All right. So move along. We'll invite Kristen back up to talk about bone marrow from the PSIS. Thanks, Kristen. Okay, I'm going to start again with a couple slides and then I'll play the video. So posterior iliac crest bone marrow aspirate, you can either lie the patient prone or lateral decubitus. I like the posterior iliac crest approach because, first of all, you don't have to worry about any neurovascular bundles, really. But also, I'm kind of short, so putting someone in the lateral D-cubed position like Dr. Ann's went through yesterday is easier for me versus where if someone is laying flat, I have to really pull and you don't have gravity. A couple little pearls, otherwise, patients don't need to be sedated to tolerate bone marrow aspiration. So if you want to do this in an office setting, I mean, we do all ours in an office setting, essentially, unless we're doing a spine. And if a patient's a little nervous, we give them a little Valium and they do great. 95% of the patients will say, that's not nearly as bad as I thought it was going to be. One of the things that happens with bone marrow is it clots very easily and it's sort of the frustration. Now, you guys are surgeons and you guys have a lot of reps that are there to help you with the clot issue. So a couple of things that are important in case you don't have a rep there and you're teaching your staff. You want to make sure the syringes and the trocar have been heparinized like Brian showed you there. You want to make sure that's very key that everything's been heparinized. It's also very important to insert the trocar and aspirate as you withdraw. Again, if you kind of get in there, you think, okay, I'm in and I'm going to start pulling marrow. And if you don't really have that trocar all the way in, you're pulling blood. So you really need to go, and don't be worried, you're not going to puncture the bone. If you think about the way that bone works, you're going to go. If you're really worried, the kits almost all come with a blunt. So you can take your sharp needle out of that trocar and then you can put the blunt in and you won't go through the other side. The other thing you can do if you're a little nervous is go in two centimeters, draw, redirect, draw, redirect. So that's another way of doing it. Again, you want to aspirate quickly because you don't want clots, but you don't want to aspirate so fast that you get bubbles because you don't want to break up those red blood cells and cause them to, I'm trying to think of, lice, yeah, sorry, my brain's not awake yet, not enough coffee. And then you want to filter it before processing and Dr. Cole showed in his video that filtering up through the filter. Now, if you do get a clot, don't freak out, it's okay. Everything you filtered is fine. And even the stuff you haven't filtered yet is fine. So if you get a clot, then remember, all you really have to do is, and I'm a big believer in you have to have not just, you want to make sure you have lots of growth factor. And so remember, if you do get a clot, you've activated your platelets, not inside the patient, but you've activated them there inside the syringe or you've activated them inside the filter. So all you have to do is just add back some peripheral blood, run it for PRP, and then you've got your platelets again. So that's just kind of a way to troubleshoot it. Why postureolite crest? Adam talked about this. Well, I totally understand with a surgeon, you guys don't want to reposition and all that. The reason we choose postureolite crest is obvious. Well, this was one little study that I could find that showed that there were 1.6 times greater colony founding connective tissue progenitors. Again, if we're talking about how important are the MSCs, we don't know. And again, I like it because I'm not sitting there staring at a patient who's wide awake as I pull their bone marrow, right? That's another reason I don't use the sternum. That's another great, great thing. And it's easy for me and it's comfortable for me. And I like having gravity. I don't have to pull as hard, so it's not as painful for the patient. So here's a little video. I think it should be. When we begin a posterior iliac graft harvest, what we're going to do is use our curvilinear probe in order to find the correct area to aspirate the marrow. So we first take the curvilinear probe when we have the patient in the lateral decubitus position and we place it along the sacrum. And I like to use ultrasound guidance so that you can use fluoroscopy. But if you use ultrasound guidance, you identify the sacrum as the bright white reflective area of the edge of the bone as shown here by Thomas. And then you move the probe cranially until you identify the L5-S1 junction. Then I turn my probe 90 degrees and I move it laterally or superiorly in this case since the patient is in the lateral decubitus. I identify the sacral spine in the middle of the screen. And then as I move, I will find the posterior iliac crest. And you will see this again as a black shadow behind a bright white area of bone. Again, Thomas is going to point that out. Right. Actually, that's a little superior, Thomas. There we go. Exactly. That's your iliac crest. You screen cranially and caudally until you find the thickest portion. And once I find that and I identify it in the middle of my screen, I'll mark the X and Y axis in order to use that as a guide point. Then once I have that area identified, again, I will have my XY axis. I'll use a combination of lidocaine and marcaine, 50-50 combination, a 10cc syringe, and a 25-gauge needle. And then I will insert this through the skin. I will be sure to thoroughly anesthetize the skin. Then also, I will move deeper and anesthetize the soft tissue between the skin and the actual iliac crest. As I get deeper, I will identify the periosteum. And you can see me sort of bounce off the periosteum. As I bounce off the periosteum, I'm going to give a good about quarter-sized periosteal block. This point in time also helps you identify that your marking via ultrasound or via fluoroscopy was correct. And it allows you to identify your landmarks and be comfortable with your approach. Then the next step is to use an 11-blade scalpel and make a small incision for where you're going to put your bone marrow trocar. You take your bone marrow aspiration trocar, and you insert it into that very small incision, and advance it to the level of the periosteum, which you can usually tap it on. Hey, can you turn the audio off completely? You then set it on the periosteum, and you insert it into the periosteum. that is in the periosteum I advance about two to three centimeters and then I'm pulling out the stylet and this is really important if your patient is awake you want to go very slowly when you do this is what hurts putting the needle in doesn't hurt and you start to pull the marrow again you're getting that pressure change and it hurts so I'm going to pull somewhere between two to five cc's I turn 90 degrees two to five cc's 90 degrees two to five cc's and I repeat that once I've gone a full 360 I should be talking about this once I go a full 360 then I will withdraw the trocar about a half a centimeter and then I'll repeat that and continue to repeat until I get the volume of aspirate that I desire for the procedure I took that syringe off I get my next syringe and it's just sort of rinse lather repeat so you can go ahead and stop the video actually no one wants to watch me do this over and over again so that's kind of a posteriorly uh approach to it um do I have time for questions okay do I anybody have any questions no it's pretty pretty straightforward one question actually uh Dr. Dragoo earlier asked me uh you know why do I use ultrasound like he said you use ultrasound to mark the posterior crest in Missouri people are a lot fluffier than they are in northern California so uh you know you frequently will get someone with you know a lot of soft tissue and trying to palpate that posterior iliac crest is not always that easy to do uh not only that but really I truly believe that if you find that area of the iliac crest just medial to where the glute comes off and you can see it on the ultrasound and hopefully today on the cadaver approach we'll be able to see it if you can get that area and anesthetize it you patients virtually don't have any discomfort with this they have someone you pull if you pull too fast but what really hurts is when you take that trocar and you stick it through the glute so if you're too lateral or too inferior to that area that's what's painful so if you can find that area if you don't have ultrasound and you don't want to do it that's fine and most of your patients will probably be you know asleep so it won't matter you mentioned fluoroscopy can you clarify if and when you're using that with any I absolutely never use fluoroscopy to mark it but I've only brought that up in case people in case some of you used fluoroscopy to do it so I don't I just have the ultrasound so I'm used to it but you can obviously use the fluoroscope to mark that the other thing to remember is that I mean most of you I would assume you have physician assistants that work with you and there's nothing that says that you can't have them go in and aspirate that bone marrow uh pre-op you know even in even you can do it even in the in the pre-op area if you wanted to so you could use that without having to reposition the patient due to anesthesia and then last in the clinic setting just reiterate your um what you do this most commonly for oh the most common thing I do this for is knee osteoarthritis so by far in a way so what's your take on your outcomes oh I could have presented that too fabulous actually our outcomes for knee osteoarthritis are really good as long as we avoid the people who are poor candidates uh you know a grade four lateral compartment uh knee is not ever a good candidate um you know I think I don't think I've ever had a good outcome so I talked them out of it um and then once you get a significant if you're a stage four medial a kelgrin kls and if you've subluxed a little they do poorly but there's a couple of things you have to do so our outcomes on our stage four knees and I do I'm doing like 180 of these a month okay so nice the stage four medial compartment away you have to put them in an offloader and you have to do an interosseous injection but our outcomes for stage four doing that are as good as our threes so adding those two things was a game changer we went from like maybe a 30 success rate on a medial stage four to much better more like an 85. Can you clarify what your interosseous what you what you're talking about? Yeah so you saw the I think it was yesterday someone was presenting the idea I think we're is there a session later today about interosseous injections? Technique okay so um the idea is so we the first time we did an interosseous injection was on a patient with an osteochondral defect who was an athlete and she was a volleyball player who had tried um many allografts she had gone through tons of different options for this defect she was in that time in her early 20s and her father was actually an ER physician and we knew him and he came to me and said you know you think you can help this girl and I'm like I highly doubt I can help your daughter but needless to say we sat down we thought about the concept of trying to get tissue to heal and just putting cells inside where when all the nutrition and everything comes from proximal didn't make any sense to us so we thought about well how about taking a needle and putting it proximal as well and kind of sandwiching it in there and have in getting through the bone so we basically go through when we do these interosseous injections we'll go through healthy we'll advance the needle through healthy bone just proximal to the area uh let's say the so the medial femoral condyle medial tibial plateau and then we'll inject about a cc of bone marrow concentrate in both those areas now I don't know if it's just placing the needle that's making it better I don't know if the bone marrow uh the bone marrow concentrate there it does or not but needless to say it seems to make a huge huge difference but remember when you have a stage 4 OA most of the time we'll get our MRIs and we'll see all that edema in both of those bones so a lot of the pain is coming from bone and so if you don't treat the bone you're not going to make the patient happy. Thanks. Are you doing that on awake patients in the office? Thanks yeah I'll just do a geniculate block so at the time I pull my aspirate out I'll do a um a superior medial and superior well if it's a medial compartment OA superior medial and uh a inferior medial geniculate block let it sit for 30 minutes and it's pain free.

bone marrow aspirate

posterior iliac crest

neurovascular bundles

heparinized syringes

ultrasound guidance