1 00:00:00,080 --> 00:00:02,259 This is Alan Condon with the Becker's Podcast, 2 00:00:02,399 --> 00:00:04,319 and I'm thrilled to be joined today by 3 00:00:04,319 --> 00:00:07,359 doctor Ravi Varshal, director of outpatient hip and 4 00:00:07,359 --> 00:00:08,660 knee replacement surgery 5 00:00:08,960 --> 00:00:10,339 at Endeavor Health. 6 00:00:10,719 --> 00:00:12,639 Doctor Varshal, pleasure to have you back on 7 00:00:12,639 --> 00:00:14,099 the podcast with us today. 8 00:00:14,799 --> 00:00:16,855 For those who might be familiar with yourself 9 00:00:16,855 --> 00:00:18,535 or the work that you do at Endeavor 10 00:00:18,535 --> 00:00:19,815 Health, can you take a beat to just 11 00:00:19,815 --> 00:00:21,655 give us a little bit, information about your 12 00:00:21,655 --> 00:00:22,714 role and your background? 13 00:00:23,815 --> 00:00:26,535 Absolutely, Alan. Thank you and the entire Vector's 14 00:00:26,535 --> 00:00:28,614 team once again, for having me on. It's 15 00:00:28,614 --> 00:00:31,250 always a great pleasure, to get to participate. 16 00:00:31,550 --> 00:00:33,469 As you mentioned, my name is Ravi Bashal. 17 00:00:33,469 --> 00:00:35,950 I'm an orthopedic surgeon specializing in hip and 18 00:00:35,950 --> 00:00:38,909 knee replacement at Endeavor Health, a large multi 19 00:00:38,909 --> 00:00:41,570 hospital, multi specialty group in the Chicagoland 20 00:00:42,030 --> 00:00:43,329 area. My particular 21 00:00:44,125 --> 00:00:46,125 research focus in the past several years has 22 00:00:46,125 --> 00:00:47,664 been on infection prevention. 23 00:00:48,445 --> 00:00:50,125 And I look forward to talking a little 24 00:00:50,125 --> 00:00:51,744 bit more about that with you today. 25 00:00:52,844 --> 00:00:55,085 Fantastic. So let's dive right in. I'm no 26 00:00:55,085 --> 00:00:55,585 doubt 27 00:00:55,929 --> 00:00:58,570 an expert in the orthopedic field focusing on 28 00:00:58,570 --> 00:01:01,770 hip and knee replacement surgery. Infection prevention, like 29 00:01:01,770 --> 00:01:03,530 you said, is a key research focus of 30 00:01:03,530 --> 00:01:04,430 yours as well. 31 00:01:04,890 --> 00:01:06,090 Can you tell us a little bit more 32 00:01:06,090 --> 00:01:07,849 about the research you're involved with and, what 33 00:01:07,849 --> 00:01:09,310 you're focused on in that realm? 34 00:01:10,295 --> 00:01:11,034 Yeah. Absolutely. 35 00:01:11,694 --> 00:01:13,174 You know, in the world of hip and 36 00:01:13,174 --> 00:01:13,834 knee replacement, 37 00:01:14,454 --> 00:01:15,834 infection or periprosthetic 38 00:01:16,215 --> 00:01:18,375 joint infection or PGI, all terms that we 39 00:01:18,375 --> 00:01:19,355 use interchangeably, 40 00:01:20,135 --> 00:01:21,115 is really devastating. 41 00:01:22,135 --> 00:01:23,814 As many of our listeners may know, if 42 00:01:23,814 --> 00:01:25,069 you get an infection inside 43 00:01:25,450 --> 00:01:25,950 of 44 00:01:26,329 --> 00:01:27,229 a hip or 45 00:01:27,530 --> 00:01:28,756 knee replacement, that is not something that can 46 00:01:28,756 --> 00:01:30,250 be treated with just antibiotics. It requires an 47 00:01:30,250 --> 00:01:32,409 operation to fix. And if you're lucky, just 48 00:01:32,409 --> 00:01:34,989 one operation, but if you're not, multiple operations, 49 00:01:35,450 --> 00:01:37,930 and can often lead to a devastating outcome 50 00:01:37,930 --> 00:01:38,890 for the patient. And, 51 00:01:40,395 --> 00:01:42,474 it's interesting to me, as time has evolved, 52 00:01:42,474 --> 00:01:44,174 we have continued to improve 53 00:01:44,715 --> 00:01:47,215 implants, techniques, approaches, technology. 54 00:01:47,834 --> 00:01:49,215 And with all of these things 55 00:01:49,834 --> 00:01:52,334 have become better outcome for our patients, yet 56 00:01:52,670 --> 00:01:54,929 we still have a baseline rate of periprosthetic 57 00:01:55,229 --> 00:01:58,349 joint infection that sort of has remained behind. 58 00:01:58,349 --> 00:01:58,849 And 59 00:01:59,390 --> 00:02:00,929 oftentimes, we see 60 00:02:01,549 --> 00:02:03,810 research focus on how to treat these infections 61 00:02:03,869 --> 00:02:06,364 once they occur, which is critically important. We 62 00:02:06,364 --> 00:02:07,885 have to know the best way to treat 63 00:02:07,885 --> 00:02:10,685 these infections once they occur. But my own 64 00:02:10,685 --> 00:02:12,604 personal twist on this has been to see 65 00:02:12,604 --> 00:02:14,844 if there's anything that we can do to 66 00:02:14,844 --> 00:02:17,884 attack or reduce that baseline rate of infection 67 00:02:17,884 --> 00:02:19,800 in and of itself, so that the number 68 00:02:19,800 --> 00:02:21,580 that we need to treat down the line, 69 00:02:22,039 --> 00:02:24,680 become even less. And Sir John Charnley, kind 70 00:02:24,680 --> 00:02:25,500 of the 71 00:02:26,039 --> 00:02:27,979 father of modern hip replacement, 72 00:02:28,919 --> 00:02:30,439 many years ago, I believe this quote is 73 00:02:30,439 --> 00:02:31,259 from 1979, 74 00:02:31,560 --> 00:02:32,219 had mentioned 75 00:02:32,759 --> 00:02:34,754 he had the foresight to see that as 76 00:02:34,754 --> 00:02:37,314 time went on, that periprosthetic joint infection would 77 00:02:37,314 --> 00:02:38,854 still be the number one issue 78 00:02:39,314 --> 00:02:41,875 that remained for implants. In years past, it 79 00:02:41,875 --> 00:02:42,775 might have been 80 00:02:43,155 --> 00:02:45,235 the parts wearing out too soon, other issues 81 00:02:45,235 --> 00:02:47,235 around the implants themselves or how we put 82 00:02:47,235 --> 00:02:47,894 them in. 83 00:02:48,435 --> 00:02:48,840 But 84 00:02:49,800 --> 00:02:52,360 those things have continued to improve while joint 85 00:02:52,360 --> 00:02:53,340 infection itself 86 00:02:53,959 --> 00:02:55,019 has sort of stabilized, 87 00:02:55,479 --> 00:02:56,840 as time has gone by in terms of 88 00:02:56,840 --> 00:02:57,900 its rate of incidence. 89 00:02:59,400 --> 00:03:01,334 I guess, could you give us more insight 90 00:03:01,334 --> 00:03:03,334 for I guess how you can go about 91 00:03:03,334 --> 00:03:05,574 redoing your due diligence as a surgeon, as 92 00:03:05,574 --> 00:03:08,294 a provider team in terms of reducing the 93 00:03:08,294 --> 00:03:10,155 occurrence of some of these joint infections, 94 00:03:10,775 --> 00:03:12,235 and you're planning your preparation 95 00:03:12,854 --> 00:03:14,534 ahead of time. How are you looking at 96 00:03:14,534 --> 00:03:15,034 this? 97 00:03:16,300 --> 00:03:18,699 Alan, when we look at modern hip and 98 00:03:18,699 --> 00:03:19,360 knee replacement, 99 00:03:20,379 --> 00:03:22,060 and we look at how we're doing as 100 00:03:22,060 --> 00:03:24,219 compared to many years ago, we've improved in 101 00:03:24,219 --> 00:03:25,819 a lot of ways. The implants are better. 102 00:03:25,819 --> 00:03:28,639 The approaches are better. The technology is better. 103 00:03:28,780 --> 00:03:30,240 In the 70s 80s, 104 00:03:30,905 --> 00:03:33,384 you would often tell patients, your implant might 105 00:03:33,384 --> 00:03:35,064 last for 10 or 15 years, the rate 106 00:03:35,064 --> 00:03:36,444 of failure was high. But 107 00:03:36,745 --> 00:03:39,224 now we're doing outpatient total joints where the 108 00:03:39,224 --> 00:03:41,144 patient can go home the same day. We 109 00:03:41,144 --> 00:03:43,004 expect the implants to last decades. 110 00:03:43,384 --> 00:03:45,919 We're often using robotics and other advanced technology 111 00:03:45,919 --> 00:03:47,520 to put these implants in in a very 112 00:03:47,520 --> 00:03:48,419 precise decision. 113 00:03:48,800 --> 00:03:50,819 So, a lot of that has dramatically improved 114 00:03:50,879 --> 00:03:52,639 in terms of the technology that we are 115 00:03:52,639 --> 00:03:53,139 using 116 00:03:53,680 --> 00:03:54,979 to improve those parameters, 117 00:03:55,439 --> 00:03:58,139 but when we look at infection, many of 118 00:03:58,319 --> 00:04:00,254 the interventions that we use to 119 00:04:00,655 --> 00:04:02,575 minimize the risk of infection have stayed the 120 00:04:02,575 --> 00:04:04,175 same for many years, and so for me, 121 00:04:04,175 --> 00:04:04,835 that really 122 00:04:05,294 --> 00:04:08,115 demonstrates an opportunity for investigation and improvement. 123 00:04:09,455 --> 00:04:11,055 Got it. And could you dive one bit 124 00:04:11,055 --> 00:04:12,909 deeper, I guess, in terms of how SIRS 125 00:04:12,909 --> 00:04:14,990 is looking to improve that or I e 126 00:04:14,990 --> 00:04:15,490 minimize 127 00:04:16,270 --> 00:04:17,730 the rate of infections there? 128 00:04:18,589 --> 00:04:20,910 Yeah. Absolutely. And and that's really been the 129 00:04:20,910 --> 00:04:22,990 focus of my research. You know, if we 130 00:04:22,990 --> 00:04:25,069 look at the the major innovations when it 131 00:04:25,069 --> 00:04:27,629 comes to preventing infection that have historically been 132 00:04:27,629 --> 00:04:30,944 done, it includes use of, perioperative antibiotics, which 133 00:04:30,944 --> 00:04:32,805 we've been doing for decades decades. 134 00:04:33,185 --> 00:04:36,225 You know, includes sterile technique and minimizing operative 135 00:04:36,225 --> 00:04:38,004 time, all things that we've kind of known 136 00:04:38,305 --> 00:04:39,605 and done for a long time. 137 00:04:40,064 --> 00:04:40,884 Something that 138 00:04:41,319 --> 00:04:43,319 came up to me as as interesting was 139 00:04:43,319 --> 00:04:46,199 irrigation. So when you're doing a surgery, you 140 00:04:46,199 --> 00:04:47,019 use irrigation, 141 00:04:47,959 --> 00:04:50,600 both for visualization and dilution, and I'll explain 142 00:04:50,600 --> 00:04:52,680 what I mean. As you're doing a surgery, 143 00:04:53,000 --> 00:04:55,240 and there's debris that's created, you're gonna wanna 144 00:04:55,240 --> 00:04:56,839 wash that debris away so you can see 145 00:04:56,839 --> 00:04:58,975 what you're doing. And, traditionally, at the end 146 00:04:58,975 --> 00:04:59,714 of the case, 147 00:05:00,175 --> 00:05:01,935 you would irrigate at the end to kinda 148 00:05:01,935 --> 00:05:04,495 help dilute out the pool to to hopefully 149 00:05:04,495 --> 00:05:05,775 clean it up and and make sure there 150 00:05:05,775 --> 00:05:06,835 was no bacteria, 151 00:05:07,615 --> 00:05:09,694 remaining behind that could then feed the joint 152 00:05:09,694 --> 00:05:11,789 and become infected. But what struck me is 153 00:05:11,789 --> 00:05:13,550 that we've kind of been doing this the 154 00:05:13,550 --> 00:05:14,370 same way, 155 00:05:14,909 --> 00:05:15,649 for decades, 156 00:05:16,110 --> 00:05:17,729 and and maybe some innovation, 157 00:05:18,509 --> 00:05:20,909 over the past, you know, 20 years, but 158 00:05:20,909 --> 00:05:23,564 but really no significant changes. And, historically, the 159 00:05:23,564 --> 00:05:25,084 way that this has been done is that 160 00:05:25,084 --> 00:05:26,524 at the end of the case, you irrigate 161 00:05:26,524 --> 00:05:28,524 with a large amount of saline. And after 162 00:05:28,524 --> 00:05:30,785 some publications in the early to mid 2000s, 163 00:05:31,564 --> 00:05:33,564 people would use a betadine wash. So they 164 00:05:33,564 --> 00:05:36,045 would use betadine mixed with saline and let 165 00:05:36,045 --> 00:05:37,899 that soak in the wound for some time 166 00:05:37,899 --> 00:05:40,000 before rinsing that out and 167 00:05:40,379 --> 00:05:42,220 closing the wound. And that sort of has 168 00:05:42,220 --> 00:05:44,379 been our standard of care really for the 169 00:05:44,379 --> 00:05:44,879 past 170 00:05:45,180 --> 00:05:47,819 15 or 20 years. And because that hasn't 171 00:05:47,819 --> 00:05:50,064 changed at all and everything else has, I 172 00:05:50,064 --> 00:05:51,685 thought that was a real opportunity, 173 00:05:52,464 --> 00:05:54,625 to investigate and innovate, and and that's really 174 00:05:54,625 --> 00:05:56,884 where my research, has has led. 175 00:05:57,985 --> 00:05:59,585 Got it. And it certainly lines up with 176 00:05:59,665 --> 00:06:01,665 when you think about how far along implants 177 00:06:01,665 --> 00:06:03,345 have come in over the last 15, 20, 178 00:06:03,345 --> 00:06:05,500 25 years, No doubt there is an additional 179 00:06:05,500 --> 00:06:07,500 space or an opportunity to your point to 180 00:06:07,500 --> 00:06:10,000 to innovate in the irrigation process as well. 181 00:06:10,780 --> 00:06:12,699 Ravi, any final notes to add on this 182 00:06:12,699 --> 00:06:14,560 research, before we wrap up? 183 00:06:15,259 --> 00:06:16,939 Yeah. You know, just to kind of go 184 00:06:16,939 --> 00:06:18,300 into this in a in a in a 185 00:06:18,300 --> 00:06:19,120 little detail, 186 00:06:20,595 --> 00:06:21,095 there's 187 00:06:21,875 --> 00:06:24,615 an innovative irrigation that I use called Xperience, 188 00:06:24,754 --> 00:06:26,854 that's the letter X followed by Perience, 189 00:06:27,555 --> 00:06:28,294 made by 190 00:06:29,154 --> 00:06:30,454 a company called Nexcience, 191 00:06:30,754 --> 00:06:32,354 which is based in Australia. And this has 192 00:06:32,354 --> 00:06:33,029 really been 193 00:06:33,750 --> 00:06:35,269 where a lot of our research has been 194 00:06:35,269 --> 00:06:36,170 focused. So, 195 00:06:37,670 --> 00:06:41,029 in 2021, in late 2021, early 2022, based 196 00:06:41,029 --> 00:06:42,550 on some research that I had done and 197 00:06:42,550 --> 00:06:44,629 some lab studies that we had looked at 198 00:06:44,629 --> 00:06:46,490 and published on in the Journal of Arthroplasty, 199 00:06:47,365 --> 00:06:50,024 we decided to use this instead of using 200 00:06:50,084 --> 00:06:51,144 the standard betadine 201 00:06:51,444 --> 00:06:53,685 irrigation. And the results for us have been 202 00:06:53,685 --> 00:06:54,425 quite dramatic. 203 00:06:54,884 --> 00:06:56,425 We've published on this now 204 00:06:56,805 --> 00:06:58,884 a couple of times. The most recent publication 205 00:06:58,884 --> 00:07:00,264 was in the Journal of Orthopedic 206 00:07:00,805 --> 00:07:02,024 Experience and Innovation 207 00:07:02,389 --> 00:07:04,629 that looked at our 1 year follow-up. We're 208 00:07:04,629 --> 00:07:07,029 now at 3 years, but essentially using this 209 00:07:07,029 --> 00:07:07,529 new 210 00:07:08,310 --> 00:07:11,509 protocol including using the Xperience solution, we've been 211 00:07:11,509 --> 00:07:13,350 able to get our infection rate down now 212 00:07:13,350 --> 00:07:15,954 to 0% over the past 3 years. We're 213 00:07:15,954 --> 00:07:18,855 almost at 1500 cases over 3 years now 214 00:07:18,915 --> 00:07:21,394 and have that 0% infection rate, which is 215 00:07:21,394 --> 00:07:24,375 really quite astonishing. Our baseline rate was low. 216 00:07:24,915 --> 00:07:27,014 It was around 0.5% or 0.48%. 217 00:07:27,795 --> 00:07:29,509 So, we were already starting pretty well. We 218 00:07:29,509 --> 00:07:31,430 were doing a pretty good job. But by 219 00:07:31,430 --> 00:07:32,729 adding this new adjuvant, 220 00:07:33,430 --> 00:07:34,949 we were really able to bring this rate 221 00:07:34,949 --> 00:07:37,269 down even more dramatically. And part of it 222 00:07:37,269 --> 00:07:40,310 is the mechanism of action of this, Irrigant. 223 00:07:40,310 --> 00:07:43,405 It's a citric acid based solution that actively 224 00:07:43,405 --> 00:07:45,824 kills planktonic or free floating bacteria. 225 00:07:46,205 --> 00:07:49,085 But because it's non toxic, unlike Betadine, it 226 00:07:49,085 --> 00:07:50,685 does not need to be rinsed out at 227 00:07:50,685 --> 00:07:52,285 the end of the case. So, we just 228 00:07:52,285 --> 00:07:53,725 use it throughout the case, but we don't 229 00:07:53,725 --> 00:07:55,245 have to rinse it all out with saline 230 00:07:55,245 --> 00:07:57,220 at the end. So, all of that solution 231 00:07:57,220 --> 00:07:59,220 is absorbed into the soft tissue and into 232 00:07:59,220 --> 00:07:59,800 the bone, 233 00:08:00,339 --> 00:08:02,660 and that allows for a persistent kill for 234 00:08:02,660 --> 00:08:04,680 up to 5 hours, which we've also published 235 00:08:05,220 --> 00:08:07,560 about in the Journal of Arthroplasty. And so, 236 00:08:07,620 --> 00:08:10,020 what we're seeing is a dramatically reduced rate 237 00:08:10,020 --> 00:08:12,354 of infection. And again, the numbers are low. 238 00:08:12,354 --> 00:08:14,675 It's 0.5%, 0.6%. But if you look at 239 00:08:14,675 --> 00:08:15,975 the cost of infection, 240 00:08:17,235 --> 00:08:20,595 a single infection in an outpatient correction, a 241 00:08:20,595 --> 00:08:23,074 single infection in a joint can cost up 242 00:08:23,074 --> 00:08:23,735 to $100,000 243 00:08:24,675 --> 00:08:26,730 in direct cost to treat and up to 244 00:08:26,730 --> 00:08:27,230 $300,000 245 00:08:27,930 --> 00:08:29,689 in terms of lifetime and sort of loss 246 00:08:29,689 --> 00:08:32,009 of work and societal costs. These are immense 247 00:08:32,009 --> 00:08:34,809 numbers. So even cutting something down from 5 248 00:08:34,809 --> 00:08:36,190 cases a year to 2, 249 00:08:36,649 --> 00:08:38,809 is really impactful when it comes to both 250 00:08:38,809 --> 00:08:41,309 financial costs, but also cost to the patient. 251 00:08:41,495 --> 00:08:42,855 What it means when you have a joint 252 00:08:42,855 --> 00:08:44,534 replacement to be told you have an infection, 253 00:08:44,534 --> 00:08:46,534 that you might need multiple surgeries to cure 254 00:08:46,534 --> 00:08:48,394 this. Again, if you're lucky, 255 00:08:49,014 --> 00:08:50,534 it really makes sense to be able to 256 00:08:50,534 --> 00:08:51,894 do anything we can to be able to 257 00:08:51,894 --> 00:08:55,029 bring that rate down low. Some studies have 258 00:08:55,089 --> 00:08:57,970 theorized that the cost of periprosthetic joint infection 259 00:08:57,970 --> 00:08:59,029 by the year 2030 260 00:08:59,490 --> 00:09:00,389 will be $1,850,000,000 261 00:09:02,129 --> 00:09:04,129 in the United States, which is something that, 262 00:09:04,129 --> 00:09:06,209 as you know, in our constraining system, really 263 00:09:06,209 --> 00:09:08,289 cannot be sustained. So if we can cut 264 00:09:08,289 --> 00:09:10,514 that even in half, going from a 0.5 265 00:09:10,575 --> 00:09:12,355 or a 0.6 rate to a 0.25 266 00:09:12,735 --> 00:09:15,215 rate, we've made a dramatic difference. And again, 267 00:09:15,215 --> 00:09:17,375 in our experience, which we continue to publish 268 00:09:17,375 --> 00:09:20,654 about, we are currently at 0 infections over 269 00:09:20,654 --> 00:09:24,029 approximately 1500 patients over 3 years. So it 270 00:09:24,029 --> 00:09:25,710 takes time for our data to be published 271 00:09:25,710 --> 00:09:26,690 and come out. So 272 00:09:27,389 --> 00:09:29,570 the 1 year data is now officially published. 273 00:09:29,790 --> 00:09:31,629 The 2 year data has been submitted for 274 00:09:31,629 --> 00:09:34,190 publication. And as I mentioned, we're just finishing 275 00:09:34,190 --> 00:09:35,549 up on the 3rd year here, so we 276 00:09:35,549 --> 00:09:37,634 plan on submitting that soon. But we've really 277 00:09:37,634 --> 00:09:40,035 seen some dramatic results where we've literally had 278 00:09:40,035 --> 00:09:42,595 a 0% infection rate over 1500 cases at 279 00:09:42,595 --> 00:09:44,695 this point, which is better for our patients, 280 00:09:44,995 --> 00:09:47,235 better for our particular system, and better for 281 00:09:47,235 --> 00:09:50,115 the overall economics of the American healthcare system. 282 00:09:50,115 --> 00:09:51,960 So I think this is truly an area 283 00:09:51,960 --> 00:09:53,639 where we should be looking to innovate. And 284 00:09:53,639 --> 00:09:56,040 while it remains important to understand how to 285 00:09:56,040 --> 00:09:58,620 best treat patients once they develop an infection, 286 00:09:58,759 --> 00:10:00,679 I think it's even more critically important to 287 00:10:00,679 --> 00:10:02,519 do everything we can to prevent those from 288 00:10:02,519 --> 00:10:03,899 happening in the first place. 289 00:10:05,154 --> 00:10:05,654 Absolutely. 290 00:10:06,034 --> 00:10:08,355 Fascinating to hear about the progress in your 291 00:10:08,355 --> 00:10:11,315 research so far. Some really impressive results in 292 00:10:11,315 --> 00:10:14,274 terms of dramatically reducing those infection rates. No 293 00:10:14,274 --> 00:10:16,995 doubt has significant impacts, not just on patient 294 00:10:16,995 --> 00:10:19,315 quality of life, patient experience, but also, as 295 00:10:19,315 --> 00:10:21,290 you said, in terms of the overall cost 296 00:10:21,290 --> 00:10:22,669 to the patient as well. 297 00:10:23,049 --> 00:10:25,210 Doctor Ravi Bashal, a pleasure having you on 298 00:10:25,210 --> 00:10:26,649 the podcast for this day. Thank you so 299 00:10:26,649 --> 00:10:28,090 much for taking the time to educate us 300 00:10:28,090 --> 00:10:30,330 on this research project. I'm looking forward to 301 00:10:30,330 --> 00:10:31,929 no doubt the publication of that 3 year 302 00:10:31,929 --> 00:10:34,190 data when it eventually comes out as well. 303 00:10:35,230 --> 00:10:37,410 Thanks, Alan. It's a great pleasure being on.