This is Alan Condon with the Becker's Podcast,
and I'm thrilled to be joined today by
doctor Ravi Varshal, director of outpatient hip and
knee replacement surgery
at Endeavor Health.
Doctor Varshal, pleasure to have you back on
the podcast with us today.
For those who might be familiar with yourself
or the work that you do at Endeavor
Health, can you take a beat to just
give us a little bit, information about your
role and your background?
Absolutely, Alan. Thank you and the entire Vector's
team once again, for having me on. It's
always a great pleasure, to get to participate.
As you mentioned, my name is Ravi Bashal.
I'm an orthopedic surgeon specializing in hip and
knee replacement at Endeavor Health, a large multi
hospital, multi specialty group in the Chicagoland
area. My particular
research focus in the past several years has
been on infection prevention.
And I look forward to talking a little
bit more about that with you today.
Fantastic. So let's dive right in. I'm no
doubt
an expert in the orthopedic field focusing on
hip and knee replacement surgery. Infection prevention, like
you said, is a key research focus of
yours as well.
Can you tell us a little bit more
about the research you're involved with and, what
you're focused on in that realm?
Yeah. Absolutely.
You know, in the world of hip and
knee replacement,
infection or periprosthetic
joint infection or PGI, all terms that we
use interchangeably,
is really devastating.
As many of our listeners may know, if
you get an infection inside
of a hip or
knee replacement, that is not something that can
be treated with just antibiotics. It requires an
operation to fix. And if you're lucky, just
one operation, but if you're not, multiple operations,
and can often lead to a devastating outcome
for the patient. And,
it's interesting to me, as time has evolved,
we have continued to improve
implants, techniques, approaches, technology.
And with all of these things
have become better outcome for our patients, yet
we still have a baseline rate of periprosthetic
joint infection that sort of has remained behind.
And
oftentimes, we see
research focus on how to treat these infections
once they occur, which is critically important. We
have to know the best way to treat
these infections once they occur. But my own
personal twist on this has been to see
if there's anything that we can do to
attack or reduce that baseline rate of infection
in and of itself, so that the number
that we need to treat down the line,
become even less. And Sir John Charnley, kind
of the
father of modern hip replacement,
many years ago, I believe this quote is
from 1979,
had mentioned
he had the foresight to see that as
time went on, that periprosthetic joint infection would
still be the number one issue
that remained for implants. In years past, it
might have been
the parts wearing out too soon, other issues
around the implants themselves or how we put
them in.
But
those things have continued to improve while joint
infection itself
has sort of stabilized,
as time has gone by in terms of
its rate of incidence.
I guess, could you give us more insight
for I guess how you can go about
redoing your due diligence as a surgeon, as
a provider team in terms of reducing the
occurrence of some of these joint infections,
and you're planning your preparation
ahead of time. How are you looking at
this?
Alan, when we look at modern hip and
knee replacement,
and we look at how we're doing as
compared to many years ago, we've improved in
a lot of ways. The implants are better.
The approaches are better. The technology is better.
In the 70s 80s,
you would often tell patients, your implant might
last for 10 or 15 years, the rate
of failure was high. But
now we're doing outpatient total joints where the
patient can go home the same day. We
expect the implants to last decades.
We're often using robotics and other advanced technology
to put these implants in in a very
precise decision.
So, a lot of that has dramatically improved
in terms of the technology that we are
using
to improve those parameters,
but when we look at infection, many of
the interventions that we use to
minimize the risk of infection have stayed the
same for many years, and so for me,
that really
demonstrates an opportunity for investigation and improvement.
Got it. And could you dive one bit
deeper, I guess, in terms of how SIRS
is looking to improve that or I e
minimize
the rate of infections there?
Yeah. Absolutely. And and that's really been the
focus of my research.
You know, if we look at the the
major innovations when it comes to preventing infection
that have historically been done, it includes use
of, perioperative antibiotics, which we've been doing for
decades decades.
You know, includes sterile technique and minimizing operative
time, all things that we've kind of known
and done for a long time.
Something that
came up to me as as interesting was
irrigation. So when you're doing a surgery, you
use irrigation,
both for visualization and dilution, and I'll explain
what I mean. As you're doing a surgery,
and there's debris that's created, you're gonna wanna
wash that debris away so you can see
what you're doing. And, traditionally, at the end
of the case,
you would irrigate at the end to kinda
help dilute out the pool to to hopefully
clean it up and and make sure there
was no bacteria,
remaining behind that could then feed the joint
and become infected. But what struck me is
that we've kind of been doing this the
same way,
for decades,
and and maybe some innovation,
over the past, you know, 20 years, but
but really no significant changes. And, historically, the
way that this has been done is that
at the end of the case, you irrigate
with a large amount of saline. And after
some publications in the early to mid 2000s,
people would use a betadine wash. So they
would use betadine mixed with saline and let
that soak in the wound for some time
before rinsing that out and
closing the wound. And that sort of has
been our standard of care really for the
past
15 or 20 years. And because that hasn't
changed at all and everything else has, I
thought that was a real opportunity,
to investigate and innovate, and and that's really
where my research, has has led.
Got it. And it certainly lines up with
when you think about how far along implants
have come in over the last 15, 20,
25 years, No doubt there is an additional
space or an opportunity to your point to
to innovate in the irrigation process as well.
Ravi, any final notes to add on this
research, before we wrap up?
Yeah. You know, just to kind of go
into this in a in a in a
little detail,
there's
an innovative irrigation that I use called Xperience,
that's the letter X followed by Perience,
made by
a company called Nexcience,
which is based in Australia. And this has
really been
where a lot of our research has been
focused. So,
in 2021, in late 2021, early 2022, based
on some research that I had done and
some lab studies that we had looked at
and published on in the Journal of Arthroplasty,
we decided to use this instead of using
the standard betadine
irrigation. And the results for us have been
quite dramatic.
We've published on this now
a couple of times. The most recent publication
was in the Journal of Orthopedic
Experience and Innovation
that looked at our 1 year follow-up. We're
now at 3 years, but essentially using this
new
protocol including using the Xperience solution, we've been
able to get our infection rate down now
to 0% over the past 3 years. We're
almost at 1500 cases over 3 years now
and have that 0% infection rate, which is
really quite astonishing. Our baseline rate was low.
It was around 0.5% or 0.48%.
So, we were already starting pretty well. We
were doing a pretty good job. But by
adding this new adjuvant,
we were really able to bring this rate
down even more dramatically. And part of it
is the mechanism of action of this, Irrigant.
It's a citric acid based solution that actively
kills planktonic or free floating bacteria.
But because it's non toxic, unlike Betadine, it
does not need to be rinsed out at
the end of the case. So, we just
use it throughout the case, but we don't
have to rinse it all out with saline
at the end. So, all of that solution
is absorbed into the soft tissue and into
the bone,
and that allows for a persistent kill for
up to 5 hours, which we've also published
about in the Journal of Arthroplasty. And so,
what we're seeing is a dramatically reduced rate
of infection. And again, the numbers are low.
It's 0.5%, 0.6%. But if you look at
the cost of infection,
a single infection in an outpatient correction, a
single infection in a joint can cost up
to $100,000
in direct cost to treat and up to
$300,000
in terms of lifetime and sort of loss
of work and societal costs. These are immense
numbers. So even cutting something down from 5
cases a year to 2,
is really impactful when it comes to both
financial costs, but also cost to the patient.
What it means when you have a joint
replacement to be told you have an infection,
that you might need multiple surgeries to cure
this. Again, if you're lucky,
it really makes sense to be able to
do anything we can to be able to
bring that rate down low. Some studies have
theorized that the cost of periprosthetic joint infection
by the year 2030
will be $1,850,000,000
in the United States, which is something that,
as you know, in our constraining system, really
cannot be sustained. So if we can cut
that even in half, going from a 0.5
or a 0.6 rate to a 0.25
rate, we've made a dramatic difference. And again,
in our experience, which we continue to publish
about, we are currently at 0 infections over
approximately 1500 patients over 3 years. So it
takes time for our data to be published
and come out. So
the 1 year data is now officially published.
The 2 year data has been submitted for
publication. And as I mentioned, we're just finishing
up on the 3rd year here, so we
plan on submitting that soon. But we've really
seen some dramatic results where we've literally had
a 0% infection rate over 1500 cases at
this point, which is better for our patients,
better for our particular system, and better for
the overall economics of the American healthcare system.
So I think this is truly an area
where we should be looking to innovate. And
while it remains important to understand how to
best treat patients once they develop an infection,
I think it's even more critically important to
do everything we can to prevent those from
happening in the first place.
Absolutely.
Fascinating to hear about the progress in your
research so far. Some really impressive results in
terms of dramatically reducing those infection rates. No
doubt has significant impacts, not just on patient
quality of life, patient experience, but also, as
you said, in terms of the overall cost
to the patient as well.
Doctor Ravi Bashal, a pleasure having you on
the podcast for this day. Thank you so
much for taking the time to educate us
on this research project. I'm looking forward to
no doubt the publication of that 3 year
data when it eventually comes out as well.
Thanks, Alan. It's a great pleasure being on.