be required to enforce the new law. Joining me now to talk about that opinion, Arizona Attorney General Terry Goddard.

>> Michael Grant:
Terry, welcome back. Is the answer "not much" to the question "what's covered"?

>> Terry Goddard:
It's a fair amount. It's not as much as some had argued, but opinion says that the proposition presented and passed by the voters applies to the well far title, it is a comprehensive title. It involves three state agencies and quite a few programs, but there are other exceptions that we're now looking at to see exactly how much of Title 46 will require the extra identification.

>> Michael Grant:
Now, what it does not apply to, though, are the federal benefit programs.

>> Terry Goddard:
That's right. But that is specific in the terms of proposition 200.

>> Michael Grant:
State and local.

>> Terry Goddard:
There is a phrase in there, state and local non-federally mandated benefits. We had a serious problem to deal with in that the proposition does not define "state and local benefits." The dictionary is not much help. We went there and we then had to look at the whole federal construct, how it fits with federal welfare benefits and federal immigration issues, because you can't preempt either one of those. The State has to fit within the cracks of a federal system. And obviously, if you fly up against it, you do it at your peril. You'll have an ineffective statute. My goal was to have the ability at the Attorney General's Office to advise state officers what they could do that would be constitutional and would be legal in the federal system.

>> Michael Grant:
We heard before the vote a whole lot of, well, television commercials, public statements, those kinds of things, that this was going to apply to a broad array of things, everything from if a paramedic came to give you -- render emergency assistance to I think library cards were tossed in there.

>> Terry Goddard:
Public parks, library cards. There were quite a few. The parade of horribles got very long.

>> Michael Grant:
Was it state and local that limited the scope? Was it the fact that you were amending a piece of legislation in Title 46 which has to do with welfare benefits that narrowed it from that vast universe to the one that we now have?

>> Terry Goddard:
Well, there were a number of things we looked at, but probably the deciding and most important was the drafters of the proposition said it should be in Title 46, the very first words, the item that people voted on, said this is going to be an amendment to Title 46. They gave it a statute number. I believe it was 46-140.01. They were very specific that this was for title 46. Also, it has criminal penalties attached to it. It's a Class 2 misdemeanor for a state official to fail to report somebody that they believe is not a qualified immigrant. That criminal penalty meant that we had to give as clear notice as we possibly could to everybody challenged, everybody required to enforce this statute that they are in fact required and that they do face criminal penalties for not following the law. And for that reason, we had to be as precise as we possibly could to protect the constitutionality of the statute.

>> Michael Grant:
So it does not apply to AHCCCS?

>> Terry Goddard:
Right.

>> Michael Grant:
It does not apply to -- I still call it AFDC, but I think it's currently called TANF; is it not?

>> Terry Goddard:
Yes, that's one of the federal benefits.

>> Michael Grant:
That was my point. The federal programs have immigration status verification procedures.

>> Terry Goddard:
Yes, they do. They require that you be a citizen or a -- what they define as a qualified immigrant. A qualified immigrant is a term of art used in the federal statute very precisely with a whole long list of definitions and qualifications. So there are many different immigration statuses which would make somebody a qualified immigrant for the purposes of receiving benefits. But by being so precise, AHCCCS, for example, requires a certification by anybody applying for AHCCCS benefits, that they are in fact -- that they meet the federal qualifications, and that gets researched. Proposition 200 adds an even larger identification component to anybody who wants welfare benefits.

>> Michael Grant:
Can you or not, Christmas tree that larger set of requirements on or for that matter, Christmas tree the misdemeanor failure to report sanctions onto the federal program or not?

>> Terry Goddard:
Well, the federal program was specifically exempted by proposition 200. By saying that, you excluded federal benefits. That took TANF, for example off the table and took Medicaid off the table. It also excluded anything that was federally mandated and by that, we interpret that to mean specific programs that are state and local but nonetheless, the federal law says you may not ask for extra identification, and those are emergency services, shelter services, certain immunization, for instance flu shots that were provided by public health agencies are specifically mandated by the federal government that those are going to apply to everybody, regardless of your immigration status.

>> Michael Grant:
Obviously one other large aspect of proposition 200 is the presentation of proof of citizenship when you register to vote. Those procedures have to be what's called pre-cleared by the Justice Department; correct?

>> Terry Goddard:
That's right. Until that's happened, either they preclear it and say that it goes into effect or they find a problem that bridges or denies, is the critical language, the rights of a minority group to vote, if they find that, they could throw out -- the Justice Department could throw out the entire voting section of proposition 200. We won't know for a couple of months what they are going to do with it.

>> Michael Grant:
What is that process, Terry? Does the attorney general office put together that package that goes to justice?

>> Terry Goddard:
My office is putting together the package. We expect to send it shortly after the certification of the election, which should be sometime after the 22nd of September. -- excuse me, November.

>> Michael Grant:
If I recall correctly, the Justice Department is supposed to act within 60 days but it has the ability to restart that clock.

>> There is a lot of leeway, but 60 days is their target.

>> Terry Goddard:
Michael Grant: It would seem to me that this is, to a certain extent, uncharted territory. How do you go about assembling a package that would demonstrate to Justice Department that this will not have chilling effects, it will not violate the Voting Rights Act? What sort of data do you amass on that subject, given the fact that we haven't had this program before?

>> Terry Goddard:
That's right. It is uncharted territory. There is an affirmative -- the statute sets up an affirmative obligation. You have to prove to the Justice Department or to the court that you have an option here, but in this case to the Justice Department, that nothing happens to a minority voter. In other words, that is adverse to their right to vote. So it is a pretty high burden that has to be borne. We're actually soliciting comments and taking all of the campaign rhetoric that you referred to earlier and we're going submit all of that, because if we didn't, they would want it anyway. They are going to ask for a complete record as to what everybody has had to say about proposition 200, pro and con, in terms of its effect on voting, and then the they act as a court. The Justice Department -- they are the national experts on this matter, and it's almost completely in their hands. A decision could be appealed but -

>> Michael Grant:
You can take their decision to a federal district court?

>> Terry Goddard:
Yes, you could. You could take it to the D.C. district court. It's a specific procedure, but the number of clauses that ever succeed against the Justice Department on a case like this are minuscule.

>> Michael Grant:
All right, we appreciate the information.

>> Terry Goddard:
Thank you.

>> Michael Grant:
More than 20 million adult Americans have osteoarthritis. It's the most common form of the disease and a leading cause of disability in the United States. But a medical breakthrough is helping one Arizona arthritis patient get back on his feet. Producer Merry Lucero and videographer Richard Torruellas bring us the story. A note to viewers, the story contains graphic video of the surgery taking place.

>> Dr. Brent Smith:
He's young, he's active and healthy. He's got over 20 years left.

>> Merry Lucero:
The surgery you are about to see took only 90 minutes, but the results mean near normal activity for the rest of this patient's life. Thanks to advances in medical technology. Jim Bonnell discovered his arthritis at age 45.

>> Jim Bonnell:
I've been a runner all of my life. So I've always ran long distance and different things. What happened was I ran a 10K and thought I pulled a muscle. And I went to the doctor's office. They said that I had no cartilage in my hip, and that from that standpoint, it was -- it then was allowing arthritis to grow in there because of no cartilage.

>> Merry Lucero:
Bonnell put up with the pain and debility in his right hip until he decided to have the joint replaced. The prosthetic implant has a metal head on the femur which fits into an implanted socket that is lined with plastic.

>> Dr. Brent Smith:
This is the shell which is the metal portion and the plastic liner. And this is the cobalt chrome femoral head. That's the old bearing service surface. The reason behind the design, the plastic sheds microscopic beads and that leads to the failure of the implants. Your body senses the beads as being foreign and sends cells out to kill it, or to degrade it, and those enzymes then try to eat the plastic away, the microscopic beads, and it can't, so it sends out more enzymes and eats your bone away instead of the plastic. That's why they get loose.

>> Merry Lucero:
The prosthetic is doing well, but his osteoarthritis has worn down his left hip.

>> Jim Bonnell: Now the second one is equally as bad, and to try to play golf has been painful. So, you know, walking, walking up steps, different things like that, lifting heavy loads has been painful. Now is a good time to do it.

>> Merry Lucero:
Dr. Brett Smith recommended that Bonnell get the new hip approved by the FDA.

>> Dr. Brent Smith:
The two articulate. That's the bearing surface that is much improved over the previous design of the plastic and metal, which hopefully in him will last his lifetime now, given his activity level and age.

>> Merry Lucero:
Some preoperative support from his family, while the doc readies for surgery. Bonnell is wheeled into the OR. The procedure begins.

>> Dr. Brent Smith:
So this is for leg length. I put a pin in the pelvis which doesn't change. It checks for offsets and leg length. We want to make sure he's got the same length when we leave here. So when he's laying on his side, this is his position on the table. We dislocate the hip and pop it out of socket. And then we cut the femoral head off. This was the femoral head that was cut out. The top part here has narrowed down. He's bone on bone. This shiny hard part is like a pool ball. That's where the cartilage has warn away. You can see there is an edge that's rough where the cartilage is starting to wear away as well. This is osteoarthritis. So this is the cup that's being inserted. The ceramic liner will go inside that. This is the ceramic liner that goes inside of this shell and has a tapered fit that will articulate with the femoral side that we'll get to shortly. This stem is anatomic. It matches the patient's femur wonderfully. So it's pressed fit down the center of the femur. That's the femoral side. The old mark is here. The mark where his leg length was before, and now I've exactly reproduced his leg length because he was equal preoperatively. The second check is for dislocation. Keep going, keep going, keep going. So this is the 32 millimeter ceramic head. Okay, rotate. I let it slide on my finger. That's it. Now we close. Can you call out to the waiting area and tell the wife that we're closing up, and I'll be out when he's in recovery, please.

>> Merry Lucero:
The surgery is over.

>> Dr. Brent Smith:
Hello, how are you? He's doing fine. He's awake. He's breathing on his own. He did great. The brand new hip is in. It just took about an hour or so.

>> Jim Bonnell's wife:
He's awake?

>> Dr. Brent Smith:
He's already doing this and wants to walk.

>> Dr. Brent Smith:
There were no complications. Your foot is already doing well.

>> Jim Bonnell:
I can move all of that stuff.

>> Dr. Brent Smith:
No worries.

>> Merry Lucero:
The new ceramic on ceramic implant will most like likely last Bonnell the rest of his life and will allow him to return to his active lifestyle.

>> Michael Grant:
Here now in the studio, the patient you just saw on tape having surgery watching it for the first time, Jim Bonnell and his doctor Brett Smith. Dr. Howard is the former chair of the Arthritis Foundation Board of Directors. Jim, that was the first time you had seen that?

>> Jim Bonnell:
Yes, that was quite interesting.

>> Michael Grant:
You were asking questions of the doctor as we were watching it. You mean that happened and stuff like that?

>> Jim Bonnell:
I had been asked prior if I ever wanted to see a video of how these had been done. I said I'm not sure I want to see that. Now after I've seen that, I'm glad I didn't have see the video first.

>> Michael Grant:
How do you feel?

>> Jim Bonnell:
I feel great. I feel excellent.

>> Michael Grant:
You had had surgery done on the other hip what, a couple of years ago?

>> Jim Bonnell:
2-1/2 years ago.

>> Michael Grant:
It was the more traditional composition method?

>> Jim Bonnell:
Right, exactly.

>> Michael Grant:
How has that been?

>> Jim Bonnell:
It's worked out fine. You don't even know it's different than your original hip. It feels the same, feels fine. I've got all of the flexibility, pretty much that I had before. So I'm looking forward to this one to get me back to playing.

>> Michael Grant:
Brett, we have a rare situation here, I assume, where you've got, you know, one modality in one hip and a modality in the other one. Why don't you compare and contrast those so we understand the differences.

>> Jim Bonnell:
The right side is the metal on plastic hip that was designed many years ago and has been put in for the past, since the late 60s, actually. The newer ceramic hip on the left side has been in manufacture and use for a year and a half and has a better wear surface between the two implants, which hopefully now will last Jim's lifetime. The old implant we say is 95% at 15 years and we're hoping now that this implant he has in will last 30, 40, 50 years and never need surgery again.

>> Michael Grant:
In fact, that was one of the reasons why, as I understand it, hip replace -- you normally tried to delay a hip replacement for as long as possible because it did have such a limited life duration?

>> Dr. Brent Smith:
Correct. The youngest patient that my partner put in was a 13-year-old. You know, I think probably 20 years ago that was unheard of. Now with the new implants and designs, we're hoping that that will last their lifetime, believe it or not.

>> Michael Grant:
Paul, how does osteoarthritis lead to the situation where this kind of intervention is necessary?

>> Dr. Paul Howard:
There is not just one disease of osteoarthritis, but there is a group of conditions that lead to the cartilage wearing out, and it can happen in the hip, in the knee, in the spine, in the hands, feet. But the hip is a commonplace for it to happen, and the example here is a young healthy man who -- I heard the story tonight, he was out jogging and first thought he sprained his hip and turns out he has a hip that's totally worn out. This can happen in young people, it can happen in old people. This is not just a, quote, old person's disease. And the deterioration goes on to the point that you can't use that joint. You need that cartilage as a spacer between the bone.

>> Michael Grant:
As I understand it, what you are get something bone to bone contact and you shouldn't get that?

>> Dr. Brent Smith:
Right, you get bone on bone, things aren't going to work very well. God designed it much better.

>> Michael Grant:
Yeah, that's right. Jim, what does that feel like?

>> Jim Bonnell:
It's very painful. I waited as long as I possibly could. I didn't believe it the first time I heard it because I had been a runner for years and years. When I heard about it, you know, I tried to talk to different doctors, sports medicine type doctors. We tried a variety of things. I spent a couple of years exercising, muscles that keep the bones apart so you can have fluid in there. But that was just temporary. I tried some injections that were experimental to help and that didn't seem to work either, but once the bone on Bonn, and you develop bone spurs and you know, then the arthritis and that, there is points where it locks up and you've got to sit there for a number of minutes to try to get it to get mobile again.

>> Michael Grant:
It's getting wetter and colder. I hear that you can become more sensitive to those kinds of weather conditions. Is that true?

>> Jim Bonnell:
With the bad hip?

>> Yeah.

>> Jim Bonnell:
I'm a perfect example. I would take my kids up in march up in sunrise to go snow boarding and I sit in the lodge and watch them. I get in the cold and that, the artificial hip works great no, problems whatsoever. The other one starts to tighten up a little bit and you can feel the difference. So down here in the valley, I haven't noticed that much.

>> Michael Grant:
Paul, why would that be the case? Why do the joints tend to be weather sensitive?

>> Dr. Paul Howard:
It's pressure sensitive. Barometric change plays a big say in it. Muscles are more relaxed when it's warmer. When it's cold they tighten up. The muscles are a major source of pain also.

>> Michael Grant:
Getting back to this new technology that we're seeing, the ceramic on ceramic, does that really open up the options that you've got to lay out for a patient? I mean, we've already discussed the fact that you no longer time constrained, so it would seem to me you could probably move to this sort of intervention more quickly than you otherwise would have under the old method.

>> Dr. Brent Smith:
Sure, absolutely. But the patient has to be ready for it. The first thing the arthritis foundation talks about is exercise. So all patients with arthritis, we talk about exercise, anti-inflammatories and other methods of therapy to get them along, and then surgery is really the last option. When the patient finally throws the towel in and says I've had it, I can't deal with this pain, then you know surgery is the option. But prior to that --

>> Michael Grant:
What other treatments proceed it?

>> Dr. Brent Smith:
First of all, exercise, secondly physical therapy, thirdly anti-inflammatories. The newest ones are having problems. But those are the things that he has tried prior to his surgery to delay things.

>> Michael Grant:
You went through the entire regiment. You look to me like a guy who didn't just immediately want to leap on to the table.

>> Jim Bonnell:
I waited almost five years, 5 and a half years, almost six years before I got the first one done, and when you talk about exercise, one of the things that I did prior to the first surgery was I spent about 10 weeks doing some very intense upper and lower body exercises and weight lifting and did cardiovascular. I did the same thing for this one. It makes the surgery and the recovery go by so much faster. I was moving parts, you know, prior to most people it takes them days before they can move their feet and things like that. I was moving different parts of my leg that morning or that afternoon. So, I mean, it -- if I could give any advice to anybody going through this, at least do some exercises prior, get yourself ready for it.

>> Dr. Paul Howard:
I'll add one more thing. Weight reduction. Many people with osteoarthritis -- he's not -- not everybody who is overweight gets osteoarthritis and not everybody who is thin will avoid it, but many people are overweight and get osteoarthritis. One of the key things is to lose the weight. That's a lot better than a lot of medicine that people take.

>> Michael Grant:
There are other forms of arthritis.

>> Dr. Paul Howard:
There are many different types of arthritis. Some of the more destructive arthritis are like rheumatoid arthritis, psoriatic arthritis. These are inflammatory diseases that are more systemic diseases as opposed to an isolated joint or two and these are conditions where the body's immune system attacks the joint and literally goes onto destroy it. We have miracles in terms of treatments that are not just good, they sometimes can stop the progression of disease. We're even seeing studies today that show that there is x-ray -- it stops the damage in the x-rays and even they are starting to get better.

>> Michael Grant:
Have we covered all of the prevention common techniques, the exercise, the other things?

>> Dr. Paul Howard:
Weight reduction. It depends on the type of arthritis. There are some diets that can help, lower fats, these cardiac diets that are low fat diets, more fish, more fish oils. They help reduce inflammation. But these are diseases that can't be controlled by one thing or one thing alone. It's not just medicine. It's not just diet, it's really a mixture of things.

>> Michael Grant:
Now, what are his restrictions, short term and long term?

>> Dr. Brent Smith:
I'm surprised he's here tonight to be honest.

>> Michael Grant:
This wasn't authorized?

>> Dr. Brent Smith:
No, he sat in a good sized chair. His precautions are hip precautions for three months. He can't flex his hip for 09 degrees. Nothing links those two together. He can dislocate or pop out of socket if he bends too far. Secondly, I put a boney in-growth prosthesis in his femur. So, his bone has to grow into it. I don't allow him to put weight for six weeks. In that six weeks time. He's cheating already, I can see. If he puts wait on it that's fiber bus tissue instead of boney tissie and that leads to failure of the implant. His precautions are number one, no weight bearing and number two, he has to abide by the hip flexion rules.

>> Well, Jim Bonnell, we wish you the best of luck-pretty remarkable procedure. Brett Smith, thank you for joining us. Paul Howard our thanks to you as well.

>> If I can put one plug in-that's the arthritis foundation. People can find it at arthritis.org. It's a great web site for people with all types of information on it.

>> Michael Grant:
In fact, for some web links about arthritis, go to our web site, that address is www.azpbs.org. Also on the sight, transcripts from past "HORIZON" programs, a link to contact us and information about upcoming "HORIZON" topics.

>> Reporter:
A new report says that police agencies and prosecutors are seizing people from property to enrich their agencies. The goods are taken from some people not convicted of a crime.

>>> The cardinal stadium is 45% done. We'll give you an update. That's Thursday at 7:00 on "HORIZON."

>> Michael Grant:
Thank you very much for joining us on this Wednesday evening. I'm Michael Grant. Have a good one. Good night.

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