ROV/\L BIOLOGICS

Introducing

MAXX™

-CELL The World's Most Advanced

Bone Marrow Extraction Device

Maxx™

-Cell has created a new gold standard in bone marrow

aspiration therapy for various uses in orthopedics, sports medicine

and pain management. Deliver the highest, most pure enriched

form of bone marrow aspirate without the need for centrifugation.

Maximize cell count yields while minimizing peripheral blood

dilution. Stem Cells and Mesenchymal cells are now easily and

effectively obtained with this breakthrough device.

ROY/\L BIOLOGICS

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�Z"CELL

TRADITIONAL NEEDLES

Produce excess peripheral blood contamination, diminishing cellular yield; thereby requiring additional maniulation steps to achieve the cellular demand necessary for most clinical

indications.

MAXX™

-CELL

"Maxx™

-Cell uses its technology to harvest high quality stem and progenitor cells from

various levels within the marrow space, limiting peripheral blood contamination."

Aspiration can be performed percutaneously (MIS) or to exposed iliac crest.

'U.S. & Foreign Patent(s) Pending'

Distributed & Marketed by:

www.HENSLERSURGICAL.comSALES@henslersurgical.com(w) 910.399.7380 (f) 910.399.7381

The New

Gold Standard in Bone Grafting for Fusions

Maxx™

-Cell has created a new Gold Standard

in point of care cellular therapy and bone grafting

�z CELL THE NEW GOLD STANDARD

by offering the most viable live cellular product in orthopedics

Maxx™

-Cell obtains higher CFU's than other "Live Cellular Premium DBM's"

MAXX™

-CELL TRINITY/OSTEOCELL **

CFU/ml- 33

Processed Al lograft Cel Is Do Not Function Due to Damage Caused by Processing and Preservation.

Maxx™

-Cell offers a unique strategy for bone grafting options in

Orthopedics. Obtain the highest level of stem cells, live and point of

care from patients during surgery and combine with local allograft,

cancellous chips or DBM. In seconds you have created the safest, most

reliable and cost efficient premium cellular product possible.

Maxx™-Cell can be used

in a wide array of clinical settings,

in-patient OR and outpatient

procedures.

Foot & Ankle Fusions

• Triple Arthrodcsis

· Subtalar Fusions

'Comparison of bone marrow aspiration and bone core biopsy as methods for Harvest and Assay of Human Connective Tissue Progenitors Rozic et al Cleveland Clinic NIH

grant RO1 AR049686

" Brown LS. Darmoc MM, Clineff TD Investigation of Mesenchymal Stem Cell Phenotype and Function in an Allograft Cellular Bone Matrix. Stryker Corp. Malvern. PA

Distributed & Marketed by:

MAXX™

-CELL ( ) 1 1 11 J 1 1 11 r (J

Maxx™

-Cell now offers a wide variety of kit components to help

enhance the extraction and delivery of stem cells in any clinical

setting.

�z-CELL

ENHANCED KIT FEATURES INCLUDE

Micron Filter (to filter bone spicules, fat

and tissue debris)

Bone Autograft Harvester

Lidocaine

Iodine

Drape

Scalpel

Gauze

Syringes

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www.HENSLERSURGICAL.comSALES@henslersurgical.com(w) 910.399.7380 (f) 910.399.7381

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MAXX™

-CELL �act sh

The Maxx™

-Cell system maximizes the yield of stem and progenitor cells

by giving the clinician the ability to efficiently harvest bone marrow from

multiple levels within the medullary space, while restricting dilution of

peripheral blood

INDEPENDENT REVIEW OF

�\:♦�-CELL

BONE MARROW ASPIRATE SYSTEMS versus "MAXX™-CELL'.'

M -CELL

2,514*

KEY BENEFITS

HARVEST

1,270

Data Acquired from Published Sources

Reduce the cost of utilizing high priced biologics. Maxx™

-Cell delivers better regenerative solutions at reduced cost compared to industry leading solutions. Create the highest live cellular product, point of care in any clinical setting.

MINIMIZE O/R TIME

Centrifugation systems typically require 20 minutes or more of spin time during the surgical procedure, not to mention the additional support.time needed fo� [)re[)aration and cleanup of equipment. No centrifuge needed.

MINIMIZE STERILITY CHALLENGES

Centrifugation systems require passing the BMA off the sterile field for processing and back on for implantation. Maxx™

-Cell

eliminates the additional steps where infection concerns must be managed.

MINIMIZE SAMPLE WASTE

Centrifugation systems typically discard 80% of the aspirate due to the high levels of peripheral blood. Worse, significant numbers of the desired cells (approx. 40%) are discarded because as these cells increase in density prior to division, they are processed into the undesired red cell centrifuge component and thus discarded, substantially limiting regenerative potential of the resulting sample.

PRODUCT ORDERING

MXC-1 Bone Marrow Aspiration KitMXC-2 Bone Marrow Aspiration Kit, Preparation Accessories KitMXC-3 Bone Marrow Aspiration Kit w/Preparation Accessories Kit & Autograft Harvester

* "Novel Technology to Increase Concentrations of Stem and Progenitor Cells in Marrow Aspiration", Harrell & David, Purita, Joseph

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MarrowCellution Index

Theimportanceofcfu-fcounts

Comparison:A) MarrowCellutions B)Trinity/OsteoCelC) CentrifugationProtocols

AllograftProcessedcellsaredamagedanddonotfunction

BoneMarrowAspirate– Aprovendriverofboneregeneration

PeripheralbloodinfiltrationduringmarrowaspirationPeripheralblood=LowStemCellYield

HowMarrowCellutions overcomestheproblemofperipheralbloodinfiltrationoftheaspirate

MarrowCellutions - Detailofcfu-fcollected

Conclusion

TheImportanceofcfu-fCounts

Authoritativestudiesinorthopedics(Hernigou etal)demonstratedstatisticalsignificanceinnon-unionandosteonecrosistothenumberofcfu-fcellsinthegraft.

Inthosesamestudies,nucleatedcellsinthegraftdidnotrisetosignificance

Interestingly,cfu-fisfoundfrequentlyinmarrowandveryrarelyinperipheralblood.

FromHernigou “Therefore,itseemsreasonabletosuggestthatagraftneedstocontaingreaterthan1000progenitors/cm^3”

Cfu-fhasbeenestablishedasthegoldstandardindeterminingthequalityofabiologicinorthopedicregenerativemedicine

Hernigou etalTreatmentofOsteonecrosiswithautologousbonemarrowgraftingClinicalOrthopaedics andRealted Researchnumber405,pp14-23

Hernigou P,etalPercutaneousAutologousBone-MarrowGraftingforNonunions – InfluenceoftheNumberandConcentrationofProgenitorCellsTheJournalofBoneandJoint”Volume87-ANo7July2005

AComparison:A)Marrow-Cellutions B)TrinityC)Centrifugation

(1)Harvestingbonemarrowwithoutcentrifugation.Scarpone etalPresentedattheAllegheney orthopedicupdatemeeting,2016(2)BrownLS.Darmoc MM,Clineff TDInvestigationofMesenchymalStemCellPhenotypeandFunctioninanAllograftCellularBoneMatrix.StrykerCorp.Malvern. PA(3)VishalHegde MDetal;“Title:Aprospectivecomparisonofthreeapprovedsystemsforautologousbonemarrowconcentrationdemonstratednon-equivalencyinprogenitorcellnumberandconcentration.” JournalofOrthopaedic TraumaPublishAheadofPrint

ThehighTNCcountandlowstemcellcountinthecentrifugedbiologicisduehighlevelsofperipheralbloodcontamination

Averagecfu 3,405

“Harvestingbonemarrowwithoutcentrifugation”ScarponeetalPresentedattheAllegheney orthopedicupdatemeeting,2016

Marrow-Cellution

ProcessedAllograftCellsDoNotFunctionDuetoDamageCausedBytheProcessing

• Cellscapableofformingacfu-fareeasilyseparatedfromfreshautogenousbone(autograft).(Standardcollagenaseprotocol)• TheproprietaryprocessingpreparationoftheOsteoCel &Trinityproductsresultsinthecellsunnaturallyadheringtothebonesurface

suchthattheycouldnotbetestedusingestablishedprotocols.(Standardcollagenaseprotocol).• Theabilityofcellstomigrateinresponsetocytokinesiscriticaltotheirabilitytofunctioninatraumaenvironment.Theun-natural

adherenceofthecellsthatresultsfromtheproprietaryprocessingoftheallograftraisesconcernovertheabilityofthose cellstocontributeposttransplantation.

• Cellsneedtobesupportedbyafunctioningbloodsupplytosurviveoveranextendedperiodoftime.(typically,within100um of abloodvessel

• Totalnucleatedcells(TNC)cellsfromthefreshautograftsamplereflectsthatnoimmunematchingisrequiredforautologous use.

(1) ComparisonofbonemarrowaspirationandbonecorebiopsyasmethodsforHarvestandAssayofHumanConnectiveTissueProgenitorsRozic etalClevelandClinicNIHgrantRO1AR049686

(2) BrownLS.Darmoc MM,Clineff TDInvestigationofMesenchymalStemCellPhenotypeandFunctioninanAllograftCellularBoneMatrix.StrykerCorp.Malvern. PA(3) Harvestingbonemarrowwithoutcentrifugation.Scarpone etalPresentedattheAllegheney orthopedicupdatemeeting,2016

FreshAutograft(1) MarrowCellution(3) OsteoCel(2) Trinity(2)

cfu-f 4,564 3,405 28 38

TNC(millions) 56 33.1 0.25 0.4

AllamountarereportedonapermLbasis

ProcessedAllograftCellsDoNotFunctionDuetoDamageCausedBytheProcessing

ClinicalEvidence– Trinity/OsteoCel

Inastandardathymic murinemodelforboneformation,theirwasnodifferenceshownattime14daysandtime28daysbetweenstandardhumanallografttissue(studygroup1)comparedtoTrinity(studygroup2)andOsteoCel(studygroup3)

BrownLS.Darmoc MM,Clineff TDInvestigationofMesenchymalStemCellPhenotypeandFunctioninanAllograftCellularBoneMatrix.StrykerCorp.Malvern.PA

OneyeararthrodesisratesinACDFusingstandarda-cellularhumanallograftscomparedtoOsteoCel didnotshowanystatisticaldifference.Althoughnotstatisticallysignificant,patientstreatedwithMSCallograftsdemonstratedlowerfusionratescomparedtoamatchednon-MSCcohort.

StevenMcAnany,MD,etalMesenchymalStemCellAllograftAsAFusionAdjunctInOneAndTwoLevelAnteriorCervicalDiscectomyAndFusion:AMatchedCohortAnalysisTheSpine Journal Accepted Date:18February 2015

Cellsfromadifferentpersonhaveanimmuneprofile.Forexample,ifyouhave500,000cellsand100,000cellsareMSC,theother400,000willcausearapidimmuneresponse.

RegulatoryConcernsTheseAllograftsAreRequiredtoSubmitforRegulatoryClearance

Valueaddedbonegraftmaterialsharvestedfromrecentlydeceaseddonors"relyonthemetabolicactivityofliving cells"fortheirprimaryfunctionandarenot for"autologoususe";and areregulatedasa"drug,device,and/orbiologicalproductundertheFD&CAct,and/orsection351ofthePHSAct(42U.S.C.262),andapplicableregulations,including21CFRPart1271,andpremarketreview"isrequired. Basedontherecently finalizedguidance,noneoftheseproductshavesubmittedforthe applicableclearancefromFDAanduseofsuch materialsistheequivalenttousingadrugthatisnotapprovedforanyindication.TherecentlyissuedfinalguidancewhereFDAhasdocumentedthatsuchproductsarenot clearedforuseinhumansputsheightenedriskonany institutionthatcontinuestousethemin theirclinicalpractice. https://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGeneTherapy/UCM585403.pdf

BoneMarrowAspirateandDowels–Aprovendriverofboneregeneration

Thereareover150referencessupportingtheuseofbonemarrowforgrafting.Marx,JBoneMarrowBoneMarrow:AValidatedDriverforBoneRegeneration,WhitePaper

BMAisasafealternativetoiliaccrestharvestwithoutassociatedcomplicationsormorbidity.Muschler,GFNakamoto,CGriffith,L.G.EngineeringPrinciplesofClinicalCell-BasedTissueEngineering,JournalofBoneandJointSurgery,2004;86(7):1541.

Theadditionofautologousmarrowisavaluedrivenandhighlyeffectivewayforachievinggraftincorporation.Deakin,D.E.,Bannister,G.C.;GraftIncorporationAfterAcetabularandFemoralImpactionGraftingWithWashedIrradiatedAllograftandAutologousMarrow.TheJournalofArthrorplasty,2007January;22(1):89-94

Acombinationofmarrowaspirate,trephineassisteddowelgraftandTCPgraftmaterialhadthesamefusionrateasautograftinthegutterofthelumbarspinewithouttheassociatedmorbidity.YamadaT etal.Hybrid grafting using bone marrow aspirate combined with porous β-tricalcium phosphate and trephine bone forlumbar posterolateralspinal fusion:aprospective,comparative study versuslocalbone grafting.Spine (Phila Pa 1976).2012Feb 1;37(3)

 Maxx  -­‐  Regen  Bone  Marrow  Aspiration  System  and  Related  Concentrations  of  Stem  and  Progenitor  Cells    Michael  A.  Scarpone,  D.O.,  Medical  Director  of  Trinity  Sports  Medicine,  Assistant  Professor  of  Orthopedic  Medicine,  Drexel  University  School  of  Medicine,  Allegheny  General  Hospital  Campus    Daniel  Kuebler,  Ph.D.,  Chair  of  the  Biology  Department;  Franciscan  University  C.  David  B.  Harrell,  Ph.D.,  OF,  FAARM,  FRIPH,  DABRM    ABSTRACT  It  is  well  known  that  the  highest  quality  bone  marrow  aspirations  (greatest  quantity  of  stem/progenitor  cells)  require  aspirating  small  volumes  of  bone  marrow  (1-­‐2  mL)  from  different  locations.1-­‐4  It  is  also  known  that  peripheral  blood  infiltrates  bone  marrow  aspirates  when  greater  than  1-­‐2  mL  is  drawn  from  any  single  location.1-­‐3  In  this  pilot  study  of  Maxx  -­‐  RegenTM  (www.RoyalBiologics.com),  a  novel  bone  marrow  access  and  retrieval  device,  greater  stem/progenitor  cell  concentrations  (as  counted  by  fibroblast-­‐like  colony-­‐forming  units,  CFU-­‐f)  were  demonstrated  compared  to  previously  published  works  that  used  a  combination  of  a  traditional  needle  with  a  centrifuge-­‐based  cellular  processing  system.  A  CFU-­‐f  test  was  conducted  to  determine  the  quality  of  the  marrow  aspirate  because  cells  capable  of  forming  a  CFU-­‐f  are  routinely  found  in  marrow  but  rarely  in  peripheral  blood.1,4-­‐6  Consequently,  CFU-­‐f  represents  a  standard  test  to  determine  the  number  of  immature  stem  and  progenitor  cells  that  are  present  in  the  aspirate.  A  comparison  of  Maxx  -­‐  Regen  CFU-­‐f  data  collected  in  this  study  to  historical  CFU-­‐f  data  from  traditional  needle  plus  centrifugation  systems  are  found  in  Table  1.    Table  1:  Comparison  of  CFU-­‐f  mean  values       Volume  (mL)   CFU-­‐f  per  ml   CFU-­‐F  Total  

Graft  Requires  Centrifuge  

Maxx  -­‐  Regen   11   3,290   37,230   NO  Celling   7   2,713   18,991   YES  Harvest   7   1,270   8,890   YES  Magellan   7   514   3,598   YES  Biomet   7   134   938   YES      BACKGROUND  Stem  and  progenitor  cells  are  enriched  in  the  spongy  marrow  that  is  located  within  the  pockets  created  by  the  honeycomb  of  trabecular  bone  within  the  medullary  space.  Only  a  finite  number  of  stem  cells  reside  within  any  given  pocket  of  spongy  marrow.  Volume  over  1  mL  retrieved  from  a  single  site  introduces  significant  peripheral  blood  into  the  aspiration.1  This  peripheral  blood  dilutes  

further  aspiration  volume  from  any  given  site  and  significantly  reduces  the  stem/progenitor  cell  quantity  of  the  aspiration  per  mL.1,3,4  It  is  well  known  that  peripheral  blood  has  a  dramatically  reduced  viscosity  compared  to  bone  marrow.8  In  response  to  vacuum  pressure,  lower  viscous  fluid  flows  preferentially  compared  to  higher  viscous  fluids.  The  channel  created  by  the  needle  upon  its  re-­‐traction  from  the  marrow  space  will  fill  immediately  with  peripheral  blood.  Modifying  the  aspiration  technique  by  re-­‐positioning  a  traditional  needle  via  retraction  from  the  marrow  space  and  aspirating  through  the  open  lumen  results  in  preferential  aspiration  of  peripheral  blood  and  a  resultant  precipitous  decline  in  the  stem/progenitor  cells  of  the  aspirate,  per  mL.4,8,9  This  decline  is  because  the  channel  created  by  the  needle  fills  with  blood  upon  its  retraction  and  the  lower  viscous  blood  enters  through  the  large  lumen  at  the  distal  end  of  the  needle,  limiting  the  flow  that  comes  through  the  side  ports  of  the  needle.10,11  The  design  of  a  traditional  marrow  aspiration  needle  that  has  a  removable  stylet  and  hollow  cannula  is  decades  old  and  was  designed  to  aspirate  1mL  of  marrow  from  a  single  location  for  diagnostic  purposes.  Marrow  aspiration  volumes  of  greater  than  2  mL  at  any  one  site  using  traditional  needles  typically  contain  total  nucleated  cell  (TNC)  counts  of  15-­‐20  x  106/mL  and  200-­‐300  CFU-­‐f/mL;5,12,13  however,  when  1  mL  of  marrow  is  aspirated  with  a  tradition  needle,  counts  of  40  x106/mL  TNC  and  1451  CFU-­‐f/mL  are  typical.1    To  overcome  the  limitations  of  lower-­‐quality  (reduced  cellularity)  high  volume  marrow  aspirations  from  traditional  needles,  clinicians  attempt  to  enhance  the  marrow  biologic  by  using  a  centrifuge-­‐based  system  (e.g.,  BMAC).  These  systems  remove  85%  of  the  starting  aspirate  volume  by  discarding  lower  density  plasma  and  higher  density  cells  comprised  primarily  of  red  cells  while  retaining  a  majority  of  the  platelets,  lymphocytes  and  monocytes,  granulocytes  and  young  red  cells  from  both  the  marrow  and  the  infiltrated  peripheral  blood  components  of  the  aspiration.  These  systems  do  not  distinguish  between  nucleated  cells  from  the  peripheral  blood  component  of  the  aspirate  compared  to  the  marrow  component  of  the  aspirate,  (both  sets  of  cells  have  the  same  density).  In  the  case  of  a  poor  aspirate  comprised  primarily  of  peripheral  blood,  the  only  difference  between  the  biologic  that  a  PRP  kit  produces  compared  to  what  a  BMAC  kit  produces  is  that  the  BMAC  kit  has  a  higher  red  cell  content  and  more  granulocytes.  The  higher  red  cell  and  granulocyte  content  is  because  the  BMAC  protocol  captures  a  higher  density  range  of  cells.  Higher  granulocytes  in  certain  situations  can  result  in  greater  inflammation.14  Maxx  -­‐  Regen  is  a  novel  bone  marrow  access  and  retrieval  device,  codeveloped  by  Endocellutions  Corp  (475  School  Street,  suite  12,  Marshfield  MA)  and  Ranfac  Corp,  (30  Doherty  Ave.  Avon  MA)  that  incorporates  features  designed  to  minimize  the  limitations  of  traditional  needles.  Flow  into  the  aspiration  system  is  collected  mainly  laterally  because  the  tip  of  the  aspiration  cannula  is  closed.  This  design  allows  for  collection  of  marrow  perpendicular  to  and  around  the  channel  created  by  the  tip  of  the  device;  traditional  needles,  even  ones  with  side  ports,  aspirate  primarily  through  an  open-­‐ended  cannula  which  leads  to  excess  peripheral  blood  in  the  aspirate.10  Additionally,  Maxx  -­‐  Regen  incorporates  technology  to  precisely  reposition  the  retrieval  system  to  a  new  location  in  the  marrow  after  each  

1  mL  of  aspiration.  The  effects  of  these  two  features  are  that  multiple  small  volume  of  high  quality  bone  marrow  aspiration  are  collected  from  a  number  of  distributed  sites  within  the  marrow  geography  while  also  retaining  clinicians’  desire  for  a  single  entry  point.  The  design  minimizes  peripheral  blood  infiltration  and  enables  a  total  volume  of  10  mL  to  be  collected.  In  effect,  a  single  puncture  with  Maxx  -­‐  Regen  appears  to  be  functionally  equivalent  to  repeated  small  aspirations  (1  mL)  from  a  number  of  puncture  sites  using  traditional  needles,  but  with  substantial  savings  of  time,  effort,  and  reduced  patient  trauma  and  risk  of  infection.    STUDY  DESIGN  A  series  of  five  patients  were  seen  by  the  same  clinician  and  laboratory  and  underwent  marrow  aspiration  from  the  iliac  crest  with  the  Maxx  -­‐  Regen  device  using  a  posterior  orientation.  A  2000  unit  per  mL  heparin  rinse  was  used  prior  to  aspiration.  No  additional  heparin  or  anti-­‐coagulant  was  used  as  the  biologic  was  used  within  a  short  period  of  time  from  collection  and  was  not  administered  systemically.  Primary  endpoints  included  total  nucleated  cell  (TNC)  and  fibroblastlike  colony-­‐forming  unit  (CFU-­‐f).  Published  literature  were  used  to  ascertain  historical  values  for  CFU-­‐f  counts  from  various  centrifuge-­‐based  systems  and  compared  with  the  aspirates  produced  by  Maxx  -­‐  Regen.  RESULTS    In  5  patients,  10-­‐14  mL  of  marrow  was  collected  from  one  iliac  crest  using  Maxx  -­‐  Regen  (aspirating  from  various  marrow  geographies  from  a  single  puncture  site).  Each  sample  was  analyzed  for  TNC  and  CFU-­‐f;  these  data  are  shown  in  Table  2.    Table  2.  TNC  and  CFU-­‐f  values  obtained  with  Maxx  –  Regen    

Patient   Aspirate  Volume  Per  

mL  

TNC  per  mL  (millions)  

CFU-­‐F  per  ml   Total  CFU-­‐f  in  Graft  

1   10   45   4,222   42,220  2   10   31   3,400   34,000  3   10   22   3,000   30,000  4   14   45   3,050   42,700  5   10   44   2,780   27,800  

Average   11   37   3,290   35,344    DISCUSSION  Centrifuge  systems  discard  85%  of  the  aspirate  by  removing  lower  density  plasma  and  higher  density  cells  composed  primarily  of  red  cells  while  retaining  15%  of  the  starting  volume  that  contains  a  majority  of  the  platelets,  lymphocytes,  monocytes,  granulocytes  and  young  red  cells.  However,  within  the  discarded  higher  density  red  cells  are  a  great  number  of  very  potent,  cycling,  high-­‐density,  proliferating  progenitor  cells.  These  cells  increase  in  density  as  they  build  up  

nucleic  mass  prior  to  division  and  are  always  found  in  the  red  cell  component  after  centrifugation  and  consequently,  are  discarded  by  all  centrifuge  protocols.15,16  In  addition,  many  protocols  require  filtering  of  the  marrow  prior  to  centrifugation.  Filtering  removes  cell  aggregates  and  clots  that  contain  many  stem  cells.7,16,17  The  rationale  for  centrifugation  protocols  based  on  aspirating  large  volumes  of  marrow  is  challenged  by  the  above  data  set.  Centrifugation  protocols  1)  require  larger  aspiration  volumes  that  are  associated  with  excess  peripheral  blood  2)  have  inherent  inefficiencies  that  leaves  significant  numbers  (approximately  40%)  of  stem  cells  behind  in  the  discarded  red  cell  portion  of  the  processed  marrow  3)  require  at  least  10%  dilution  by  volume  for  the  addition  of  anti-­‐coagulant  to  allow  the  sample  to  separate  4)  and  require  another  10%  dilution  in  the  form  of  a  neutralizing  agent  such  as  thrombin  and  calcium  chloride  in  order  for  the  marrow  to  clot  in  the  graft.  Finally,  centrifugation  protocols  require  the  marrow  to  be  filtered  prior  to  centrifugation.  Cells  bound  within  a  clot  cannot  be  counted  but  they  can  be  delivered  to  the  patient  when  mixed  with  graft  material  or  injected.  This  is  not  the  case  when  clots  are  filtered  out  prior  to  centrifugation.  This  sentiment  is  best  summarized  by  Muschler  et  al  who  concluded  “A  larger-­‐volume  of  aspirate  (more  than  2mL)  from  a  given  site  is  contraindicated  with  the  additional  volume  contributing  little  to  the  overall  number  of  bone-­‐marrow  cells  and  results  principally  in  unnecessary  blood  loss”  (p  1707).1  At  the  clinician’s  discretion,  adding  additional  heparin  to  the  aspiration  syringe  to  keep  the  sample  stable  for  an  extended  period  of  time  outside  the  body  is  possible.  Despite  demonstrating  higher  CFU-­‐f  counts  from  Maxx  -­‐  Regen  needles,  there  are  a  number  of  caveats  associated  with  this  pilot  study.  First,  while  suitable  for  a  pilot  study,  the  sample  size  is  small.  Future  studies  utilizing  Maxx  -­‐  Regen  should  incorporate  a  larger  sample  size.  Second,  while  higher  numbers  of  stem/progenitor  cells  have  been  associated  with  regeneration  and  healing,7,15,18,19  future  studies  should  include  patient  follow-­‐up.  Third,  comparison  to  historical  values  of  CFU-­‐f  data  has  limitations  given  the  significant  patient-­‐to-­‐patient  variability.  Maxx  -­‐  Regen  System  has  advantages  over  centrifugation  devices;  the  biologic  produced  by  the  System  never  leaves  the  sterile  field,  the  System  requires  less  O.R.  staff  support  and  time,  the  entire  sample  generated  by  the  System  is  used,  the  System  minimizes  peripheral  blood  contamination,  the  System  requires  minimal  anti-­‐coagulation,  and  the  biologic  does  not  require  filtering.  We  were  able  to  demonstrate  that  Maxx  -­‐  Regen  was  successful  in  obtaining  TNC  and  CFU-­‐f  similar  to  what  is  expected  from  numerous  insertion  points  along  the  iliac  crest  for  multiple  1  mL-­‐only  draws;  however,  with  Maxx  -­‐  Regen,  only  one  insertion  point  was  required.  While  this  pilot  study  was  not  designed  to  be  an  equivalence  study,  the  comparison  of  the  CFU-­‐f  data  to  previously  published  results  from  multiple  centrifuged-­‐based  systems  is  intriguing  and  suggests  that  Maxx  -­‐  Regen  could  provide  at  least  as  many  CFU-­‐f,  if  not  more,  than  traditional  needles  and  centrifugation  systems  (Table  1).      

CONCLUSION  There  are  several  benefits  of  the  Maxx  -­‐  Regen  novel  design.  First,  the  design  automatically  repositions  the  aspiration  cannula  and  aspirates  from  side  ports  across  a  greater  geography  of  the  marrow  space  so  that  it  mimics  multiple  puncture  sites  with  1  mL  aspirations.  The  system  does  not  require  filtering  or  10%  dilution  with  anti-­‐coagulant.  The  number  of  TNCs  and  CFU-­‐f  was  greater  than  traditional  aspirations  of  similar  volumes  and  was  comparable  or  greater  than  centrifuge-­‐based  final  products.  In  this  pilot  study,  the  Maxx  -­‐  Regen  device  produced  results  suggesting  that  it  can  effectively  replace  aspiration  of  large  volumes  of  marrow  using  traditional  needles  combined  with  the  volume  reduction  of  centrifuge-­‐based  systems.  Secondly,  Maxx  -­‐  Regen  allows  the  clinician  to  retain  the  process  and  product  entirely  on  the  sterile  field.  Centrifuge-­‐based  systems  require  the  bone  marrow  aspiration  to  leave  the  sterile  field  for  centrifugation  and  the  final  product  then  re-­‐enters  the  sterile  field  after  centrifugation  and  product  withdrawal.  The  ability  to  keep  the  product  on  the  sterile  field  reduces  risk  of  infection  to  the  patient  undergoing  the  procedure.  Thirdly,  cells  and  growth  factors  are  reduced  in  centrifuge-­‐based  systems  through  filtration  and  discarded  material.  This  accounts  for  the  yields  of  35-­‐65%  in  such  systems.  These  cells  and  growth  factors  are  not  discarded  in  the  Maxx  -­‐  Regen  device.  Our  testing  was  performed  independently  without  third  party  commercial  sponsorship  or  influence.    REFERENCES  1.  Muschler  GF,  Boehm  C,  Easley  K.  Aspiration  to  obtain  osteoblast  progenitor  cells  from  human  bone  marrow:  the  influence  of  aspiration  volume.  J  Bone  Joint  Surg  Am  1997;79:1699-­‐709.  2.  Batinic  D,  Marusic  M,  Pavletic  Z,  et  al.  Relationship  between  differing  volumes  of  bone  marrow  aspirates  and  their  cellular  composition.  Bone  marrow  transplantation  1990;6:103-­‐7.  3.  Bacigalupo  A,  Tong  J,  Podesta  M,  et  al.  Bone  marrow  harvest  for  marrow  transplantation:  effect  of  multiple  small  (2  ml)  or  large  (20  ml)  aspirates.  Bone  marrow  transplantation  1992;9:467-­‐70.  4.  Hernigou  P,  Homma  Y,  Flouzat  Lachaniette  CH,  et  al.  Benefits  of  small  volume  and  small  syringe  for  bone  marrow  aspirations  of  mesenchymal  stem  cells.  International  orthopaedics  2013;37:2279-­‐87.  5.  Hegde  V,  Shonuga  O,  Ellis  S,  et  al.  A  prospective  comparison  of  3  approved  systems  for  autologous  bone  marrow  concentration  demonstrated  nonequivalency  in  progenitor  cell  number  and  concentration.  Journal  of  orthopaedic  trauma  2014;28:591-­‐8.  6  6.  Hernigou  P,  Poignard  A,  Beaujean  F,  Rouard  H.  Percutaneous  autologous  bone-­‐marrow  grafting  for  nonunions.  Influence  of  the  number  and  concentration  of  progenitor  cells.  J  Bone  Joint  Surg  Am  2005;87:1430-­‐7.  7.  Pettine  KA,  Murphy  MB,  Suzuki  RK,  Sand  TT.  Percutaneous  injection  of  autologous  bone  marrow  concentrate  cells  significantly  reduces  lumbar  discogenic  

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