A Prospective, Single-Center, Randomized, Triple-Blinded, Placebo-Controlled Study of IL-1RA Treatment in Patients With Acute ACL Tear and Painful Effusions
Phase: PHASE2
Conditions: Anterior Cruciate Ligament Tear
Sponsor: Cale Jacobs, PhD

A Prospective, Multi-Center, Randomized, Triple-Blinded,  Placebo-
Controlled study of IL-1RA Treatment in Patients with Acute ACL 
Tear and Painful Effusions 
 
NCT Number: NCT02930122 
 
Document Date: 03 March 2020 
 
 
 
 
 
 
 
 

A Prospective, Multi-Center, Randomized, Triple-Blinded,  Placebo-
Controlled study of IL-1RA Treatment in Patients with Acute ACL 
Tear and Painful Effusions 
 
Short title:  EASI ACL 
 
Sponsor:  
 
Austin Stone MD, PhD  
 
 
 
Univeristy of Kentucky 
Department of Orthopaedic Surgery & Sport Medicine 
760 S Limestone, Suite K401 
Lexington, KY 40536-0284 
 
Phone Number:   (859)218-3065 
                                    Fax:      (859) 323-2412 
 
Email:  austin.stone@uky.edu 
 
Principal Investigator: Cale Jacobs, PhD 
                                        University of Kentucky  
                                        Department of Orthopaedic Surgery &   
                                        Sport Medicine 
                                        Lexington, KY 40536 
                                        Phone Number:  859-797-8197 
                                        Fax:    859-323-2412 
                                        Email:  cale.jacobs@uky.edu 
 
 
IND#:  116,316 
Funded by: Arthritis Foundation and Sobi Pharmaceuticals 
Version Number:  7.0 
3 March 2020

 
Table of Contents 
LIST OF ABBREVIATIONS ....................................................................................................................................... 1 
STATEMENT OF COMPLIANCE ............................................................................................................................. 3 
INVESTIGATOR SIGNATURE ................................................................................................................................. 4 
PROTOCOL SUMMARY ........................................................................................................................................... 5 
SCHEMATIC OF STUDY DESIGN .......................................................................................................................... 7 
1 
KEY ROLES ......................................................................................................................................................... 8 
2  INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ............................... 9 
2.1 
Background Information ........................................................................................................................ 9 
2.2 
Rationale............................................................................................................................................... 14 
2.3 
Potential Risks and Benefits ................................................................................................................. 15 
2.3.1 
Known Potential Risks ..................................................................................................... 15 
2.3.2 
Known Potential Benefits ................................................................................................. 16 
3 
OBJECTIVES AND PURPOSE .......................................................................................................................... 16 
4 
STUDY DESIGN AND ENDPOINTS ................................................................................................................ 16 
4.1 
Description of the Study Design ........................................................................................................... 16 
4.2 
STUDY ENDPOINTS ......................................................................................................................... 17 
4.2.1 
Primary Endpoint .............................................................................................................. 17 
4.2.2 
Secondary Endpoints ........................................................................................................ 17 
5 
STUDY ENROLLMENT AND WITHDRAWAL .............................................................................................. 17 
5.1 
Participant Inclusion Criteria ................................................................................................................ 17 
5.2 
Participant Exclusion Criteria............................................................................................................... 17 
5.3 
Strategies for Recruitment and Retention ............................................................................................. 18 
5.4 
Participant Withdrawal or termination ................................................................................................. 18 
5.4.1 
Reasons for Withdrawal or Termination ........................................................................... 18 
5.4.2 
Handling of Participant Withdrawals or termination ........................................................ 19 
5.5 
Premature Termination or Suspension of Study ................................................................................... 19 
6 
STUDY AGENT .................................................................................................................................................. 19 
6.1 
Study Agent(s) and Control Description .............................................................................................. 19 
6.1.1 
Acquisition ........................................................................................................................ 19 
6.1.2 
Formulation, Appearance, Packaging, and Labeling ........................................................ 19 
6.1.3 
Product Storage and Stability ........................................................................................... 20 
6.1.4 
Preparation ........................................................................................................................ 20 
6.1.5 
Dosing and Administration ............................................................................................... 21 
6.1.6 
Route of Administration ................................................................................................... 21 
6.1.7 
Starting Dose and Dose Escalation Schedule ................................................................... 21 
6.1.8 
Dose Adjustments/Modifications/Delays ......................................................................... 21 
6.1.9 
Duration of Therapy ......................................................................................................... 21 
6.1.10 
Tracking of Dose .............................................................................................................. 21 
6.2 
Study agent Accountability Procedures ................................................................................................ 21 
7 
STUDY PROCEDURES AND SCHEDULE ...................................................................................................... 22 
7.1 
Study Procedures/Evaluations .............................................................................................................. 22 
7.1.1 
Study related ..................................................................................................................... 22 
7.1.2 
Standard of care study procedures .................................................................................... 24 
7.2 
Laboratory Procedures/Evaluations ...................................................................................................... 24 
7.2.1 
Clinical Laboratory Evaluations ....................................................................................... 24 
7.2.2 
Other Assays or Procedures .............................................................................................. 25 

 
7.2.3 
Specimen Preparation, Handling, and Storage .................................................................. 26 
7.2.4 
Specimen Shipment .......................................................................................................... 26 
7.3 
Study Schedule ..................................................................................................................................... 26 
7.3.1 
Screening/enrollment ........................................................................................................ 26 
7.3.2 
Schedule of Events Table ................................................................................................. 27 
7.4 
Justification for Sensitive Procedures ................................................................................................... 29 
7.5 
Concomitant Medications, Treatments, and Procedures ...................................................................... 29 
7.6 
Prohibited Medications, Treatments, and Procedures .......................................................................... 29 
7.8 
Rescue Medications, Treatments, and Procedures ............................................................................... 29 
7.9 
Participant Access to Study Agent At Study Closure ........................................................................... 29 
8 
ASSESSMENT OF SAFETY .............................................................................................................................. 29 
8.1 
Specification of Safety Parameters ....................................................................................................... 29 
8.1.1 
Definition of Adverse Events (AE)................................................................................... 29 
8.1.2 
Definition of Serious Adverse Events (SAE) ................................................................... 30 
8.1.3 
Definition of Unanticipated Problems (UP)...................................................................... 30 
8.2 
Classification of an Adverse Event ...................................................................................................... 30 
8.2.1 
Severity of Event .............................................................................................................. 30 
8.2.2 
Relationship to Study Agent ............................................................................................. 31 
8.2.3 
Expectedness .................................................................................................................... 32 
8.3 
Time Period and Frequency for Event Assessment and Follow-Up ..................................................... 32 
8.4 
Reporting Procedures ........................................................................................................................... 33 
8.4.1 
Adverse Event Reporting .................................................................................................. 33 
8.4.2 
Serious Adverse Event Reporting ..................................................................................... 33 
8.4.3 
Unanticipated Problem Reporting ..................................................................................... 35 
8.4.4 
Events of Special Interest ................................................................................................. 36 
8.4.5 
Reporting of Pregnancy .................................................................................................... 36 
8.5 
Study Halting Rules.............................................................................................................................. 36 
8.6 
Safety Oversight ................................................................................................................................... 36 
9 
CLINICAL MONITORING ................................................................................................................................. 37 
10 STATISTICAL CONSIDERATIONS ................................................................................................................. 37 
10.1 
Statistical and Analytical Plans ............................................................................................................ 37 
10.1.1 
General Approach ............................................................................................................. 37 
10.1.2 
Analysis of the Primary Efficacy Endpoint(s) .................................................................. 38 
10.1.3 
Analysis of the Secondary Endpoint(s) ............................................................................. 38 
10.2 
Measures to Minimize Bias .................................................................................................................. 38 
10.2.1 
Enrollment/ Randomization/ Masking Procedures ........................................................... 38 
10.2.2 
Evaluation of Success of Blinding .................................................................................... 39 
10.2.3 
Breaking the Study Blind/Participant Code ...................................................................... 39 
11 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS .............................................. 39 
12 QUALITY ASSURANCE AND QUALITY CONTROL .................................................................................... 40 
13 ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................................................................ 40 
13.1 
Ethical Standard ................................................................................................................................... 40 
13.2 
Institutional Review Board ................................................................................................................... 40 
13.3 
Informed Consent Process .................................................................................................................... 40 
13.3.1 
Consent/assent and Other Informational Documents Provided to Participants................. 41 
13.3.2 
Consent Procedures and Documentation .......................................................................... 41 
13.4 
Participant and data Confidentiality ..................................................................................................... 41 

 
13.4.1 
Research Use of Stored Human Samples,Specimens or Data ........................................... 42 
13.5 
Future Use of Stored Specimens .......................................................................................................... 42 
14 DATA HANDLING AND RECORD KEEPING ................................................................................................ 42 
14.1 
Data Collection and Management Responsibilities .............................................................................. 42 
14.2 
Study Records Retention ...................................................................................................................... 42 
14.3 
Protocol Deviations .............................................................................................................................. 42 
14.4 
Publication and Data Sharing Policy .................................................................................................... 43 
15 STUDY ADMINISTRATION ............................................................................................................................. 44 
15.1 
Study Leadership .................................................................................................................................. 44 
16 CONFLICT OF INTEREST POLICY ................................................................................................................. 44 
17  LITERATURE REFERENCES ........................................................................................................................... 44 
18  Appendixes ........................................................................................................................................................... 47 
 

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LIST OF ABBREVIATIONS 
 
ACL 
Anterior cruciate ligament (ACL) 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
CIOMS 
Council for International Organizations of Medical Science 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CMS 
Center for Medicare and Medicaid Services 
COMP 
Cartilage oligomeric protein 
CSQ 
Coping Strategies Questionnaire 
CTXII 
Collagen Type II 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FFR 
Federal Finance Report 
GAG 
glycomsaminoglycan 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
GMP 
Good Manufacturing Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation 
ICH E6 
International Conference on Harmonisation Guidance for Industry, Good 
Clinical Practice: Consolidated Guidance 
ICMJE 
International Committee of Medical Journal Editors 
IKDC 
International Knee Documentation Committee 
IL-1ra 
Interleukin 1 receptor antagonist 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
KOOS 
Knee Injury and Osteoarthritis Outcome Score 
LSMEANS 
Least-squares means 
MedDRA 
Medical Dictionary for Regulatory Activities 
MOON 
Multicenter, Orthopaedic Outcome Network 
MOP 
Manual of Procedures 
MRI 
Magnetic Resonance Imaging 
MSDS 
Material Safety Data Sheet 
NIH 
National Institutes of Health 
NIH IC 
NIH Institute and Center 
NtxI 
 
Collagen Type I 
 

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OA 
Osteoarthritis 
OHRP  
Office for Human Research Protections 
PI 
Principal Investigator 
PTOA 
Post-traumatic osteoarthritis 
QA 
Quality Assurance 
QC 
Quality Control 
RA 
Rheumatoid Arthritis 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 
XO 
Xanthine Oxidase 
 
 
 

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STATEMENT OF COMPLIANCE 
 
 
 
The trial will be carried out in accordance with Good Clinical Practice (GCP) as required by the 
following (use applicable regulations depending on study location and sponsor requirements; 
examples follow): • United States (US) Code of Federal Regulations (CFR) applicable to clinical 
studies (45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 
812) • ICH E6 All key personnel (all individuals responsible for the design and conduct of this 
trial) have completed Human Subjects Protection Training. 
 
 
Sponsor: _______ _Austin Stone, MD,PhD______________________ 
                                 Print/Type Name  
 
 
Signed: _____________________________________ Date: ______________ 
                             Signature 
 
 
 
 
 
 
 

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INVESTIGATOR SIGNATURE 
I, the undersigned Investigator, have read the following protocol and agree to conduct the study 
in compliance with the protocol, International Conference on Harmonization (ICH) Good 
Clinical Practice (GCP), Good Laboratory Practice (GLP) and all applicable regulatory 
requirements. 
I, the undersigned Investigator, agree:  
• To assume responsibility for the proper conduct of the study and not to deviate from the 
procedures described in the protocol. 
• I am thoroughly familiar with the investigational product(s) as described in the protocol, 
Investigator’s Brochure and any other relevant information sources provided to me. 
• I am aware of and will conduct the study in compliance with the protocol, ICH GCP 
guidelines and all applicable regulatory requirements. 
• I agree to permit monitoring and auditing of the study by the Sponsor and its designates, and 
inspection by appropriate regulatory authority (ies). 
• I agree to ensure that all persons assisting with the conduct of the study are properly qualified 
for their function. 
 
Investigator Name & Signature: 
 
Principal Investigator: __ Cale Jacobs, PhD _______________________________________ 
                                         Print/Type Name  
 
 
Signed: _____________________________________ Date: ______________ 
                             Signature 
 
 
 
 
 
 

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PROTOCOL SUMMARY 
 
Title: 
 
A Prospective, Multicenter, Randomized, Triple-Blinded, Placebo-
Controlled study of IL-1RA Treatment in Patients with Acute ACL 
Tear and Painful Effusions 
Précis: 
This study aims to establish efficacy and timing of administration, to 
reduce post-injury pain, decrease inflammatory biomarkers in ACL 
injured patients undergoing ACL reconstruction and correlate 
function, patient reported outcomes and MRI findings at 1 years after 
ACL injury.  The study population will include 40 subjects, ages 14-
40 who will be randomized into 2 groups (20 subjects per group).   
Objectives: 
 
1. Test the efficacy of a treatment protocol using IL-1ra and knee 
arthrocentesis to alleviate inflammation related knee pain and 
improve patient-reported outcomes (PRO) following ACL rupture. 
2.  Determine if intra-articular IL-1ra therapy improves levels of a 
panel of inflammatory, meniscus and cartilage metabolism, and 
oxidative stress biomarkers as measured in synovial fluid, serum and 
urine from patients immediately after ACL injury (baseline, 2 weeks 
after injury and at 1 and 2 years after surgery). 
3.  Answer the question if MRI T1rho changes correlate with 
synovial biomarker levels and show predictive value for the overall 
subject patient outcome at 2 years. 
Endpoint 
Primary endpoint :    
Change in Patient reported outcomes as measured by KOOS-
Symptoms  
 
Secondary endpoints:  
KOOS QOL,  
KOOS-pain,  
KOOS-Sports/Rec,  
Biomarker levels in synovial fluid, serum and urine at time of surgery 
MRI T1rho changes at 2 years 
 
Study Stopping Criteria 
 
• Local intolerance of the administered Anakinra (Kineret®) or 
any sign of allergic response. 
• Development of signs and symptoms before the second time 
point preventing the second administration of the study drug. 
• Any patient reported and drug related SAE after the first or 
second administration of the study drug. 
• Diagnosis with any condition as outlined in the exclusion 
criteria during the course of the initial 2 weeks of study 
enrollment. 
Population: 
The study population will include up to 40 subjects within 28 days 
following of injury.  The study is open to male and female 
participants who are between the ages of 14 and 40, who have ACL 
tears. Participants will be enrolled at the University of Kentucky. 

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Phase: 
2 
Number of Sites 
enrolling 
participants: 
1 (University of Kentucky) 
 
 
Description of Study 
Agent : 
IL-1ra (Kineret®, anakinra), supplied by Sobi Pharmaceuticals,  is a 
recombinant, nonglycosylated form of human interleukin-1 receptor 
antagonist (IL-1Ra).  Kineret® consists of 153 amino acids and has a 
molecular weight of 17.3 kilodaltons.  It is produced by recombinant 
DNA technology using an E coli bacterial expression system.  It is 
available as pre-filled syringes (100 mg in 0.67 mls) and is FDA 
approved for daily subcutaneous injection (100 mg/day) for treatment 
of rheumatoid arthritis (age > 10).  A total of 1.5 ml (150 mg) will be 
injected intra-articularly after synovial fluid aspiration 'to dryness' 
once between 1 and 28 days after ACL injury. 
Study Duration: 
24-36 months 
Participant 
Duration: 
2 years 
 
 
 

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SCHEMATIC OF STUDY DESIGN 
 
Flow diagram  
 
Prior to Enrollment   
 
 
 
 
 
 
 
Visit 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
Visit 2  
Surgery 
 
Visit 3  
4-14 days  
After Visit 2  
 
Visit 4 
6 Mo After Visit 2 
 
Visit 5 
12 Mo After Visit 2 
 
Visit 6 
24 Mo After Visit 2 
 
 
Total 40: Obtain informed consent. Screen potential subjects by inclusion and 
exclusion Enrollment criteria; obtain history, document. 
  Randomization for 
those present within 
Day 1-28 of injury
 
 
Group 1 
20 Subjects 
 
 
Perform baseline assessments. Refer to Section 7.3.2 Schedule of Events Table 
Administer initial study intervention. 
Group 1:  Anakinra 1-28 days post-injury 
Group 2:  Saline 1-28 days post-injury  
Refer to Section 7.3.2 Schedule of Events Table 
 Follow-up assessments Refer to Section 7.3.2 Schedule of Events 
Final Assessments 
 Refer to Section 7.3.2 
Schedule of Events 
Group 2 
20 Subjects 
Follow-up assessments Refer to Section 7.3.2 Schedule of Events 
Follow-up assessments Refer to Section 7.3.2 Schedule of Events 

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1 
KEY ROLES 
 
Sponsor 
Name, degree, title:  Austin Stone, MD, PhD  
Institution Name:      University of Kentucky 
Address:                    760 S Limestone, Suite K401 
                                  Lexington, KY 40536-0284 
Phone Number:         (859) 218-3065 
Fax:                           (859) 323-2412 
Email:                       austin.stone@uky.edu 
 
 
Principal Investigator   
 
Name, degree, title:  Cale Jacobs, PhD 
Institution Name:      University of Kentucky  
Address:                    Department of Orthopaedic Surgery and Sport Medicine 
                                  Lexington, KY 40536-0284 
Phone Number:         (859) 797-8197 
Fax:                           (859) 323-2412 
Email:                       cale.jacobs@uky.edu 
 
Monitor: 
Name, degree, title:   Karen Bowen, RN 
Business Name:         Bluegrass Research Consultants, Inc 
Address:                     8020 Sea Hero Run 
                                   Versailles, KY 40383 
Phone Number:          (859) 396-4655 
Email:                         bowen73@windstream.net 
 
Sponsor Regulatory 
 
Name, degree, title:  Laura Ashe 
Business Name:        Center for Clinical and Translational Science 
Address:                    800 Rose Street, Pavilion H, Suite C300 
                                  Lexington, KY 40536 
Phone Number:         (859) 323-2782 
Email:                        Laura.Ashe@uky.edu  
 
 
SAE Reporting 
 
Name, degree, title:  Austin Stone, MD, PhD  
Institution Name:      University of Kentucky 
Address:                    760 S Limestone, Suite K401 
                                  Lexington, KY 40536-0284 
Phone Number:         (859) 218-3065 
Fax:                           (859) 323-2412 
Email:                       austin.stone@uky.edu 
 
                                              

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2  
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE  
 
2.1 
BACKGROUND INFORMATION  
 
A majority of individuals with partial or complete rupture of the anterior cruciate ligament 
(ACL) develop post-traumatic osteoarthritis (PTOA) 5-15 years after the initial injury. The long-
term consequences of PTOA include arthrofibrosis, pain, limited motion, and recurrent 
instability.  Because ACL injuries occur most often in younger individuals (average age 14-29 
years), pain and other debilitating symptoms occur most often during patients’ most productive 
years costing society upwards of 3.06 billion dollars annually [1]. Current surgical and non-
surgical treatment options for ACL injury, while relatively successful in restoring function and 
stability in the short term, do little or nothing to reduce or prevent the development of PTOA 
later in life.  
 
ACL rupture, with or without accompanying damage to nearby cartilage and bone, initiates a 
persistent cascade of inflammation and catabolic enzyme activity leading to OA of the knee 
joint.  We propose to disrupt the inflammation-driven cascade with recombinant Interleukin 1 
receptor antagonist (IL-1ra).   
 
IL-1ra was chosen because it is safe, well tolerated, and has been used to treat RA, juvenile 
inflammatory arthritis, and post-surgical persistent knee effusions as well as knee stiffness.[2-4.] 
Our own preliminary data suggests that IL-1ra reduces pain and improves function in patients 
with acute knee injury and arthrofibrosis.  IL-1ra binds to the Interleukin 1 receptor and 
nonproductively blocks the proinflammatory and cartilage catabolic activities of Interleukin 1 
alpha and beta.  IL-1ra levels in synovial fluid are initially higher following acute ACL injury 
but vanish rather quickly.  Subsequently, IL-1β levels rise slower in joint fluid after ACL rupture 
and remain high for longer periods of time.  IL-1ra has had mixed results in the treatment of 
established OA, possibly due to its short half-life in vivo.  However, if given shortly after the 
initial inciting event potentially initiating the development of OA, the effectiveness may be 
significantly higher.   
 
Unlike primary OA, which typically strikes older individuals and develops silently over the 
course of many years, post-traumatic OA is thought to begin at the moment of ACL injury in 
many individuals. Capitalizing on the expertise and experience of our collaborative team of 
investigators, we have chosen to seize this window of opportunity and provide the field with 
valuable new data regarding the importance of reduction of the initial inflammatory response to 
injury in acute ACL tears.  
 
It is estimated 250,000 injuries to the anterior cruciate ligament (ACL) occur each year (1). 
These injuries predominantly occur at young age (14-18 years) The incidence of these injuries in 
Kentucky alone is 108/100.000 (2), a number that is on par with the incidence of prostate cancer 
in men in the US (125/100.000) and higher than lung cancer in the US (79/100.000)(2) A high-
school soccer player has a knee injury risk of 1/50 player hours. In light of the fact that 
regardless of whether or not the ligament is reconstructed, at least 50% of these patients will 
develop post-traumatic osteoarthritis (PTOA) 10-20 years after injury. (3,4) The consequences of 
PTOA are debilitating, often resulting in participation restrictions and activity limitations that 
affect thousands of individuals each year. Currently the identification of treatment interventions, 
prevention strategies, or changes to current treatment algorithms to delay or deter the 
development of post-traumatic structural damage and subsequent PTOA development is limited 
as the precise mechanism and risk factors for the development of PTOA following ACL injury is 
unknown.  

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Early inflammation: Early inflammation leads to 
swelling, pain and pain related muscle shut down 
affecting recovery. Hemarthrosis and intra-articular 
pathogenic processes (e.g., down-regulation of 
proteoglycan synthesis and up-regulation of matrix 
metalloproteinases) initiate inflammation at the time 
of injury [5-7].  It is widely accepted that the 
balance between IL-1 and IL-1Ra are critical in the 
regulation of the pathological processes involved in 
joint tissue breakdown [8, 9]. IL-1 levels are 
elevated in patients with ACL rupture and correlate 
with severity of chondral damage in a study by 
Marks [10]. Additionally, chondroprotective 
cytokine levels are decreased with increasing 
severity of chondral damage [10]. The superficial 
cartilage layers have been shown to be more 
susceptible to IL-1 induced damage than deeper 
layers, in an in vitro study [11].  Moreover, synovial 
fluid levels of IL-1Ra are reported to decrease 
significantly after ACL injury, resulting in 
relatively unopposed activity of IL-1 [12]. This 
overall up-regulated catabolic state and inflammation leads to recurrent and painful effusions 
which significantly hinder early rehabilitation after injury but also post-operatively. Post-injury 
pain and intra-articular effusion are a major contributing factor to extensor mechanism shut 
down (quadriceps femoris) after injury or surgery which in itself is a significant risk factor for 
delayed recovery and posttraumatic OA development.  
 
Development of posttraumatic 
OA:  It is increasingly recognized 
that biochemical abnormalities of 
the joint precede radiographic 
abnormalities of primary or 
secondary OA by as much as 
decades. A growing body of 
evidence strongly suggests that 
the progression from ACL injury 
to osteoarthritis is multifactorial, 
involving the interplay between 
biomechanical disturbances and 
biochemical homeostasis of 
articular cartilage.  However, 
unlike primary OA, post-
traumatic secondary OA is 
initiated by intra-articular 
pathogenic processes with a 
known date of onset, namely the 
date of joint injury.  This makes 
it much more amenable to early intervention than primary OA whose onset is not clearly 
definable at this time.  For many years, however, it was believed that the biomechanically and 
anatomically correct reconstruction of the ACL would restore near normal joint kinematics. 
Biomechanically the knee joint can be restored to near normal knee kinematics using the latest 
Figure 1: Onset of early posttraumatic OA in a 24-year old 
patient 2 years after ACL reconstruction and partial medial 
meniscectomy. medial joint space narrowing and beginning 
subchondral sclerosis as well as mild squaring of the lateral 
femoral condyle can be seen in comparison to the opposite, 
uninjured side.  This patient ended up receiving a meniscal 
allograft transplant. 
 
 

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anatomic ACL reconstruction techniques. However, the considerable variation in response to 
surgical treatment even in well-controlled studies (2, 13-16) and  recent systematic reviews has 
suggested that reconstructive surgery of the ACL or meniscus fails to protect against OA 
development (2,4). When abnormal joint stressors and abnormal joint physiology occur together, 
the outcome is potentially even more severe (Figure 2, from Lohmander et al (2)).  This is 
illustrated by the fact that severe meniscal damage to the knee is more likely to cause eventual 
knee OA in patients with hand OA (evidence for a genetic predisposition to OA) compared with 
patients without hand OA (17). 
 
ACL Injury and Damage to Articular Cartilage: Chondrocytes (matrix secreting cells) are 
pressure sensitive, and cannot survive compressive forces above a certain threshold, even if the 
cartilage matrix itself is not injured directly.  This threshold may often be exceeded during ACL 
injuries. Without a sufficient number of chondrocytes to maintain a scaffold, the matrix 
eventually breaks down over time, causing pain and potential disability to the affected knee joint, 
often many years after ACL rupture.  While the injury mechanism may lead to direct cartilage 
damage, resulting biomechanical changes of knee function such as increased rotational 
instability, postsurgical changes or subtle loss of range of motion may lead to progressive 
breakdown of articular cartilage in the medial or lateral compartment and may appear as early as 
2 years after injury (18,19) as illustrated in Figure 1.  Indeed, Neuman et al. (20) reported knee 
cartilage glycosoaminoglycans changes within 2 years after ACL injury.  These changes are 
indicative of posttraumatic OA.  
 
Previous Clinical Research: The IL-1ra drug we are planning to use has been previously 
utilized in this patient population. The use of this drug is advantageous as it constitutes a 
meaningful repurposing of an already existing drug that has been shown to be safe in this patient 
population. 
 
Study 1: IL-1Ra decreased pain in an open label trial of arthrofibrosis:  Dr. Virginia Kraus, Co-
Investigator of this study, conducted two small clinical trials to test the beneficial effect of IL-
1ra, an inhibitor of IL-1 biological activity, in vivo.  Six patients who failed to meet entry criteria 
for a separate randomized trial because of age or time from injury to presentation, were entered 
into a small open label study in which they received 150 mg IL-1ra (anakinra, Amgen) intra-
articularly for the treatment of acute ACL injury (n=2), or chronic, recurrent, arthrofibrosis 
following surgical lysis of adhesions (n=4). All 4 arthrofibrosis patients reported improvement in 
knee pain, swelling, and joint motion.  Examination by the treating physician and by physician 
global assessment confirmed these results.  Five out of six patients reported clinically 
significant pain relief after the treatment.  There were no other complaints related to the 
drug and no evidence of significant adverse events in any patient. These results corroborate 
findings from animal studies and imply that adequate exposure to IL-1Ra early in the course of 
disease may potentially reduce pain and stiffness (21).  
 
Study 2: IL-1Ra decreased pain, and improved function, and lowered IL-1α levels in synovial 
fluid in a randomized pilot trial of ACL rupture:  In a second randomized trial, 11 patients with 
isolated ACL tears scheduled for later ACL surgery were treated with 150 mg (anakinra, Amgen; 
6 patients) or equal volume saline placebo (5 patients) intra-articularly within the first 30 days of 
acute knee injury. Mean age of participants was 24 + 4 (SD) years, (6 male, 5 female). 
Enrollment was limited to patients under 40 years of age to try to insure the lack of underlying 
pre-existing arthropathy. Patients were recruited a mean 15 + 7 (SD) days from injury (range 6-
27 days). Self-report of pain on a Likert scale 0-10 was recorded at baseline (0), 4 days, 14 days, 
and 28 days after treatment as well as on the day of surgery.  The standardized KOOS and IKDC 
questionnaires were also obtained.  

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Using the non-parametric Wilcoxon signed-rank sum test, significant differences (p<0.05) were 
observed in the anakinra treated group only: Pain was reduced in the anakinra treated group of 
patients by 23% after 4 days, improvement in Activities of Daily Living by 46%, and 
improvement in total KOOS by 24%; in contrast the placebo group improved by only 4%, 6% 
and 7% for these outcomes, respectively. This suggests a significan early effect in this patient 
population that is beneficial for the early rehab process prior to surgery(22). 
Synovial fluid IL-1α decreased over 1 month in response to a single IL-1Ra intra-articular 
injection in our pilot trial.   The change with treatment (Day 0 to Day 28) in synovial fluid 
IL-1α constituted the most intriguing and promising cytokine result from this pilot trial.  
IL-1α increased in all the placebo treated patients (n=4 pairs of samples available); whereas IL-
1α decreased in 4 or 5 of the anakinra treated patients (n=5 pairs of samples available)(21).   
 
Study 3: In order to prove that we have the 
ability to perform a high level (GCP) 
randomized clinical trial our group has 
performed a randomized clinical trial 
involving ACL patients in the same study 
design featuring identical enrollment 
(inclusion/exclusion) criteria as the one 
proposed in this contract (MOON-AAA 
Clinicaltrials.gov identifier: NCT01692756). 
In this multicenter early intervention trial 
testing the effect of Triamcinolone 
administration patients underwent knee joint 
aspirations, blood draws and urine collections 
at three time points prior to ACL surgery. 
PRO’s and clinical exams were performed at all time points prior to surgery and at 4 time points 
post-surgery up to 6 months post-surgery.   We have successfully enrolled 3-4 patients per month 
in the last 12 months actually exceeding the goal of 2 patients / month as initially estimated. The 
average time from injury to enrollment is 4.2 days with an average patient age of 18.6 years. No 
patients have been lost to follow-up. This trial has just completed enrollment and is in the 
process of data analysis (see table 1). This trial has been extraordinarily successful and was able 
to show that the initial chondrodegradatory response, as measured in synovial fluid can be 
modified intraarticularly with the administration of triamcinolone acetonide.  
 
Pediatric dosing -  Kineret®, was studied in a single randomized, blinded multi-center trial in 
86 patients with polyarticular course Juvenile Rheumatoid Arthritis (JRA; ages 2-17 years) 
receiving a dose of 1 mg/kg subcutaneously daily, up to a maximum dose of 100 mg. The 50 
patients who achieved a clinical response after a 12-week open-label run-in were randomized to 
Kineret® (25 patients) or placebo (25 patients), administered daily for an additional 16 weeks. 
 
A subset of these patients continued open-label treatment with Kineret® for up to 1 year in a 
companion extension study. An adverse event profile similar to that seen in adult RA patients 
was observed in these studies. Pediatric use of Kineret® was not recommended due to difficulty 
dosing the medication in smaller children requiring less than 100mg per dose and because  
efficacy could not be demonstrated due to low trial enrollment. No safety issues were seen. The 
dosing problem will not come to bear in our patient population as we only enroll children 14 
years and older. 
 
Trial Registration Number: NCT00339157. First prospective placebo controlled trial to evaluate 
the effectiveness of IL-1Ra for SJIA. Enrolled a total of 24 patients: mean (SD) age of 9.5 (5) 
years; female subjects entering the study were prepubescent, sexually inactive or required to use 
Table 1: Enrollment data MOON-AAA 
trial 
 

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effective contraception; 12 received 2 mg/kg sc daily for 1 year; 10 received placebo for one 
month then 2 mg/kg sc daily for 11 months. Max dose 100 mg qd. Anakinra treatment was 
effective in SJIA. They noted in the Discussion that: " PK data suggested that low-weight 
children might have benefited from a higher anakinra dosage." 
 
Safety: Between month 1 and month 12, six patients stopped treatment owing to an adverse event 
(n=2), lack of efficacy (n=2) or a disease flare (n=2). "One patient was diagnosed with 
inflammatory bowel disease, a complication reported in some patients initially diagnosed with JIA 
and treated with anti-TNF agents. An additional patient experienced a sudden rise in serum 
transaminases." Of note, patients were on concurrent corticosteroid therapy.39 
An open-label retrospective observational trial of 46 SJIA patients (median age 7.6 years) who 
received anakinra alone (n=10) or in combination with corticosteroids or remittive agents 
including methotrexate or cyclosporine.   
 
Dose: "The median starting dose of anakinra was 1.5 mg/kg/day (IQR 1.1–2.0 mg/kg/day; 
minimum 0.93 mg/kg/day, maximum 11.2 mg/kg/day), and subsequent dose escalation was 
required in 24% of patients. Patients requiring dose escalation received a median initial dose of 
1.3 mg/kg/day, compared with a median initial dose of 1.6 mg/kg/day in patients who did not (P 
not significant). Among 19 patients who started with a dose <1.5 mg/kg/day, 8 (42%) ultimately 
required a higher dose. One patient received anakinra twice daily. In most patients, therapy with 
anakinra could not be interrupted during the term of observation, but recurrent dose escalation 
(tachyphylaxis) was not observed. At the last follow-up visit, anakinra had been discontinued for 
inefficacy in 1 patient, for intolerance in 2, and because of remission in 3; 7 patients could be 
weaned to dosing every other day, although symptoms returned if the interval exceeded 48 
hours." Of note, the patient who received the highest dose of anakinra monotherapy (11.2 
mg/kg/day intravenously administered as 5.6 mg/kg every 12 hours) was being treated in 
intensive care for macrophage activation syndrome, a potentially life-threatening complication of 
SJIA. On this treatment: "She improved dramatically, but her response remained partial, and at 
the last follow-up visit, she was requiring anakinra at 2.3 mg/kg/day, abatacept, and monthly 
pulse corticosteroids."  
 
They concluded that "in general, improvement was rapid and striking." series, children older than 
7 years were more likely to exhibit a complete response to anakinra-based therapy than those 
ages 7 years and younger (75% versus 41%; P < 0.05). 
 
Safety: Five patients developed macrophage activating syndrome while on anakinra but this was 
believed to be due to SJIA and not anakinra. They stated: "the role of anakinra as a trigger for 
these 5 cases cannot be determined, in no case was permanent discontinuation necessary. 
Further, dose escalation often seemed to help control macrophage activation syndrome." 
Injection site reactions occurred in 44% of the 45 patients with evaluable data, leading to 
permanent discontinuation of drug in 1 patient and transient discontinuation in several others.  
 
There were 3 cases of serious infection. A 4-year-old child treated with anakinra at 1 mg/kg/day 
and 6 weeks of corticosteroids developed pneumococcal bacteremia at 2 months in the setting of 
parainfluenza infection. Anakinra was withheld for 1 week but was restarted because of rising 
levels of markers of inflammation. The patient remained well during an additional 6 months of 
observation. An 11-year-old child treated with anakinra (1.2 mg/kg/day) and high-dose oral 
corticosteroids developed an infection at a healed gastric feeding tube site. Anakinra was 
withheld for 2 weeks but was ultimately escalated to 1.9 mg/kg/day without further complication 
during 21 additional months of observation. A 3-yearold child receiving anakinra at 1.7 
mg/kg/day was admitted to the hospital for several days with pneumonia. No organism was 
cultured. Anakinra was restarted after discharge." 
 

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Other events included two episodes of bronchitis, 1 episode of eosinophilic hepatitis requiring 
discontinuation of anakinra, elevation of liver enzymes in 2 patients but anakinra could be 
continued, and mild neutropenia resolved on alternate day anakinra.40 
 
2.2 
RATIONALE  
 
We hypothesize that IL-1Ra administered intra-articularly during the early phase of acute ACL 
injury will provide symptomatic pain relief and decrease synovial fluid inflammatory and cartilage 
degradation markers.  ACL injury produces high levels of inflammatory mediators, including as 
IL-1, which mediate knee pain, perpetuate synovitis, and decrease functional recovery post injury 
and post-surgically. We have designed a clinical trial that specifically tests the ability of IL-1ra to 
alleviate pain following acute ACL injury and potentially changes patient reported outcomes at 2 
years.  
 
A total of 1 mL (150 mg) will be injected intra-articularly after synovial fluid aspiration 'to 
dryness' once at study entry 1-28 days after injury depending on time of presentation).  
 
Rational for including pediatric population 
 
The specific reason for enrolling the age group of children aged 14-18 is that these children have 
a musculoskeletal physiology like adults. 
• Their major growth plates are closed.  
• These patients may be treated surgically like adult patients with exactly the same surgical 
preparation, technique and rehabilitation as adults.  
• Children, particularly girls, between the ages of 14 and 18 have the highest statistical risk 
in any population of tearing their Anterior Cruciate Ligament. 25,45 
• Children in this age group are particularly vulnerable to the later development of 
osteoarthritis. Lohmander et al showed that young female soccer players in this age group 
developed symptomatic knee Osteoarthritis secondary to the ACL injury within 12 years 
of the injury.24  One could therefore argue that particularly children between completed 
puberty and 18 years of age have to be the patients requiring most of our concern 
regarding development of OA.  
• Furman et al. showed that early post-injury administration of IL-1Ra did not alter bone 
morphology or fracture healing after intra-articular fracture but significantly reduced 
cartilage degradation and inflammation.(46) 
• The value of intraarticular IL-1 blockade when given immediately after intraarticular 
injury has been demonstrated repeatedly. In a recent publication of Genemaras et al. the 
early administration of IL-1Ra could be shown to significantly down-regulate pro-
inflammatory Il1-β, TNF-α) and chondrodegredatory markers ( MMP-3,ADAMTS-
4,ADAMTS-5) immediately after non-destructive chondral impact injury to porcine 
articular cartilage(45). 
• Chevalier et al. showed in 2005 that intra-articular injection of anakinra in patients with 
knee OA is safe (47). It is important to realize that patients who have suffered an ACL 
injury are a substantial risk for chronic inflammatory changes leading to OA and, in fact, 
display these changes as early as 4 weeks after injury lasting for up to 5 years after ACL 
injury. (48,49) 
• A study performed by Brown et al. enrolled 8 patients with arthrofibrosis who were 
treated with intra-articular administration of 150mg of anakinra. Five of the eight 
enrolled patients were under the age of 24, 3 under the age of 21, and one patient aged 
15. None of these patients have shown any adverse events and all of them improved in 
their clinical outcomes. In addition the same group completed a study enrolling young 
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significant adverse events regarding safety of the drug administration. In contrary, they 
show improved post-injury pain scores.52 
 
In summary: We would like to argue that skeletally mature adolescents of ages 14-18 are 
musculoskeletally no different than their 19 year old and older counterparts and therefore 
deserve the same potential benefit that early treatment with IL-1Ra may offer older patients. We 
find of no data to indicate that intra-articular use of IL-1Ra would have a different effect in the 
14-18 year old over the 19-40 year old. There is no in-vitro or in-vivo data indicating a 
detrimental effect of Il-1Ra to articular cartilage or the knee joint as a whole in the dosages we 
are intending to use. We believe that the potential benefits of this trial for this patient population 
outweighs by far the uncertainty of unknown risks that may be associated specifically with being 
14-18 year old.  
 
The Federal Drug Administration has approved daily subcutaneous injections (100 mg) to 
patients with rheumatoid arthritis. Our goal is to sustain therapeutic levels of IL-1Ra in the joint 
during the early phase of acute joint injury.  We hypothesize that the post injury intra-articular 
administration of 150 mg IL-1Ra (Kineret®) will be well tolerated. 
 
By slowing the initial inflammatory process after injury and preventing the significant 
quadriceps muscle shutdown early, we aim to work towards this goal in this trial. We therefore 
conclude that given the limited risk of local side effects and the potential large benefit that this 
study would provide to the scientific community and its potential to significantly improve and 
alter patient care of young individuals suffering ACL injuries it is not reasonable to withhold 
pediatric patients aged 14-18 from this important trial. 
 
2.3 
POTENTIAL RISKS AND BENEFITS  
 
2.3.1 KNOWN POTENTIAL RISKS  
 
Safety Precautions: Participants will be followed at regular intervals by their study doctor.  
During each visit participants will be evaluated for adverse events according to GCP guidelines 
and reported accordingly to IRB and FDA regulations. 
 
Risks associated with Kineret®:   
 
Reproductive Risks:  It is not known whether receiving Kineret® is harmful to an unborn child.  
Pregnancy after administration of Kineret® may involve risks to the mother, and her embryo or 
fetus.  Therefore, females who are capable of reproducing, must use effective contraceptive 
methods.  These methods must be used from the time of screening until Visit 2 during which  
any remaining medication will be washed out of the joint during the surgery.  If the participant 
does not elect to have surgery (visit 2) contraception methods will be documented until the end 
of the study. Examples of effective birth control are:  hormonal contraceptives (the pill, implant, 
transdermal patch, or injection), barrier methods (condom with spermicide, diaphragm with 
spermicide), IUD, or a male partner had a vasectomy. 
 
Lactating women:  It is not known whether this drug or its metabolites are excreted in human 
milk.  Because many drugs are excreted in human milk, caution should be exercised when 
Kineret® is administered to a nursing woman. 
 
Limitations, potential problems, and alternatives:  This study will allow for safety and 
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• Dose:  Based on our work and the work of others, we believe 150 mg dosage is 
appropriate.  The goal of the study is to sustain levels of IL-1Ra long enough and a high 
enough concentrations during the critical, early time period to be effective.  For this 
reason, we have increased our dosage from a single injection (carried out in the 
preliminary study) to two injections. 
• Patient attrition:  Close and regular communication, particularly in the intensive first few 
months, will be provided to all subject participants.  Patients will be fully informed of the 
time commitments and need for a total of three arthrocenteses in order to recruit study 
subjects willing to participate in the full study.  Because arthrocentesis alone can be 
expected to benefit subjects, education regarding direct and indirect benefits of all aspects 
of the trial will be provided.  Subjects will also receive appropriate compensation for the 
time and travel. 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
 
IL-1Ra, while potent, has had mixed results in the treatment of established OA, possibly due to 
its short half-life in vivo.  In this trial, we expect that an early intervention with IL-1Ra will 
effectively block the deleterious cascade of joint degradation events after joint injury.  We expect 
a significant effect of IL-1Ra on post-injury pain and concomitantly an increased improvement 
in early function. 
 
3 
OBJECTIVES AND PURPOSE 
 
Primary Objective:   To assess the efficacy of using IL-1ra and knee arthrocentesis to alleviate 
inflammation related knee pain and improve patient-reported outcomes (PRO) following ACL 
rupture. 
 
Secondary Objectives: 
 
1.   To determine if intra-articular IL-1ra therapy improves levels of a panel of inflammatory, 
meniscus and cartilage metabolism, and oxidative stress biomarkers as measured in synovial 
fluid, serum and urine from patients immediately after ACL injury (baseline, 2 weeks after injury 
and at 1 and 2 years after surgery). 
 
2.  To assess if MRI T1rho changes correlate with synovial biomarker levels and show predictive 
value for the overall subject patient outcome at 2 years 
 
4 
STUDY DESIGN AND ENDPOINTS 
 
4.1 
DESCRIPTION OF THE STUDY DESIGN 
 
This is a phase 2, prospective, randomized, triple-blinded, placebo-controlled study of IL-1RA 
treatment in patients with acute ACL tear and painful effusions.  The study population will 
include up to 40 participants within 28 days of injury.  The study is open to male and female 
participants  who are between the ages of 14 and 40, who have ACL tears.  Once enrolled  will 
be randomized into 2 groups (20 subjects per group). 
 
• Group 1 will receive intra-articular injection of Anakinra (Kineret®,  IL-1ra; 150mg) 1-
28 days after ACL injury.  
• Group 2 will receive intra-articular injection of saline placebo 1-28 days after ACL 
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4.2 
STUDY ENDPOINTS 
 
4.2.1 PRIMARY ENDPOINT 
 
Patient reported outcomes as measured by KOOS-Symptoms  
 
4.2.2 SECONDARY ENDPOINTS 
 
KOOS QOL,  
KOOS-pain,  
KOOS-Sports/Rec,  
Biomarker levels in synovial fluid, serum and urine at time of surgery 
MRI T1rho changes at 2 years 
 
5 
STUDY ENROLLMENT AND WITHDRAWAL 
 
5.1 
PARTICIPANT INCLUSION CRITERIA 
 
In order to be eligible to participate in this study, an individual must meet all of the following 
criteria: 
 
• 
Isolated Acute ACL Tear (1-28 days post injury) and painful effusion, with no more than 
a clinical grade 2 MCL injury. 
• 
Provision of signed and dated combined informed consent/HIPAA form and if a minor, a 
signed assent. 
• 
Stated willingness to comply with all study procedures and availability for the duration of  
• 
the study  
• 
Male or female, aged 14-40 years  
• 
For females of reproductive potential: use of highly effective contraception.   
• Currently participating in a sporting activity 
• Documentation of closed growth plates as noted on the screening x-ray 
5.2 
PARTICIPANT EXCLUSION CRITERIA 
 
An individual who meets any of the following criteria will be excluded from participation in the 
study: 
 
• History of underlying inflammatory disease (i.e. Rheumatoid Arthritis, Psoriatic 
Arthritis etc.)  
• History of having been diagnosed with hepatitis B or tuberculosis 
• Currently have an infections, including infection of the skin, or have signs and 
symptoms of an infection, including fever.  
• History any abnormalities in their white blood cell counts 
• History of having a disease that weakens your immune system such as diabetes, cancer, 
HIV or AIDs 
• History of other major medical condition requiring treatment with immunosuppressant 
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• A history of chronic use of non-steroidal anti-inflammatory drugs  
• Currently taking immunosuppressant medication, including oral and parenteral 
corticosteroids (topical and stable dose inhaled corticosteroids are acceptable) 
• Females who are pregnant or breastfeeding 
• Received a “live” vaccine (smallpox, MMR (measles, mumps and rubella), flu, polio, 
typhoid, chicken pox, yellow fever, herpes zoster) 1 week prior to screening or are 
scheduled to receive a “live” vaccine within 1 week after study injection. 
• History of bleeding disorders or are taking any blood thinning medications, aspirin or 
other medications affecting blood clotting. 
• Previous exposure or allergic reaction to anakinra 
• Allergy to latex or tape 
• Allergy to Kineret or have had a reaction to any local or general anesthesia 
• Prior ipsilateral knee surgery  
• Complete ligament tear other than the ACL 
• Received any investigational drug with 4 weeks of study Visit 1 
• Does not have the cognitive ability to provide informed consent. 
 
5.3 
STRATEGIES FOR RECRUITMENT AND RETENTION 
 
Participants in this trial will be recruited within 28 days from injury following a clinical 
appointment with one of the study’s participating orthopaedic surgeons. 
 
Participants in this trial will be recruited within 28 days from injury from the Emergency 
Department or walk-in clinics for acute injuries. 
 
No prisoners will be enrolled into the study.   
 
We will enroll children between the ages of 14-17. Parental consent will be needed in order to 
enroll children into the study. 
 
Participants will receive $150.00 for taking part in this study.  The participant will receive 
$50.00 for each MRI they complete (Visit 1, Visit 5, and Visit 6).  Payment will be in the form of 
a check which will be mailed approximately four to six weeks following the study visit.  If the 
participant is a minor the compensation will be mailed to the minor. 
 
Advertising may be used to promote this study to the public.  All advertisements and public 
marketing will be approved by the IRB prior to use. 
 
5.4 
PARTICIPANT WITHDRAWAL OR TERMINATION 
 
5.4.1 REASONS FOR WITHDRAWAL OR TERMINATION 
 
Subjects are free to withdraw from participation in the study at any time upon request. An 
investigator may terminate participation in the study if:  
 
• Any clinical adverse event (AE), laboratory abnormality, or other medical condition or 
situation occurs such that continued participation in the study would not be in the best 
interest of the participant  
• The participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
 

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5.4.2 HANDLING OF PARTICIPANT WITHDRAWALS OR TERMINATION 
 
A subject may withdraw from the study at any time at his or her own request, or may be 
withdrawn at any time at the discretion of the Investigator for due to safety or scientific reasons.  
Reasons for discontinuation from the study at any time point will be collected.  If subject 
discontinues the study for any reason prior to 3-month visit, then the collected data will be 
evaluated but not included in the analysis and a replacement subject will be enrolled in the 
study. 
 
5.5 
PREMATURE TERMINATION OR SUSPENSION OF STUDY 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party. If the study is prematurely 
terminated or suspended, the PI will promptly inform the IRB and will provide the reason(s) for 
the termination or suspension.  
Circumstances that may warrant termination or suspension include the above mentioned stopping 
criteria as well as: 
 
• Determination of unexpected, significant, or unacceptable risk to participants 
• Demonstration of efficacy that would warrant stopping  
• Insufficient compliance to protocol requirements  
• Data that are not sufficiently complete and/or evaluable  
• Determination of futility  
 
Study may resume once concerns about safety, protocol compliance, data quality are addressed 
and satisfy the sponsor, IRB and/or FDA. 
 
6 
STUDY AGENT 
 
6.1 
STUDY AGENT(S) AND CONTROL DESCRIPTION 
 
6.1.1 ACQUISITION 
 
Unblinded study drug will be shipped from the manufacturer Swedish Orphan Biovitrum (Sobi) 
directly to the site research pharmacist, after all required regulatory and legal documents have 
been received by the Sponsor. 
 
Replacement Procedures For Investigational Medicinal Product: Resupply shipments or 
replacement of study drug will be provided by Sobi after consultation with Dr. Stone. 
 
6.1.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
 
Formulation, Packaging and Labeling:  Kineret® is a recombinant, nonglycosylated form of 
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a molecular weight of 17.3 kilodaltons.  It is produced by recombinant DNA technology using an 
E coli bacterial expression system. 
 
Kineret is supplied in single use prefilled glass syringes with 29 gauge needles as a sterile, clear, 
colorless-to-white, preservative free solution for daily subcutaneous (SC) administration. The 
solution may contain trace amounts of small, translucent-to-white amorphous proteinaceous 
particles. Each prefilled glass syringe contains: 0.67 mL (100 mg) of anakinra in a solution (pH 
6.5) containing anhydrous citric acid (1.29 mg), disodium EDTA (0.12 mg), polysorbate 80 (0.70 
mg), and sodium chloride (5.48 mg) in Water for Injection, USP. 
 
The prefilled syringe contains an outer rigid plastic needle shield attached to an inner needle 
cover. The syringe or needle shield components are not made with natural rubber latex. 
 
Each syringe will have a label that will contain, at minimum, the protocol number, 
contents (written as “Kineret®”), applicable regulatory cautions, storage conditions, route 
of administration, and a space to write in the dispensing date, subject identification number and 
subject initials.  
 
6.1.3 PRODUCT STORAGE AND STABILITY 
 
The prepared syringes of Kineret or placebo will be stored in a separate, temperature controlled 
refrigerator at the investigative site.  
Kineret® should be stored in the refrigerator at 2° - 8° C (36° - 46°F).  DO NOT FREEZE OR 
SHAKE.  Protect from light. Kineret® should not be used after the expiration date unless 
otherwise notified by the Principal Investigator.   
 
The study drug will be sent to the designated research staff at the University of Kentucky.   
 
Once a subject is identified and consented, the study coordinator will utilize the syringe 
corresponding to the assigned patient ID to administer the study medication.  It has been shown 
by HPLC analyses, that Kineret is stable for at least 4 hours at ambient temperature and in light 
in 0.9%NaCl and in a plastic culture vial.38 
 
The refrigerator temperature must be monitored by site personnel on a regular basis and must be 
recorded on a temperature log sheet or recorded electronically.  In the event that the 
refrigerator’s temperature goes outside the 2° - 8° C (36° - 46°F) range, the Sponsor or designee 
should be contacted immediately at the telephone number provided in the protocol.  Only 
temperature excursions outside of the acceptable range, per the Sponsor’s procedures, are 
reported as protocol deviations. 
 
6.1.4 PREPARATION 
 
The study drug will be kept in a temperature controlled environment according to the 
manufacturer’s recommendations  
 
Under aseptic clean conditions, a total of 200 mg (1.34 mL) of Kineret® (concentration 
100mg/0.67ml) will be injected from 2 sterile original prefilled 100 mg syringes of Kineret into a 
sterile vial. A sterile graduated 5 mL syringe will then be used to draw 150 mg (1 mL) of Kineret 
for intraarticular injection into the knee. The medication must be transferred from the original 
prefilled Kineret syringes as the needles are intended for subcutaneous delivery and are not 
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For the placebo we will utilize 1 mL of 0.9%NACL sterile saline solution drawn up in the same 
type of syringe as for the Kineret administration in order to maintain double blinding of the study 
investigator and patients. 
The number of study syringes prepared by the designated research personnel or research 
pharmacist, per day, will depend on the number of potential enrollees or return patients requiring 
Kineret® injections that day. 
 
6.1.5 DOSING AND ADMINISTRATION 
Study treatment must only be dispensed by a pharmacist or other medically qualified staff.  
Study treatment is to be dispensed only to subjects enrolled in this study. 
 
Once a subject is identified and consented, the investigator will utilize the syringe corresponding 
to the assigned patient ID to administer the study medication.  It has been shown by HPLC 
analyses, that Kineret is stable for at least 4 hours at ambient temperature and in light in 
0.9%NaCl and in a plastic culture vial.38 
 
• Group 1 will receive intra-articular injection of Anakinra (Kineret®,  IL-1ra; 150mg) 1-
28 days after ACL injury. 
• Group 2 will receive intra-articular injection of saline placebo 1-28 days after ACL 
injury. 
 
6.1.6 ROUTE OF ADMINISTRATION 
 
Intra-articular injection 
 
6.1.7 STARTING DOSE AND DOSE ESCALATION SCHEDULE 
 
The starting dose of Kineret is 150mg.  There is no planned dose escalation. 
 
6.1.8 DOSE ADJUSTMENTS/MODIFICATIONS/DELAYS 
 
No dose adjustments or modifications are allowed in this study. 
 
6.1.9 DURATION OF THERAPY 
 
Enrolled participants will receive, based on their randomization, either Kineret or a matching 
saline placebo within 1-28 days after suffering an ACL injury.   
 
If a participant discontinues the study for any reason prior to 3-month visit, then the collected 
data will be evaluated but not included in the analysis and a replacement participant will be 
enrolled in the study. 
 
6.1.10 TRACKING OF DOSE 
 
6.2 
STUDY AGENT ACCOUNTABILITY PROCEDURES 
 
It is the responsibility of the Sponsor/Investigator to supervise accurate monitoring of the receipt, 
storage, dispensing, and accounting of all study drug according to accepted medical and 
pharmaceutical practice, and should also comply with state and local regulations. The originals 
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drug inventory and dispensing must be maintained using the forms provided by the 
Sponsor/Investigator. All disposition records must be made available for inspection by the FDA, 
DSMB, monitor or designee upon request. 
Forms will be provided for the accounting of study drug and for the accounting of study drug for 
each subject. A reason(s) must be given for any study drug that is not accounted for. Site must 
keep all used and unused study drug in their original box until the monitor either arranges return 
to the distribution center or gives instruction on their disposal. If any unused study drug remain 
at the end of the study, they will be accounted for at the end of the study in the presence of the 
monitor who will provide instructions on their disposal 
 
7 
STUDY PROCEDURES AND SCHEDULE 
 
7.1 
STUDY PROCEDURES/EVALUATIONS 
 
7.1.1 STUDY RELATED   
 
Demographic information:  Demographic data to be collected at Visit 1 will include height, 
weight, date of birth, age, gender and race. 
 
Medical and Medication History A detailed past medical history and a list of current 
medication, to include prescription and over-the-counter medications, will be collected at Visit 1.  
Assessment of eligibility should include a review of permitted and prohibited medications. Both 
the medical and medication history will be reviewed with the subject throughout the study for 
any changes in baseline history. 
 
Physical examination including vital signs, height, weight, BMI. All subjects must have a 
clinical exam that is consistent with an ACL tear at Visit 1. All subjects will have range of 
motion (ROM) collected at all visits. 
 
Knee Aspiration:  All subjects undergo knee aspiration to dryness at initial encounter Visit 1 (1-
28 days after ACL injury), Visit 2 (the time of surgery) and again at Visit  3 (4-14 days post-op).   
Should a subject be enrolled into the study and choose not to undergo ACL reconstruction, 
subject will receive treatment according to this protocol but, aspiration at time of surgery will be 
omitted. 
 
Assessment of Pain and Function –Subject Reported Outcomes – The study will use the 
standardized subject self-report Knee Injury and Osteoarthritis Outcome Score (KOOS) 
instrument to assess pain and function in response to the intervention for acute ACL injury. The 
KOOS is a 100 item instrument that consists of 5 subscales (pain, other symptoms, function in 
daily living, function in sport and recreation, and knee-related quality of life). The 5 separate 
subscales provide a complete picture of patients' perceptions of their knee injury and 
consequences to their daily activities, etc.. KOOS includes the WOMAC osteoarthritis index, 
which allows for potential comparison with other earlier studies. The KOOS has high test-retest 
reproducibility (ICC > 0.75). The KOOS subscales for function in sport and recreation and knee-
related quality of life have been shown to be the most sensitive subscales pre-operatively and 
change the most post-operatively (27).  The study will supplement the KOOS with self-reported 
function score assessments from the International Knee Documentation Committee (IKDC) form 
for evaluation of knee ligament injuries (28) as well as the. Veterans Rand 12-Item (VR-12) 
health survey and the Patient Acceptable Symptoms State (PASS) question. The questionnaires 
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through a password coded entry portal or during routine clinical visits using an IPad or paper 
forms. Paper forms may be used during routine clinical visits or directly mailed to patients. 
  
Specific Pain assessments - Pain coping strategies are important in understanding improvements 
in pain and psychological disability [46-48].  This study will use a simple Likert pain scale as a 
pain assessment tools (Figure 3). Pain catastrophizing has been identified as one of the strongest 
predictors of pain and has been defined as “an individual’s tendency to focus on and exaggerate 
the threat value of painful stimuli and negatively evaluate one’s own ability to deal with pain.” 
[49] Not only do individuals who catastrophize, experience more experimental pain (29-31) but 
also, catastrophizing has been shown to account for 7% to 31% of the variance in pain ratings in 
varied populations of patients having persistent pain.  
 
MRI analysis: All subjects will undergo MRI examination following Visit 1 and subsequent 
MRIs will be performed at Visits 5 and 6. Sagittal and axial MRI images will be acquired using a 
3.0-T MRI scanner and an 1Tx/15Rx phased array knee coil. Sagittal and axial T1-weighted spin 
echo images (FSE) will be acquired to allow semi-quantitative analysis at the conclusion of the 
study. These sequences will be followed by a sagittal high-resolution 3D dual echo steady state 
(DESS) sequence for cartilage segmentation and a sagittal combined T1ρ/T2 mapping for the 
quantification of cartilage composition. The major parameters for the DESS sequences are: FOV 
= 140 mm, matrix = 384×307×176, resolution = 0.36×0.45×0.7 mm3, time of repetition 
(TR)/time of echo (TE) = 17.6ms/6.0ms. The T1ρ/T2 mapping will be acquired using a 3D 
MAPSS sequence with major parameters: FOV = 140 mm, image matrix = 320×160×24, 
resolution = 0.44×0.44×4 mm3, time of recovery = 1.5 seconds, bandwidth = 400 Hz/Pixel, 
TR/TE = 7ms/3ms, time of spin lock (TSLs) = 0, 10, 40, 80 ms for T1ρ mapping and preparation 
TEs = 0, 20, 40, 60 ms for T2 mapping. The scan time will be approximately 12 minutes for the 
combined T1ρ/T2 mapping. Images will obtained with the knee in full extension.  
 
Images collected at the University of Kentucky will then be transferred digitally to the University 
of California, San Francisco to be analyzed by Dr. Majumdar and her laboratory. Based on the 
high resolution DESS images, articular cartilage will be segmented using a spline-based, 
semiautomatic technique. The T1ρ map will be created on a voxel-by-voxel basis using 
established fitting routines. The segmented masks will then be overlaid on the T1ρ maps after 
registration between DESS and T1ρ images, and mean T1ρ  values will be calculated for the 
entire tibiofemoral cartilage, medial and lateral tibial plateau, medial and lateral femoral 
condyles, and the patellofemoral compartment  will be calculated.  
 
 
 

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7.1.2 STANDARD OF CARE STUDY PROCEDURES  
 
Radiographic Analysis: 
Plain x-ray analysis: All subjects would have undergone a routine clinical x-ray analysis prior to 
Visit 1.   This includes bilateral x-ray views of the knee joint using a standing a/p, synaflexer 
standardized flexion weight bearing p/a (Synarc®), Merchant views and weight bearing lateral 
views. Radiographs will be assessed to determine study eligibility as open growth plates are an 
exclusion criteria. Plain radiographs will be reviewed for radiographic progression of joint space 
narrowing or osteophyte formation using the Kellgren-Lawrence classification system as well as 
the Iwano classification for the patello-femoral joint.  
 
Previous studies have shown that that joint space narrowing measured on a standardized 
synaflexor platform has a high reproducibility and accuracy. At 2 years koint space narrowing 
has been identified in an ACL injured cohort using this system (32).  
 
7.2 
LABORATORY PROCEDURES/EVALUATIONS 
 
7.2.1 CLINICAL LABORATORY EVALUATIONS  
 
Clinical Laboratory Evaluations: none 
 
Pregnancy test: Female participants of child bearing potential will have a urine pregnancy test at 
Visit 1.  Pregnancy testing results must be negative in order for enrollment into the study.  
 
Procedure for minors: A female minor is identified as a potential candidate for the study. The 
investigator or approved study staff approach the patient and accompanying parent/guardian to 
inform them that the patient may qualify for a study.  Both parties are informed of the study.  If 
interested in participating in the study, each research team will perform a pregnancy test for 
inclusion/exclusion in correspondence with their locally approved minor pregnancy testing 
protocol.  
 
Non-Clinical Laboratory Evaluations: 
 
Figure 3. (A) Cartilage subcompartment definition in medial (left) and lateral (right) sides. (B) 
Meniscal region definition in medial (left) and lateral (right) sides. 109 

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Sample collection including joint arthrocentesis. Synovial fluid will be aspirated and spun at 
3500 RPM for 10 minutes and the supernatant will be frozen at -70°C. Joint aspiration will be 
performed aseptically with local anesthesia through a superolateral suprapatellar approach.  The 
aspiration syringe will be gently removed and the study drug/placebo-containing syringe will be 
attached, followed by injection. The supernatants will be stored, pending analysis, in the UK 
Center for Clinical and Translational Science Bioanalysis Lab.  All biomarker analyses in 
synovial fluid, serum, and urine will be performed by co-Investigator Dr. Virginia Kraus at Duke 
University.  
 
IL-1ß, IL-1α, IL-6 and IL-1Ra analyses - These cytokines will be measured in the 
synovial fluid using the high-sensitivity Quantikine (sandwich) Immunoassays (R&D).  As 
described previously (39), the standard curve will be extended in the low range for the IL-1α 
assay to further improve the specificity as we have found the standard curve of the assay to be 
reproducible and linear below the lower standard described in the procedural literature 
accompanying the reagents.    
 
 
Glycosaminoglycan (GAG) - The S-GAG content, a marker of proteoglycan degradation, 
will be measured in synovial fluid with the dimethyl methylene blue dye (DMMB) assay as 
noted previously (40). Chondroitin sulfate from shark cartilage will be used as a standard 
between 5 and 50 mg/ml.   
 
Type II collagen (cartilage) degradation assay - CTX-II is derived from the C-terminal 
crosslinked telopeptide of type II collagen. Following degradation of cartilage it is released into 
the synovial fluid, the circulation, and subsequently secreted into urine. CTX-II correlates with 
the degree of joint destruction and increases significantly within one month after ACL tear 
(P=0.012)(41).  CTX-II will be measured in synovial fluid by ELISA (IDS, Herlev, Denmark 
(42).  
 
 
Type I collagen (meniscus) degradation assay – NTX-I is derived from the N-
telopeptide of type I collagen and was significantly elevated in synovial fluid after acute ACL 
tear (P=0.008) in our pilot study (42)  We will measure NTX-I in synovial fluid by ELISA(42) In 
serum it is considered to be indicative of bone resorption. In synovial fluid in the setting of acute 
joint injury we believe it to be indicative of meniscal injury and metabolism due to the fact that 
meniscus is primarily a type I collagen containing tissue.  
 
 
Cartilage Oligomeric Matrix Protein (COMP) - COMP is a pentameric, anionic, 
noncollagenous glycoprotein and member of a thrombospondin family of extracellular proteins 
that was initially isolated from cartilage (43) Although other joint tissues express COMP (44), it 
is most abundant in articular cartilage. Serum COMP levels are representative of cartilage 
catabolism (45,46) and we have demonstrated that serum COMP is associated with the presence 
and severity of radiographic OA and progression of OA [60]. COMP will be measured by 
sandwich ELISA (Biovendor) with mAbs 17C10 and 16F12 a recombinant COMP standard with 
an assay range of 0.1-32 U/L and the CV is <5%. 
 
 
Xanthine Oxidase (XO) - generates superoxide, a powerful reactive oxygen species. 
Synovial fluid XO is indicative of oxidative stress and increases in the first month after joint 
injury (Kraus unpublished data). It is measured by a multistep enzymatic reaction available from 
Cayman Chemical (Ann Arbor, Michigan) whose end product resorufin, is a highly fluorescent 
compound that can be easily analyzed using an excitation wavelength of 520-550 nm and an 
emission wavelength of 585-595 nm.  
 
7.2.2 OTHER ASSAYS OR PROCEDURES 

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None 
 
7.2.3 SPECIMEN PREPARATION, HANDLING, AND STORAGE 
 
Refer to the study lab processing manual 
 
7.2.4 SPECIMEN SHIPMENT 
 
Refer to the study lab processing manual 
 
7.3 
STUDY SCHEDULE 
 
7.3.1 SCREENING/ENROLLMENT 
 
Visit 1 Screening 1-28 days following injury)  
• Obtain informed consent and assent, if necessary, of potential subjects  
• Review medical history to determine eligibility based on inclusion/exclusion criteria.  
• Review medication history to determine eligibility based on inclusion/exclusion criteria.  
• Perform medical examinations and collect vital signs as needed to determine eligibility  
   based on inclusion/exclusion criteria. All subjects must have a clinical exam that is 
consistent with an ACL tear. 
• Collection of urine and blood for laboratory testing. Women of child bearing potential will 
be given a urine pregnancy test.  Test must be negative in order to enroll into the study. 
• Subjects will have the following assessments:  range of motion, knee instability 
(Lachman’s test) and standardized MTP-2 weight bearing x-rays.   
• Standard questionnaires including the KOOS, IKDC, VR-12 and a Likert pain scale. 
• Research knee MRI 
 
Following the review of above assessment results and a review of inclusion/eclusion criteria, 
subjects will be randomized into 1 of 3 treatment groups.  Following randomizing, subjects will 
undergo a knee aspiration and will receive their first dose study medication. 
 
Visit 2 (day of surgery or 4-6 weeks post injury) 
• Knee aspiration (in the operating room under anesthesia) 
• Patient reported outcomes (PROs) administered prior to surgery 
• KOOS, IKDC, VR-12 and a Likert pain scale administered prior to surgery 
• Biomarkers (urine and blood) pre-operatively 
• Review for AE’s and SAE’s 
• ROM will be performed prior to surgery 
 
Visit 3 (4-14 days After Visit 2  ) 
• Knee aspiration (if clinically indicated) 
• Biomarkers (urine and blood) 
• Review for AE’s and SAE’s 
• ROM will be performed 
 
Visit 4 (6 month After Visit 2+/- 2 weeks) 
• Patient reported outcomes (PROs) administered 
• KOOS, IKDC,  VR-12 and a Likert pain scale administered  
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• ROM will be performed 
 
Visit 5 (12 monthsAfter Visit 2+/- 2 weeks) 
• MRI 
• Patient reported outcomes (PROs) administered 
• KOOS, IKDC,  VR-12 and a Likert pain scale administered  
• Biomarkers (serum and urine only) 
• Review for AE’s and SAE’s 
• ROM will be performed 
 
Visit 6 (24 month After Visit 2+/- 2 weeks) 
• MRI 
• Patient reported outcomes (PROs) administered 
• KOOS, IKDC,  VR-12 and a Likert pain scale administered  
• Biomarkers (serum and urine only) 
• Review for AE’s and SAE’s 
• ROM will be performed 
 
7.3.2 SCHEDULE OF EVENTS TABLE 
 
This section should capture the procedures that will be accomplished at each study visit and 
correspond to the descriptions in the above sections. 
 
Procedures 
Screening 
(Visit 1) 
Visit 
2e 
Visit 
3 
Visit 4 
Visit 5 
End of 
Study 
Visit 6 
 Time point 
1-28 days 
post injury 
Surgery 
day or 
4-6 
weeks 
post 
injury 
4-14 
After 
Visit 2 
6  months 
After 
Visit 2 
(+/- 2 
weeks) 
 
12  After 
Visit 2 
(+/- 2 
weeks) 
 
 
24 months 
After Visit 2 
(+/- 4 
weeks) 
 
Informed Consent 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
Medical  history 
X 
X 
X 
X 
X 
X 
Randomization 
X 
 
 
 
 
 
Administer Investigational 
Product 
X 
 
 
 
 
 
Concurrent meds 
X 
X 
X 
X 
X 
X 
Physical Exam 
X 
 
 
 
 
 
Range of motion 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
 
 
 
 
 
Height 
X 
 
 
 
 
 
Weight 
X 
 
 
 
 
 
Questionnaires 
X 
X 
 
X 
X 
X 
Knee Aspiration 
X 
Xa 
Xh 
 
 
 
Biomarkers 
X 
X 
X 
 
Xd 
Xd 
Safety Lab Testsb 
X 
 
 
 
 
 

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Procedures 
Screening 
(Visit 1) 
Visit 
2e 
Visit 
3 
Visit 4 
Visit 5 
End of 
Study 
Visit 6 
Urine pregnancy testsc 
X 
 
 
 
 
 
Adverse event evaluation 
X 
X 
X 
X 
X 
X 
X-Rayf 
X 
 
 
 
 
 
MRIg 
X 
 
 
 
X 
X 
a:    Should a subject be enrolled into the study and choose not to undergo ACL reconstruction aspiration at time of surgery will be 
omitted.    
b:   Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, 
potassium, total protein, SGOT [AST], SGPT [ALT], sodium.  
c:  Urine pregnancy test (women of childbearing potential). 
d:  Serum and urine only 
e.  Should a subject be enrolled into the study and choose not to undergo ACL reconstruction, subject will received treatment according 
to this protocol.  For subjects that do not have ACL reconstruction, the time windows will be relative to Visit 2. For example, Visit 3 will 
be 4-14 days after Visit 2 
f.  All subjects must have standardized MTP-2 weight bearing x-ray.  Documentation of closed growth plates at screening will be noted 
in the routine SOC x-ray 
g.  All subjects enrolled will have an MRI performed regardless if surgery is to be scheduled or not.  However, randomization can be 
performed prior to MRI as the MRI examination is not necessary or required to diagnose the ACL tear. 
h.  We will only perform the aspiration at Visit 3 if participants had elected to have surgery performed, and if they have fluid on their 
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7.4 
JUSTIFICATION FOR SENSITIVE PROCEDURES 
 
Not Applicable. 
 
7.5 
CONCOMITANT MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
All concomitant prescription medications taken during study participation will be recorded on 
the case report forms (CRFs). For this protocol, a prescription medication is defined as a 
medication that can be prescribed only by a properly authorized/licensed clinician. Medications 
to be reported in the CRF are concomitant prescription medications, over-the-counter 
medications and non-prescription medications including herbal supplements. 
 
7.6 
PROHIBITED MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
Treatment with (list specific drugs) will not be permitted unless discussed with and approved by 
the PI. 
 
• Immunosuppressant including oral and parenteral corticosteroids (topical and stable dose 
inhaled corticosteroids are acceptable)or modulating drugs.  
• Non-steroidal anti-inflammatory drugs  
• Any blood thinning medications, aspirin or other medications affecting blood clotting. 
 
7.7 
PROPHYLACTIC MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
Not applicable 
 
7.8 
RESCUE MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
  Not Applicable 
 
7.9 
PARTICIPANT ACCESS TO STUDY AGENT AT STUDY CLOSURE  
 
Not applicable. 
 
8 
ASSESSMENT OF SAFETY 
 
8.1 
SPECIFICATION OF SAFETY PARAMETERS 
 
8.1.1 DEFINITION OF ADVERSE EVENTS (AE) 
 
Adverse event means any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
 
 
 

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8.1.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 
 
Serious adverse event or serious suspected adverse reaction. An AE or suspected adverse 
reaction is considered "serious" if, in the view of either the investigator or sponsor, it results in 
any of the following outcomes: death, a life-threatening adverse event, inpatient hospitalization 
or prolongation of existing hospitalization, a persistent or significant incapacity or substantial 
disruption of the ability to conduct normal life functions, or a congenital anomaly/birth defect. 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, they 
may jeopardize the patient or subject and may require medical or surgical intervention to prevent 
one of the outcomes listed in this definition. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias 
or convulsions that do not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse. 
 
8.1.3 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
 
OHRP considers unanticipated problems involving risks to participants or others to include, in 
general, any incident, experience, or outcome that meets all of the following criteria:  
 
• Unexpected in terms of nature, severity, or frequency given (a) the research procedures that  
   are described in the protocol-related documents, such as the IRB-approved research  
   protocol and informed consent document; and (b) the characteristics of the participant  
   population being studied;  
• Related or possibly related to participation in the research (“possibly related” means there is  
   a reasonable possibility that the incident, experience, or outcome may have been caused by  
   the procedures involved in the research); and  
• Suggests that the research places participants or others at a greater risk of harm (including 
   physical, psychological, economic, or social harm) than was previously known or 
   recognized.  
 
This study will use the OHRP definition of UP. 
 
8.2 
CLASSIFICATION OF AN ADVERSE EVENT 
 
8.2.1 SEVERITY OF EVENT 
 
All AEs will be assessed by the clinician using a protocol defined grading system.  The protocol 
defined grading system to be used is:  
 
• Mild – Events require minimal or no treatment and do not interfere with the participant’s daily  
 activities. 
• Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
  measures. Moderate events may cause some interference with functioning.  
• Severe – Events interrupt a participant’s usual daily activity and may require systemic drug  
  therapy or other treatment. Severe events are usually potentially life-threatening or  
  incapacitating. 
 
 
 

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8.2.2 RELATIONSHIP TO STUDY AGENT 
 
All AEs will have their relationship to study agent or study participation assessed with a level of 
specificity appropriate to the study design. The clinician’s assessment of an AE's relationship to 
study agent (drug) is part of the documentation process, but it is not a factor in determining what 
is or is not reported in the study. If there is any doubt as to whether a clinical observation is an 
AE, the event should be reported. All AEs must have their relationship to study agent assessed. 
In a clinical trial, the study product must always be suspect. To help assess, the following 
guidelines are used.  
 
• Related – The AE is known to occur with the study agent, there is a reasonable possibility 
   that the study agent caused the AE, or there is a temporal relationship between the study  
   agent and event. Reasonable possibility means that there is evidence to suggest a causal  
   relationship between the study agent and the AE.  
• Not Related – There is not a reasonable possibility that the administration of the study  
  agent caused the event, there is no temporal relationship between the study agent and event  
  onset, or an alternate etiology has been established. OR For all collected AEs, the clinician 
  who examines and evaluates the participant will determine the AE’s causality based on  
  temporal relationship and his/her clinical judgment. The degree of certainty about causality  
  will be graded using the categories below.  
 
1. Definitely Related – There is clear evidence to suggest a causal relationship, and 
other possible contributing factors can be ruled out. The clinical event, including an 
abnormal laboratory test result, occurs in a plausible time relationship to drug 
administration and cannot be explained by concurrent disease or other drugs or 
chemicals. The response to withdrawal of the drug (dechallenge) should be clinically 
plausible. The event must be pharmacologically or phenomenologically definitive, 
with use of a satisfactory rechallenge procedure if necessary.  
 
2. Probably Related – There is evidence to suggest a causal relationship, and the 
influence of other factors is unlikely. The clinical event, including an abnormal 
laboratory test result,    occurs within a reasonable time after administration of the 
drug, is unlikely to be attributed to concurrent,  disease or other drugs or chemicals, 
and follows a clinically reasonable response on withdrawal (dechallenge). Rechallenge 
information is not required to fulfill    this definition.  
 
3.  Possibly Related – There is some evidence to suggest a causal relationship (e.g., the 
event occurred within a reasonable time after administration of the trial medication). 
However, other factors may have contributed to the event (e.g., the participant’s 
clinical condition, other concomitant events). Although an AE may rate only as 
“possibly related” soon after discovery, it can be flagged as requiring more 
information and later be upgraded to “probably related” or “definitely related,” as 
appropriate.  
 
4.  Unlikely to be related – A clinical event, including an abnormal laboratory test 
result, whose temporal relationship to drug administration makes a causal relationship 
improbable (e.g., the event did not occur within a reasonable time after administration 
of the trial medication) and in which other drugs or chemicals or underlying disease 
provides plausible explanations (e.g., the participant’s clinical condition, other 
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5. 
Not Related – The AE is completely independent of study drug administration, 
and/or evidence exists that the event is definitely related to another etiology. There 
must be an alternative, definitive etiology documented by the clinician 
 
8.2.3 EXPECTEDNESS  
 
Expected adverse reactions are AEs that are common and known to occur for the study agent 
being studied and should be collected in a standard, systematic format using a grading scale 
based on functional assessment or magnitude of reaction.  
 
An AE or suspected adverse reaction is considered "unexpected" if it is not listed in the IB or is 
not listed at the specificity or severity that has been observed; or, if an IB is not required or 
available, is not consistent with the risk information described in the general investigational plan 
or elsewhere in the protocol or the USPI, as amended. For example, under this definition, hepatic 
necrosis would be unexpected (by virtue of greater severity) if the IB referred only to elevated 
hepatic enzymes or hepatitis. Similarly, cerebral thromboembolism and cerebral vasculitis would 
be unexpected (by virtue of greater specificity) if the IB listed only cerebral vascular accidents. 
"Unexpected," as used in this definition, also refers to AEs or suspected adverse reactions that 
are mentioned in the IB as occurring with a class of drugs or as anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation.  
 
The Principal Investigator will be responsible for determining whether an AE is expected or 
unexpected. An AE will be considered unexpected if the nature, severity, or frequency of the 
event is not consistent with the risk information previously described for the study agent. 
 
8.3 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP 
 
The occurrence of an AE or SAE may come to the attention of study personnel during study 
visits and interviews of a study participant presenting for medical care, or upon review by a 
study monitor. All AEs including local and systemic reactions not meeting the criteria for SAEs 
will be captured on the appropriate CRF. Information to be collected includes event description, 
time of onset, clinician’s assessment of severity, relationship to study product (assessed only by 
those with the training and authority to make a diagnosis), and time of resolution/stabilization  as 
well as seriousness of the event. All AEs occurring while on study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution.  
 
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s condition 
deteriorates at any time during the study, it will be recorded as an AE. UPs will be recorded in 
the data collection system throughout the study.  
Changes in the severity of an AE will be documented to allow an assessment of the duration of 
the event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode.  
 
The PI will record all reportable events with start dates occurring any time after informed 
consent is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study 
participation. At each study visit, the investigator will inquire about the occurrence of AE/SAEs 
since the last visit. Events will be followed for outcome information until resolution or 
stabilization. 
 

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8.4 
REPORTING PROCEDURES 
 
8.4.1 ADVERSE EVENT REPORTING  
 
The Principal Investigator will assess the occurrence of AEs throughout the subjects’ 
participation in the study.  Subjects will be followed for toxicity for 30 days after treatment has 
been discontinued or until death, whichever occurs first.  The clinical course of each event will 
be followed until resolution, stabilization, or until it has been determined that the study treatment 
or participation is not the cause.   
 
The investigator is responsible for ensuring that all adverse events observed by the investigator 
or reported by the subject, which occur after the subject has signed the informed consent, are 
fully recorded in the subject’s case report form, subject’s medical records, and/or any other 
institutional requirement.  Source documentation must be available to support all adverse events.  
 
A laboratory test abnormality considered clinically relevant (e.g., causing the subject to 
withdraw from the study), requiring treatment or causing apparent clinical manifestations, or 
judged relevant by the investigator, should be reported as an adverse event.   
 
The investigator will provide the following for all adverse events: 
• Description of the event 
• Date of onset and resolution 
• seriousness of the event  
• Attribution of relatedness to the investigational agent 
• Action taken as a result of the event 
• Outcome of event 
 
The Principal Investigator will report adverse events to the IRB according to their policies and 
procedures in reporting adverse events.   
 
8.4.2 SERIOUS ADVERSE EVENT REPORTING  
 
Investigator Reporting to the FDA:   Adverse reactions will be reported promptly to the Food 
and Drug Administration (FDA) via Medwatch by the Sponsor if the type of event is serious, 
unlisted/unexpected and possibly related to the study drug.  A clear description of the suspected 
reaction will be provided along with an assessment as to whether the event is drug or disease 
related.  The Sponsor will call the FDA as soon as he/she is aware (within ten (10) working days) 
that an adverse reaction has occurred.  The phone number for the FDA is 301-594-5778.   
 
The study sponsor will be responsible for notifying FDA of any unexpected fatal or life-
threatening suspected adverse reaction as soon as possible but in no case later than 7 calendar 
days after the sponsor's initial receipt of the information.  
 
The Principal Investigator will complete an Internal Prompt Reporting Form within the following 
timelines:  

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EVENT 
TIMELINE 
An Unanticipated problem involving risks to 
subjects or others 
  
1. Unexpected (in terms of nature, severity, or  
frequency) given (a) the research procedures that  
are described in the protocol-related documents,  
such as the IRB-approved research protocol and  
informed consent document; and  
(b) the characteristics of the subject population 
 being studied;  
2. Related or possibly related to participation in the 
 research; and  
3. Suggests that the research places subjects or  
others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was 
previously known or recognized.  
 
If the event is life-threatening, report within  
7 calendar days of receipt of the information. 
Follow-up reports for these events should be  
Submitted within 14 calendar days of receipt 
of information. 
  
All other events/problems must be reported 
within 14 calendar days of the investigator’s 
receipt of the information  
 
All Research-Related Deaths 
(anticipated/unanticipated) 
Immediately (i.e. within 48 hours) upon 
receipt of information 
Other event that in the PI's judgment, warrants 
reporting or is in the best interest of the subject(s) 
(e.g., because it may affect the safety and/or welfare 
of subjects; it changes the risk level of the study; or 
the frequency of the same event significantly 
increases) 
If life-threatening, report within 7 calendar 
days of receipt of the information.  
 
All other events/problems must be reported 
within 14 calendar days of the investigator’s 
receipt of the information. 
Other unanticipated problems that impact the 
conduct or integrity of the study (e.g. FDA Clinical 
hold or recall, published literature or data and safety 
monitoring board report impacting risk-benefit ratio, 
FDA Form 483 or warning letter, investigator medical 
license restriction or suspension, participant is 
incarcerated) 
If life-threatening, report within 7 calendar 
days of receipt of the information.  
 
All other events/problems must be reported 
within 14 calendar days of the investigator’s 
receipt of the information. 
 
All SAEs will be followed until satisfactory resolution or until the site investigator deems the 
event to be chronic or the adherence to be stable.  
 
Sponsor Safety Reporting contact information: 
Name, degree, title:  Austin Stone, MD, PhD 
Institution Name:      University of Kentucky 
Address:                    760 S Limestone, Suite K401 
                                  Lexington, KY 40536-0284 
Phone Number:          859-218-3065 
Email:                        austin.stone@uky.edu 
FAX:                   
(859)-323-2412 
 
Name: Caitlin Conley, PhD 
Address: 740 S Limestone, Suite K401 

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Phone #: (859) 257-1939 
Email: caitlin.whale@uky.edu 
Fax:  (859) 323-2412 
 
The reporting of serious adverse events to the study sponsor does not relieve the investigator  
from other regulatory reporting responsibilities. 
 
Investigator reporting to SOBI:  The Sponsor must inform Swedish Orphan Biovitrum (SOBI) in 
writing using a SOBI SAE or a MEDWATCH 3500A form of any SAE, independent of 
causality. The written report must be completed and supplied to SOBI by e-mail or facsimile 
within 24 hours/1 business day of first awareness. The initial report must be as complete as 
possible, including an assessment of the causal relationship between the event and the 
investigational product(s), if available. Information not available at the time of the initial report 
(e.g., an end date for the adverse event or laboratory values received after the report) must be 
documented on a follow-up report.  
 
A final report to document resolution of the SAE is required. A copy of the email transmission of 
the SAE report to SOBI (drugsafety@sobi.com) should be attached to the SAE and retained with 
the patient records. 
 
SOBI Safety Reporting contact information: 
Drug Safety Swedish Orphan Biovitrum SE-112 76 Stockholm, Sweden Fax: 011-46 8 697 32 30 
Phone: 011-46 8 697 20 00 (switchboard) e-mail: drugsafety@sobi.com 
The reporting of serious adverse events to SOBi does not relieve the sponsor from other 
regulatory reporting responsibilities. 
SOBi Safety Reporting contact information: 
Fax: 011-46 8 697 32 30 
e-mail: drugsafety@sobi.com 
 
8.4.3 UNANTICIPATED PROBLEM REPORTING  
 
Incidents or events that meet the OHRP criteria for UPs require the creation and completion of 
an UP report form. It is the site investigator’s responsibility to report UPs to their IRB and to the 
DCC/study sponsor. The UP report will include the following information:  
 
• Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
  number;  
• A detailed description of the event, incident, experience, or outcome;  
• An explanation of the basis for determining that the event, incident, experience, or outcome  
  represents an UP;  
• A description of any changes to the protocol or other corrective actions that have been  
  taken or are proposed in response to the UP.  
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following 
timeline:  
 
• UPs that are SAEs will be reported to the IRB and to the DCC/study sponsor within of the  
  investigator becoming aware of the event.  
• Any other UP will be reported to the IRB and to the DCC/study sponsor within of the  
  investigator becoming aware of the problem.  

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• All UPs should be reported to appropriate institutional officials (as required by an  
  institution’s written reporting procedures), the supporting agency head (or designee), and 
  OHRP within (insert timeline in accordancy with policy) of the IRB’s receipt of the report  
  of the problem from the investigator.  
 
8.4.4 EVENTS OF SPECIAL INTEREST  
 
Not applicable. 
 
8.4.5 REPORTING OF PREGNANCY  
 
Pregnancy is neither an AE nor SAE.  All subject pregnancy must be reported to their study 
doctor or study staff immediately.  Once confirmed, study medication will be stopped and the 
study site will request permission from the woman to follow her for pregnancy outcomes.  All 
confirmed pregnancies will be reported to the study sponsor, FDA, SOBI  and IRB and followed 
until resolution (i.e., termination [voluntary or spontaneous] or birth) to assess for pregnancy-
associated AEs or SAEs such as congential anomaly.   
 
8.5 
STUDY HALTING RULES  
 
Administration of study agent will be halted when three grade 3 AEs determined to be “probably 
related” are reported to the FDA/IRB and enrollment screens will stop accepting new study 
participants. The study sponsor will inform the DSMB members within 24 hours of this 
occurrence and will provide the DSMB with AE listing reports. The DSMB will convene an ad 
hoc meeting by teleconference or in writing as soon as possible. The DSMB will provide 
recommendations for proceeding with the study to the study sponsor.  The study sponsor will 
inform the FDA of the temporary halt and the disposition of the study. 
 
Study Stopping Criteria 
 
• Local intolerance of the administered Kineret or any sign of allergic response. 
• Development of signs and symptoms before the second time point preventing the second 
administration of the study drug. 
• Any patient reported drug related SAE after the first or second administration of the study 
drug. 
• Diagnosis with any condition as outlined in the exclusion criteria during the course of the 
initial 2 weeks of study enrollment. 
 
 
8.6 
SAFETY OVERSIGHT 
 
Monitoring for adverse events will be conducted in real-time by the study investigators and study 
coordinators.  Risks involved with this study are considered greater than minimal risk.  For this 
reason, we will utilize the standing independent Data Safety Monitoring Board (DSMB) as 
chartered by the Center for Clinical and Translational Science (CCTS).  The DSMB will meet 
semiannually or as needed, and will review subject recruitment, AE’s, side effects, laboratory 
results, dropouts, protocol violations, and inclusion/exclusion criteria.  More frequent meetings 
will take place if side effects or other problems are prevalent.  
 
 

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9 
CLINICAL MONITORING 
 
Clinical site monitoring will be performed by Bluegrass Research Consultants Inc. The monitor 
will conduct monitoring to verify that a) the rights and well-being of human subjects are 
protected; b) the reported trial data are accurate, complete and verifiable from source documents; 
c) the conduct of the trial is in compliance with the currently approved protocol/amendment(s), 
Food and Drug Administration (FDA) regulations and ICH guidelines d) Provide practical 
guidelines for Site Monitors, Study Monitors and Medical Monitors; e) Provide consistent 
monitoring procedures across all clinical sites; f) Ensure the quality and integrity of clinical 
study data; g) Evaluate the progress of the study and ensure completion of the clinical study in a 
timely manner.  A monitoring visit report will be provided to the Sponsor within 21 business 
days following the completion of a visit. 
 
The first monitoring visit will be conducted within two weeks following enrollment of the first 
subjects.  Subsequent monitoring visits will be completed based on enrollment and are expected 
to occur every four to six weeks. 
 
10 
STATISTICAL CONSIDERATIONS  
10.1 STATISTICAL AND ANALYTICAL PLANS 
 
10.1.1 GENERAL APPROACH 
 
Sample Size and Power Analysis - The primary outcome aim of the study is to determine if 
treatment with the study medication results in greater improvements in patient-reported 
outcomes one year following surgery.  We will use the validated Knee Osteoarthritis and injury 
Outcome Score (KOOS),[27] which is a self-administered, knee-specific instrument that 
evaluates the course of knee injury and treatment outcomes. To reduce the risk of an 
underpowered RCT, an a priori sample size estimation was calculated from data collected from 
recent studies of ACL-injured and –reconstructed patients.[28-32] The previously published one-
year KOOS Quality of Life Scores are 60.2 ± 24.2 [31] and the minimal detectable change of this 
instrument is 7.2 [32]. Assuming that the standard deviation of the change scores between the 
day of surgery and one year postoperative visits will be 20% of the standard deviation of the 
standard deviation of the one-year KOOS Quality of Life Scores (.2 x 24.2 = 4.8), a sample size 
of 16 patients per group (32total) would be at least 80% powered to detect a difference of 7.2 
points between the treatment group and the control group (One-way ANOVA model with alpha 
= 0.05, Effect size = 7.2/4.8 = 1.5, G*Power 3.0.10).  This sample size would adequately power 
the study for the primary outcome variable, but would also adequately power the study for the 
second aim of the study. The second aim of the study is to compare chondrodegenerative 
biomarkers between groups at the 1 year follow up. We have previously observed large effect 
sizes between groups in preliminary studies (ES = 1.34), and a sample size of 32 patients (16 per 
group) would be at least 80% powered to detect effect sizes of this magnitude.  However, to 
protect against an underpowered study due to patient attrition, we will monitor compliance and 
potentially enroll up to 20 patients per group in order to adjust for attrition. Patient costs will not 
occur until sample or MRI analysis.  
 
The power calculations include several caveats. First, for purposes of power calculation, we did 
not assume a full repeated measures analysis, but instead analyzed at a single time point (one-
year follow-up). Second, we note that in trials such as this, the power of a non-parametric 
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the Wilcoxon test is at least 0.95), leading us to conclude that our parametrically based power 
calculations should apply with equal force to a non-parametric analysis.   
 
Statistical analyses - Results from a sample of this size may not be normally distributed. 
Therefore, non-parametric statistical measures may be used.  Primary outcome measures 
evaluating for change in KOOS will be assessed at multiple points and will be analyzed for 
change between groups using Friedman two-way ANOVA for repeated measures. Synovial fluid 
analyses comparing the three groups at five time points will be analyzed using the Wilcoxon 
Signed Rank Sum Test with Hochberg corrections for multiple time points.  Alternatively, if 
results are normally distributed or can be transformed (e.g., by log transformation) to meet the 
criteria for normality for parametric analysis, then repeated measures ANOVA will be utilized 
comparing treatment groups.  P-values of less than or equal to 0.05 will be considered 
statistically significant. 
  
Predicted Results:  IL-1ra, while potent, has had mixed results in the treatment of established 
OA, possibly due to it’s short half-life in vivo. In this trial, we expect that an early intervention 
with IL-1ra will effectively block the deleterious cascade of joint degradation events after joint 
injury.  We expect a significant effect of IL-1ra on post-injury pain and concomitantly an 
increase in patient-reported outcomes due to the improved early function 
 
Minimization of bias: Due to the randomized study design and the blinding of the investigator 
and patient to the drug used, we hope to eliminate any investigator or subject bias. Using broad 
and previously established enrollment criteria we hope to reduce selection bias to a minimum 
while protecting potentially vulnerable individuals through the exclusion criteria. Procedural bias 
and measurement bias will be reduced by the multicenter design and the blinded data analysis. 
  
10.1.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
 
A safety review of treatment Groups 1 and 2will be performed.  Safety endpoints will be 
monitored at each study visit and at each monitoring visit.  
 
Study Stopping Criteria 
 
• local intolerance of the administered Kineret or any sign of allergic response. 
• development of signs and symptoms before the second time point preventing the second 
administration of the study drug. 
• Any patient reported SAE after the first or second administration of the study drug. 
• Diagnosis with any condition as outlined in the exclusion criteria during the course of the 
initial 2 weeks of study enrollment. 
 
10.1.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
 
Not applicable 
 
10.2 MEASURES TO MINIMIZE BIAS 
 
10.2.1 ENROLLMENT/ RANDOMIZATION/ MASKING PROCEDURES 
 
Randomization:  Following informed consent and after successfully being screened into the 
study, subjects will be randomized to one of three treatment groups.   
 

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• Group 1 will receive intra-articular injection of Anakinra (Kineret®,  IL-1ra; 150mg) 1-
28 days after ACL injury.  
• Group 2 will receive intra-articular injection of saline placebo 1-28 days after ACL 
injury.  
 
Blinding: To ensure triple-blindness, an uninvolved third party will generate the allocation 
sequence of the intervention and provide this to the principal investigator.  Allocation of drug or 
placebo will be by permutated random block size, ensuring that approximately equal numbers of 
subjects will be treated with drug or placebo in the unlikely event that the study will need to be 
terminated prematurely. 
 
If subject discontinues the study for any reason prior to 3-month visit, then the collected data will 
be evaluated but not included in the analysis and a replacement subject will be enrolled in the 
study. 
 
10.2.2 EVALUATION OF SUCCESS OF BLINDING  
 
Not applicable. 
 
10.2.3 BREAKING THE STUDY BLIND/PARTICIPANT CODE 
 
Breaking the randomization code will be performed by the Principal Investigator and will occur 
if  it is necessary for the care of the subjects.  For example, if an AE or SAE occurs with the a 
subject and knowledge of the drug randomization would be important for clinical care or to 
determine appropriate treatment, then the principal investigator will break the code and the 
subject will be withdrawn from the study. 
 
Unblinding of a subject(s) dosing will be documented and will include an explanation of why the 
study medication was unblinded. 
 
Following data lock, subject dosing information can be unblinded and the unblinded information 
can be sent to the study participants at the discretion of the principal investigator. 
 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE 
DATA/DOCUMENTS 
 
The principal investigator will maintain appropriate medical and research records for this trial, in 
compliance with ICH E6 and regulatory and institutional requirements for the protection of 
confidentiality of participants.  The principal investigator will permit authorized representatives 
of the FDA, Institutional Review Board, Center for Clinical and Translational Science, Bluegrass 
Research Consultants, Inc. and regulatory agencies to examine (and when permitted by 
applicable law, to copy) clinical records for the purposes of quality assurance reviews, audits, 
and evaluation of the study safety, progress, and data validity.  
 
Source data are all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial. Examples 
of these original documents and data records include, but are not limited to, hospital records, 
clinical and office charts, laboratory notes, memoranda, participant’s memory aids or evalulation 
checklists, pharmacy dispensing records, recorded audio tapes of counseling sessions, recorded 
data from automated instruments, copies or transcriptions certified after verification as being 
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rays, and participant files and records kept at the pharmacy, at the laboratories, and medico-
technical departments involved in the clinical trial.  
 
It is not acceptable for the CRF to be the only record of a patient’s participation in the study.  
This is to ensure that anyone who would access the patient medical record has adequate 
knowledge that the patient is participating in a clinical trial. 
 
12 
QUALITY ASSURANCE AND QUALITY CONTROL 
 
Quality Control rocedures will be implemented beginning with the data entry system and data 
QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.  
 
Following written SOPs, the monitors will verify that the clinical trial is conducted and data are 
generated, documented (recorded), and reported in compliance with the protocol, GCP, and the 
applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing 
Practices (GMP)).  
 
The investigational site will provide direct access to all trial related sites, source data/documents, 
and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local 
and regulatory authorities. 
 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS  
 
13.1 ETHICAL STANDARD  
 
The investigator will ensure that this study is conducted in full conformity with Regulations for 
the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 21 
CFR Part 56, and/or the ICH E6. If the study is conducted at international sites, the statement 
could be as above and/or could reference compliance with the Declaration of Helsinki, Council 
for International Organizations of Medical Science (CIOMS), International Ethical Guidelines 
for Biomedical Research Involving Human Subjects (2002), or another country’s ethical policy 
statement, whichever provides the most protection to  human subjects. 
 
13.2 INSTITUTIONAL REVIEW BOARD  
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the IRB for review and approval. Approval of both the protocol and the consent 
form must be obtained before any participant is enrolled. Any amendment to the protocol will 
require review and approval by the IRB before the changes are implemented to the study. All 
changes to the consent form will be IRB approved; a determination will be made regarding 
whether previously consented participants need to be re-consented. 
 
13.3 INFORMED CONSENT PROCESS  
 
Prior to the start of the trial, the investigator should have the IRB’s written approval for the 
protocol and the written informed consent form(s) and any other written information to be 
provided to the participants. 
 

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13.3.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS 
PROVIDED TO PARTICIPANTS 
 
Consent forms describing in detail the study agent, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study product. The following consent materials are submitted with 
this protocol. 
 
13.3.2 CONSENT PROCEDURES AND DOCUMENTATION 
 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in 
the study and continues throughout the individual’s study participation. Extensive discussion of 
risks and possible benefits of participation will be provided to the participants and their families. 
Consent forms will be IRB-approved and the participant will be asked to read and review the 
document. The investigator will explain the research study to the participant and answer any 
questions that may arise. All participants will receive a verbal explanation in terms suited to their 
comprehension of the purposes, procedures, and potential risks of the study and of their rights as 
research participants. Participants will have the opportunity to carefully review the written 
consent form and ask questions prior to signing. The participants should have the opportunity to 
discuss the study with their surrogates or think about it prior to agreeing to participate. The 
participant will sign the informed consent document prior to any procedures being done 
specifically for the study. The participants may withdraw consent at any time throughout the 
course of the trial. A copy of the informed consent document will be given to the participants for 
their records. The rights and welfare of the participants will be protected by emphasizing to them 
that the quality of their medical care will not be adversely affected if they decline to participate 
in this study. 
 
13.4 PARTICIPANT AND DATA CONFIDENTIALITY  
 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, 
and the sponsor(s) and their agents. This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be 
held in strict confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval of the sponsor. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB or 
pharmaceutical company supplying study product may inspect all documents and records 
required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records.  
 
The study participant’s contact information will be securely stored at each clinical site for 
internal use during the study. At the end of the study, all records will continue to be kept in a 
secure location for as long a period as dictated by local IRB and Institutional regulations.  
 
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting will not include the participant’s contact or identifying information. Rather, individual 
participants and their research data will be identified by a unique study identification number. 
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will be secured and password protected. At the end of the study, all study databases will be de-
identified and archived at the the University of Kentucky.  
 
13.4.1 RESEARCH USE OF STORED HUMAN SAMPLES,SPECIMENS OR DATA 
 
All samples/specimens or data collect will be used for the purpose of this research study only.  
No future use of the samples/specimens or data will be allowed. 
 
13.5 FUTURE USE OF STORED SPECIMENS  
 
N/A 
 
14 
DATA HANDLING AND RECORD KEEPING  
 
14.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of 
the site PI. The investigator is responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported.  
 
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data. Black ink is required to ensure clarity of reproduced copies. When making 
changes or corrections, cross out the original entry with a single line, and initial and date the 
change. DO NOT ERASE, OVERWRITE, OR USE CORRECTION FLUID OR TAPE ON 
THE ORIGINAL. 
 
Copies of the CRF (CRF) will be provided for use as source documents and maintained for 
recording data for each participant enrolled in the study. Data reported in the CRF derived from 
source documents should be consistent with the source documents or the discrepancies should be 
explained and captured in a progress note and maintained in the participant’s official electronic 
study record.  
 
Clinical data (including AEs, concomitant medications, and expected adverse reactions data) and 
clinical laboratory data will be entered onto paper CRFs or a eCRF 21 CFR Part 11-compliant 
data capture system provided by the Sponsor. The data system includes password protection and 
internal quality checks, such as automatic range checks, to identify data that appear inconsistent, 
incomplete, or inaccurate. Clinical data will be entered directly from the source documents. 
 
14.2 STUDY RECORDS RETENTION  
 
Records should not be destroyed without the sponsor’s agreement.  Study documents should be 
retained for a minimum of 6 years in keeping with local IRB record retension policy.   
 
14.3 PROTOCOL DEVIATIONS  
 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or MOP 
requirements. The noncompliance may be either on the part of the participant, the investigator, or 
the study site staff. As a result of deviations, corrective actions are to be developed by the site 
and implemented promptly. 
 

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These practices are consistent with ICH E6:  
 
 
• 4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
 
 
• 5.1 Quality Assurance and Quality Control, section 5.1.1  
 
• 5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of the site to use continuous vigilance to identify and report deviations 
within working days of identification of the protocol deviation, or within working days of the 
scheduled protocol-required activity. All deviations must be addressed in study source 
documents, reported to Program Official and protocol deviations must be sent to the local IRB 
per their guidelines. The site PI/study staff is responsible for knowing and adhering to their IRB 
requirements. Further details about the handling of protocol deviations will be included in the 
MOP. 
 
14.4 PUBLICATION AND DATA SHARING POLICY 
 
This study will comply with the NIH Public Access Policy, which ensures that the public has 
access to the published results of NIH funded research. It requires scientists to submit final peer-
reviewed journal manuscripts that arise from NIH funds to the digital archive PubMed Central 
upon acceptance for publication.  
 
The International Committee of Medical Journal Editors (ICMJE) member journals have adopted 
a clinical trials registration policy as a condition for publication. The ICMJE defines a clinical 
trial as any research project that prospectively assigns human subjects to intervention or 
concurrent comparison or control groups to study the cause-and-effect relationship between a 
medical intervention and a health outcome. Medical interventions include drugs, surgical 
procedures, devices, behavioral treatments, process-of-care changes, and the like. Health 
outcomes include any biomedical or health-related measures obtained in patients or participants, 
including pharmacokinetic measures and adverse events.  
 
The ICMJE policy, and the Section 801 of the Food and Drug Administration Amendments Act 
of 2007, requires that all clinical trials be registered in a public trials registry such as 
ClinicalTrials.gov, which is sponsored by the National Library of Medicine. Other biomedical 
journals are considering adopting similar policies. For interventional clinical trials performed 
under NIH IC grants and cooperative agreements, it is the grantee’s responsibility to register the 
trial in an acceptable registry, so the research results may be considered for publication in ICMJE 
member journals. The ICMJE does not review specific studies to determine whether registration 
is necessary; instead, the committee recommends that researchers who have questions about the 
need to register err on the side of registration or consult the editorial office of the journal in 
which they wish to publish. 
 
FDAAA mandates that a "responsible party" (i.e., the sponsor or designated principal 
investigator) register and report results of certain "applicable clinical trials":  
 • Trials of Drugs and Biologics: Controlled, clinical investigations, other than Phase I 
investigations, of a product subject to FDA regulation  
 • Trials of Devices: Controlled trials with health outcomes of a product subject to FDA 
regulation (other than small feasibility studies) and pediatric postmarket surveillance 
studies.  
 
NIH grantees must take specific steps to ensure compliance with NIH implementation of 
FDAAA. 
 

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15 
STUDY ADMINISTRATION 
 
 
15.1 STUDY LEADERSHIP 
 
The study leadership will be comprise of the sponsor and site principal investigators. 
 
16 
CONFLICT OF INTEREST POLICY 
 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed 
and managed. Furthermore, persons who have a perceived conflict of interest will be required to 
have such conflicts managed in a way that is appropriate to their participation in the trial. The 
study leadership in conjunction with the has established policies and procedures for all study 
group members to disclose all conflicts of interest and will establish a mechanism for the 
management of all reported dualities of interest. 
 
17  
LITERATURE REFERENCES  
 
References: 
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with pre-radiographically defined and radiographically defined knee osteoarthritis in a population-based 
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10. dunn 
11. Faber KJ, Dill JR, Amendola A, Thain L, Spouge A, Fowler PJ. Occult osteochondral lesions after anterior 
cruciate ligament rupture. Six-year magnetic resonance imaging follow-up study. Am J Sports Med. 1999 
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12. Felson DT. Validating markers in osteoarthritis. Acta Orthop Scand Suppl. 1995 Oct;266:205-7. Review. 
PubMed PMID: 8553853.   
13. Frobell RB, Le Graverand MP, Buck R, et al. The acutely ACL injured knee assessed by MRI: changes in 
joint fluid, bone marrow lesions, and cartilage during the first year. Osteoarthritis Cartilage. Feb 

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APPENDIXES  
Figure 3 – Pain VAS – Initial Visit