A Randomized Controlled Clinical Trial Evaluating the Efficacy of a Borate-based Bioactive Glass Advanced Wound Matrix and Standard of Care Versus Standard of Care Alone
Phase: NA
Conditions: Diabetic Foot Ulcer, Ulcer Foot, Diabetic Foot
Sponsor: ETS Wound Care, LLC

ETS-MG-DFU-02 
Version 2.0 
 Date: May 12, 2023 
CONFIDENTIAL 
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Protocol Number: ETS-MG-DFU-02 
Version: 2.0 
Date: May 12, 2023 
A Randomized Controlled Clinical Trial Evaluating 
The Efficacy Of A Borate-Based Bioactive Glass 
Advanced Wound Matrix And Standard Of Care 
Versus Standard Of Care Alone 
NCT06403605

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INVESTIGATOR’S SIGNATURE PAGE 
 
 
 
 
INVESTIGATOR’S SIGNATURE 
 
I have read the protocol specified above and agree to participate in and comply 
with the procedures, as outlined herein for the conduct of this clinical trial. I also 
agree to comply with the applicable US Food and Drug Administration (FDA) 
regulations and Investigational Review Board (IRB) requirements for testing on 
human subjects. I agree to ensure that the requirements for obtaining informed 
consent are met.  
 
 
 
 
 
Investigator’s Signature 
 
 
 
 
Date 
Print Name 
 
 
 
 
 
Site Number 
 
 
 
 
 
  

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Table of Contents 
LIST OF ABBREVIATIONS ...................................................................................... 9 
PROTOCOL SYNOPSIS: ETS-MG-DFU-02 ........................................................... 10 
1 INTRODUCTION ................................................................................................ 14 
1.1 Costs of Non-healing Diabetic Foot Ulcers ...................................................... 14 
1.2 MIRRAGEN™ Advanced Wound Matrix .......................................................... 14 
2 RATIONALE FOR STUDY ................................................................................. 16 
3 STUDY ENDPOINTS ......................................................................................... 17 
4 STUDY DESIGN ................................................................................................ 18 
4.1 Phase 1: Screening ......................................................................................... 18 
4.2 Phase 2: Treatment ......................................................................................... 19 
4.3 Subject Treatment Assessments ..................................................................... 19 
4.3.1 DFU Assessments ..................................................................................................... 19 
4.3.2 Wound Healing Assessment .................................................................................... 19 
4.4 Study Subjects ................................................................................................. 20 
4.4.1 Inclusion Criteria ......................................................................................................... 20 
4.4.2  Exclusion Criteria .................................................................................................... 20 
4.5 Study Schedule ............................................................................................... 21 
4.5.1 Visit Windows ............................................................................................................... 22 
4.5.2 Screening Phase ......................................................................................................... 26 
4.5.3 Treatment Phase ......................................................................................................... 27 
4.5.4 End of Study (EOS1) Visit ......................................................................................... 30 
4.5.5 HCV: Healing Confirmation Visit ............................................................................... 31 
4.5.6 Unscheduled Visits ..................................................................................................... 31 
4.5.7 Missed Visits ................................................................................................................ 32 
5 SUBJECT COMPLETION, SUCCESS/FAILURE, WITHDRAWAL AND 
SCREEN FAILURE ............................................................................................ 33 
5.1 Subject Completion .................................................................................................. 33 
5.2 Success and Failure ...................................................................................... 33 
5.3 Premature Withdrawal from the Study ........................................................ 33 

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5.4 Screen Failures .............................................................................................. 34 
6 STANDARD OF CARE STUDY TREATMENT PRIMARY DRESSING ............. 35 
6.1 Method for Assigning Eligible Subjects to Treatment ...................................... 35 
6.2 MIRRAGEN™ Product Information (provided from IFU) ................................. 35 
6.3  FIBRACOL™ Product Information (provided from IFU) .................................. 36 
7 STANDARD OF CARE, CONCOMITANT MEDICATIONS, 
EXCLUDED/ALLOWED THERAPIES/MEDICATIONS AND ALLOWED 
DRESSINGS ...................................................................................................... 39 
7.1 SOC Procedures ............................................................................................ 39 
7.1.1 Cleaning the Index Ulcer ................................................................................. 39 
7.1.2 Debridement of the Index Ulcer ................................................................................ 39 
7.1.3 Offloading ..................................................................................................................... 39 
7.2 Concomitant Medications ............................................................................. 39 
7.3 Prohibited Medications and Therapies ........................................................ 39 
7.4 Allowable Medications and Therapies ......................................................... 40 
7.5 Approved Dressings ..................................................................................... 41 
8 DESCRIPTION OF PROTOCOL ASSESSMENTS AND PROCEDURES ......... 42 
8.1 Informed Consent .......................................................................................... 42 
8.2 Assessment of Eligibility .............................................................................. 42 
8.3 Re-Screening ................................................................................................. 42 
8.4 Subject Demographics, Medical History and Ulcer History ....................... 42 
8.4.1 Demographics .............................................................................................................. 42 
8.4.2 Medical History ............................................................................................................ 43 
8.4.3 Foot Ulcer History........................................................................................................ 43 
8.4.4 Physical Exam ............................................................................................................. 44 
8.4.5 Vital Signs ..................................................................................................................... 44 
8.4.6 Pregnancy test ............................................................................................................. 44 
8.5 ABI or Arterial Doppler Ultrasound .............................................................. 44 
8.6 SPP ................................................................................................................. 45 
8.7 TCOM .............................................................................................................. 45 

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8.8 WOUND-Q Assessment ................................................................................ 45 
8.9 Pain Assessment: NPRS ............................................................................... 45 
8.10 Ulcer Assessments ....................................................................................... 46 
8.10.1 Index Ulcer Appearance Assessment (Pre-debridement) ................................ 46 
8.10.2 Index Ulcer Exudate Assessments ...................................................................... 46 
8.10.3 Index Ulcer Infection Assessments ...................................................................... 46 
8.10.4 Investigator Assessment of Index Ulcer Closure ............................................... 47 
8.11 Randomization ............................................................................................... 48 
8.12 Assessment of Offloading ............................................................................ 48 
8.13 Semmes Weinstein Monofilament Test for Peripheral Neuropathy .......... 48 
8.14 SnapshotNIR .................................................................................................. 48 
9 DATA AND STATISTICAL ANALYSES ............................................................ 49 
9.1 Data Analysis ................................................................................................. 49 
9.2 Statistical Analysis ........................................................................................ 49 
10 ADVERSE EFFECTS AND EVENTS (DEFINITIONS AND REPORTING) ........ 50 
10.1 SOC Adverse Events ..................................................................................... 51 
10.1.1 AE Severity Assessments ...................................................................................... 51 
10.1.2 AE Causality Assessments .................................................................................... 52 
10.1.3  Serious Adverse Events ........................................................................................ 52 
11 DIRECT ACCESS TO SOURCE DATA/DOCUMENTATION ............................ 54 
12 QUALITY CONTROL AND QUALITY ASSURANCE ........................................ 55 
12.1 Acceptability of CRF ..................................................................................... 55 
12.2 Modification of Protocol................................................................................ 55 
12.3  Reporting Protocol Deviations ..................................................................... 55 
13 ETHICS AND REGULATORY REQUIREMENTS ............................................. 56 
13.1 IRB .................................................................................................................. 56 
13.2 Investigator’s Responsibilities ..................................................................... 56 
13.3 Subject Informed Consent Requirements ................................................... 56 
14 DATA HANDLING AND RECORD KEEPING ................................................... 58 
14.1 Recording and Collection of Data ................................................................ 58 

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14.2 Clinical Data Management and Monitoring ................................................. 58 
14.3 Archiving ........................................................................................................ 58 
15 PUBLICATION PLAN ........................................................................................ 60 
16 REFERENCES ................................................................................................... 61 
17   SIGNATURES .................................................................................................. 63 
APPENDICES ......................................................................................................... 64 
Appendix A: Wagner Grades ................................................................................ 64 
Appendix B: ABI or Arterial Doppler Ultrasound ................................................ 65 
Appendix C: SPP ................................................................................................... 67 
Appendix D: TCOM ................................................................................................ 68 
Appendix E: Debridement ..................................................................................... 69 
Appendix F: WOUND-Q Instrument ..................................................................... 70 
SCALE STRUCTURE ............................................................................................ 70 
WOUND CHARACTERISTICS ........................................................................................... 70 
HEALTH-RELATED QUALITY OF LIFE ........................................................................... 70 
EXPERIENCE OF CARE ...................................................................................................... 70 
WOUND TREATMENT ....................................................................................................... 70 
Appendix G: SnapshotNIR .................................................................................... 72 
 
 
 
 

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TABLE 1: CONTACT INFORMATION 
Role 
Contact Information 
Sponsor 
ETS Wound Care, LLC 
13210 Dillon Outer Road 
Rolla, MO 65401 
 
Sponsor Clinical Contact 
 
Donald W. Buck II, MD 
Phone: 410-490-5998 
Email: dbuck@etswoundcare.com 
 
Zachary Davis 
Phone: 573-201-4023 
Email: Zachary.Davis@heraeus.com 
 
Study Chair  
David G Armstrong, DPM MD PhD 
Phone: (520) 360-0044 
Email: Armstrong@usa.net 
 
Robert Galiano MD 
Phone: (312) 502-3176 
Email:  Rgaliano@NM.org 
 
Principal Investigators 
Charles M Zelen, DPM FACFAS 
Phone:(540) 520 5863 
Email:  cmzelen@periedu.com 
 
Medical Monitor 
Donald W. Buck II, M.D. 
Phone: 410-490-5998 
Email: dbuck@etswoundcare.com 
 
Clinical Research 
Organization 
Professional Education and Research Institute 
Jillian Boertlein 
Phone 513-882-8483  
Email Jboertlein@periedu.com 
 
 
 

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TABLE 2: VERSION HISTORY 
Version 
Number 
Release Date 
Change(s) 
Reason for Change 
1.0 
08AUG2023 
 
Initial Release 
2.0 
04MAY2023 
Revised language to 
Exclusion Criteria #10 to a 
30% heal rate from SV1-
TV1.   
 
Addition of Randomization 
Review Panel between SV2 
and TV1 
 
Updated number of sites 
and other minor 
administrative changes 
were also added. 
Change to 
Inclusion/Exclusion 
Criteria  
 
 
Change to 
Randomization 
Process 
 
 
 
Administrative 
Change 
 
 
 

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LIST OF ABBREVIATIONS 
 
 
TERM 
DEFINITION 
ABI/ABPI 
Ankle/Brachial Index/Ankle Brachial Pressure Index 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
DFU 
Diabetic foot ulcer 
EOS 
End of study 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HCV 
Healing Confirmation Visit 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency virus 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
PAR 
Percentage area reduction 
RCT 
Randomized controlled trial 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
SOC 
Standard of care 
SOP 
Standard operating procedure 
SPP 
Skin perfusion pressure  
SV 
Screening visit 
TCOM 
Transcutaneous oxygen measurement 
TV 
Treatment Visit 
US 
United States of America 
WOUND-Q 
Wound quality scale 

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PROTOCOL SYNOPSIS: ETS-MG-DFU-02 
Objective 
The purpose of this clinical evaluation is to collect patient outcome data on a 
commercially available 510K FDA cleared synthetic, absorbable skin 
substitute matrix. The commercially available product is MIRRAGEN™ 
Advanced Wound Matrix and consists of a borate-based bioactive glass fiber 
and particulate. 
In this trial, two groups of diabetic foot ulcers (DFUs), will receive standard of 
care (SOC) treatment for their condition. Half of the patients will have their 
SOC treatment with a 510K FDA cleared Collagen alginate dressing 
FIBRACOL™ and the other half will have a 510K FDA cleared MIRRAGEN™ 
Advanced Wound Matrix as the primary treatment. The primary endpoint is 
the percentage of patients that go on to complete closure of the target ulcer 
between the two groups: SOC with FIBRACOL™ or SOC with MIRRAGEN™. 
Secondary endpoints include the proportion of subjects achieving complete 
wound closure of the target ulcer by end of 12 weeks.  
Intervention 
Groups 
Group 1: SOC primary dressing with MIRRAGEN™  
Group 2: SOC primary dressing with FIBRACOL™ 
Study 
Design 
Multi-center, open label, randomized controlled trial 
Sample Size 
For this RCT, N = up to 240 subjects 
Centers 
Up to 15 centers within the United States, Open/competitive enrollment. 
Endpoints 
Primary endpoint: 
- 
The proportion of subjects that obtain complete closure over the 12-
week treatment period  
Secondary endpoints: 
- 
The time to achieve complete wound closure of the target ulcer by the 
end of 12 weeks  
- 
Percentage wound area reduction from TV1 to TV13 measured weekly 
with digital photographic planimetry and physical examination  
- 
The number and type of Treatment Emergent Adverse and Serious 
Adverse Events  
- 
Change in peripheral neuropathy of the target foot assessed using the 
standard 10-point Semmes-Weinstein monofilament exam [Time 
Frame: TV1, TV3, TV7, TV9, and EOS1] 
- 
Change in pain in the target ulcer assessed using the NPRS scale. 
[Time Frame: TV1, TV3, TV7, TV9, and EOS1] 

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- 
Change in quality of life using WOUND-Q assessment [Time Frame:  
SV1, TV3, TV7, EOS1] 
Exploratory Endpoint: 
• 
Difference in cellulitis and/or infection at 12 weeks 
• 
Use of near-infrared tissue oxygenation imaging assessment of wounds 
at select sites to evaluate changes in vascularization/oxygenation of 
wounds with treatment (Kent Imaging SnapshotNIR: Time Frame: SV1, 
TV1 pre-randomization, TV2, TV4, TV7, and EOS1. 
Safety 
There is no formal safety objective for this study as MIRRAGEN™ and 
FIBRACOL™ are commercially available, 510K FDA cleared dressings for 
diabetic foot wounds. Therefore, in accordance with FDA regulations, adverse 
reactions to the dressings will be recorded and provided to the study Sponsor 
for required FDA reporting and will be concurrently reported to all 
Investigators and IRBs.  
Adverse events associated with application of standard of care dressing will 
be collected during the course of the study. 
Collection and reporting of any adverse reaction data, in accordance with FDA 
regulations and adverse events associated with dressing application will 
ensure study subject safety. 
Surveillance 
Schedule 
Following initial enrollment, subjects will undergo a screening phase, 
consisting of 14 days, to determine eligibility. Eligible subjects will then 
undergo up to a 12-week treatment phase involving weekly evaluations and 
after 12 weeks, will exit the study. Additionally subjects in either group whose 
ulcers have not reduced by 50% at week 7 of treatment will be considered a 
treatment failure and will be exited from the study and permitted to seek 
alternative treatment.  
Study 
Duration 
It is estimated that about 15 months will be required to complete the study 
with data collection and reporting. 

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Inclusion 
Criteria 
Potential subjects are required to meet all the following criteria for enrollment 
into the study and subsequent randomization.  
1. Subjects must be at least 18 years of age or older.  
2. Subjects must have a diagnosis of type 1 or 2 Diabetes mellitus. 
3. At randomization subjects must have a target diabetic foot ulcer with a 
minimum surface area of 1.0 cm2 and a maximum surface area of 20.0 
cm2 measured post debridement with a photographic planimetry app.  
4. The target ulcer must have been present for a minimum of 4 weeks and 
a maximum of 52 weeks of standard of care prior to the initial screening 
visit. 
5. The target ulcer must be located on the foot with at least 50% of the 
ulcer below the malleolus.  
6. The target ulcer must be full thickness on the foot or ankle that does not 
probe to bone. 
7. Adequate circulation to the affected foot as documented by any of the 
following methods performed within 3 months of the first screening 
visit:  
a. TCOM ≥30 mmHg  
b. ABI between 0.7 and 1.3 
c. PVR: Biphasic 
d. TBI ˃0.6 
e. As an alternative arterial Doppler ultrasound can be performed 
evaluating for biphasic dorsalis pedis and posterior tibial 
vessels at the level of the ankle 
8. If the subject has two or more ulcers, they must be separated by at least 
2 cm. The largest ulcer satisfying the inclusion and exclusion criteria will 
be designated as the target ulcer.  
9. Target ulcers located on the plantar aspect of the foot must be offloaded 
for at least 14 days prior to randomization.  
10. The subject must consent to using the prescribed off-loading method for 
the duration of the study. 
11. The subject must agree to attend the weekly study visits required by the 
protocol.  
12. The subject must be willing and able to participate in the informed 
consent process.  

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Exclusion 
Criteria 
Exclusion Criteria: 
Potential subjects meeting any of the following criteria will be excluded from 
enrollment and subsequent randomization. 
1. A subject known to have a life expectancy of < 6 months is excluded. 
2. If the target ulcer is infected or if there is cellulitis in the surrounding 
skin, the subject is excluded. 
3. Presence of osteomyelitis or exposed bone, probes to bone or joint 
capsule on investigator’s exam or radiographic evidence.  
4. A potential subject cannot have an infection in the target ulcer or in a 
remote location that requires systemic antibiotic therapy.  
5. A 
subject 
receiving 
immunosuppressants 
(including 
systemic 
corticosteroids at doses greater than 10 mg of Prednisone per day or 
equivalent) or cytotoxic chemotherapy is excluded. 
6. The topical application of steroids to the ulcer surface within one month 
of initial screening is not permitted. 
7. A subject with a previous partial amputation on the affected foot is 
excluded if the resulting deformity impedes proper offloading of the 
target ulcer. 
8. If a subject has a glycated hemoglobin (HbA1c) greater than or equal to 
12% taken at or within 3 months of the initial screening visit he/she is 
excluded.  
9. If a subject has a serum creatinine ≥ 3.0mg/dL within 6 months of 
randomization he/she is excluded. 
10. The subject is excluded if the surface area measurement of the target 
ulcer has reduced in size by more than 30% in the 2 weeks prior to the 
initial screening during the 2-week screening phase: the 2 weeks from 
the initial screening visit (SV1) to the TV1/randomization visit during 
which time the subject received SOC.  
11.  A subject with an acute Charcot foot, or an inactive Charcot foot, that 
impedes proper offloading of the target ulcer is excluded.  
12. Women who are pregnant or considering becoming pregnant within the 
next 6 months are excluded.  
13. A potential subject with end stage renal disease requiring dialysis is 
excluded.  
14. A subject who participated in a clinical trial involving treatment with an 
investigational product within the previous 30 days is excluded.  
15. A subject who, in the opinion of the Investigator, has a medical or 
psychological condition that may interfere with study assessments is 
excluded.  

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16. A subject treated with hyperbaric oxygen therapy or a Cellular and/or 
Tissue Product (CTP) in the 30 days prior to the initial screening visit 
is excluded. 
1 
INTRODUCTION 
1.1 Costs of Non-healing Diabetic Foot Ulcers 
The economic burden of DFUs costs the United States over $50 billion each year.1  The cost 
to treat one patient with DFUs ranges from $11,700 to $16,883.2  Although approximately 
70% of DFUs are shown to heal with good SOC, at least 30% become chronic wounds.3  
These non-healing wounds are at greater risk for infection and lower extremity amputation.4  
Consequently, good standard of care therapy is important for patients with chronic DFUs to 
improve patient outcomes, lower treatment costs and reduce the risk of complications. 
1.2 MIRRAGEN™ Advanced Wound Matrix 
MIRRAGEN™ Advanced Wound Matrix is intended for the use in the management of 
wounds. Wound types include: partial and full thickness wounds, pressure ulcers, venous 
ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical 
wounds, trauma wounds and draining wounds. 
Boron-containing compounds have an extensive history of use in medicine due to several 
mechanisms of action, including inhibition of phodsphodiesterase-4 (PDE4), which reduces 
production of pro-inflammatory cytokines4; broad-spectrum antifungal activity (inhibitor of 
amino-acyl (leucyl) tRNA synthetase)5; treatment of various cancers (e.g., non-Hodgkin’s 
lymphoma and multiple myeloma)6,7; antimicrobial activity against Gram-negative bacteria 
(AN3365)8; and antiprotozoal activity against Trypanosoma brucei.9  
Although borate itself was shown to accelerate wound healing in wounds nearly 30 years 
ago10, it has taken some time to understand the mechanisms involved. Boron facilitates the 
activity of several key enzymes in fibroblasts, including elastase, trypsin-like enzymes, 
collagenase, and alkaline phosphatase.11 Further research showed that it also regulates 
mRNA expression of a wide range of extracellular-matrix proteins, including collagen type 1 
(COL1), osteopontin (OPN), bone sialoprotein (BSP), and osteocalcin (OCN), as well as 
alkaline phosphatase and bone morphogenetic proteins (BMPs).12,13  
In vitro studies of bioactive boron-based glass fiber matrices have been conducted for 
several years, primarily in bone and cartilage although two in-vitro studies suggest that 
boron-doped bioactive glass fibers are capable of eliciting VEGF responses from cells14,15 
although no studies to date have confirmed such responses in chronic wounds. In general, it 
has been found that the degradation rate of bioactive glass can be altered by changing its 
composition; for example, by partially replacing the SiO2 in silicate 45S5 or 13–93 glass with 
B2O3 (yielding a borosilicate bioactive glass), or fully replacing the SiO2 with B2O3 (producing 
a borate bioactive glass)16,17. 
Recent clinical studies have pointed to the efficacy of boron-based bioactive glass fiber 
matrix in wound management18-21. This RCT is a larger, follow-up study to the recently 

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published 40-patient pilot study in DFU which demonstrated a statistically significant 2.8 fold 
increase in healing rates compared to SOC alone (p=0,004) and doubled the rate of wound 
are reduction at all time points (p-0.027)22. 
 

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2 
Rationale for Study 
MIRRAGEN™ is a bioactive borate-based glass fiber matrix (BBGFM) that can dissolve in 
wound fluids over a period of several days. A recent 40-patient RCT and additional case 
studies involving the treatment of chronic diabetic foot ulcers (DFUs) with BBGFM suggest 
that when used as dressing as part of the standard of care (SOC), improved healing 
trajectories result. Based on this early promising data, a larger RCT is necessary to further 
validate these results. For consistency one type of wound will be studied in this trial and we 
have chosen DFU’s as they are some of the most common wounds seen in the wound 
clinics.  
 

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3 
Study Endpoints  
The purpose of this clinical evaluation is to collect patient outcome data on 2 commercially 
available standard of care dressings in partial/full-thickness diabetic foot ulcer subjects. 
Patient outcomes will be compared at 6 and 12 weeks.  
The primary endpoint is the proportion of subjects that obtain complete closure over the 
12-week treatment period.  
Secondary endpoints include a comparison between groups of the following clinical 
measures:   
1. The time to achieve complete wound closure of the target ulcer by the end of 12 
weeks.  
2. Percentage wound area reduction from TV1 to TV13 measured weekly with digital 
photographic planimetry and physical examination. 
3. The number and type of Treatment Emergent Adverse Events. 
4. Change in peripheral neuropathy of the target foot assessed using the standard 10-
point Semmes-Weinstein monofilament exam [Time Frame: TV1, TV3, TV7, TV9, 
and EOS1]. 
5. Change in pain in the target ulcer assessed using the NPRS scale. [Time Frame: 
TV1, TV3, TV7, TV9, and EOS1]. 
6. Change in quality of life using WOUND-Q assessment. 
Exploratory/Tertiary Endpoints 
7. Difference in cellulitis and/or infection at 12 weeks. 
8. Use of near-infrared tissue oxygenation imaging assessment of wounds at select 
sites to evaluate changes in vascularization/oxygenation of wounds with treatment 
(Kent Imaging SnapshotNIR; Time Frame: SV1, TV1 pre-randomization, TV2, TV4, 
TV7, and EOS1). 
 
 
 

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4 
Study Design 
This study is a prospective, multi-center, open label, RCT designed to collect patient 
outcome data on two commercially available SOC dressings for the treatment of DFUs. 
Wound healing assessment will be conducted by a clinician, other than the Investigator at 
each site.  Confirmation of wound healing will be overseen by an independent adjudication 
committee made up of wound care experts. 
 
There are two standard of care arms in the study:  
 
Arm 1: The SOC therapy in this study is offloading of the DFU (CAM boots or total contact 
casting [TCC] if the subject’s foot is too large for a CAM), appropriate sharp or surgical 
debridement, infection management (systemic antibiotics only in conjunction with 
debridement) and wound care covering with Bioactive glass dressing, MIRRAGEN™, 
followed by a padded 3-layer dressing comprised of 4x4 gauze pads, soft roll and 
compressive wrap (DynaflexTM or equivalent).  
Arm 2: The SOC therapy in this study is offloading of the DFU (CAM boots or total contact 
casting [TCC] if the subject’s foot is too large for a CAM), appropriate sharp or surgical 
debridement, infection management (systemic antibiotics only in conjunction with 
debridement) and wound care covering with calcium alginate FIBRACOL™ dressing 
followed by a padded 3-layer dressing comprised of 4x4 gauze pads, soft roll and 
compressive wrap (DynaflexTM or equivalent).  
The study involves two phases: Screening and Treatment.  
FIGURE 2: OVERVIEW OF STUDY PHASES 
4.1 Phase 1: Screening 
The Screening Phase (14 days required) is designed to determine whether subjects are 
eligible to proceed to the Treatment Phase of the study and consists of a series of screening 
assessments designed to determine eligibility.  
At the first Screening Phase Visit (SV1), written informed consent (ICF) from the subject will 
be obtained by the Investigator or suitably qualified designee before any protected health 
information is obtained and prior to the performance of any protocol-specific procedures. 
After obtaining ICF, the Investigator will select the study index ulcer. Each subject will have 
only one DFU selected as the index ulcer. If the subject has more than one DFU at the SV 1 
visit, the Investigator will select the largest DFU that meets the eligibility criteria of the 
protocol as the index ulcer. 
Subjects whose index ulcer has been treated with SOC for two weeks during screening are 
eligible to enter the Treatment Phase immediately once all of the inclusion and exclusion 
criteria are met. Further, a panel of three board-certified plastic surgeons will review each 
wound, as well as inclusion/exclusion criteria, in a blinded fashion to ensure that 
randomizations are appropriate.  The review will occur between SV2 and the day of 
randomization.  The plastic surgeon will provide correspondence to the trial manager that 
the subject is appropriate for randomization, prior to the site being able to randomize the 
patient.   

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4.2 Phase 2: Treatment 
The Treatment Phase (up to 13 weeks) begins with a series of assessments designed to 
confirm the subject’s continued eligibility. Investigators will debride the ulcer, in accordance 
with SOC if required. Subjects whose ulcers continue to meet eligibility criteria will then be 
randomized to one of two groups: (1) SOC with MIRRAGEN™ primary dressing or (2) SOC 
with FIBRACOL™ primary dressing. Additionally for the most compassionate care subjects 
in either group whose ulcers have demonstrated wound area reduction by less than 50% at 
week 7 of treatment will be considered a treatment failure and will be permitted to obtain 
additional outside treatment and thus will be exited from the study.  
4.3 Subject Treatment Assessments 
4.3.1 DFU Assessments 
During the Treatment Phase, subjects will be evaluated on a weekly basis. Weekly patient 
outcome evaluations include the Investigator’s assessment of ulcer healing and 
measurements of ulcer size using digital imaging to measure wound area and provide photos 
of wounds, including photos of healed wounds for adjudication.  
Note: All procedures required during baseline are included in TV1 prior to the 
Randomization visit. 
Other evaluations during the Treatment Phase are detailed in the procedures section.  
Subjects will be seen weekly (± 3 days) until the ulcer is healed or they meet protocol criteria 
to exit the study.  
4.3.2 Wound Healing Assessment 
Initial and confirmation evaluations of wound healing will be subject to oversight to reduce 
bias. An adjudication panel, consisting of at least two wound care experts with significant 
experience in treating diabetic foot ulcers will be employed. 
The adjudication will be made using photographs of the DFU and will comprise: 
1. An initial wound healing assessment by an Investigator.  
2. The subject proceeds to the wound healing confirmation visit, two weeks later. 
3. Subject photographs will be cataloged and presented to the adjudicators during an 
adjudication meeting held at interim points throughout the study (up to two interim 
adjudication meetings) and at the end of the study (up to three total adjudication 
meetings).  
4.  Final healing confirmation will be determined by the adjudicator during an adjudication 
meeting. 
 
 
 

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4.4 Study Subjects 
This prospective RCT will enroll up to 240 subjects in up to 12 centers located in the USA.  
4.4.1 Inclusion Criteria 
Potential patients are required to meet all of the following criteria for enrollment into the 
study and subsequent randomization: 
1. Subjects must be at least 18 years of age or older.  
2. Subjects must have a diagnosis of type 1 or 2 Diabetes mellitus. 
3. At randomization subjects must have a target diabetic foot ulcer with a minimum 
surface area of 1.0 cm2 and a maximum surface area of 20.0 cm2 measured post 
debridement with a photographic planimetry app.  
4. The target ulcer must have been present for a minimum of 4 weeks and a maximum 
of 52 weeks of standard of care prior to the initial screening visit. 
5. The target ulcer must be located on the foot with at least 50% of the ulcer below the 
malleolus.  
6. The target ulcer must be full thickness on the foot or ankle that does not probe to 
bone. 
7. Adequate circulation to the affected foot as documented by any of the following 
methods performed within 3 months of the first screening visit:  
a. TCOM ≥30 mmHg  
b. ABI between 0.7 and 1.3 
c. PVR: Biphasic 
d. TBI ˃0.6 
e. As an alternative arterial Doppler ultrasound can be performed evaluating for 
biphasic dorsalis pedis and posterior tibial vessels at the level of the ankle. 
8. If the subject has two or more ulcers, they must be separated by at least 2 cm. The 
largest ulcer satisfying the inclusion and exclusion criteria will be designated as the 
target ulcer.  
9. Target ulcers located on the plantar aspect of the foot must be offloaded for at least 
14 days prior to randomization.  
10. The subject must consent to using the prescribed off-loading method for the duration 
of the study. 
11. The subject must agree to attend the weekly study visits required by the protocol.  
12. The subject must be willing and able to participate in the informed consent process.  
  
Patients must have read and signed the IRB approved ICF before screening procedures are 
undertaken. 
 
4.4.2  Exclusion Criteria 
Potential subjects meeting any of the following criteria will be excluded from enrollment and 
subsequent randomization: 

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1. A subject known to have a life expectancy of < 6 months is excluded. 
2. If the target ulcer is infected or if there is cellulitis in the surrounding skin, the subject 
is excluded. 
3. Presence of osteomyelitis or exposed bone, probes to bone or joint capsule on 
investigator’s exam or radiographic evidence. 
4. A potential subject cannot have an infection in the target ulcer or in a remote location 
that requires systemic antibiotic therapy.  
5. A subject receiving immunosuppressants (including systemic corticosteroids at 
doses greater than 10 mg of Prednisone per day or equivalent) or cytotoxic 
chemotherapy is excluded. 
6. The topical application of steroids to the ulcer surface within one month of initial 
screening is not permitted. 
7. A subject with a previous partial amputation on the affected foot is excluded if the 
resulting deformity impedes proper offloading of the target ulcer. 
8. If a subject has a glycated hemoglobin (HbA1c) greater than or equal to 12% taken 
at or within 3 months of the initial screening visit he/she is excluded.  
9. If a subject has a serum creatinine ≥ 3.0mg/dL within 6 months of randomization 
he/she is excluded. 
10. The subject is excluded if the surface area measurement of the target ulcer has 
reduced in size by more than 30% in the 2 weeks prior to the initial screening during 
the 2-week screening phase: the 2 weeks from the initial screening visit (SV1) to the 
TV1/randomization visit during which time the subject received SOC.  
11. A Subject with an acute Charcot foot, or an inactive Charcot foot, that impedes 
proper offloading of the target ulcer is excluded.  
12. Women who are pregnant or considering becoming pregnant within the next 6 
months are excluded.  
13. A potential subject with end stage renal disease requiring dialysis is excluded.  
14. A subject who participated in a clinical trial involving treatment with an investigational 
product within the previous 30 days is excluded.  
15. A subject who, in the opinion of the Investigator, has a medical or psychological 
condition that may interfere with study assessments is excluded.  
16.  A Subject treated with hyperbaric oxygen therapy or a Cellular and/or Tissue 
Product (CTP) in the 30 days prior to the initial screening visit is excluded. 
 
4.5 Study Schedule 
The study is divided into two phases: Screening and Treatment Phases. The schedules for 
the protocol-specified assessments and procedures in each phase are detailed in the 
following sections. Note that there is an end of study visit (EOS1) scheduled on Week 13 or 

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earlier if the wound heals or does not demonstrate at least 50% wound area reduction at 6 
weeks after randomization (Week 7) and a follow-up visit (HCV1) to confirm that a wound is 
healed two weeks after first being assessed as healed.   
4.5.1 Visit Windows 
Subject visit dates must be scheduled within the visit windows detailed in the Schedule of 
Study Visits table. One week equals 7 days (± 3 days). During the Screening Phase, each 
visit is scheduled, with reference to the allowed visit window. During the Treatment Phase, 
each visit is also scheduled with reference to the allowed visit window.  
 

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TABLE 1: SCHEDULE OF VISITS. LIGHT GREY (SCREENING); LIGHT YELLOW (TREATMENT); LIGHT BLUE (END OF TREATMENT VISIT); 
LIGHT PURPLE (ADDITIONAL WOUND HEALING CONFIRMATION VISIT FOR THOSE WOUNDS THAT HEAL) 
Visit 
SV1 
SV2 
Wk 1 TV1  
Wk 2 
TV2 
Wk 3  
TV3 
Wk 4 
TV4 
Wk 5 
TV5 
Wk 6 
TV6 
Wk 7 
TV7 
Wk 8 
TV8 
Wk 9 
TV9 
W 10 
TV10 
W 11 
TV11 
W 12 
TV12 
W 13* 
EOS 1 
HCV1 
Pre 
Rand 
Post  
Rand 
Weeks from 
Randomization 
Date 
-2 
-1 
0 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
13 
2 weeks 
after initial 
healing 
Window Period 
±3 
days 
±3 
days 
±3 days** 
 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 
days 
±3 days 
±3days 
Assessment of 
eligibility 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ulcer history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History or 
changes 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Prohibited 
Therapies 
assessment 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Medication 
assessment 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ABI/SPP/TCOM/ 
TBI or arterial 
Doppler study 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
WOUND-Q 
instrument 
assessment 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
X 
 
Ulcer assessments 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Infection 
assessment of 
index ulcer 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Physical exam or 
changes 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Assess for Adverse 
Effects and 
Adverse Events 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X[A] 

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Visit 
SV1 
SV2 
Wk 1 TV1  
Wk 2 
TV2 
Wk 3  
TV3 
Wk 4 
TV4 
Wk 5 
TV5 
Wk 6 
TV6 
Wk 7 
TV7 
Wk 8 
TV8 
Wk 9 
TV9 
W 10 
TV10 
W 11 
TV11 
W 12 
TV12 
W 13* 
EOS 1 
HCV1 
Pre 
Rand 
Post  
Rand 
Urine or blood 
pregnancy test 
control (females of 
childbearing 
potential) 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
Assurance of 
effective birth 
control (females of 
childbearing 
potential) 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
Pain assessment 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Monofilament Test 
with vibratory (10 
point) 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Serum Creatinine 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood Sugar 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HbA1c Lab 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Take X-ray to rule 
out osteomyelitis or 
bone infection 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SnapshotNIR 
X 
 
X 
 
X 
 
X 
 
 
X 
 
 
 
 
 
     X 
 
Index ulcer 
photographs 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Index ulcer 
measurements 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X  
X 
X 
X 
X 
X 
X[A] 
Assess index ulcer 
healing ˃ 50% 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Index ulcer 
cleaning 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X[A] 
Index ulcer 
debridement 
X[B] 
X[B] 
X[B] 
 
X[B] 
X[B] 
X[B] 
X[B] 
X[B] 
X[B] 
X[B] 
X[B] 
XB] 
X[B] 
X[B] 
X[B] 
X[A] 
Index ulcer closure 
assessment 
 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X[C] 
Assessment of 
offloading 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Apply 
MIRRAGEN™ or 
FIBRACOL™ 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Apply outer 
dressing 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X[D] 
X[D] 

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[A]: Only assess for reopening of wound; [B]: If required per guidelines; [C]: Confirmation of wound closure; [D] Only if subject is not 
healed 
*Will be earlier if wound heals before this date or subject is withdrawn from the study. 
**Visit windows applicable given that TV1 is at least 14 days from SV1. Subject MUST complete a minimum of a 14-day screening 
period. 
 

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4.5.2 Screening Phase 
The subject will sign and date the ICF and HIPAA authorization (according to site practices) 
prior to the collection of any protected health information, as well as any study-related 
procedures. A screening number will be assigned to each subject in successive order of 
entering the study after signing the ICF at each center, beginning with 001 at each site.  
The screening phase may be broken into two visits. SV1 can occur up to 14 days prior to 
Randomization. SV2 should occur seven days prior to randomization.  
SV1: Procedures to be performed include: 
▪ 
Informed consent will be obtained prior to the collection of any protected health information 
as well as any study related procedures and the subject will sign a written ICF 
▪ 
Assess current wound therapies for anything prohibited within 30 days of Randomization 
▪ 
Demographics  
▪ 
Medical history   
▪ 
Physical examination 
▪ 
Assess concomitant medications and any prohibited therapies 
▪ 
Vital signs   
▪ 
 Pain assessment (see section 8.9) 
▪ 
Labs: HbA1c (if no documented results within 90 Days of Randomization are available), 
assess blood glucose, and serum creatinine (if no documented results within 6 months of 
Randomization are available)   
▪ 
Pregnancy test (blood or urine) if female subject is of childbearing potential. If female is 
not of childbearing potential the reason for inclusion must be included in the study record  
▪ 
Assurance of effective birth control if female subject is of childbearing potential    
▪ 
Ulcer history  
▪ 
Index Ulcer assessment 
▪ 
Assess signs and symptoms for clinical infection of the index ulcer (see section 8.10.3)  
▪ 
 Index ulcer foot neuropathy Semmes Weinstein 10-point test with vibratory; See section 
8.14 
▪ 
Clean the index ulcer 
▪ 
Debridement of the index ulcer, if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer 
▪ 
Record Index ulcer measurements 
▪ 
Obtain X-ray to rule out osteomyelitis or bone infection of the affected foot  
▪ 
ABI, SPP, TCOM, TBI, PVR measurement or Arterial Doppler Study will be obtained (see 
Appendices B-D) 
▪ 
Initiate offloading of the index ulcer  
▪ 
WOUND-Q 

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▪ 
Assessment of subject’s eligibility to continue in the study 
▪ 
Apply appropriate SOC to index ulcer and outer dressing 
▪ 
SnapshotNIR (at select sites) 
SV2: Procedures to be performed include: 
▪ 
Medical history changes from previous visit   
▪ 
Physical examination changes from previous visit 
▪ 
Assess concomitant medications, changes from previous visit and prohibited therapies 
▪ 
Vital signs   
▪ 
Pain assessment (see section 8.9) 
▪ 
Assess blood glucose 
▪ 
Index ulcer assessment 
▪ 
Assess signs and symptoms for clinical infection of the index ulcer (see section 8.10.3) 
▪ 
Index ulcer foot neuropathy Semmes Weinstein10 point test with vibratory; See section 8.14  
▪ 
Clean the index ulcer 
▪ 
Debridement of the index ulcer if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer    
▪ 
Record Index ulcer measurements 
▪ 
 Assessment of offloading 
▪ 
Assessment of subject’s eligibility to continue in the study  
▪ 
Apply appropriate SOC to index ulcer and outer dressing 
A panel of three board-certified plastic surgeons will review each wound, as well as 
inclusion/exclusion criteria, in a blinded fashion to ensure that randomizations are appropriate.  
The review will occur between SV2 and the day of randomization.  The plastic surgeon will 
provide correspondence to the trial manager that the subject is appropriate for randomization, 
prior to the site being able to randomize the patient.   
4.5.3 Treatment Phase 
When determining the visit dates, the reference should always be seven days (±3 days). 
Every attempt should be made to maintain subjects on their original treatment schedule.  
 
4.5.3.1 TV1: Prior to Randomization 
The following assessments and activities are performed at this visit: 
▪ 
Medical history changes from previous visit  
▪ 
Physical examination changes from previous visit 
▪ 
Assess concomitant medications, changes from previous visit and prohibited therapies 
▪ 
Vital Signs 

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▪ 
Pain assessment (see section 8.9) 
▪ 
Assess Blood glucose  
▪ 
Index ulcer Assessments 
▪ 
Assess signs and symptoms for clinical infection of the index ulcer (see section 8.10.3)  
▪ 
Index ulcer foot neuropathy Semmes Weinstein 10-point test with vibratory; See section 
8.14 
▪ 
Clean the index ulcer 
▪ 
Debridement of the index ulcer if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer  
▪ 
Record Index ulcer measurements 
▪ 
Assessment of offloading 
▪ 
Index ulcer closure assessment will be determined by a site Investigator  
▪ If the index ulcer is 100% re-epithelialized, the subject will be considered a screen 
failure. 
▪ 
Assessment of subject’s eligibility to continue in the study 
▪ 
SnapshotNIR (at selected sites)  
▪ 
If the subject is eligible, randomization will be performed 
▪ 
If the subject is not eligible, discharge the subject from the study as a screen failure 
4.5.3.2 TV1: Randomization 
The following assessments and activities are performed at this visit: 
▪ 
Randomize the subject 
▪ 
Apply appropriate treatment to index ulcer: 
▪ 
Apply SOC therapy with MIRRAGEN™ group 1  
▪ 
Apply SOC therapy with FIBRACOL™ group 2 
▪ 
Apply outer layer dressing 
▪ 
Ensure offloading of the wound is satisfactory 
▪ 
Schedule the next study visit for one week later (±3 days) 
4.5.3.3 Treatment Phase Visits: Weeks 2-12 (with additional tests week 2, 3, 4, 6 and 7 listed 
below) 
The following assessments and activities are performed at these visits: 
▪ 
Medical history changes from previous visit  
▪ 
Physical examination changes from previous visit 
▪ 
Assess concomitant medications, changes from previous visit and prohibited therapies 
▪ 
Vital Signs 

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▪ 
Pain assessment (see section 8.9) 
▪ 
Assess Blood glucose 
▪ 
Assessment of offloading  
▪ 
Index ulcer foot neuropathy Semmes Weinstein 10-point test with vibratory; See section 
8.14  
▪ 
Check for any changes in the subject’s health and assess them for any adverse effects 
and adverse events  
▪ 
Index ulcer closure assessment will be determined by a site Investigator 
▪ 
If the index ulcer is 100% re-epithelialized, the subject will be scheduled for an 
HCV two weeks later. Please perform all applicable assessments and study 
procedures. 
▪ 
Index ulcer Assessments 
▪ 
Check for signs of clinical infection. If a clinical diagnosis of infection has been made, then 
the subject can be treated with oral antibiotics, but topical antibiotics or antimicrobial 
dressings CANNOT be used on the study ulcer 
▪ 
Clean the index ulcer 
▪ 
Debridement of the index ulcer if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer 
▪ 
Record Index ulcer measurements 
▪ 
Apply appropriate treatment to index ulcer: 
▪ 
Apply SOC therapy with MIRRAGEN™ group 1  
▪ 
Apply SOC therapy with FIBRACOL™ group 2 
▪ 
Ensure offloading of the index ulcer is satisfactory 
▪ 
Apply outer layer dressing  
▪ 
The next visit will be scheduled for one week (+/- 3 days)  
4.5.3.3.1 TV2: Treatment Visit 2 
In addition to the procedures required at every treatment visit, perform the following additional 
procedures:  
▪ 
SnapshotNIR (at select sites)  
4.5.3.3.1 TV3: Treatment Visit 3 
In addition to the procedures required at every treatment visit, perform the following additional 
procedures:  
▪ 
WOUND-Q 
4.5.3.3.1 TV4: Treatment Visit 4 
In addition to the procedures required at every treatment visit, perform the following additional 
procedures:  

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▪ 
SnapshotNIR (at select sites)  
4.5.3.3.2 TV6: Treatment Visit 6 
In addition to the procedures required at every treatment visit, perform the following additional 
procedures:  
▪ 
Pregnancy test (blood or urine) if female subject is of childbearing potential 
▪ 
Assurance of effective birth control if female subject is of childbearing potential     
4.5.3.3.3 TV7  
In addition to the procedures required at every treatment visit, perform the following additional 
procedures:  
▪ 
Evaluate wound for greater than 50% wound area reduction, and if less than 50% healed 
proceed to End Of Study (EOS1) visit 
▪ 
SnapshotNIR (at selected sites) 
▪ 
WOUND-Q 
4.5.4 End of Study (EOS1) Visit 
The following assessments and activities are performed at this visit: 
▪ 
Medical history changes from previous visit  
▪ 
Physical examination changes from previous visit 
▪ 
Assess concomitant medications, changes from previous visit and prohibited therapies 
▪ 
Vital Signs 
▪ 
Pain assessment (see section 8.9) 
▪ 
Assess Blood glucose 
▪ 
HbA1c  
▪ 
Assessment of offloading 
▪ 
Index ulcer foot neuropathy Semmes Weinstein 10-point test with vibratory; See 
section 8.14  
▪ 
WOUND-Q 
▪ 
Check for any changes in the subject’s health and assess them for any adverse effects 
and adverse events  
▪ 
Index ulcer closure assessment will be determined by a site Investigator 
• 
If the index ulcer is 100% re-epithelialized, the subject will be scheduled for a Healing 
Confirmation Visit (HCV) two weeks later. Please perform all applicable 
assessments and study procedures. 
▪ 
Index Ulcer Assessments 
▪ 
Check for signs of clinical infection. If a clinical diagnosis of infection has been made, then 
the subject can be treated with oral antibiotics, but topical antibiotics or antimicrobial 
dressings CANNOT be used on the study ulcer 

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▪ 
Clean the index ulcer 
▪ 
Debridement of the index ulcer if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer  
▪ 
Record Index ulcer measurements 
▪ 
Ensure offloading of the index ulcer is satisfactory and make an appointment for the 
subject with their desired clinician for follow-up care OR if subject is healed apply outer 
layer dressing and schedule Healing Confirmation Visit two weeks later (+/- 3 days) 
▪ 
SnapshotNIR (at select sites) 
▪ 
Apply outer layer dressing  
4.5.5 HCV: Healing Confirmation Visit 
Perform the following procedures and assessments at this visit:  
▪ 
Medial History Changes from previous visit 
▪ 
Physical examination changes from previous visit 
▪ 
Assess concomitant medications, changes from previous visit and prohibited therapies 
▪ 
Vital signs 
▪ 
Pain assessment (see section 8.9) 
▪ 
Assess Blood glucose 
▪ 
Assessment of offloading  
▪ 
Index ulcer foot neuropathy Semmes Weinstein 10-point test with vibratory; See section 
8.14  
▪ 
Check for any changes in the subject’s health and assess them for any adverse effects 
and adverse events 
▪ 
If wound has re-opened, clean index ulcer 
▪ 
If wound has re-opened, apply outer layer dressing 
▪ 
Debridement of the index ulcer if applicable (see Appendix E) 
▪ 
Digital imaging of the index ulcer 
▪ 
If wound has re-opened, index ulcer measurements 
▪ 
Confirm that the wound remained completely epithelized  
▪ 
If wound has re-opened, document any other index ulcer assessments. If this is the EOS 
visit, discharge the subject from the study and make an appointment for the subject with 
their desired clinician for follow-up care; otherwise continue subject in study with allocated 
treatment schedule 
4.5.6 Unscheduled Visits 
Unscheduled visits may be required in addition to the visits detailed above. Additional visits 
are at the discretion of the Investigator. An example of an unscheduled visit is when a change 
in dressings is required between scheduled visits. The details of these unscheduled visits with 

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subjects will be recorded in the medical records/source documents and on the Unscheduled 
Visit CRF. 
4.5.7 Missed Visits 
If a subject misses a visit, the site is to make every effort to have the subject return as soon as 
possible to make up the visit. Once the subject is seen, he/she is to return to his/her original 
weekly visit schedule. For example, if a subject was seen regularly on Mondays but missed a 
scheduled Monday visit and came in on Wednesday, he/she should return the next Monday to 
maintain his/her weekly Monday visit schedule. 
 
 

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5 
Subject Completion, Success/Failure, Withdrawal and Screen Failure 
5.1 Subject Completion 
▪ 
A subject whose index ulcer has closed will be considered as having completed the study 
▪ 
A subject who completes the Treatment Phase up to TV7 with the wound healed less than 
50% will be considered as having completed the study 
▪ 
A subject who completes the Treatment Phase but still has an unhealed index ulcer will be 
considered as having completed the study 
▪ 
A subject who does not complete the Treatment Phase and still has an unhealed index 
ulcer will be considered as not completing the study 
5.2 Success and Failure 
▪ 
A subject whose ulcer heals by 13 weeks and has been confirmed as healed two weeks 
later will be considered a treatment success  
▪ 
A subject whose ulcer has failed to heal by 50% or greater at TV7 or six weeks after 
randomization will be considered a treatment failure 
▪ 
A subject whose ulcer has failed to heal by 13 weeks will be considered a treatment failure  
▪ 
A subject who is withdrawn from the trial and/or experiences an amputation is also 
considered a treatment failure 
5.3 Premature Withdrawal from the Study 
A subject who is randomized into the Treatment Period of the study but who does not 
complete the study has prematurely discontinued. 
All subjects have the right to withdraw at any point during treatment without prejudice. It will be 
documented whether or not each subject completes the study. If for any subject, study 
treatment or observations were discontinued, the reason(s) will be recorded.  
The Investigator can discontinue a subject at any time if it is considered medically necessary. 
In addition, the subject will be withdrawn from the study, if any of the following events occur: 
▪ 
A subject is significantly non-compliant with the requirements of the protocol 
▪ 
A subject becomes pregnant or does not confirm use of birth control. (Note: the pregnancy 
will be followed up to term for safety. Relevant safety information collected after the study 
has been completed will be reported as supplemental information.)   
▪ 
A subject has revascularization surgery on the lower extremity on which the index ulcer is 
located 
▪ 
The subject’s index ulcer deteriorates and is infected to the point where there is exposed 
bone   
▪ 
An infection episode lasting more than two weeks with no response to allowable 
treatments 
Premature withdrawal from the study may occur if: 
▪ 
A subject is treated with a prohibited medication. This decision will be made by the 
Investigator as to whether premature withdrawal is warranted. 

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Every attempt should be made to collect follow-up information. The reason for treatment 
discontinuation or withdrawal from the study will be recorded in the source documents and on 
the appropriate CRF. 
Before a subject is identified as lost-to-follow up, the site should make all reasonable efforts to 
contact the subject. Three follow-up attempts are required. These attempts must be 
documented and should include two phone calls and one certified letter.  
In the event that a subject is prematurely discontinued from the study at any time due to an 
adverse effect or adverse event, the procedures in Section 10 of this protocol must be 
followed.  
5.4 Screen Failures 
A subject who has signed a consent form, has been assigned a screening number, but is not 
randomized is classified as a screen failure. Subject number, demography and reason for 
screen failure will be collected. Subjects who fail their first screening attempt may be re-
screened again (i.e., up to two screenings total) and may be enrolled if they are found to meet 
all inclusion and none of the exclusion criteria at SV2. Rescreening follows a subject, not a 
specific wound, so subjects cannot be screened > 2 times for different wounds. Anytime a 
subject screen fails and later rescreens (outside of the original 2 weeks screening window), 
they must be re-consented for the study.  
 
 

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6 
Standard of Care Study Treatment Primary Dressing 
6.1 Method for Assigning Eligible Subjects to Treatment 
Eligible subjects will be assigned to one of the treatment groups based on a randomization 
schedule. Details of the randomization are provided in the statistical analysis section. 
6.2 MIRRAGEN™ Product Information (provided from IFU) 
Product Description 
The MIRRAGEN™ Advanced Wound Matrix is a wound dressing solely composed of 
biocompatible and resorbable borate-based bioactive glass fibers and particles. It is a flexible 
and moldable advanced wound dressing that can be easily customized to fit the wound bed. 
The fiber structure of the MIRRAGEN™ Advanced Wound Matrix allows it to absorb fluid from 
the wound and facilitate natural wound healing. The bioabsorbable material used in the 
MIRRAGEN™ Advanced Wound Matrix is a borate glass specially designed for medical 
applications. The material is biocompatible and will eventually be fully absorbed at the wound 
site. This resorption process is initiated by the exposure of the dressing to fluid at the wound 
site. 
Indications for Use 
The MIRRAGEN™ Advanced Wound Matrix is intended for use in the management of 
wounds. Wound types include: 
• Partial and full-thickness wounds 
• Pressure ulcers 
• Venous ulcers 
• Diabetic ulcers 
• Chronic vascular ulcers 
• Tunneled/undermined wounds 
• Surgical wounds (donor sites/grafts, post-Mohs surgery, post laser surgery, 
Podiatric, wound dehiscence) 
• Trauma wounds (abrasions, lacerations, first- and second-degree burns, skin 
tears) 
• Draining wounds 
The product is designed for single patient/single treatment use only. DO NOT reuse. 
Warnings MIRRAGEN™ Advanced Wound Matrix is sterile only if the packaging is unopened 
and undamaged. DO NOT re-sterilize. DO NOT use expired product. 
Precautions MIRRAGEN™ Advanced Wound Matrix dressings are intended to be used 
under the supervision of a healthcare professional. 
Adverse Reactions Possible adverse reactions may include local irritation, swelling, 
inflammation, excessive redness, or pain. 
Contraindications The use the MIRRAGEN™ Advanced Wound Matrix should be 
discontinued if any adverse reactions are observed. 
 

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How Supplied MIRRAGEN™ Advanced Wound Matrix is supplied sterile. The dressing is 
packaged in a two-piece disposable tray that is sealed in a foil pouch. 
Instructions for Use The MIRRAGEN™ Advanced Wound Matrix is sterile. Use aseptic 
techniques when applying the dressing. 
1. Prepare the wound bed using standard wound cleaning and debridement procedures. 
2. Dry the area surrounding the wound. 
3. Cut or shape the MIRRAGEN™ Advanced Wound Matrix dressing to fit the size of the 
wound bed. Place the dressing directly in contact with the wound, ensuring the entire wound 
area and wound margins are covered. 
4. If applying MIRRAGEN™ Advanced Wound Matrix to a dry wound, moisten the dressing 
with sterile saline to aid in maintaining a moist wound environment. 
5. Place a suitable secondary dressing over the MIRRAGEN™ Advanced Wound Matrix to 
manage the wound environment and protect the wound area. The secondary dressing should 
completely cover the MIRRAGEN™ dressing. 
6. Dressing changes are conducted according to standard wound care practices every 3 to 
7days. As healing occurs, new tissue may grow into the MIRRAGEN™ Advanced Wound 
Matrix. Do not forcibly remove or debride areas of the MIRRAGEN™ dressing that are 
embedded or adhered to the wound site. The MIRRAGEN™ dressing is 100% bioabsorbable 
and will eventually be absorbed at the wound site. 
7. Loose sections of the MIRRAGEN™ Advanced Wound Matrix may be removed. Apply 
additional MIRRAGEN™ dressing to fill and cover the wound. Moisten the dressing with sterile 
saline, as needed. 
8. Secondary dressings should also be replaced at each dressing change. 
9. Heavy exuding wounds may require more frequent dressing changes. 
Storage Do not expose to excessive heat and humidity. 
Shelf-life Refer to pouch label. 
Sterilization This device has been sterilized with gamma irradiation 
Manufactured and Distributed by: 
ETS Wound Care, LLC 
13210 Dillon Outer Road 
Rolla, MO 65401 USA 
P h o n e + 1 - 573-202-2550 
Fax: + 1 - 573-755-0588 
 support@etswoundcare.com 
             www.etswoundcare.com 
 
6.3  FIBRACOL™ Product Information (provided from IFU) 
 

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Product Description  
FIBRACOL™ Plus Collagen Wound Dressing with Alginate is an advanced wound care device 
composed of collagen and calcium alginate fibers. FIBRACOL™ Plus dressing contains 80% 
more collagen than our traditional FIBRACOL™ Dressing. Its unique combination of natural 
biopolymers created by a patented process combines the structural support of collagen and 
the gel forming properties of alginates into a sterile, soft, absorbent, conformable topical 
wound dressing. In the presence of wound fluid FIBRACOL™ Plus dressing maintains a 
physiologically moist microenvironment at the wound surface that is conducive to granulation 
tissue formation, epithelialization, and enables healing to proceed at a rapid rate. 
FIBRACOL™ Plus dressing is versatile as a primary wound dressing, it can be cut to the 
exact size of the  
wound, multi-layered for the management of deep wounds and used in combination with 
either a semi-occlusive or non-occlusive secondary dressing.  
Indications  
FIBRACOL™ Plus dressing is indicated for the management of exuding wounds  
including:  
• 
Full-thickness and partial-thickness wounds  
Pressure ulcers  
• 
Venous ulcers  
• 
Ulcers caused by mixed vascular etiologies  
Diabetic ulcers  
• 
Second-degree burns  
• 
Donor sites and other bleeding surface wounds  
Abrasions  
• 
Traumatic wounds healing by secondary intention  
Dehisced surgical incisions  
Precautions  
FIBRACOL™ Plus dressing may be used when visible signs of infection are  
present in the wound area only when proper medical treatment addresses the underlying 
cause. FIBRACOL™ Plus dressing may be used under compression therapy with healthcare 
professional supervision.  
Contraindications  
FIBRACOL™ Plus dressing is not indicated for wounds with active vasculitis, third-degree 
burns, or patients with known sensitivity to collagen or alginates.  
 
Adverse Reactions  

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FIBRACOL™ Plus dressing should not be used on patients with known sensitivities to 
collagen or alginates. Discontinue use if signs of sensitivity appear.  
Directions for Use  
Debride when necessary and irrigate the wound site with normal saline  
solution. Remove excess solution from surrounding skin. For heavily exuding wounds, apply 
to wound bed directly. For wounds with minimal exudate, apply to moistened wound bed; this 
will initiate the gel forming process.  
Pack deep wounds loosely. The dressing can be cut to size with sterile scissors. The amount 
of FIBRACOL™ Plus dressing to be used depends on the size of the wound and the amount 
of exudate.  
FIBRACOL™ Plus dressing may be covered with either a non-occlusive secondary dressing 
and fixed to the skin with a non-irritating tape or a semi-occlusive dressing. Reapply 
FIBRACOL™ Plus dressing when the secondary dressing has reached its absorbent capacity 
or whenever good wound care practice dictates that the dressing should be changed. A 
heavily exuding wound may require daily or twice daily dressing changes. More moderately  
exuding wounds will require less frequent changes 
Following the initial application, irrigate the wound with saline solution. Reapply FIBRACOL™ 
Plus dressing as previously instructed.  
Dressing Removal  
After gently removing the secondary dressing, lift any FIBRACOL™ Plus dressing that has not 
formed a gel and discard. Using normal saline, gently irrigate the wound to remove any 
residual gel.  
Do not re-use.  
Do not re-sterilize.  
Do not use it if the package is damaged.  
The use by date of this product is printed on the packaging.  
Caution: Federal Law (USA) restricts this device to sale by or on the order of  
a properly licensed healthcare practitioner.  
 

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7 Standard of Care, Concomitant Medications, Excluded/Allowed 
Therapies/Medications and Allowed Dressings 
Beginning at the screening visit, ALL subjects must have their index ulcer managed using the 
SOC procedures noted below. 
7.1 SOC Procedures 
7.1.1 Cleaning the Index Ulcer 
Remove all dressings and wash the foot. The leg should be elevated for as much time as 
possible during this process. Wash the foot with sterile water or saline solutions. Gently 
irrigate the index ulcer prior to each dressing change with the same solution. Wound 
cleansers containing antiseptics (examples: Hypochlorous Acid, Vashe, ExSept, PrepIt, etc.) 
are prohibited for use during the duration of this study.  
During the Treatment Phase, the washing and cleaning of the DFU must be done prior to 
application of SOC primary dressing 
7.1.2 Debridement of the Index Ulcer 
Debridement is an essential technique and SOC in the treatment of DFU. It is important to 
remove all non-viable and necrotic material from the index ulcer prior to enrolling the patient. 
Debridement is allowed during the treatment phase at the treating Investigator’s discretion. 
For detailed guidelines please see Appendix E. 
7.1.3 Offloading 
Offloading is essential if the wound is to heal. A diabetic offloading CAM boot will be given to 
each subject or if the subject cannot be accommodated into a CAM boot, a TCC will be 
provided. 
Subjects will be educated on the importance of using the device to offload their DFU and 
instructed on keeping dressings dry and to call or visit the study site if the dressing becomes 
soiled, wet or is removed. In addition, subjects should be educated on wound infection and if 
they observe infection, to call or visit the study site. 
7.2 Concomitant Medications 
The subject may be administered any necessary medications, at the discretion of the 
Investigator; provided such medications are not applied topically to the index ulcer surface 
(topical medication can be applied to other surfaces around the ulcer or other non-reference 
ulcers). 
All medications and therapies administered or taken by the subject beginning 30 days prior to 
signing the ICF and throughout the study will be recorded in the source documents and for 
randomized subjects, on the appropriate CRF.  
7.3 Prohibited Medications and Therapies  
The following treatments and medications are prohibited 30-days prior to screening period and 
throughout the trial: 
▪ 
Any cellular and/or tissue-based products or wound dressings that include growth factors 
(e.g., EpiFix, Regranex, Dermagraft, Apligraf, GraftJacket, OASIS, Primatrix, Matristem) 
▪ 
Revascularization surgery on the lower extremity with the index ulcer 

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▪ 
Radiation therapy to the foot 
Excluded at SVI 
▪ 
Topical antibiotics* or other topical agents, including or containing silver, honey, hydrofera 
blue, etc. (with the exception of anesthetics used during debridement) 
▪ 
Systemic steroids/oral corticosteroids in excess of 10mg daily dose. (Note: inhaled 
steroids are acceptable) 
▪ 
Other immunosuppressive agents and chemotherapy 
▪ 
Cytotoxic therapies 
▪ 
Negative pressure wound therapies 
▪ 
Hyperbaric oxygen  
▪ 
Any other investigational treatment/medications in the Investigator’s opinion are likely to 
seriously impact wound healing 
▪ 
Heat lamps 
▪ 
UV lights 
▪ 
Whirlpool baths 
▪ 
Water Piks 
▪ 
Jet water streams (other than gentle water irrigation) 
▪ 
Wound cleansers that contain active ingredients and are not just normal saline (e.g., 
Hypochlorous Acid, Vashe, ExSept, PrepIt, etc.) 
▪ 
Selective COX-2 inhibitors (such as Celecoxib) 
*Topical antibiotics must be stopped at the first screening visit. 
7.4 Allowable Medications and Therapies 
The following medications and therapies are allowed during the study, if in the opinion of the 
Investigator, they are required for proper care of the study subject: 
▪ 
Use of anesthetics for debridement 
▪ 
Treatment with systemic antibiotics for acute or chronic infection, however, prophylactic 
use of systemic antibiotics is not allowed 
▪ 
Other medications/therapies that are not otherwise prohibited and in the opinion of the 
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7.5 Approved Dressings 
The following is a list of approved dressings suitable for study DFUs receiving SOC treatment: 
SOC FIBRACOL™ Group 
▪ 
FIBRACOL™ – Collagen / Calcium alginate 
▪ 
Plain foam (e.g., Allevyn gentle, Mepilex) 
▪ 
Three-layer dressing, (4x4 gauze, soft cast roll, ace bandage / coban) 
SOC MIRRAGEN™ Group 
▪ 
MIRRAGEN™ – Wound Matrix 
▪ 
Plain foam (e.g., Allevyn gentle, Mepilex) 
▪ 
Three-layer dressing, (4x4 gauze, soft cast roll, ace bandage / coban) 
 
 
 

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8 Description of Protocol Assessments and Procedures 
8.1 Informed Consent 
Written informed consent will be obtained for this study by the Investigator or suitably qualified 
designee from all subjects before the collection of any protected health information and 
performance of any protocol-specific procedure.  
In obtaining and documenting informed consent, the Investigator must comply with applicable 
regulatory requirements and must adhere to Good Clinical Practice (GCP). The Investigator, 
or designee, must fully inform subjects of all pertinent aspects of the study. Before informed 
consent may be obtained, the Investigator, or a person designated by the Investigator, must 
provide the subject ample time and opportunity to inquire about details of the study and to 
decide whether or not to participate in the study.  All questions about the study must be 
answered to the satisfaction of the subject. Prior to the subject’s participation in the study, the 
ICF must be signed and personally dated by the subject and by the person who conducted the 
informed consent discussion. For screen failure subjects who rescreen at a later date, re-
consenting is required.  
8.2 Assessment of Eligibility 
At each visit during the Screening Period, the Investigator must assess a subject’s continued 
suitability and eligibility for the study, especially with regard to the Inclusion and Exclusion 
criteria. If the subject is no longer suitable or eligible for the study, the subject will be 
considered a screen failure. Screen failure subjects may be re-entered into the study at a later 
time and re-screened.  
Further, a panel of three board-certified plastic surgeons will review each wound, as well as 
inclusion/exclusion criteria, in a blinded fashion to ensure that randomizations are appropriate.  
The review will occur between SV2 and the day of randomization.  The plastic surgeon will 
provide correspondence to the trial manager that the subject is appropriate for randomization, 
prior to the site being able to randomize the patient.   
8.3 Re-Screening 
If a subject initially fails to meet Inclusion/Exclusion criteria and is later reconsidered for 
participation, the subject will be re-consented and assigned a new screening number at the 
time of re-screening. Subjects who fail their first screening attempt may be re-screened again 
(i.e., up to two screenings) and may be enrolled if they are found to meet all Inclusion and 
none of the Exclusion criteria at the second screening visit.  
8.4 Subject Demographics, Medical History and Ulcer History 
8.4.1 Demographics 
For the purposes of this study, demographic information will include: 
▪ 
Date of ICF signature  
▪ 
Date of birth 
▪ 
Gender  
▪ 
Race (American Indian/Alaskan Native, Asian, Black/African American, Native 
Hawaiian/Pacific Islander, Caucasian or other) 
▪ 
Ethnicity (Hispanic/Latino or Not Hispanic/Latino) 

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▪ 
Use of tobacco products 
8.4.2 Medical History 
A medical history will be recorded during the Screening Period and will include: 
▪ 
All ongoing medical conditions 
▪ 
All previously resolved medical conditions related to diabetes or foot ulceration or which 
are relevant in the opinion of the Investigator  
Events that emerge prior to the randomization visit will be recorded in the medical history and 
not as Adverse Events. Aside from being used to determine subject eligibility, this information 
will permit the Investigator to record the nature, duration and severity of any ongoing baseline 
medical conditions that occur prior to randomization 
Medical histories will be recorded using the body system categories outlined below: 
▪ 
Cardiovascular 
▪ 
Lymphatic 
▪ 
Respiratory 
▪ 
Hematologic 
▪ 
Gastrointestinal 
▪ 
Immunologic 
▪ 
Renal 
▪ 
Dermatologic 
▪ 
Hepatic 
▪ 
Psychiatric 
▪ 
Neurological 
▪ 
Genitourinary 
▪ 
Endocrine 
▪ 
Other 
▪ 
DFU History 
For each relevant history, the following will be documented:   
▪ 
Disease/disorder/condition 
▪ 
Date of diagnosis 
▪ 
History status (resolved or ongoing) 
8.4.3 Foot Ulcer History 
▪ 
Duration of the current DFU 
Note: “Duration” is defined as the length of time that the index ulcer has been open at this 
location since the last time it was fully closed.  
▪ 
Current offloading system used for the DFU (if any) and length of time that this has been 
used 
▪ 
Prior treatments that have been used on the DFU for up to 1-year 
▪ 
Age when the subject developed his/her first DFU  
▪ 
Total number of previous DFUs 
▪ 
Location of the current DFU 
Note: “Index ulcer location” is defined by the ulcer being on the left or right foot, by the 
location of the ulcer on the foot, dorsal or plantar, toe (which toe), forefoot, midfoot, hind 
foot, ankle heel and by the positioning of the ulcer as lateral, medial, dorsal, or plantar 
located. 
▪ 
Number of additional DFUs and location of each present at the screening visits 
▪ 
History of DFU recurrence 

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Note: “Recurrence” is defined as the re-opening of the index ulcer after complete healing. 
▪ 
History of any amputations in the study foot and contralateral foot or leg 
▪ 
History of any significant foot deformities, dermatological abnormalities, fungal lesions, or 
other findings. 
8.4.4 Physical Exam  
The physical examination will include routine examinations for the following: 
▪ 
Head, ears, eyes, nose, and throat 
▪ 
Abnormalities of the extremities 
▪ 
Neurologic abnormalities 
▪ 
Heart/cardiovascular abnormalities 
▪ 
Musculoskeletal abnormalities 
▪ 
Dermatologic abnormalities 
▪ 
Any other body system for which an abnormality is noted and which, in the opinion of the 
Investigator, is relevant to the safety of the subject or could impact safety or efficacy 
results for the subject, i.e., the abnormality is clinically significant  
Each abnormality will be recorded, and the Investigator will record an assessment of its 
clinical significance.  
8.4.5 Vital Signs 
The following vital signs will be collected:    
▪ 
Height 
▪ 
Weight  
▪ 
Body mass index (BMI) 
▪ 
Seated blood pressure (take after the subject has been seated for at least 5 minutes) 
▪ 
Pulse 
▪ 
Temperature 
8.4.6 
Pregnancy test 
Females who are of childbearing potential must have a urine or blood pregnancy test at SV1 
and at TV6. 
8.5 
ABI or Arterial Doppler Ultrasound 
ABI, also known as the Winsor Index and the Ankle Brachial Pressure Index, is the ratio of 
blood pressure measured at the ankle to that measured at the arm. Details of the procedure 
can be found in Appendix B. An ABI < 0.8 indicates that there is a high probability that arterial 
insufficiency is present (positive predictive value 95% in a general practice population). 
It should be noted that incompressible, calcified arteries may occur in diabetes causing a 
falsely elevated ABI, so if the subject has other signs or symptoms that could suggest 
peripheral arterial disease, further investigations to determine vascular status may be 
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A documented record of an ABI test performed using the index ulcer leg, within one month of 
SV1 is acceptable for the purposes of this study, otherwise this must be completed in the 
Screening Period.  
As an alternative arterial Doppler ultrasound can be performed evaluating for biphasic dorsalis 
pedis and posterior tibial vessels at the level of the ankle. 
8.6 
SPP 
SPP provides another noninvasive method for measuring microcirculatory pressure of the 
artery at the skin level. It measures the pressure at which perfusion first returns to the 
cutaneous microcirculation following a controlled release of occlusion. SPP is useful in 
assessing the ischemic severity of lower limb and predicting ulcer healing in chronic critical 
limb ischemia with a value of <30 mmHg. See Appendix C for the appropriate technique of 
assessment. 
8.7 
TCOM 
A TCOM assesses the partial pressure of oxygen molecules dissolved in the blood plasma. 
The amount of oxygen detected by the sensor is a balance of the oxygen delivery and local 
physiologic demands and reflects the metabolic status of the skin; it indicates the level of 
oxygen available at the ulcer site to assist in the ulcer healing process. A TCOM less than 30 
mmHg of oxygen indicates impaired ulcer healing and ischemic disease. An appropriate 
technique for a TCOM assessment is provided in Appendix D.  
8.8 
WOUND-Q Assessment  
The WOUND-Q will be administered to all subjects on SV1, TV3, TV7 and EOS1. This tool will 
document the impact of the wound on the subject’s life and whether the treatment 
interventions helped to return them to improved functioning. 
If a subject discontinues the study, every effort should be made to contact them to complete 
the WOUND-Q tool on their EOS1 visit. 
Further details and the tool itself can be found in Appendix E. 
8.9 
Pain Assessment: NPRS 
Pain intensity of the reference DFU is to be assessed before any dressing changes or other 
ulcer manipulations at all screening and treatment visits.  
The subject will be asked to indicate a numerical value that best represents the current pain 
intensity at the index ulcer site on a scale of 0 to 10, anchored by word descriptors at each 
end, as "no pain" on the left side and "worst possible pain" on the right side of the number line. 
The number 0 represents “no pain,” the number 5 represents “moderate pain”, and the 
number 10 represents the “worst possible pain.”  The subject indicates the level of pain 
intensity by selecting a number on the line shown in Figure 3 below that represents their 
perception of their current state.  
 
FIGURE 3: SUBJECT PAIN SCALE (NPRS) 

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8.10 
Ulcer Assessments 
A number of different index ulcer assessments are required, including appearance, exudate 
characteristics, infection, and peri-wound characteristics. 
8.10.1 Index Ulcer Appearance Assessment (Pre-debridement) 
Index Ulcer Appearance Assessment (pre-debridement) categories includes: 
▪ 
% Granulating (red/brown bumpy tissue that bleeds upon light debridement)   
▪ 
% Non-viable tissue 
▪ 
% Epithelialized Skin 
Note: the categories should add to 100%. 
8.10.2 Index Ulcer Exudate Assessments 
The Investigator will determine the amount and type, if any, of index ulcer exudate. In 
determining the amount of index ulcer exudate, the Investigator must take into account the 
amount of exudate absorbed into the index ulcer dressing.  Table 2 below details the 
categories will be used to quantify the amount and describe the type of index ulcer exudate: 
TABLE 2: INDEX ULCER EXUDATE ASSESSMENT 
Index Ulcer Exudate Assessment 
Volume 
• 
No exudate 
• 
Minimal amount 
• 
Light (scant) or small amount 
• 
Moderate amount 
• 
Heavy/large/copious amounts 
Type 
• 
Not applicable: no exudate present 
• 
Serous: clear or light-yellow watery plasma 
• 
Serosanguinous: pink to light-red watery plasma 
• 
Sanguineous: red with fresh bleeding 
• 
Purulent: thick and opaque exudate, of creamy yellow, green, white, 
or tan color 
  
8.10.3 Index Ulcer Infection Assessments 
The presence/absence of the following signs of infection at the index ulcer site will be 
documented at each visit. Infection of the index ulcer will be assessed using the STONEES 
method developed by Woo and Sibbald.19 Table 3 below lists the criteria for considering an 
index ulcer infected:  
TABLE 3: INDEX ULCER INFECTION ASSESSMENT 
Index Ulcer Infection Assessment 
Three or more of the following signs or symptoms are present: 
• 
Increased surface area 
• 
Increased peri-wound margin temperature by more than 3⁰F difference 
between two mirror image sites 
• 
Exposed bone or can be probed to the bone 

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• 
New areas of breakdown or satellite lesions 
• 
Presence of swelling or reddened skin in peri-wound area 
• 
Increased wound drainage 
• 
Unpleasant, sweet, or sickening odor present 
NOTE: An ulcer that Is deemed to be infected with three or more of the following 
signs will undergo a wound culture to confirm the presence of infection and identify 
the pathogenic organism, so the study subject receives the most appropriate 
antibiotic treatment 
Infection at Index Ulcer site prior to Randomization 
If the infection occurs prior to randomization i.e., prior to TV1, then the subject will be ineligible 
to be randomized.  
Infection at Index Ulcer site after Randomization 
If infection of the index ulcer site occurs after randomization i.e., after the Randomization visit, 
record the infection as an adverse event and treat it as appropriate with oral antibiotics at the 
discretion of the Investigator. 
 
Note: application of topical antibiotics and anti-microbial dressings to the index ulcer site are 
prohibited. 
A subject with an infected index ulcer that is being treated by the Investigator will remain in the 
study unless the situation requires an alternative methodology that violates the protocol. 
Antibiotic interventions will be recorded on the Concomitant Medications CRF, and the event 
will be categorized as an Adverse Event, serious if it meets the definition of that category. All 
subjects who show evidence of an ulcer infection must have it reported on an Adverse Event 
CRF. 
All subjects will be instructed to contact the Investigator if signs or symptoms of infection 
develop prior to their next scheduled visit. 
During an episode of infection, the Investigator should not continue TCC, if it is being used, 
until the infection is resolved, and dressings should be changed at least every 72 hours.  
Evaluate the skin surrounding the index ulcer for presence of signs such as erythema, edema, 
and cellulitis.  
8.10.4 
Investigator Assessment of Index Ulcer Closure 
“Complete healing” of the index ulcer is defined as 100% re-epithelialization without drainage. 
At each visit, the Investigator will assess the ulcer by answering the following questions: 
• 
Index ulcer 100% re-epithelialized? 
• 
Drainage is absent? 
Both questions must be answered “yes” for the index ulcer to be considering having reached 
“complete closure.” 
The date of complete healing is defined as the date of the first assessment of 100% re-
epithelialization. 
Confirmation of Wound Healing 

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Note that if a wound is initially judged as healed, it must be confirmed as healed with one 
healing confirmation visit at two weeks (plus or minus three days, HCV 1). The assessment 
details can be found in section 4.3.2. 
Index Ulcer Photographs and Measurements 
The index ulcer will be digitally imaged with a Sony digital camera that is at least 20 (twenty) 
megapixels, with the photo taken at a focal distance of 18 inches and a two-dimensional 
calibration scale. The Investigator will also take a planimetry photo for appropriate wound 
measurement.  
8.11 
Randomization 
Subjects who are eligible to participate in the study will be randomized to one treatment group 
at the time of completion of screening. 
8.12 
Assessment of Offloading  
The following questions will be asked to assess the performance of the offloading during the 
Screening and Treatment Phase visits and at selected follow-up visits: 
• 
Did the subject have the offloading device with him or her or is the TCC cast still present?  
(Yes/No) 
• 
What percentage of the time is the subject using the offloading device while not sleeping?  
(Note: heel ulcers might still need to be offloaded while sleeping.) 
8.13 
Semmes Weinstein Monofilament Test for Peripheral Neuropathy 
This is a non-invasive topical evaluation of neuropathy with a monofilament wire and with 
vibratory evaluation. The test will be performed in a standard manner with 10 points being 
evaluated on each visit. At each point, the Investigator asks the subject whether they can feel 
the filament and / or vibration (yes or no). Note: If a subject is missing a body part called out in 
the Semmes Weinstein test and with vibratory, the most skin in the area where the missing 
body part is located is used for the test.  
8.14 
SnapshotNIR 
SnapshotNIR imaging for tissue perfusion will be obtained at SV1, TV1 pre-randomization, 
TV2, TV4, TV7, and EOS1. The procedure is described in Appendix H.  
 

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9 
Data and Statistical Analyses  
9.1  Data Analysis 
This study consists of primary, secondary and exploratory/tertiary (research) endpoints. Data 
analysis of study endpoints includes use of validated DFU wound healing measures, 
quantitative and qualitative analyses, as well as exploratory methodologies. Table 4 below 
details each study endpoint, corresponding data, and planned analyses. 
TABLE 4: ETS WOUND CARE, LLC DFU ENDPOINT DATA ANALYSIS  
Endpoint  
Endpoint 
Description 
Supporting Study Data  
Endpoint Analysis 
Primary 
Comparison of the 
proportion of index 
ulcers “healed” at 12 
weeks  
Investigator assessment of 
healing (100% 
epithelization w/no 
drainage), measurements 
of ulcer size using digital 
imaging and photos 
Adjudication panel will 
determine using 
photographs of the DFU 
Secondary 
Proportion of Index 
Ulcers healed at 6 
weeks 
PAR at 6 and 12 
weeks 
Digital imaging  
Mathematical wound 
area change 
Time to healing 
within 6 and 12 
weeks 
Primary endpoint 
Mathematical time 
based on healing 
Changes in 
peripheral 
neuropathy 
Semmes Weinstein with 
vibratory 
Mathematical change in 
scores 
Changes in wound 
quality of life 
WOUND-Q (Quality of life 
tool) 
Mathematical change in 
scores 
Change in pain levels 
during trial 
NPRS 
Mathematical change in 
scores 
Difference in cellulitis 
and/or infection at 12 
weeks 
Observation  
Count of positive and 
negative responses 
Exploratory/Tertiary 
Changes in tissue 
perfusion of wound 
bed and periphery 
with treatment 
SnapshotNIR 
Exploratory   
9.2 
Statistical Analysis 
Descriptive statistical methods will be used to summarize the data from this study with 
hypothesis testing performed for the primary and other selected efficacy endpoints. All testing 
for endpoints will be two-sided with alpha set at .05 level of significance if no statistical testing 
is done at the interim analysis at 0.044 if statistical testing is done at N=240. 
A formal Statistical Analysis Plan (SAP) will be created prior to database lock. The primary 
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endpoints will be analyzed at 6 and 12 weeks. The SAP will provide a more technical and 
detailed description of the proposed data analysis methods and procedures. Any deviation 
from the analyses outlined in the protocol will be described in the most current version of the 
SAP. All statistical analyses will be conducted using PASW 28. 
The primary study hypothesis is that the proportion of wounds healed at 12 weeks, after up to 
12 weeks of SOC with MIRRAGEN™ and SOC with FIBRACOL™, will be equal for Groups 1 
and 2. Formally, H0: I1–I2 = 0; HA: I1–I2 = D1≠0, where I1 is the proportion of wounds healed 
in Group 1, I2 is same metric for Group 2, D1 is the difference (I1–I2); assuming the 
alternative hypothesis and statistical test used is chi square/Fisher exact test.  Analysis may 
be adjusted using generalized linear modeling based on available variables at baseline known 
to affect wound healing. 
Group sequential trials with sample sizes of 120 and 120 at the final look achieve 100% power 
to detect a difference of 0.35 between group 1 (the MIRRAGEN™ group) (proportion 0.70) the 
control group (SOC with FIBRACOL™) proportion of 0.35 at the 0.049 significance level 
(alpha) using a two-sided Z-Test (Pooled). 
The populations defined for analysis will include the intent-to-treat (ITT) and per protocol (PP). 
Additional analysis populations may be defined to evaluate study results. Any additional 
analysis populations will be defined in the SAP. 
Envelopes will be created with a random allocation sequence, which will be composed of a 
random sequence of block sizes of 10 designed to achieve a balanced design. 
One interim analysis will be performed (N~100). The object of the interim analysis is to assess 
subject outcomes between the groups, in particular to assess any adverse effects or events, 
such as infection and to recalculate sample size for the primary endpoint.  
Primary analysis: Proportion of index wounds closed at 12 weeks (group 1 versus group 2) 
using chi square. Analysis will be adjusted using logistic regression. 
Secondary analysis: (1) proportion of Index Wounds closed at 6 weeks (group 1 versus group 
2) using chi square; (2) time to heal within 6 and 12 weeks using Kaplan-Meier analysis; (3) 
PAR at 6 and 12 weeks (group 1 versus group 2) using the Mann-Whitney test; (4) mean 
difference between groups 1 and 2 of change in weekly peripheral neuropathy score 
surrounding the DFU using the Semmes Weinstein monofilament with vibratory procedure 
based on GLM repeated measures; (5) mean difference between groups 1 and 2 of change in 
WOUND-Q score based on difference between baseline and 12 weeks using t test if data are 
normal or Kolmogorov–Smirnov test if data are non-normal; and (6) mean difference between 
groups 1 and 2 of change in weekly wound pain VAS score based on GLM repeated 
measures. 
Control of the familywise error rate (all endpoints) will be achieved through the Hochberg step-
up procedure. 
Every effort will be made to obtain required data at each scheduled evaluation from all 
subjects who have been randomized and treated. Subjects who are withdrawn or lost to 
follow-up will be included in the ITT analysis of primary and secondary endpoints using data 
imputation methods detailed in the SAP. Sensitivity analysis will also be conducted for the 
primary endpoint using different imputation algorithms. 
10 
Adverse Effects and Events (Definitions and Reporting) 
The Investigator is responsible for the detection and documentation of any events meeting the 
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During the study when there is a safety evaluation, the Investigator or site staff will be 
responsible for detecting, documenting, and reporting any adverse effect or adverse event, as 
detailed in this Section of the protocol.  
10.1 SOC Adverse Events 
Since this a post market study involving commercially available SOC dressings of FDA 
cleared and approved medical devices; adverse events associated with their use may also 
require reporting to FDA.  
An AE is defined as any unfavorable or unintended sign, symptom or disease that occurs or is 
reported by the subject to have occurred, or a worsening of a pre-existing condition related to 
the procedure or medical treatment (device/drug) used. All AEs related to the study procedure 
or medical treatment, including intercurrent illnesses, must be recorded in the subject’s 
medical records and on the CRF. CTCAE v4.0 will be used for AE reporting.  
AEs will be defined as those events that occur after the first study treatment is applied at TV1, 
through the final study visit. A description of the AE along with the onset date, end date, 
severity, action taken, treatment, outcome, likely cause and relationship to the study 
procedure or products will be recorded in the CRF.   
AEs associated with each treatment arm will be tabulated and compared at the end of the 
study. AEs will be elicited through direct questioning, subject reports, and physical 
examination. 
An abnormal laboratory test result is not by itself considered to be an AE unless the Investigator 
considers the finding of clinical significance that should be reported in such a manner.  
The Investigator is responsible for assessing the relationship of the AE to the procedure or 
medical treatments used and the seriousness and expectedness of the AE at the time of 
occurrence. A medically qualified person appointed by the Sponsor will also assess this once 
the Sponsor has been notified of an AE. All AEs that occur during the trial will be documented 
on the AE CRF. 
AEs reported during the study should be followed to resolution of the AE or within thirty days 
from the end of the study. A final assessment of the outcome will be made at that time. 
Each AE related to the study procedure or medical treatment used will be categorized as 
“serious” or “not serious,” based on the definition of a serious adverse event (SAE). An SAE is 
defined as an AE resulting in at least one of the outcomes described in Section 10.1.3. 
10.1.1 AE Severity Assessments 
The guidelines outlined in CTCAE v4 will be used for severity assessments. Note: the term 
“severe” is a measure of intensity and that a severe AE is not necessarily serious. Table 5 below 
provides guidance on determining the severity of an AE.  
 
 
 
TABLE 5: AE SEVERITY GRADING SCALE 

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Severity Grade 
Description 
Mild (1) 
Awareness of sign, symptom, or event, but easily tolerated; 
does not interfere with usual daily activities or tasks. 
Moderate (2) 
Discomfort is enough to cause interference with usual daily 
activity. It may warrant therapeutic intervention. 
Severe (3) 
Incapacitating: inability to perform usual activities and daily 
tasks; significantly affects clinical status; requires therapeutic 
intervention. 
Life-threatening (4) 
Emergency treatment required, life-threatening, death. 
A grade of 1-4 is assigned by the Investigator to each AE. 
10.1.2 AE Causality Assessments 
AEs will be assigned a relationship (causality) to the study procedure or medical treatments. 
The Investigator will be responsible for determining the relationship between an AE and the 
study procedure or medical treatment. 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 study 
procedure or medical treatment. The relationship of AEs to study procedures or medical 
treatments will be classified as follows: 
▪ 
Not Related: No relationship exists between the AE and the study procedure or medical 
treatment. The event is attributed to a pre-existing medical condition or an inter-current 
event unrelated to the study procedure or medical treatments. 
▪ 
Possibly Related: Follows the study procedure or medical treatment but may have 
developed as a result of an underlying clinical condition or treatments/interventions 
unrelated to the study. 
▪ 
Probably Related: Follows the study procedure or medical 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 study procedure or medical treatment and physical 
evidence shows a convincing relationship to the study procedure or medical treatment. 
▪ 
Unknown: Follows the study product or medical treatment, but unable to determine the 
relationship to the study procedure or medical treatment. 
10.1.3  Serious Adverse Events  
A SAE is any untoward medical incident that occurs during the course of the study beginning 
after informed consent has been executed.  
A SAE is defined as any AE that: 
▪ 
Results in death 
▪ 
Is life threatening (the subject is at immediate risk of dying from the adverse experience) 
▪ 
Requires subject hospitalization or prolongs existing hospitalization 
▪ 
Results in persistent or significant disability/incapacity  
▪ 
Is a congenital anomaly/birth defect 
Note: Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a SAE when, based upon appropriate medical judgment, 

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they may jeopardize the subject and may require medical or surgical intervention to prevent 
one of the outcomes listed in this definition. 
10.1.3.1 Reporting of Serious Adverse Events 
The Investigator or delegated site personnel is required to report all SAEs that occur during 
the study. Once the Investigator or delegated site personnel becomes aware of an SAE, 
he/she must report the SAE to the CRO and/or ETS Wound Care, LLC, the study Sponsor, 
within 24 hours.  
The study sponsor contact is: Zachary Davis: ETS Wound Care. LLC, (573) 201-4023 email: 
Zachary.davis@heraeus.com 
The CRO contact information is listed on the SAE reporting form.  
A written SAE report must follow and must include a full description of the event and all 
supporting documentation available at the time (e.g., lab reports, culture reports, etc.). 
Additional follow-up information as it becomes available must be reported to the CRO and / or 
Sponsor. 
The Investigator or delegated site personnel is also responsible for reporting all SAEs to the 
IRB in accordance with local laws and regulations. The Investigator is responsible for 
maintaining documentation in the study file that indicates the IRB has been properly notified.  
10.1.3.2 
SAE Follow-up 
All SAEs will be monitored for a minimum of 30 days until they are resolved, have stabilized, 
or are clearly determined to be due to a subject’s stable or chronic condition or intercurrent 
illness (es). 
 
 

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11 
Direct Access to Source Data/Documentation 
Subjects will be identified on CRFs by a unique subject identification number and on source 
documents by name and date of birth. No personal identifier will be used in any publication or 
communication used to support this research study. The subject identification number will be 
used if it becomes necessary to identify data specific to a single subject.  
The monitors, auditors, personnel authorized by the Sponsor, the local IRB and applicable 
regulatory bodies are eligible to review medical and research records related to this study as a 
part of their responsibility to protect human subjects in clinical research and will be given 
direct access to source data and documentation (e.g., medical charts/records, printouts, etc.) 
for source data verification, provided that subject confidentiality is maintained in accordance 
with local requirements.  Access to electronic medical records may be governed by institution 
policy and each site will be required to ensure access while remaining compliant with 
institutional requirements. 
 
 

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12 
Quality Control and Quality Assurance 
12.1 
Acceptability of CRF 
CRF must be completed for each subject who has signed an ICF. For subjects who are 
screen failures, this would be limited to the Screening or other applicable forms. All source 
documents and CRFs will be completed as soon as possible after the subject’s visit.  
12.2 
Modification of Protocol 
The Investigator will not modify or alter this protocol without first obtaining the concurrence of 
the Sponsor. Approval by the Investigator’s IRB must also be obtained prior to implementation 
of the change, with two exceptions: 
When necessary to eliminate apparent immediate hazard to the subject, or 
When the modification does not involve the subject’s participation in the trial. 
An amendment may also require modification of the ICF. The Investigator will provide an 
approval letter for the amendment and revised ICF, if applicable, to the Sponsor. An 
amendment must be made in writing, and it must be dated by both the Sponsor and the 
Investigator. All material must be approved by the IRB. 
12.3  Reporting Protocol Deviations 
The Investigator is obligated to follow the protocol without departure from the requirements 
written in the protocol. Any time there is deviation from any protocol requirements, a protocol 
deviation is required to be reported. If the deviation may impact subject participation, the 
Sponsor should be notified and will make the determination as to whether the subject will 
continue in the study. The Sponsor also has the right to discontinue the subject for protocol 
violations. The IRB may also have to be contacted if safety to the subject or if the scientific 
soundness of the study is involved. All protocol deviations must be documented in the CRFs. 
Protocol deviations will be tracked at the site level and (by the Sponsor) at the study level for 
the duration of the trial.  
 
 

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13 
Ethics and Regulatory Requirements 
This study is to be conducted in accordance with the requirements of this protocol and in 
accordance with principles consistent GCP, ICH E6, HIPAA regulations (45 CFR Part 164) 
and the Belmont Principles of respect for persons, beneficence, and justice. No protocol 
changes will be implemented without prior review and approval of the IRB, except where it 
may be necessary to eliminate an immediate hazard to a study subject. In such a case, the 
change will be reported to the IRB as soon as possible, according to IRB requirements. 
Additionally, all products used in this study are manufactured, handled, and stored in 
accordance with their FDA labeling. 
13.1 
IRB 
The Investigator at each center will provide the IRB with study materials, including but not 
limited to the clinical study protocol, ICF and any advertising materials. The study will not be 
initiated until the IRB provides written approval of the aforementioned documents and until 
approval documents have been obtained by the Principal Investigator and Sponsor or 
Sponsor designee. The site Investigator will not participate in the decision. If the Investigator 
is an IRB member, documentation must be provided indicating recusal from the approval 
process. Appropriate reports on the progress of this study by the Investigator will be made to 
the IRB as required by local and applicable government regulations and in agreement with 
policy established by the Sponsor. The Investigator is required to maintain an accurate and 
complete record of all written correspondence to and received from the IRB and must agree to 
share all such documents and reports with the Sponsor. 
No changes from the final approved protocol will be initiated without IRB prior written approval 
or favorable opinion of a written amendment, except when necessary to eliminate immediate 
hazards to subjects or when the change involves only logistics or administration.  
13.2 
Investigator’s Responsibilities 
The Investigators are responsible for performing the study in full accordance with the protocol 
and the current revision of the Declaration of Helsinki, the ICH GCP Consolidated Guideline 
and any applicable national and local laws and regulations. Information regarding any study 
centers participating in this study that cannot comply with these standards will be 
documented. 
13.3 
Subject Informed Consent Requirements 
Written and oral information about the study in a language understandable by the patient will 
be given to all patients by the Investigator and/or designee. Written informed consent will be 
obtained from each patient before any procedures or assessments that would not otherwise 
be required for the care of the patient are done and after the aims, methods, anticipated 
benefits, potential hazards, and insurance arrangements in force are explained, and the 
patient has been given sufficient time to ask questions and consider participation in the study.  
It will also be explained to the patients that they are free to refuse entry into the study and free 
to withdraw from the study at any time without prejudice to future treatment. It is permissible 
for a third person (e.g., a family member) to be present during the explanation of the study. 
The written ICF is to be in compliance with 21 CFR § 50.27 and GCP requirements.  The 
Sponsor and/or designated CRO will approve the ICF and all amendments to the ICF prior to 
submission to the IRB. A copy of the ICF to be used will be submitted by the Investigator to 
the IRB for review and approval prior to the start of the study. Each study site must provide 
the Sponsor with an unsigned copy of the IRB-approved ICF along with applicable 
documentation to support this approval. The original signed ICF is retained in the subject's 

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study records and a copy is provided to the subject. A second copy may be filed in the 
subject’s medical record, if allowed by institutional policy.  
 
 

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14 
Data Handling and Record Keeping 
14.1 
Recording and Collection of Data 
The primary source document for this study will be the subject's medical record. If separate 
research records are maintained by Investigators, the medical record and the research 
records will be considered the source documents for the purposes of auditing the study.  
Applicable source data will be manually transcribed to the approved CRF. The Investigator is 
ultimately responsible for the accuracy of the data transcribed on the forms. All source 
documents and CRFs will be completed as soon as possible after the subject's visit. 
The Investigator will review CRFs to indicate that, to his/her knowledge, they are complete 
and accurate. If further changes are made after this, the Investigator will need to again sign 
the Investigator signature page. Designated source documents will be signed and dated by 
the appropriate study personnel. The Investigator must agree to complete and maintain 
source documents and CRFs for each subject participating in the study. 
All research data will be entered, either electronically or manually, into a computerized 
database, designed in accordance with the clinical data manager.  
14.2 
Clinical Data Management and Monitoring 
The CRO will be responsible for the processing and quality control of the data. The study will 
be monitored by the CRO. Monitoring may consist of either on site or remote review of any 
and all applicable study records. All study CRFs and background source documents will be 
made available for monitoring. The study monitor will ensure that the investigation is 
conducted according to the protocol design and regulatory requirements.  
14.3 
Archiving 
All study documentation at the Investigator site will be archived in accordance with PERI 
SOPs. 
Study records are subject to inspection by applicable health and regulatory agencies at any 
time.  
Records to be retained by the Investigator include, but are not restricted to: 
▪ 
Source data and the primary records upon which they are based (e.g., subject’s progress 
notes, AE data, test results and any other diagnostic procedures required to evaluate the 
progress of the study) 
▪ 
Signed protocols and protocol amendments 
▪ 
Laboratory results, ranges, and certifications 
▪ 
Product (SOC dressing supplies) and accountability records 
▪ 
Study personnel signature log 
▪ 
Correspondence to and from the Sponsor, designee, and IRB 
▪ 
Investigator and sub-Investigator CVs 
▪ 
Signed ICF and HIPAA consent forms 
▪ 
Subject screening and randomization log 
▪ 
AE or SAE event reports 

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▪ 
IRB approval, re-approval letters and reports 
▪ 
Any documents pertaining to the conduct of the study 
These documents must be maintained and kept on file by the Investigator so that the conduct 
of the study can be fully documented and monitored. 
 
 

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15 
Publication Plan 
Manuscripts and abstracts will be prepared by both the Investigators and the Sponsor. The 
results of the study may be published in scientific literature and may also be used in 
submissions to regulatory authorities. It is the intent of the Sponsor and the Principal 
Investigator to publish or present the study results together with the other sites unless specific 
permission is obtained in advance from the Sponsor to publish separate results. Co-
authorship with any of the Sponsor’s personnel will be discussed and mutually agreed upon 
submission of a manuscript for publication. 
All information concerning the Sponsor’s operations (such as patent applications, formulae, 
manufacturing processes, basic scientific data or formulation information supplied to the 
Investigator and not previously published) is considered confidential by the Sponsor and shall 
remain the sole property of the Sponsor. The Investigator agrees not to use it for other 
purposes without written consent. 
Publication and Disclosure: Because this is a multi-center study, sites and Investigators shall 
not independently publish, publicly disclose, present or discuss any results or information 
pertaining to site’s and Investigator’s activities conducted under this agreement, until such a 
multi-center publication is released under Sponsor’s direction; provided, however, that if a 
publication is not released within eighteen (18) months after completion of analysis of all study 
data from all sites within the multi-center study, site and Investigator shall have the right to 
publish the results of and information pertaining to site’s and Investigator’s activities 
conducted under this protocol and the clinical trial agreement with sponsor permission.  Site 
and Investigator agree to submit any proposed manuscript, presentation, or other public 
disclosure regarding the study to Sponsor for review at least thirty (30) days prior to submitting 
such proposed manuscript to a publisher or delivering or making such presentation or other 
public disclosure to any third party. Within thirty (30) days of its receipt, Sponsor shall advise 
site and/or Investigator, as the case may be, in writing of any information contained therein 
that is confidential information (other than research results included in a proposed manuscript) 
or that may impair Sponsor’s ability to obtain patent protection. Sponsor shall have the right to 
require site and/or Investigator, as applicable, to remove specifically identified confidential 
information (but may not require removal of research results from a proposed manuscript) 
and/or to delay the proposed submission or delivery of the proposed manuscript or 
presentation or other public disclosure, for an additional sixty (60) days to enable Sponsor to 
seek patent protection.  Site and Investigator shall not publish, publicly disclose, present, or 
discuss any results of or information pertaining to sites and Investigator’s activities prior to 
completion of the trial, even if the study is terminated before its completion and the final 
clinical study report is signed off or with respect to any endpoints or analyses, other than 
those specified in this protocol. 
 
 

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16 
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22. Armstrong DG, Orgill DP, Galiano RG, Glat PM, DiDomenico LA, Carter MJ, Zelen CM. 
A multi-centre single-blinded randomized controlled clinical trial evaluating the effect of 
resorbable glass fibre matrix in the treatment of diabetic foot ulcers. Int Wound J 2021; 1-
11. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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 17   SIGNATURES 
The Protocol has been reviewed in respect to compliance with ISO 14155: 2020, 
applicable national regulations and with ETS Wound Care LLC SOPs. 
 
 
 
Nicolas Guggenheim, PhD 
 
 
 
                            Date 
Chief Executive Officer 
ETS Wound Care LLC 
 
 
May 15, 2023
May 15, 2023
Donald W. Buck II, M.D.
Chief Medical Officer
ETS Wound Care LLC

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Appendices  
Appendix A: Wagner Grades 
Grade 1: Superficial diabetic ulcer 
Grade 2: Ulcer extension 
• 
Involves ligament, tendon, joint capsule, or fascia 
• 
No abscess or osteomyelitis 
Grade 3: Deep ulcer with abscess or osteomyelitis 
Grade 4: Gangrene to portion of forefoot 
Grade 5: Extensive gangrene of foot 
 
 

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Appendix B: ABI or Arterial Doppler Ultrasound 
ABI Technique 
Place the subject in the supine position, with the arms and legs at the same level as the heart, 
for a minimum of 10 minutes before measurement,  
Select an appropriately sized blood pressure cuff for both the ankle and the arms (see figure 
below), the cuff width should be, at a minimum, 20% greater than the diameter of the 
extremity. The ankle cuff should be placed on the leg between the malleolus and the calf. 
Enough room should be left below both cuffs to permit placement of the ultrasound gel, so that 
the Doppler device can adequately detect the brachial, dorsalis pedis and posterior tibial 
arteries.  
Obtain the brachial systolic pressures of both arms. Use the higher of the arm pressures in the 
ABI calculation. Obtain the pressure in the dorsalis pedis and posterior tibial arteries for the 
extremity with the target ulcer. Use the highest pressure for the ABI calculation.  
Ankle-Brachial Index = Highest ankle pressure/ Highest brachial pressure.  
Care should be taken to cover the index ulcer during the ABI measurement. In addition, 
subjects should be informed that they may experience discomfort during the test, secondary to 
the pressure exerted by the cuff in the area of skin breakdown. 
 
 
 
 
 
Arterial Doppler Ultrasound Technique 

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Place the subject in the supine position, with the arms and legs at the same level as the heart. 
Ultrasound gel will be applied at the ankle level to the anatomic position of the dorsalis pedis 
and posterior tibial vessels. The Doppler will then be applied to each vessel until a waveform 
is established, a printer will be used to document the Doppler waveform and at least five 
waveforms will be printed for each vessel. The clinician will verify biphasic or triphasic 
waveforms.
 
 
 
 
 

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Appendix C: SPP 
 
 
SPP can be employed to evaluate the subject’s vascular status. SPP is obtained using a laser Doppler. 
Technique  
1. Secure the laser Doppler flow sensor within the bladder of a blood pressure cuff equipped with a transparent 
polyvinyl chloride window for measuring microcirculatory perfusion during cuff inflation and deflation. 
2. Place the subject in supine position and keep still for five minutes.  
3. Apply the cuff to the proximal margin of the ulcer and inflate to 20 mmHg above the brachial systolic pressure. A 
stable laser Doppler output value near zero (< 0.1 volume %) should be reached before deflating.  
4. Deflate the cuff, first in 10 mmHg-stepwise decrements every five seconds to a pressure of 50 mmHg, and then 
in 5-mmHg decrements every 15 seconds until the laser Doppler output increased for two consecutive pressure 
values.  
5. The pressure at which this first occurred is considered the SPP value. 
Subjects with SPP less than 30 mmHg have vascular insufficiency and are not candidates for enrollment.  
 
 

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Appendix D: TCOM 
Technique 
Place the subject in the supine position, with the arms and legs at the same level as the heart. Electrodes must be 
in contact with the tissue through the contact liquid. If there is air between the tissue and an electrode, TCOM 
values will be questionable. Erroneous readings may also occur if electrodes are placed directly over a bone or 
there is severe edema around the wound. For the best results, tests should be conducted at ambient temperature 
(21-23⁰) and the subject should not have smoked, nor had caffeine for several hours prior. 
 
 
 
1. Calibrate the TCOM electrode—this takes about 15-20 minutes.  
2. Clean the selected measuring site with alcohol or other skin-preparation solution. 
3. Dry the site well with a gauze pad. 
4. Take a standard fixation ring. 
5. Remove the fixation ring from the protective film. 
6. Apply the fixation ring to the measuring site as follows: 
• 
Press the center of the fixation ring onto the measuring site with a finger. 
• 
Run a finger around the rim circumference. 
• 
Press firmly to prevent leaks. 
7. Fill the hole in the fixation ring with 3-5 drops of the contact liquid. 
8. Affix the electrode into the fixation ring as follows: 
• 
Align the arrow on the electrode with one of the marks on the fixation ring. 
• 
Turn the electrode 90° clockwise to fasten it in the fixation ring. 
9. Repeat steps 1 to 8 if more electrodes are to be applied; note: several electrodes can be calibrated at the 
same time. 
It is sometimes advantageous to simultaneously use several electrodes placed strategically around the wound and 
calculate mean values from individual readings.  
The normal sequence of events for TCOM is measurement in air, the leg elevation test (optional) and the oxygen 
challenge. Shah et al20 determined that the optimal times for these events in terms of measurement time are 20, 5 
and 10 minutes, respectively. 
 
 

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Appendix E: Debridement 
Many chronic wounds contain necrotic tissue that has a black or dark gray appearance. Wound eschar is usually 
full-thickness, dry devitalized tissue arising from prolonged ischemia and slough is an adherent fibrous material 
commonly creamy yellow in appearance. Chronic wounds can also have colonized bacteria in the form of biofilm or 
cells, particularly along the margins of a wound, which have stopped dividing - a process known as senescence. 
Finally, devitalized tissue and biofilms can harbor high levels of cytokines or cellular remnants that maintain the 
wound in the inflammatory or proliferative stages of healing, through cellular trafficking processes.  Any of these 
factors can disrupt the normal stages of wound healing. 
Debridement is the process by which these elements are removed to permit healing, in effect changing the stalled 
chronic wound into an acute wound. In this clinical study, we have restricted the type of debridement to sharp 
debridement. 
Technique 
Sharp debridement comprises the following elements: 
1. The index ulcer and the surrounding skin are prepped with water or Saline.  
2. Anesthesia, topical or injected, is applied to the ulcer as necessary to reduce subject discomfort.  
3. Using a sterile technique, all non-viable tissue in the wound bed is excised using a scalpel and scissors. 
4. Excessive bleeding is controlled by using direct pressure, but cautery may be employed if necessary. 
If extensive surgical debridement is necessary during the run-in period (e.g., general anesthesia is required), the 
patient is not a candidate for this trial. Likewise, if other forms of debridement (e.g., enzymatic) are required during 
run-in, based on the opinion of the treating clinician, the subject should be screen failed. During the Treatment 
Phase of the trial, other forms of debridement are NOT permitted. If this should happen, the type of debridement 
should be noted in the CRF, using other forms of debridement besides sharp debridement more than once during 
the treatment phase will result in the subject being withdrawn from the trial. 
Although there is increasing evidence that more frequent debridement results in faster healing on average, the 
frequency and level of debridement in this trial is left up to the treating physician’s judgment. Excessive debridement 
can be as deleterious to healing as too little debridement.  
For wound bed preparation, follow the TIME principles: Tissue management (primarily debridement in this trial), 
control of Infection and Inflammation (management of infection, control of edema, management of exudate, etc.), 
Moisture imbalance (ensuring that the wound is at all times in a moist healing environment, as well as dealing with 
excessive wound exudate), and advancement of the epithelial Edge of the wound (addressing hypoxia, infection, 
desiccation, dressing trauma, hyperkeratosis and calluses, and cell senescence at the wound margin).  (Dowsett C, 
Newton H. Wounds UK 2005; 1:58-70).  
 
 

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Appendix F: WOUND-Q Instrument 
 
SCALE STRUCTURE 
Protocols for interventions to treat and prevent wounds have typically overlooked the patient perspective of 
outcomes and have focused instead on objective measures. The WOUND-Q is a rigorously developed patient-
reported outcome measure that can be used with all types of chronic wounds in any anatomical location. The 
WOUND-Q measures 4 overarching domains. Each domain includes 2 or more independently functioning scales. 
Clinicians and researchers are able to administer the subset of scales relevant to their situation. 
WOUND CHARACTERISTICS 
Three scales measure wound characteristics. The first scale measures how concerned someone is with their 
chronic wound(s) in the past week. The other two scales measure how bothered people are with drainage and 
smell. 
HEALTH-RELATED QUALITY OF LIFE 
Four scales measure health-related quality of life. The first scale measures life impact and the other three measure 
specific concerns, i.e., how chronic wound(s) affect sleep, psychological, and social function. 
EXPERIENCE OF CARE 
Four scales measure patients’ experience of healthcare. The first scale measures satisfaction with information and 
the other three measure satisfaction with members of the health care team, i.e., home care nurses, wound team, 
and office staff in a wound clinic. 
WOUND TREATMENT 

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Two scales measure common treatments for chronic wounds. One scale measures satisfaction with dressing and 
the other scale measures satisfaction with the use of a suction device (e.g., vacuum pump device, negative pressure 
therapy dressing). 
Data analysis 
  
WOUND-Q  Instrument 
 
1.  Wound – Assessment 
2.  Wound – Drainage 
3.  Wound – Smell 
4.  Health-Related Quality  of Life 
5.  Treatment - Dressing 
 

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Appendix G: SnapshotNIR 
 
 
SnapshotNIR is a near-infrared (NIR), reflectance-based technology that measures tissue 
oxygen saturation (StO2) in superficial tissue. Using multiple wavelengths of NIR light, 
SnapshotNIR measures relative amounts of oxygenated and deoxygenated hemoglobin in the 
microcirculation where oxygen exchange is happening. SnapshotNIR provides users with a 
tissue oxygenation map that can be used in medical decision making, for tracking and 
trending oxygenation, and for evaluating tissue viability. 
 
The imaging device is completely non-invasive, eliminating the need for patient contact or 
injected dyes. Accurately capture diagnostic insight into the availability of oxygenated blood in 
tissue. SnapshotNIR’s actionable data is helping to provide insight for improved decision-
making, forging a path in advanced diagnostic-driven wound care throughout the continuum of 
care.  
 
THE SCIENCE BEHIND SNAPSHOT 
Chronic wounds are a health problem with significant reductions in quality of life and can have 
devastating consequences such as limb amputations and premature death. SnapshotNIR is 
an imaging device that visualizes and maps tissue oxygen saturation in the capillary network.  
 
Ability to treat nearly all patients, regardless of melanin content for universal peace of 
mind and care for everybody.  Portable and lightweight technology fits easily into your 
workflow. Both Doctors and nurses can operate it.  
Ability to image the actual wound bed and surrounding tissue for a more accurate and 
precise reading of the wound area.  
 

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Precise visualization of oxygen saturation for faster assessments and healing trajectory 
predictions. A means to track and document patient progress to improve clinical 
outcomes and mitigate risks early.