A Comparative Efficacy Study: Treatments of Non-Healing Diabetic Foot Ulcers
Phase: PHASE3
Conditions: Diabetic Foot Ulcer
Sponsor: VA Office of Research and Development

 
i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TITLE OF THE STUDY: A comparative efficacy study: 
bioengineered living dermal replacement tissue vs. non-
viable extracellular matrix for the treatment of non-
healing diabetic foot ulcers. 
 
ClinicalTrials.gov ID: NCT01450943 
Date: February 27,2019 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
ii 
 
PROTOCOL SUMMARY 
 
TITLE OF THE STUDY: A comparative efficacy study: bioengineered living dermal replacement 
tissue vs. non-viable extracellular matrix for the treatment of non-healing diabetic foot ulcers. 
 
PHASE: Equivalence Study 
 
METHODOLOGY: Randomized, controlled, stratified, prospective 
 
STUDY DURATION: 8 weeks 
 
FOLLOW-UP: 16 weeks 
 
STUDY CENTERS: 2 centralized study locations (Mather and Martinez Wound Clinics) 
Note: Satellite clinics (Redding, Chico, Oakland and Fairfield) will refer patients to the study 
locations 
 
NUMBER OF SUBJECTS: 3 treatment arms, 57 subjects per arm for a total of 171 
 
STUDY OBJECTIVES: The primary objective of this study is to assess the effectiveness of 
cellular dermal replacement tissue vs. non-viable extracellular matrix (ECM) for the treatment of 
non-healing diabetic foot ulcers. The primary endpoint will be the measurement of wound 
closure at 12 weeks, secondary outcomes will be measured at 20 weeks and the rate of healing 
in each treatment arm. 
 
Secondary objective of study is to determine cost effectiveness of the bioengineered cellular vs. 
acellular ECM products. Cellular ECMs (Dermagraft®) are costly devices, $1800 per 
application, difficult to use and time sensitive (weeks). The acellular ECM, (Oasis®) is easier to 
use and at a cost $80 per application and has a longer shelflife (2 years). These devices 
typically require multiple applications, on a weekly basis. If the findings show that these devices 
are equivalent, then the use of acellular ECM would lead to significant savings for the VA. 
Genetic markers of non-healing vs. healing diabetic ulcers will also be investigated, which will 
be useful information in predicting healing potential. 
 
INCLUSION CRITERIA: 
Subjects must meet all of the following inclusion criteria to enroll in the study:  
1. Patients with ICD-9 codes of diabetic foot ulcer or other foot ulcer present for at least 4 
weeks (any location on the foot, no more than 1 ulcer on the target limb). 
2. Diagnosis of diabetes with either Type 1 or 2, and HbA1c less than 10%. 
3. Over the age of 18 and younger than 85 years of age. 
4. Based on the Curative Health Services Classification, subjects with a Grade 2 foot ulcer, full 
thickness and subcutaneous tissue that extend through the dermis but without tendon, 
muscle, capsule or bone exposure. 
5. Area greater than or equal to 1.0 cm2 and less than or equal to 25.0 cm2 post debridement. 
6. Foot ulceration with no clinical signs or symptoms of infection, as determined with clinical 
assessment of 2 or more signs of inflammation, and quantitative analysis of bacterial load of 
the wound. No systemic signs of infection, such as fever/chills, nausea or vomiting, and 
normal CBC. 

 
iii 
 
a) A sample of the wound after debridement with curettage technique will be taken for 
quantitative analysis of bacterial load. If findings of 1 x 105 CFU per gram of tissue, the 
wound will be considered subclinical infected and excluded from study. 
b) Lab test taken at start of study, CBC—white blood count within normal range. 
7. Patients will be required to have an assessment for arterial insufficiency, which includes a 
formal ankle-arm index. If the ankle-arm index is equal to or greater than 0.8 and less than 
1.4 or a toe-arm index is equal to or greater than 0.6 will be eligible. Note: Patients that have 
inconclusive physical examination or indirect physiologic testing (ankle-arm index) will 
require an arterial duplex studies that can image directly the arterial flow velocities and 
perfusion to the distal extremity or computed tomography angiography and conventional 
angiography, which may be considered as a subset group if findings show no arterial 
insufficiency per vascular surgeon consultant. In addition, patients that undergo 
revascularization procedure and do meet ABI requirement post-intervention will be included 
in the study as a subset group. 
8. Females of childbearing age potential, with negative serum pregnancy test and not lactating 
during length of the study. 
9. Willingness to comply to wound care assigned and attend follow-up visits. 
 
EXCLUSION CRITERIA: 
Those subjects will be excluded from the study with any of the following reasons: 
1. Diagnosis of cancer, treatment with immunosuppressive or chemotherapeutic agents, 
radiotherapy or systemic corticosteroids less than 30 days before enrollment. 
2. Immunocompromised diseases (HIV/AIDS). 
3. Bleeding disorders. 
4. Connective tissue diseases. 
5. Pregnant women. 
6. History of drug or alcohol abuse within one year of the study. 
7. Infected wounds or osteomyelitis (confirmed by bone biopsy, MRI or bone scan). 
8. Active Charcot as described by Saunder’s classification system. 
9. Poor nutritional status, Albumin level < 2.9. 
10. Ulceration size less than 1.0 cm2 or greater than 20 cm2. 
11. Porcine allergy. 
12. Chemistry tests serum creatinine, 2 times above the upper limits and LFTs 3 times above 
the upper limits. 
 
TREATMENT: Total duration of study per subject: Up to 22 weeks (Includes to 2 weeks of 
screening and up to 12 weeks until the end of the follow-up period). 
     
DURATION OF ADMININSTRATION: 8 weekly applications (starting at Visit 4/Week 1). 
 
STUDY DESIGN: This is a randomized, single-blinded, four-armed controlled clinical 
equivalence trial comparing the effectiveness of three intervention arms (acellular ECM, Oasis® 
and a cellular ECM, fibroblast-only Dermagraft®) and a standard treatment arm. 
 
EFFICACY ENDPOINTS: 
PRIMARY EFFICACY OUTCOME 
1. Complete closure of ulcer by Week 12 
 
SECONDARY EFFICACY OUTCOME   
1. Complete closure of ulcer by Week 20 
2. Rate of ulcer healing 

 
iv 
 
3. Cost effectiveness comparing Oasis® and Dermagraft® 
 
QUALITY OF LIFE ASSESSMENT: We will also evaluate the cost-effectiveness of the Oasis® 
compared to Dermagraft® and the standard of care by measuring QALYs as the measure of 
effectiveness, based on results obtained from SF-36v2™ questionnaire. Multiple regression will 
be used to allow to evaluate continuous dependent variable outcomes, including change scores 
between baseline and end of study physical (PCS) and mental (MCS) component summaries 
from the SF-36v2TM questionnaire. 
 
DATA ANALYSIS: The primary outcome is wound closure by Week 12, will use Chi-square test 
to compare the percentages of subjects with complete closure in each group. Exploratory 
analysis with logistic regression, using the complete closure at 12 weeks as the dependent 
variable and the independent variables would include, treatment, size of ulcer, location on foot, 
how long ulcer has been present, previous revascularization, offloading compliancy, 
concomitant medications, foot deformity, history of amputation, diabetes complications index, 
CRP level, and glucose control (HbA1c). Selection of covariates will be performed by stepwise 
modeling procedures. 
  
Secondary outcomes, will use  ANOVA or Kruskal-Wallis test to analyze cost effectiveness. 
depending if data is normally distributed for comparison of the three treatment arms. If 
significant, we will further analyze with pair-wise comparisons by using t-test or Wilcoxon rank-
sum test with the Bonferroni correction to control for type I experiment-wise error rate of 0.05. 
 
Rates of healing among the four groups will be analyzed using log-rank test to compare time of 
healing within 20 weeks. 
 
Descriptive statistics will include demographics, smoking history, and characteristics of the 
wound. For comparison nominal categorical secondary outcome variables, we will use Chi-
square test. For comparison of ordinal categorical variables, we will use the Wilcoxon rank-sum 
test (for two independent group comparison) and Kruskal-Wallis test (for three independent 
group comparison). 

 
5 
 
TABLE OF CONTENTS 
 
1 BACKGROUND AND RATIONALE 
2 OBJECTIVES 
3 STUDY POPULATION 
4 STUDY PROCEDURES 
4.1 DESIGN AND METHODOLOGY  
4.2 DESCRIPTION OF STUDY GROUPS 
4.3 STUDY FLOW CHART 
4.3.1 SCREENING/BASELINE PERIOD (VISIT 1 to 2/WEEKS -1 to -2) 
4.3.2 RANDOMIZATION (VISIT 3/WEEK 0) 
4.3.3 TREATMENT PHASE (VISIT 4/WEEK 1) 
TREATMENT PHASE (VISIT 5/WEEK 2) 
TREATMENT PHASE (VISIT 6/WEEK 3) 
TREATMENT PHASE (VISIT 7/WEEK 4) 
TREATMENT PHASE (VISIT 8/WEEK 5) 
TREATMENT PHASE (VISIT 9/WEEK 6) 
TREATMENT PHASE (VISIT 10/WEEK 7) 
TREATMENT PHASE (VISIT 11/WEEK 8) 
TREATMENT PHASE (VISIT 12/WEEK 9) 
TREATMENT PHASE (VISIT 13/WEEK 10) 
TREATMENT PHASE (VISIT 14/WEEK 11) 
TREATMENT PHASE (VISIT 15/WEEK 12) 
TREATMENT PHASE (VISIT 16/WEEK 13) 
TREATMENT PHASE (VISIT 17/WEEK 14) 
TREATMENT PHASE (VISIT 18/WEEK 15) 
4.3.4 STUDY ENDPOINT (VISIT 19/WEEK 16) 
4.3.5 FOLLOW-UP PHASE (VISIT 20/WEEK 17) 
FOLLOW-UP PHASE (VISIT 21/WEEK 20) 
FOLLOW-UP PHASE (VISIT 22/WEEK 24) 
FOLLOW-UP PHASE (VISIT 23/WEEK 28)  
5 ADVERSE EVENTS  
6 STATISTICAL DESIGN 
7 REFERENCES 
8 APPENDIX 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
6 
 
1 
BACKGROUND AND RATIONALE 
Diabetic foot ulcers (DFU), chronic, non-healing wounds, pose a serious problem to our 
healthcare system. Those with DFU are at higher risk for developing infections, which lead to 
limb amputations. The long-term effects are detrimental on quality of life and productivity loss. 
Within the VA system, diabetics with foot ulcers account for significant amount of sums of 
money to treat wounds and to improve healing in DFU. Thus far, studies have shown that the 
current standard of care to heal wounds is about 10-20% slower after 12 weeks of treatment 
compared to advanced therapy regimens. This unfavorable cure rate has prompted increased 
research for therapeutic alternatives, and novel approaches including topical application of 
growth factors, extracellular matrix scaffold materials and bioengineered living tissue 
replacements have been developed. This study plans to address the question of the 
comparative effectiveness of wound care modalities that could potentially translate into millions 
of dollars of savings for our health care system, as well as simplification of the treatment 
regimens for our patents—all without sacrificing clinical outcome. We propose to compare the 
clinical efficacy of two of the most expensive novel treatments for DFU, bioengineered cell-
based bioengineered extracellular matrix tissues containing living dermal fibroblasts 
(Dermagraft®) to a device that is 15-fold less expensive but has related biologic rationale—an 
extracellular matrix scaffold devoid of living cellular elements (Oasis®). We hypothesize that 
these three treatments will yield equivalent clinical outcomes, supporting the adoption of the 
less expensive, cell-free, matrix device. The importance of this study would then be to establish 
a protocol approach to wound care that would be implemented system wide. 
 
2 
OBJECTIVES 
The primary objective of this study is to assess the effectiveness of cellular dermal replacement 
tissue vs. non-viable extracellular matrix (ECM) for the treatment of non-healing diabetic foot 
ulcers. The primary endpoint will be the measurement of wound closure at 12 weeks, secondary 
outcomes will be measured at 20 weeks and the rate of healing in each treatment arm. 
 
The secondary objective of study is to determine cost effectiveness of the bioengineered cellular 
vs. acellular ECM products. Cellular ECMs (Dermagraft®) are costly devices, $1800 per 
application, difficult to use and time sensitive (weeks). The acellular ECM (Oasis®) is easier to 
use and at a cost $80 per application and has a longer shelf life (2 years). These devices 
typically require multiple applications, on a weekly basis. If the findings show that these devices 
are equivalent, then the use of acellular ECM would lead to significant savings for the VA. 
Genetic markers of non-healing vs. healing diabetic ulcers will also be investigated, which will 
be useful information in predicting healing potential. 
 
3 
STUDY POPULTATION 
The study population includes all Veterans’ between the ages of 18-85, with a documented 
diagnosis of diabetes and a foot ulceration that has existed for at least 4 weeks at the time of 
enrollment into the study. Diabetic patients with foot ulcers will be selected from a random 
sample of patients from six clinical sites at the Veteran Affairs Northern California Health Care 
System (VA NCHCS): Mather, McClellan, Fairfield, Martinez, Chico and Redding. There were 
approximately 25,815 patients with diabetes mellitus receiving care at VA NCHCS within the last 
2 fiscal years.1 Of these, 893 patients were treated with diabetic foot ulcerations.2 Figure 2 
illustrates the selection process with the anticipated number of participants in the study. With a 
minimum of 60% participation, there should be adequate recruitment for this study. The sites will 
accrue a total target sample of approximately 360 subjects and assuming approximately 20% 
dropout rate, the goal is to enroll 171 subjects in total from all sites involved in study. 

 
7 
 
Selection of Cases and Controls: 
The investigators will query the CPRS/VISTA database at the 6 respective sites for eligible 
participants. Patients will be screened at the various VA clinics as potential study subjects which 
will be called by the research nurse and invited to participate in the study. Those who agree will 
be given an appointment for screening and enrollment. 
 
FIGURE 2: Summary of Selection Process 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment/Study Groups: 
Participants that are recruited who have met the inclusion criteria and agree to join the study will 
be required to sign an informed consent, which has been approved by the Institutional Review 
Board (IRB). The selected cases will be randomly stratified matched by age, gender, race, and 
date of diagnosis with diabetes and size of ulceration. 
 
Run-in phase in which all potential subjects are given the standard of therapy for 2 weeks, will 
be performed to determine compliance with return visits and performing standard of care 
dressings. 
 
Each subject will be given a unique identifier that will have no personal information linked after 
assignment of a randomly computer generated list of three repeated numbers which will be 
available for each site. The request for assignment will be emailed to the Data Coordinator with 
a completed eligibility form, and no personal identifiers except for initials and a last 4 digits of 
social security. The Data Manager will assign a number and the next sequential group 
assignment with each subsequent request will be placed in sealed envelopes. Subject 
demographics will not be provided until this assignment is complete. Participants will be 
randomly placed into the standard therapy, Oasis® or Dermagraft® groups. There will be an 
estimated of 57 patients in each group. 
 
The patients will not be informed of treatment administered. However, due to the handling of the 
Dermagraft® (packaging and thawing), whereas Oasis® is readily available at room 
45 Cases 
Dropped Out 
144 Cases 
Unsuitable for Study 
57 Cases 
(Standard Therapy) 
57 Cases 
(Oasis® Group) 
57 Cases 
(Dermagraft® Group) 
 171 Cases 
 Study Population 
Informed Consent 
360 Cases 
Total Recruitment 
216 Cases 
Meet Eligibility 

 
8 
 
temperature, the Investigator/clinician will be able to identify the two treatments. Therefore, to 
avoid assessment bias, we will have an Inter-observer that will be blinded to treatment to 
perform all follow-up wound evaluations and record measurements. Following 
measurement/wound assessment, the treatment will be performed by another assigned 
clinician, which will not the involvement of the Inter-observer. 
 
Withdrawal: 
The subjects may withdraw from the study at any time during the study, upon request. The 
investigator may also discontinue a subject if it is determined that the subject has not responded 
to therapy or adverse event occurred, which requires alternative therapy. Those subjects that 
have undergone treatment will be followed and documented until end of the study. If there is 
more than 10 percent loss to follow-up, then investigators will attempt to recruit additional 
subjects.  
 
4 
STUDY PROCEDURES 
 
4.1 
DESIGN AND METHODOLOGY   
We propose a randomized, single blinded, three-armed controlled clinical equivalence trial 
comparing the effectiveness of two intervention arms (acellular ECM, Oasis® and cellular ECM, 
Dermagraft®) and a standard treatment arm to address the problem of efficacy and cost 
effectiveness among synthetic skin grafts in treating DFUs in the VA system 
 
4.2 
DESCRIPTION OF STUDY GROUPS 
Standard (Conventional) Therapy: 
Standard therapy will consist of the typical foot evaluation and care provided by the Department 
of Veteran Affairs facilities, which will include weekly sharp debridement, cleansing of wound 
with normal saline, and application of non-adhesive dressing (Adaptic® or Mepitel®), Iodosorb® 
gel over wound bed, covered by dry dressings. The investigator will document the standard care 
provided during clinic visits including weekly follow-up evaluations. Offloading will be 
standardized, which will involve placement in modified offloading insert (trilaminar plastazote) 
and removable Cam Walker boot. 
 
Oasis®: 
Patients in the Oasis® group will undergo the same wound care and offloading modality as the 
Standard Therapy group, with weekly wound evaluation dressing changes. The Oasis® matrix 
will be applied on the wound (cut to size), moistened with normal saline to assure adherence to 
wound bed, then apply non-adhesive dressing (Adaptic® or Mepitel®), moist sterile gauze, dry 
and gauze dressings. Up to 8 weekly applications will be applied to wound until healed. 
 
Dermagraft®: 
Patients in the Dermagraft® group will receive the same Standard Therapy, with weekly wound 
evaluation and dressing changes. The Dermagraft® will be thawed as directed by the 
manufacturer, then under sterile technique Dermagraft® will be cut to size of wound, covered 
with non-adhesive coverage (Adaptic® or Mepitel®), moistened sterile gauze and dry dressings.  
Up to 8 weekly applications will be applied to wound until healed. 
 
 
 
 
 
 

 
9 
 
4.3 
STUDY FLOW CHART 
 
Study Plan Schematic 
Procedure 
Visit 1 
(Week -2) 
Visit 2 
(Week -1) 
Visit 3 
(Week 0) 
Randomization 
Visits 4-10 
(Week 1-7) 
Treatment 
Visits 11-18 
(Week 8-15) 
Treatment 
Visit 19 
(Week 16) 
Study Endpoint 
Visits 20-23 
(Week 17-28) 
Follow-Up 
Informed Consent 
X 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X 
X 
X 
 
 
 
 
Physical Exam 
X 
 
 
 
 
X 
 
Vital Signs 
X 
X 
X 
X 
X 
X 
 
Ankle-Brachial Index 
X 
 
 
 
 
 
 
Fungal Infection Culture 
and Malignancy 
Evaluation 
X 
 
 
 
 
 
 
Blood Sample Drawn for 
Labs 
X 
 
 
 
 
 
 
SF-36v2™, EQ-5D, 
QALYs Questionnaires 
X 
 
 
 
 
 
Visit 20 only 
Ulcer Assessment 
X 
X 
X 
X 
X 
X 
X 
Debridement 
X 
X 
X 
X 
X 
X 
X 
Ulcer Photography and 
Area Measurement 
X 
X 
X 
X 
X 
X 
X 
Randomization 
 
 
X 
 
 
 
 
Dermagraft® Tx + SOC 
 
 
X 
X 
 
 
 
Oasis® Tx + SOC 
 
 
X 
X 
 
 
 
SOC 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
 
 
4.3.1 Screening/Baseline Period (Visit 1, 2/Week -2, -1) 
Subjects that meet all criteria of the study will be given an informed consent form to review and 
sign. Subjects will be required to complete all screening assessments within the 2 weeks prior to 
randomization and start of treatments. 
 
Screening assessments and pre-treatment: 
 
1)   Demographic information: gender, age, race, socio-economic status.   
2)   Medical history: medical problems, surgeries, trauma, history of previous ulcers, 
amputations, characteristic and duration.  
3)   Physical examination: vital signs, height, weight, Body Mass index 
4)   General health and lifestyle: smoking history, alcohol, drugs abuse, regular physical activity. 
5)   Lower extremity exam: vascular - pedal pulses, color of skin, temperature, edema; 
dermatological – clinical description of the ulcer (staging per UT wound classification), 
fungal infection of skin and/or nails, skin integrity (calluses, dryness); musculoskeletal – foot       
deformities such as bunion, hammertoe, bony prominence, fat pad atrophy, altered gait; 
neurological – absence or presence of sensation with 5.07/10 Semmes-Weinstein       
monofilament, reflexes. 
6)   Non-invasive vascular study: ankle-brachial systolic pressure (ABI) and toe-brachial systolic 
pressure (TBI). In order to meet criteria, ankle-arm index must be equal to or greater than 
0.8 and less than 1.4 or a toe-arm index is equal to or greater than 0.6. 
7)   Foot ulcer history (location, length of time, treatments used, pain, etiology of ulcer). 
8)   Laboratory: Hga1c, chemistry, CBC, pregnancy test (for women of childbearing ages), LFT, 
ESR, CRP and albumin. 

 
10 
 
9)   Radiological imaging – plain foot and/or ankle films for baseline. 
10) Subjects will be given the health-related quality of life survey, the Medical Outcomes Study 
      36 item Short Form (SF-36v2™) health survey. 
11) Sharp debridement of ulcer will be performed per standard method. A small sample will be 
collected for microbiology (gram stain, cultures/sensitivities, and fungal) and pathology. 
12) Photographs of ulcer will be obtained before and after debridement, using Silhouette 
Mobile™ ulcer tracing, surface area calculation. 
13) Dressings applied will include non-adhesive dressing (Adaptic® or Mepitel®), Iodosorb® gel 
over wound bed, covered by dry dressings. 
14) Off-loading shoes will be given, modified offloading insert (trilaminar plastazote) as 
determined appropriate per discretion of clinician. 
 
4.3.2 Randomization (Visit 3/Week 0) 
Those subjects that meet all eligibility criteria will be randomly assigned to one of the three 
groups. A randomized number will be assigned to each subject participating in the study, where 
one will receive either Dermagraft®, Oasis® or the control (standard therapy). 
4.3.3 Treatment Phase (Visits 4 to 18/Weeks 1 to 15) 
Subjects will be evaluated and receive treatments on weekly basis (7 days +/- 2 days). 
Appointments will be made as determined by investigator at each VA facility. 
• 
At each visit, vital signs will be obtained and recorded.  
• 
The ulcer will be assessed – visual inspection – complete ulcer characteristics form (see 
appendix). 
• 
If there is concern for infection after evaluation of ulcer, then a confirmatory bacterial 
culture will be obtained (deep swab culturette or tissue specimen/biopsy). 
Radiographical xrays and blood work (CBC, ESR, CRP, and Chem) may also be 
performed if deemed necessary by investigator clinician. 
• 
Next, a digital image will be taken one image before debridement and one image 
immediately after debridement (camera will capture dimensional size of ulcer). The 
images will be stored on a central server, with unique identifier as well as loaded on 
CPRS Vista imaging. 
• 
Surgical debridement of ulcer will be performed using curette or blade. Clinician should 
debride wound to promote mild bleeding from ulcer site and removal of necrotic or 
fibrinous tissue and excess hyperkeratotic margins if possible. Clinician may use 
lidocaine topical jelly/ointment if ulcer is too tender to debride. 
• 
All wound beds will be cleaned gently with normal saline 0.9%. 
• 
Application of treatments: 
o Standard (Conventional) Therapy: 
Application of non-adhesive dressing (Adaptic® or Mepitel®), Iodosorb® gel over 
wound bed, covered by dry gauze dressings. 
Oasis®: 
The Oasis® matrix will be applied on the wound (cut to size using scissors), 
moistened with normal saline to assure adherence to wound bed, then apply 
non-adhesive dressing (Adaptic® or Mepitel®), moist sterile gauze, dry and 
gauze dressings. Up to 8 weekly applications will be applied to wound until 
healed. 
Dermagraft®: 
The Dermagraft® will be thawed as directed by the manufacturer, then under 
sterile technique Dermagraft® will be cut to size of wound using scissors, 

 
11 
 
covered with non-adhesive coverage (Adaptic® or Mepitel®), moistened sterile 
gauze and dry dressings. Up to 8 weekly applications will be applied to wound 
until healed. 
• 
Offloading devices: 
o Plantar foot ulcers – offload with post operative style shoe (with plastazote cut 
out (aperature or extravasation) as necessary to offload ulcer pressure area. 
o Heel ulcers – use multi-podus splint or Rooke boot. 
• 
Changes in concomitant medications, adverse events, compliance to offloading, will be 
recorded. 
• 
If ulcers heal sooner than 8 weeks, the subject will be assessed the following week. 
Ulcer healing is defined by 100% epithelization as determined by the clinician. The 
subject with healed ulcer will also return for follow-up visits Weeks 9, 16, 20. 
 
NOTE: if ulceration remains open after 8th application – then will switch back to standard 
of care therapy (if budget allows, may consider extending graft course). 
 
4.3.4 Study Endpoint (Visit 19/Week 16) 
• 
Subjects to complete the health-related quality of life survey, the Medical Outcomes 
Study 36 item Short Form (SF-36v2™) health survey. 
• 
Vital signs will be obtained and recorded. 
• 
The ulcer will be assessed – visual inspection – complete ulcer characteristics form (see 
appendix). Determine if reaches 100% epithelization determined by clinician.  
• 
Labs drawn from each subject, hematological and chemistry panel. Pregnancy test of 
childbearing age. 
• 
If concern for infection, confirmatory bacterial culture will be obtained (deep swab 
culturette or tissue specimen/biopsy). Radiographical x-rays and blood work (CBC, ESR, 
CRP, and Chem) may also be performed if deemed necessary by investigator clinician. 
• 
Digital imaging of ulcer location, if remains non-healing then 2 images to be obtained 
prior to and after surgical debridement. 
• 
Surgical debridement of ulcer if not healed, will be performed using curette or blade and 
standard therapy. 
• 
Changes in concomitant medications, adverse events, compliance to offloading, will be 
recorded. 
 
4.3.5 Follow-Up Phase (Visits 20 to 23/Weeks 17 to 28) 
• 
The ulcer will be assessed – visual inspection – complete ulcer characteristics form (see 
appendix). Determine if reaches 100% epithelization by clinician. 
• 
Digital imaging of ulcer location, if remains non-healing then 2 images to be obtained 
prior to and after surgical debridement. 
• 
Surgical debridement of ulcer if not healed, will be performed using curette or blade and 
standard therapy. 
• 
Changes in concomitant medications, adverse events, compliance to offloading, will be 
recorded. 
 
5 
ADVERSE EVENTS 
 
All adverse events reported spontaneously by the subject/or in response to questioning or 
observation by the investigator will be recorded. 
 
 

 
12 
 
Reporting of Adverse Events: 
The Investigator will be responsible for assessing the relationship of the adverse event to the 
investigational product, and the seriousness and expectedness of the adverse event at the time 
of occurrence. All adverse events that occur during the trial will be documented. 
 
AE’s/SAE’s reported during the study, or SAE’s reported within 30 days of the end of the study, 
should be followed to resolution of the AE/SAE or, within thirty days from the end of the study, a 
further and final assessment of the outcome should be made. Each AE will be categorized as 
“serious” or “not serious” based on the definition of an SAE. An SAE is defined as an AE 
resulting in at least one of the outcomes described in the sections below. 
 
The severity of AEs will be classified as “mild”, “moderate”, or “severe”, based on the following 
definitions: 
 
• 
Mild: Awareness of sign, symptom, or event, but easily tolerated; does not interfere with 
usual daily activities or tasks. 
• 
Moderate: Discomfort enough to cause interference with usual daily activity; may warrant 
therapeutic intervention. 
• 
Severe: Incapacitating; inability to perform usual activities and daily tasks; significantly 
affects clinical status; requires therapeutic intervention. 
 
Adverse events will be assigned a relationship (causality) to the study products. The 
Investigator will be responsible for determining the relationship between an AE and the study 
product. The type of event, organ system affected, and timing of onset of the event will be 
factors in assessing the likelihood that an AE is related to the treatment. Relationship of AEs to 
study products will be classified as follows: 
 
• 
Not Related: No relationship exists between the AE and the treatment. The event is 
attributed to a pre-existing medical condition or an intercurrent event unrelated to the 
study product. 
• 
Possibly Related: Follows the treatment, but may have developed as a result of an 
underlying clinical condition or treatments/interventions unrelated to the study product. 
• 
Probably Related: Follows the treatment, but is unlikely to have developed as a result of 
the subject’s underlying clinical condition or other treatment or other interventions. 
• 
Definitely Related: Follows the treatment and physical evidence shows a convincing 
relationship to the treatment. 
• 
Unknown: Follows the treatment, but unable to determine the relationship to the 
treatment. 
 
Subject Follow-up: 
Subjects who experience an AE will be followed until the AE has resolved, if possible. 
 
Serious Adverse Events: 
A serious AE (SAE) will be defined as any untoward medical occurrence that occur after signing 
the informed consent until the Final Evaluation that: 
 
• 
Results in death, 
• 
Is life-threatening, 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization, 
• 
Results in persistent or significant disability/incapacity, 

 
13 
 
• 
Is a congenital anomaly/birth defect, 
• 
Other (event not covered by SAE categories but in the investigator’s opinion, should be 
considered serious). 
 
Important medical events that may not result in death, be immediately life threatening, or require 
hospitalization may be considered an SAE when, based upon medical judgment, they may 
jeopardize the subject and require intervention to prevent one of the outcomes listed above. 
 
Reporting Serious Adverse Events: 
The Investigator must report all SAEs (including any subject deaths) occurring during the study 
(from informed consent until the Final Evaluation). Once the Investigator becomes aware of an 
SAE, he/she must e-mail (preferred method of communication) or telephone the IRB within 24 
hours. 
 
A written report must follow within 48 hours of the time the Investigator learned of the event. 
This written report must include a full description of the event and all supporting documentation 
available at that time (e.g., lab reports, electrocardiogram [ECG] reports, etc.). Additional follow-
up information must be reported to the Sponsor on the appropriate form as it becomes available 
and/or upon Sponsor request. 
 
Data Safety Monitoring Board: 
Since this is an open-label trial, no data safety monitoring board will be established. 
 
Stopping Criteria: 
The emerging clinical and safety data will be reviewed during the trial, and as a result of this 
review it may be necessary to terminate the study before all patients have completed the 
protocol. In such circumstances subjects will be followed up for safety assessment. 
 
6 
STATISTICAL DESIGN 
 
Measures: 
Measures will be collected at baseline, weekly thereafter, with primary endpoint of complete 
healing at Week 12, and final secondary endpoint measurement at Week 20. The ulcer will be 
assessed weekly and will be treated as described above. A designated inter-observer will be at 
each of the testing sites, (blinded to the treatment of the subjects) which will perform all 
measurements. The following measurements will be taken: size (surface area calculation), 
photos (digital includes ruler) and complete foot ulcer assessment (description of 
ulcer/characteristics), before and after debridement. Subjects where ulceration healed earlier 
than Week 12 will have follow-up assessment one week after healing, then at Week 12 and 20. 
If ulcerations healed after 12 weeks, then the subjects will be assessed at one week after 
healing and at Week 20. There will be 4 follow-up visits (Weeks 17, 20, 24, 28), assessed every 
4 weeks for a total of 16 weeks. 
 
During the study, if ulceration appears to be infected as determined by clinical presentation 
characterized by the presence of two or more signs of inflammation,3 the clinician will follow the 
protocol of obtaining wound culture for microbiology, radiographs, blood work (CBC, chemistry 
panel, sedimentation rate, and C-reactive protein), and treatment immediately with appropriate 
antibiotics. Subjects with infected ulcers will be withdrawn from study and investigators will be 
notified. In addition, adverse events will be well documented and treated per protocol, and 
subjects will be withdrawn from study. 
 

 
14 
 
Clinical Outcomes: 
• 
The percentage of subjects that have complete closure of ulceration by Week 12 and 
Week 20. Complete healing will be defined as full re-epithelization with no drainage, or 
callus formation and remains closed after 1 week of wound closure. 
• 
Rate of wound healing to achieve complete closure. Weekly measurements of surface 
area will be recorded on a grid marked acetate sheet, using a metric ruler to determine 
length and width of the wound. 
• 
A diabetic foot ulcer assessment form will be filled out at weekly follow-up visits, that 
describes characteristics of ulceration including peri-ulcer erythema, wound margins, 
fibrin, granular tissue, peri-ulcer pruritus, edema and location, pain, amount of drainage 
and type, amount of epithelization, pain level, depth, and bioburden. 
• 
Number of incident subjects with infection, osteomyelitis and acute Charcot during the 
study, will be withdrawn from the study. 
• 
Number of incidence of adverse effects will be reported from all sites, and will be 
withdrawn from the study. 
• 
Veterans’ Short Form Health Survey (SF-36v2TM), a self-administered questionnaire will 
be used to measure quality of life, given at beginning and at the end of the study. 
• 
EuroQol Questionnaire (EQ-5D) to evaluate overall quality of life and to facilitate the 
calculation of health utilities and quality adjusted life years (QALYs). The EuroQol 
questionnaire (EQ-5D) will be administered at beginning and at the end of the study. 
 
 
 
Sample Size Estimation: 
The sample size was estimated based on 80 percent power, significance level 0.05, to detect a 
difference in the incidence of ulcer closure of the two study groups and the standard of care 
group (Stplan4.3).4 It is expected that 50% of the Dermagraft® and Oasis® groups will reach 
complete ulcer closure by Week 12 and approximately 25% closure with those subjects that 
received the standard of care (numbers based on previous studies as described previously). We 
would expect the difference to be 25% between the standard and the treatment group. By using 
a Chi-square test without continuity correction test would require 57 subjects in each group. If 
we estimate the difference to be 20% and lower of the cure rates to be 30%, then we would 
require 88 patients in each group. 
Analyses: 
The primary end point is wound closure by Week 12, which will be analyzed using Chi-square 
test to compare the percentages of subjects with complete closure in each group. We will also 
perform exploratory analysis with logistic regression, using the complete closure at 12 weeks as 
the dependent variable and the independent variables would include, treatment, size of ulcer, 
location on foot, how long ulcer has been present, previous revascularization (will analyze as 
subset group), offloading compliancy, concomitant medications, foot deformity, history of 
amputation, diabetes complications index, and glucose control (HbA1c). Selection of covariates 
will be performed by stepwise modeling procedures. 
 
We will perform a cost-effectiveness analysis comparing the treatment groups Dermagraft®, 
Oasis® and the standard care group at the NCHCS using ANOVA or Kruskal-Wallis test 
depending if data is normally distributed for comparison of the three treatment arms. If 
significant, we will further analyze with pair-wise comparisons by using t-test or Wilcoxon rank-
sum test with the Bonferroni correction to control for type I experiment-wise error rate of 0.05. A 
p-value less than 0.05/3 =0.0167 will be considered statistically significant. 
 

 
15 
 
We will evaluate the cost-effectiveness of the Oasis® compared to Dermagraft® and the 
standard of care by measuring QALYs as the measure of effectiveness, based on results 
obtained from SF-36v2TM questionnaire. Multiple regression will be used to allow to evaluate 
continuous dependent variable outcomes, including change scores between baseline and end 
of study physical (PCS) and mental (MCS) component summaries from the SF-36v2TM 
questionnaire. 
 
Rates of healing among the three groups will be analyzed using log-rank test to compare time of 
healing within 20 weeks among the 3 treatment groups. 
 
Secondary endpoint (complete healing at 20 weeks), recurrence ulceration rate at 20 weeks will 
be analyzed using Chi-square tests. In addition, demographics, smoking history, and 
characteristics of the wound will also be summarized in table. Data that are continuous variables 
will be summarized by using mean, median, standard deviation, coefficient of variation, 
minimum and maximal values. Frequency tables will summarize categorical variables. 
 
Timeline and Milestones: 
  
  
Year 1 
Year 2 
 Months 
1-6 
7-12 
1-6 
7-12 
Aim 1: Recruitment 
 
 
 
 
Step 1: Screening (2-week run-in phase)  
✓  
✓  
✓  
 
Step 2: Randomization/Assignment 
✓  
✓  
✓  
 
Aim 2: Data Collection 
 
 
 
 
Step 1: Healed by Week 12 
✓  
✓  
✓  
✓  
Step 2: Wound not healed by Week 12, continue in 
study until Week 20  
✓  
✓  
✓  
✓  
Step 3: If wound has not reached closure beyond 
the 8 weeks of Dermagraft® – will switch to 
standard of care (expensive). Oasis® – continue to 
the end of study 
✓  
✓  
✓  
✓  
Aim 3: Data Analysis 
 
 
 
 
Step 1: Outcome effectiveness 
If outcome show significant difference will cross 
over for intent-to-treat 
✓  
✓  
✓  
✓  
 
7 
References 
1. Vista/CPRS data record system from 2006-2008, retrieved on 4/7/2009. 
2. Vista/CPRS data record system from 2006-2008, retrieved on 4/7/2009. 
3. Lipsky BA, Berendt AR, Deery HG Diagnosis and treatment of diabetic foot infections. 
Clinical Infectious Diseases: An official publication of the infectious diseases society of 
America. 2004; 203:885-910. 
4. Stplan4.3 Statistical Software, Department of Biostatistics and Applied Mathematics, 
University of Texas M.D. Anderson Cancer Center, 2006. 
 
 
 
 

 
16 
 
8  
APPENDIX 
 
Ulcer Characteristic Form 
 
Size: Dimensions _____x_____x_____cm 
 
Location of Foot Ulcer: 
 
A. Dorsal foot 
 
B. Plantar digits (1, 2, 3, 4 or 5) 
 
B. Plantar forefoot (excludes digits) 
 
C. Plantar midfoot (cuneiform, navicular level) 
 
D. Plantar heel 
 
Wound Bed/Base:  
 
Percentage of Granulation (Red) Tissue  
 
A. Bright, beefy red; 75% to 100% of wound bed  
 
B. Bright, beefy red; Greater than 50% to less than 75% of wound bed 
 
C. Pink, dull red; Greater than 25% to less than 50% of wound bed 
 
D. No granulation tissue present and/or less than 25% of wound bed 
 
 
Percentage of Fibrinous (Yellow) Tissue 
 
A. None 
 
B. Less than 25% of wound bed 
 
C. 25% to less than 50% of wound bed 
 
D. 50% to less than 75% of wound bed 
 
E. 75% to 100% of wound bed 
 
 
Percentage of Necrotic (Black/Eschar) Tissue 
            A. None 
 
B. Less than 25% of wound bed 
 
C. 25% to less than 50% of wound bed 
 
D. 50% to less than 75% of wound bed 
 
E. 75% to 100% of wound bed 
 
 
Epithelialization (appearance of skin – may appear pink or red skin): 
 
A. Less than 25% of wound bed 
 
B. 25% to less than 50% of wound bed 
 
C. 50% to less than 75% of wound bed 
 
D. 75% to less than 100% of wound bed 
 
E. 100% all intact skin 
 
Wound Edges/Margins:  
 
A. Healed 
 
B. Greater than 50% advancing epithelialization of wound edges 
 
C. Less than 50% advancing epithelialization of wound edges 
 
D. No advancing border of epithelium 
 
Depth:  
 
A. None – intact skin 
 
B. Partial thickness involving skin loss of epidermis and/or dermis 
 
C. Full thickness involving skin loss of epidermis/dermis and subcutaneous layer 

 
17 
 
 
D. Tendon/joint capsule exposed 
 
E. Probes to bone 
 
 
Peri-wound Erythema: 
 
A. Normal, no appearance of redness/pinkness 
 
B. Mild pinkness surrounding wound 
 
C. Bright red and/or blanches to touch 
 
D. Pallor, pale 
 
E. Violaceous, dusky red and or non-blanchable 
 
F. Black, necrosis 
 
Peri-wound Edema: 
 
A. None 
 
B. Minimal edema 
 
C. Non-pitting edema within 4 cm of wound 
 
D. Non-pitting edema extends beyond 4 cm of wound 
 
E. Pitting edema within 4 cm of wound 
 
R. Pitting edema extends beyond 4 cm of wound 
 
Drainage/Exudate:  
 
A. None 
 
B. Serosanguinous 
 
C. Serous 
 
D. Seropurulent 
 
E. Purulent 
 
Amount of Drainage/Exudate: 
 
A. None 
 
B. Scant (less than 1 ml) 
 
C. Mild (Less than 25% of dressing saturation) 
 
D. Moderate (50% to less than 75% of dressing saturation) 
 
E. Copious (75% or more of dressings saturated) 
 
Tenderness/Pain at Wound Site (pain scale 0-10): 
 
A. None 
 
B. 1 to 2 
 
C. Greater than 3 to 4 
 
D. Greater than 4 to 7 
 
E. 8 to 10 
 
 
 
 
 
 

 
18 
 
Statistical Analysis Plan 
 
Analyses: The primary outcome is wound closure by Week 12, which will be analyzed using 
Chi-square test to compare the percentages of subjects with complete closure in each group. 
We will also perform exploratory analysis with logistic regression, using the complete closure at 
12 weeks as the dependent variable and the independent variables would include, treatment, 
size of ulcer, location on foot, how long ulcer has been present, previous revascularization (will 
analyze as subset group), offloading compliancy, concomitant medications, foot deformity, 
history of amputation, diabetes complications index, CRP level, and glucose control (HbA1c). 
Selection of covariates will be performed by stepwise modeling procedures, and overseen by 
biostatistician Dr. Li.  
 
Cost effectiveness analysis: We will perform a cost-effectiveness analysis comparing the 
treatment groups Dermagraft®, Apligraf®, Oasis® and the standard care group at the NCHCS 
using ANOVA or Kruskal-Wallis test depending if data is normally distributed for comparison of 
the three treatment arms. If significant, we will further analyze with pair-wise comparisons by 
using t-test or Wilcoxon rank-sum test with the Bonferroni correction to control for type I 
experiment-wise error rate of 0.05. A p-value less than 0.05/3 =0.0167 will be considered 
statistically significant.  
 
We will evaluate the cost-effectiveness of the Oasis® compared to Dermagraft® or Apligraf® 
and the standard of care by measuring QALYs as the measure of effectiveness, based on 
results obtained from SF-36v2TM questionnaire. Multiple regression will be used to allow to 
evaluate continuous dependent variable outcomes, including change scores between baseline 
and end of study physical (PCS) and mental (MCS) component summaries from the SF36v2TM 
questionnaire.  
 
Rates of healing among the four groups will be analyzed using log-rank test to compare time of 
healing within 20 weeks.  
 
Secondary outcomes such as complete healing at 20 weeks, recurrence ulceration rate at 20 
weeks will be analyzed using Chi-square tests. In addition, demographics, smoking history, and 
characteristics of the wound will also be summarized in table. For comparison nominal 
categorical secondary outcome variables, we will use Chi-square test. For comparison of ordinal 
categorical variables, we will use the Wilcoxon rank-sum test (for two independent group 
comparison) and Kruskal-Wallis test (for three independent group comparison).