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c o n c e n t r a t i o n s y s t e m

Concentrating the Power of Stem Cells

This brochure is for International use only. It is not for distribution in the United States.

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Would you like to improve your Treatment by: • Improvingtissueregeneration? • Acceleratingwoundhealing? • Reducingswelling? • Stimulatingbonehealing? • Reducingtheriskofinfection?

Do you recognize these problems as a result of: Delayed Wound Healing • Increasedriskofinfections

Soft Tissue Swelling • Pain • Longerimmobilisation • Decreasedrangeofmotion

Pseudarthrosis • Longerimmobilisation • Re-operation

Infection • Needforantibiotics • Re-operation

Leading to: • Highercosts • Morenursingcare • Longerhospitalstay • Increaseinnarcotics • Longerrehabilitation • Dissatisfiedpatients,surgeonsand nursingpersonnel • Revisions/surgicalfailure

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Published literature has shown that: The Proof In Hard Tissue • Bonemarrow-derivedstemcellscansignificantlyimproveboneformationincasesofbonenonunion1–3

• Bonemarrow-derivedstemcellscansignificantlyreducejointpainandincreasejointfunction in osteonecrosis4–5

• Bonemarrow-derivedstemcell-enrichedallograftisaseffectiveasautograftwhenusedinbonegrafting andspinalfusionprocedures8–10

In Soft Tissue • Bonemarrow-derivedstemcellscaninducehealinginrecalcitrantchronicwoundsanddiabeticulcers11–12

• Bonemarrow-derivedstemcellscanhelprevascularizeanischemiclimb14–16

• Bonemarrow-derivedstemcellscanassistinvascularanastomosis17

• Bonemarrow-derivedstemcellscanhelppreventscartissueformationandpreserveheartfunctionafter myocardialinfarction18–19

In General • Bonemarrow-derivedstemcellscanreducemorbidity,bloodlossandoperatingtime20

• Bonemarrowaspiratecontainswhitebloodcells,whicharecriticalinfightinginfection21

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Thepresenceofstemcellsmakestheiliaccrestgraftveryappealing.Thisgraftprovidesthesurgicalsitewiththescaffold,cellsandsignalsnecessaryforsuccessfulbonehealing.However,graftsitemorbiditycoupledwithacomplicatedandtimeconsumingharvestmakeitdifficulttojustifytheuseofthisgraftinmanydifferentprocedures.Asaresult,theuseofautologousbonemarrowaspirate(BMA)forbonegraftinghasbeenadvocatedasameanstoprovideanosteogeniccellsource.6TheMarrowstim™ConcentrationSystemenablesstemcellsfromtheiliaccresttobeeasilyandefficientlyconcentratedandtransferredtoasurgicalsitewithorwithoutgraftmaterial.TheabilityoftheMarrowstim™devicetorecoverandconcentratethenucleatedcellpopulationeasestheconcernofperipheralblooddilutionduringthemarrowaspiration.

Bonemarrowaspiratecontainsmesenchymalstemcells,whichareabletoproliferateanddifferentiateintoanumberofdifferentsoftandhardtissues.UtilisingMarrowstim™ technology,thesestemcellscanbeconcentratedatthepatient’spointofcare.Clinicalevidencesuggestscellularconcentrationpositivelyaffectstheclinicaloutcomeofbonegraftingprocedures.1,20

Marrowstim™ Concentration System is the next generation in hard and soft tissue grafting.

Why nucleated cell concentrate?

MesenchymalCells

Oste

oblasts

Bone

Cartilage

ConnectiveTissues

Muscle

Tendon/Ligament

Fibroblasts

Myocytes

Chond

rocyte

s

Fibroblasts

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What is the Marrowstim™ Concentration System?Marrowstim™ConcentrationSystemusesaproventechnologytoconcentratepowerfulstemcells,whichareobtainedwiththeMarrowstim™aspirateneedle.Thisuserfriendlykitprovidesallcomponentsneededtoobtainconcentratedstemcells.

Marrowstim™ Concentration System consists of Proven Marrowstim™ Technology • Consistent6.1xconcentrationoftotalnucleatedcellscomparedtobaselinelevel21

• 79%recoveryoftotalnucleatedcells(TNC’s)21

• Consistent6.9xconcentrationofmononuclearcellscomparedtobaselinelevel21

• 80%recoveryofmononuclearcells21

• 15minutecentrifugationspinmakesimplementationfeasibleinapointofcaresetting

Histologicalsectionofnucleated cell concentrate

Specially designed aspirate needle with the following features: • Five(5)holesplacedatthedistaltip,allowingforbetteraspiration • Stylet,withitstrocarpoint,makesitpossibletoeasilypenetratethe bonemarrowcavity • Ergonomicallydesignedhandleenablesasafermaneuverability, sincetheforceneededtopenetratethebonemarrowcavityis homogenouslydistributedovertheentirepalmofthehandrather than locally • Two(2)styletsforsurgeonconvenience

Histologicalsectionofbone marrowaspirate

DistalTip

TrocarPoint

Handle

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Step 1: AnticoagulationRinseMarrowStim™bonemarrowaspirateneedle,disposable andtwo30mlsyringeswithanticoagulanttoensureinnersurfacesarecoated.Thiswillpreventclottingofbonemarrow duringaspiration.Performoneofthefollowingtechniques.

Method 1: Heparinonlytechnique(heparin notsuppliedinthesekits): Draw3mlheparinsolution(1000U/ml)intoasterile30mlsyringe;ensuretheheparincoatstheentireinnersurfaceofthesyringeandsetaside.Draw10mlheparinsolutionintoasecondsterile30mlsyringe;ensuretheheparincoatstheentireinnersurfaceofthesyringe.RemoveinnertrocarfromBMAneedle.Attachthesecond30mlsyringetotheBMAneedleandprimewithheparin,ensuring3mlofheparinremainsinthe30mlsyringe.RemoveBMAneedleandreplacethetrocar.

Method 2:ACD-Awithheparincoatingtechnique(heparinnotsuppliedinthesekits):

HeparinCoating:Draw10mlheparinsolution(1000U/ml)intoasterile30mlsyringe.Pullsyringeplungerbackcompletely,ensuringtheheparincoatstheentireinnersurfaceofthesyringe.Aftercoatingthesyringe,pushtheplungercompletelydownonsyringetodispenseallremainingheparin.Draw10mlheparinsolutionintoasecondsterile30mlsyringe.Pullsyringeplungerbackcompletely,ensuringtheheparincoatstheentireinnersurfaceofthesyringe.RemoveinnertrocarfromBMAneedle.Attachthesecond30mlsyringetotheBMAneedleandprimewithheparin,ensuringallheparinhasbeendispensedfromthesyringethroughtheneedle.RemoveBMAneedleandreplacethetrocar.

ACD-A:Draw6mlACD-Aintoeachoftheheparincoated30mlsyringes.

For the Marrowstim™ Mini System, only one 30ml syringe of anticoagulated marrow is utilised.

Step 2: Prepare PatientAftersuitableanesthesiaisachieved,placethepatientinthelateraldecubitusposition.Usingsteriletechnique,preparetheskinwithantisepticanddrape.(Figure1)

Step 3: Position NeedleHoldtheneedlewithproximalendinpalmandtheindexfingeragainsttheshafttowardthetip.(Figure2)

Marrowstim™ Concentration System Instructions

Cortical boneSpongybone

Marrow

Figure1

Figure2

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Step 4: Advance NeedleUsinggentlebutfirmpressure,advancetheneedle,rotatingitinanalternatingclockwise/counterclockwisemotion.Entranceintothemarrowcavityisgenerallydetectedbydecreasedresistance.Allofthesideholesatthedistalendoftheneedlemustbeintroducedintothemarrowcavitybeyondthecorticalbone,otherwiseairwithextrabonysofttissuemayappearwiththeaspiratedmarrow.(Figure3)

Step 5: Remove Stylet/TrocarOnceneedleisinplace,removethestyletbypullingstraightout.(Figure4)

Step 6: Aspirate MarrowFollowtheBMAneedlemanufacturerpackageinsert(steps7–9)toobtainatotalof60mlanticoagulatedbonemarrowaspirate(3mlheparinwith27mlBMAper30mlsyringeor 6mlACD-Awith24mlBMAper30mlsyringe).(Figure5)

For the Marrowstim™ Mini System, only one 30ml syringe of anticoagulated marrow is utilised.

Figure3

Figure4

Figure5

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Step 1: LoadEnsureBMAfromonlyonepatientisprocessedperspin.

UnscrewcaponcentreportNo.1andremovecapandgreenpackagingpost.(Figure1)

Slowlyloadbothaspiratefilled30mlsyringes(6mlofACD-Aand24mlofbonemarrowaspiratepersyringeor3mlofheparinand27mlofBMApersyringe),foratotalof60ml ofanticoagulatedmarrowintocentreportNo.1.(Figure2)

Mini Marrowstim™ Concentration System: Slowly load one 30ml syringe of anticoagulated marrow into centre port No. 1.

Removeprotectivecoveronwhitetetheredcapanddiscard.ScrewwhitecapontocentreportNo1.(Figure3)

Preparation of the Marrowstim™ and Mini Marrowstim™ Concentration Systems

Figure1

Figure2

Figure3

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Step 2: BalancePressredbuttontoreleaselidofcentrifuge.Openandplacethetubeintothecentrifuge.(Figure4) Mini Marrowstim™ Concentrate Kit: If using the mini kit, the purple mini buckets must be inserted into the centrifuge.

InsertMarrowstim™ConcentrationSystemcounterbalancewith60mlofsterilesalineorasecondMarrowstim™ disposablewithBMA(whenprocessingtwotubes)intooppositesideofcentrifuge. (Figure5)

Mini Marrowstim™ Concentrate Kit: Fill purple mini counterbalance with 30ml of sterile saline and place into opposite side of centrifuge.

Figure4

Figure5

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Step 3: SpinCloselid.Setspeedat3200RPMandtimeto15minutes.Pressgreenbuttontostartspin.Oncespiniscompleted,pressredbuttontoreleaselidandopen.(Figure6)

RemoveMarrowstim™tubefromcentrifugeandensureBMAhasseparatedintothreedistinctlayers.(Figure7).

Step 4: Cell Poor Plasma (CPP) ExtractionRemoveyellowcaponsideportNo.2andconnectasterile 30mlsyringe.Invertthetubeandwithdrawthecellpoorplasma.(Figure8)

Figure6

Figure7:Nucleatedcellconcentrate(NCC)processed withtheMarrowstim™ConcentrationSystem

Figure8

Cell Poor Plasma

Nucleated Cell Concentrate

Red Blood Cells

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Step 5: Suspend Nucleated Cell Concentrate (NCC)Whileholdingthetubeintheuprightposition,shakevigorouslyfor30secondstosuspendthecellularelements.(Figure9)

Step 6: Nucleated Cell Concentrate (NCC) ExtractionRemoveredcapfromsideportNo.3andconnectasterile10mlsyringetoextractthenucleatedcellconcentrate. (Figure10)

Figure10

Figure9

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Application possibilities for Marrowstim™ Concentration System Hard Tissue Bone Marrow Aspirate Orthopedics • DelayedUnionandNonunion1–3,22

• AvascularNecrosis4,5

• SpinalFusion8–9,23

• CartilageRegeneration24–26

Bone Marrow Aspirate + Platelet-rich Plasma Orthopedics • Osteonecrosis32

• BoneRegeneration7,33

Cranio/Maxillofacial • PeriodontalRepair34–35

• AlvedarBoneRegeneration35–36

Bone Marrow Aspirate + Demineralized Bone Matrix Orthopedics • DelayedUnionandNonunion7,20

• BoneCysts28–29

Bone Marrow Aspirate + Fibrin Sealant Orthopedics • BoneRegeneration30

Soft Tissue Bone Marrow Aspirate WoundHealing • ChronicWounds12

• IschemicUlcers11

Cardiovascular Surgery • MyocardialInfarction18–19

• PeripheralVascularDisease14–16

Bone Marrow Aspirate + Fibrin Sealant • VascularAnastomosis17

Nucleatedcellconcentrate,platelet-richplasmaandBonus®DBMappliedtoafibulanonunion.

NucleatedcellconcentrateandBonus®DBMap-pliedtoakneerevision.

NucleatedcellconcentrateandBonus®DBMinspinesurgery.

NucleatedcellconcentrateandBonus®DBMappliedtoahiprevision.

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Liquid to Bonus® DBM Ratio Application Delivery Handling

Consistency

10cc: 10cc,5cc: 5cc or

1cc: 1cc

Percutaneousinjections,

Contained defects

Finebeadnozzle, BOS™ needle Flowablegel

6cc: 10cc, 3cc: 5cc or.6cc: 1cc

Standardpacking,Molding

Fine bead nozzle,Log Putty

4cc: 10cc, 2cc: 5cc or.4cc: 1cc

Verybloodyenvironmentswithheavyirrigation

Logonly Crunchy

Bonus® DBM (with Stem Cells) Traditional DBM

Scaffold Yes Yes

Signals Yes Yes

Cells Yes No

Nutrition Yes No

Marrowstim™ Concentration System and Bonus® DBMDBMisanidealbalancebetweenallograftandautograft.Itpromotesbonegrowthbyprovidingosteoinductivegrowthfactorsandanosteoconductivescaffold.TheMarrowstim™ConcentrationSystemprovidesconcentratedstemcells,whichhavebeenadvocatedasameanstoprovideanosteogeniccellsourceinavarietyofprocedures.Thispowerfulcombinationprovidesthesurgeonwiththescaffold,cells,signalsandnutritionnecessaryforsuccessfulbonehealing.(Table1)

Patient-specific demands require optionsSurgeryisnotanassemblyline.Eachpatienthasspecificneeds.ThepowerfulstemcellsobtainedwithandconcentratedbytheMarrowstim™concentrationsystemcanbeeasilytransferredtohydratesynthetic,allograft andautograftboneinavarietyofmethods.Thisallowsthesurgeontocustomizeaccordingtotheapplication. ForusewiththeBonus®DBM,thefollowingratiosshouldbeuseful,dependingonthedesiredhandlingcharacteristics.(Table2)

Table 1

Table 2

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UtilisingtheGPS®IISystemthepatient’sownplatelets,whichtravelthroughthebloodstream,canbecollectedintoahighlyconcentratedformula.Whenplateletsbecomeactivated,growthfactorsarereleased.

TGF-ß1

VEGF

FGF

PDGF

TGF-ß2

EGF

Platelet Derived Growth Factor (PDGF-aa, PDGF-ab, PDGF-bb) • Stimulatescellreplication • Promotesangiogenesis • Promotesepithelialisation • Promotesgranulationtissueformation

Vascular Endothelial Growth Factor (VEGF) • Promotesangiogenesis

Fibroblast Growth Factor (FGF) • Promotesproliferationofendothelialcells andfibroblasts • Stimulationofangiogenesis

Transforming Growth Factor (TGF-ß1, TGF-ß2) • Promotesformationofextracellularmatrix • Regulatesbonecellmetabolism

Epidermal Growth Factor (EGF) • Promotescelldifferentiationandstimulates re-epithelialisation,angiogenesisand collagenaseactivity

Advantages of Adding Platelet-rich Plasma to Stem Cells

Theadditionofplatelet-richplasma(PRP)tobonemarrowaspiratehasbeenshowntostimulateproliferationofmesenchymalstemcellsin vitro.37,38 In vivo,PRPadditiontobonemarrowstemcellsandallografthascontributedtobetterallograftintegrationandincreasedboneformation.39

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Description Catalog Number

Ordering Information

Biomet Biologics Manual Spray Applicator Kit (Tip not included) 800-0250

Two12mlSyringes Two1mlSyringes

TwoSyringeAssemblySets ThreeLiquidTransferCups

OnePlasticTrayCompletewithSterileDrape

Malleable Dual Cannula Tip 20 Gauge x 4 inch Length 800-0202

Malleable Dual Cannula Tip 20 Gauge x 7 inch Length 800-0203

Blending Connector Tip Single Cannula 800-0204

Malleable Dual Cannula Tip 20 Gauge x 10 inch Length 800-0206

Drucker 230 Volt 50–60 Hz Centrifuge 755VES-230V

Graft Preparation System 800-0300

Biomet Biologics Standard Non-Sterile Counterbalance (Blue) 800-0508

Biomet Biologics Mini Non-Sterile Counterbalance (Purple) 800-0505

Biomet Biologics Spare Bucket Kit (Drucker Centrifuge; 2 Blue Buckets) 7431

Biomet Biologics Mini Spare Bucket Kit (Drucker Centrifuge; 2 Purple Buckets) 7433

5ml Bonus® DBM 48-DBM1

10ml Bonus® DBM 48-DBM2

1ml Bonus® DBM 48-DBM4

Autologous Thrombin Spray Tip (Pack of 10; To be used with 800-0204) ST-3 Tip

SprayApplicatorKit(800–0250)

MalleableDualCannulaTip20Gaugex4inchLength(800–0202)20Gaugex7inchLength(800–0203)20Gaugex10inchLength(800–0206)

GraftPreparationSystem

(800–0300)

BiometBiologics SpareBucketKit (7431[Blue])

BiometBiologics MiniSpareBucketKit

(7433[Purple])

BlendingConnector TipSingleCannula

(IncludestwoFlexibleSheaths)

(800–0204)

BiometBiologicsStandardandMiniNon-Sterile

Counterbalance(800–0508

[Standard;Blue])(800–0505

[Mini;Purple])

Drucker230 Volt50–60HzCentrifuge

(755VES-230V)

5mlBonus®DBM (48-DBM1)

10mlBonus®DBM (48-DBM2)

1mlBonus®DBM (48-DBM4)

AutologousThrombinSprayTip (ST-3Tip)

If autologous thrombin is needed, ordering information can be found in the Clotalyst Brochure (BBI0004).

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Description Catalog Number

Ordering Information

Marrowstim™ Standard Kit with 30 ml ACD-A 800-0613A

Contents:

OneDisposable60mlMarrowstim™ Tube

One10mlSyringe

Four30mlSyringes

One18GaugeCentesisNeedle

One18GaugeSafetyApheresisNeedle

One30mlBottleofACD-A

OneBoneMarrowAspirationNeedle

OneAdhesiveTape54Inch

Two2x2Gauze

FourSyringeTips

Provides 6ml of concentrated BMA from 60 ml of anticoagulated aspirate.

Marrowstim™ Mini Kit with 30 ml ACD-A 800-0612A

Contents:

OneDisposable30mlMiniMarrowstim™ Tube

One10mlSyringe

Three30mlSyringes

One18GaugeCentesisNeedle

One18GaugeSafetyApheresisNeedle

One30mlBottleofACD-A

OneBoneMarrowAspirationNeedle

OneAdhesiveTape54Inch

Two2x2Gauze

FourSyringeTips Provides 3ml of concentrated BMA from 30ml of anticoagulated aspirate.

Standard Kit Contents:

(1)Marrowstim™ Tube

(1)30mlBottleof ACD-A

(1)18Gauge Needle

(1)10mlSyringe

(4)30mlSyringes

(1)BoneMarrow AspirationNeedle

(1)ApheresisNeedle

(2)2x2Gauze(1)AdhesiveTape

(4)SyringeTips

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1. Hernigou,P.,Poignard,A,Beaujean,F.,Rouard,H.Percutaneous autologousbone-marrowgraftingfornonunions.Influenceofthenumber andconcentrationofprogenitorcells.Journal of Bone and Joint Surgery (American).87(7):1430–7,2005. 2. Hernigou,P.,Mathieu,G.,Poignard,A.,Manicom,O.,Beaujean,F., Rouard,H.Percutaneousautologousbone-marrowgraftingfornonunions. Surgicaltechnique.Journal of Bone and Joint Surgery (American). 88 (Suppl1Pt2):322–7,2006. 3. Connolly,J.,Guse,R.,Lippiello,L.,Dehne,R.Developmentofan osteogenicbone-marrowpreparation.Journal of Bone and Joint Surgery (American).71(5):684–91,1989. 4. Gangji,V.,Hazeur,J.P.,Matos,C.,DeMaertelaer,V.,Toungouz,M., LambermontM.Treatmentofosteonecrosisofthefemoralheadwith implantationofautologousbonemarrowcells.Apilotstudy.Journal of Bone and Joint Surgery (American).86–A(6):1153–1160,2004. 5. Hernigou,P.,Poignard,A.,Manicom,O.,Mathieu,G.,Rouard,H. Theuseofpercutaneousautologousbonemarrowtransplantationin nonunionandavascularnecrosisofbone.Journal of Bone and Joint Surgery (British).87(7):896–902,2005. 6. Block,J.E.Theroleandeffectivenessofbonemarrowinosseous regeneration.Medical Hypotheses.65(4):740–7,2005. 7. Brodke,D.,Pedrozo,H.A.,Kapur,T.A.,Attawia,M.,Kraus,K.H.,Holy,C.E. et al.Bonegraftspreparedwithselectivecellretentiontechnologyheal caninesegmentaldefectsaseffectivelyasautograft.Journal Orthopedic Research.24(5):857–66,2006. 8. Muschler,G.F.,Matsukura,Y.,Nitto,H.,Boehm,C.A.,Valdevit,A.D., Kambic,H.E.,Davros,W.J.,Easley,K.A.,Powell,K.A.Selectiveretention ofbonemarrow-derivedcellstoenhancespinalfusion.Clinical Orthopaedics and Related Research.432:242–51,2005. 9. Muschler,G.F.,Nitto,H.,Matsukura,Y.,Boehm,C.,Valdevit,A.,Kambic, H.,Davros,W.,Powell,K.,EasleyK.Spinefusionusingcellmatrix compositesenrichedinbonemarrow-derivedcells.Clinical Orthopaedics and Related Research.407:102–18,2003.10. Tiedeman,J.J.,Garvin,K.L.,Kile,T.A.,Connolly,J.F..Theroleofa composite,demineralizedbonematrixandbonemarrowinthetreatment of osseous defects. Orthopedics.18(12):1153–58,1995.11. Kohlman-Trigoboff,D.,Lawson,J.H,Murphy,M.P..Stemcelluseina patientwithanischemicfootulcer:acasestudy.Journal of Vascular Nursing.24(2):56–61.2006.12. Badiavas,E.V.,Falanga,V.Treatmentofchronicwoundswithbone marrow-derivedcells.Archives of Dermatology.139(4):510–16,2003.13. Bystrov,A.V.,Polyaev,Y.A.,Pogodina,M.A.,Rasulov,M.F., Krasheninnikov,M.E.,Onishchenko,N.A.Useofautologousbone marrowmesenchymalstemcellsforhealingoffreefull-thicknessskin graftinazonewithpronouncedhypoperfusionofsofttissuescausedby arteriovenousshunting.Bulletin of Experimental Biology and Medicine. 142(1):123–8,2006.14. Tateishi-Yuyama,E.,Matsubara,H.,Murohara,T.,Ikeda,U.,Shintani, S.,Masaki,H.et al.Therapeuticangiogenesisforpatientswithlimb ischaemiabyautologoustransplantationofbone-marrowcells:apilotstudy andarandomisedcontrolledtrial.Lancet.360(9331):427–35,2002.15. Esato,K.,Hamano,K.,LiTS,Furutani,A.,Seyama,A.,Takenaka,H.et al. Neovascularizationinducedbyautologousbonemarrowcellimplantation inperipheralarterialdisease.Cell Transplant.11(8):747–52,2002.16. Higashi,Y.,Kimura,M.,Hara,K.,Noma,K.,Jitsuiki,D.,Nakagawa,K. et al.Autologousbone-marrowmononuclearcellimplantationimproves endothelium-dependentvasodilationinpatientswithlimbischemia. Circulation.109(10):1215–8,2004.17. Cardon,A.,Chakfe,N.,Thaveau,F.,Gagnon,E.,Hartung,O.,Aillet,S. et al.Sealingofpolyesterprostheseswithautologousfibringlueandbone marrow.Annals Vascular Surgery.14(6):543–52.2000.18. Gao,L.R.,Wang,Z.G.,Zhu,Z.M.,Fei,Y.X.,He,S.,Tian,H.T.,et al. EffectofIntracoronaryTransplantationofAutologousBoneMarrow- DerivedMononuclearCellsonOutcomesofPatientsWithRefractory ChronicHeartFailureSecondarytoIschemicCardiomyopathy.American Journal of Cardiology.98(5):597–602,2006.19. Oakley,R.E.,Msherqi,Z.A.,Lim,S.K.,Lee,S.H.,Ho,K.T.,Sutandar,A. et al.Transplantationofautologousbonemarrow-derivedcellsintothe myocardiumofpatientsundergoingcoronarybypass.Heart Surgery Forum.8(5):348–50,2005.20. Connolly,J.F.Clinicaluseofmarrowosteoprogenitorcellstostimulate osteogenesis.Clinical Orthopaedics and Related Research.355(Suppl): S257–S266,1998.21. Welch,Z.R.,McKale,J.M.,Woodell-May,J.Citrate-basedAnticoagulant DoesNotHinderStemCellViabilityandConcentrationfromBoneMarrow Aspirate.Submittedat54thAnnualMeetingoftheOrthopaedicResearch Society.March2–5,2008.

22. Siwach,R.C.,Sangwan,S.S.,Singh,R.,Goel,A.Roleofpercutaneous bonemarrowgraftingindelayedunions,non-unionsandpoor regenerates.Indian Journal of Medical Sciences.55(6):326–36,2001.23. Muschler,G.F.BoneGrafting.Physician’s Weekly.21(15):19,2004.24. Adachi,N.,Ochi,M.,Deie,M.,Ito,Y.Transplantofmesenchymal stemcellsandhydroxyapatiteceramicstotreatsevereosteochondral damageaftersepticarthritisoftheknee.Journal of Rheumatology. 32(8):1615-18,2005.25. Wakitani,S.,Imoto,K,Yamamoto,T.,Saito,M.,Murata,N.,Yoneda,M. Humanautologouscultureexpandedbonemarrowmesenchymalcell transplantationforrepairofcartilagedefectsinosteoarthriticknees. Osteoarthritis Cartilage.10(3):199–206,2002.26. JohnstoneB,YooJU.Autologousmesenchymalprogenitorcellsin articularcartilagerepair.Clinical Orthopaedics and Related Research. 367(Suppl):S156–S162,1999.27. Sanchez,M.,Azofra,J.,Anitua,E.,Andia,I.,Padilla,S.,Santisteban,J. et al.Plasmarichingrowthfactorstotreatanarticularcartilageavulsion:a casereport.Medical Science Sports Exercise.35(10):1648–52,2003.28. Docquier,P.L.,Delloye,C.Treatmentofaneurysmalbonecystsby introductionofdemineralizedboneandautogenousbonemarrow.Journal of Bone and Joint Surgery (American).87(10):2253–8,2005.29. Rougraff,B.T.,Kling,T.J.Treatmentofactiveunicameralbonecystswith percutaneousinjectionofdemineralizedbonematrixandautogenous bonemarrow.Journal of Bone and Joint Surgery (American).84–A(6): 921–9,2002.30. Yamada,Y.,Boo,J.S.,Ozawa,R.,Nagasaka,T.,Okazaki,Y.,Hata,K. et al.Boneregenerationfollowinginjectionofmesenchymalstemcellsand fibringluewithabiodegradablescaffold.Journal of Craniomaxillofacial Surgery.31(1):27–33,2003.31. Chong,A.K.,Ang,A.D.,Goh,J.C.,Hui,J.H.,Lim,A.Y.,Lee,E.H.et al. Bonemarrow-derivedmesenchymalstemcellsinfluenceearlytendon- healinginarabbitachillestendonmodel.Journal of Bone and Joint Surgery (American).89(1):74–81,2007.32. Centeno,C.J.,Kisiday,J.,Freeman,M.,Schultz,J.R.Partialregeneration ofthehumanhipviaautologousbonemarrownucleatedcelltransfer:a case study. Pain Physician.9(3):253–6,2006.33. Yamada,Y.,Ueda,M.,Naiki,T.,Takahashi,M.,Hata,K.,Nagasaka,T. Autogenousinjectableboneforregenerationwithmesenchymalstem cellsandplatelet-richplasma:tissue-engineeredboneregeneration. Tissue Engineering.10(5–6):955–64,2004.34. Yamada,Y.,Ueda,M.,Hibi,H.,Baba,S.Anovelapproachto periodontal tissueregenerationwithmesenchymalstemcellsandplatelet-richplasma usingtissueengineeringtechnology:aclinicalcasereport.International Journal of Periodontics and Restorative Denistry.26(4):363–9,2006.35. Yamada,Y.,Ueda,M.,Naiki,T.,Nagasaka,T.Tissue-engineered injectableboneregenerationforosseointegrateddentalimplants.Clinical Orthopaedics and Related Research.15(5):589–97,2004.36. Oyama,T.,Nishimoto,S.,Takeda,M.Alveolarboneregenerationutilizing b-TCPandplatelet-richplasma(PRP)derivedfrombonemarrowaspirate. Annals of Plastic Surgery.54(2):222–3,2005.37. Haynesworth,S.E.,Kadiyala,S.,Liang,L.,Bruder,S.P.Mitogenic stimulationofhumanmesenchymalstemcellsbyplateletreleasate suggestamechanismforenhancementofbonerepairbyplatelet concentrates.Transactionsofthe48thAnnualMeetingoftheOrthopaedic ResearchSociety.42:0462,2002.38. Lucarelli,E.,Beccheroni,A.,Donati,D.,Sangiorgi,L.,Cenacchi,A., DelVentoA.M.et al.Platelet-derivedgrowthfactorsenhanceproliferation ofhumanstromalstemcells.Biomaterials.24(18):3095–100,2003.39. Lucarelli,E.,Fini,M.,Beccheroni,A.,Giavaresi,G.,Di,B.C.,Aldini,N.N. et al.Stromalstemcellsandplatelet-richplasmaimproveboneallograft integration.Clinical Orthopaedics and Related Research.435:62–8, 2005.

References

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c o n c e n t r a t i o n s y s t e m

c o n c e n t r a t i o n s y s t e m

Biomet Biologics, Inc. 01-50-1436P.O.Box587 Date:07/0756E.BellDriveWarsaw,Indiana46581USA

MarrowStim™ and MarrowStim™ Mini Concentration Systems with ACD-A

ATTENTION OPERATING SURGEON

FOR INTERNATIONAL USE ONLY

NOTE: FOR SINGLE-USE ONLY. Discard the entire disposable system after one use, using an acceptable method for devices potentially contaminated with blood products.

DESCRIPTIONMarrowStim™ Concentration System with ACD-ATheMarrowStim™ConcentrationSystemwithACD-Aseparatesupto60mlofthepatient’sbonemarrowcomponentsbydensitythroughtheuseoftheMarrowStim™ cellseparator.

MarrowStim™ Mini Concentration System with ACD-ATheMarrowStim™MiniConcentrationSystemwithACD-Aseparatesupto30mlofthepatient’sbonemarrowcomponentsbydensitythroughtheuseoftheMarrowStim™Minicellseparator.

TheabovelistedsystemsaretobeusedwithacentrifugedistributedbyBiometBiologics,Inc.(“BBI”).

Heparin,utilizedintheanticoagulationstepoftheInstructionsforUse,isnotsuppliedinthesesystems.

MATERIALSThematerialsusedforsyringes,needles,tubing,connectors,andcellseparatorsconsistofmedicalgradepolymers,elastomersandstainlesssteelssuitableforuseinmedicaldevices.

Allcomponentsinthesesystemsarepackaged,labeledandsterilizedasindicatedbytheirmanufacturer’slabeling.

Allcomponentsinthesesystemsarelatex-free.

ACD-AisananticoagulantsuppliedbyCitraAnticoagulants,Inc.,Braintree,MA,andmanufacturedbyCytosolLaboratories,Inc.,Braintree,MA.ForfurtherinformationregardingACD-AAnticoagulant,pleasecontactthesupplierat1-800-299-3411.

TheACD-AprovidedisonlyforusewiththeMarrowStim™andMarrowStim™MiniConcentrationSystems.

INDICATIONS FOR USETheMarrowStim™andMarrowStim™MiniConcentrationSystemswithACD-Aaredesignedtobeusedforthesafeandrapidpreparationofautologousconcentratedbonemarrowaspirate(cBMA)fromasmallsampleofbonemarrowaspirateatthepatient’spointofcare.ThecBMAcanbeappliedtoasurgicalsiteorcanbemixedwithgraftmaterialpriortoapplicationtoasurgicalsiteasdeemednecessarybytheclinicaluserequirements.

WARNINGS AND PRECAUTIONS1. Singleusedevice.Donotreuse.2. Usepropersafetyprecautionstoguardagainstneedlesticks.3. Donotusesterilizedcomponentsofthissystemifpackageisopenedor damaged.4. UsepreparedcBMAwithin4hoursafteraspiratingbonemarrowfrompatient.5. Thesurgeonistobethoroughlyfamiliarwiththeequipmentandthesurgical procedurepriortousingthisdevice.6. Thepatientistobemadeawareofgeneralrisksassociatedwithbonemarrow aspiration.Theserisksinclude,butarenotlimitedto:hemorrhage,seroma formation,infection,and/orpersistentpainatthesiteofaspiration.7. Followmanufacturerinstructionswhenusingcentrifuge.UseonlyaBBI centrifuge(IECcentrifugeorTheDruckerCompanycentrifuge).Outcomes usingcentrifugesfromothermanufacturersareunknown.8. Followmanufacturerpackageinsertforthebonemarrowaspirate(BMA) needle.

POSSIBLE ADVERSE EFFECTS1. Damagetobloodvessels,hematoma,delayedwoundhealing,and/orinfection.2. Temporaryorpermanentnervedamagethatmayresultinpainornumbness.

3. Earlyorlatepostoperativeinfection.4. Painatbonemarrowharvestsite.

STERILITYTheMarrowStim™andMarrowStim™Minicellseparatorsaresterilizedbyexposuretoaminimumdoseof25kGygammairradiation.AllotherMarrowStim™ andMarrowStim™MiniConcentrationSystemcomponentsaresterilizedbytheirrespectivesuppliersasindicatedontheirlabeling.Donotresterilize.Donotusepastexpirationdate.

INSTRUCTIONS FOR USENOTE: Use standard aseptic technique throughout the following procedures.

MarrowStim™ Concentration System1. REMOVE:RemoveBMAneedlefromitssterilizedpackage.Removethe innertrocarfromtheBMAneedle,andsetaside.2. ANTICOAGULATION: Perform ONE of the following techniques. METHOD 1 (Heparin only technique): Heparin:Draw3mlheparinsolution(1000U/ml)intoasterilized30ml syringe;ensuretheheparincoatstheentireinnersurfaceofthesyringeand setaside.Draw10mlheparinsolutionintoasecondsterilized30mlsyringe; ensuretheheparincoatstheentireinnersurfaceofthesyringe.Attachthe second30mlsyringetotheBMAneedleandprimewithheparin,ensuring 3mlheparinremainsinthe30mlsyringe.RemoveBMAneedleandreplace the trocar. METHOD 2 (ACD-A with Heparin coating technique): Heparin:Draw10mlheparinsolution(1000U/ml)intoasterilized30ml syringe.Pullsyringeplungerbackcompletely,ensuringtheheparin coatstheentireinnersurfaceofthesyringe.Aftercoatingthesyringe,push theplungercompletelydownonsyringetodispenseallremainingheparin. Draw10mlheparinsolutionintoasecondsterilized30mlsyringe.Pull syringeplungerbackcompletely,ensuringtheheparincoatstheentireinner surfaceofthesyringe.Attachthesecond30mlsyringetotheBMAneedle andprimewithheparin,ensuringallheparinhasbeendispensedfromthe syringethroughtheneedle.RemoveBMAneedleandreplacethetrocar. ACD-A:Draw6mlofACD-Aintoeachofthetwoheparin-coatedsyringes.3. ASPIRATION:FollowtheBMAneedlemanufacturerpackageinserttoobtain atotalof60mlanticoagulatedBMA(3mlheparinmixedwith27mlBMAper 30mlsyringeOR6mlACD-Amixedwith24mlBMAper30mlsyringe),usingthe syringespreparedinthepreviousstep.4. LOAD: ENSURE BMA FROM ONLY ONE PATIENT IS PROCESSED PER SPIN, and that the cell separator remains upright.Unscrewcaponcenter port#1ofthecellseparator.Removeanddiscardcapandgreenpackaging post.Attachandslowlyloadboth30mlanticoagulated,BMA-filledsyringesone atatimeintocenterport#1.Unscrewanddiscardclearprotectiveinnerpiece fromwhitecaptetheredtoport#1.Screwwhitecapbackontoport#1.Place cellseparatorfilledwithanticoagulatedBMAintotheBBIcentrifuge.5. BALANCE:Fillbluecounterbalancetube(800-0508)withanamountof sterilizedsaline/waterequaltothatofBMAplusanticoagulantdispensedin thecellseparator.Placecounterbalancedirectlyoppositefromaspirate-filled separatorincentrifuge.6. SPIN:Closecentrifugelid.Setspeedfor3.2(x1,000rpm)andsetthetimeto 15minutes.Pressthestartbutton.Oncespiniscomplete,opencentrifugeand removecellseparator.7. EXTRACT PLASMA:Unscrewyellowcaponport#2,andsavecap.Connect sterilized30mlsyringe,tiltcellseparatortowardport#2,andextractplasma. Removethe30mlsyringefromport#2,capwithasterilizedsyringecap,and setaside.Replaceyellowcaponport#2.8. SUSPEND cBMA:Holdingthecellseparatorintheuprightposition,shake tubevigorouslyfor30seconds.9. EXTRACT cBMA:ImmediatelyaftersuspendingthecBMA,unscrewthered caponport#3.Attachsterilized10mlsyringetoport#3,andextractthecBMA. Removethe10mlsyringe,andcapwithasterilizedsyringecap.10. APPLY:ApplycBMAtosurgicalsite,withorwithoutgraftmaterialasrequired.

MarrowStim™ Mini Concentration System1. REMOVE:RemoveBMAneedlefromitssterilizedpackage.Removetheinner trocarfromtheBMAneedle,andsetaside.2. ANTICOAGULATION:PerformONEofthefollowingtechniques. METHOD 1 (Heparin only technique): Heparin:Draw10mlheparinsolution(1000U/ml)intoasterilized30ml syringe;ensuretheheparincoatstheentireinnersurfaceofthesyringe. AttachthesyringetotheBMAneedleandprimewithheparin,ensuring 3mlheparinremainsinthe30mlsyringe.RemoveBMAneedleandreplace the trocar. METHOD 2 (ACD-A with Heparin coating technique): Heparin:Draw10mlheparinsolution(1000U/ml)intoasterilized30ml syringe.Pullsyringeplungerbackcompletely,ensuringtheheparincoats

Package Insert

16

theentireinnersurfaceofthesyringe.Attachthe30mlsyringetotheBMA needleandprimewithheparin,ensuringallheparinhasbeendispensed fromthesyringethroughtheneedle.RemoveBMAneedleandreplacethe trocar. ACD-A:Draw6mlofACD-Aintotheheparin-coatedsyringe.3. ASPIRATION:FollowtheBMAneedlemanufacturerpackageinserttoobtain 30mlofanticoagulatedBMA(3mlheparinmixedwith27mlBMAOR6mlACD-A mixedwith24mlBMA)usingthesyringepreparedinthepreviousstep.4. LOAD: ENSURE MARROW FROM ONLY ONE PATIENT IS PROCESSED PER SPIN, and that the cell separator remains upright.Unscrewcapon centerport#1onthecellseparator.Removeanddiscardcapandgreen packagingpost.Attachandslowlyloadthe30mlanticoagulated,BMA-filled syringeintocenterport#1.Unscrewanddiscardclearprotectiveinnerpiece fromwhitecaptetheredtoport#1.Screwwhitecapbackontoport#1.Place cellseparatorintotheBBIcentrifuge.5. BALANCE:Fillpurplecounterbalancetube(800-0505)withanamountof sterilizedsaline/waterequaltothatofBMAplusanticoagulantdispensedin thecellseparator.Placecounterbalancedirectlyoppositefromaspirate-filled separatorincentrifuge.6. SPIN:Closecentrifugelid.Setspeedfor3.2(x1,000rpm)andsetthetimeto 15minutes.Pressthestartbutton.Oncespiniscomplete,opencentrifugeand removecellseparator.7. EXTRACT PLASMA:Unscrewyellowcaponport#2,andsavecap.Connect sterilized30mlsyringe,tiltcellseparatortowardport#2,andextractplasma. Replaceyellowcaponport#2.

8. SUSPEND cBMA:Holdingthecellseparatorintheuprightposition,shake tubevigorouslyfor30seconds.9. EXTRACT cBMA:ImmediatelyaftersuspendingthecBMA,unscrewthered caponport#3.Attachsterilized10mlsyringetoport#3,andextractthecBMA. Removethe10mlsyringe,andcapwithasterilizedsyringecap.10. APPLY:ApplycBMAtosurgicalsite,withorwithoutgraftmaterialasrequired.

These devices are only approved for distribution outside the United States.

MarrowStim™andBiometBiologics™aretrademarksofBiometManufacturingCorp.

CommentsregardingthesedevicescanbedirectedtoAttn:RegulatoryDept.,Biomet,Inc.,P.O.Box587,Warsaw,IN46581USA,FAX:574-372-1683.

AuthorizedRepresentative: BiometU.K.,Ltd. WatertonIndustrialEstate Bridgend,SouthWales CF313XAUK

0086

01-50-1435Tel.+39069201961–Fax+39069275519

HSHOSPITALSERVICES.p.A.

GENERAL USE INFORMATION: • BoneMarrowTransplantationneedle.

WARNINGS AND PRECAUTIONS: Thisdeviceisdesignedtobeusedbyaphysician. Theseinstructionsarenotmeanttodefineorsuggestanymedicalorsurgical

technique.Theindividualpractitionerisresponsiblefortheproperprocedure andtechniquestobeusedwiththisdevice.. Checkiftheinnerpackageisunopenedanddamaged.Incaseofdamaged

innerpackage,donotusetheproduct. Checktheexpirydateandthegauge. Possibleallergicreactionsshouldbeconsidered. Afteruseconsideritaswastematerial. Storeinacoolanddryplace,protectfromlight. Useofthedeviceisrestrictedonlytophysician. EthyleneOxidesterilized. Sterilityandintegrityguaranteedonlyifobserved,withtheprescribed

conditions. Itmustbeusedonlyinhospitals.

INSTRUCTIONS FOR USE:1. Aftersuitableanesthesiaisachieved,placethepatientintheventral supineposition.2. Usingsteriletechnique,preparetheskinwithantisepticanddrape.3. Holdtheneedlewiththeproximalendinpalmandtheindexfingeragainstthe shaftnearthetip.Thispositionstabilizestheneedleandallowsforbetter control.4. Introducetheneedlethroughtheskinandbringitintocontactwiththeposterior iliac crest.5. Usinggentle,butfirmpressure,advancetheneedle,rotatingitinanalternating clockwise/counterclockwisemotion.Entranceintothemarrowcavityis generallydetectedbydecreasedresistance.(Allofthesideholesatthedistal endoftheneedlemustbeintroducedintothemarrowcavitybeyondthe corticalbone,otherwiseairandextrabonysofttissuemayappearwiththe aspiratedmarrow).6. Onceneedleisinplace,removethestyletbyrotatingtheuppersection90°, andpullingstraightout.7. Attachasyringewithaluertapertothehubofthebonemarrowharvestneedle usingafirmpushandtwistmotion.8. Applysuctionbywithdrawingthesyringeplunger.Removethesyringewiththe harvestedmarrow.9. Repeattheharvestprocedureuntilanappropriateamountofmarrowis obtainedtosatisfytheclinicalrequirement.

Sterile-Nonpyrogenic-DisposableSterileifunopenedandundamagedinnerpackaged

NOTFORUSE WARNING

0373

Theinformationcontainedinthesepackageinsertswascurrentonthedatethisbrochurewasprinted.However,thepackageinsertsmayhavebeenrevisedafterthatdate.Toobtaincurrentpackageinserts,pleaseusethecontactinformationprovidedherein.

AlltrademarkshereinarethepropertyofBiomet,Incoritssubsidiariesunlessotherwiseindicated.

This brochure is for international use only,andisnotfordistributionintheUSA.

ThismaterialisintendedforsoleuseandbenefitoftheBiometBiologicssalesforceandphysicians.Itisnottoberedistributed,duplicatedordisclosedwithouttheexpresswrittenconsentofBiomet.

ResponsibleManufacturer

BiometBiologics,Inc.ASubsidiaryofBiomet,Inc.P.O.Box58756E.BellDriveWarsaw,Indiana46581-0587USA

Tel.:+15742676639

AuthorizedRepresentativeBiometUK,Ltd.WatertonIndustrialEstateBridgend,SouthWalesCF313XAUK

www.biometbiologics.comwww.biometeurope.com

FormNo.BBI0017.0•REV021508

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