Pilot Study: Augmentation of ACL Reconstruction With Bone Marrow Stem Cells and Amnion Collagen Matrix Wrap
Phase: NA
Conditions: ACL - Anterior Cruciate Ligament Rupture
Sponsor: Andrews Research & Education Foundation

Pilot Study: Augmentation of ACL Reconstruction with Bone Marrow Stem Cells and Amnion 
Collagen Matrix Wrap 
 
Date: 11/27/2017 
NCT03294759 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pilot Study: Augmentation of ACL Reconstruction with Bone Marrow 
Stem Cells and Amnion Collagen Matrix Wrap 
 
 
 
 
 
Principal Investigators:  Adam Anz, M.D., Steve Jordan, M.D. 
 
Investigators:    
Chris Warrell, M. D. 
James Andrews, M.D. 
Roger Ostrander, M.D. 
Nicole Rendos, PhD 
Hillary Plummer, PhD 
 
 
 
Study Design:  Randomized Controlled Trial 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
No. 1   Background /Scientific Rationale 
 
 
Histologic studies have determined that graft ligamentization following anterior cruciate 
ligament (ACL) reconstruction may take from 6 to 18 months. (1) It has been reported that 
incomplete graft maturation and incorporation is one cause of clinical graft failure.   Animal 
studies have illustrated improved tendon healing/integration in ACL models augmented with 
stem cell technologies. (2-4). Basic scientists theorize that optimization of stem cell treatments 
for tissue regeneration requires that a “regenerative triad” be employed, i.e., use of a scaffold, 
stem cells and growth factors.   In the intra-articular environment, research has shown that a 
scaffold such as an amnion wrap is necessary to contain the stem cells and growth factors in close 
proximity to the ACL graft. (2, 4, 5) 
 
The normal, uninjured human ACL is covered by a layer of synovial tissue which contributes to 
the blood supply and nutrition of the native ACL.  It is theorized that the lack of a synovial  lining 
after injury  and following traditional ACL reconstruction contributes to slow ligamentization and 
possible failure of reconstructed grafts.(5) Two studies have demonstrated accelerated 
maturation and ligamentization of human ACL graft augmented with point of care blood 
products. (6, 7)  In one, leucocyte poor platelet rich plasma was injected directly into the body of 
the graft. (6)    In the other, the platelet derived growth factors were loaded in a gelatin carrier 
which was wrapped around the graft. (7) In both studies accelerated and increased ligament 
maturation was documented compared to the controls.  Collagen membranes derived from 
amniotic tissue have been successful to aid healing when used in difficult wounds and meniscal 
repair surgery. (8, 9) 
 
We believe that use of a collagen based -membrane derived from amniotic tissue can be used to 
help reestablish the natural synovial lining of the reconstructed ACL, in effect acting as both a 
barrier from the synovial fluid and as a scaffold to contain autologous mesenchymal stem cells 
and growth factors contiguous with the graft, thus aiding and perhaps accelerating the natural 
maturation and ligamentization process of the implanted graft tissue. Acceleration and 
improvement in graft maturation and strength would be a significant advancement in sports 
medicine allowing safer and earlier return to sports and activity. 
 
No. 2 Objectives 
 
The objective of this study is to evaluate the use of wrapping an ACL graft with a collagen matrix 
tissue wrap and injecting autologous bone marrow aspirate concentrate under the wrapping and 
into the graft. We hypothesize that this method of augmenting ACL surgery will accelerate and 
improve the graft maturation and ligamentization process.  We propose to test this hypothesis 
with a series of cases of ACL reconstructions evaluated with post-operative MRI mapping 
sequences and validated clinical outcome measures. 
 
 

 
No. 3.  Subject Eligibility 
 
Inclusion Criteria:  Patients between the ages of 18 and 35 who are scheduled to have anterior 
cruciate ligament reconstruction with autologous grafts by  one of the investigating physicians 
will be screened for participation in this study.  Patients must be willing to undergo MRI scans 
post –operatively at 3, 6, 9 months and 1 year. 
 
Exclusion criteria:  Patients with prior procedures or significant prior injuries to the same knee 
are excluded.  Any patient who will have difficulty obtaining internet access, does not have an 
active e-mail address, or is unable to comprehend study documents or give informed consent 
will be excluded.  Patient who are unable to complete MRI examinations due to claustrophobia 
or anxiety will be excluded.   
 
No. 4.  Subject Enrollment 
 
Patients meeting the inclusion criteria will have the study explained to them by one of the 
members of the investigating team, and they will be given an opportunity to participate if they 
are interested.  Up to 50 patients who agree to participate will go through the described 
informed consent process and be enrolled in the SOS registry, which is an IRB approved 
research database with Baptist Hospital that collects post-surgical outcome surveys. No specific 
advertising or recruitment material will be utilized.  
 
No. 5.  Study Design and Procedures 
 
Study design will be a Level I prospective randomized and blinded trial. Subjects who meet the 
inclusion criteria will have the study explained in detail and informed consent will be obtained 
as outlined above.  Subjects will be enrolled in the SOS knee arthroscopy registry and complete 
all pre-operative questions prior to the surgical date either on line or in the office with the 
assistance of the staff. The patient will complete all routine pre-operative, operative and post-
operative protocols for the procedure.  An Andrews Institute standard post-operative protocol 
for the procedure will be followed and physical therapy will be ordered for all participants per 
normal standard of care.  Compliance in physical therapy will be documented. 
 
The study will involve 20 patients undergoing ACL reconstruction with patellar tendon 
autografts and 20 patients with hamstring autografts for a total of 40 patients.  During surgery 
the grafts will be harvested and prepared in the standard fashion.  Patients undergoing ACL 
reconstruction with patellar and hamstring autografts will be randomized into 2 groups of 10 
patients each.  One group will have the collagen wrap and stem cell concentrate injection and 
one will have standard ACL surgery without augmentation of wrap and stem cell injection.  All 
of these procedures are commonly performed at the Andrews Institute and standard protocols 
will be followed for all procedures. Patients will be blinded to the randomization results.    
 

Bone marrow aspirate will be collected through the surgical site from the distal femur or the 
iliac crest with a trocar designed for this purpose.  Therefore patients will be unable to 
determine if they have had stem cells harvested.  The aspirate will be centrifuged using the 
Arthrex Angel system (see Appendix 1) to optimally concentrate the cells for implantation.  The 
graft for the experimental groups will be wrapped with a sterile amnion matrix wrap, supplied 
by Arthrex (see attached Appendix 2), which will be sutured in place. (12) (Fig. 1) The grafts will 
be implanted and affixed using standard procedure. (Fig. 2)  The mesenchymal stem cell 
concentrate will then be injected under direct visualization inside the collagen matrix wrap and 
into the graft construct. (Fig.3) A cell count of the stem cell concentrate will be performed prior 
to implantation to determine quality of the concentrate. After injection any remaining stem cell 
concentrate will be destroyed.  Photographs will be taken to document the delivery of the cells 
into the graft construct. The grafts for the control groups will be implanted and affixed per 
normal procedure. 
 
Both groups will be followed utilizing the SOS outcomes system protocol for 2 years.  Both 
groups will undergo post-operative MRI at 3, 6, 9 months and one year utilizing a validated T2 
star sequence which will undergo region of interest mapping to produce mean T2 values.  (Fig. 
4)  These values have been shown to detect differences in ACL content, structure and 
maturation.  Mapping will be performed by a blinded musculoskeletal radiologist.  After the 12 
month MRI, patients will be offered an office needle arthroscopy performed under local 
anesthesia for the purpose of gross and histological evaluation of their graft.  An equal number 
from each randomized group will be recruited.   The goal is to recruit 3 patients from each 
group, for a total of 12 patients. 
 
No. 6 Expected Risks and Benefits 
 
Risks and Discomforts:  There have been no documented risks or side effects from using 
collagen membranes in human subjects. For patients randomized to the collagen wrap stem cell 
group, the stem cells will be harvested from either the femur or iliac crest during surgery. This 
will result in a small needle insertion hole in either the femur or iliac crest for the bone marrow 
stem cell collection, which will be about the same size as an IV insertion. This may cause some 
minor pain or swelling and there is a very minor risk of infection. The risks of needle 
arthroscopy include minor puncture site pain and infection, less than that published for 
standard arthroscopy. (13) There is a small risk of the exposure of patient’s health information, 
which will be minimized through the rigorous requirements set up in the SOS IRB protocols and 
the use of subject codes in place of names on all data sheets.  
 
Benefits:  Patients may experience accelerated graft maturation as a result of agreeing to 
participate in the study.  Some patients will receive at no extra charge mesenchymal stem cell 
augmentation of their ACL grafts.   Patients will receive follow up MRI scans at no extra charge.  
Participation in the patient reported outcomes system gives the attending physician the 
opportunity to remotely monitor patient’s health progress and outcomes.  Future patients may 
benefit from the information obtained in this study. 
 

 
No. 7.  Data Management Procedures 
 
All personal information is strictly confidential and no names will be disclosed except as 
required by law.  All data sheets will have names and identifying information replaced with a 
subject code to protect the confidentiality of the patient. The principal investigator, co-
investigators and research staff will have access to the de-identified data.  All subject data 
forms will be scanned and stored, along with summary information forms and spreadsheets in a 
secure protected folder on a laptop to which only study investigators will have access.  This 
data will be permanently deleted following any and all publications or presentations have been 
completed related to this research.  All records related to this research will be retained in a 
secure location for a period of 3 years following the completion of all study related activities, 
after which time they will be properly destroyed. 
 
No. 8.  Data Analysis 
 
The research committee will meet at appropriate intervals to evaluate and analyze the data.  
The investigators may also access the “Patient Analysis” panel on the SOS website at any time. 
This allows the investigator to perform comparative analysis on individual outcomes, 
institutional outcomes and the global de-identified average by choosing filters.  De-identified 
data can be exported in raw data or graphical format. 
 
 
No. 9.  Statistical Considerations 
 
This study will continue to enroll patients until 40 patients complete the study.  The data will be 
arranged in Microsoft Excel spreadsheet format.  Ranges, means and standard deviations for all 
measures will be determined and calculated. Common statistical procedures, such as ANOVA 
and analysis of covariance will be used to interpret changes in outcome variables from the 
survey results over time. 
 
No. 10.  Quality Control and Assurance 
 
All protocols will be monitored and analyzed data will be checked for accuracy by the principal 
investigator and /or a designated AREF research team member.  All medical data will be kept in 
compliance with HIPAA guidelines. 
 
No. 11.  Regulatory Requirements 
 
Informed Consent:  The informed consent process will be performed by one of the study 
investigators or staff, in the office at the time the decision for surgery is made.  All subjects will 
have the study described to them and will give as much time as they require to read an 
approved, stamped version of the informed consent document.  After signing of the informed 

consent document, participants will be given a copy for their records.  This process will take 
place only after the patient has consented to proceed with the surgical procedure. 
 
 
Subject Confidentiality:  Subject confidentiality information is listed above under #7.  All medical 
data will be recorded and stored in compliance with HIPAA guidelines. 
 
No. 12.  References 
 
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ligament reconstruction: What happens to the human graft? A systematic review of the 
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2. Jang KM, Lim HC, Jung WY, Moon SW, Wang JH.  Efficacy and safety of human umbilical 
cord blood-derived mesenchymal stem cells in anterior cruciate ligament reconstruction of a 
rabbit model: new strategy to enhance tendon graft healing. Arthroscopy. 2015 31(8):1530-
1539.  
3. Matsumoto T, Kubo S, Sasaki K, Kawakami Y, Oka S, Sasaki H, Takayama K, Tei K, 
Matsushita T, Mifune Y, Kurosaka M, Kuroda R.  Acceleratioof tendon-bone healing of 
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Jun; 40(6)1296-302.  
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Huard J.  Tendon graft revitalization using adult anterior cruciate ligament derived CD34+ 
cell sheets for acl reconstruction.  Biomaterials. 2013 34:5476-5487.   
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histology.  Arthroscopy. 2010. 26(4):470-480. 
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Slomczykowski M. Complex meniscus tears treated with collagen matrix wrapping and bone 
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10. Li H, Tao H, Cho S, Chen S, Yao Z, Chen S.  Difference in graft maturity of the 
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12. Riboh JC, Saltzman BM, Yanke AB, Cole BJ. Human amniotic membrane-derived products 
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13. Baeten D,  Van den Bosch F,  Elewaut D,  Stuer A,  Veys EM,  DeKeyser F.  Needle 
arthroscopy of the knee with synovial biopsy sampling: technical experience in 150 Patients.  
Clinical Rheumatology. 1999 18(6): 434-441.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1: Graft preparation prior to implantation. 
 
 
 
 
 
 
 
 
Figure 2: Graft implanted with surgeon’s standard technique 
  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 3: Injection of biologic under membrane  
 
 
 
 
Figure 4: MRI mapping of ACL