Baumauer Aspirate Techniques, and we'll have Brian come up and talk about ASIS. Morning. So, I use ASIS largely because probably the area that we do most of it is in the shoulder, and I do a beach chair technique, and it's kind of all about efficiency. So, I can't say we have data that says that one is better than the other, and now we're hearing from Arnold that maybe it doesn't matter at all what the stem cell count or the nucleated cell count is. So, I'm not sure. As you, I'll probably be more confused than I started an hour before I arrived yesterday. That being said, I think there's a general level of acceptance that nucleated cells matter in some fashion, even if it's a surrogate marker for something else that's doing it. So, we do talk about cell counts and CFUs and flow cytometry. So, we do flow cytometry for all of our studies, and basically flow cytometry is a sort of a gating technique where we look for cell markers, and we'll take an aliquot of our bone marrow concentrate and our bone marrow, well, the bone marrow aspirate, then the concentrate, and then we'll look for those cells that express CD105, CD73, and CD90, and then we'll look for the cells that lack expression of those other cell surface markers, and then they sort of get matched up into a diagram, and you can assess what the amplification of those specific cells are, and it doesn't speak to function like a CFU, but it speaks to the presence of these cells, and we have three studies going on now. One is a BMAC ACL allograft study, which is a randomized trial looking at allograft by MRI. The other was a BMAC meniscectomy with OA to see if these patients behave differently, and the other one is with rotator cuff, and I just took a snapshot of where we are from a data perspective, and you can just see from those that we believe are MSCs, you can see that the concentration increased several-fold increase in the numbers of cells. So, we're not doing CFUs on these just because logistically an expense, but we're doing something to characterize it, and then we also do smears as well to characterize the phenotype. There are individuals who are not concentrating at all, and you have to ask, you know, what's the value of concentrating? This is just an example of a slide, and I'm not sure how many samples are used, but looking at bone marrow aspirin versus bone marrow concentrate in CFU, and they seem to be more productive and capable in a CFU assay at 96 hours when you do a concentrate versus the full aliquot of just the aspirate, but it's interesting when you ask around the country, there's various individuals who have not concentrated at all and just inject the raw aspirate. As far as where we go, because I'm not sure, you know, there are MSCs or nucleated cells in all of these, and certainly I'm going to tell you that we found more than five. I wish Arnie were here. Is Arnie even here? Is he gone? I think he's gone. Yep, he tells it and he runs, so he will have to, I'm going to have to send him an email later. The, for knee procedures, we'll often go to the proximal tibia. Any study patient we do gets iliac crest, but then the other we do by convenience, so I use ASIS for study patients and shoulder patients, but I will occasionally do proximal humerus, and there are, you know, the numbers are there, but they're not as, they're not amplified as much, and then we'll do proximal tibia for our knee procedures, and the most common place, I don't do a lot of it for OA, but I'll do it for our study patients, and which, you know, we have, these are internal funding for, it's not corporate funded, and we'll also do it for our OA graft patients. That's how we'll do it, so that just, that's what I do. The technique is pretty straightforward. I always like to have the rep there. Can you, hopefully that'll run. Will it run? I'm not sure what's, it's my computer, I can't, you can't do much back there, can you? Hang on. Here we go. Let's see if I can get this. So they will set it up ahead of time for us, and that's convenient. So the trocar's flush with heparin. The reps are terrific at this, and they're all very well trained, and there's not a lot of inefficiency or anxiety getting this done, so I pretty much ask the tech and the rep and the nurse to draw everything up and get it done and mark the syringes and so forth. So on the ASIS, I will use local anesthetic to triangulate, and I simply pinch the inner and the outer table and get the angle, and you'll kind of know if you bust out in the anterior posterior cortex because you'll get more, a wobble factor in the trocar, and I'll go in about three centimeters typically, and what you're not trying to get is just venous blood or bone marrow, blood that's freely available. What you're trying to do is traumatize the area, and frankly I didn't think much about this initially until I listened to some of things that Kristen was saying and others, and this is an area that's now the subject of study, is the maximal way to traumatize the trabeculae to release parasites. That's kind of what we're thinking. So while it may be very gratifying to get the blood off when you put the thing in, like hey home run, I've got something coming out of there, the objective is actually to maximize the trauma to the trabeculae so that you get something that maybe has a larger aliquot of nucleated cells, and then we put it into the machine, and I have no role in this. The reps do it, and I go to work typically, and then what we'll do is complete our surgery. This spin takes 15 minutes, so it's for us if it's the shoulders, it's we try to get a rotator cuff done in 15 minutes, right? So at any rate, when we're done, we dry the field out, and then we inject it between the tendon and the bone, and that's pretty much it. It's very straightforward for us. It's not super inconvenient. I think if I was a lateral decubitus cuff person, I probably would go posteriorly just because we know of numbers, if numbers matter, but something that might be worthy of discussion is not every study has shown that more is better. There's actually often, you know, a lot of orthopedics, and especially biologics, is a bimodal distribution, and in fact, in the OSIRIS study, which was done years ago, I don't know if Tom's in the room yet, but they showed that the high dose did less well than the low dose. Oh, there you go, Tom, right? So correct me if I'm wrong. So, you know, sort of a preserved principle in orthopedics is that it isn't always true that more matters, right? And in that study, they did have a dose response in a cultured MSC model, correct? And that the more MSC is the less good the outcome was when they looked at either meniscal volume or the response in OA. Is that fair to say? Did I quote it correctly? Short term. Okay. All right. So that's it. So we're pretty much on schedule. Go ahead. Can you just clarify how much you typically aspirate? 60 cc's. Sorry. Yep. And then also any tips or pearls to avoid any nerve issues around the ASIS, or have you seen any? I haven't seen. I don't even use a knife anymore. I just squeeze it, stay in the widest part as if I was doing an autographed harvest and use my 20 gauge to numb it up. And, you know, these patients are sedated, but still just to numb them up and then punch through the cortex. A couple of pearls, like, so one of the things I told you is if you're off angle, you'll know you're coming out the inner of the outer table and that's, it's not, you're not going to plunge, right? But that's, you know, just poor technique. The other thing is if you want to redirect because it's a dry tap, I will say this can be more, I know it's more time consuming than going posterior. It could be a really slow draw. So you have to be very patient. The other thing is if you come out and go back in again and you lose your seal, you don't get negative pressure. So that could be a problem too. So just keep that in mind. The good thing about this system is that you can take whole blood at least to volume it up. I'm not sure you're getting much. So the system can still work in the centrifuge and so forth. But you're really trying to get 60 cc's minimum from the bone marrow itself, from something that's traumatic, you know, traumatically induced. Besides your, you have a question? Yeah, go ahead. Go ahead. Sorry. Besides your study patients and OCA's, do you see any role for this potentially in osteotomies healing or do you? Yeah, I mean, I think the data for bone healing is probably at least as good as anywhere else for the use of BMAC. But it's funny, you're there, you're doing an osteotomy and you're making it bleed and you got all that stuff there. So you wonder, are we really making a difference? But what I will do is I will hydrate allogeneic bone. So I'll make a cocktail of maybe, if I'm doing an osteotomy of say 7.5 or greater, I'll do a cocktail of demineralized bone matrix, the cancellous bone and BMAC or PRP. And I don't know if it makes a difference or not, but you feel a whole lot better and non-unions are awful. So, Brian, you mentioned yesterday the poor man's PRP in the shoulder or whatever. How do that compare to this, if you're doing holes in the proximal humerus and all that bleed into the joint? Well, so we'll go lateral for whatever it's worth. I don't go down where the footprint is, but you could. I do it before we do the arthroscopy. So we do it percutaneously into the cancellous bone. So before we even introduce it, if we ever take it from the proximal humerus, we'll just do it percutaneously. I'm not sure if that was your question. Really more about how does that compare if you did the poor man's technique? Oh, I don't know the answer. I can't tell you. I mean, I was fascinated when I first started talking about biologic in the shoulder to find these three studies that were pretty decent, looking at healing rates with just marrow stimulation of the tuberosity. And there's another study, which I don't think it was ever published, and I forget the author, so I would love it if someone knew who that was, but it was they did a subacromial decompression and then ELISE analysis on what was coming out of that. And there were tons of growth factors that came from the acromion. Ben Ness, you're usually an encyclopedia. Who? Rendelli. Did he publish it? Okay, because I remember the abstract, but the bottom line is growth, you know, anytime you denude the cortical surface or something, you're going to get growth factors. So yeah, I mean, I think arguably we're faced, we don't have efficacy data that says that one is going to be better than the other. So we're, I think where we are with a lot of this is we're comfortable that we're not hurting the patient. It's not super inefficient. It's a little bit of time, inconvenience, and money. So if that's not at stake, then, you know, the concept of managing an athlete, we often do things we don't have complete clinical evidence for right or wrong. And, but no, that's why we're doing these studies to try to figure it out to the best we can. You mentioned yesterday that you're doing the hospital's billing for the bone marrow part of it. No, no, we're doing all the billing. So what I said yesterday was that in the office, we have the patient sign the advanced beneficiary notice, which we are told that sort of maximizes all the compliance blind spots. That's if you take a CMS, Medicare, CMS, TRICARE, or Medicaid, or any other government program, that's pretty much the main government programs. But some private insurers follow those guidelines. So we just do it for everyone, right? And in that, it's really an informed consent that also discusses that it's an uncovered benefit, that, you know, it's investigational, it's experimental. And we lay it all, it's amazing to me that you can lay all that out and the patient will say, I want it, you know, but they don't want to pay their $15 copay, but they'll write a check for 2,500 bucks. And no matter how you try to talk them out of it, you know, you're getting a pretty mainstream discussion over the course of this day and a half, where I'm not sure you always get. I mean, I wanted speakers who are open-minded about this, but not, but know that there's holes in the science, right? So I think we are, and I started yesterday with saying that, look, we are in a position of influence. And the last thing we want to do is fall prey to the economics of this without at least being entirely transparent. So our forms say investigational, experimental, uncovered benefit, that kind of thing. And we say it to them. And I said, look, it's not going to hurt you. I think it might or could help. No matter what you say, once you say MSC or mesenchymal stem cell, or even use the word stem, they're in, you know? I mean, you can't even talk them off the ledge, you know? So at least in Chicago, okay? But look, 2,500 bucks to some people is a lot of money. And they'll say, look, I wish I could do it. And I try to make them so they don't feel badly. I say, look, you know, I don't know for sure that it makes a difference. I know it won't hurt. But, you know, the main thing is the operation you're going to get. It's not the cells. It's not the stuff we're putting in. So, you know, you should be confident that statistically you're going to get a good outcome. Because there's a little, that's a dynamic in the office that you really have to be sensitive to. So we charge the patient, then the surgery center or the hospital reverse bills us a set fee plus 5% for handling. That's how we handle it. We don't let the hospital bill the patient. That's just, the numbers in the hospital are enormous. And they've already, you've already had a cash pay conversation. Next thing you know, they're getting billed for something that insurance is still not going to cover, but it's coming from the hospital charges. So that gets pretty ugly quickly. All right, thanks.

ASIS technique

bone marrow aspirate concentrate

BMAC procedures

flow cytometry

cell concentration