A Study of INFUSE Bone Graft (Recombinant Human Bone Morphogenetic Protein-2/Absorbable Collagen Sponge) in the Treatment of Tibial Pseudarthrosis in Neurofibromatosis 1 (NF1)
Phase: NA
Conditions: NF1, Congenital Pseudarthrosis of Tibia
Sponsor: University of Alabama at Birmingham

NF PROTOCOL 107 
A Study of INFUSE Bone Graft (recombinant human Bone 
Morphogenetic Protein-2/absorbable collagen sponge) in the 
treatment of Tibial Pseudarthrosis in Neurofibromatosis 1 
(NF1) 
Study Protocol & Statistical Analysis Plan 
  NCT02718131 
March 14, 2018 
Bruce Korf, M.D., PhD, Principal Investigator 
  University of Alabama at Birmingham 
Birmingham, AL 35294 

NF Protocol #107   Version 5 
March 14, 2018 
Neurofibromatosis (NF) Consortium 
NF PROTOCOL 107 
A Study of INFUSE Bone Graft (recombinant human Bone 
Morphogenetic Protein-2/absorbable collagen sponge) in the treatment 
of Tibial Pseudarthrosis in Neurofibromatosis 1 (NF1) 
(Version for U.S. Sites) 
Sponsored by: 
Department of Defense 
USAMRMC 
And the 
Office of the Congressionally Directed Medical Research Programs (CDMRP) 
IDE # G140004 
Protocol Chairs 
Elizabeth K. Schorry, MD, Chair 
B. Stephens Richards, MD, Co-Chair
David H. Viskochil, MD, PhD, Co-Chair 
David G. Little, MBBS, FRACS, PhD, Co-Chair 
Research Monitor 
John P. Dormans, MD, FACS 

 
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PROTOCOL ROSTER: 
 
Protocol PI/IDE-Holder: 
 
Elizabeth K. Schorry, MD, Cincinnati Children’s Hospital 
 
Co-Investigators:  
 
B. Stephens Richards, MD, Texas Scottish Rite Hospital for Children, Dallas, TX 
Dave H Viskochil, MD, PhD, University of Utah 
David G Little, MBBS, FRACS, PhD, The Children’s Hospital at Westmead, AustraliaAU  
 
Statistician / 
Data Management  
and Analysis Center:  
Gary Cutter, PhD 
 
Director, Department of Biostatistics 
School of Public Health, University of Alabama at Birmingham 
1665 University Boulevard, RPHB 410B 
Birmingham, AL  35294 
Phone: 205-934-4937 
Fax:  
205-975-2540 
cutterg@uab.edu 
 
Joan E Hilner, MPH, MA  
Department of Biostatistics  
School of Public Health, University of Alabama at Birmingham 
1665 University Boulevard RPHB 514D 
Birmingham, AL  35294 
Phone:  205-934-4943 
Fax:   
205-975-2500 
jhilner@uab.edu 
 
Operations Center  
Research Nurse Manager:   
Vivien Phillips, RN, BSN  
 
 
Department of Genetics, University of Alabama at Birmingham 
 
 
1918 University Boulevard, MCML 252 
 
Birmingham, AL  35294 
 
Phone: 205-934-5376 
 
vphillip@uab.edu 
 
Operations Center  
Karen A. Cole-Plourde, BS 
Program Director: 
Department of Genetics, University of Alabama at Birmingham 
 
1918 University Boulevard, MCML 256 
 
Birmingham, AL  35294 
 
Phone: 205-934-5140  
 
kplourde@uab.edu   

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Research Compliance 
Specialist: 
Roy McDonald, MPH, CHRC, CCRP  
Department of Genetics, University of Alabama at Birmingham 
1918 University Boulevard, MCML 262A  
Birmingham, AL  35294 
Phone: 205-975-4075 
rmcdonald@uab.edu  
Research Monitor: 
John P. Dormans, MD, FACS 
Texas Children’s Hospital 
Baylor College of Medicine, Pediatric Orthopaedic Surgery & Scoliosis 
Agent(s)/Device:  INFUSE Bone Graft (recombinant human Bone Morphogenetic Protein-2 + absorbable 
collagen sponge)   
Supplier: 
Medtronic Sofamor Danek USA, Inc. 
Drive1800 Pyramid Place 
Memphis, TN  38132 
Laboratory Support (antibody levels): Intertek USA, Inc. d/b/a Intertek Pharmaceutical Services 

 
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Consortium Participating Sites 
Bruce R. Korf, MD, PhD 
University of Alabama at Birmingham 
720 20th Street South, KAUL 230 
Birmingham, Alabama  35294-0024 
Phone:  205-934-9411 
bkorf@uabmc.edu 
Elizabeth K. Schorry, MD  
Cincinnati Children’s Hospital Medical Center 
3333 Burnet Avenue - ML 4006 
Cincinnati, OH  45229 
Phone:  513-636-4760 
elizabeth.schorry@cchmc.org 
Michael J. Fisher, MD 
Children’s Hospital of Philadelphia 
34th Street & Civic Center Boulevard 
Philadelphia, PA 19096 
Phone:  215-590-2800/Lab: 215-590-2107 
fisherm@email.chop.edu 
 
James H. Tonsgard, MD 
University of Chicago 
5841 South Maryland Avenue, MC 3055 
Chicago, IL  60637 
Phone:  773-702-6488 
tonsgard@midway.uchicago.edu 
Roger J. Packer, MD 
Children’s National Medical Center 
111 Michigan Avenue, NW 
Washington, DC  20010 
Phone:  202-884-2120 
rpacker@cnmc.org 
David Viskochil, MD, PhD 
University of Utah 
50 North Medical Drive – 2C412 SOM 
Salt Lake City, UT  84132 
Phone:  801-581-8943 
dave.viskochil@hsc.utah.edu 
D. Wade Clapp, MD 
Indiana University  
1044 West Walnut Street  
Cancer Center, Room 402A  
Indianapolis, IN  46202 
Phone: 317-278-9290 
dclapp@iupui.edu 
David Gutmann, MD, PhD 
Washington University School of Medicine 
660 South Euclid Avenue – Box 811 
St. Louis, MO  63110 
Phone: 314-362-7379  
gutmannd@neuro.wustl.edu 
Tena Rosser, MD 
Children’s Hospital Los Angeles 
300 Medical Plaza Box 696824 
Los Angeles, CA  90095 
Phone: 323-361-2471 
trosser@chla.usc.edu 
Jeffrey C. Allen, MD 
New York University - Pediatrics 
160 E. 32nd Street – 2nd Floor 
Hassenfeld Children’s Center 
New York, NY 10016 
Phone: 212-263-9907 
Jeffrey.Allen@nyumc.org  
Nicole J. Ullrich, MD, PhD 
Children’s Hospital Boston 
300 Longwood Avenue- Fegan 11 
Boston, MA  02115 
Phone: 617-355-2066 
Nicole.Ullrich@childrens.harvard.edu  
 
 
 

 
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Todd Mildbrandt, MD (ortho) 
Dusica Babovic-Vuksanovic, MD (Medical Genetics) 
Mayo Clinic 
200 1st St SW 
Rochester, MN 55905 
 
Affiliate Sites: 
Massachusetts General Hospital (Plotkin)/Dana Farber Cancer Institute (Kieran): Ullrich 
Johns Hopkins (Blakeley): Packer 
Lurie Children's Hospital of Chicago (Listernick and Goldman): Tonsgard 
 
 
 
 
 
 
 
 
Shriners Hospitals Sites (5):  
 
Shriners Hospitals for Children, Los Angeles 
909 S. Fair Oaks Ave. 
Pasadena, CA 91105 
Robert Cho, MD 
Dr. Selina Poon   spoon@shrinenet.org 
 
Shriners Hospitals for Children, Salt Lake City, Utah 
Kristen Carroll, MD 
 
Shriners Hospitals for Children, Chicago 
Purnendu Gupta, MD 
  
Shriners Hospitals for Children, St. Louis 
Perry Schoenecker, MD  (P.I. for all Shriners sites) 
 
Shriners Hospital for Children, Philadelphia 
Corinna Franklin, MD 
Scott Kozin, MD 
 
U. Texas Southwestern/ Texas Scottish Rite Hospital  
Laura Klesse, MD, Ph.D.,  site P.I. (oncology) 
B. Stephens Richards, MD (orthopaedics) 
Texas Scottish Rite Hospital for Children 
2222 Wellborn Street 

 
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Dallas, TX  75219 
Phone: (214) 559-5000 
Steve.richards@tsrh.org  
 
 
 
 
 
 
 
 
Radiology Review Panel: 
Molly Dempsey-Robertson, MD (head), TSRHC 
B. Stephens Richards, MD, TSRHC 
David Wilkes, MD, TSRHC 
Pam Nuremberg, MD, TSRHC 
 
 
Biospecimen Allocation Committee (BAC): 
David Viskochil, MD, PhD, University of Utah 
David Gutmann, MD, PhD, Washington University St Louis 
Carol A. Wise, PhD, TSRHC 
+CTF 
Other Members to be determined 
 
 
Data and Safety Monitoring Board (DSMB) Members  
Laura Klesse, MD, PhD, Oncology, University of Texas Southwest, Dallas 
       Laura.Klesse@UTSouthwestern.edu  
Benjamin Alman, MD, Orthopaedics, Duke University   
       Ben.alman@duke.edu  
Richard Browne, PhD, Statistician (retired, Texas Scottish Rite Hospital)  
       Rbrowne46@att.net   
 
 

 
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Roles and Responsibilities Page:  
 
Michael Fisher, MD: Executive Director of NF Consortium, oversight of trial coordination  
Elizabeth Schorry, MD: Study PI, Protocol Chair / IDE-holder 
B. Stephens Richards, MD: Protocol Co-Chair, oversight of orthopedic efforts in US sites 
David H Viskochil, MD, PhD: Protocol Co-Chair 
David Little, MBBS, FRACS, PhD: Protocol Co-Chair; oversight of international orthopedic efforts 
Bruce Korf, MD, PhD: NF Consortium PI, NFC Operations Center PI, Study Committee 
Gary Cutter, PhD: Deputy Director of NF Operations Center & Trial Statistician – NF Data Center  
John P. Dormans, MD, FACS: Medical Monitor 
Molly Dempsey-Robertson, MD: Head of Radiology Review Panel (RRP) for Tibial Xrays   
Joan Hilner, MPH: Data Director – NF Data Center  
Vivien Phillips, RN, BSN: Clinical Research Nurse Manager – NF Operations Center 
Karen Cole-Plourde, BS: Program Director II – NF Operations Center 
Roy McDonald, MPH, CHRC, CCRP: Regulatory Compliance – NF Operations Center   
 
 

 
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ABBREVIATIONS: 
ACS – Absorbable collagen sponge 
AE – Adverse event 
BAC – Biospecimen Allocation Committee 
BMP-2 – Bone morphogenetic protein-2 
DMAC – Data Management and Analysis Center (at UAB) 
DSMB – Data and Safety Monitoring Board 
eDES – electronic data entry system 
FDA – Federal Drug Administration 
FFPE – formalin fixed, paraffin embedded 
FPS-R – faces pain scale, revised 
HRPO – Human Research Protection Office 
IDE – Investigational Device Exemption 
MPNST – malignant peripheral nerve sheath tumor 
NF1 – neurofibromatosis type 1 
NFCTC – Neurofibromatosis Clinical Trials Consortium   
PODCI – Pediatric Outcome Data Collection Instrument   
rhBMP-2 – recombinant human Bone Morphogenetic Protein-2 
RRP – Radiology Review Panel 
RUST score – Radiograph union score for tibial fractures 
SAE – serious adverse event 
TPA – tibial pseudarthrosis 
TSF – Tissue Storage Facility 
TSRHC – Texas Scottish Rite Hospital for Children 
UAB – University of Alabama at Birmingham 
 

 
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Table of Contents 
1.0        Name and address of sponsor 
 
 
 
 
 
 
1 
      1.0 Abstract 
 
 
 
 
 
 
 
 
10 
   2.0 Device description and report of Prior Investigations  
 
 
 
11 
2.1 Device description/specifications 
 
 
 
 
 
11 
2.2 Summary of Prior Studies 
 
 
 
 
 
 
14 
2.2.1     Adults  
 
 
 
 
 
 
14 
2.2.2 
Pediatric use, including NF1 
 
 
 
 
15 
 
2.3 Goals and Objectives (Scientific Aims) 
 
 
 
 
16 
              3.0 Background and Significance 
 
 
 
 
 
 
17 
  
3.1 Prevalence of the problem  
 
 
 
 
 
17 
  
3.2 Pathophysiology 
 
 
 
 
 
 
 
18 
  
3.3 Animal Models 
 
 
 
 
 
 
 
19 
  
3.4 Surgical management of TPA:  background  
 
 
 
21 
  
3.5 Bone morphogenetic proteins 
 
 
 
 
 
23 
  
3.5.1 Safety of BMP-2  
 
 
 
 
 
 
24 
  
3.5.2 Use of BMP-2 in children  
 
 
 
 
 
25 
  
3.5.3 Use of BMP-2 in NF1 
 
 
 
 
 
 
25 
  
3.6 Radiographic measures of tibial fracture healing (RUST) 
 
 
26 
  
3.7 Pilot Data 
 
 
 
 
 
 
 
 
26 
  
3.8 Summary of preliminary data 
 
 
 
 
 
28 
  
3.9 Rationale for clinical trial 
 
 
 
 
 
 
28 
 4.0 Methodology  
 
 
 
 
 
 
 
 
29 
  
4.1    Overview of proposed study 
 
 
 
 
 
29 
  
4.2.1 Study population, screening, and enrollment 
 
 
 
30 
  
4.2.2 Recruitment 
 
 
 
 
 
 
 
31 
  
4.3    Inclusion and Exclusion Criteria 
 
 
 
 
 
33 
  
4.3.1 Vitamin D Supplementation 
 
 
 
 
 
35 
  
4.4    Administrative role of Operations Center (UAB) 
 
 
 
36 
  
4.5    Data collection and data handling  
 
 
 
 
36 
 5.0 Treatment Program 
  
5.1 Agent information:  Bone Morphogenetic Protein 
 
 
 
37 
  
5.2 Surgical protocol for Treatment of Tibial Pseudarthrosis 
 
 
38 
  
5.3 Protocol to Radiographically Score Tibial Healing after Surgery 
 
39 
  
5.4 Quality of Life Assessments  
 
 
 
 
 
41 
  
5.5 Functional Assessment: 10 meter timed walk 
 
 
 
41 
  
5.6 Protocol to collect biological specimens for future research  
 
42 
  
5.7 Risk/Benefit Analysis 
 
 
 
 
 
 
42 
  
5.8 Evaluation and material to be accessioned  
 
 
 
44 
  
5.9 Adverse Reporting Requirements 
 
 
 
 
 
48 
 
6.0 Statistical and Ethical Considerations 
 
 
 
 
 
53 
  
6.1 Statistical Considerations 
 
 
 
 
 
 
53 
  
6.2 Power analysis 
 
 
 
 
 
 
 
53 
  
6.3 Human Subjects Protection  
 
 
 
 
 
56 
  
6.4 Monitoring Procedures 
 
 
 
 
 
 
58 
6.5 References  
 
 
 
 
 
 
 
60 
6.6 Schema 
 
 
 
 
 
 
 
 
66 
 
 

 
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APPENDICES: 
 
Appendix I:  Schedule of evaluations 
Appendix II:  Biologic Specimen collection  
Appendix III:  Performance Status Scales/Scores (Karnofsky and Lansky) 
Appendix IV:  Labeling/ Patient brochure  (Not Numbered)  
Appendix V:  Case Report Forms  (Not Numbered) 
Appendix VI:  Template Informed Consent and Assent  (Not Numbered) 
 
 
 
 

 
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1.0  ABSTRACT/ PROJECT SUMMARY 
Neurofibromatosis type 1 (NF1) is a dominantly inherited disorder with a prevalence of 1/3,000 
individuals. Patients with NF1 have an increased risk of bone complications, including tibial 
dysplasia, a congenital deficiency making the bone prone to fracture and non-union (tibial 
pseudarthrosis, TPA).  Between 2% and 5% of patients with NF1 have TPA, making this a rare 
condition with overall prevalence of about 1/60,000 and qualifying it as an orphan disorder.  TPA 
causes significant morbidity to those affected, management is fraught with difficulty, and up to 
1/3 will eventually require amputation. There is significant evidence from mouse models and 
human tissues that deficient bone formation occurs in NF1, resulting in decreased ability to form 
new bone as well as increased resorption of bone. Bone morphogenetic proteins (BMPs) are 
osteoinductive signaling proteins of the transforming growth factor-beta superfamily, and their 
mechanism of action involves the recruitment and differentiation of mesenchymal progenitor 
cells into osteoblasts. When applied to bone at the time of surgery, BMPs induce mesenchymal 
stem cells to infiltrate the fracture zone and to differentiate into osteoblasts, which subsequently 
form new bone. Bone morphogenetic protein-2 (BMP-2), as a collagen sponge device marketed 
as INFUSE, has shown efficacy in healing of complex traumatic tibial fractures in adult 
populations. The current study proposes adding BMP-2 (INFUSE), an anabolic agent, at the 
surgical site of TPA repair in children with NF1, compared to a control group of patients treated 
surgically without BMP-2. The following Specific Aims will be addressed:  1) to determine if use 
of an osteogenic agent (BMP-2) at the time of surgical repair of TPA in NF1 patients will result in 
improved bone healing; 2) to document safety of BMP-2 in a pediatric NF1 population; and 3) to 
collect, process, and preserve biologic specimens at the time of surgery for future studies.    
 
Methods: A Phase 2 clinical trial will be performed by a multi-center group of the NF 
Consortium, to compare treatment with or without INFUSE Bone Graft at the time of surgical 
repair. Parents of patients will have the option of choosing whether they have a 
preference for the BMP group or the Control group. Those with a preference will be 
placed in the group of their choice (Choice Arm).  Those without a preference will be 
placed in a Randomized arm, and will be randomized at a ratio of 3:2 for Control group: 
BMP group.   For all patients, a standard surgical procedure will be used, including: resection of 
pseudarthrosis tissue; placement of a rigid intramedullary rod; and placement of autogenous 
bone graft from iliac crest.  For patients in the BMP group, the INFUSE device containing BMP-
2 will in addition be applied intraoperatively to the osteotomy site. A minimum of 36 and 
maximum of 52 patients will be enrolled.  Fracture union will be determined by scoring of 
radiographs (RUST score) for cortical bone fusion and callus formation at the osteotomy site. 
Score will be by a group of radiologists blinded to the group assignment of the patients.  RUST 
score at 12 months post-surgery will be the primary outcome measure to determine efficacy. 
Secondary measures will include determination of time to healing (months); quality of life 
measures; functional walking measures; and incidence of refracture after surgery.  This study, 
once successfully completed, will determine if use of INFUSE Bone Graft improves healing of 
tibial pseudarthrosis in NF1 and will document safety issues.  Regardless of results, the better 
performing of the two groups (control or BMP) will be able to serve as a much-needed control 
arm for future studies of additional targeted therapeutic agents for NF1-related bone disease.   
An international working group of orthopaedic surgeons and NF specialists has been formed 
and is committed to successful completion of this trial. 
 
 
 
 

 
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2.  DEVICE DESCRIPTION AND PRIOR INVESTIGATIONS 
 
2.1 Device description/specification:  
 
INFUSE® is a device consisting of 2 components.   The active component is recombinant 
human bone morphogenetic protein -2 (rhBMP-2) and it is reconstituted onto an absorbable 
collagen sponge (ACS) that serves as a carrier/scaffold.  This device induces new bone tissue 
at the site of surgical implantation. 
 
rhBMP-2 is a disulfide-linked dimeric protein with 2 subunits of 114 and 131 amino acids.  Each 
subunit is glycosylated at one end with high-mannose-type glycans.  The recombinant form is 
produced by genetically engineered Chinese hamster ovary cell line.  rhBMP-2 and excipients 
are lyophilized and packed in the kit.  It is reconstituted so that each milliliter of rhBMP-2 
solution contains:  1.5 mg of rhBMP-2; 5mg sucrose, NF;  25mg glycine, USP; 3.7 mg L-
glutamic acid, FCC; 0.1 mg sodium chloride, USP; 0.1 mg polysorbate 80, NF; and 1.0 ml of 
sterile water.  The reconstituted rhBMP-2 solution has a pH of 4.5, and is clear, colorless, and 
essentially free from plainly visible particulate matter.  
 
The absorbable collagen sponge (ACS) is a soft, white, pliable, absorbent implantable matrix for 
rhBMP-2. It is made from bovine Type I collagen obtained from deep flexor (Achilles) tendon. 
The ACS acts as a carrier for the rhBMP-2 and serves as a scaffold for new bone formation. 
 
The INFUSE® Bone Graft device is designed to be used along with internal stabilization with an 
intramedullary rod or nail to help heal fractures of the lower leg bone (tibia).  INFUSE® is 
supplied in a kit containing all the components necessary to prepare the device including: the 
collagen sponge, a vial with the lyophilized rhBMP-2, a vial with the sterile water for 
reconstituting the rhBMP-2, syringes and needles.  rhBMP-2 is provided as a lyophilized powder 
in vials delivering either 4, 8, or 12 mg of protein, which is reconstituted at the time of surgery to 
1.5 mg/mL.  The solution is uniformly distributed across the entire sponge and no sooner than 
15 minutes after applying rhBMP-2 the ACS is placed at the fracture site.  Kits are stored at 
room temperature (15-25 degrees Centigrade). 
 
Indications for Use:  INFUSE kits are indicated for treating acute, open tibial shaft fractures 
that have been stabilized with intramedullary nail fixation after appropriate wound management.   
 
Device Regulatory History:  INFUSE was developed over a decade ago, and the Premarket 
approval application was approved in 2004 (PMA 000054).  The original PMA for INFUSE® was 
filed December 20, 2000.  There were 24 amendments, and it was formally approved as a 
device by the Centers for Devices and Radiological Health in the Food and Drug Administration.  
There were conditions of approval that included the following: premarket approval application 
(PMA) supplements, post-approval reports, adverse reaction and device defect reporting, and 
reporting under the medical device reporting (MDR) regulation.  These documents were 
retrieved from the FDA website, and are provided as a 58-page document (PMA approval letter 
(7 pages), Summary of Safety and Effectiveness Data (29 pages), Important Medical 
information packet (15 pages), and a patient information brochure (7 pages).  The approval was 
originally provided to Wyeth Pharmaceutical, Inc.; however, the present manufacturer is 
Medtronic Spinal and Biologics (2600 Sofamor Danek Dr., Memphis, TN 38132). 
 
Source and Pharmacology [Summary of Safety and Effectiveness Data from premarket 
approval application].  
 
 
 

 
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Absorption 
Animal studies using subcutaneous implantation in rats and implantation at orthotopic sites in 
rats and rabbits of radiolabeled rhBMP-2 embedded in absorbable collagen sponges provide the 
best assessment of absorption of rhBMP-2. In the femoral onlay model, 125I-rhBMP-2 was 
slowly released from the implant site with a mean residence time of approximately 8 days. The 
peak amount of radiolabeled rhBMP-2 detected in blood was 0.1% of the implanted dose, and 
consistent with other studies showing rapid clearance of IV-administered rhBMP-2 in non-
human primates (t1/2=6.7 minutes). 
 
Binding to ACS: 
INFUSE has its effect by binding of BMP-2 to the collagen sponge (ACS) and retaining an 
effective local concentration of rhBMP-2 to induce bone formation. Studies of use of rhBMP-2 in 
vitro show that with a soak time of at least 15 minutes for the rhBMP-2 solution onto the ACS, 
an average of 95.1% of the initial rhBMP-2 protein was retained by the ACS after squeezing and 
rolling of the ACS strips.   [Hsu et al, 2006]. This provides evidence that minimal amounts of 
rhBMP-2 are lost from the implant site.  An in vivo study using rat and rabbit models confirmed 
that bone deposition occurred only when rhBMP-2 was associated with the ACS, and there was 
no significant ectopic bone formation when rhBMP-2 was injected without a carrier [Hsu et al., 
2006]. This further indicates that there is little risk of forming bone at ectopic sites as a result of 
rhBMP-2 solution dripping from the implant during the surgical process.       
 
Distribution 
In animal studies, IV-administered radiolabeled rhBMP-2 is rapidly distributed to highly perfused 
tissue (1 minute after dosing, 82.4% of the dose was recovered in the liver, lung, kidney and 
spleen with the liver being the prominent site).  
 
Metabolism 
In animal studies, IV-administered radiolabeled rhBMP-2 primarily localized and was 
metabolized in the liver. 
 
Excretion 
In animal studies, 24 hours post IV administration of rhBMP-2 showed 92% recovery in the 
urine, which indicates that excretion is primarily renal. 
 
Storage information 
At room temperature (15-25 degrees Centigrade/50-77 degrees Farenheit). 
 
Formulation and Stability 
The rhBMP-2 and excipients are lyophilized, and upon reconstruction, each milliliter of rhBMP-2 
solution contains: 1.5 mg of rhBMP-2, 5.0 mg sucrose (NF), 25 mg glycine (USP), 3.7 mg L-
glutamic acid (FCC), 0.1 mg sodium chloride (USP), 0.1 polysorbate 80 (NF), and 1.0 mL of 
sterile water. The reconstituted rhBMP-2 solution has a pH of 4.5, and is clear, colorless, and 
essentially free of from visible particulate matter. 
 
Supplier 
The supplier of this device is Medtronic Sofamor Danek USA, Inc. located in Memphis, 
Tennessee. INFUSE® will be provided by the company with demonstration of FDA approval of 
this clinical trial and funding of the clinical trial from external sources. The INFUSE device has 
been approved by FDA through the premarket approval process (PMA #000054) for use in 
treatment of acute, open tibial shaft fractures that have been stabilized by intramedullary 
fixation. As outlined in the background, INFUSE has been applied in a physician-directed 
approach in conjunction with placement of an intramedullary rod combined with autogenous 

 
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bone grafting. The safety profile of INFUSE in the pediatric population [Oetgen and Richards, 
2010] provides an acceptable benefit/risk ratio in those children with tibial pseudarthrosis, 
including those with NF1.  We have recently received approval from the manufacturer of the 
device, Medtronic Spinal and Biologics for 28 Medium INFUSE Bone Graft kits with a current list 
price of $162,240. Except for this provision of INFUSE kits, there is no other sponsorship from 
Medtronic.  Our formal application to the FDA for an IDE was on the basis of an investigator-
initiated, government-sponsored clinical trial (this proposal).  Medtronic provided a “Letter of 
Access” to the FDA which allowed the FDA permission to review Medtronic files in their effort to 
address questions regarding animal testing or other studies of this device. Formal FDA approval 
of IDE application for the use of INFUSE as outlined in this clinical trial proposal was obtained 
on September 30, 2014.  
 
Toxicities 
BMPs participate in embryologic development, and BMPs and their receptors have also been 
found to be present in various tumor types, including bone and soft-tissue sarcomas [Yoshikawa 
et al., 1994].  This has raised theoretical concerns about risks for carcinogenicity or reproductive 
toxicity.  However, extensive studies have thus far found evidence for neither of these [Poynton 
& Lane, 2002]. Preclinical studies by manufacturers showed no proliferative effect of rhBMP-2 
on human osteosarcoma, prostate, breast, tongue, or lung carcinoma cell lines [Poynton & 
Lane, 2002].  When applied to certain cancer cell lines, rhBMP-2 did not cause proliferation of 
cells, but rather had an inhibitory effect [Soda et al., 1998].  Data on use of BMP-7 (OP-1, a 
similar compound to BMP-2) in humans shows that only 5 of 571 patients treated subsequently 
developed malignancy, mostly non-osseous tumors in elderly patients, and not at a higher rate 
than in the general population [Poynton & Lane, 2002].  There is a single case report of a 
malignancy (MPNST) occurring in a 23 year old patient with NF1 and large paraspinal 
neurofibromas who was treated with BMP during spine surgery [Steib et al., 2010]. However, no 
other cases have been reported, and it is unclear if this is simply a chance association, as 
MPNST is known to occur with a lifetime frequency of 8- 13% in patients with NF1 [Evans et al., 
2002].  In order to address the theoretical increased rate of malignancy, our proposed study will 
exclude patients with plexiform neurofibroma of the leg undergoing surgery.    
 
In initial animal studies, IV administration of rhBMP-2 failed to identify acute toxicities. Chronic 
toxicity of implanted rhBMP-2/ACS was evaluated as a 6-month mandibular/maxillary inlay in 
beagle dogs and as a 1-year femoral onlay in Sprague-Dawley rats. There were no systemic 
toxicities, and local effects were associated with the osteoinductive activity of rhBMP-2. 
Transient, low-titer immune responses were seen in the dog study. In human studies, there 
were no systemic toxicities associated with rhBMP-2/ACS in the adult (Govender et al., 2002) or 
pediatric populations (Oetgen and Richards, 2010); however, there were some adverse events 
or local toxicities reported that were potentially due to the osteoinductive effect of rhBMP-2. As 
with any surgery, surgical treatment of fracture is not without risk for adverse events. These 
include the adverse events noted in a clinical trial of INFUSE in open tibial fractures requiring 
surgical stabilization with an intramedullary rod or nail in adults. Even though the adverse event 
incidences were quite similar between controls without rhBMP-2 versus rhBMP-2/ACS implants 
at the surgical site for 2 different concentrations, the manufacturer of the device lists the 
following potential adverse events (alphabetized).  Data on potential adverse events was 
obtained from adult studies, and may not apply to pediatric patients.   
 
• 
Abnormal cellular growth 
• 
Abnormal structure of the newly-formed bone 
• 
Adhesion formation (sticking together of tissue surfaces) 
• 
Aggressive bone resorption (breaking down of bone) or remodeling 
• 
Allergic reaction 

 
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• 
Bone resorption (breaking down of bone) which may be transient 
• 
Cyst or pseudocyst (collection of fluid) formation 
• 
Delayed or failed healing 
• 
Death 
• 
Edema (swelling) 
• 
Erythema (redness of the skin) 
• 
Exuberant (too much) bone formation 
• 
Failure of bone induction (bone growth) 
• 
Fluid retention 
• 
Foreign body (allergic) reaction 
• 
Formation of antibodies (type of protein that helps protect the body against foreign 
matter) 
• 
Formation of blood clots 
• 
Hematoma or bruise (collection of blood caused by bleeding from a broken blood 
vessel) 
• 
Heterotopic bone (bone in the wrong place) formation 
• 
Implant fracture 
• 
Implant migration (movement) 
• 
Infection 
• 
Inflammation (swelling, redness, and pain in tissues) 
• 
Interference with wound healing when used in the closure of skin incisions 
• 
Irritation 
• 
Loss of purchase (loosening of the implant) 
• 
Osteolysis (breaking down of bone tissue) 
• 
Seroma (a collection of clear fluid), and/or fluid collections/ fluid-filled sacs 
• 
Slow dissolving of the implant 
• 
Spinal stenosis (narrowing of the spinal canal) 
o Incidences of spinal stenosis have only been reported when BMP-2 was 
used in spinal surgery.  In this study, we will only utilize BMP-2 in tibial 
repair.  
and 
• 
Swelling near the surgical site.   
 
 
The review by Oetgen and Richards [2010] puts these potential complications in perspective for 
pediatric patients exposed to rhBMP-2. They performed a retrospective review of 81 patients 
less than 18 years of age in whom rhBMP-2 was used as a surgical adjunct to promote bone 
healing in spine (47), femur (7), cervical spine (5), tibia (21), and ribs (1). There were no 
instances of systemic toxicity defined as clinical deterioration of an organ system function. A 
total of 16 complications were identified (~20%), and of these 9 involved the local operative site. 
Only one case of dural fibrosis with subsequent weakness was possibly attributable to rhBMP-2 
when used in spinal fusion [Oetgen and Richards, 2010]. 
 
2.2 Summary of Prior Studies with the Device:  
 
2.2.1 Adults:  There are several key studies showing the efficacy of INFUSE.  Extensive 
data exists on use of rhBMPs for treatment of open tibial fractures in adults.  Govender et al. 
[2002] studied 421 adults with open tibial fractures, who were randomized to receive one of the 

 
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two methods:  routine surgical care with intramedullary nail fixation, or routine care plus an 
implant containing rhBMP-2.  With the additional use of rhBMP, they found significant 
shortening of time to fracture healing, and decreased rate of infections.  The group treated with 
rhBMP-2 also had 44% reduction in need for a secondary procedure for delayed union.  There 
was no increase in soft-tissue calcifications or ectopic ossification in the treated group, and 
overall complications were lower in the BMP-treated group compared to the standard surgery 
group.  Several additional large, multi-center studies performed since then have confirmed the 
efficacy and safety of rhBMP-2 for open tibial fractures in adults [Swiontkowski et al., 2006; 
Jones et al., 2006].  Recently, a clinical trial entitled Tibial Delayed Healing Pivotal Clinical Trial 
(NCT01016067; ClinicalTrials.gov identifier) was opened in 2010 to evaluate 
INFUSE/MASTERGRAFT™ Delayed Healing Device (Medtronic) as an alternative to autograft 
in the treatment of tibial delayed healing.  Those with congenital pseudarthrosis of the tibia (NF1 
patients with tibial pseudarthrosis) and patients less than 21 years of age were excluded.   
 
Woo [2013] reviewed adverse events associated with use of rhBMP-2 in nonspinal orthopaedic 
procedures, many of which involved off-label use.  There were a total of 62 events reported to 
the FDA through 2011, including:  wound complications (15), heterotopic bone formation (12), 
pseudarthrosis (10), local inflammation (9), osteolysis or resorption (5), compartment syndrome 
(2), and peripheral nerve injury (2).  Of the 12 reports of heterotopic ossification, 5 required 
surgery to remove extra bone.  The author noted that this data could not be used to estimate 
incidence rates of adverse events, as the total number of surgical procedures using rhBMP-2 is 
unknown.  It was additionally noted that occurrence of pseudarthrosis might simply reflect the 
refractory nature of certain fractures, regardless of use of BMP-2.     
 
Use of BMP-2 during spinal fusion surgery in adults has received recent attention regarding 
safety and efficacy data.  As reviewed by Carragee et al. [2011], initial industry-sponsored 
studies reported an extremely low rate of adverse events, despite significant events reported to 
the FDA.  Carragee et al. undertook a review of the literature comparing the original industry-
sponsored trials to data reported by the FDA and subsequent publications.  From their review, 
they estimated the rate of adverse events associated with rhBMP-2 use in spinal fusion ranging 
from 10%-50%, depending on approach.  Complications included swelling of neck and throat 
(associated with cervical spine fusion), inflammatory effect with increased rate of wound 
complications, urological complications including bladder retention and retrograde ejaculation in 
patients with lumbar spine fusions, and osteolytic defects.  These data have likely influenced the 
approach of many orthopaedic surgeons in their use of rhBMP-2 during spinal fusion.  
 
More recently, the FDA submission of a high dose rhBMP-2 product for spinal fusions, 
AMPLIFYTM, which includes a total dose of 40 mg rhBMP-2 (10-fold higher than the dose in a 
small packet of INFUSE), reported a mild increase in cancer risk in elderly patients in a 5 year 
follow-up (3.9% of 239 patients).  The increased cancer risk just reached significance (p=.05) 
according to the analysis of Carragee et al. [2011].  No increased cancer risk has been reported 
to date in patients treated with the lower-dose INFUSE product.  The occurrence of tumors in 
this high dose BMP-2 group prevented the product being approved by the FDA, but the INFUSE 
product at a lower dose remains approved. 
 
Recombinant human rhBMP-2 is currently approved by the FDA as a device for use in adults for 
lumbar spine fusion and open tibial fractures (INFUSE® Bone Graft).  The FDA lists skeletal 
immaturity (age less than 18 years) as a contraindication to its use, primarily because there is 
limited data on its safety in children.  Despite this, the device has been used on a physician-
directed off-label basis in increasing numbers of children, and data are beginning to accumulate.   
 
 
 

 
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2.2.2 Pediatric use, including NF1 
Chin et al. [2005] were among the first to report use of rhBMP-2 in children.  They used rhBMP-
2 instead of autogenous bone graft in repair of congenital facial clefts in 43 children (ages 6-14 
years).  Successful union of bone was achieved in 98% of patients, and no systemic adverse 
effects or ectopic bone formation occurred during up to two years of follow-up.  Alonso et al. 
[2010] also reported use of rhBMP-2 in 16 patients who underwent repair of cleft lip and palate, 
between 8 and 12 years of age.  Good bone union occurred in all patients, with no ectopic bone 
growth.  Richards et al. [2010] performed a retrospective review of 7 patients, with congenital 
tibial pseudarthrosis (4 with NF1; age ranges 1.9-11 years) treated with rhBMP-2 applied locally 
at time of surgery with intramedullary rod.  In 5/7 patients, there was a good healing after one 
surgery, with average time to union of 6.4 months.  During a prolonged follow-up time of 4-9 
years, there was no evidence of tumor growth or systemic effects noted from rhBMP-2 use.   
 
Oetgen and Richards [2010] also performed a review of 81 children who have been treated with 
rhBMP-2 between 2001 and 2008, between the ages of 1 and 17 years.  Of this group, 52 
children received rhBMP-2 during spine surgery and 21 during tibial repair.  Sixteen (16) of the 
children had NF1.  One patient with NF1 subsequently had enlargement of a previously 
identified optic nerve glioma, but this was interpreted as unlikely to be related to rhBMP-2.  
There was a total complication rate of 17%, most of which were surgical wound inflammatory 
responses.  Only one complication was postulated to be related to rhBMP-2, and that was a 
case of dural fibrosis developing after direct exposure of the dura to rhBMP-2.  There were no 
reports of systemic toxicity, excessive bone growth, sarcomas, or other tumors. 
 
2.3 GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
Neurofibromatosis type 1 (NF1) is a dominantly inherited disorder occurring with a prevalence of 
1/3,000 individuals.  Patients with NF1 have an increased risk of osseous complications, 
including tibial dysplasia and tibial pseudarthrosis (TPA) with chronic fracture and non-union.  
Although occurring in only 2-5% of NF1 patients, management of TPA is fraught with difficulty, 
with many patients requiring multiple surgeries and up to 33% eventually requiring amputation.  
Significant evidence from both animal models and human tissue documents a difference in bone 
biology in NF1, with decreased ability to form new bone as well as increased resorption and 
remodeling of bone.  An international working group of NF specialists and orthopedic surgeons 
has been formed, and proposes a clinical trial to document efficacy of an osteogenic agent 
(INFUSE; recombinant human bone morphogenetic protein-2) as a supplement to surgical 
approaches to TPA in NF1.  This international group is committed to successful completion of 
this trial.   
 
PRIMARY AIMS: 
 
Specific Aim 1:  To determine if use of an osteogenic agent (rhBMP-2) at the time of 
surgical treatment of TPA in NF1 patients will result in improved bone healing when compared 
to patients treated with the same surgical protocol but without BMP-2.    
 
Specific Aim 2:  To document safety of BMP-2 in a pediatric NF1 population 
 
Specific Aim 3:  To collect, process, and preserve biologic specimens at the time of 
surgery for future studies related to NF1.  
 
Primary Objectives: 
Objective 1: To perform a phase 2 single-blind, randomized clinical trial to determine if 
use of INFUSE (rhBMP-2 on a collagen sponge) applied at time of surgical repair of TPA 
in NF1 patients will result in: 
1a. Improved bone healing rates compared to patients treated without INFUSE, 
based on radiographic evidence of cortical bone union at 12 months after surgery 
(RUST score; Primary Outcome Measure at 12 months) 

 
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1b. Shorter time (months) to objective radiographic union than in patients treated 
without INFUSE.   
Objective 2: To evaluate the feasibility and potential toxicities of BMP-2 administration 
in this population. 
Objective 3: To collect, process, and preserve biologic specimens at the time of surgery 
for future studies. 
 
 
SECONDARY AIMS/OBJECTIVES:   
• 
To evaluate quality of life at the time of surgery, and at 6 months and 12 months after 
surgery. 
• 
To determine the incidence and timing of re-fracture after surgery. 
• 
To provide a cohort of patients with NF1 and TPA treated with a standardized surgical 
protocol, which can be used as a much-needed arm for future clinical trials. 
• 
To provide annual long-term follow up of this cohort of patients for up to 10 years after 
surgery to monitor for rate of refracture and safety issues.  (Note:  this objective will not 
be funded by the current funding for the NF Clinical Trials Consortium).  
  
3.0 BACKGROUND AND SIGNIFICANCE 
 
Neurofibromatosis Type 1 and Tibial Pseudarthrosis:  Neurofibromatosis type 1 (NF1) is an 
autosomal dominant disorder whose features involve many systems, including skin (cafe-au-lait 
spots, cutaneous neurofibromas), central nervous system (learning disabilities), 
musculoskeletal, and tumor predisposition.  Up to 38% of patients with NF1 have one or more 
skeletal abnormality [Crawford and Schorry, 1999], including long bone dysplasia, scoliosis, 
sphenoid wing dysplasia, and bone cysts.   We have proposed a clinical trial for a rare osseous 
complication of NF1, tibial pseudarthrosis (TPA), which presents with significant morbidity for 
patients and extreme difficulty in surgical management.   
 
3.1 Prevalence of the Problem:  NF1 occurs with a prevalence of 1/3000 in all populations 
regardless of ethnicity, race, or gender [Huson et al, 1988; Friedman and Riccardi, 1999].  Tibial 
pseudarthrosis (TPA) is a relatively rare complication of NF1;  data from a large international 
NF1 database has documented tibial pseudarthrosis to occur in between 2-5% of patients with 
NF1[Friedman and Birch, 1997], resulting in a maximum estimated prevalence of 1/60,000 
individuals.  With a US population of 315 million, there are only estimated to be 5,250 
individuals in the US with tibial pseudarthrosis related to NF1, qualifying it as an orphan 
disease.     
Tibial pseudarthrosis is defined as a chronic non-union in a bone which has fractured.  It can 
occur in the general population as well as in patients with NF1, although more than half of all 
individuals with TPA have NF1. In patients with NF1, TPA typically occurs in a bone which is 
congenitally dysplastic, presenting as an anterior-laterally bowed tibia and/or fibula which has a 
high risk for fracture.  Stevenson et al. [1999] surveyed a multi-center cohort of patients with 
NF1 and tibial dysplasia and found that tibial dysplasia was 1) most often unilateral, 2) evident 
in the first year of life, and 3) affected males more often than females by a ~2:1 ratio. Additional 
findings demonstrated that tibial pseudarthrosis usually results as a progression from tibial 
anterolateral bowing. This anterolateral bowing is recognized as tibial dysplasia, whereas the 
non-union of bone after fracture is defined as tibial pseudarthrosis (Figure 1). Analyses in the 
report by Stevenson et al. [1999], which reviewed a total of 160 NF1 subjects, showed that 61-
66% of individuals with tibial dysplasia progressed to fracture and pseudarthrosis. The average 
age of fracture was 4.6 years with a range of 0 to 28 years, and the average number of 
surgeries in cases with pseudarthrosis was 3, with some patients having as many as 10 surgical 
procedures.  

 
NF Protocol #107   Version 5 
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Figure 1 A and B:  Radiographs of tibial dysplasia   
TPA in NF1 patients leads to major morbidity, including possible lower leg amputation. 
Presently, best care guidelines for the treatment of TPA in NF1 do not include medical 
management protocols. We have assembled a multidisciplinary team of clinicians who provide 
specialized care for patients with NF1.  Principal investigators of this clinical trial participated in 
two clinical trial strategy meetings for treatment of bone abnormalities in NF1 (New York City, 
02/2008 and 4/2011) [Elefteriou et al., 2009], which led to a consensus to prioritize the 
development of a clinical trial for the combined medical/surgical treatment of tibial 
pseudarthrosis (TPA). Drs. Viskochil, Schorry, and Little recruited Dr. Richards to jointly work 
with the NF Clinical Trials Consortium to develop a multi-center clinical trial that implements 
medical treatment combined with well-established surgical protocols to optimally manage tibial 
pseudarthrosis in NF1 patients. 
 
3.2 Pathophysiology 
The pathophysiology of bone manifestations in NF1 is not yet fully elucidated, although recent 
research with animal models and human tissues has made great progress in our understanding 
of this area.  The Nf1 gene is classified as a tumor suppressor gene [reviewed in Viskochil et al., 
1993]. Its encoded product, neurofibromin, is a 240-kDa peptide [reviewed in Sherman et al., 
1998] that stimulates the intrinsic hydrolysis of ras-bound guanosine triphosphate (GTP) [Martin 
et al., 1990]. Ras is a small intracellular protein that must be attached to the inner membrane of 
the cell to be active in signal transduction. When bound to GTP, the protein transduces growth 
signals to the cell's nucleus through both mitogen-activated protein kinase (MAPK) and AKT 
signaling. MAPK signaling cascades are operational in the key cells playing a role in bone 
homeostasis, remodeling, and fracture healing: osteoclasts and osteoblasts [Chaudhary and 
Avioli, 1998; Hipskind and Bilbe, 1998]. While NF1haploinsufficiency is associated with tumor 
predisposition, studies support the hypothesis that NF1 haploinsufficiency also results in a 
range of non-tumor phenotypes [Wu et al., 2006], including skeletal abnormalities [Alwan et al, 
2005]. Osteopenia has been reported in both children and adults with NF1, and is one of the 
recognized manifestations of this underlying bone disorder [Illes et al. 2001; Kuorilehto et al. 
2004; Stevenson et al 2007].  More localized osseous manifestations also occur, including 
sphenoid wing dysplasia, bone cysts, pectus excavatum, and scoliosis (both idiopathic and 
dystrophic forms). Bi-allelic inactivation of the NF1 gene in surgically resected pseudarthrosis 
tissue has been demonstrated in at least 6 NF1 patients to date [Stevenson et al., 2006; Lee et 
al., 2012], which suggests that somatic genetic changes contribute to abnormal bone 
Figure 1.  Image A 
shows typical tibial 
dysplasia with 
anterolateral bowing, 
thickening of cortex 
and narrowing of 
medullary canal.  
Image B 
demonstrates a tibia 
with chronic 
pseudarthrosis. 
 

 
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remodeling and pseudarthrosis in NF1.  It is likely that generalized bone changes in NF1 (such 
as short stature and osteopenia) are related to haploinsufficiency of neurofibromin, whereas 
focal changes such as tibial dysplasia are related to bi-allelic inactivation of Nf1.   
Bone is regulated by two competing forces:  anabolism (new bone formation) and catabolism 
(bone resorption).  The cell types driving these two processes are osteoblasts and osteoclasts, 
respectively. Osteoblasts, derived from mesenchymal stem cells, are stimulated to produce 
bone matrix by Bone Morphogenetic Proteins and other growth factors.  Osteoclasts are derived 
from the macrophage/monocyte lineage, and play a major role in bone resorption and 
remodeling.  Neurofibromin is expressed in multiple cell types involved in bone development, 
including osteoblasts, osteoclasts, chondrocytes, and vascular endothelial cells.  Substantial 
evidence shows a role for dysfunction of both osteoblasts and osteoclasts in NF1-related bone 
disease [reviewed in Schindeler and Little, 2008].  This cumulating data in both human and 
animal tissues documents significant differences in bone biology in NF1,  leading to poor 
bone formation as well as overly active bone resorption, and justifying a therapeutic trial 
that addresses these issues in NF1 tibial pseudarthrosis. 
 
3.3. Animal models 
The development of animal models that recapitulate the bone phenotype in NF1 has yielded 
insights for the role(s) of neurofibromin in bone development and remodeling. Murine models 
provide an opportunity to dissect the processes of union after fracture and are important in 
determining the most appropriate biologic compounds to enhance bone strength in long-bone 
dysplasia and healing in NF1-related TPA. 
 
Several studies have shown reduced expression of bone markers and decreased mineralized 
matrix in cultured osteoblasts from NF1 mouse models and human NF1 haploinsufficient 
embryonic bone cells [Klein et al., 1995; Schindeler et al., 2008; Wu et al., 2006; Yu et al., 
2005].  NF1 heterozygous mice showed elevated numbers of multinucleated osteoclasts 
compared to wild type mice, with increased migration capacity and increased capacity to resorb 
bone [Yang et al., 2007].   
 
Mouse models for NF1 include Nf1+/- mice as well as conditional knockouts (somatic Nf1-/- cells) 
that target bone-specific cells The major characteristics of the skeletal phenotype of these Nf1 
genetically engineered mouse (GEM) models are highlighted in a modified table as reviewed by 
Elefteriou et al., [2009] (Table I).  
 
Table I. Osseous characteristics of the Nf1 mouse models. (adapted from Elefteriou et al., 2009) 
  
Nf1+/- 
[Yu et al. 2005] 
Nf1ob-/- 
[Elefteriou et al. 
2006] 
Nf1Prx-/- 
[Kolanczyk et al. 
2007] 
NF1 Col2.3 Cre 
[zhang  et al.,  
 2011] 
Loss of Nf1 
activity 
Whole body 
Mature osteoblasts 
Limb 
mesenchymal 
osteoprogenitors 
Osteoblast  
lineage 
Osteoblast 
differentiation 
Decreased 
Normal 
Decreased 
Decreased 
Osteoclast 
differentiation 
Increased  
Increased  
Increased  
Increased 
Bone quality 
Not determined 
Decreased 
cristalinity 
Increased cortical 
porosity 
Decreased bone 
density 
Mechanical 
property 
Decreased 
stiffness 
Decreased stiffness Not determined 
 

 
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21 
Parallels with 
human NF1 
skeletal 
phenotype 
- Increased 
bone resorption 
- Delayed bone 
healing 
- Increased bone 
resorption 
- Delayed bone 
healing 
- Increased 
osteoidosis 
- Increased bone 
resorption 
- Tibial bowing 
- Low bone density 
- Delayed bone 
healing 
-low bone mass 
-tibial nonunion 
-shortened 
vertebrae 
 
 
No mouse model fully replicates the human skeletal manifestations, but Nf1-deficient mice are 
highly valuable for the pre-clinical testing of candidate therapies for NF1 skeletal defects. Bone 
healing in the distal tibia, where TPA is most common, is abnormal in Nf1+/- mice [Schindeler et 
al., 2008a; Schindeler et al., 2008b]. The cortical porosity of the Nf1Msc-/- GEM mouse model and 
human long bone from an NF1 patient are remarkably similar, as shown in preliminary studies 
kindly shared by colleagues Elefteriou and Stevenson (see Figure 2).  
 
The Nf1prx-/- model, which produces bi-allelic inactivation of  Nf1  in mesenchymal cells of the 
developing limbs, probably most closely parallels that of tibial pseudarthrosis in humans with 
NF1 [Kolanczyk et al, 2007].The resulting Nf1 prx-/- mice showed stunted growth, tibial bowing, 
joint abnormalities, and highly porous cortical bone in the limbs. Osteoblasts from these mice 
showed increased proliferation but decreased ability to differentiate and mineralize.  
 
Another bone phenotype was created by bi-allelic inactivation of Nf1 in committed osteoblasts 
(Nf1ob-/-). These mice had delayed mineralization of bone, increased numbers of osteoclasts, 
and increased bone resorption.  A more recent mouse model of NF-1 bone disease, NF1col2-/- 
GEM, demonstrated neurofibromin loss in osteochondroprogenitor cells affecting both axial and 
appendicular skeleton [Zhang et al., 2011]. These mice showed progressive scoliosis and 
kyphosis, tibial bowing, chest wall deformities, severe growth retardation, and vertebral disc 
defects. There were also abnormal bone biomechanical properties, including a significant 
reduction in stiffness of bone. Studies of these Col2.3 Cre mice by Rhodes et al. [2013] recently 
demonstrated that the transforming growth factor beta (TGF-B1) pathway may also play a 
significant role in NF1 bone disease, and may represent  additional targets for future 
therapeutics.    
 
Lastly, none of these models actually demonstrated the classic features of TPA.  Based on the 
findings by Stevenson et al. and Lee et al. that loss of heterozygosity of Nf1 may be present in 
the fibrous tissue in TPA, El-Hoss et al [2012] used NF1 flox/flox mice and a cre-expressing 
adenovirus to produce bi-allelic inactivation in a fracture site. This was performed in mice of 
Nf1+/- and Nf1+/+ background. When Nf1 was deleted at the fracture site, fewer than half of the 
mice showed effective union of bone when an open osteotomy was performed with periosteal 
stripping. The model featured the anabolic deficiency noted in TPA, as well as the fibrous tissue 
containing multiple osteoclast-like cells, typical of TPA. This model confirms that 
neurofibromin is essential for fracture healing, and that its induced absence leads to a 
TPA-like picture. These mouse bone data clarified that total loss of NF1 function is likely the 
underlying molecular cause of the NF1 focal dysplastic defects, and correlates with the human 
data from tibial pseudarthrosis tissue [Stevenson et al., 2006; Lee et al. 2012]. 
 
 
 
 
 
 
 
 

 
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Figure 2. 3-D reconstruction of microCT images of tibia from mice (A) and human (B) 
A
B
  
 (A) Image of tibial bone on left taken from wild-type mouse; image of tibial bone on right taken from an 
Nf1Msc-/- mouse showing cortical porosity.  (B)  Image on left taken from the tibia of a deceased child 
without NF1, while the image on the right is taken from a tibial sample during surgical repair of an NF1 
child with tibial pseudarthrosis showing cortical porosity similar to what is observed in the mouse model. 
The tibial sample was cut longitudinally for the NF1 child but control tibial sample is left intact [courtesy F. 
Elefteriou (mouse images) and D. Stevenson (human images)]. 
 
Several animal studies have investigated use of BMPs in in bone healing.  Earlier studies 
showed that BMPs were capable of restoring function with large diaphyseal bone defects, and in 
preventing non-unions in severe open fractures [Lane et al., 1999; Little et al. 2005; Hak et al. 
2006].  Schindeler et al. [2008] investigated osteoblast response from cultured calvarial 
osteoblasts of NF1-deficient mice, and found that NF1+/- cells responded to BMP-2 in culture 
with a 2-fold increase in alkaline phosphatase expression, although the final effect was less than 
that seen in wild type mice.  Similarly, BMP documented osteogenic effect by producing 
heterotopic bone when injected into mouse quadriceps muscle, although again to a lesser 
extent for NF1 deficient mice compared to wild type [Schindeler et al., 2008].   
 
Innovation:  These preclinical findings from animal models encourage clinical trials 
using a medical approach to treat NF1-related TPA.  Confirmation of NF1 target pathways 
in bone-forming cells provides a compelling justification for a medical approach aimed at 
increasing local bone anabolism.  This approach can be used in combination with 
surgical techniques to promote fracture healing and to diminish non-union complications 
in repair of tibial pseudarthrosis.   
3.4 Surgical Management of TPA: Background 
In the general population, open fractures of the tibia are one of the most difficult fractures to 
heal, with approximately 60% of all non-unions occurring in the tibia. This is true when bone is 
perceived to be normal prior to fracture. Individuals with congenital pseudarthrosis of the tibia 
are unique in that the underlying bone is abnormal, which likely contributed to the fracture as 
well as the non-union [Johnston and Birch, 2008]. Thus, surgical management for these patients 
requires extraordinary approaches to establish bone union.    
 
Surgical stabilization of tibial pseudarthrosis has evolved over the last 2 decades [Coleman et 
al., 1995; Grill et al., 2000]. External distraction procedures, such as the Ilizarov approach, are 
rarely implemented in the initial management of congenital pseudarthrosis of the tibia. An 
alternative approach is preferred by most pediatric orthopedic surgeons whereby the tibia is 
stabilized with placement of an intramedullary rod. Various institutions use different types of 
intramedullary rods, and the surgical management goal is to optimize both tibial healing and 
ankle function. The technique now used by most experienced NF surgeons includes; 1) excision 
of the pseudarthrosis site, 2) intramedullary rod placement (with or without transfixing the ankle 
Mouse Tibia 

 
NF Protocol #107   Version 5 
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joint), and 3) placement of autogenous bone harvested from the iliac crest around the 
pseudarthrosis site [Johnston, 2002; Dobbs et al, 2005].  
 
Johnston [2002] reported the results of 23 consecutive patients with congenital pseudarthrosis 
of the tibia (12 with NF1) who were treated between 1978 and 1992 by 7 different pediatric 
orthopaedic surgeons using an intramedullary rod (Charnley-Williams procedure [Charnley J, 
1956]) for fixation and bone graft, with and without transfixation of the ankle. Outcomes were 
reviewed 4-14 years after surgical intervention and scored on a scale of 1 to 3.    Eleven of 23 
(48%) had a grade 1 outcome, which represents unequivocal union of the tibia; however, only 5 
patients had this outcome with a single operation (5 had 2 surgeries and 1 required 3 surgeries) 
[Johnston, 2002].  Outcome was not presented separately for patients with NF1.  
 
Dobbs et al., [2004] reported using this surgical technique in a cohort of 21 patients with TPA 
(12 with NF1) who were followed for 14 years. Patients were reported to have an eventual 
healing rate of 86% with mean time to union of 16 months; however, multiple surgeries were 
required for the majority of these patients. The healing rate after a single surgical procedure was 
not reported. In addition, 57% of patients re-fractured over time at the site of the initial 
pseudarthrosis. Of the 12 with NF1, 3 required amputation.  In many of these studies, it has 
become apparent that healing rates in patients with NF1 and TPA are poorer than in those 
without NF1. 
 
Other treatment methods used for TPA include free-vascularized fibular graft, McFarland 
bypass graft, and Ilizarov bone transport, with reported union rates ranging from 14% to 75% 
[Grill et al., 2000]. The Ilizarov technique of external fixation in experienced hands showed an 
overall 75% fusion rate [Grill et al., 2000]; however, given the high frequency of repeat surgeries 
needed and extensive time to final healing, this technique of external fixation is not an optimal 
initial procedure for the young patient population with TPA. 
 
It is clear from the above data that surgical management of TPA, particularly in patients with 
NF1, has not yet been optimized and that significant numbers of patients continue to require 
multiple surgeries and/or progress to need for amputation.  Subsequently, adjunctive treatments 
have been sought to improve healing and lower re-fracture rate.  Orthopedic surgeons have 
begun to use bone morphogenetic proteins as adjunctive anabolic agents at the time of 
surgery for patients with open tibial fractures [Govender et al, 2002] and tibial fractures with 
cortical defects [Jones et al., 2006]. In a small case series conducted by one of the co-PIs,  
Richards et al., [2010] recently reported a group of 7 patients with TPA (4 with NF1) who were 
treated with intramedullary rod fixation; autogenous graft from the iliac crest; and placement of 
rhBMP-2 saturated absorbable collagen sponges (INFUSETM; Medtronic) around the site of the  
tibial defect site intraoperatively.  Five of 7 patients (71%) had radiographic union at a mean 
time of 6.4 months post-operatively (see figure 3).  Although a number of orthopaedists now 
routinely use BMP-2 in NF1 patients with TPA, organized clinical trials have not yet been 
implemented to prospectively evaluate its utility.  
 
 
 
 
 
 
 
 
 
 
 

 
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Figure 3.  Williams rod procedure 
 
 
Radiographs after Williams rod placement across the ankle joint, autogenous bone-grafting, and rhBMP-2 
application, showing excellent early alignment (left panel). The pseudarthrosis was healed at 6.7 months 
and remained so 7.8 years later (from figure 2B and 2C in Richards et al, 2009). The fibula has been fixed 
with a nail. 
 
The improved rate of radiologic union with use of rhBMP-2 is highly relevant to the NF1 
population.  Even though tibial dysplasia with fracture is a rare complication of NF1, it leads to 
significant morbidity due to poor bone union and high likelihood for re-fracture, regardless of 
surgical approach. A better understanding of bone remodeling in NF1 opens a new avenue of 
medical treatment to enhance fracture healing. Abnormal bone formation seen in both 
animal models and human NF1 tissues raises the opportunity to improve outcome in 
NF1-related TPA by treatment with a protocol that utilizes a biologically-based anabolic 
agent (Bone Morphogenetic Protein-2) to improve bone union.   
 
 
It is also clear from the previously reviewed studies, that results from individual 
surgeons or groups in TPA techniques and outcomes are not directly comparable.  Many 
surgeons have lumped NF1 patients with non-NF1 patients in their reports of surgical 
success; when data are extracted separately, it is clear that the outcome is poorer with 
all approaches for patients with NF1.  This underscores the need to perform a trial 
specifically for NF1-related CPT, utilizing a standard surgical protocol and standard 
outcome measurements.   
 
3.5 Bone Morphogenetic Proteins 
Bone morphogenetic proteins (BMPs) are signaling molecules which are part of the 
transforming growth factor-beta (TGF-B) superfamily of proteins.  They play a role in 
organogenesis of many cell types, including skeletogenesis. There are 14 or more known 
BMPs; one of the most well-studied is BMP-2, which is known to play a major role in bone 
development.  Although present in high levels during embryogenesis, very minute amounts of 
BMP-2 occur naturally in bone in children and adults.  BMPs are expressed during normal 
fracture repair. Gerstenfeld and colleagues [2003] noted early expression of BMP-2 during 
fracture repair, with expression of BMP-4, -5 and -6 coming later and BMP-7 later still. Recently 

 
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it has been proven that BMP-2 is an essential factor in the initiation of fracture healing [Tsuji et 
al., 2006]. 
 
BMPs bind to BMP receptors in target cells, resulting in a signal transduction cascade through 
the SMAD family of proteins.  Of interest, other pathways, including the Ras-MAPK pathway 
important in NF1, can also be activated by BMPs.  For example, M-Ras is activated by BMP-2 in 
transdifferentiation of C2C12 muscle cell lines to the osteoblastic lineage [Watanabe et al., 
2010].  However, in a circumstance such as NF1 where Ras is abnormally regulated, the 
balance between SMAD mediated signaling and any further stimulation of the Ras/MAPK 
pathway may be important in determining cell fate decisions. 
 
The ultimate effect of BMP signaling is to induce mesenchymal progenitors to infiltrate the 
fracture zone and to differentiate into osteoblasts, which subsequently form new bone. A 
concomitant increase in vascularity is also notable.  BMPs can stimulate new bone formation 
even in extra-skeletal sites in a host, leading to their use in treatment of skeletal injuries, spinal 
fusions, and facial clefting repairs. 
 
Through molecular technology, recombinant forms of human BMP-2 and BMP-7 are currently 
commercially available.  The largest amount of data regarding safety and efficacy exists for 
rhBMP-2, which is currently approved by the FDA for use in adults for lumbar spine fusion and 
open tibial fractures. The device is used in the form of an absorbable collagen sponge 
impregnated with rhBMP-2 (INFUSE).   
 
Extensive data exists on use of rhBMPs for treatment of open tibial fractures in adults.  
Govender et al. [2002] studied 421 adults with open tibial fractures, randomized to receive one 
of two methods:  routine surgical care with intramedullary nail fixation, or routine care plus an 
implant containing rhBMP-2.  With the additional use of rhBMP, they found significant 
shortening of time to fracture healing, and decreased rate of infections.  The group treated with 
rhBMP-2 also had a 44% reduction in need for a secondary procedure for delayed union.  There 
was no increase in soft-tissue calcifications or ectopic ossification in the treated group, and 
overall complications were lower in the BMP-treated group compared to the standard surgery 
group.  Several additional large, multi-center studies performed since then have confirmed the 
efficacy and safety of rhBMP-2 for open tibial fractures in adults [Swiontkowski et al., 2006; 
Jones et al., 2006].   
 
Of importance, BMPs under certain conditions, such as in high doses, can also induce activity of 
osteoclasts involved in bone resorption [Kanatani et al., 1995; Tsuji et al., 2006].  Therefore, 
appropriate doses must be used to achieve the correct balance between osteoblast and 
osteoclast activity.  It appears that although rhBMP-2 may cause some increased osteoclastic 
activity, it is coupled with an osteoblastic upregulation of greater magnitude, with a purported 
end result of increased volume of bone fusion mass [Poynton & Lane, 2002]. 
   
3.5.1 Safety of rhBMP-2 
BMPs participate in embryologic development, and BMPs and their receptors have also been 
found to be present in various tumor types, including bone and soft-tissue sarcomas [Yoshikawa 
et al., 1994].  This has raised theoretical concerns about risks for carcinogenicity or reproductive 
toxicity.  However, extensive studies have thus far found evidence for neither of these [Poynton 
& Lane, 2002]. Preclinical studies by manufacturers showed no proliferative effect of rhBMP-2 
on human osteosarcoma, prostate, breast, tongue, or lung carcinoma cell lines [Poynton & 
Lane, 2002].  When applied to certain cancer cell lines, rhBMP-2 did not cause proliferation of 
cells, but rather had an inhibitory effect [Soda et al., 1998].  Data on use of BMP-7 (OP-1, a 
similar compound to BMP-2) in humans shows that only 5 of 571 patients treated subsequently 
developed malignancy, mostly non-osseous tumors in elderly patients, and not at a higher rate 

 
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than in the general population [Poynton & Lane, 2002].  There is a single case report of a 
malignancy (MPNST) occurring in a 23 year old patient with NF1 and large paraspinal 
neurofibromas who was treated with BMP during spine surgery [Steib et al., 2010]. However, no 
other cases have been reported, and it is unclear if this is simply a chance association as 
MPNST is known occur with a lifetime frequency of 8- 13% in patients with NF1 [Evans et al., 
2002].  In order to address the theoretical increased rate of malignancy, our study will exclude 
patients with plexiform neurofibroma of the leg undergoing surgery.    
 
Recently, the FDA submission of a high dose rhBMP-2 product for spinal fusions, AMPLIFYTM, 
which includes a total dose of 40mg rhBMP-2 (10-fold higher than the dose in INFUSE), 
revealed a mild increase in cancer risk in elderly patients in a 5 year follow-up.  The increased 
cancer risk just reached significance according to the analysis of Carragee et al.  [2011]. No 
increased cancer risk has been reported to date in patients treated with the lower-dose INFUSE 
product. The occurrence of tumors in this high dose BMP-2 group prevented the product being 
approved by the FDA, but the INFUSE product at a lower dose remains approved. 
 
Human and animal studies have not demonstrated any evidence of systemic toxicity from  
rhBMP-2.  When applied locally or by IV in animal studies, rhBMP-2 was found to have a very 
rapid systemic clearance, with a half-life of 6 minutes in primates, making the risk from systemic 
exposure low [Poynton & Lane, 2002].  Despite its role in embryologic development, there has 
been no evidence of embryolethality or teratogenicity in animal studies.  Reproductive toxicity 
has not been studied in humans, however. There is also little evidence of excessive immune 
response to rhBMP-2:  studies have shown that only 0.7% of patients (same as controls) 
mounted an antibody response to rhBMP-2 [McKay and Sandhu, 2002].  
 
Woo [2013] reviewed adverse events associated with use of rhBMP-2 in nonspinal orthopaedic 
procedures.  There were a total of 62 events reported to the FDA through 2011, including:  
wound complications (15), heterotopic bone formation (12), pseudarthrosis (10), local 
inflammation (9), osteolysis or resorption (5), compartment syndrome (2), and peripheral nerve 
injury (2).  Of the 12 reports of heterotopic ossification, 5 required surgery to remove extra bone.  
The author noted that this data could not be used to estimate incidence rates of adverse events, 
as the total number of surgical procedures using rhBMP-2 is unknown.  It was additionally noted 
that occurrence of pseudarthrosis might simply reflect the refractory nature of certain fractures, 
regardless of use of BMP-2.     
 
 
3.5.2 Use of rhBMP-2 in children: 
The INFUSE Bone graft (rhBMP-2 plus absorbable collagen sponge) is currently approved by 
the FDA as a device for use in adults for lumbar spine fusion and open tibial fractures.  The FDA 
lists skeletal immaturity (age less than 18 years) as a contraindication to its use, primarily 
because there is limited data on its safety in children.  Despite this, the device has been used 
on a physician-directed off-label or compassionate basis in increasing numbers of children, and 
data are beginning to accumulate. 
Chin et al. [2005] were among the first to report use of rhBMP-2 in children.  They used rhBMP-
2 instead of autogenous bone graft in repair of congenital facial clefts in 43 children (ages 6-14 
years).  Successful union of bone was achieved in 98% of patients, and no systemic adverse 
effects or ectopic bone formation occurred during up to two years of follow-up.  Richards et al. 
[2010] performed a retrospective review of 7 patients with congenital tibial pseudarthrosis (4 
with NF1; age ranges 1.9-11 years) treated with rhBMP-2 applied locally at time of surgery with 
intramedullary rod.  In 5/7 patients, there was good healing after one surgery, with average time 
to union of 6.4 months.  During a prolonged follow-up time of 4 – 9 years, there was no 
evidence of tumor growth or systemic effects noted from rhBMP-2 use.   

 
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Oetgen and Richards [2010] also performed a review of 81 children (ages 1-17 years; 16 with 
NF1) treated with rhBMP-2 between 2001 and 2008.  Of this group, 52 children received 
rhBMP-2 during spine surgery, and 21 during tibial repair.  One patient with NF1 subsequently 
had enlargement of a previously identified optic nerve glioma, but this was interpreted as 
unlikely to be related to rhBMP-2. There was a total complication rate of 17%, most of which 
were surgical wound inflammatory responses.  Only one complication was postulated to be 
related to rhBMP-2, and that was a case of dural fibrosis developing after direct exposure of the 
dura to rhBMP-2.  There were no reports of systemic toxicity, excessive bone growth, sarcomas, 
or other tumors.   
 
3.5.3 Use of rhBMP-2 in NF1: 
The role of the NF1 gene raises concerns that NF1 patients might respond differently to rhBMP-
2 compared to non-NF patients in terms of clinical response and risks. This potential difference 
was assessed in a mouse model, whereby BMP-2 application in long bone and calvarial cell 
culture system showed that Nf1+/- cells have a reduced osteogenic response compared to wild-
type cells [Schindeler et al., 2008c]. Even though this response (in terms of alkaline 
phosphatase expression and matrix mineralization) was greatly enhanced by BMP-2 
application, it still fell short of wild-type responses, and when 20µg BMP-2 was implanted 
intramusclularly, about half as much bone formed in Nf1+/- animals as wild-type littermates 
[Schindeler et al., 2008c]. These studies highlight that bone cell differentiation responses are 
abnormal in NF1, but also highlight that Nf1+/- osteoblasts can respond to BMP-2 stimulation. 
 
Several studies reporting use of rhBMP-2 in humans have included individuals with NF1; 
however, in general the data have not been analyzed separately comparing NF1 patients to 
those without NF.  Patients with NF1 have distinct differences in bone biology, including 
osteopenia [Stevenson et al. 2007], as well as an increased susceptibility to tumors due to 
neurofibromin’s role in regulation of the Ras pathway. Animal studies with Nf1 heterozygous 
mice showed abnormal proliferation and apoptosis of osteoblasts, and impaired matrix synthesis 
[Yu et al., 2005]. There is also evidence for increased activity of osteoclasts [Yang et al., 2006].  
These differences in bone biology, when applied to humans, may significantly impact 
response to BMP-2, and therefore study of the NF1 population as a separate group is 
crucial.   
 
3.6  Radiographic Measures of Tibial Fracture Healing (RUST; Primary Outcome 
Measure). 
 
The determination of success for surgical intervention in tibial pseudarthrosis repair (ie. tibial 
fracture union) has not been standardized. The two key outcomes studies of surgical treatment 
of TPA without rhBMP-2, by Johnston [2002] and Dobbs et al. [2004], used different measures 
of success. Johnston [2002] used weight-bearing status, use of orthotic support, presence of 
pain, level of physical activity, and radiographic presence of cortical bone defects across the 
operative site and signs of remodeling. Dobbs et al. [2004] used radiographic osseous union, 
limb-length discrepancy, range of motion of the ankle, and angular deformity at the ankle.  
 
The literature has documented significant subjectivity in interpretation of radiographic evidence 
of tibial fracture healing. Govender et al. [2002] reported that radiologists interpreted tibial 
healing on average 3 months later than did orthopedic surgeons.  Such observer variation in the 
assessment of tibial fracture healing after intramedullary fixation [Whelan et al., 2002] led 
Whelen et al., [2010] to devise a novel Radiographic Union Score for Tibial fractures (RUST) 
based on the cortical bone as viewed on AP and lateral radiographs. This assessment tool 
includes scoring of fracture line on the medial and lateral cortices on the anteroposterior 
radiograph, and anterior and posterior cortices on the lateral radiograph, and scoring of callus 
as none, visible or bridging [Whelan et al., 2010]. This study included 7 reviewers who 

 
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independently scored 45 radiographs, and overall agreement was demonstrated by an inter-
observer ICC (intra-class correlation coefficient) of ~86% with the 95% confidence interval of 
0.79-0.91 and intra-observer ICC of 0.88 with 95% confidence interval of 0.80-0.96.  The 
primary outcome measure for the proposed study is post-surgical tibial union using the 
RUST scale.  RUST scores of NF1 patients randomized to the BMP-2 group will be compared 
to those treated without BMP-2.   The same group of 4 reviewers will review all images and 
assign scores while blinded to the group assignment of the patients.  
 
 
3.7 Pilot Data:   
 
As an extension of the study by Stevenson et al. [1999], in preliminary studies we collected data 
from a multi-center natural history study of patients with tibial dysplasia and/or tibial 
pseudarthrosis (PI-Carey, Co-Investigators-Viskochil and Schorry, Shriner research grant 
#9165; 2004) in an attempt to better define the outcomes. The centers included NF clinics in the 
USA and Canada and Shrine Hospitals in North America, and included 27 patients with tibial 
dysplasia (anterolateral bowing) and 31 with tibial pseudarthrosis. Of the 31 patients with tibial 
pseudarthrosis, 24 had surgery involving the placement of a rod for fixation and tissue grafting, 
and 7 had an amputation as their initial surgical intervention. Fourteen of the 24 (58%) with 
rod/graft had a successful union without requiring a second surgery (at the time of survey). The 
range of follow-up in these 14 patients was 1 year to 16 years. The other 10 of 24 (42%) did not 
have a complete union after the first surgery (or re-fractured) and required a second surgery, 4 
of which had amputations. In this preliminary assessment, of those with pseudarthrosis, 11 of 31 
or just over 33% had amputations 
 
Direct comparison of efficacy of rhBMP-2 in the NF1 population with tibial pseudarthrosis is 
limited because of small sample sizes.  Richards et al. [2010] reported improved average time 
to initial union in a group of 7 patients with congenital pseudarthrosis of the tibia (4 with NF1) 
who were treated with intramedullary rod fixation; autogenous bone graft from the iliac crest; 
and rhBMP-2 (INFUSETM).  Five of 7 patients (71%) had radiographic union at a mean time of 
6.4 months post-operatively (range, 3.7-8.1 months).  In a recent update to this study that was 
presented at the 2013 Pediatric Orthopaedic Society of North America meeting, Richards 
reported 23 patients with CPT (16 with NF1) have now been treated using BMP-2. Radiographic 
healing was achieved in 16 of the 23 patients at an average of 9.5 months postop (7/7 idiopathic 
and 9/16 NF). Of these 16 patients who healed primarily after the addition of BMP-2, those with 
fixation across the ankle had no refractures, whereas three of six patients whose fixation did not 
cross the ankle subsequently refractured.  The overall refracture rate was 25% in these 16 
patients. Two of these four refracture patients subsequently healed, one persisted, and one had 
amputation.  Of the 7 patients who did not heal after this first operation using BMP-2, three 
healed after revision, two had persistent nonunions, and two had subsequent amputations.  
Three cases were complicated by deep infection (2 at tibia, 1 at iliac crest).  No adverse effects 
attributable to BMP-2 were encountered. This update suggests that the addition of BMP-2 in the 
NF1 tibial pseudarthrosis population improves the chance of persistent union, but does not 
result in as high a success rate as seen in patients without NF1. 
 
When compared to published data by Dobbs et al. [2004] performed without rhBMP-2 in 18 
patients, the average time to union was 16 months (range, 5-43 months), many required 
multiple surgeries and 5 of 12 (41%) of NF1 patients refractured.  Although small numbers, 
the potential benefit of rhBMP-2 as an adjunct to surgical management of NF1-related 
tibial pseudarthrosis clearly deserves further assessment.  
 
As additional pilot data for the proposed project, radiologists at Texas Scottish Rite Hospital 
used the RUST scale to retrospectively score radiographs of 12 individuals with NF1 and TPA 

 
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treated without BMP-2 [Wilkes et al, unpublished data].  A group of 4 reviewers independently 
reviewed 36 sets of radiographs (3 per patient) and assigned RUST scores for degree of tibial 
healing (see Figure 4). There were several challenges in scoring these patients, such as 
eccentric position of internal rods which may have made one cortex inevaluable.  However, they 
were able to successfully score the patients with good inter-observer and intra-observer 
reliability (kappa of 0.73 and 0.88 respectively).  The group concluded that the RUST scale is 
reliable and reproducible, and can be modified to measure outcome in tibial pseudarthrosis.  
Modifications made for using the RUST in NF1 patients included:  
 
Scoring system: 
1 = no new calcification, or rod eccentricity precludes evaluation 
2 = new calcification or callus present 
3 = smooth continuous outer cortex, even if underlying lucency 
Total score ranges from 4 to 12.   
For the purpose of this study, a RUST score of 9-12, with at least 2 evaluable cortices having a 
score of 3, will be considered to be healed.   
 
These preliminary data are crucially important as they document that the RUST scale can 
be used reliably in the NF1 population with TPA.  
 
 
Figure 4a. and 4b. RUST score examples   
 
   
 
 
 
 
 
 
 
3.8 Summary of Preliminary Data 
A number of key preliminary studies have contributed to the development of this clinical trial. 
Bone in NF1 patients and Nf1 mice is abnormal, as summarized in the proceedings of a clinical 
trial strategy meeting whereby key investigators of this proposal (Viskochil, Schorry, Little, 
Richards) significantly contributed [Elefteriou et al., 2009].  NF1-related pseudarthrosis tissue 
has been harvested from surgery and shown to have double inactivation of the NF1 gene 
[Viskochil as senior author; Stevenson et al., 2006] suggesting that biochemical properties of 
this tissue make it different from routine tibial fractures and likely more difficult to achieve 
healing. A better understanding of the natural history of tibial dysplasia and tibial pseudarthrosis 
Figure 4a.  NF1-TPA patient with 
complete union in all 4 cortices,  
RUST score of  3+3+3+3 = 12 
Figure 4b.NF1-TPA patient with partial 
bridging/ callus formation of 4 
cortices. Rust score 2+2+2+2 = 8 

 
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has been provided by a Shriners-funded study on outcomes of tibial pseudarthrosis in which 
Schorry and Viskochil were co-investigators with Dr. John Carey as PI (Shriner research grant 
#9165, 2004). These studies provide us with an estimate of eventual amputation rate of 33% in 
patients with tibial pseudarthrosis, and provide quality of life information that demonstrates the 
PODCI is an effective Quality of Life (QOL) measure that can be used to investigate outcome 
for treatment of TPA in the NF1 population. The most significant preliminary studies for the sake 
of this clinical trial are those from Dr. Richards at Scottish Rite Hospital in Texas.  His recent 
presentation of 16 NF1 patients treated with a surgical protocol including BMP-2 suggests that 
patients with NF1 have an improved outcome with addition of BMP-2, although their response is 
not as good as in the non-NF population.  Safety of BMP-2 has been documented by Oetgen 
and Richards [2010], who reviewed 81 children treated with BMP-2 between 2001 and 2008, 
and identified no systemic toxicity, excessive bone growth, sarcomas, or other tumors in 
association with rhBMP-2.  
 
 
3.9 Rationale for Clinical Trial 
Tibial pseudarthrosis is a rare childhood complication of neurofibromatosis type 1, however it 
carries significant morbidity for those affected. When fracture occurs, surgical intervention is 
required to optimize bone union; however, long-term success is achieved in only half of the 
cases who undergo surgery.  The NF Bone Consortium group, a group of basic bone biologists, 
NF mouse modelers, clinicians and orthopedists which met in 2008 and 2011, has provided 
guidance on development of the proposed clinical trial for TPA.  
 
A phase II study of BMP-2 versus control is needed to better assess the potential 
improved rate of union in the NF1 population with tibial pseudarthrosis.  Small series and 
anecdotal reports have not enabled the orthopedic community to confirm the best 
approach toward management of this complicated condition.  The implementation of a 
clinical trial to prospectively evaluate efficacy and safety of rhBMP-2 as a medical adjuvant to 
surgical intervention could potentially direct future therapy and have significant implication to 
affected patients. This trial also has the ability to serve as a foundation for additional medical 
interventions of other compounds which affect bone anabolism or catabolism in NF1. The best 
performing arm from this study (BMP-2 or Control) can be subsequently used as a future 
control arm for studies involving additional targeted therapies for NF1, such as inhibitors 
of osteoclast activity or newly developed Ras pathway inhibitors.   
 
4.0 METHODOLOGY 
 
4.1 Overview of Proposed Study 
This phase II, single-blind, randomized study will evaluate children with neurofibromatosis type 
1 (NF1) who undergo surgical management of tibial pseudarthrosis. The rationale is predicated 
on the observation that union of tibial fracture in patients with NF1 is difficult to achieve without 
extraordinary measures to optimize bone healing, and that deficits in bone formation as well as 
excessive bone resorption occur in NF1. The preliminary success in improved rate of tibial 
fracture healing when rhBMP-2 is locally applied intra-operatively, as outlined by Richards et al. 
(2010), has influenced the need for a carefully controlled clinical trial to document efficacy and 
safety of this device.  Outcomes of this trial will likely influence surgical decisions in 
management of patients with NF1 and TPA.  
 
Children with NF1 and TPA whose primary orthopedic surgeon deems surgical intervention is 
required are eligible for this trial. At time of enrollment, participants will be offered participation in 
a preference arm or randomized arm, and will be assigned to the BMP-2 or control group based 
on these choices. Surgery must take place at one of the participating consortium sites, and the 
standard surgical approach will include:  extensive resection of abnormal pseudarthrotic 

 
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material, tibial osteotomy, placement of an intramedullary rod, and autogenous bone graft from 
the iliac crest to the osteotomy tibial gap.  Those in the BMP-2 group will in addition have 
INFUSE in a collagen sponge wrapped around the tibia during the surgical process.   
 
All patients will be immobilized for a minimum of 3 months after surgery in either a spica or 
above knee cast; surgeons will use clinical discretion to determine if further casting is needed 
on an individual basis. After the cast is removed, patients will be permanently braced (24 hours 
per day) in a custom-made above- or below-the-knee orthosis. The primary outcome measure 
is radiographic evidence of union by the RUST scoring system at 12 months after 
surgery. The rate of tibial healing will be assessed by application of the RUST scoring criteria 
for radiographs obtained at 6 weeks, 3 months, 6 months, 9 months, and 12 months after 
surgery. Quality of life will be assessed by the Pediatric Outcome Data Collection Instrument, 
and walking function will be assessed by the 10 meter timed walk, performed at baseline, 6 
mos, and 12 mos.   Biologic specimens including discarded pseudarthrosis tissue and bone 
fragments from the iliac crest will be collected at the time of surgery and sent to the Texas 
Scottish Rite Hospital. 
 
The assessment of effectiveness of BMP-2 will be made by comparing the RUST union score at 
12 months after surgery between the two groups (BMP-2 and Control).    In addition, the rate of 
healing will be assessed by comparing the RUST score from radiographs at designated 
intervals in the post-operative period (6 weeks, 3 months, 6 months, and 12 months). Patients 
will continue to be followed in a registry with annual clinical assessments to determine long-term 
outcome, especially re-fracture and amputation.  
Patients entered on the trial will be carefully monitored for the development of toxicities 
associated with BMP-2.  BMP-2 and collagen antibody levels in serum will be measured 
preoperatively in all participants and results will be generated prior to enrollment for participants 
with documented prior exposure. All participants will be monitored at multiple intervals after 
surgery to test for antibody formation to the components of INFUSE.     
 
Secondary Objectives: 
Quality of life assessments for the 2 experimental groups will be obtained at baseline, and at 6 
and 12 months after surgery. Pain assessment will be made at baseline and at clinical visits at 6 
weeks, 3 mos, 6 mos, and12 mos post-op).  Functional walking outcome will be measured by 
the 10 meter walking test, performed at baseline, 6 and 12 months.   
 
Biological specimens (optional studies) will be collected and processed from those patients 
enrolled in this study who consent for their samples to be stored for future NF1 research. 
Pseudarthrosis tissue will be excised at surgery, and excess tissue not needed for pathology will 
be stored for future research study and sent to TSRHC.  A sample of the pseudarthrosis tissue 
will be sectioned for histochemical analysis while the remainder of tissue will be frozen at 
TSRHC. Excess Iliac crest bone fragments will also be frozen at TSRHC for bone 
histomorphometry. Blood, serum, urine and tissue specimens for participants will be stored at 
the Tissue Processing Facility at Texas Scottish Rite Hospital. Access to the tissue will be 
provided to the NF1 research community through committee approval of applications submitted 
by investigators whose research is supported independently from this clinical trial.  The 
Biospecimen Allocation Committee, composed of 4 members, will review and make decisions 
on all applications for use of these biospecimens.  (Details for processing of biological research 
specimens are contained in Appendix II.   
 
 
 
 
 

 
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4.2 STUDY POPULATION, SCREENING AND ENROLLMENT PROCEDURES 
The NF Clinical Trials Consortium Operations Center (UAB) will oversee recruitment, screening 
and enrollment procedures.  
 
4.2.1 Study population 
The target population for this study is limited to patients with NF1 who have tibial pseudarthrosis 
amenable to surgical intervention by intramedullary rod and autogenous bone graft. In general, 
approximately 2-5% of NF1 patients clinically present with tibial dysplasia in infancy through 
early childhood. All ethnic groups are affected equally, although more boys are affected with 
TPA than girls. The decision to surgically intervene is most often made in childhood, typically 
before age 10 years. Historically, participating members of this multi-center study have treated a 
significant portion of those afflicted with tibial pseudarthrosis. Participants will be recruited from 
the 13 NF Clinical Trials Consortium Centers (funded by DOD), with additional sites including 
the Texas Scottish Rite Hospital in Dallas, Texas.  Five Shriners’ Hospital sites in the US have 
also been added, and the Mayo Clinic site was added when the NF Consortium expanded in 
2017.  The involvement of a large group of centers (20 total sites) invested in orthopaedic care 
of NF1 patients is crucial for enrollment of patients with this relatively rare, but serious, 
complication.   
 
Table 2:   Possible participating sites and patient numbers.   
 
  A table outlining the accessible study population is shown below: 
Sites 
TPA 
Patients 
NF1  
Patients 
Surgeries/ 
4 yrs 
Cincinnati Children’s Hospital (Jain; Schorry) 
30 
1000 
6 
University of Utah (D’Astous; Viskochil) 
10 
200 
7 
University of Chicago (Sullivan; Tonsgard) 
20 
1400 
0 
Lurie Children’s, Chicago (Goldman) 
 
 
6 
Boston Children’s Hospital (Kasser, Spencer, 
Ullrich) 
14 
845 
8 
University of Alabama at Birmingham (Gilbert; 
Reddy) 
6 
300 
4 
St. Louis Childrens (Dobbs; Gutmann) 
12 
302 
16 
DC Childrens (Oetgen; Packer) 
17 
1200 
4 
Hopkins, Baltimore (Blakeley, Sponseller) 
 
 
4 
Childrens Hospital of Philadelphia (Davidson; 
Fisher) 
20 
545 
 
Indiana University (Loder; Robertson) 
16 
268 
 
Children’s Hospital Los Angeles (Arkader, 
Rosser) 
10-15 
195 
8 
New York University  (Feldman; Allen) 
3 
170 
 
 
 
 
 
Texas Scottish-Rite (Richards) 
20 
N/A 
20+ 
Mayo Clinic  
 
 
n/a 
 
 
 
 
Shriner’s Hospitals (5 sites)  
 
 
10+ 
 
 
 
 
Total 
208 
>6,000 
90+ 
Additional candidates will also be drawn from families who are members of support group 
organizations (i.e. Children’s Tumor Foundation) that routinely provide ongoing information on 
clinical trials and studies to their members.  
 

 
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Subject Accrual 
Subjects of both genders, from all racial and ethnic groups are eligible for this trial if they meet 
the criteria outlined in Section 4.3. To date, there is no information that suggests differences in 
drug metabolism or disease response among racial or ethnic groups or between the genders, 
indicating that results of the trial will be applicable to all groups. Most tibial pseudarthrosis arises 
in early childhood, with fewer cases after age 11, thus we anticipate an enrollment of younger 
children.  If differences in outcome that correlate to gender, age, racial, or ethnic identity are 
noted, accrual may be expanded or additional studies may be performed to investigate those 
differences. 
 
4.2.2 Recruitment 
The primary recruitment for this study will be through participating NF Consortium Centers and 
orthopaedic centers. This prospective clinic trial will be posted on websites and included in the 
newsletters of the NF support organizations (CTF and NF Network). Directors and coordinators 
at each of the 42 clinics affiliated with the CTF NF Clinic Network will be notified of the trial and 
eligibility.   
 
A total of between 36-52 patients will be enrolled prospectively in this trial.  The maximum 
number of patients that will be enrolled in the BMP arm is 26, based on the numbers of Infuse 
kits supplied by the sponsor. The ideal number of Control patients is also 26, but may range 
from 10-26, based on preferences of enrollees.  This is further discussed in the Study 
Modification section below, 4.2.3.  We expect that dropout rate of participants, once they have 
been enrolled and had their surgical procedure performed, should be very low, in the range of 
5%. The experience of participating surgeons is that their TPA patients who have had surgery 
are extremely likely to attend subsequent follow-up visits.   The final endpoint of the trial is at the 
one-year assessment of the last patient enrolled. Due to slow enrollment in the first year of the 
trial, we have added 5 Shriners orthopedic centers in the U.S. as participants in the trial.  
Funding has been included to help support family travel as outlined, in the Informed Consent 
forms (range of $200-$500 per patient, with the greater amount for patients living further than 50 
miles from the participating center).  Participants who live further than 50 miles from a 
participating center may have an option to  elect to have several of the  follow-up visits and 
Xrays (3 and 9 months post-op) performed by their local orthopedic surgeon, with results sent to 
the DMAC and radiographic team at TSRH. However, the surgical procedure and follow-up 
visits at 6 and 12 months must be at a participating center with either the orthopaedic surgeon 
or the NF specialist.   All centers performing any subject evaluations for the study must have 
completed the appropriate mandatory electronic training modules prior to performing any 
assessments.    
 
4.2.3 Enrollment procedures 
The NF Clinical Trials Consortium will enroll subjects in this trial. Selected subjects with NF1 
and tibial pseudarthrosis will be enrolled at the participating sites where surgery is anticipated. 
Personnel at the UAB NF Clinical Trials Consortium Operations Center will coordinate 
enrollment with the participating site, and ensure that eligibility requirements are met, prior to 
scheduling of surgery and shipment of rhBMP-2. As part of the consent process, patients and 
families will be provided information about the research aspect of this prospective clinical trial.  
 
Study Modification: Enrollment:  Patients may be enrolled on the study once all eligibility 
requirements for the study have been met. All patients/parents will discuss the study in detail 
with their surgeon, and will view a Powerpoint presentation about the study with a study 
coordinator present.  At the time of enrollment, parents/patients will be offered to choose 
either the Choice Arm or Randomized Arm of the study.  Those selecting the Choice Arm 
will be assigned to their treatment of choice (either BMP or Control).  Those who choose the 
Randomized arm will be randomly assigned at a 2:3 ratio to BMP or Control group. It is 

 
NF Protocol #107   Version 5 
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34 
expected based on prior experience that more patients are likely to prefer the BMP arm.  
Therefore, the mildly unequal randomization of 2 BMP: 3 Controls is planned to improve the 
ability to achieve adequate controls for the study.  For those in the Randomized arm, 
assignment will be accomplished by accessing a password controlled website maintained by the 
DMAC. The website is 21 CFR 11.10(d) compliant for FDA clinical trials.  
 
That website will assign a new subject to a treatment group determined by a randomization list 
produced by the study statisticians employing a permuted block design.  Randomization will be 
stratified by age (≤ 8 vs > 8 years) and prior surgery (Y/N).  Enrollment and randomized 
treatment assignment must occur before the date of surgery but should be as close to the date 
of surgery as feasible.     
 
Blinding:  For subjects in the Choice Arm, all subjects, parents, and surgeons will of necessity 
be unblinded to the patient’s treatment status of BMP versus no BMP.  For those in the 
Randomized group, all subjects, parents, radiologists, data recorders, and (non-surgeon) site 
PIs will be blinded with respect to the treatment status of each participant.  Only the surgeon 
and one study coordinator or OR tech (designated to deliver the device to the OR) at the site will 
be aware of the treatment status.  If the surgeon is also the site PI, then that site PI will be 
unblinded.  For the measurement of outcome measures, the radiology panel calculating the 
RUST score and all data recorders will be blinded to the treatment status of all participants.  
Therefore, calculation of the primary outcome measure will be blinded for all participants, 
ensuring a non-biased measure for the primary study outcome.    
 
 4.2.4 Informed Consent/Assent  
The investigational nature and objectives of the trial, the procedures and treatments involved 
and their attendant risks and discomforts, and potential alternative therapies will be carefully 
explained to the patient or the patient’s parent(s) or guardian if the patient is a child, and a 
signed informed consent and assent will be obtained according to both institutional and U.S. 
Army Medical Research and Materiel Command, Office of Research Protections, Human 
Research Protection Office (USAMRMC ORP HRPO) guidelines.  Patients between the ages of 
2 – 18 years at time of surgery will be eligible for consent. The principal investigator at the 
enrolling site will be responsible for obtaining informed consent. The study trial coordinator can 
provide information on the study and obtain consent if qualified as determined by the PI of the 
site. Most patients in this study will be less than 7 years of age. Those older than 7 will undergo 
age-appropriate assent tailored for both children aged 7-12 years, and for those aged 13-17 
years (or until the age of majority in the state of the clinical center). 
A study participant should sign the institution’s HIPAA Consent. 
A study participant should sign the institution’s Release of Medical Information Waiver. 
 
4.2.5 Rationale for Subject Selection 
Neurofibromatosis type 1 is a pan-ethnic genetic disorder with an incidence of 1 in 3,000 
people.  Subject accrual in regards to gender, and racial and ethnic groups is described in 
Section 3.6.  None of these groups are excluded from participation in the trial.  Females who are 
pregnant or breast feeding will not be eligible for entry onto the trial because of the potential 
risks that rhBMP-2 could pose to the fetus or newborn.  This trial is designed to determine the 
activity of BMP-2 in children with NF1 and surgically treated pseudarthrosis; therefore children 
will be entered onto this research trial. Almost all individuals with NF1-related congenital  
pseudarthrosis of the tibia will have their first or second surgery within the first 18 years of life. 
Individuals will be enrolled at one of the participating sites that collaborate with the NF Clinical 
Trials Consortium with additional affiliate sites at TSRHC and possibly Australia, and the United 
Kingdom.  Patients may be referred from outside centers but treatment will be directed at a 
participating consortium site. 
 

 
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4.2.6 Participation of Children  
Since tibial pseudarthrosis typically requires surgical intervention before age 10 years of age, 
children who meet eligibility criteria for this trial will be entered in the study.  Children will be 
evaluated and cared for by physicians trained in pediatrics and in the orthopedic management 
of children with NF1.  
 
4.2.7 Screening Procedures 
No diagnostic or laboratory studies performed exclusively to determine eligibility for this 
trial will be done before informed consent has been obtained. 
Diagnostic or laboratory studies to determine candidacy for surgical intervention will be 
performed by the patient’s orthopaedic surgeon on a clinical basis, prior to obtaining written 
informed consent. Once a patient’s surgeon determines the need for surgical intervention for 
tibial pseudarthrosis, the patient and his family will be offered an opportunity to enroll in the 
clinical trial and written informed consent will be obtained.  Documentation of informed consent 
will be maintained in the patient’s research chart. After consent has been obtained, pre-
operative tibial Xrays and an Eligibility Form will be sent to the DMAC and forwarded 
electronically to the group of 4 protocol co-chairs for final eligibility determination. The 
co-chairs will review eligibility data and will make a decision by phone call or email, with at least 
2 of the 4 co-chairs participating. 
   
4.3 PATIENT ELIGIBILITY/ INCLUSION AND EXCLUSION CRITERIA 
Any individual with NF1 based on either NIH-diagnostic criteria or congenital pseudarthrosis of 
the tibia plus documented mutation in the Nf1 gene is eligible for this study. Furthermore, 
decisions for surgical intervention must be made on a clinical basis with a determination that 
intramedullary rod plus autogenous bone graft is the most appropriate management approach 
for that individual patient. Patients may be enrolled only at the time of 1st or 2nd surgery for tibial 
pseudarthrosis, not subsequent surgeries.  Candidates must be able to travel to an orthopedic 
surgical site that is participating in the study. Patient insurance must approve coverage of the 
surgical procedure and short-term post-operative care at the orthopedic center performing the 
operation, or patients can use a self-pay procedure to cover the surgical and hospital costs 
associated with the surgical procedure. 
 
Inclusion Criteria for all patients: 
• 
All patients who do not have a documented NF1 mutation must meet the clinical 
diagnosis of NF1 using the NIH Consensus Conference criteria. In addition to tibial 
pseudarthrosis, one or more of the following diagnostic criteria for NF1 must be present: 
 
 
Six or more café-au-lait spots (≥0.5cm prepubertal; ≥1.5cm postpubertal) 
 
 
Freckling in the axilla or groin 
 
 
Optic pathway glioma 
 
 
Two or more iris Lisch nodules 
 
 
Two or more neurofibromas or one plexiform neurofibroma 
 
 
A first-degree relative with NF1 
• 
Patients must have tibial pseudarthrosis that has the potential to cause significant 
morbidity. Radiographic findings (AP & lateral leg radiographs) must support the 
diagnosis of tibial pseudarthrosis with chronic non-union. 
• 
Age between 2 years and 18 years of age at time of study entry. 
• 
Performance Level:  Karnofsky ≥ 50% for patients > 10 years of age and Lansky ≥ 50 for 
patients ≤ 10 years of age (Appendix III). 
• 
Prior Therapy:  
o Patients who have undergone 1 previous surgery for tibial pseudarthrosis repair 
will be eligible to enter the study if they have refracture. Use of BMP-2 in the prior 
surgery is permitted, however patients with prior exposure must be screened for 
antibodies to BMP-2, bovine collagen, and rhBMP-2 neutralizing antibodies.  

 
NF Protocol #107   Version 5 
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36 
Prior use of BMP-2 is allowed but will be recorded as a possible compounding 
factor.  
o Patients who have had 2 or more prior surgeries for pseudarthrosis repair are 
ineligible  
• 
Absence of Tumors:   
o Patients must undergo thorough physical examination of the leg undergoing 
surgery.  If physical exam is equivocal for presence of tumors, then a normal MRI 
of the lower extremity will be required before eligibility is met.   
o If there is evidence of plexiform neurofibroma or nodular neurofibroma of > 3 cm 
diameter on the ipsilateral leg, then they are ineligible for the study.   
• 
Organ Function Requirements 
Adequate bone marrow function defined as: 
Absolute neutrophil count (ANC) > 1500/µl 
Platelet count > 100,000/µl 
Hemoglobin ≥ 10.0 gm/dl  
Adequate renal function defined as: maximum serum creatinine of 1.5 mg/dL OR 
a creatinine clearance≥70ml/min/1.73m2. 
Adequate liver function defined as: 
 
Total bilirubin < 1.5 X upper limit of normal for age, and 
 
SGPT (ALT) < 2 X upper limit of normal for age 
Serum Vitamin D level ≥ 10 ng/ml  
 
Exclusion Criteria: 
• 
Lack of documentation for a diagnosis of NF1 
• 
Tibial fracture without evidence of pseudarthrosis or tibial dysplasia 
• 
Tibial dysplasia/bowing without fracture or pseudarthrosis 
• 
Plexiform neurofibroma of any size, or nodular neurofibroma of  > 3 cm diameter 
involving the ipsilateral leg, including the hip 
If presence of plexiform is suspected but not certain on physical exam, MRI of the leg 
may be indicated to rule this out.   
• 
History of MPNST (malignant peripheral nerve sheath tumor) or any malignancy other 
than asymptomatic and stable optic nerve glioma 
• 
Optic nerve glioma that has resulted in precocious puberty or visual impairment of any 
degree 
• 
Visual impairment from any cause 
• 
Precocious puberty from any cause 
• 
Hypertension other than mild essential hypertension controlled with medication 
• 
Metastatic disease of any kind  
• 
Inadequate neurovascular status in the involved limb that may jeopardize healing 
• 
Active or known prior infection at the pseudarthrosis site 
• 
Active systemic infection 
• 
Other injury or condition that prevents ambulation or completion of study assessments 
• 
Two or more prior surgeries for tibial pseudarthrosis 
• 
Bilateral tibial dysplasia 
• 
Selection of a surgical approach that does not include prescribed surgical intervention, 
which must include removal of pseudarthrosis tissue, placement of an intramedullary rod 
using the Williams approach, and autogenous bone graft from the iliac crest distributed 
at the osteotomy site 
• 
Normal ipsilateral fibula without planned fibular osteotomy at time of surgery 
• 
Allergy to bone morphogenetic protein 
• 
Allergy to bovine collagen products 

 
NF Protocol #107   Version 5 
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• 
Positive antibody titers to BMP-2, bovine collagen, or BMP-2 neutralizing antibodies prior 
to surgery 
• 
History of using any of the following medications, regardless of dose, for at least 1 
month, within 3 months of enrollment: Anabolic agents, Glucocorticoids (does not 
include inhaled glucocorticoids), Growth hormone, Parathyroid hormone (PTH) 
• 
Need for postoperative medications that could interfere with bone healing of the implant, 
such as steroids, (but not including low-dose aspirin or routine perioperative anti-
inflammatory drugs) 
• 
Untreated endocrine abnormality, such as hypothyroidism, parathyroid hormone disorder 
• 
Severe Vitamin D deficiency with serum 25-OH Vitamin D < 10 ng/ml (25 nmol/l) 
Patients with Vitamin D levels < 10 ng/ml may be treated with Vitamin D and 
reconsidered for enrollment when levels are sufficient 
• 
Females who are sexually active without use of effective contraception 
• 
Females who are pregnant or breastfeeding 
 
4.3.1 VITAMIN D SUPPLEMENTATION 
It is recommended that all patients be sufficient for Vitamin D (25-OH Vitamin D) throughout the 
trial, as standard of care.  Those with severe Vitamin D deficiency (< 10 ng/ml or 25 nmol/L) are 
excluded from the trial, although they can be re-screened after treatment with vitamin D.  For all 
other patients, the following Vitamin D supplementation is recommended: 
• 
Vit D insufficient (11-30 ng/ml) treat with 1,000 IU Vit D daily 
• 
Vit D sufficient (31-60 ng/ml) treat with 400 IU Vit D daily  
• 
Vit D level > 60 ng/ml, no need for additional supplementation 
• 
Physicians will have the option to use differing doses of Vitamin D if they deem to be 
clinically indicated.   
 
4.4 ADMINISTRATIVE ROLE OF OPERATIONS CENTER (UAB) 
The Operations Center for the NF Clinical Trials Consortium, funded by the DOD, will provide 
administrative support for this clinical trial. In addition to what is described throughout this 
protocol, it will organize and oversee the clinical trial initiation meeting wherein all aspects of the 
protocol will be finalized and standard operating procedures fully elucidated. The Operations 
Center will continue to organize annual face-to-face meetings, and administer all 
teleconferences. There will be a minimum of one teleconference call per month, and the co-PIs 
on this protocol will also join the executive committee monthly teleconference call for the NF 
Clinical Trials Consortium. Data-sharing between sites will be overseen by the DMAC, and 
approvals for human subjects research will be orchestrated between the institutional review 
boards from the University of Alabama at Birmingham and the Department of Defense prior to 
distributing to all other participating sites for approval at their respective institutions.  
 
Each participating institution is required to maintain a current MPA or FWA in order to 
participate in government-sponsored Group research.  The files will be copied or made available 
for review by authorized persons as required for conduct of this trial. 
 
Continuing Reviews, Amendments and Consents 
The PI from each participating institution will provide the NF Consortium Operations Center with 
a copy of IRB approval of all amendments to the protocol or consent. The NF Consortium 
Operations Center will provide these institutional reviews to the USAMRMC ORP HRPO.  As 
this trial receives funding by the US Army, approval of all protocol amendments will be obtained 
from the USAMRMC ORP HRPO in addition to the institutional IRB prior to implementation.   
 
4.5 Data Collection and Data Handling 
The trial is being conducted by the NF Clinical Trials Consortium.  Electronic Case Report 
Forms (eCRFs) developed by the NF Consortium Operations Center will be used for submitting 

 
NF Protocol #107   Version 5 
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38 
clinical data to the DMAC.  Data must be submitted to the DMAC within two weeks of 
completing each required evaluation while the patient is on study.  
 
The Radiology Review Panel (RRP), comprised of a group of 4 physicians (3 radiologists and 
1 orthopaedic surgeon) from Scottish Rite Hospital in Dallas will independently review all 
radiographs using the RUST scoring system. The RRP will receive radiographic studies with 
clinical trial study identifiers on a CD, which will then be uploaded with only study identifiers onto 
the reading system that allows each member to score the radiographs, blinded to other panel 
member’s scores. After individual scoring is completed, the panel will meet as a group and 
assign a consensus score to each radiograph.  The score sheets will be entered into a database 
interface created by the data management center.  
 
The Biospecimen Allocation Committee (BAC) will oversee the review of applications for use 
of biological specimens. Once decisions have been made by the BAC to approve access to 
samples, the TSRH Tissue Processing Facility will distribute to the investigator using standard 
operating procedures. The BAC will be comprised of participants of the rhBMP-2 tibial 
pseudarthrosis clinical trial, one representative from TSRHC, members of the steering 
committee of the NF Clinical Trials Consortium, operating independently of the Operations 
Center, and other members from outside the Consortium, as deemed appropriate. 
Guidelines for the BAC review process will be finalized prior to enrollment of patients for the 
study. 
 
Representatives from the FDA, and the U.S. Army Medical Research and Materiel Command 
will have access to the data and research records.  
 
 
Role of Data Management 
Instructions concerning the recording of study data on CRFs will be provided by the Data 
Management Center (DMAC) of the NF Operations Center. It is the responsibility of the DMAC 
to assure the quality of data for their study.  This role extends from protocol development to 
generation of the final study database. 
 
The DMAC has extensive experience in data management, currently managing 18 
national/international collaborative trials/studies. For the purpose of the proposed trial, they will 
be using an existing electronic Data Entry System (eDES) that serves as a shared platform that 
seamlessly supports the data management needs across the spectrum of these projects.  This 
system has a common administrative site and a consistent platform that reduces the enormous 
effort required to initiate, manage, maintain and validate multiple individual applications used, 
particularly those involved with FDA oversight, where extra requirements apply. The electronic 
Data Entry Management Systems (eDEMS) and methodologies employed for the other NF 
studies will be built on the existing highly successful MITS Suite.   
 
The MITS Suite consists of the MITS Studio (electronic Data Entry Management System [eDES] 
Authoring Tool) and the Testing Framework.  The architecture is designed to efficiently 
accommodate trial organizations, that have multiple projects operating across a common set of 
clinics. The MITS Studio provides a structured design environment that ensures repeatable 
results across trials by utilizing a common set of vetted software components. Our systems are 
designed to adhere to FDA 21 CFR Part 11 guidelines in developing the authoring and testing 
framework components and are compliant with the evolving FDA CDISK standards.  
 
All centers participating in subject evaluation for this trial will complete mandatory electronic 
training modules developed by the DMAC prior to performing any of the study assessments to 
ensure compliance with 21 CRF11.10(i).    

 
NF Protocol #107   Version 5 
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39 
 
Data and Center Audits 
The trial will be audited by the NF Consortium Operations Center for compliance and safety. 
Independent monitors will visit participating sites and review case report forms and source 
documentation. Missing or spurious information and protocol deviations will be communicated in 
a report to the clinical site and trial coordinating center.  Protocol deviations, which may result in 
compromise to safely administer medical device, or to determine study endpoints will be 
reported promptly to the USAMRMC ORP HRPO.   
 
All unexpected and serious adverse events will be forwarded to the Medical Monitor, the Study 
PI and the USAMRMC ORP HRPO by the NF Clinical Trials Consortium Operations Center.  
 
5.0 TREATMENT PROGRAM 
 
5.1 Agent Information:  Bone Morphogenetic Protein -2 
rhBMP-2 is the active agent of the INFUSE® device, which consists of two parts: 
a recombinant human protein (rhBMP-2) to stimulate bone healing, and 
an absorbable collagen sponge (ACS) made from cow (bovine) collagen that is soaked with the 
protein. rhBMP-2 is the active agent in INFUSE®. It is a disulfide-linked dimeric protein 
molecule with 2 major subunit species of 114 and 131 amino acids. Each subunit is glycosylated 
at one site with high-mannose-type glycans.  rhBMP-2 is produced by a genetically engineered 
Chinese hamster ovary cell line.  The INFUSE® Bone Graft device is designed to be used along 
with internal stabilization with an intramedullary rod or nail to help heal fractures of the lower leg 
bone (tibia).   
Further details are in Sections 2.1 and 2.2 
 
5.2 Surgical Protocol for Treatment of Tibial Pseudarthrosis 
The surgical protocol to be used is outlined in Richards et al. [2010] and includes tibial 
osteotomy with resection of the pseudarthrosis tissue, followed by placement of an 
intramedullary rod which provides rigid fixation. The exact type of rod used will vary based on 
availability in different centers and different countries, but will be a rigid rod similar in size and 
configuration to a Williams or Rush type rod. In no cases will the intramedullary canal be 
reamed.  Fixation of the ankle will be at the discretion of the surgeon regardless of the patient’s 
age.   Bone grafting will be performed with autogenous bone from iliac crest placed into the 
excised pseudarthrosis site.  As per instructions provided by the provider of the INFUSE® kit 
device (Medtronic), rhBMP-2 will be applied to an absorbable collagen sponge.  The sponge is 
applied as an onlay, bridging the area of pseudarthrosis.  The application of the collagen 
sponge saturated with rhBMP-2 is shown below. 
 
 
Figure 5:  Application of INFUSE at surgery.    
 
 
 
 

 
NF Protocol #107   Version 5 
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40 
FIG 1A.  
 
 
 
 
 
FIG 1B.  
 
The BMP-2 soaked collagen sponge is placed around bone junction at the tibial osteotomy site. 
After autogenous bone graft has been placed in the tibial osteotomy site, the collagen sponge is 
wrapped around both the tibia and the bone graft. 
 
The dosing of rhBMP-2 is restricted to the size of absorbable collagen sponge used in the 
surgical field. The concentration of rhBMP-2 in the sponge is standardized to 1.5  mg/cc sterile 
water on the sponge. For the purposes of this trial, the size of INFUSE bone graft used will be 
adjusted for weight. Patients less than 30 kilogram weight will receive a small INFUSE package 
(4.2mg of rhBMP-2 on 2 collagen sponges, with concentration of 1.5 mg/cc); those greater than 
or equal to 30kg weight will receive a medium INFUSE package (8.4 mg BMP-2 and 4 collagen 
sponges, with concentration of 1.5 mg/cc). Higher doses were avoided due to the concern that 
higher doses of rhBMP-2 can induce osteoclasts that initiate bone resorption, and to decrease 
theoretical risk of carcinogenicity possibly seen with very high doses of BMP-2. 
 
In addition to surgical management of the tibia, the ipsilateral fibula will be assessed 
radiologically and decisions for surgical intervention will be incorporated into the operative 
strategy to stabilize the tibia. In cases where the fibula is intact, the fibula will undergo 
osteotomy with intramedullary fixation in order to shorten the fibula and prevent distraction by 
the intact fibula. In cases where the fibula was severely resorbed (“sucked candy” configuration 
on Xray), an osteotomy is not necessary and intramedullary fibular fixation is impossible to 
perform. 
 
Patients will be immobilized with above-the-knee cast or spica cast for a minimum of 3 months 
post-operatively.  Managing surgeons can decide on an individual basis whether a patient 
requires casting for longer than 3 months.  After the cast is removed, patients will be 
permanently braced (24 hours per day) in a custom-made orthosis, either above-the-knee or 
below-the-knee, at the discretion of the surgeon.  Radiographs of the lower leg and ankle will be 
performed at 6 weeks, 3, 6, 9, and 12 months after surgery at times corresponding to follow-up 
evaluations and cast changes.    
 
Summary of Surgical Protocol: 
• 
Tibial osteotomy 
• 
Resection of pseudarthrosis tissue 
• 
Fibular osteotomy if intact fibula 
• 
Placement of intramedullary rod providing rigid fixation 
o Williams, Rush, or other type 
• 
Ankle fixation at discretion of the surgeon 
• 
Placement of  iliac crest autograft at the surgical site 
• 
If randomized to BMP-2 treatment group: 
o Reconstitution of BMP-2 in sterile water as per package instructions (at least 15 
min before application) and applied to the collagen sponge(s). 
o A small INFUSE package (4.2 mg total BMP-2 and 2 sponges with concentration 
of 1.5 mg/ml) will be used for patients weighing  < 30 kg 
o A Medium INFUSE package (8.4 mg total BMP-2 and 4 sponges, with 
concentration of 1.5 mg/ml) will be used for patients weighing ≥ 30 kg.  INFUSE 
bone graft sponge is wrapped around the tibial osteotomy site and autograft. 
• 
Incision is closed 
• 
Above-the-knee or spica cast x minimum of 3 months 
 
 
Rehabilitation Protocol 

 
NF Protocol #107   Version 5 
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41 
• 
All patients will be in an above-the-knee or spica cast for a minimum of 3 months 
• 
Recommend no weight-bearing on affected leg for 3 months post-op 
• 
Further cast immobilization may be used if the surgeon interprets the radiographs as 
having too little callus formation at the tibial pseudarthrosis site 
o Cast time may be extended in 4-6 week intervals, followed by radiographic re-
evaluation until satisfactory healing has been achieved.  
o If casting is required beyond 3 months, it may be below-the-knee instead of 
above-the-knee.    
• 
Braced (above or below knee) with partial weight-bearing beginning at 3 months 
• 
Knee mobilization exercises beginning at 3 months (or after removal of cast if later than 
3 months). 
• 
Full weight-bearing (braced)  based on X-ray appearance (RUST score of 9 or greater) 
• 
No sports participation until 1 year post-operative and with brace in situ.  
• 
Individual questions about rehabilitation protocol may be addressed to the two study 
surgeons (Drs. Richards and Little).    
 
 
5.3 Protocol to Radiographically Score Tibial Healing (RUST score, Primary Outcome 
Measure; Specific Aim 1) 
 
The assessment of tibial healing in patients with tibial pseudarthrosis will be based on 
radiographic evidence of union by determination of cortical continuity on Xray and scoring by a 
novel system called the Radiographic Union Score for Tibial fractures (RUST) score [Whelan et 
al., 2010]. This validated method assigns a score to a set of anteroposterior (AP) and lateral 
(Lat) radiographs based on healing at each of the 4 cortices. The lateral and medial cortices are 
denoted on the AP radiograph and the anterior and posterior cortices on the lateral radiograph.  
A score of 1-3 is assigned based on the persistence of the fracture line and the presence or 
absence of callus formation. If all 4 cortices are evaluable then scores range from 4 (non-union 
all bone columns) to 12 (complete union of all 4 bone columns). As this method was validated in 
fractured normal tibias, any lucency was considered residual fracture. However, in these 
patients there is known underlying dysplasia affecting the appearance of the bone underlying 
the osteotomy; therefore an intact peripheral cortex with residual intramedullary dysplasia will be 
considered healed.  A cortex that is not visualized due to eccentric overlying hardware will be 
given a value of 1. 
Scoring system: 
1 = no new calcification, or rod eccentricity precludes evaluation 
2 = new calcification or callus present 
3 = smooth continuous outer cortex, even if underlying lucency 
 
Total score ranges from 4 to 12.   
 
For the purpose of this study, a RUST score of 9-12, with at least 2 evaluable cortices 
having a score of 3, will be considered to be healed, and a successful outcome.   
 
Figure 6:  RUST scoring  
 

 
NF Protocol #107   Version 5 
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42 
 
 
Implementation of the RUST scoring method as the sole criterion for tibial fracture healing will 
enable the same radiology review panel (RRP) of 4 individuals to score both prospective cases 
and historic controls. The total RUST point score range is 4 to 12. Additionally, information on 
functional status will be collected before surgery, and at each subsequent evaluation after 
surgery, as outlined in Johnston [2002] and Richards et al., [2010]. This includes status of the 
ability to walk with weight-bearing, use of orthotic support, presence of pain, point tenderness at 
the site, level of physical activity, additional surgery of the ipsilateral leg in addition to 
radiographic evidence of union, knee and ankle motion, foot position, leg-length discrepancy, 
and overall clinician satisfaction. 
 
5.4 QUALITY OF LIFE ASSESSMENTS  
 
 
Pediatric Outcome Data Collection Instrument (PODCI) 
An important outcome measure of clinical trials in treatment of tibial pseudarthrosis is quality of 
life. Many individuals with TPA undergo multiple surgical interventions with long rehabilitation 
times, precluding their participation in school and recreational activities. In preliminary studies 
performed by collaborators Viskochil and Schorry, an outcomes trial led by John Carey 
(Shriners Research Grant #9165; Multi-Center Study of Outcome of Tibial Dysplasia in NF1 
Patients) used the pediatric outcome data collection instrument (PODCI) to evaluate the quality 
of life of individuals with NF1, with and without tibial dysplasia. The PODCI consists of five 
domains, with a number of items in each domain [Daltroy et al, 1998; Vitale et al, 2001]. Twenty-
three individuals with NF1 with tibial dysplasia were compared to 63 NF1 individuals without 
tibial dysplasia. Notably, the Basic Mobility normative scores, the Sports and Physical Function 
scores, and Global Functioning were significantly decreased (p<0.001) in NF1 with tibial 
dysplasia with the mean score for cases about one-third of controls [Stevenson and Carey, 
2009]. The PODCI has also been reviewed by the REINS committee (Response Evaluation in 
Neurofibromatosis and Schwannomatosis), and found to be an appropriate outcome measure 
for this population. These data demonstrate that the PODCI is an effective QOL measure 
that can be used to investigate outcome for treatment of TPA in the NF1 population, and 
can accompany more traditional clinical measures such as union, range of motion, leg length 
discrepancy, and limitation of walking distance. Other measures of quality of life have been 
implemented for the NF1 population [Krab et al., 2009] and the orthopedic community [Vitale et 
al., 2001; Furlong et al., 2005]; however, these measures have not been applied to the pediatric 
NF1 population with orthopedic issues. 
 
• 
Quality of Life will be assessed using the Pediatric Outcome Data Collection Instrument 
(PODCI) questionnaire The PODCI is a comprehensive orthopedic-specific instrument 
(Pencharz et al., 2001) comprised of over 100 questions and takes 15-20 minutes to 
Figure showing partial bridging and 
callus formation of all 4 cortices. 
RUST score = 2+2+2+2 = 8 

 
NF Protocol #107   Version 5 
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43 
complete.  Quality of Life Questionnaires are to be completed by patient and parents as 
follows at baseline, at 6 months, and at 12 months. 
• 
PODCI Pediatrics-parent/child:  baseline and follow-up (completed by the parent for all 
children 2-10 years old). 
• 
PODCI Pediatrics-parent/adolescent:  baseline and follow-up (completed by the parent 
for all adolescents 11-18 years old). 
• 
PODCI Pediatrics-adolescent baseline and follow-up (completed by patient between 11 
and 18 years old) 
• 
In addition to the PODCI, pain intensity will be assessed using the Faces Pain Scale-
Revised (FPS-R) for patients aged 4 years and older, at baseline and at 6 weeks, 3 mos, 
6 mos, and 12 mos after surgery.  This is a self-report pain scale which has been 
validated for use in research, in patients as young as 4 years.  Children chose one of 6 
faces as indicating their current pain.  There are no validated self-report pain scales for 
children between 2 and 4 years.  Additional pain measures, including pain interference, 
are included in the PODCI for all ages participating in the study.   
 
5.5 FUNCTIONAL ASSESSMENT:  Ten Meter Timed Walk 
The timed 10 meter walk test is a functional outcome measure that has been used extensively 
in the fields of rehabilitation medicine, neurology, and orthopaedics.  In this well-validated, easily 
administered test, a 10 meter (32.8 feet) hallway is measured and marked, with starting line and 
end line.  The patient is given instructions either to walk the distance at his/her normal, 
comfortable speed, or as quickly as safely possible.  The walk is timed using a standard 
stopwatch, and results are recorded in seconds.  The patient performs the test 3 times, and the 
mean value of the 3 trials is used as the result.  Results from this test will be compared for 
individuals at baseline, 6 mos after surgery, and 12 mos after surgery, and will be used as a 
secondary outcome measure. The timed 10 meter walk is easy to perform in a clinic setting 
without special equipment such as a gait analysis lab. The test has been used extensively in 
studies of muscular dystrophy, spinal cord injury and cerebral palsy, and has been validated 
from ages 4 ears through adults [Pirpis et al, 2003]. It has also been used as an outcome 
measure in a Phase 3 clinical trial for multiple sclerosis [Cohen et al., 2001]. A 20% change in 
walking speed is considered to be significant.  The test can be performed while a patient is in a 
brace or other adaptive device.   This test and other functional outcome measures have recently 
been reviewed extensively by the REINS committee, and based on its reliability and ease of use 
was recommended as a secondary outcome measure for NF trials assessing ambulation.  
 
The 10 meter Timed Walking Test will be performed before surgery, and at 6 months and 12 
months post surgery.  The test can be performed with the leg braced, and any bracing or other 
assistive device will be recorded at each time point.  The test will be performed 3 times, and the 
mean of the 3 times (in seconds) will be recorded as the final score at each visit.  
  
Data will be entered into eDES at the clinical sites and sent electronically to the DMAC for 
subsequent analysis. 
 
5.6 Protocol to Collect, Process, and Store Biologic Specimens (Specific Aim 3) 
Numerous biologic specimens will be collected for future NF1 studies funded independently and 
performed by investigators who are formally approved to access the specimens from the Tissue 
Storage Facility at the Texas Scottish Rite Hospital, Dallas, TX. The purpose of this collection is 
to preserve tissue for appropriate biologic screening, when techniques and funding become 
available. The patient or patient’s parents must initial the informed consent document indicating 
that tissue can be collected for this processing. Depending on level of consent for use of tissue 
and/or DNA specimens, samples will be coded with the patient’s study trial registration number 
prior to shipment.  
 

 
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Any consortium member (including TSRH members) can request access to the specimens for 
research purposes by contacting the Operations Center of the Consortium with a valid proposal 
for their use. The Biospecimens Allocation Committee (BAC) will make decisions regarding 
future use of tissues.  Researchers will be encouraged to request outside funding for further 
study of these biologic specimens, such as through a CTF research award. 
   
5.7 RISK/ BENEFIT ANALYSIS  
 
Evaluation of benefits and risks/discomforts  
The potential benefit from participation in this trial is improved union of surgically treated tibial 
pseudarthrosis, faster time to union, and improved quality of life. There are risks for surgery that 
exist regardless of enrollment on the clinical trial. The primary risks to the subjects from 
participation in this clinical trial are complications related to BMP-2. Toxicities and anticipated 
adverse events are outlined in Sections 2.1 and 2.2.  Patients enrolled on this trial will be 
carefully monitored for the development of toxicities, including development of antibodies to 
BMP-2, and a toxicity stopping rule is in place to prevent additional patients from exposure to 
BMP-2. Clinical report forms, radiographic studies, and biologic specimens for future research 
studies, will have identifiers that can be traced to the patient only by contacting the NF Clinical 
Trials Consortium Operations Center. However, as the samples are linked to the patient’s name, 
a small risk persists that unauthorized persons could gain access to information. Some testing 
may eventually reveal information that could result in discrimination with health or life insurance 
or employment.  We believe that these risks are minimal since it is already known that patients 
enrolled on the study have NF1.  All research results will be kept confidential.  
Patients also have the right to withdraw the blood specimens obtained for research purposes at 
any time.  
 
Potential benefits to all participants of this trial include:  1) receiving their surgery from an 
experienced surgeon with expressed interest in neurofibromatosis; 2) screening and treatment 
for factors such as low Vitamin D levels which may affect bone healing; 3) use of a standardized 
protocol for intramedullary rod and iliac crest bone graft; and 4) use of a standardized 
rehabilitation protocol.  In addition, all participants will have Xray assessment of bone healing by 
a group of radiologists experienced in NF1 bone disease, using the RUST score, which may 
reflect a more accurate measure of bone healing than local radiographic reading.   
 
Risk/benefit analysis 
The primary objective of this phase II trial is to determine integrity of tibial union at 12 months 
after surgery for NF1-related tibial pseudarthrosis. Thus, patients entered on the trial will be 
treated with therapeutic intent and response to the therapy will be closely monitored. Therefore, 
this protocol involves greater than minimal risk to children, but presents the potential for direct 
benefit to individual subjects. The potential benefit of this treatment with BMP-2 is that it may 
improve healing of tibial pseudarthrosis.  In addition, treatment may lessen the symptoms, such 
as pain, that are caused by the pseudarthrosis. The radiographic union scoring (RUST) used as 
the outcome measure will provide more precise assessment of union, and therefore will give 
more complete and objective information on which to base any possible future treatment 
decisions.  Radiographic assessment by the RUST criteria is currently not available on a routine 
clinical basis. 
 
Potential Risks: 
a. Device dropped or deemed unsterile 
Mitigation strategy:  For centers that do not have a backup clinical supply, an additional 
sterile package provided by Medtronic to prevent procedure termination. 
 
b. Pain at surgical site 

 
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Discussion:  Post-operative pain is expected in both control and experimental groups. 
Mitigation strategy:  standard post-operative pain control with close monitoring of 
patient’s pain. This risk is included on the patient consent form.  
 
c. Inflammation or tissue swelling at surgical site 
Discussion:  Some studies suggest increase rate of inflammation at surgical site with use 
of BMP-2.   
Mitigation strategy:  Anti-inflammatory medications as needed post-operatively, close 
monitoring. Monitoring for fever or signs of infection.  This risk is included on the patient 
consent form. 
 
d. Infection at surgical site 
 
Discussion:  This is a risk with any surgical procedure 
Mitigation strategy:  Monitor clinically for infection in post-op period.  Treat with 
antibiotics if clinically indicated.  This risk is included on the patient consent form. 
 
e. Allergic/ antibody response 
Discussion:  Studies in adults show very low rate of antibody formation to BMP-2, and no 
clinical allergic reactions.  However, antibody formation has not yet been tested in a 
pediatric population. 
Mitigation strategy:  Information about management of antibody testing will be included 
as part of investigator training.  Participants with prior exposure will have expedited 
antibody testing pre-operatively as part of eligibility screening.  All participants (control 
and experimental) will be tested for antibodies to BMP-2 and bovine collagen before and 
at multiple intervals after surgery.  Those that test positive to rhBMP-2 will have 
additional bloodwork drawn to check for neutralizing antibodies.   Any clinically evident 
allergic response will be treated if clinically indicated with anti-histamines or other 
medications.  Patients continuing to be antibody positive at the 12 month endpoint of the 
study will continue to have antibody levels checked on a yearly basis thereafter.   
 
f. Failure of bone healing/ persistent pseudarthrosis 
Discussion:  This is a risk for both the control and experimental groups.  The expectation 
(and purpose of this study) is that the BMP-2 group will have a better healing rate/ lower 
incidence of non-union post-surgery. This risk is included on the patient consent form. 
Mitigation strategy:  All patients will be followed closely by their participating orthopedic 
surgeons post-operatively, with Xrays obtained a minimum of every 3 mos to document 
healing of tibia.  Patients with clear non-union after 12 months may be offered a second 
surgical procedure (outside of the research protocol), if clinically indicated.   
 
g. Theoretic increased risk of malignancy 
Discussion: BMP-2 is a potent osteogenic agent, and there is theoretical concern that it 
may increase risk of malignancy in a pediatric population or an NF1 population known to 
have an increased risk of tumors.   In actuality, BMP-2 has been used successfully in 
over 81 reported children without occurrence of malignancy, and in over 30 pediatric 
NF1 patients. It has been well documented that BMP-2 is very rapidly cleared from the 
serum, and its effect is expected to be limited to the surgical site.   The severity of 
continued pseudarthrosis and possible amputation justifies this small theoretic risk in our 
opinion. This risk is included in the patient consent form.  Further details are in section 
3.5, pages 23-25.   
Mitigation strategy:   Patients will be excluded from the study if they have a known 
malignancy, or plexiform neurofibroma of 3 cm diameter or larger on the surgical leg, to 
decrease risk of malignant transformation.  Patients will be monitored throughout the 
study for any new tumor growths. 

 
NF Protocol #107   Version 5 
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h. Theoretical increased risk of teratogenicity 
Discussion:  There is no information available about risk of exposure of pregnant women 
to BMP-2; however as a potent growth agent it could have potential to cause fetal harm. 
Mitigation strategy: Young women of childbearing age must have a urine pregnancy test 
performed within 7 days before surgery and again at the 6 week post-op visit.  Patients 
who are pregnant or who are sexually active without use of effective contraception are 
excluded from the study.   
 
i. 
Ectopic bone formation. 
Discussion:  There have been several reports of heterotopic ossification in patients 
treated with INFUSE, although the frequency of this complication is not known.   
Mitigation strategy: the INFUSE device will be placed only at the area of the tibial 
pseudarthrosis repair.   Xrays obtained at standard intervals during the study will be 
monitored for signs of ectopic calcification.  If asymptomatic, no intervention may be 
necessary.  If causing symptoms or functional impairment, surgery may be performed to 
remove the ectopic bone.   
 
j. 
Excessive bone resorption.   
Discussion:  In rare cases, excessive bone resorption has been noted when using high 
doses of BMP2, due to a potential stimulation of osteoclastic activity. 
Mitigation strategy:  the dosage of BMP-2 chosen for the study was selected in a range 
in which excessive bone resorption has not been reported in pediatric patients.  In 
addition, patients are required to have adequate Vitamin D levels prior to surgery, which 
may help counteract bone loss. If excessive bone resorption of the affected tibia does 
occur, the patient may require prolonged bracing, or may require an additional surgery, 
to be determined by the attending surgeon.   
 
k. Death. 
Discussion:  Although quite rare in this population, death is a possibility with any surgical 
procedure.  All patients will have their surgery and post-operative care at a hospital with 
extensive experience in caring for medical and surgical pediatric patients.  ICU care is 
available in the case of serious complications.   
 
5.8 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
Pre and on-study evaluations are described in table format in Appendix I. 
 
 
Required Clinical, Laboratory and Disease Evaluation 
 
All entry/eligibility studies must be performed within 2 weeks prior to entry onto the trial (unless 
otherwise specified).  
 
 
History, physical examination and vital signs 
Physical examination will be performed prior to surgery, 6 weeks (+/- 2 week) after surgery, 12 
weeks (+/- 2 weeks), 6 months (+/- 4 weeks), 9 months (+/- 4 weeks), and 12 months (+/- 4 
weeks). This exam includes total body examination (general appearance, skin, neck, including 
thyroid, eyes, ears, nose, throat, lungs, heart, abdomen, back, lymph nodes, extremities and 
basic nervous system). The affected extremity must be palpated (when no longer casted) for 
evidence of point tenderness or growth of tumors or masses.  Significant findings made after the 
use of INFUSE, which meet the definition of an Adverse Event must be recorded.  
Vital sign assessment consists of height, weight, head circumference, pulse, blood pressure, 
temperature and weight.  
 

 
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Clinical information to be documented includes a description of any bracing device, ability to 
bear weight on the affected leg while walking, leg-length discrepancy, leg asymmetry, knee and 
ankle range of motion, foot position, tenderness at the site, pain, documentation of intervening 
surgeries subsequent to the initial surgery, and overall satisfaction of the surgeon regarding 
outcomes. 
 
For the purposes of the study, end of study will be 12 months; however, additional data will be 
collected on an annual basis through a registry maintained by Texas Scottish Rite Hospital for 
Children.  
 
 
Hematology 
Hematology labs will include hemoglobin, hematocrit, platelets, total white blood cell count 
(WBC) and differential.  CBC, differential and platelets must be obtained within two weeks prior 
to surgery, and again at 3 months and 12 months after surgery. 
 
 
Blood chemistry 
Blood chemistry must include sodium, potassium, chloride, bicarbonate, calcium, phosphorous, 
glucose, creatinine, blood urea nitrogen, albumin, total protein, SGOT (AST), SGPT (ALT), 
GGT, uric acid, and alkaline phosphatase. The initial serum studies prior to surgery include 
calcium, phosphorus, magnesium, and Vitamin D (25-OH Vit D). Enrollment cannot proceed if 
any of the serum levels indicate that treatment for abnormal levels needs to be initiated. Blood 
chemistries should be drawn within two weeks prior to study entry, and at 3 months and 12 
months post-surgery. 
 
 
Urinalysis routine 
Standard urinalysis dipstick assessment (pH, protein, glucose, blood, ketones, and leukocytes) 
should be performed at the beginning of study, 3 months, and 12 months.  
 
Urinalysis/Pregnancy 
Standard pregnancy tests will be given to all females of childbearing age within 7 days prior to 
surgery to ensure that females are not pregnant at the time they are treated with BMP-2.  This 
will be repeated at 6 weeks after surgery for females of childbearing age.   
 
Antibody Studies 
For safety purposes, all subjects will be assayed for antibodies to bovine type I collagen and 
rhBMP-2. Testing will be performed by Intertek Pharmaceutical Services, San Diego, CA, using 
a validated enzyme linked immunosorbent assay (ELISA).  Intertek Pharmaceutical laboratory 
previously validated the BMP-2 assay for FDA approval of the INFUSE device in adult patients.  
The following methods were used for validation:  
 
Samples are incubated with rhBMP-2 or bovine Type I collagen, which has been immobilized on 
an ELISA plate, to allow any rhBMP-2 (or bovine collagen I) specific immunoglobulins to bind.  
After incubation, the plates are washed and the bound antibody is detected using assay-specific 
peroxidase conjugated detection antibody which produced a color end-product when the 
substrate was added. 
 
A normal human serum pool and an antibody positive serum which recognizes and binds to 
rhBMP-2 (or bovine I collagen) are included on each plate as negative and positive controls, 
respectively, to monitor assay performance.  The optical density (OD) values of the samples 
were compared to the cutpoint OD of the plate to determine if antibodies specific for rhBMP-2 or 
bovine I collagen were present or absent.  The cutpoint OD was defined as two times the mean 
of the negative control OD.  Samples were initially tested in duplicate in a screening format at 2 
dilutions.  Any samples that generated an OD greater than or equal to the cutpoint were 

 
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reanalyzed in the titer format.  In the titration format, the same samples were also incubated on 
plates that were uncoated (no rhBMP-2 or bovine I collagen) to determine if a positive signal 
generated was specific or non-specific.  The antibody titer was defined as the reciprocal dilution 
of the sample which generated an OD equal to the cutpoint OD.  This was reported as the 
arithmetic antibody titer.   
 
Antibody testing will be performed on serum samples at the following timepoints: 
• 
Pre-operatively; 6 weeks + 2 weeks, 3 months + 2 weeks, 6 months + 4 weeks, 
and 12 months + 4 weeks post-op. 
• 
Any subject testing positive to antibodies to bovine collagen will be tested for 
antibodies to human collagen.   
• 
Any subject testing positive to antibodies to rhBMP-2 will be tested for BMP-2 
neutralizing antibodies 
 
Patients with history of prior exposure to BMP-2 in a previous surgery, who are positive 
for antibodies to rhBMP-2, bovine collagen, or neutralizing antibodies pre-operatively are 
excluded from participation in the study.   
 
 
 
Radiographs of tibial union 
Standard anteroposterior (AP) and lateral (lat) radiographs of the tibia and fibula will be obtained 
within 2 weeks prior to surgical intervention and postoperatively at the following intervals: 6 
weeks (+/- 2 weeks), 12 weeks (+/- 2 weeks), 6 months (+/- 4 weeks), 9 months (+/- 4 weeks) 
and 12 months (+/- 4 weeks). Postoperative exams will be acquired out of cast. 
 
The imaging protocol of the lower leg is standard anteroposterior and lateral radiographs of 
lower leg and ankle. Images will be sent on CD to the Radiography Review Panel at TSRH. 
 
 
Tissue Collection for Future Studies (US Centers; Further details in Appendix II 
and Lab Manual) 
 
The following tissue will be collected following participant consent: 
 
Tibial pseudarthrosis and adjacent bone: These samples will be obtained intraoperatively, and 
sent by overnight shipment to the Tissue Storage Facility (TSF) at TSRHC. In those 
circumstances where the orthopedic surgeon deems clinical pathology is needed, samples will 
be collected, cataloged, and shipped only after the clinical pathologist agrees to release the 
samples from the medical facility. Bone and pseudarthrosis samples will be shipped overnight in 
packages.  Once received in the TSF, samples will be photographed before processing. The 
cataloging from the originating site will include documentation of orientation of the sample, 
which must include designation of the proximal tibial bone – tibial pseudarthrosis tissue – distal 
bone. After obtaining additional consent, provided clinical information will be identified with study 
participant number and will stay with the tissue sample at the TSF. 
 
Iliac crest bone: with informed consent these samples will be obtained intraoperatively, and 
shipped overnight to the TSF for storage.   
   
At the time of enrollment (pre-operatively), peripheral blood will be collected (1 EDTA tube, 1 
citrate tube) and shipped at ambient temperature to the tissue processing facility at TSRH for 
DNA extraction and future lymphocyte immortalization. Samples will be cataloged and stored for 
future use. DNA concentrations will be denoted on each aliquot tube.  
 
First morning void urine will be collected at the time of enrollment and shipped frozen in 5ml 
aliquots to the TSF.  

 
NF Protocol #107   Version 5 
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Participants will be able to check a box on the informed consent form if they wish to participate 
in the optional research tissue collection.  Details of research sample collection are in Appendix 
II.   
 
 
Quality of Life and Pain Evaluations 
 
Quality of Life will be assessed using the Pediatric Outcome Data Collection Instrument 
(PODCI) questionnaire and the Faces Pain Scale Revised (FPS-R) The PODCI is a 
comprehensive orthopedic-specific instrument (Pencharz et al., 2001) comprised of over 100 
questions and takes 15-20 minutes to complete.  As discussed in our preliminary data we have 
demonstrated that the PODCI is a valid tool for the NF1 population and has demonstrated 
differences in NF1 individuals with and without tibial dysplasia in expected domains (Stevenson 
and Carey, 2009). 
  
Quality of Life Questionnaires are to be completed by patient and parents as follows at time of 
surgery (pre-op), at 6 months, and at 12 months post-surgery.  In addition, the pain intensity 
scale (FPS-R) will also be obtained at baseline, 6 weeks, 3 months, 6 months and 12 months 
post-surgery, in order to assess post-operative pain.  
 
PODCI Pediatrics-parent/child baseline and follow-up (completed by the parent for all children 
2-10 years of age). 
 
PODCI Pediatrics-parent/adolescent baseline and follow-up (completed by the parent for all 
adolescents 11-18 years of age). 
 
PODCI Pediatrics-adolescent baseline and follow-up (completed by patient between 11 and 18 
years of age) 
 
FPS-R (completed by patients aged 4 – 18 years).  Obtained at baseline, 6 weeks, 3 mos, 6 
mos, and 12 mos post-surgery.   
 
The 10 meter Timed Walking Test will be performed before surgery, and at 6 months and 12 
months post-surgery.  The test can be performed with the leg braced, and any bracing or other 
assistive device will be recorded at each time point.  The test will be performed 3 times, and the 
mean of the 3 times (in seconds) will be recorded as the final score at each visit.   
 
Forms will be forwarded to the UAB Operations Center for collation and subsequent analysis. 
 
5.9 
Adverse Reporting Requirements and unanticipated problems 
 
 
Definitions 
 
 
Adverse Events: An adverse event is any new, undesirable medical occurrence or 
change (worsening) of an existing condition in a subject that occurs during the study, whether or 
not considered to be related to BMP-2. Therefore, adverse events are treatment emergent signs 
or symptoms. Elective hospitalizations for pretreatment conditions (e.g., elective cosmetic 
procedures) are not considered adverse events for this study. Non-clinically significant abnormal 
laboratory values should not be reported as adverse events; however, any clinical 
consequences of the abnormality should be reported as adverse events.  All adverse events 
must be entered into the data-entry system.  
 

 
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For all adverse events, the investigator must pursue and obtain information adequate both to 
determine the outcome of the adverse event and to assess whether it meets the criteria for 
classification as a serious adverse event requiring immediate notification (within 24 hours) to the 
site PI and clinical coordinator, as well as the NF Operations Center and follow 21CFR812.140 
investigator responsibilities.  Follow-up of the adverse event, even after the date of therapy 
discontinuation, is required if the adverse event or its sequelae persist. Follow-up is required 
until the event or its sequelae resolve or stabilize at a level acceptable to the investigator and 
sponsor. 
 
 
Serious Adverse Events: A serious adverse event is defined by regulatory agencies as 
one that suggests a significant hazard or side effect, regardless of the investigator’s or 
sponsor’s opinion on the relationship to investigational product. 
 
This includes, but may not be limited to, any event that (at any dose): 
is FATAL 
is LIFE THREATENING (places the subject at immediate risk of death); 
requires HOSPITALIZATION or prolongation of existing hospitalization; 
is a persistent or significant DISABILITY/INCAPACITY; or 
is a CONGENITAL ANOMALY/BIRTH DEFECT 
 
Important medical events that may not be immediately life threatening or result in death or 
hospitalization, but may jeopardize the subject or require intervention to prevent one of the 
outcomes listed above, or result in urgent investigation, may be considered serious. Examples 
include allergic bronchospasm, convulsions, and blood dyscrasias.  
 
 
Unanticipated Adverse Device Effects:  An unanticipated adverse device effect is any 
serious adverse effect on health or safety, any life-threatening problem or death caused by, or 
associated with a device, if that effect, problem or death was not previously identified in nature, 
severity or degree of incidence in the IDE application.  Or, any other unanticipated serious 
problem associated with a device that relates to the rights, safety or welfare of participants.  
 
 
Common Terminology Criteria for Adverse Events (CTCAE) 
This study will utilize the CTCAE of the National Cancer Institute for reporting of adverse events.  
A copy of the current version of the CTCAE version 4.03 can be downloaded from the CTEP 
home page: http://ctep.cancer.gov/reporting/ctc.html  
 
 
 
Attribution: Definitions of relationship to study medical device are as follows: 
 
 
Unrelated: bears no relation to timing of medical device use, similar to  
 
 
 
symptoms or signs expected in the disease process, does not recur on  
 
 
 
rechallenge. 
 
 
 
Unlikely: does not have temporal relationship to intervention, could readily have  
 
 
been produced by the subject’s clinical state, environmental, or other  
 
 
 
interventions, does not reappear or worsen with reintroduction of intervention. 
 
 
 
Possibly: bears relation to timing of medical device use, similar to   
 
 
 
symptoms or signs expected in the disease process, does not recur on  
 
 
 
rechallenge. 
 
 
 
Probably: bears clear relation to timing of medical device use, distinct  
 
 
 
from symptoms or signs expected in the disease process, does not recur on  
 
 
rechallenge. 
 

 
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Definitely: bears clear relation to timing of medical device use, distinct  
 
 
 
from symptoms or signs expected in the disease process, occurs on rechallenge. 
 
The expected adverse events related to administration of BMP-2 are listed in Section 2.1 and 
in the Informed Consent Forms.  All other adverse events not attributed to BMP-2 will be 
considered unexpected. Adverse events attributable to BMP-2 will also be reported if the 
adverse events are at an intensity that is more severe than previously documented or 
considered significant by the investigator and noted in the product insert and/or protocol. 
 
 
Reporting Procedures for All Adverse Events 
All observed or volunteered adverse events, regardless of suspected causal relationship to 
study medical device will be recorded as Adverse Events in the electronic data system at the 
time of surgery and at each follow-up visit, and entered into the electric system within 2 weeks 
of the visit.  Events involving adverse reactions to the device, illnesses with onset during the 
study, or exacerbation of pre-existing illnesses should be recorded. Objective test findings (e.g., 
abnormal laboratory test results) should also be recorded.   
 
As the investigational intervention (INFUSE bone graft) occurs only at the time of surgery, it is 
not expected that adverse events noted at follow-up visits would require removal of a participant 
from the study.  If a subject voluntarily withdraws from the study, he or she will be given 
appropriate care under medical supervision until symptoms cease or until the condition 
becomes stable. 
 
The severity of toxicities will be graded in accordance with the Common Terminology Criteria for 
Adverse Event (CTCAE) version 4.03 (http://ctep.info.nih.gov). 
 
The relationship of adverse events to the medical device will be assessed by the physician 
using the categories of “unrelated, unlikely, possibly, probably, or definitely” as listed above.   
 
 
Expedited Reporting Guidelines 
 
The following adverse events require expedited reporting as required by 21CFR812.150: 
• 
All adverse events that are both serious and unexpected per section 2.1.   
• 
Adverse events that might influence the benefit-risk assessment of administration of 
INFUSE as outlined in the protocol 
• 
All grade 5 adverse events 
• 
A serious adverse event that occurs within 30 days of the placement of an 
investigational device 
• 
Expedited AE reporting timelines defined: 
“24 hours; 3 calendar days” – The investigator must initially report the AE within 24 hours of 
learning of the event to Operations Center followed by a complete report within 7 calendar days 
of the initial 24-hour report. All adverse events must be entered into the electronic data system.   
 
Adverse events requiring expedited reporting will be reported and documented on a designated 
Serious Adverse Event case report form developed for this protocol, “NF Clinical Trials 
Consortium Operations Center IDE Serious Adverse Event Form for IDE# G140004”and 
forwarded to: 
 
NF Clinical Trials Consortium Operations Center 
Research Nurse Manager:  Vivien Phillips, RN BSN  
Regulatory Compliance:  Roy McDonald, MPH  
Phone:  Vivien: 205-934-5376 / Roy: 205-975-4075. 
Email:  NFConsortium@uab.edu 

 
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The Operations Center Research Nurse Manager will forward all related adverse events that are 
both serious and unexpected to the FDA.  If paper forms are sent, they will be sent on the “NF 
Clinical Trials Consortium Operations Center IDE Serious Adverse Event Form for IDE# 
G140004.”   
 
The Operations Center will also forward to the Study sponsor within 3 working days all adverse 
events which require expedited reporting and subsequently to the Principal Investigators of 
participating sites. 
 
Adverse Event Reporting to US Army 
 
This trial receives funding by a grant from the U.S. Army. Per US Army Medical Research & 
Materiel Command (USAMRMC) Office of Research Protections Human Research Protections 
Regulatory requirements, adverse events will be reported to the USAMRMC by the NF Clinical 
Trials Consortium Operations Center regulatory compliance specialist as follows:  
 
All adverse events, which require prompt reporting (as defined in Section 5.9), will be 
immediately reported by the sites to NF Clinical Trials Consortium Operations Center.  NF 
Clinical Trials Consortium Operations Center representative will promptly report by email 
(usarmy.detrick.medcom-usamrmc.orther.hrpo@mail.mil), telephone (301-619-2165), or by 
facsimile (301-619-7803) to the USAMRMC Deputy Chief of Staff for Regulatory Compliance 
and Quality.  An initial written report will follow the site’s notification within three working days to 
NFConsortium@uab.edu.  The NF Clinical Trials Consortium Operations Center will notify all 
appropriate study regulatory personnel and send written report to the U.S. Army Medical 
Research and Materiel Command within seven working days of the initial notification of the 
adverse event requiring prompt reporting.  The written report will be sent to ATTN: MCMR-RP, 
810 Schreider Street, Fort Detrick, Maryland 21702-5000 or email, usarmy.detrick.medcome-
usamrmc.other.hrpo@mail.mil, using appropriate HRPO log number assignment.  
 
Reporting of Protocol Violations/Deviations and Unanticipated Problems 
 
Any protocol deviations or unanticipated problems will be compiled by the DMAC on a monthly 
basis. Sites should report all unanticipated problems as soon as possible in the data entry 
system. Sites will report deviations that impact subject safety or the scientific integrity of the 
study to the Operations Center promptly by email and into the data entry system. The 
Operations Center will provide this information to the protocol team, Medical Monitor, DSMB, 
and Sponsor, as needed.  
 
The Operations Center will report deviations that impact subject safety or the scientific integrity 
of the study to the USAMRMC ORP HRPO promptly. Other protocol deviations will be provided 
annually to the Sponsor.  Suspensions, clinical holds (voluntary or involuntary), or terminations 
of this research by the IRB, the institution, the Sponsor, or regulatory agencies will be promptly 
reported to the USAMRMC ORP HRPO. 
 
 
 
Grading of Adverse Events 
 
Adverse events (toxicities) will be graded according to the NCI Common Terminology Criteria 
for Adverse Events v4.03 (CTCAE) http://ctep.cancer.gov/reporting/ctc.html 
 
 
CRITERIA FOR REMOVAL FROM STUDY  
 
 
a.  Non-compliance with casting or bracing post-operatively 

 
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b.  Development of a secondary diagnosis post-operatively which may affect bone metabolism 
(diabetes, renal disease, hyperparathyroidism, etc.) 
 
c.  Non-attendance at more than 2 scheduled follow-up visits  
 
 
Off Study Criteria 
 
a) 
Death 
 
b) 
Lost to follow-up 
 
c) 
Withdrawal of consent for any further data submission. 
 
d) 
Initiation of medical treatment (e.g. chemotherapy, biologic therapy, 
 
radiation therapy) directed towards NF1-related tumor such as an optic pathway  glioma 
or MPNST. 
  
6.0 STATISTICAL AND ETHICAL CONSIDERATIONS   
 
Subject Accrual 
Subjects of both genders, from all racial and ethnic groups are eligible for this trial if they meet 
the criteria outlined in Section 4. To date, there is no information that suggests differences in 
drug metabolism or disease response among racial or ethnic groups or between the genders, 
indicating that results of the trial will be applicable to all groups. Most tibial pseudarthrosis arises 
in early childhood, with fewer cases after age 11; thus we anticipate an enrollment of younger 
children.  If differences in outcome that correlate to gender, age, racial, or ethnic identity are 
noted, accrual may be expanded or additional studies may be performed to investigate those 
differences. 
 
6.1 Statistics and Feasibility 
The primary objective of this study is to determine if there is improved healing of tibia in patients 
treated with BMP-2, compared to those treated with standard surgical protocol alone.  The 
primary outcome for the study will be radiographic evidence of tibial healing 12 months after 
surgery, using the RUST criteria as described in section 6.4. For each cortex a score of 1, 2, or 
3 will be given.  A non-visible cortex will be given a score of 1.  The cortex scores will be added 
together for a total score.  We will define three levels of healing:  RUST score of 4-7, score 8-9, 
or score 10-12.  The primary analysis will be to compare the distribution of scores across the 3 
groups (4-7, 8-9, 10-12) at 12 months post-surgery using a Wilcoxon Test. The proportion of 
patients achieving complete healing (score 9-12, with at least 2 evaluable cortices having a 
score of 3) will also be calculated and an exact 95% confidence interval computed.  
 
Analyses based on the actual 4 – 12 scores will also be performed and compared between the 
two groups.  In addition, the % of patients having a successful outcome (defined as RUST 
score of 9 or greater, with at least 2 evaluable cortices having a score of 3) will be compared 
between the two groups.  Time to union will be compared between the two groups based on 
Xrays obtained at 5 points after surgery (6 weeks, 3 mos, 6, 9, and 12 mos).  
 
Subjects who experience a serious treatment-related adverse event, refracture, or need for 
reoperation will be considered to be study failures.  The proportion of failures within each 
group will be compared to assess safety success.   
 
6.2 Power Analysis/Sample Size Justification 
The primary study endpoint will be the subject’s RUST score 12 months after surgery.  The 
radiology panel determining RUST score will be blinded to the treatment status of all patients, 
whether in the Choice or Randomized arms.  The two treatment groups will be compared with 

 
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respect to the RUST score using the Wilcoxon Rank Sum Test at the one sided 0.05 
significance level.  
 
Data from the TSRH of 12 patients treated without BMP but an identical surgical protocol 
showed RUST scores at 12 mos post surgery of:  Score 4-7 in 33%; Score of 8-9 in 42%; and 
score of 10-12 in 25%.   If the use of BMP improves these scores to: 15% 4-7; 20% 8-9, and 
65% 10-12, as suggested by our data from Dr. Richards’ 16 patients treated with BMP, then it 
follows that for two patients randomly chosen, one from each treatment group, the probability 
that the patient in the BMP group will have a better score than the patient in the Control group is 
.691.  Using a standard formula [Kolassa, 1995] implemented in nQuery Advisor® 7.0 this study 
with the initially planned sample size of 50 (25 per group) will have 86% power for a Wilcoxon 
Rank Sum Test at the one sided p.05 significance level.   
 
Study Modification:  Based on data from the first year of the trial, more eligible patients 
declined to participate than agreed to participate; however, in many of these cases the family 
would have agreed to a Parental Preference trial.  Similar Parental Preference clinical trials 
have achieved acceptance within the orthopedic field, as demonstrated by the large BrAIST 
study of bracing versus no bracing for adolescent scoliosis [Weinstein et al, 2013; Schwieger et 
al., 2016]. The study was thus modified after initiation to allow a Choice Group, wherein after 
offering whether a potential participant had a preference, this would be honored.  If there were 
no preference or if there is no option to obtain BMP at the institution where the participant is 
being seen, they would be randomized to BMP or Control using a 2:3 randomization.  The 
rationale for this unbalanced randomization is to obtain or achieve enough controls to have a 
reasonable comparison of the effect of BMP.  It is expected by participating surgeons that more 
patients would prefer the BMP arm to the Control arm if given the choice.    
 
We anticipate that this would leave the study with a potential slight imbalance in BMP treatment 
and controls.  Thus, we evaluated the impact on the primary analysis given various scenarios on 
recruitment and testing treatment effects assuming the results of choice and randomized 
allocation could be pooled.   
 
The study is limited by the company’s allocation of just 26 BMP devices, so we examined the 
power of the study under various scenarios of BMP treated to Controls.  The table below shows 
the power, along with the sample sizes (shown in italics in the table in the 4th and 5th rows), if the 
study ends up with 5 and 26 patients in Usual Care versus BMP, up to comparison of 20 Usual 
Care versus 26 BMP across the columns of the table.  The power ranges from 46% power to 
detect a difference in RUST scores using a 1 tailed test at 0.05 to over 80% (as per our original 
primary analysis and endpoint).  This is testing the RUST scores assuming UC of: 33% (Rust 
Scores 4-7), 42% (8-9) and 25% (10-12) compared to 15% (4-7); 20% (8-9) and 65% (10-
12).  So if we enroll at least 10 -15 controls, we have approaching 70% power to declare a 
significant difference.  Obviously, we need to have a sufficient number of controls to enhance 
the power, and to help ensure this result, we will randomize 3 controls to 2 BMP cases in the 
randomization to enhance our ability to achieve at least 10 controls. 
   
  Power using a Wilcoxon (Mann-Whitney) rank-sum test that P(X<Y) = .5 (ordered 
categories) (unequal n's), One sided Type I error=0.05 
(Control Rust scores  33% (4-7), 42% (8-9), 25% (>=10) versus BMP 15%, 20%, 65% 
respectively) 
   
 
1
2
3
4
5
6
7
8 
 Number of categories, k 
 3
 3
 3
 3
 3
 3
 3
 3 
 p1 = P(X<Y) 
 0.702
 0.702
 0.702
 0.702
 0.702
 0.702
 0.702
 0.702 
 Power ( % ) 
     46
     51
     56
     59
     62
     65
     76
     82 

 
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 n1 
 26
 26
 26
 26
 26
 26
 26
 26 
 n2 
 5
 6
 7
 8
 9
 10
 15
 20 
 
  
Our analysis will be a primary analysis combining the Choice and randomized participants.  We 
will perform sensitivity analyses within the Choice and Randomized cohorts separately.  Given 
the limited sample sizes, we do not expect significant differences, but will examine descriptive 
statistics comparing the Choice Group to the Randomized Group.  We will examine the RUST 
scores amongst those who choose BMP versus those who refuse and choose usual care.   We 
will of course, consider comparisons to historical controls should the results prove clearly 
different between the Choice and Randomized Groups.    
 
As noted above we are likely giving up some power with this change to a Choice Design.  
Our assumption based on the current rate of declining to participate is that more patients 
will chose the BMP arm above the Control arm, but if we are incorrect, we would have 
adequate power (76% - 82%) if we were able to enroll 15-20 patients in the Control arm 
and 26 patients in the BMP arm.  Even in a worse scenario that we were only able to 
recruit 10 patients to the Control arm + 26 to BMP, we would still have reasonable power 
of 65% to show a difference between the groups.   
 
It is important to note that, although participants and providers in the Choice Arm will no 
longer be blinded to the treatment status of the participants, the Primary Outcome 
Measure (RUST score), will be determined by a group of 4 radiologists, all blinded to the 
treatment status of all participants.    
 
Missing data:  Reason for any missing 12 month radiographic data will be recorded by 
treatment group.  Data from subjects missing the 12 month radiograph will not be included, 
unless multiple imputation is applied. Although minimal data are expected to be missing, 
multiple imputation technique will be used if 5% or more data are missing. This multiple 
imputation will replace the missing value with a set of plausible values that represent the 
uncertainty about the right value to impute.  The multiply imputed data sets will then be 
analyzed by using the Wilcoxon Rank Sum Test for complete data on each and combining the 
results from these analyses.  The variables used for the imputation will be RUST score at 6 
months, age, prior surgery (Yes=1, No=0), and timed 10 meter walk at 12 months post-surgery.    
 
Generalizability of the Results: 
 
As we noted above, we expect that most of the data from this study will be generated by the 
choice arm and hope to maintain at least 10 randomized controls.   We will compare the 
participant characteristics as well as Rust Scores between any controls identified by choice to 
those controls by randomization and more importantly RUST scores between the choice and 
randomized BMP treated arms.  We will look at the overlap of the confidence intervals and test 
the equivalence of the two sets of results using two one sided tests of equivalence at the 5% 
level with an equivalence margin of 0.513.  The margin of equivalence of 0.513 was derived 
based on the hypothesized difference between treatment and control originally planned and 
assuming these scores are normal continuous variables.  Here we used the midpoint of each 
Rust Scoring Interval (5.5, 8.5 and 11) and computed the average Rust score for each group 
based on the hypothesized distribution in each group and ended up with a mean of 9.675 in the 
BMP group compared to 8.135 in the control group yielding an average difference in Rust Score 
of 1.54.  We took 1/3 of the difference between the treatment average Rust score and the usual 
care Rust score ending up with an equivalence margin of 0.513.  Since these sample sizes are 
small, we don’t expect to reject the null hypothesis of differences as the power is probably low, 
but if they are different we understand that pooled results will be difficult to interpret.  If these 

 
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tests of Choice versus Randomized treatment arms are not able to reject nonequivalence, we 
understand that this is not strong evidence for a lack of poolability between choice and 
randomization.  Nevertheless, it will be sufficient to allow a comparison and calculation of the 
differences between the treatments and an overall assessment of the benefit of BMP in healing 
especially if we can demonstrate equivalence.  Sensitivity analyses will be conducted using 
pooled and unpooled results as no statistical evidence of a lack of nonequivalence is not 
absolute evidence for nonequivalence. 
 
 
Analyses:  
All statistical analyses will be performed using SAS (version 9.3).  All analyses are based on 
evaluable patients, as defined in section 10.5 with sensitivity analyses considering inevaluable 
patients as failures (scores 4-7).  Summary statistics will be used to describe the study 
population (such as ranges, medians of ages, gender, baseline performance characteristics). 
The quality of life assessment in this study is based on the Pediatric Outcomes Data Collection 
Instrument, the PedsQL Pediatric Pain Questionnaire, and the 10 meter Timed Walk. From data 
collected on these questionnaires, scales are formed that measure domains such as global 
functioning, extremity and physical function, transfers and basic mobility, sports/physical 
function, happiness, and pain/comfort. These QOL and pain measures will be given pre-surgery, 
3 months, 6 months, and 12 months after surgery. Since the scales are continuous, summary 
statistics will be generated for each measure at each time-point.  The paired t-test will be used 
to look at changes in these measures from pre-treatment levels through 12 months. Longitudinal 
data analysis methods will be used to evaluate long-term changes in these measure using 
regression techniques employing mixed models. 
 
 
In order to determine factors which may be prognostic for the success of BMP-2 treatment, we 
will perform Wilcoxon Rank Sum Tests to within each group to compare: 
 
 
 
1) age < 8 years versus age > 8 years 
 
2) prior surgery versus no prior surgery; and 
 
3) prior rhBMP-2 exposure versus rhBMP-2 naïve. 
 
Regarding dose of rhBMP-2, those with 4.2 mg of rhBMP-2 implanted will be compared to those 
with 8.4 mg of rhBMP-2 implanted with respect to success rate using a chi square contingency 
table and with respect to number of adverse events using the Wilcoxon Rank Sum Test.   
 
Relationships between quality of life measures and other variables (i.e., pain) will be 
investigated using correlational analyses.  Performance status will be assessed using the 
Karnofsky Performance Scale.  Generalized linear models will be used to evaluate changes in 
these scales and scores over time.   
 
Early Stopping Rule 
While BMP-2 has been evaluated extensively in non-NF1 patients, it has not been administered 
as a clinical trial in children with NF1 who have tibial pseudarthrosis. An early stopping rule will 
be invoked to prevent accrual of patients onto the study in the event that BMP-2 is associated 
with a higher than acceptable rate of severe toxicity identified at 6 weeks and 12 weeks post 
surgery  [types:  Grade 3 opportunistic infection, Grade 4 rash, Grade 3 hypertension, grade > 3 
allergic reaction (determined by clinical assessment and antibody levels), grade 3 renal toxicity, 
severe ectopic bone formation requiring surgery, or  the development of malignant peripheral 
nerve sheath tumor or other cancers].  Toxicity assessment will be graded according to the 
National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) (v4.03).  
After 10 patients are enrolled in each arm, toxicity will be reviewed and if greater than the 

 
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number of patients shown in the table below experiences severe toxicity, accrual will be 
stopped.  Based upon results calculated using the binomial distribution, the following holds true 
for the table as a whole: 
 
True probability of toxicity 
Chance of stopping early 
.10 
7% 
.20 
32% 
.25 
47% 
.30 
.40 
62% 
83% 
Number of patients 
Trial will be stopped if the number  
of patients with severe toxicity 
is greater than or equal to the number below 
10 
3 
 
Should the number of patients showing severe toxicity during treatment with BMP-2 exceed 
25% of the total number of patients enrolled, the study committee and medical monitor will 
review the toxicities and define whether a protocol revision is required. This 25% level was 
determined based on prior studies showing a total complication rate of 17% in pediatric patients 
treated with BMP-2 [Oetgen and Richards, 2010]. 
 
Likewise, the trial may be stopped early if at least 6 patients of the first 10 enrollees in the BMP-
2 arm have complete failure of union by 12 months postop (RUST score of 5 or less).  This will 
be determined after the first 10 enrollees in the BMP-2 arm have completed the 12 month 
assessment.  The entire study will be terminated if the BMP-2 group is stopped early due to 
toxicity or failure of union.   
 
Since subjects, once they have had surgery, will need to be seen regularly for follow-up, we 
expect little or no attrition or loss to follow-up.  Therefore, we will plan to enroll a total of 
between 36-52 patients, with a minimum goal of 15 eligible patients in the control arm and 26 
patients in the BMP arm.     
 
 
6.3 HUMAN SUBJECTS PROTECTION 
 
The PI from each participating institution will provide the NF Clinical Trials Consortium 
Operations Center with a copy of the initial IRB protocol approval and the yearly IRB continuing 
reviews. The Operations Center Regulatory Manager will submit these to the USAMRMC ORP 
HRPO. Enrollment will be halted at a participating institution if a current continuing approval is 
not on file at the NF Consortium Operations Center.  
 
As the Operations Center receives funding by the US Army, approval of the protocol and of all 
protocol amendments will also be obtained from the USAMRMC Office of Research Protections 
(ORP), Human Research Protection Office (HRPO) in addition to the institutional IRB and the 
NF Consortium IRB prior to implementation. 
 
 
Rationale for Subject Selection 
Neurofibromatosis type 1 is a pan-ethnic genetic disorder with an incidence of 1 in 3,000 
people.  Subject accrual in regards to gender, and racial and ethnic groups is described in 
Section 3.6.  None of these groups are excluded from participation in the trial.  Females who are 
pregnant or breast feeding will not be eligible for entry onto the trial because of the potential 
risks that rhBMP-2 could pose to the fetus or newborn.  This trial is designed to determine the 

 
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activity of BMP-2 in children with NF1 and surgically treated pseudarthrosis, therefore children 
will be entered onto this research trial. Almost all individuals with NF1-related congenital  
pseudarthrosis of the tibia will have their first or second surgery within the first 18 years of life. 
Individuals will be enrolled at one of 13 sites that collaborate with the NF Clinical Trials 
Consortium with additional affiliate sites at TSRH, Australia, and the United Kingdom.  Patients 
may be referred from outside centers but treatment will be directed at a participating consortium 
site. 
 
 
Participation of Children  
Since tibial pseudarthrosis typically requires surgical intervention before age 10 years of age, 
children who meet eligibility criteria for this trial will be entered in the study.  Children will be 
evaluated and cared for by physicians trained in pediatrics and in the orthopedic management 
of children with NF1.  
 
Compensation of Participants 
Participants who live further than 50 miles from the center where surgery will be performed can 
receive partial compensation for travel expenses.  Maximum reimbursement will be $500 per 
patient (US dollars), with $250 payable at the 6 week post- surgical follow-up visit and the 
remainder after all follow-up visits have been completed at 12 months.  As travel costs for 
families will often exceed this amount, this would not be considered unduly influential.  
Participants who live within 50 miles of the surgical center will be reimbursed a maximum total 
of (US) $200 per patient for time and travel involved ($100 payable at 6 week post-surgical 
follow-up visit and remainder at 12 months).   
 
Consent and assent process and documentation 
The investigational nature and objectives of this trial, the procedures and treatments involved 
and their attendant risks and discomforts and benefits, and potential alternative therapies will be 
carefully explained to the patient and the patient’s parents or guardian. A signed informed 
consent document will be obtained. Consent will be obtained by the site PI or an associate 
investigator on the trial according to state and institutional guidelines.  Where deemed 
appropriate by the clinician and the child’s parents or guardian, the child will also be included in 
all discussions about the trial. Age appropriate assent forms for children from 7 through 12 
years, and for children from 13 through 17 years have been developed for use in this trial.  This 
is a multi-institutional trial, and the NF Operations Center will require evidence of local IRB 
approval and of USAMRMC ORP HRPO approval of the protocol prior to allowing for accrual of 
patients at that institution. This trial will be conducted in compliance with the protocol, Good 
Clinical Practice (GCP) and the applicable regulatory requirements.  
 
6.4  MONITORING PROCEDURES 
Research Monitor and Data Safety Monitoring Plan 
The trial PI and co-investigators will review the study progress regularly. Patients entered on the 
trial and adverse events will be reviewed to ensure that the study is implemented as outlined in 
the protocol. Monthly reports will be generated by the NF Consortium DMAC to assess 
completeness of data. There will be monthly phone conferences between the NF Consortium 
Operations Center and the Principal Investigators to address QA issues.  An independent Data 
Safety Monitoring Board will be established for the purpose of ensuring data compliance and 
regular monitoring of this trial of adverse events and study timepoints.  
 
All DOD funded studies that are greater than minimal risk requires that a research monitor be 
identified by name with their DOD specific role included (see * below). In the past NF 
Consortium trials, the medical monitor has been identified to function in this role.  

 
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 The research monitor’s duties should be based on specific risks or concerns about the 
research. The research monitor may perform oversight functions and report their observations 
and findings to the IRB or a designated official.  The research monitor may be identified from 
within or outside the PI’s institution. 
*Research monitor functions may include: observing recruitment and enrollment procedures and 
the consent process for individuals, groups or units, overseeing study interventions and 
interactions, reviewing monitoring plans and UPIRTSO reports, overseeing data matching, data 
collection, and analysis 
There may be more than one research monitor. The monitor may be an ombudsman or a 
member of the data safety monitoring board. 
At a minimum, the research monitor: may discuss the research protocol with the investigators, 
interview human subjects, and consult with others outside of the study about the research; shall 
have authority to stop a research protocol in progress, remove individual human subjects from a 
research protocol, and take whatever steps are necessary to protect the safety and well-being 
of human subjects until the IRB can assess the monitor’s report; shall have the responsibility to 
promptly report their observations and findings to the IRB or other designated official and the 
HRPO. 
John P. Dormans, MD, FACS (Pediatric Orthopaedic Surgery & Scoliosis, Baylor College of 
Medicine) will serve as the research monitor.  He will serve as a patient advocate and is 
independent of the clinical study team.  He will oversee the progress of the protocol, especially 
issues of individual subject/patient management and safety.  The research monitor is required to 
review all unanticipated problems involving risks to subjects or others, including all serious and 
unexpected adverse events associated with the protocol as defined in Section 5.9.  The monitor 
provides an unbiased written report of the event.  
 
Research Monitor Language required by the DOD:  
 
The research monitor is required to review all unanticipated problems involving risk to subjects 
or others, serious adverse events and all subject deaths associated with the protocol and 
provide an unbiased written report of the event.  At a minimum, the research monitor should 
comment on the outcomes of the event or problem, and in the case of a serious adverse event 
or death, comment on the relationship to participation in the study.  The research monitor should 
also indicate whether he concurs with the details of the report provided by the study 
investigator.  Reports for events determined by either the investigator or medical monitor to be 
possibly or definitely related to participation and reports of events resulting in death should be 
promptly forwarded to the USAMRMC ORP HRPO.  
 
 
 
 

 
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6.6 EXPERIMENTAL DESIGN SCHEMA                     
 
 
 
 
 
 
 
 
 
 
 
        Ineligible for trial  
 
 
 
  
 
 
 
 
  
 
 
 
 
Surgery:  Tibial Osteotomy 
Rigid Intramedullary Rod 
Autogenous Bone Graft (iliac crest) 
Post-op visits at 6 weeks, 3, 6, 9, 12 months after surgery   
Tibial Xrays at each visit 
Antibody studies at 6 weeks, 3, 6, 12 months 
QOL: studies at baseline, 6, and 12 months 
ANALYSIS 
Efficacy of rhBMP-2, determined by RUST score at 12 months 
Rate of Tibial Healing (months) 
Quality of Life Assessment 
 Optional 
Blood, Urine, Bone, TPA Tissue 
Collected at surgery, processed, and 
stored at TSRH Tissue Facility 
Available for future NF1 
investigations 
(Experimental) 
BMP-2 (INFUSENFUSE) 
added to surgical site 
(Control) 
No BMP- 2 
Eligibility form reviewed by 4 co-PIs 
Pre-screening labs, BMP-2 antibodies* 
Baseline tibial X-rays reviewed  
Positive for BMP-2 or 
collagen antibodies exposure 
Negative for BMP-2 antibodies, 
or no prior BMP exposure.  
Meets all pre-screening criteria 
Eligible for trial 
Primary Outcome Measure at 12 months 
RUST SCORE 
4 = Non-Union 
9-12 = Complete Union 
Ineligible for trial 
* Antibody results will be 
generated prior to enrollment 
for participants with prior 
exposure as part of eligibility 
criteria. Results for other 
participants will be provided at 
designated intervals. 
Patient/ parent selects:  
Choice Arm:  assigned to Control or 
BMP per parental preference  
Randomized arm:  assigned randomly 
to Control or BMP arm 

 
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APPENDIX I:  Schedule of Evaluations 
STUDIES TO BE OBTAINED 
Pre-Study 
Surgery Post-Surgical Follow-up 
Post-Trial 
FU 
Informed Consent/ Assent 
X 
 
 
 
Eligibility Checklist 
X 
 
 
 
History and Physical Exam 
X 
 
6 w, 12 w (± 2 wks)  
6 m, 9 m, 12 m  (± 4 wks) 
Annual 
PE with vital signs (including T, P, RR, 
BP), Ht, weight 
X 
 
6 w, 12 w (± 2 wks)  
6 m, 9 m, 12 m (± 4 wks) 
 
Performance Status (Karnofsky, Lansky 
scales) 
X 
 
 
 
Adverse Event Reporting  
 
X 
6 w, 12 w, 6 m, 9 m, 12 m 
Annual 
CBC, differential, platelets 
X 
 
3 m, 12  m 
 
Total bilirubin 
X 
 
 
 
Urinalysis 
X 
 
3 m, 12 m 
 
Urine Pregnancy2 
X 
 
6 w 
 
Blood Electrolytes, BUN, creatinine, 
albumin, total protein, alkaline 
phosphatase, uric acid, SGOT, SGPT, 
GGT,  
X 
 
 
 
 3 m, 12 m 
 
 
Serum calcium (ionized), magnesium, 
phosphorus 
X 
 
3 m, 12 m 
 
Serum Vitamin D 
X 
 
3 m, 12 m 
 
Bovine collagen I antibodies 
X 
 
6 w, 3m, (± 2 wks) 
6 m, 12 m (± 4 wks) 
Until 
negative 
BMP-2  antibodies 
X 
 
6 w, 3 m, (± 2 wks) 
6 m, 12 m (± 4 wks) 
Until 
negative 

 
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1.  All studies to determine eligibility must be performed within 2 weeks prior to 
enrollment unless otherwise indicated below. 
2.  For females of childbearing age.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radiographs (PA/Lat) of the affected leg 
X 
 
 
6 w, 3 m, (± 2 wks)  
6 m, 9 m, 12 m (± 4 wks) 
Annual 
PODCI (QOL scale) 
X 
 
6m, 12 m 
 
 
Faces pain scale 
X 
 
6 w, 3m,  6 m,  12 m 
 
10 Meter timed walk 
X 
 
6 m, 12 m 
 
OPTIONAL STUDIES TO BE OBTAINED 
(if participant consents) 
 
 
 
 
Blood for research studies 
 
X 
 
 
Pseudarthrosis tissue 
 
X 
 
 
Iliac crest bone  
 
X 
 
 
Urine for research studies 
 
X 
 
 

 
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APPENDIX II: Biologic Specimen Collection 
 
RESEARCH SAMPLES: 
Bone/Pseudarthrosis samples: 
Up to 3 small samples of excess bone or pseudarthrosis tissue removed at surgery will be 
obtained and sent for research studies. 
Estimated size of each sample approx. 1 cm diameter 
In addition, a small sample of excess bone from the iliac crest bone site may be sent (max size 5 
mm).   
All bone samples should be labeled in the OR by site (pseudarthrosis tissue, tibia, iliac crest) 
1. The surgeon will excise the specimen and place it on a sterile container moist with saline. 
 
2. Obtain up to 3 small pieces (maximum 1 cm diameter each) of excess pseudarthrosis tissue or 
bone and place each piece into a single 50 mL conical tube containing 40 mL L-15 media 
(provided by TSRHC) 
 
3. Label each conical tube containing tissue with the following: appropriate collection site 
description (pseudoarthrosis tissue, tibia, iliac crest, etc.), study number, the subject’s research 
number, collection date 
 
4. Place all conical tubes containing tissue into a Ziploc plastic bag and store in the refrigerator 
(4°C). DO NOT FREEZE 
 
 
 
Blood – Will be obtained before or on the day of surgery.  Will be provided as maximum of 2 
EDTA tubes of 5 ml each.    These will be processed at TSRH to isolate and store DNA for future 
studies.   
1. Prior to surgery, collect 5 mL* each into 1 or 2 EDTA purple top tubes 
      *volume depends on subject size and institutional safety guidelines 
2. Invert purple top tube 5 times.  DO NOT SHAKE VIGOROUSLY. 
3. Label all purple top tubes with the appropriate information: study number, the patient’s 
research number, collection date, and collection timepoint (baseline, 6 weeks, 3 months, 
etc.) 
4. Place in a Ziploc plastic bag and store all purple top tubes in the refrigerator (4°C) 
 
Urine – obtained before or on the day of surgery, as a first morning void.   
• Aliquot 5 ml of urine sample each into between 3 – 5 urine transport vials, 
labelled with the Participant’s ID, date, volume, and “urine”.  Place all urine 
transport vials in a biohazard bag and freeze in -20C or -80C until shipping. 
 
 

 
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SHIPPING INFORMATION: 
 
*TSRHC should be contacted prior to shipping. Tracking number and scanned copy of de-identified 
requisition form should be sent to Reuel.Cornelia@tsrh.org and Jonathan.Rios@tsrh.org. 
Test Requisition: NF Repository 
a) Fresh Bone/Pseudarthrosis samples from above 
Pack in biohazard bag and ship with 2 – 3 frozen ice packs in an insulated (styrofoam) container 
by overnight courier FedEx. Specimen should arrive in the laboratory within 48 hrs of collection. 
Do not heat or freeze. 
b) Blood sample from above 
Place in biohazard bag and ship with frozen ice packs in an insulated (Styrofoam) container by 
overnight courier FedEx. Specimen should arrive in the laboratory within 48 hrs of collection. Do 
not heat or freeze. This may be shipped with the fresh tissue sample. 
c) Urine from above 
Pack in biohazard bag and ship with 5 lbs dry ice pack in an insulated container (Styrofoam) by 
overnight courier FedEx. Specimen should arrive in the laboratory within 48 hrs of collection. 
May be shipped with frozen tissue sample. 
All specimens must be properly packed and labeled to indicate the general nature of the materials 
transported. All shipments must comply with all applicable local, state and federal laws governing 
packaging, labeling and transportation. There will be one FedEx account number for NF repository. After 
packaging and shipment are done please inform the following with the FedEx account tracking number 
thru email Reuel.Cornelia@tsrh.org and Jonathan.Rios@tsrh.org  to track down arrival of delivery. 
All Shipment should be address to the following: 
Shipping address:   
REUEL CORNELIA OR JONATHAN RIOS 
RESEARCH DEPARTMENT 
TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN 
2222 WELBORN ST. 
DALLAS, TEXAS 75219 
TELEPHONE NUMBER: 214-559-7766 OR 214-559-8532 
 
 
ADDITIONAL DETAILS CAN BE FOUND IN THE SOP MANUAL.   
 
 
 

 
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BMP ANTIBODY TESTING PROTOCOL: 
Samples will be obtained from each study participant for antibodies to BMP and collagen at 5 different 
timepoints. 
Time of antibody tests:  Baseline, 6 weeks, 3 months, 6 months, and 12 months after surgery.   
Blood volume needed:  3 ml per blood draw. 
 
INSTRUCTIONS FOR ANTIBODY BLOOD DRAW AND PROCESSING: 
1.  3 ml blood is drawn in a red top serum separator tube.  
2. After obtaining blood sample, invert the collection tube 5 times to allow the blood to clot for 
30minutes at ambient temperature (19-24°C). 
3. Centrifuge sample at approximately 1000-1300 RCF for 10 minutes at room temperature in a 
swinging bucket centrifuge. 
4. Serum is then aliquotted to 3 separate 2 ml polypropylene screw cap tubes 
a. At least 0.5 serum per tube 
5. Tubes are labeled with the study number (NF107), patient’s research number, date, and timing 
of the test (i.e., baseline, 6 weeks, etc) 
6. Within 90 minutes of collection, store aliquot samples upright at -20°C. 
7. Tubes are frozen to at least -20 Celsius (-4 Fahrenheit). When ready for shipping, samples are 
packaged in dry ice.  Samples from the pre-surgery blood draw should be shipped as soon as 
possible, as antibody levels are a pre-enrollment screening requirement.  Samples post-surgery 
can be batched if desired, but must be marked with the appropriate research number, date, 
and timing.   
8.  Package sent by Federal Express overnight (next day delivery) Monday through Wednesday 
only, to Intertek Pharmaceutical Services, 10420 Wateridge Circle, San Diego, CA 92121; 
Attention: Trang Le.  Phone : (858) 558-2599  Fax: (858) 558-2600; Direct Line: (858) 210-3413  
9. Samples from international sites should be shipped using World Courier services.  
10. A paper copy of the CRF   should be sent in the package with the samples.    
 
 
 
 

 
NF Protocol #107   Version 5 
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APPENDIX III: PERFORMANCE STATUS SCALES/SCORES 
 
PERFORMANCE STATUS CRITERIA 
Karnofsky and Lansky performance scores are intended to be multiples of 10 
Karnofsky 
Lansky 
Score 
Description 
Score 
Description 
100 
Normal, no complaints, no evidence 
of disease 
100 
Fully active, normal. 
90 
Able to carry on normal activity, 
minor signs or symptoms of disease. 
90 
Minor restrictions in physically 
strenuous activity. 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
80 
Active, but tires more quickly 
70 
Cares for self, unable to carry on 
normal activity or do active work. 
70 
Both greater restriction of and less time 
spent in play activity. 
60 
Required occasional assistance, but 
is able to care for most of his/her 
needs. 
60 
Up and around, but minimal active play; 
keeps busy with quieter activities. 
50 
Requires considerable assistance and 
frequent medical care. 
50 
Gets dressed, but lies around much of 
the day; no active play, able to 
participate in all quiet play and activities. 
40 
Disabled, requires special care and 
assistance. 
40 
Mostly in bed; participates in quiet 
activities. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
30 
In bed; needs assistance even for quiet 
play. 
20 
Very sick, hospitalization indicated.  
Death not imminent. 
20 
Often sleeping; play entirely limited to 
very passive activities. 
10 
Moribund, fatal processes 
progressing rapidly. 
10 
No play; does not get out of bed.