A Two-Phase, Multicenter, Randomized Study Comparing Autologous Protein Solution With Hyaluronic Acid Intra Articular Injections in Patients With Knee Osteoarthritis
Phase: NA
Conditions: Osteoarthritis, Knee
Sponsor: Zimmer Biomet

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STUDY SYNOPSIS 
Protocol Number: 
APSS-66-00 
Title: 
A Two-Phase, Multicenter, Randomized Study Comparing 
Autologous Protein Solution (APS) with Hyaluronic Acid (HA) Intra 
Articular Injections in Patients with Knee Osteoarthritis (OA) 
Sponsor: 
Zimmer Biomet  
Name of Product: 
nSTRIDE APS Kit  
Device Description: 
The nSTRIDE autologous protein solution (APS) Kit with 
anticoagulant citrate dextrose solution, formula A (ACD-A), is a 
self-contained, sterile-packaged, single-use device designed to 
concentrate anti-inflammatory cytokines and growth factors from 
whole blood. The device system is to be used at the point of care 
to create an autologous solution. This device system consists of 
two parts: the nSTRIDE Cell Separator and the nSTRIDE 
Concentrator. The nSTRIDE Cell Separator separates the cellular 
components from plasma and red blood cells in whole blood. The 
cell solution is then loaded into the nSTRIDE Concentrator, which 
uses filtration through polyacrylamide beads to concentrate the 
cytokines in the injectable output. 
Intended Use: 
The nSTRIDE APS Kit is designed to be used for the safe and rapid 
preparation of autologous protein solution (APS) from a small 
sample of blood at the patient’s point of care. The APS is to be 
injected intra-articularly for the treatment of knee OA and 
associated symptoms. 
Comparator Name: 
Synvisc-One® (hylan G-F 20) 
Comparator 
Description: 
Synvisc-One (hylan G-F 20) is a sterile, nonpyrogenic, 
elastoviscous fluid containing hylans. Hylans are derivatives of 
hyaluronan (sodium salt of hyaluronic acid) and consist of repeating 
disaccharide 
units 
of 
N-acetylglucosamine 
and 
sodium 
glucoronate. Hylan A has an average molecular weight of 
approximately 6,000,000 daltons and hylan B is a hydrated gel. 
Hylan G-F 20 contains hylan A and hylan B (8.0 mg ± 2.0 mg per 

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ml) in buffered physiological sodium chloride solution (pH 7.2 ± 
0.3). 
Comparator Intended 
Use: 
Synvisc-One is only intended for intra-articular use by a physician 
to treat pain associated with osteoarthritis of the knee. 
Study Center(s): 
The study will be conducted at up to 15 investigative centers in 
Europe. 
Planned Sample 
Size: 
246 subjects will be randomized (1:1) into one of two treatment 
groups (APS and HA). 
Study Population: 
Patients with symptomatic OA in one knee, who have not been able 
to get satisfactory pain relief with prior treatment.  
Study Objectives: 
Primary Objective 
The primary objective of this study is to determine whether 
nSTRIDE APS is superior to HA with regard to the improvement in 
mean Western Ontario and McMaster Universities Osteoarthritis 
Index (WOMAC) LK 3.1 pain score (change from baseline to 12 
months post-injection). 
 
Secondary Objectives 
Secondary objectives of this study include determining whether 
nSTRIDE APS is superior to HA in improving WOMAC LK 3.1 
function at 12 months (as evaluated using the percentage of 
subjects showing at least the minimal clinically important difference 
(MCID)), and WOMAC LK 3.1 pain at 12 months (as evaluated 
using the percentage of subjects showing at least the minimal 
clinically 
important 
difference 
(MCID)), 
OMERACT-OARSI 
responder rates at 12 months, analyzing WOMAC pain and 
function in only the KL-II Subgroup at 12 months, evaluating 
superiority of APS over HA in improving Numeric Rating Scale 
(NRS) pain at 12 months, assessment of the changes in WOMAC 
Pain scores over time (baseline through 12 months), and 
evaluation of the usage of rescue medication within 12 months.  
Exploratory Objectives 

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Exploratory objectives of this study include determining whether 
nSTRIDE APS is superior to HA in improving patient reported 
outcomes including pain, function, stiffness, and quality of life in 
subjects with early to moderate symptomatic OA. 
 
A long-term follow-up phase will examine the superiority of 
nSTRIDE APS in the duration of the treatment effect, injection 
frequency, patient preferences, healthcare resource utilization, and 
associated costs.   
        
Safety Objectives 
Safety of nSTRIDE APS will be compared to HA following intra-
articular knee injections in subjects with early to moderate 
symptomatic OA. 
 
Study Design and 
Procedures: 
The study will compare the efficacy of nSTRIDE APS injection to 
HA in patients with symptomatic OA in one knee, who have failed 
at least one prior conservative OA therapy (e.g. physiotherapy, 
simple analgesics). This will be done using a double-blind, 
multicenter, Randomized Controlled Trial (RCT) with study 
subjects receiving either a single injection of nSTRIDE APS or HA. 
The primary efficacy measure will be pain as measured utilizing the 
WOMAC LK 3.1 scale; other measures of efficacy will include 
function, stiffness, and quality of life. In addition to clinical efficacy 
measures, safety will be assessed by tracking adverse events 
(AEs). 
 
Anatomical changes will be evaluated by radiographs (X-ray). In 
the long-term follow-up phase (12 – 60 months), the study will 
evaluate treatment durability, patient preferences, and treatment 
cost effectiveness over time. During this long-term follow-up period, 
safety will be assessed by tracking the occurrence of AEs of 
interest only. 

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During screening, potential subjects who provide informed consent 
will be assessed for eligibility. Screening will consist of meeting all 
inclusion and exclusion criteria, including a WOMAC LK 3.1 pain 
subscale score ≥ 9 and ≤ 19 and by providing objective 
physiological evidence of OA using the Kellgren-Lawrence (K-L) 
scale (assessed from radiographs). Subjects will also provide 
demographic and medication use information. Baseline X-ray1 and 
an MRI2 will be collected. 
Within 28 days of the screening visit, subjects will return to the clinic 
for treatment. Subjects will complete the baseline outcomes 
measurements including the EuroQol questionnaire (EQ-5D), and 
Numeric Rating Scale (NRS)  for knee pain. The WOMAC score 
recorded at the screening visit will serve as the baseline (pre-
injection) WOMAC score, and the WOMAC questionnaire will not 
be re-administered prior to treatment. 
An injection visit occurring between 28 and 32 days after the 
screening visit will be considered a minor protocol deviation. In the 
event that the injection procedure cannot be completed within 32 
days of the screening visit, the subject will be screen-failed, but is 
eligible for immediate re-screening. The re-screening and injection 
visits can be combined, as long as the subject still qualifies per all 
                                               
 
 
1 Radiographs up to 24 months of follow-up will be sent to a core imaging laboratory for assessment of 
eligibility and therefore must always be performed following the criteria set in the Imaging Review Charter 
from Core Imaging Laboratory.  
2 Baseline MRIs will not be sent to a Core Imaging Laboratory and should be performed only after 
subject meets all other eligibility criteria. Also, previously taken MRI may be used if obtained up to 90 
days prior to study treatment. Furthermore, in the event that an otherwise eligible subject is unable to 
undergo the MRI procedure due to significant safety risk (i.e. subject has pacemaker, documented 
diagnosis of claustrophobia, etc.), MRI does not need to be performed and this will be not be 
documented as a protocol deviation   

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inclusion/ exclusion criteria. Baseline imaging acquisition and 
review are not required to be repeated. The Core Imaging 
laboratory will then be requested to re-issue an X-Ray eligibility 
report with the new subject ID. 
 
During the treatment visit, all subjects will have a blood draw, from 
which the APS will be prepared for injection. After all available joint 
fluid is aspirated and, according to randomization group 
assignment, approximately 2.5 milliliters (ml) of APS or 6.0 ml of 
HA will be injected into the joint. Needle placement in the joint may 
be verified using ultrasound (if standard of care). To ensure the 
subject will be blinded to the treatment assignment, the syringe 
(regardless of the study arm) shall be taped with opaque medical 
tape. The tape will be used to wrap the entire length of the syringe 
including the needle hub. To protect the double-blind, the treating 
health care professional and evaluating health care professional 
will be different individuals. Any AEs associated with the blood draw 
and/or injection procedure will be recorded. All subjects will be 
instructed to refrain from exceeding the pre-injection level of activity 
for 14 days. 
Efficacy and safety will be assessed at 1, 3, 6, 12, 18, 24, 30, 36, 
48, and 60 months post injection. Subjects will be asked to abstain3 
                                               
 
 
3 During follow-up subjects will not be asked to abstain from low-doses of aspirin taken for cardio-
protection. Long-term treatment with low doses of aspirin – usually max 100mg/day  –  only has an 
antiplatelet effect. Aspirin in low dose would not be enough to impact any pain sensations. Also, the 
low dose aspirin is supposed to be taken every day when taken for cardio-protection, so they should 
remain consistent on their regimen throughout the study. Aspirin taken prior to the follow-up visits will 
not be documented as a Protocol Deviation. Sites will document the low-dose of Aspirin in the patient 
medical file 
 

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from analgesic use for 48 hours prior to assessments. They will 
complete the WOMAC, EQ-5D, and NRS for pain.  
An X-ray will be obtained at 12 months and annually thereafter to 
assess anatomical changes. Only radiograph images taken up to 
24 months of follow-up will be transferred to the Core Imaging 
Laboratory for independent review. Image acquisition, transfer, and 
analysis 
procedures 
will 
be 
performed 
using 
validated, 
prospectively defined methods. All AEs that occur during the 12 
month blinded study period will be recorded. In the long-term 
follow-up phase (12 – 60 months), only events of interest will be 
recorded. 
After each subject completes all 12-month follow-up evaluations, 
only subjects will be blinded to the individual treatment allocation 
resulting in single-blind design following 12-month follow-up time 
point. Subjects from both groups will be able to request additional 
injections of their originally assigned treatment as frequently4 as 
needed, provided they did not experience any significant clinical 
concerns after previous treatment administrations and are 
benefiting from it, as determined by the investigator. During the 
long-term follow-up phase (12 – 60 months), subjects may also 
elect to cross over to the other treatment arm and receive additional 
injections of the other treatment as frequently as needed, provided 
they did not experience any significant clinical concerns after 
previous treatment administrations and are benefiting from it, as 
determined by the investigator. Subjects may only cross over from 
their originally assigned treatment group to the other treatment 
group one time during the study. Subjects seeking alternative 
invasive OA treatment in the index knee who do not wish to cross 
over or who have already crossed over will exit the study, and their 
selected treatment option will be recorded. 
                                               
 
 
4 Please refer to Synvisc One IFU for specified clinical use requirements. 

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Study Duration: 
Maximum study duration per subject is 62 months: 60 months from 
treatment to last follow-up, and two additional months if the 
maximum visit window time is realized. 
Inclusion Criteria: 
1. Male or female at least 18 years of age at time of screening. 
2. Willingness and ability to comply with study procedures and 
visit schedules and able to follow oral and written 
instructions. 
3. A standing knee radiograph showing a K-L grade of 2 to 4 
and an absence of severe osteoarthritis (defined as 
advanced stage osteoarthritis, including large osteophytes, 
chronic fractures or bone remodeling, severe deformity or 
bone attrition, and/or bone-on-bone contact indicative of 
severe osteoarthritis/full thickness cartilage loss), as 
confirmed by the Core Imaging Laboratory.  
4. Body mass index ≤ 40 kg/m2. 
5. A WOMAC LK 3.1 pain subscale total score ≥ 9 and ≤ 19. 
6. Has undergone at least one prior conservative OA 
treatment (e.g. physical therapy, simple analgesics). 
7. Signed an ethics committee-reviewed and approved 
informed consent form. 
Exclusion Criteria: 
1. Presence of clinically observed active infection or severe 
inflammation 
in 
the 
index 
knee 
joint 
or 
skin 
disease/breakdown or infection in the area of the planned 
injection site of the index knee. 
2. Presence of symptomatic OA in the non-study knee at 
screening; if unclear then the WOMAC LK 3.1 pain sub-
scale for the non-index knee must be ≤ 5.0. 
3. Diagnosed with rheumatoid arthritis, Reiter’s syndrome, 
psoriatic arthritis, gout, ankylosing spondylitis, or arthritis 
secondary to other inflammatory diseases; Human 
Immunodeficiency 
Virus 
(HIV), 
viral 
hepatitis; 
chondrocalcinosis, 
Paget’s 
disease, 
or 
villonodular 
synovitis. 

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4. Diagnosed with leukemia, known presence of metastatic 
malignant cells, or ongoing or planned chemotherapeutic 
treatment. 
5. Disease of spine, hip or other lower extremity joints judged 
by the investigator to be contributing to the pain in the index 
knee (e.g. sciatica, nerve pain, hip OA). Note: Patients with 
contra-lateral knee replacement, or hip replacement in 
either hip, may be enrolled provided there is sufficient pain 
relief after knee replacement or hip replacement that 
analgesics are not required. 
6. Untreated symptomatic injury of the index knee (e.g., acute 
traumatic injury, anterior cruciate ligament injury, clinically 
symptomatic meniscus injury characterized by mechanical 
issue such as locking or catching). 
7. Presence of surgical hardware or other foreign body 
intended to treat arthritis or cartilage-related pathology in 
the index knee. Note: this does not include small hardware 
(e.g. screws). 
8. Presence of venous or lymphatic stasis in the index leg. 
9. Orally administered systemic steroid use within 2 weeks 
prior to screening. 
10. Planned/anticipated surgery of the index knee during the 
study period. 
11. Major surgery (e.g. osteotomy) of the index knee within 12 
months prior to screening. 
12. Minor surgery (e.g. shaving or arthroscopy) of the index 
knee within 6 months prior to screening. 
13. A history of local anesthetic allergy. 
14. Use of systemic immunosuppressants within 6 weeks prior 
to screening. 
15. Currently on anticoagulant therapy, such as Warfarin, 
vitamin K antagonists, direct thrombin inhibitors, or factor 
Xa inhibitors or on potent anti-platelet therapy, such as 
GPIIb-IIIa antagonists, Par-1 antagonists or dual anti-

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platelet therapy; i.e. an ADP receptor antagonist in 
combination with aspirin5. 
16. Any documented clinically significant degree of cognitive 
impairment or other condition, finding, or psychiatric illness 
at screening, which, in the opinion of the investigator, could 
compromise patient safety or interfere with the assessment 
of the safety and treatment effects of the study injection. 
17. Pregnant or nursing mothers or women planning to become 
pregnant during the time they will be participating in the 
study. 
18. Known hypersensitivity (allergy) to hyaluronan (sodium 
hyaluronate) preparations. 
19. Previously documented failed treatment with nSTRIDE APS 
or Synvisc One. 
20. Known drug or alcohol dependence currently or within the 
last year. 
21. Use of any investigational drug or device within 30 days 
prior to screening. 
22. Use of any investigational biologics within 60 days prior to 
screening. 
Schedule of Visits: 
• 
Screening 
• 
Procedure (within 28 days of screening) 
• 
1 Month (± 7 days) 
• 
3 Month (± 14 days) 
• 
6 Month (± 14 days) 
• 
12 Month (± 28 days) 
• 
18 Month (± 28 days) 
                                               
 
 
5 Subjects taking low-doses of aspirin (maximum 100 mg/day) in combination with an ADP-receptor 
antagonist should be excluded from the study per exclusion criteria 15. A low doses of aspirin alone is 
not considered an exclusion criteria.  

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• 
24 Month (± 28 days) 
• 
30 Month (± 28 days) 
• 
36 Month (± 28 days) 
• 
48 Month (± 28 days) 
• 
60 Month (± 28 days) 
• 
Interim (when patient seeks additional intervention 
between regularly scheduled visits) 
Clinical Assessment 
Tools: 
The Western Ontario and McMaster Universities Osteoarthritis 
Index using the Likert scale, Version 3.1: 
The WOMAC LK 3.1 questionnaire is a validated tool used for 
assessing knee pain, stiffness, and function. The WOMAC LK 3.1 
has 24 items; 5 items assessing knee pain, 2 items assessing knee 
stiffness, and 17 items assessing physical function. Each item is 
answered on a 5-point Likert scale, with grading from 0 (none or 
never) to 4 (extreme or always). A higher score indicates worse 
pain, stiffness, or functional limitation. 
The EuroQol-5 Dimensions 
The EuroQol-5 Dimensions (EQ-5D) is a validated instrument 
which assesses an individual’s current health status and heath 
related quality of life. The EQ-5D-3L descriptive component 
assesses five dimensions: mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression over three levels of 
severity. The EQ visual analogue scale (EQ VAS) assesses the 
respondent’s self-rated overall health state on a scale from 0 (worst 
imaginable health state) to 100 (best imaginable health state). 
Numeric Rating Scale 
The NRS is a validated measure of knee pain. The NRS is an 11 
point Likert type scale anchored by 0 “no pain” and 10 “worst 
possible pain”. Subjects rate their average pain over the last 48 
hours. 
Patient Preference Questionnaire 
Patient preferences are concerned with determining patient-related 
factors such as patients’ adherence to treatment, patients’ 

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satisfaction with treatment, and health outcomes. Patient 
preferences will be measured utilizing questions to elicit patients’ 
preferences following their knee OA treatment.  
Resource Utilization and Costing 
Health economics will be evaluated throughout the study.  
Healthcare resource utilization for each subject will be recorded to 
capture information about healthcare costs following index 
treatment with nSTRIDE APS or HA and follow-up. 
Imaging 
Assessment 
Tools: 
Radiographs 
Standing posterior-anterior (PA) fixed flexion knee radiographs (X-
rays) are used to assess structural features of the joint, including 
joint space width, and presence or absence of subchondral 
sclerosis, subchondral cysts, and osteophytes. X-ray assessments 
will be performed by a core imaging laboratory. 
Primary Endpoint: 
The primary endpoint will be the change in pain from baseline to 12 
months following injection of nSTRIDE APS or HA, as measured by 
the WOMAC LK 3.1 pain subscale. 
Primary Hypothesis 
for nSTRIDE 
Superiority Testing: 
H0: µAPS = µHA  vs  H1: µAPS ≠ µHA 
 
Where: 
H0 is the Null Hypothesis 
The mean change in WOMAC Pain score from baseline to 12 
months following an APS injection is equal to the mean change in 
WOMAC Pain score from baseline to 12 months following an HA 
injection. 
 
H1 is the Alternative Hypothesis 
The mean change in WOMAC Pain score from baseline to 12 
months following an APS injection is not equal to the mean change 
in WOMAC Pain score from baseline to 12 months following an HA 
injection. 
µAPS is the mean change in WOMAC Pain from baseline to 12 
months for nSTRIDE APS group. 

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µHA is the mean change in WOMAC Pain from baseline to 12 
months for HA group. 
Secondary Endpoints • 
The subjects showing a minimum clinically important difference 
(MCID) in the WOMAC Function subscale 
• 
The subjects showing a minimum clinically important difference 
(MCID) in the WOMAC Pain subscale 
• 
Change in function as measured by the WOMAC function scale 
(baseline to 12 months) 
• 
Percentage of subjects achieving clinical success as defined by 
OMERACT-OARSI Responder Criteria (1) and including 
restricted and rescue medication usage 
• 
Change in pain as measured by the WOMAC pain scale 
(baseline to 12 months) in KL-II subgroup 
• 
Change in function as measured by the WOMAC function scale 
(baseline to 12 months) in KL-II subgroup 
• 
The effects of rescue and restricted medication on changes in 
WOMAC pain (baseline to 12 months) 
• 
Change in pain as measured by the NRS pain scale (baseline 
to 12 months) 
• 
Change in WOMAC LK 3.1 Pain subscale over time 
Exploratory 
Endpoints: 
The following exploratory endpoints will be assessed at all post-
injection time points: 
• 
Change in pain as measured by NRS pain scale 
• 
Percentage of subjects achieving clinical success as defined by 
OMERACT-OARSI Responder Criteria (1) 
• Change in WOMAC LK 3.1 pain (excluding 12-month time 
point), function and stiffness subscale scores   
• 
Change in overall WOMAC LK 3.1 score  
• 
Change in quality of life and global assessment as measured 
by the EQ-5D-3L and EQ-VAS  
• 
The effects of rescue and restricted medication on changes in 
WOMAC pain (baseline to 12 months) 

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The following secondary endpoints will be assessed until the 24-
month follow-up: 
• 
Joint Space Narrowing (JSN)  
• 
Correlation of JSN to change in NRS pain score 
• 
Relationship between JSN and OMERACT-OARSI status 
• 
Change in K-L grade 
 
The following endpoints will be assessed at all long-term follow-up 
time points (months 12 - 60): 
• 
Percentage of patients achieving treatment success from initial 
injection (i.e. patients who have not received additional 
injection, cross-over, or study exit for other invasive treatment 
and have clinically meaningful improvement in WOMAC Pain 
score6) 
• 
Percentage of patients achieving treatment success from 
originally assigned treatment (i.e. patients who have not 
crossed over or exited the study due to dissatisfaction with 
symptom relief and have clinically meaningful improvement in 
WOMAC Pain score) 
• 
Percentage of patients achieving success in each treatment 
arm (i.e. patients with clinically meaningful improvement in 
WOMAC Pain score, inclusive of originally assigned and cross-
over patients) 
• 
Average number of cumulative interventions per patient 
• 
Time from the initial injection (nSTRIDE APS or HA) to 
subsequent injection(s), cross-over, or study exit for other 
invasive treatment 
• 
Resource utilization for index knee OA.  
                                               
 
 
6 Clinically meaningful improvement is considered to be an improvement of at least 20% from baseline 

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The following endpoint will be assessed annually in the long-term 
follow-up phase for patients that have crossed over: 
• 
Percentage of patients preferring each treatment due to: 
1. Greater pain relief 
2. Longer lasting pain relief 
3. Greater improvement in function 
4. Longer lasting improvement in function 
5. Fewer post-injection side effects 
Safety Endpoints 
• 
Occurrence of all AEs up to 12 month time-point and 
occurrence of  AEs of interest across all post-operative time 
points 
 
This Clinical Investigation Plan is written in accordance with ISO14155:2011 “Clinical 
Investigation of medical devices for human subjects – Good clinical practice” (40). The 
Adverse Events sections is written in accordance with the ISO14155:2020 “Clinical 
Investigation of medical devices for human subjects – Good clinical practice” (41).