It was a great session. We'll actually bring Jack back up because he's gonna moderate the live surgery session. Thank you everybody. So we have Jason, can you hear us? Yeah, loud and clear. How about you guys? Loud and clear here, too. So as you told me, Jason, you're going to do both of your techniques in a row instead of what's on the agenda. So the first one, it looks like you're going to do the arthroscopic harvest of the adipose tissue. Right. So we'll go over a couple things together. The first is the arthroscopic harvest. So that's the reason for the live demo and not bringing all the arthroscopic equipment out into the lab, because it's busy enough in there with all of the techniques that we're going to be doing today. But the arthroscopy is remarkably easy. So this is certainly not a technical type of case. And so then we'll just kind of show this. And I think the most important part will be then the processing of the fat. And there's two main ways to do that. So we'll show you one here, and then Tim Orman will show you another one in just a couple of minutes by a video. So if you guys don't mind, I'm just going to show you the setup here. Annette's here with me. We've already put the arthroscope in, and you can kind of see the arthroscopic typical image. The key thing about this, and if we can see here, is that the standard arthroscopic shaver for the infant patella fat pad, although I don't have the right attachment, but the synovial-based shaver systems are typically the best. They tend to really not create damage to the cells. So that's the one with the smooth border of the tip, but a standard arthroscopic shaver. And then this arthroscopic shaver is then connected directly via its out port here, its suction. And then we'll turn the cameras over right behind me here, and you see that this cord is then connected to a sterile container. And this sterile container, again, is specially made for fat. And if we could also show you maybe even a side view of this here, and we can see that this canister is made for the patient's aspiration or the fat to come and to drop directly in from the shaver down into the central chamber. And then this port here is hooked up to the suction system, so it's a real easy type of canister to use. At the beginning, there's this port right here, and this is where the saline is put in. So 400 mLs of saline is just placed at the base of the canister, and that's really all you need for setup. But again, this is specialized type of equipment that you would need at the time of arthroscopy just to be prepared. That being said, it's really just the use of the standard shaver systems and the standard types of shaver tips, so nothing special there. One question, Jason. A lot of us will do just a scope. We'll do it under a local anesthetic with intraarticular injection preoperatively. Do you avoid that intraarticular, you know, ropivacaine injection, whatever, preoperatively if you're going to be harvesting? I would say yes, because we know that all of those local anesthetics tend to have a significant effect on the cells. And so to minimize the different sort of medications that I think would probably be the most reasonable thing. That being said, ropivacaine, that's the best choice, you know, because that certainly has the least effect on these cells. But we all do know that they're sensitive, and we're about to, again, make them more sensitive by really changing their environment. So maybe not the best choice. And if you could maybe have the option of just anesthetizing the portals first and the subcutaneous tissues, but not an intraarticular injection, may be reasonable. The other thing is, is that although we won't show it today, this infrapatellar fat pad technique is basically, the precedent is that whenever we do anything to the infrapatellar fat pad, we always must cauterize it due to the high vascular supply. Obviously, that's that thing that gives all the good cells that we're after, but also that not so good arthrofibrosis afterwards. So really making sure that whenever we take a shaver of any type to the fat pad, and making sure that we really take the time to cauterize it. And that cautery is the thing that makes some patients, via this local type of sedation, it makes it tough for them to tolerate. So that's the only caveat to not using a spinal or a low-level general anesthesia for these cases, because that radiofrequency probes sometimes can make those patients real sensitive, especially in the fat pad. That's what Scott Dye showed. Exactly right. Exactly right. All right. Well, thank you, Annette. And so what we'll do now is we'll kind of, if we can here, get the shaver into the knee. And pressurized here. Maybe I'll take this 11 blade again. Alright, so this is just again a standard shaver setup and what we'll do is the arthroscopic technique is really keeping the back of the shaver along the condyle and a little easier in live folks rather than in the cadavers where the fat pad for most folks is pretty prolific but the bottom line is again just hooking up the shaver system and just holding against the condyle and that will allow the aspiration of the fat to come in as we typically do as we're preparing the area for an ACL. Any ligamentum that's there can also be taken because we've also looked that the synovial cells that are on the posterior border of the fat pad also contain a significant amount of as we'll say MSC's and so then that can also be a very useful adjunct as well and I'll show you how on the system here you can actually separate out the cells from the synovium if for some reason you would want to do that and the cells from the fat pad so and again just from the basic science perspective we've looked at both and so really to conclude that both this posterior border of the fat pad is rich in cells as well as the fat pad itself and so this is kind of boring in the same way of preparing your cases for an ACL but what I wanted just to make sure to communicate is that you see the shaver just running along the condyles and so therefore we're not shaving out a significant amount of the fat pad but it's just really in the same method that many of you would just to prepare yourself for that ACL so again nothing technically challenging whatsoever for this particular part now if with the cameras can also then veer over to see our area here a fat collection system because it doesn't take much time and if we can see that vessel the fat collection container maybe I'll just pause here because we have a lot of saline now and thank you we'll just keep that in just in case and maybe we'll switch over here now and to see a couple of things that that this has really had a lot of saline mixed with it and you see the fat layer that's floating towards the top here and this system is built to not only collect the fat but it will provide some separation and most specifically it will also wash the fat cells so much more saline than there is fat cells but by deliberate intention to really wash the cells as well now one thing I learned the hard way here with all of this is that the infant patella fat pad again is really vascular so this sort of harvest is best to be done under tourniquet otherwise there is a significant amount of red blood cells in this area and of course that from a biologic perspective is not what we're after and so then it takes quite a few washes and there's a couple of techniques to unsnap this and to what and to add more saline and wash it but if you use a tourniquet there's really no need for that so then we'll go on to the second part of this and this is the processing of the fat and looks like a net I think we'll have enough here so we can maybe let go of that and what we see with this system is there is a port down here below and and if you don't mind to net can we turn off the suction and then that will allow this to flow out of the container and at the bottom here you see that this is where all of the tissue comes out on the end and this system comes with two different types of adapters the first is a larger type of adapter here and this is for the to me syringe and so they both comes with both of these attachments and then what that allows is this chunkier tissue and it's hard to see that floats to the bottom at the beginning that is the synovial tissue it's heavier than the fat tissue and the fat tissue course is floating so the synovial tissues at the bottom so if you wish to harvest it then you can just use the to me attachment and the to me syringe and then take out this bottom layer and then it's still I hope this won't blow up on us here there we go okay and so now what we'll do is decant all this extra fluid and so again if you are saving the synovial tissue which we won't do today and and switch hoses here but you can take that and keep it in a separate syringe otherwise you can just drain out this fluid here in a kind of a boring way but it goes pretty fast until the area where we start getting the fat tissue to come into the funnel so everything's kind of funneled into the bottom portion here and you see the fat coming down now and then right around here we'll start collecting the fat in our syringes and so then standard at least 20 ml syringes and you just hook it up to the supplied lure lock adapter and go ahead and start taking the syringes full and sometimes they get caught and there so you really have to pull and then you keep the syringes suspended either way and that could be in this direction here and then you can use a stand like we have supplied here or I'll show you on the next and that would you mind bringing those arthroscopic graspers a little closer and again so we're just getting to the fat layer here so you see there's not much but if you don't have a fancy stand like this no big deal right because you can just use your arthroscopic grasper systems and you can put typically is a little different than mine but you can put your syringes up like this and so you see when you do that then the fat automatically is preparing itself by separating from the saline and moving towards the top of the syringe and then we'll keep doing this in a little more just to get a little more tissue here to show the processing of this and here's a more of a significant amount right that's in the syringe and then sometimes the fat depending and I think a little more for the cabber here gets gets on the sidewall and so you can easily then just rinse this back into the bottom and then we'll put it back in and get the rest of the golden tissue here all right almost done with this part any questions thus far kind of standard stuff Jason can you hear oh there we go I can hear you now when would you use this I know tissue what would be ready so what are your indications for this oh this is when we ever you would like to use the adipose derived cells for any type of procedure and especially from an orthopedic perspective the perspective is that arthroscopy is something that a we commonly do and especially if you're doing a knee procedure then it's an easy source of cells for that this whole thing of homology and we're you know of course the FDA and orthopedics are trying to work this out but it seems to me that there would be homology that if you have cells that are from the knee and you put them back to the knee it's hard to say that that's not homologous use I guess it goes always goes back to what's the reason that the fat pad is in the knee in the first place but certainly reasonable to conclude that there may be a source of cells and renewative capacity and that's the reason that the the fat pad is in there and I think for most of us this technique the indications for it is for those who just don't feel comfortable with the abdominal side of it and this team arms going to show you the abdominal side is actually pretty easy but it's just foreign to us in orthopedic so this brings it a little bit closer to home your question about the synovium is a good one and the answer is that I that number one it may be reasonable to harvest the synovial layer in those patients where you don't have a good bountiful harvest of fat and that could be and you know patients with a real small fat pad somebody who's had previous trauma to the knee that you don't feel that you have a good enough harvest of the fat tissue so that could be one where you're supplementing the supply of cells and and I think the reason is to is just we've made sure that there's plenty of cells there so you can feel comfortable harvesting that layer all right so here is the syringes with the fat and you can see the fat then is towards the top of the syringe and so what we do now is we're going to get all of this into one syringe to work with initially and so this is all part of the initial technique of just kind of gathering things into one syringe all the saline then can be wasted and here we go and we'll take this again we're going to just add everything together and this is a standard lure lock adapter and then it can go into the upper syringe how many mils do you typically harvest yes so typically at least 10 mls to 20 mls of fat and that's been a consistent harvest through all of our pre work on this or basic science work has consistently been a harvest of a minimum of 10 cc's and an average harvest of over 20 and you don't know it depends how much you want at the end of the day but certainly with the use of arthroscopy plenty of usable fat so really that's the arthroscopic technique and then what I would do as this fat was sitting I go back and electric use the electric coterie and make sure there's no bleeding in the fat pad and then of course go on to whatever part of the procedure that you do in the knee or close up at that point so again real simple and probably not worth the time for everyone just for that basic part of it but at the same time at least for the lab but for the setup is the important thing and so I think that's the important thing to focus on today Jason yeah sorry just so many questions all from a sort of ultra structure of what you've got in the syringe there versus what T's gonna show next what's your sense of how it differs the shavers kind of doing the mechanical you know emulsification and so forth of it versus what we're gonna see next what do you think if and I wouldn't even I wouldn't even know how you study it you look at whatever loan or microscope or you know what's it how's it gonna differ and does it even matter yeah probably not going to matter and I think maybe if I understand your question Brian and that is if you get it from the abdomen through a tumescent liposuction which T's going to show you in a few minutes and if you do that technique and disrupt it and get the fat to come through the little cannula of the liposuction it's very similar in consistency to this now ours just as mulch with the shaver but it's through a much larger bore so then overall the shaver does a very similar job as far as the breaking up initially of the fat very similar as far as the percent viability of the cells or let's just say the lot the lack of the loss of viability this high viability and with T Mormons technique in the abdomen high viability going through very small cannula as well so very similar at this stage but that's what we both of us are going to talk about that this stage isn't enough like we cannot implant this sort of fat tissue because there's a lot of mature fat that's in here so this would be highly inflammatory if given into the joint so therefore we need to go through some additional steps and so that's why we just wanted to go through these two main pathways of how to do this and you can break it down to the two main harvest techniques so this arthroscopic harvest is one and then T Mormons technique he's going to show you of the abdominal buttock and thigh that subcutaneous harvest that's technique number two and so then so that's the harvest techniques all right and quickly how do you bill for this bill for this is this is this is for this this is cash pay so this is a BN this is not something that's billable independently this is cell collection none of no codes for cell collection at this time so this is certainly pre discussed with the patient that this is the goal to harvest this tissue you certainly bill for your arthroscopy you've built bill for your synovectomy if you're going to do that portion of the case etc but no special parts of the billing for the collection of the tissue that has to be via the ABN as you discussed yesterday what do you charge well it's it's a little complicated because it's in the big system you know in a university system so that's tough it's tough to get a straight answer from them it's around $3,000 for the whole additional parts of the procedure for the fat harvest that being said almost all of this is done by a research now so we're not having a big portion of the practice where we're just offering this independently with the full admission that we just need a little bit more information first before we start doing this widespread so that's that's the answer 3,000 at our institution I know it varies widely from one institution to another so this is the next part of the processing and you see in your programs that this is the syringe emulsification so we'll just do that just because I'm here and we have everything put together and what you see is that as we wait and as we talk this further separates out and we can see that there's additional areas of the the saline that washes out so we have a really now condensed portion of fat and so one way to prepare this this is the second part of processing fat first is to get in the syringe in one of two ways and second is to process it in one of two ways so here's technique as we have it in a lab number you guys will all have a chance to do this in the lab but this is taking this harvested fat and we are going to now fraction the fat itself we're gonna blow up the fat into pieces then this microvasculature that we have actually harvested through this will be also blown up and that can be done through the lipo gems which will go over next which is in theory very similar and this is passing it through a small aperture lure lock adapter so we're gonna go from one syringe to the other with a larger lure lock adapter and so then it's go from one and you can just feel the resistance as it goes back and if you could please also note I hope it shows that how yellow this fat is and globular I don't know if it shows very well on the camera but it is it is very I don't know another word but globular and yellow so then when we do this is we're gonna go through and the typical repetitions is somewhere around 30 but at the same time what we also feel for the change we feel for the change where it was really difficult to begin with and then becomes pretty easy and so when you either get around 25 or 30 or when you really feel that this is starting to become easier then it's time for step number two you can see the fat is already turning white and more consistent just from this first step I'm gonna disconnect the syringes and then we're gonna put on a special adapter and these two are smaller lure lock adapters and so you see one here has 1.4 millimeters on it and that's this one this is even smaller at 1.2 and so we'll put on the larger of the two now and so this is again just the same thing it's the bridge in between the two and what you will notice and what I would love for everyone to feel today is that this is actually gets really tough to push it through because again it's it's a smaller aperture and you can just you can even hear it that it's it's in high pressure and high velocity as it goes through here and we had initial worries that this would decrease the cell viability but it just doesn't seem to be a problem after looking this after you do this and you can see I'm putting a significant amount of resistance to get it through here and the same sort of thing that with this lower diameter that we just want to get this and so it's easy and you see every time we do this the fat becomes much more homogenous it becomes white almost like milk and that's what we want we want really those mature lipocytes to be destroyed and so here we go getting to the end of doing this one more time so then we have again 1.4 and then we switch it to the 1.2 what's this entire kit cost well that's that's the interesting thing and I think I I wouldn't speak on that because there's a wide variety of course of the costs of the the kits what we're doing what we opened up here is the adiprep kit from harvest and so the adiprep folks are here so ask them about the cost because it does vary widely and I've heard you know that's up to each institution to get the pricing on that these little cannulas here these lure lock adapters are actually for a box of 10 it's around $100 yeah between 75 and $100 and so these what I can tell you is many companies are going to be developing this so the summary is that the cost of this equipment and this particular technique are going to be going down just because of the the competition environment so overall I would say that this is somewhere around 200 $150 in equipment for this particular technique but again that varies and I'm probably not the best resource for the actual costs of it and here we go with just doing the same thing and again hard at the beginning to push it through even the smaller diameter and but overall then gets easier and once again I want to just to show you a couple more reps here so Jason is your goal here to keep the cells intact or to disrupt them they keep the cells intact but the overall microvasculature and septae within the fat the connective tissue part of the fat to disrupt that but the cells to we want the cells to fall out in solution rather than to be confined within their matrix so I think that's probably the best way to describe it but cells intact the mature adipocytes with a large volume of water etc when when they flow through the syringe like this many of them will not survive but those are the cells we don't want anyway just because of their volume and that the degree of water that's within them but the small we'll call them MSC's parasites is probably the best technical term are the ones that are much smaller cells and those are the ones that survive this process okay so then what we'll do is we'll go back here we're kind of finished with that initial processing and so the next step and this is for the adiprep set again we're going to show you two ways to do this adiprep and lipogens this is the adiprep and so it comes with it with all these syringes and lower lock adapters and then here is the actual tube but that's going to go to the next step of processing the fat and all of this is is another centrifuge tube that's specially designed for fat and this is again the same way of taking now our prepared tissue in the syringe and this injecting it into the syringe and making taking care that if I can grab it here whoa the cap because I forgot this once and that was not pretty so the cap goes on to the end and it seals in and keeps us sterile as you go through the centrifuge process this is a special type of device because there is the fat tissue and then there is a little floatable ring in here and so as the centrifuge process continues which is the next step the mature fat will float above the disc the tissue will then be below it which is the still undisrupted matrix tissue and the stromal vascular fraction or the ones that contains the cells that we are interested in will be dropped will drop to the bottom and so I'll have a chance to use the centrifuge I won't you know because it takes a few minutes won't do it now but then this you pull out the plunger and just then drop this in the centrifuge and then we'll show you later on in the lab where then at the end you'll see that stromal vascular cells at the base you just take off the lid put your sterile syringe on it and then you have your system again press from the top and then just deliver that small fraction of cells and that's the one we're after how many mils is that small fraction anywhere between 1 and 3 ml typically depending on your volume of fat so if you're going to use the abdominal technique and a true liposuction you can get a huge volume of SVF that's about 10 cc's from the infant patella fat pad that volume is much smaller and typically again between 1 and 3 cc's we typically overall put in about 4 or 5 cc's because we will get some of the surrounding tissue above the SVF layer but just because we don't know where the SVF layer truly ends but somewhere let's just say between 1 and 4 cc's any other questions I don't see any awesome well thank you very much and then team Orman's going to show you a entirely different way to do this which I think will be a good compare and contrast thank you thank you very much Jason

arthroscopic harvest

adipose tissue

knee surgeries

fat collection

fat processing

centrifuge