A Post-Market, Prospective, Randomized, Controlled Study To Evaluate The Iovera° Device In Treating Pain Associated With Total Knee Arthroplasty
Phase: NA
Conditions: Total Knee Arthroplasty
Sponsor: Pacira Pharmaceuticals, Inc

Official Title: 
NCT Number: 
Document Date: 
A POST-MARKET, PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY TO 
EVALUATE THE IOVERA° DEVICE 
NCT03327220 
Protocol Revised Version (REV) 01 : 14 September 2017 

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Protocol MYO-1265 REV 01 
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A POST-MARKET, PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY TO 
EVALUATE THE IOVERA° DEVICE IN TREATING PAIN ASSOCIATED WITH 
TOTAL KNEE ARTHROPLASTY 
PROTOCOL NUMBER: 
MYO-1265 REV 01 
VERSION:  
September 14, 2017 
SPONSOR: 
Myoscience, Inc. 
46400 Fremont Blvd. 
Fremont, CA 94538 
510-933-1500 (office)
510-933-1501 (fax)
SPONSOR REPRESENTATIVE(S): 
Jessica Preciado, PhD 
Director, Clinical Operations and Principal 
Scientist 
The information contained in this document is confidential and proprietary property of 
Myoscience, Inc. 

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Revision 
Description 
DCO# Release Date 
01 
• Initial Release 
3269 
10/02/2017 
 
 
 

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Investigator Protocol Signature Page (REV 01) 
Read and initial below. 
 
____ 
I understand this protocol contains information that is confidential and proprietary to 
Myoscience, Inc. 
____ 
Any additional information added to this protocol is also confidential and proprietary 
to Myoscience, Inc. and must be treated in the same manner as the contents of this 
protocol. 
____ 
I have read the entire protocol. 
____ 
I understand what the protocol asks me to do as an Investigator. 
____ 
I will conduct this study following this protocol and will make a reasonable effort to 
complete the study in the time noted. 
____ 
I will provide this protocol to study staff under my direct supervision. My study staff 
will keep the protocol and associated documents confidential.  
____ 
I will discuss this information with the study staff to ensure they are fully informed 
about the study and the test articles.  
____ 
I will not start enrolling in this study until it is approved by a governing Institutional 
Review Board.  
____ 
I understand the study may be terminated or enrollment suspended at any time by 
Myoscience, Inc., with or without cause, or by me if it becomes necessary to protect 
the interests of the study Subjects. 
 
 
____________________________________ 
Name of Investigator 
 
 
____________________________________ 
 
_____________________ 
Investigator Signature  
 
 
 
 
Date 
 
 

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Protocol Synopsis 
Title 
A Post-Market, Prospective, Randomized, Controlled Study to 
Evaluate the iovera° Device in Treating Pain Associated with Total 
Knee Arthroplasty 
Study Device 
iovera° (Myoscience Inc., Fremont, CA) 
Study Objective 
To evaluate the outcomes of patients undergoing iovera° treatment of 
the ISN and AFCN prior to total knee arthroplasty to provide 
temporary postoperative pain relief  
Study Design 
Single site, prospective, randomized 
Treatment Groups 
Pre-operative iovera° treatment vs. standard of care treatment  
Duration of Participation 
Up to 16 weeks (12 weeks post-op) 
Study Population 
Male or female, ages 22 to 79 scheduled to undergo a total knee 
replacement as a result of osteoarthritis  
Total Number of Subjects 
Up to 120 subjects (randomized 1:1) 
Number of Sites 
1 
Study Procedures 
iovera° treatment introducing temporary nerve conduction block of the 
ISN and AFCN 
Data Collection Tools 
 
• 
KOOS JR. 
• 
NRS for Pain 
Primary Endpoint  
Cumulative Opioid Consumption at 6 weeks post-TKA Surgery  
Secondary Endpoints  
• 
Changes from Baseline in KOOS JR. Scores 
through 6 weeks post-TKA 
• 
Changes from Baseline through 6 weeks post-
TKA in NRS for Pain 
• 
Changes from Baseline through 6 weeks post-
TKA in Timed Get Up and Go (TUG) test 
  
  
 
 
 
 
 
 
Safety Assessment 
• 
Adverse Event/Safety 
 

 
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Table of Contents 
PROTOCOL SYNOPSIS......................................................................................................................................... 4 
ABBREVIATIONS ...................................................................................................................................................... 7 
1. 
BACKGROUND.................................................................................................................................................. 8 
2. 
REGULATORY STATUS .................................................................................................................................. 9 
3. 
STUDY OBJECTIVE .......................................................................................................................................... 9 
4. 
STUDY DESIGN ................................................................................................................................................. 9 
5. 
DURATION ........................................................................................................................................................ 9 
6. 
INVESTIGATOR QUALIFICATIONS ............................................................................................................ 9 
7. 
STUDY POPULATION ..................................................................................................................................... 9 
7.1 
TARGET PATIENT POPULATION .............................................................................................................................. 9 
7.2 
SUBJECT ELIGIBILITY ................................................................................................................................................ 9 
8. 
STUDY DEVICE AND TREATMENT PROCEDURE ............................................................................... 11 
8.1 
DESCRIPTION ........................................................................................................................................................... 11 
8.2 
INSTRUCTIONS FOR USE AND ADMINISTRATION ............................................................................................... 11 
8.3 
CONTRAINDICATIONS ............................................................................................................................................. 13 
8.4 
RISKS ......................................................................................................................................................................... 13 
9. 
STUDY PROCEDURES ................................................................................................................................. 13 
9.1 
OVERVIEW ................................................................................................................................................................ 13 
9.2 
RECRUITMENT ......................................................................................................................................................... 14 
9.3 
SCREENING /VISIT 1 (-30 TO -1 DAYS) .............................................................................................................. 14 
9.4 
RANDOMIZATION ..................................................................................................................................................... 15 
9.5 
IOVERA° TREATMENT/VISIT 2 (5 DAYS +- 2 DAYS PRIOR TO TKA) ............................................................. 15 
9.6 
VISIT 3 / TOTAL KNEE ARTHROPLASTY (DAY 0) ............................................................................................. 16 
9.7 
STUDY FOLLOW UP ................................................................................................................................................. 17 
9.8 
PHOTOGRAPHS ......................................................................................................................................................... 20 
9.9 
STUDY EXIT .............................................................................................................................................................. 20 
9.10 
SUBJECT DISCONTINUATION ................................................................................................................................. 20 
9.11 
STUDY TERMINATION ............................................................................................................................................. 20 
9.12 
STUDY-RELATED ASSESSMENTS ........................................................................................................................... 21 
9.12.1 
Knee Injury and Osteoarthritis Outcomes Score (KOOS) ............................................................... 21 
9.12.2 
Numeric Rating Scale for Pain (NRS for Pain) ................................................................................... 21 
9.12.3 
Subject Satisfaction Questions.................................................................................................................... 21 
 
 21 
10. 
STATISTICAL METHODOLOGY AND ANALYSES............................................................................ 22 
10.1 
INTRODUCTION ........................................................................................................................................................ 22 
10.2 
STUDY ENDPOINTS ............................................................................................................................................... 23 
10.2.1 
Primary Effectiveness Endpoint .................................................................................................................. 23 
10.2.2 
Secondary Effectiveness Endpoints .............................................. Error! Bookmark not defined. 
10.2.3 
Safety ...................................................................................................................................................................... 25 
10.3 
ANALYSIS COHORTS ................................................................................ERROR! BOOKMARK NOT DEFINED. 
10.3.1 
Screening Cohort ................................................................................. Error! Bookmark not defined. 
10.3.2 
Safety/ITT (Intent to Treat) Cohort .............................................. Error! Bookmark not defined. 
10.3.3 
Per-Protocol Cohort .......................................................................... Error! Bookmark not defined. 
10.3.4 
Cohort for Primary Endpoint ......................................................... Error! Bookmark not defined. 

 
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10.3.5 
Cohort for Secondary Endpoint .................................................... Error! Bookmark not defined. 
10.4 
STATISTICAL METHODS ..........................................................................ERROR! BOOKMARK NOT DEFINED. 
10.4.1 
General .................................................................................................... Error! Bookmark not defined. 
10.4.2 
Derived Data – Change from Baseline Parameters ............. Error! Bookmark not defined. 
10.5 
HANDLING OF DROPOUTS OR MISSING DATA ............................................................................................. 26 
10.6 
POOLABILITY .............................................................................................ERROR! BOOKMARK NOT DEFINED. 
10.7 
SUBGROUP ANALYSIS .............................................................................ERROR! BOOKMARK NOT DEFINED. 
10.8 
ANALYSIS WINDOWS AND DEFINITIONS ....................................................................................................... 26 
10.9 
SENSITIVITY ANALYSES ..................................................................................................................................... 26 
10.10 
SAMPLE SIZE JUSTIFICATION ............................................................................................................................ 26 
11. 
ADVERSE EVENTS ................................................................................................................................... 26 
11.1 
ADVERSE DEVICE EFFECT (ADE) ........................................................................................................................ 27 
11.2 ....... SERIOUS ADVERSE EVENT (SAE)/ SERIOUS ADVERSE DEVICE EFFECT (SADE)/ANTICIPATED 
SERIOUS DEVICE EFFECT (ASADE)/ UNANTICIPATED SERIOUS ADVERSE DEVICE EFFECT (USADE) 27 
11.3 
AE SEVERITY AND RELATEDNESS ........................................................................................................................ 28 
12. 
DEVICE TRACKING ................................................................................................................................. 29 
13. 
DEVICE DEFICIENCIES AND MALFUNCTIONS ................................................................................ 29 
14. 
ETHICAL AND REGULATORY CONSIDERATIONS ......................................................................... 29 
14.1 
COMPLIANCE WITH GOOD CLINICAL RESEARCH PRACTICE ............................................................................. 29 
14.2 
INSTITUTIONAL REVIEW BOARD (IRB) AND INFORMED CONSENT ............................................................... 29 
14.3 
PROTOCOL COMPLIANCE ........................................................................................................................................ 30 
14.4 
PROTOCOL REVISIONS ............................................................................................................................................ 30 
14.5 
STUDY MONITORING ............................................................................................................................................... 30 
14.6 
SAFETY REPORTING ................................................................................................................................................ 30 
14.7 
CASE REPORT FORMS ............................................................................................................................................. 31 
14.8 
QUALITY ASSURANCE AUDITS ............................................................................................................................... 31 
14.9 
CONFIDENTIALITY ................................................................................................................................................... 32 
14.10 
RECORDS RETENTION ....................................................................................................................................... 32 
14.11 
PUBLICATION AND REPORTING OF STUDY RESULTS .................................................................................... 32 
15. 
SELECTED REFERENCES ....................................................................................................................... 32 
 
 
 
 
 
 

 
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Abbreviations 
ADE 
Adverse Device Effect 
AE 
Adverse Event 
AFCN 
AO 
Anterior Femoral Cutaneous Nerve 
Anticipated Observation 
ASDE 
Anticipated Serious Device Effect 
CFR 
Code of Federal Regulations 
CNS 
Central Nervous System 
CRF 
Case Report Form 
FCTTM 
Focused Cold TherapyTM 
ESE 
Expected Side Effect 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
IRB 
ISN 
Institutional Review Board 
Infrapatellar branch of the Saphenous nerve 
ISO 
International Organization for Standardization 
KOOS JR. 
MedDRA 
Knee Injury and Osteoarthritis Outcomes Score 
Medical Dictionary for Regulatory Activities 
NRS Pain 
NSAID 
Numeric Rating Scale for Pain 
Non-Steroidal Anti-Inflammatory Drug 
NSR 
Non-Significant Risk 
OTC 
Over-the-Counter 
QA 
Quality Assurance 
SADE 
Serious Adverse Device Effect 
SAE 
SOC 
Serious Adverse Event 
System Organ Classes 
TKA 
UG 
Total Knee Arthroplasty 
User Guide 
UADE 
USADE 
Unanticipated Adverse Device Effect  
Unanticipated Serious Adverse Device Effect 
 
 
 
 

 
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1. 
BACKGROUND 
 
Total Knee Arthroplasty (TKA) is a highly effective procedure to relieve symptoms in patients with 
severe arthritis. Improvements in pain, physical function, and enhanced quality of life in patients 
who have undergone TKA are well established in the literature1,2.  However, post-operative pain 
associated with TKA is severe. Effective pain control following TKA allows for earlier ambulation 
and initiation of physical therapy, which speeds recovery, reduces hospital length of stay, and 
decreases the risk of postoperative complications3.  The VHA/DoD and the American Society of 
Anesthesiologists have both issued guidelines suggesting that wherever possible, practitioners 
should use multimodal pain management4.  Clinical management of post-op TKA pain should 
include both pharmacologic and non-pharmacologic modalities and minimize preventable 
postoperative complications5. As demand for primary TKAs is projected to grow to 3.48 million 
procedures per year by 2030 in the United States alone6, the need for effective and economic multi-
modal pain management has never been greater. 
 
Managing pain via multi-modal strategies, including peripheral nerve blocks, in the inpatient 
postoperative phase has been shown to decrease opioid consumption7, decrease opioid related side 
effects, decrease hospital stay, and increase time to ambulation8,9,10.  Nursing, hospital, and 
pharmacy utilization in managing PCA, continuous regional nerve blocks, and administration of 
oral opioid dosing are associated with higher costs of care and introduce sources for staff error11,12. 
Furthermore, the idea of multi-modal pain management extends beyond the in-patient phase of 
treatment.  Decreasing prescription opioid use during outpatient rehabilitation decreases NSAID 
and opioid related side effects, especially important among the aging population13,14.   
 
The iovera° device introduces a new mode of pain management delivery in TKA.  The iovera° 
system uses liquid nitrous oxide contained within the device and closed-end needles to create a 
precise zone of cold at the target nerve sites.  This Focused Cold Therapy™ delivery platform 
causes a temporary peripheral nerve block based on a process called Wallerian degeneration (2nd 
degree axonotmesis) without disrupting connective nerve tissue. With nerve conduction blocked, 
pain is relieved in sensory nerves (nerves that pass impulses from receptors toward or to the central 
nervous system). Degeneration of the nerve axons is followed by a predictable restoration of nerve 
function involving axon regeneration from the point of treatment to the distal end of the nerve at a 
rate of 1.0–1.5 mm a day15,16.  Early clinical study results have demonstrated that the duration of 
effect of iovera°, when applied to the infrapatellar branch of the saphenous nerve for knee pain, is 
two to three months; longer than that of other clinically adopted modalities (PCA opioids, single 
shot regional nerve blocks, continuous regional nerve blocks, extended-release peri-operative local 
opioids, oral and IV NSAIDs, acetaminophen, and oral opioids).  Early clinical data further suggests 
that iovera°, when applied to the infrapatellar branch of the saphenous nerve (ISN) and anterior 
femoral cutaneous nerve (AFCN) prior to TKA, reduces the amount of opioids requested by 
subjects to maintain similar levels of pain relief17.  
 
This study is designed to investigate whether iovera° treatment prior to TKA decreases cumulative 
patient opioid use over the course of 6 weeks following TKA while maintaining similar levels of 
pain relief.  The study will also investigate whether there is a relationship between patients treated 
with iovera° and patient reported pain and function as measured by KOOS JR., NRS for Pain,
 
 
 
 

 
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2. 
REGULATORY STATUS 
  The iovera° device is 510(k)-cleared (K133453 and K161835) and is used to destroy tissue during 
surgical procedures by applying freezing cold. It can also be used to produce lesions in peripheral 
nervous tissue by the application of cold to the selected site for the blocking of pain. It is also 
indicated for the relief of pain and symptoms associated with osteoarthritis of the knee for up to 90 
days. The iovera° system is not indicated for treatment of central nervous system tissue 
Additionally, Myoscience and an independent review board have determined that the iovera° device 
is a non-significant risk device under 21 CFR §812.2(b) as described for use within this protocol. 
Therefore, an approved Investigational Device Exemption (IDE) from FDA is not required to 
legally perform the study described herein in the US. 
3. 
STUDY OBJECTIVE 
To evaluate the outcomes of patients undergoing iovera° treatment of the ISN and AFCN prior to 
total knee arthroplasty to provide temporary postoperative pain relief.  
4. 
STUDY DESIGN 
This is a single-site, prospective, randomized trial. 
5. 
DURATION 
Each Subject participates for up to 16 weeks.  Enrollment is expected to take up to 5 months.  Total 
study duration is expected to be up to 8 months. 
6. 
INVESTIGATOR QUALIFICATIONS 
To participate in this study, an Investigator must have an active medical license and board 
certification in Orthopedic Surgery, Anesthesia, Pain Management, or Physical Medicine and 
Rehabilitation.  The Investigator or designee must undergo training conducted by Myoscience, Inc., 
on the study device prior to enrolling Subjects in the study.   
7. 
STUDY POPULATION 
7.1 
Target Patient Population 
The target patient population is adult men and women ages 22 to 79 in the United States 
scheduled to undergo primary unilateral TKA under spinal anesthesia for primary 
diagnosis of osteoarthritis. 
 
7.2 
Subject Eligibility 
To be included in the study, Subjects must meet all of the inclusion criteria and none of 
the exclusion criteria list in Table 1. 
 
 
 
 
 
 
 
 
 

 
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Table 1. Study Eligibility Criteria. 
Inclusion Criteria 
 
1. 22 to 79 years of age 
2. Scheduled to undergo primary unilateral TKA under spinal anesthesia for primary 
diagnosis of osteoarthritis 
3. Subject is a class I-III on the American Society of Anesthesiology (ASA) Physical 
Classification System  
4. Anticipation of discharge to home after inpatient acute post-op phase based on age, co-
morbidities, home environment, and social support are in favor of discharge to home in 
the opinion of the Investigator. 
5. Subject is willing and able to give written informed consent. 
6. Subject is fluent in verbal and written English.  
7. Subject is willing and able to comply with study instructions and commit to all follow-
up visits for the duration of the study. 
8. Subject is in good general health and free of any systemic disease state or physical 
condition that might impair evaluation or which in the Investigator’s opinion, exposes 
the Subject to an unacceptable risk by study participation. 
Exclusion Criteria 
 
1. Chronic opioid use (defined as daily or almost daily use of opioids for >3 months). 
2. Concurrent painful physical condition, surgery, or musculoskeletal disease that requires 
analgesic treatment during study follow-up that is not strictly related to the target knee 
being treated with iovera°, which have the potential to confound the postoperative 
assessments (e.g., significant pain from other joints, chronic neuropathic pain, 
concurrent or planned contralateral TKA, concurrent foot, neck, spine, hip, or other 
musculoskeletal disease, arthritis, or planned surgery, etc.). 
3. Greater than 15° malalignment (varus or valgus) on pre-operative radiograph. 
4. Previous Myoscience treatment.  
5. Previous Partial or Total Knee Arthroplasty. Partial or Total Knee Arthroplasty of the 
contralateral knee is permitted if surgery was completed at least nine (9) months prior to 
Screening. 
6. Body Mass Index ≥ 40 
7. Prior surgery in the treatment areas that may alter the anatomy of the infrapatellar 
branch of the saphenous nerve (ISN) or the anterior femoral cutaneous nerve (AFCN) or 
result in scar tissue in the treatment area. 
8. Any clotting disorder and/or use of an anticoagulant (e.g. warfarin, clopidogrel, etc.) 
within seven (7) days prior to administration of the device. Low dose aspirin (81mg or 
less daily) for cardiac prophylaxis allowed. 
9. Any local skin condition at the treatment sites that in the Investigator’s opinion would 
adversely affect treatment or outcomes. 
10. Open and/or infected wound in the treatment areas. 
11. Allergy to lidocaine. 
12. History of cryoglobulinemia 
13. History of paroxysmal cold hemoglobinuria. 
14. History of cold urticaria. 
15. History of Raynaud’s disease. 
16. History of opioid or alcohol abuse. 
17. Subject is pregnant or planning to become pregnant while enrolled in the study. 

 
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18. Current enrollment in any investigational drug or device study or participation within 30 
days prior to screening. 
19. Currently being treated for related knee injury under worker’s compensation claim or 
equivalent (i.e. legal case). 
20. Any chronic medical condition that in the Investigator’s opinion would prevent 
adequate participation. 
21. Any chronic medication use (prescription, over-the-counter, etc.) that in the 
Investigator’s opinion would affect study participation or Subject safety.  
22. For any reason, in the opinion of the Investigator, the Subject may not be a suitable 
candidate for study participation (i.e., history of noncompliance, drug dependency, etc.). 
 
 
8. 
STUDY DEVICE AND TREATMENT PROCEDURE 
The study device is described briefly below.  
8.1 
Description 
The Myoscience iovera° device is a next generation device designed to temporarily reduce 
pain.  The device consists of a reusable, portable Handpiece, along with single-patient use 
sterile Smart Tips (aka cryoprobes) and disposable nitrous oxide (N2O) cartridges.  The 
Smart Tip contains embedded software that manages procedure parameters and provides 
physician feedback throughout all states of device preparation, treatment and post-treatment 
via communication with the Handpiece.  The Handpiece is battery powered and is stored 
and recharged via the Charging Dock. 
The iovera° device produces the desired effect through initiation of a cooling cycle.  Each 
cooling cycle is initiated by fully inserting the Smart Tip into the selected procedure site 
and activating the cryogen flow.  A freezing zone forms around the end of the Smart tip 
affecting the adjacent tissue. 
The cryogen is provided in a nitrous oxide cylinder attached to a custom filter, known as the 
Cartridge.  To remove contaminants that may be present in the cylinder, a custom filter is 
added to the cylinder to filter the liquid nitrous oxide before it enters the Handpiece.  This 
ensures optimal performance of the device. 
A specially designed Smart Tip is included.  The Smart Tip needles are made of stainless 
steel and have a closed-tip, fully enclosing the cryogen.  As the cryogen gas travels through 
the length of the needle, an ice ball develops around the needle causing the surrounding 
tissue to be frozen.  Operation instructions and further details on the device are provided in 
the User Guide.     
Device training will be provided to the Investigator and study staff prior to the initiation of 
study enrollment. 
8.2 
Instructions for Use and Administration 
Use of the iovera° device is described briefly herein. For details see the User Guide as 
provided by Myoscience, Inc. 
The iovera° device is used on awake Subjects who are prepared with local anesthesia only.  
The treatment targets are the infrapatellar branch of the saphenous nerve (ISN) and the 

 
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anterior femoral cutaneous nerve (AFCN) shown in Figure 1.  Training for the treatment 
procedure will be provided to the Investigator and study staff prior to the initiation of study 
enrollment. 
Figure 1.  Infrapatellar branch of the Saphenous Nerve and Anterior Femoral Cutaneous Nerve 
 
 
 
Treatment will be performed unilaterally and will be guided by visualization and palpation 
of anatomical landmarks. Landmarks and treatment line will be marked on the skin as 
shown in Figure 2.   
Figure 2 Treatment Lines (not to scale) 
 
 
Note that the study Sponsor will provide the following supplies: 
• iovera° devices, Smart Tips and cryogen cartridges 
• Surgical pen or other marking tool  
• Measuring tape 
• Goniometers (2) 
AFCN Treatment Line: 
Located at 1/3 the length of the 
distance from the center of the patella 
to the top of the femur, with a width 
equal to the width of the patella. 
ISN Treatment Line: 
Located along the line that connects a 
point 5cm medial to the lower pole of 
the patella and the point 5cm medial to 
the tibial turbercle. 

 
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• Stop Watch 
• Marking Ruler 
 
The investigational site will provide the following: 
• Injectable lidocaine (no epinephrine) used for local anesthesia 
• Syringes for administration of local anesthesia 
• Needles for administration of local anesthesia 
• Gauze 
• Alcohol wipes 
• Wound dressing(s) 
 
8.3 
Contraindications 
Use of iovera° is contraindicated in the following situations: 
• Cryoglobulinemia  
• Paroxysmal cold hemoglobinuria 
• Cold urticaria 
• Raynaud’s disease 
• Open and/or infected wounds in the target treatment area 
Note: physician discretion should be exercised when patient presents with existing neuromuscular disease 
compromising the regeneration of peripheral nerves that may be involved in the treatment.  
 
8.4 
Risks 
The iovera° device involves percutaneous access to subcutaneous tissue using a needle and 
use of dermal anesthesia. Passage of a needle into the skin, cooling of subcutaneous soft 
tissue and delivery of local anesthesia are known to be associated with the following risks: 
• Bruising (ecchymosis)  
• Swelling (edema)  
• Inflammation and/or redness (erythema) 
• Pain and/or tenderness along the treatment line 
• Altered sensation (localized dysesthesia) 
 
Proper use of the device as described in the User Guide can help reduce or prevent the 
following complications:  
• Injury to the skin related to application of cold or heat 
• Hyper- or hypo-pigmentation at the treatment site 
• Skin dimpling at the treatment site  
• Loss of motor function outside the target area 
 
9. 
STUDY PROCEDURES 
9.1 
Overview 
An Overview of the study visits is shown in Figure 3.  Eligible Subjects are randomized to 
iovera° treatment or to the standard of care group. The standard of care group treatment 
consists of all of the standard pre-, peri- and post-operative protocols except that the iovera 
treatment is not provided.  The primary endpoint is cumulative opioid consumption at 6 
Weeks Post-TKA. 

 
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Figure 3.  Overview of Study Visits 
 
 
*Screening and Treatment can occur on the same day.   
9.2 
Recruitment 
Potential study participants will be recruited from the clinics of the participating 
Investigator, as well as local advertising.  Any study-related advertisements will be 
approved by the governing IRB prior to use. 
9.3 
Screening /Visit 1 (-30 to -1 days) 
A patient who signs the informed consent document will be considered a study Subject. A 
Subject who withdraws from the study prior to randomization will not count toward the 
study’s sample size.  Potential participants will be screened for eligibility against Table 1. 
Once the informed consent form is signed, the Subject is assigned a study number. The 
Subject number is comprised of the 2-digit site number followed by a consecutively 
assigned 3-digit Subject number that starts with 001.  For example, the first screened Subject 
for site 01 will be assigned study number 01-001.  The Subject number is the identification 
number used on CRFs and other study documents throughout the study. In the event a 
Subject withdraws from the study, their Subject number cannot be reassigned to any other 
Subject. 
 
The Investigator, or designee, will document the Subject’s medical history, demographic 
information, obtain vital signs and complete an assessment of the intended treatment areas 
and concomitant medications/concurrent procedures. Subjects will be asked to bring all 
prescription opioid bottles to all study follow-up visits. A pill count will be completed by 
the study coordinator, or designee.  
Once a Subject has been determined to meet all inclusion and none of the exclusion criteria, 
the Subject will complete the following: 
 
Assessments: 
• NRS for Pain when standing from a seated position in target knee 
• KOOS JR. (English version 1.0) 
 
 
 
Screening 
iovera° 
Treatment* 
Day of 
TKA 
72 Hours 
Post-op 
(Phone call) 
2 Weeks 
Post-op 
6 Weeks 
Post-op 
12 Weeks 
Post-op 

 
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Physical Performance Measures in the following order: 
 
 
• Timed Get Up and Go Test  
 
Subjects may be complete Screening / Visit 1 and iovera° Treatment / Visit 2 on the same 
day.  
 
9.4 
Randomization 
After meeting all of the inclusion and none of the exclusion criteria and prior to study 
treatment, Subjects will be randomized in a 1:1 manner to either: 
• iovera° Treatment: Subject undergoes treatment with the study device using study 
supplied  Smart Tip. 
• Standard of Care Treatment: Subject does not undergo iovera° Treatment 
The Investigator or designee will record the randomization assignment in the source 
documentation and CRF.  Any Investigator who is discovered to tamper with randomization 
will be immediately terminated from the study. 
9.5 
iovera° Treatment/Visit 2 (5 Days +- 2 days prior to TKA) 
 
Medical history will be reviewed as well as concomitant medications and procedures.  Blood 
pressure and heart rate will be assessed.  The Investigator, or designee, will reconfirm all 
eligibility criteria are met. 
The iovera° device will be prepared by the trained Investigator (or Sponsor designee) 
according to the User Guide. If at any time the device does not perform as expected the 
Investigator (or designee) will follow procedures as outlined in the User Guide.  
Prior to the initiation of the iovera° treatment, the Investigator, or designee, will mark the 
treatment lines on the knee to be treated as shown in Figure 2 located in section 8.2.   
Then the skin along the treatment lines will be cleansed with alcohol.  Lidocaine, no 
epinephrine, will be injected along the treatment lines superficially in order to achieve 
cutaneous anesthesia and to the bottom of the subcutaneous layer, atop the fascia, to 
temporarily block conduction of the infrapatellar branch of the saphenous nerve and the 
anterior femoral cutaneous nerve. 
Once localized anesthesia of the treatment lines and the nerves is achieved, the Investigator, 
or designee, will complete the iovera° treatment along the treatment lines.  Regardless of 
the length of treatment lines (width of patella or from lower pole of the patella down to tibial 
tubercle), adjacent insertions are placed along the treatment lines until the entire line has 
been treated so all Subjects receive the same treatment.  Treatment is not to be modified or 
influenced by any Subject response to changes in knee pain. Representatives of Myoscience, 
Inc. may be present during the treatment. Photos of the treatment area may be taken.  
Upon completion of treatment, the treatment areas will be cleansed and the skin will be left 
undressed. The Investigator or designee will assess the treatment areas for adverse events.  
A dressing may then be applied. 

 
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The Subject will be instructed to report any adverse events to the Investigator between and 
at the follow-up visits.  
9.6 
Visit 3 / Total Knee Arthroplasty (Day 0) 
The Investigator or Designee will confirm their ability to safely perform TKA within the 
following protocol requirements.  All surgical and in-patient data, safety information 
including adverse event assessments, will be collected retrospectively from hospitalization 
records: 
 
• Pre-operative History & Physical Exam, including assessment of the target knee, 
must be documented in the medical record and included as study data. 
• Surgery and Implant - Medial parapatellar surgical approach; cruciate-retaining or 
posterior-stabilized TKA; all surfaces replaced. 
• Pre-emptive analgesia – medications administered prior to TKA, orally, 
intravenously, or otherwise, for the purpose of pain management before, during, or 
after surgery, are to be recorded in the medical record and included as study data. 
• Procedural anesthesia – during Arthroplasty this will be limited to spinal 
anesthesia, the formulation, or “cocktail,” of medications used are to be recorded 
in the medical record and included as study data.  
• Local Infiltration Analgesia – The control group (standard of care) may utilize 
local infiltration analgesia (including periarticular and posterior capsule 
infiltration). The use of periarticular local infiltration analgesia (eg. Exparel) is not 
permitted to be used as part of this protocol in the treatment (iovera) group.  
However, for the treatment group, local infiltration analgesia may be used in the 
posterior capsule as the iovera treatment does not affect this region of the knee. 
The medications used in both groups are to be recorded in the medical record and 
included as study data.     
• Regional nerve block for post-operative analgesia – single shot Adductor Canal 
Block required, the formulation, or “cocktail,” of medications used are to be 
recorded in the medical record and included as study data.  
• Post-operative analgesia will be prescribed as detailed below.  All opioid or other 
pain medications used are to be recorded in the medical record and included as 
study data. 
 Oxycodone, 5mg, q4h/PRN, N=40 
 Tramadol, 50mg q6, N=40 
 Tylenol, 100mg, TID, N=40 
 Neurontin, 100mg, TID, N=40 
 Meloxicam, 15mg, OD, N=15 
• Post-operative discharge criteria: Ability to tolerate fluids, ambulate with physical 
therapist for first ambulation, Void >200cc, Pain under control. 
• Other data to be collected retrospectively from hospitalization medical records 
may include: 
 
pain scores collected during physical therapy and 
adverse events, including Opioid-related adverse events.   
 
Outpatient analgesia – The subject will be required to bring all of their unused prescription 
narcotic medications dispensed during study participation to all study follow-up visits for 
pill count.  A pill count/ accountability will be completed by the study coordinator, or 
designee. Any other over-the-counter analgesic medications or other pain relief therapies 

 
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used (per patient report) will also be recorded by the study coordinator, or designee, at 
each follow-up visit.   
 
 
9.7 
Study Follow Up  
Study-related follow-up visits occur at the investigational site at, 72 Hours (Visit 4) Post-
TKA as well as Week 2 (Visit 5), Week 6 (Visit 6), and Week 12 (Visit 7) Post-TKA.  
The study’s schedule of assessments is shown in Table 2. 
 
 
Follow Up Visit 4 (72 hours ± 24 hours post op) - Phone Call 
Visit 4 (72 Hours Post-TKA) will occur via a phone follow-up.  No physical performance 
measures will be collected at these visits.  Subjects will self-report the amount of opioids 
used.  Subjects will report the NRS Pain Scores, answer the KOOS Jr. questions and 
report any AEs if present. 
Follow Up Visit 5 (2 Weeks; ±3 Days Post Op), and Visit 6 / 6 Weeks Post-op (6 weeks; 
±5 Days Post-Op) 
Subjects will be evaluated and data collected per the schedule of events. Any changes in 
concomitant medications/concurrent procedures will be documented. Any anticipated 
observations, adverse events, adverse device effects and/or SAE/UADE/USADE will be 
assessed and documented. Photographs may be taken of the treatment area.  
The Subject will complete a KOOS JR. questionnaire and NRS for Pain when standing from 
a seated position for all follow-up visits. The Subject will also complete a 
 
 will answer Satisfaction questions at Visit 6. 
The subject will complete the Physical Performance Measures for Visit 5, 6 and 7 in the 
following order under supervision of the investigator or designee: 
 
 
• Time Get-Up and Go 
 
Subjects will be asked to bring all prescription opioid bottles to all study follow-up visits. 
A pill count will be completed by the study coordinator, or designee, and opioid medication 
will be returned to subjects.  
Follow Up Visit 7 (12 Weeks; ±7 days Post-Op) 
Subjects will be evaluated and data collected per the schedule of events. Any changes in 
concomitant medications/concurrent procedures will be documented. Any anticipated 

 
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observations, adverse events, adverse device effects and/or SAE/UADE/USADE will be 
assessed and documented. Photographs may be taken of the treatment area.  
The Subject will complete a KOOS Jr. questionnaire, NRS for Pain when standing from a 
seated position. The Subject will also complete a 
 will answer 
Satisfaction questions.  
The subject will complete the Physical Performance Measures in the following order under 
supervision of the investigator or designee: 
 
 
• Get up and Go Test 
 
The total number of outpatient Physical Therapy visits conducted between each study visit  
will also be obtained. Additional Data collected from Physical Therapy Visits will include:  
 
  
• Pain while seated  
 
 
 
 
 
 
 
 
 
 
Subjects will be asked to bring all prescription opioid bottles to all study follow-up visits. 
A pill count will be completed by the study coordinator, or designee, and opioid medication 
will be redispensed to subjects.  
At the completion of this visit, the Subject will be exited from the study unless the Subject 
has any ongoing device-related or iovera° treatment-related adverse events as described in 
section 10.8.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Table 2. Schedule of Assessments 
Assessment 
Visit 1 / Screening  
Visit 2 / iovera° 
Treatment 
Visit 3 / DAY OF 
TKA (Day 0) 
Visit 4 / 72 Hours 
Post-op 
Visit 5 / 2 Weeks 
Post-op 
Visit 6 / 6 Weeks 
Post-op 
Visit 7 / 12 Weeks 
Post-op 
Informed Consent 
X 
 
 
 
 
 
 
Eligibility 
X 
X 
 
 
 
 
 
Medical history 
X 
X 
 
 
 
 
 
Concomitant medication 
assessment 
X 
X 
X 
X 
X 
X 
X 
Prior/Concurrent Therapy 
X 
X 
 
X 
X 
X 
X 
Randomization* 
X 
 
 
 
 
 
 
Study Treatment 
 
X 
 
 
 
 
 
Physical Exam 
X 
 
 
 
 
 
 
Vital signs 
X 
X 
 
 
 
 
 
Knee Circumference 
X 
 
 
 
 
 
 
KOOS JR. Questionnaire 
X 
 
 
X 
X 
X 
X 
NRS for Pain 
X 
 
 
X 
X 
X 
X 
Subject Satisfaction Questions 
 
 
 
 
 
X 
X 
Physical Performance 
Measures 
X 
 
 
 
X 
X 
X 
Pain Medication 
Accountability 
 
 
 
X 
X 
X 
X 
AE/SAE Assessment 
 
 
X 
X 
X 
X 
X 
X 
* Randomization occurs after the subject has met eligibility criteria 
 
Follow-up visits generally consist of the following:  
• The Investigator or designee assesses the occurrence of health status changes and 
adverse events since last study visit; 
• The Investigator or designee determines whether any changes in daily medications 
have occurred; 
• The Investigator or designee performs drug accountability (pill counts) of post-
operative outpatient opioid medication and re-dispenses unused opioid medications to 
subjects after use.  The Investigator or designee records other over-the-counter 
concurrent pain medication use and pain relief therapies used per subject report; 
• The Subject completes a KOOS JR. questionnaire,
 
Satisfaction questions (Visit 6 and 7 only), and reports NRS for Pain when 
standing from a seated position; 
• The Investigator or designee performs Physical Performance Measures (
 
Get Up and Go Test). 

 
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9.8 
Photographs  
Photographs are optional; and may be requested by sponsor in the event a local skin reaction 
occurs at the treatment site. Photographs will be labeled appropriately, stored electronically 
(e.g., JPEG, PNG or other relevant format) and sent to the Sponsor according to Sponsor 
instructions. 
9.9 
Study Exit 
When the final study visit is complete, the Subject’s participation in the study is complete 
and the Investigator, or designee, will complete the study exit CRF.  
If a Subject is experiencing an unresolved device or iovera° treatment related adverse events 
at the final study visit, the Subject will be followed by the Investigator until resolution 
occurs. 
9.10 
 Subject Discontinuation 
A Subject may be withdrawn from the study prior to completion for any of the following 
reasons: 
• Voluntary withdrawal of consent 
• Adverse event preventing continued study participation 
• Investigator believes risk of further subject participation outweighs benefit 
• Medical need for prohibited medications or treatment 
• Persistent non-compliance or lost to follow-up (A Subject is considered lost to follow-
up after the site makes 3 attempts to contact the Subject via email or phone call and a 
certified letter is sent to the Subject.) 
  
The Investigator/Coordinator will complete a study exit form in the CRF for any subject 
who prematurely discontinues from the study.  If discontinuation was the result of an AE, 
the AE will also be recorded in the CRF. 
 
9.11 
Study Termination 
The Sponsor may terminate the study as a whole or at individual study sites under the 
following circumstances: 
• Suspicion of risk to subjects, including occurrence of high rate of known AEs or 
unexpectedly high rate of unexpected AEs 
• Poor site compliance with the study protocol 
• Inadequate site enrollment 
• Obtaining new scientific knowledge that shows that the study is no longer valid or 
necessary 
• Persistent non-compliance with IRB or regulatory requirements 
• Persistent failure to comply with obligations arising from the clinical trial agreement 
• Other business reasons (e.g., insolvencies or business entity liquidation) 
 

 
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The Sponsor will document reasons for study suspension and notify relevant site 
Investigators and governing IRBs.  If suspension occurred because of a safety issue, all 
Investigators will be notified. When terminating the study, the Sponsor and Investigator will 
assure that adequate consideration is given to the protection of the subjects’ interests.   
9.12 
Study-Related Assessments 
9.12.1 Knee Injury and Osteoarthritis Outcomes Score (KOOS JR.) 
The KOOS JR. score consists of 7 questions from 3 subscales: Stiffness (1 question), 
Pain (4 questions), and Function in daily living (2 questions). Standardized answer 
options are given (5 Likert boxes) and each question is assigned a score from None 
(0) to Extreme (4). A normalized score (100 indicating no symptoms and 0 indicating 
extreme symptoms) is calculated.  A copy of the KOOS JR. is located in Attachment 
1.Completion of the KOOS JR. questionnaire will take approximately 5 minutes to 
complete.  After completion by the Subject, the study coordinator or designee will 
enter into the CRF. 
9.12.2 Numeric Rating Scale for Pain (NRS for Pain) 
The Numeric Rating Scale for Pain (NRS for Pain) is a measure of pain intensity. 
The investigator or designee conducts the 11-point scale verbally with the research 
subject in reference to the target knee.  The investigator or designee will ask the 
following questions,  
•  “On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst 
pain imaginable, how would you rate your pain IN THE PAST 7 DAYS 
when standing from a seated position?” 
• “On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain 
imaginable, how would you rate your pain RIGHT NOW when standing 
from a seated position?”   
The Subject responds verbally and the study coordinator or designee will record the 
response. 
 
The NRS for Pain will be completed by the Subject and will take approximately 2 
minutes to complete.  The study coordinator or designee will enter the data into the 
CRF. 
 
9.12.3 Subject Satisfaction Questions 
Subject satisfaction questions will be verbally administered by the study coordinator 
or designee at Visit 6 and Visit 7.  Questions will take approximately 3 minutes to 
complete.  The Subject satisfaction questions are located in Attachment 2. 
9
4 S
s 
 
 
 
 
 

 
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10. 
STATISTICAL METHODS 
10.1 
Introduction 
This is a prospective, randomized, single-site, post-market trial to evaluate the iovera° device in 
treating pain associated with total knee arthroplasty (TKA).  The study is designed to investigate 
whether iovera° treatment prior to TKA decreases cumulative patient opioid use over the course of 
6 weeks following TKA while maintaining similar levels of pain and functioning as measured by 
reductions from the Baseline visit in the KOOS JR. score.   
 
The study will also investigate whether there is a treatment effect of iovera° on the following 
measures of effectiveness: NRS for Pain, Timed Get Up and Go Test, 
 
  
 
One study site within the United States will screen a sufficient number of subjects to ensure that 
120 subjects (randomized 1:1 to obtain approximately 60 iovera° subjects and 60 Standard of Care 
subjects) will be randomized.   
10.2 
General 
Categorical data will be summarized using frequency tables, presenting subject counts and 
percentages. Continuous variables will be summarized using descriptive statistics (number of 
subjects, mean, standard deviation, median, minimum, and maximum).   
The SAS system will be used to perform all statistical analyses. 
Exact binomial confidence intervals will be generated for proportions.  Confidence intervals based 
on the t-distribution will be generated for means and differences of means.  Fixed sequential testing 
will be performed to control the overall Type I error rate.   
Except where noted otherwise, within-subject change-from-baseline (pre-treatment baseline) 
values for a variable are calculated as: 
 
Change-from-Baseline = Follow-Up value – Pre-Treatment value,  
such that a positive value indicates an increase from the pre-treatment value to the follow-up value, 
whereas a negative value indicates a decrease. 

 
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10.3 
Analysis Populations 
10.3.1 Screening Population 
All subjects who are screened for the study will be included in the Screening Population.  For 
this population, only an accounting of the numbers of subjects screened in the study, plus the 
reasons given for subjects not being enrolled in the study, will be summarized. 
10.3.2 ITT (Intent to Treat) Population 
All subjects who are randomized will be included in the ITT Population.  Subjects will be 
analyzed according to the treatment group to which they were randomized. The primary 
analyses of effectiveness will be conducted based on the ITT Population.  
10.3.3 Per-Protocol Population 
The Per-Protocol Population is defined as the group of subjects who are randomized, who 
receive the treatment to which they were randomly assigned, and who complete their 6-week 
visit without any major protocol deviations.  Subjects will be analyzed according to the 
treatment group to which they were randomized. Secondary analyses of effectiveness will be 
conducted based on the Per-Protocol Population.  
10.3.4 Safety Population 
All subjects who receive study treatment will be included in the Safety Population.  Subjects 
will be analyzed according to the treatment they actually receive, regardless of their randomized 
treatment. All safety analyses will be based on the Safety Population.  
10.4 
Study Endpoints 
10.4.1  Primary Effectiveness Endpoint 
The primary effectiveness endpoint is the cumulative consumption of opioids from the time of 
hospital discharge to 6 weeks post-TKA Surgery.  Opioid consumption will be converted to 
morphine equivalents, and subject consumption will be verified by pill count at follow-up visits.  
The cumulative morphine equivalent will be divided by the number of days to provide the Total 
Daily Morphine Equivalent (TME) for the subject. 
 
The difference in the mean TME between the two treatment groups will be calculated as Standard 
of Care TME mean – Active TME mean, such that a positive difference indicates that the Standard 
of Care Treatment group had a larger mean TME than the Active Treatment group, while a negative 
difference indicates the opposite.  A positive difference between the two treatment groups reflects 
a positive outcome for the study. 
Let µ1,Active and µ1,SOC denote the true mean TMEs for the active and standard of care treatments, 
respectively.  Then the null and alternative hypotheses for the primary effectiveness endpoint are 
as follows: 
H0:   µ1,Active ≥ µ1,SOC  
H1:   µ1,Active < µ1,SOC  

 
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A one-sided, two-independent sample, Satterthwaite t-test will be used to test the null hypothesis. 
The Primary Effectiveness Study Objective will be met if this t-test is statistically significant using 
a one-sided α = 0.025 level of statistical significance. 
This endpoint will be summarized by treatment group using descriptive statistics. The difference in 
mean TMEs between the two treatment groups and a 95% confidence interval based on the t-
distribution for the true difference in the mean TMEs between the two treatments will also be 
provided.  
The database will be “soft-locked” after all 6 week data has been collected (all data monitored 
with the exception of data points collected beyond 6 weeks).  An interim analysis of the primary 
endpoints will be performed on the soft-locked data for internal Myoscience purposes.  The full 
dataset will be locked upon completion of all visit and adverse event follow-ups and this data will 
be reported in the clinical study report. 
 
10.4.2 Secondary Effectiveness Endpoints 
The secondary effectiveness endpoints are as follows: 
 
1. AUC/time (see definition of AUC/time below) based on Changes from Baseline in KOOS 
JR. Scores through 6 weeks post-TKA 
2. AUC/time based on Changes from Baseline through 6 weeks post-TKA in NRS for Pain 
3. AUC/time based on Changes from Baseline through 6 weeks post-TKA in Timed Get Up 
and Go (TUG) test 
Change in KOOS JR. scores from the Baseline visit to each post-baseline visit will be calculated 
for each subject as: 
      Change in KOOS JR. score =  
         Post-Baseline Visit KOOS JR. score – Baseline Visit KOOS JR. score, 
such that a positive value indicates an increase in the KOOS JR. score, while a negative value 
indicates a decrease. The first and key secondary effectiveness endpoint, AUC/time based on 
Changes from Baseline in KOOS JR. scores through 6 weeks post-TKA, is the area under the curve 
(AUC) of Change in KOOS JR. scores from the Baseline visit through the 6-week visit divided by 
the number of days from TKA until the 6-week visit. AUC will be calculated using the trapezoidal 
rule and the changes in the KOOS JR. score at the following time points: Baseline (change=0), 72 
hours, 2 weeks, and 6 weeks post-TKA.  
The difference in mean AUC/time between the two treatment groups will be calculated as the mean 
Active AUC/time – the mean Standard of Care AUC/time, such that a positive difference indicates 
that the Active Treatment group had a larger mean AUC/time based on Change in KOOS JR. score 
than the Standard of Care Treatment group, while a negative value indicates the opposite.  Because 
a positive Change in the KOOS JR. score is indicative of pain relief, a positive difference between 
treatment groups reflects a positive outcome for this endpoint. 
Let µ2,Active and µ2,SOC denote the true mean AUC/time based on the Change from Baseline in KOOS 
JR. score from the Baseline visit through the six-week visit for the active and standard of care 
treatments, respectively.  Then the null and alternative hypotheses for the test for non-inferiority 
for this endpoint are as follows: 

 
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H0:   µ2,SOC - µ2,Active ≥ δ 
H1:   µ2,SOC - µ2,Active < δ,  
where the non-inferiority margin δ=14. 
The null hypothesis will be tested using a two-independent sample t-test. One of the secondary 
objectives of the study is to show that, over the 6-week post-TKA period, the Active Treatment 
group has similar levels of pain and functioning as compared to the Standard of Care Treatment 
group. This objective will be met if the t-test for non-inferiority is statistically significant using a 
one-sided α = 0.025 level of statistical significance. 
The fixed sequential testing procedure will be used for the comparison of the two treatments with 
respect to the first (and key) secondary effectiveness endpoint.  Therefore, for this endpoint, the 
analysis comparing the two treatments will be formally conducted only if the analysis for the 
primary effectiveness endpoint yields a statistically significant result. For informational purposes, 
however, the results of the analysis (i.e., p-value) will be presented regardless of the results for the 
primary effectiveness endpoint. 
Each secondary effectiveness endpoint will be summarized by treatment using descriptive statistics. 
For each treatment, the null hypothesis that the true mean AUC/time equals zero will be tested using 
a paired t-test. Ninety-five percent confidence intervals based on the t-distribution for the true mean 
AUC/time for each treatment and for the true difference in these means between treatments will be 
provided.  In addition, for each secondary effectiveness endpoint, the initial result (e.g., KOOS JR. 
score at 6-weeks post-TKA), as well as the Change from Baseline value, will be summarized at 
each visit at which data for the endpoint are collected using descriptive statistics.   
The database will be “soft-locked” after all 6 week data has been collected (all data monitored 
with the exception of data points collected beyond 6 weeks).  An interim analysis of the 
secondary endpoints will be performed on the soft-locked data for internal Myoscience purposes.  
The full dataset will be locked upon completion of all visit and adverse event follow-ups and this 
data will be reported in the clinical study report. 
 
 
 
 
 
 
 
 
 
 
 
. 
10.4.4 Safety 
Adverse events (AEs) will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA). Treatment-emergent AEs (TEAEs) are adverse events with onset after study treatment 
begins and that are not present at baseline or, if present at baseline, have worsened in severity.  For 
AEs with missing start dates, the AE will be considered treatment-emergent unless there is 
additional information indicating that the AE started prior to study treatment. Only treatment 
emergent AEs will be summarized.  

 
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The number and percentage of subjects with at least one TEAE, at least one device-related TEAE, 
at least one serious TEAE, at least one serious adverse device effect, at least one unanticipated 
serious adverse device effect, at least one anticipated serious adverse device effect, and at least one 
TEAE leading to study withdrawal will be presented by treatment group. AEs that are definitely, 
probably, or possibly related to the device, or for which the relationship to the device is missing, 
will be considered device-related. TEAEs will be summarized at the subject level by MedDRA 
system organ class (SOC) and preferred term using frequencies and percentages. TEAEs will also 
be tabulated at the event level by severity and by relationship to the device for each treatment group.  
10.5 
Handling of Dropouts or Missing Data 
Missing data for the primary effectiveness endpoint and the first secondary effectiveness endpoint 
will be imputed using multiple imputation methods.  First, the relatively uncommon, non-monotone 
missing data will be imputed using the MCMC option of SAS® PROC MI. For example, for the 
primary effectiveness endpoint, the imputation model will include a term for treatment and the pill 
counts at visits 4, 5, and 6. Second, the monotone missing values will be imputed using the chained 
equation method by SAS® PROC MI option MONOTONE REG. For each subject within each 
imputed dataset, the value of the endpoint will then be determined. The imputed data sets will each 
be analyzed as specified in Sections 10.4.1 and 10.4.2, and the results will be summarized using 
PROC MIANALYZE.   
10.6 
Analysis Windows 
All analyses will be based on nominal visits. 
10.7 
Sensitivity Analyses  
Sensitivity analyses may be considered and will be described in the final Statistical Analysis Plan 
for the study.  Nevertheless, the primary results will be used when evaluating overall Study Success. 
10.8 
Sample Size Determination 
The required sample size was determined based on providing at least 80% power for the primary 
effectiveness endpoint using a one-sided, two-independent sample, Satterthwaite t-test to test for 
non-inferiority of iovera treatment to Standard of Care treatment, with a significance level of 0.025, 
assuming a 1:1 allocation to treatment, a true treatment effect (µ1,Active - µ1,SOC) of -12.0 mg, and 
true standard deviations of 16.9 mg and 26.0 mg, for the iovera and Standard of Care treatments, 
respectively. Based on these specifications, the required sample size is 57 subjects per treatment 
group, for a total of 114 subjects. To account for a small number of the subjects withdrawing early 
or not having data available for the analysis of the primary effectiveness endpoint, the required 
sample size was increased to 120 randomized subjects (approximately 60 Active Treatment subjects 
and 60 Standard of Care Treatment subjects).  
 
11. 
ADVERSE EVENTS 
The study Investigator and Coordinator will evaluate, characterize and record in the CRF all adverse 
events (AEs) occurring in all subjects from the initiation of study treatment to study exit (or 
premature withdrawal).  Device or procedure related AEs will be followed until resolution.  AEs 
may be reported spontaneously by the subject or detected by the Investigator or coordinator.  AEs 
should be evaluated for diagnoses not just symptoms (i.e., “angina”, not “chest pain”). 

 
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AEs may be either spontaneously reported or elicited during questioning and examination of a 
subject.  All AEs must be completely recorded within the Subject’s source documentation.  All AEs 
will be evaluated by the Investigator for relationship to the iovera° device and to the treatment. 
In addition to verbatim terms, the Sponsor will categorize all AEs using MedDRA preferred terms 
and system organ classes (SOC).  Analysis will report both verbatim and MedDRA terms. 
Adverse events1 (AEs) will be assessed continuously from the initiation of study treatment 
through study exit. Per ISO14155:2011, an AE is any untoward medical occurrence, 
unintended disease or injury, or untoward clinical signs in subjects, users or other persons, 
whether or not related to the investigational medical device.  An AE can arise from any use 
of the device (e.g., off-label use, use in combination with any drug) and from any route of 
administration. 
Timely and complete reporting of all AEs assists the Sponsor in identifying any untoward 
medical occurrence, thereby allowing:  
1) 
protection of the safety of study subjects;  
2) 
a greater understanding of the overall safety profile of the device;  
3) 
recognition of device-related ill effects; 
4) 
appropriate modification of study protocols;  
5) 
improvements in study design or procedures; and  
6) 
adherence to worldwide regulatory requirements.   
11.1 
 
Adverse Device Effect (ADE) 
Per ISO14155, an adverse device effect is an adverse event related to the use of an 
investigational medical device. Adverse events related to the use of iovera° include 
events resulting from insufficient or inadequate instructions for use, deployment, 
operation or any malfunction of the device.  User error or intentional misuse of the 
device is also defined as an ADE. 
 
ADEs may be either spontaneously reported or elicited during questioning and 
examination of a subject.  All ADEs must be completely recorded within the 
subject’s source documentation and reported to the Sponsor within 48 hours of 
Investigator becoming aware of the ADE. 
11.2 
Serious Adverse Event (SAE)/ Serious Adverse Device Effect (SADE)/Anticipated 
Serious Device Effect (ASADE)/ Unanticipated Serious Adverse Device Effect (USADE) 
Per ISO14155, an international clinical trial standard, an SAE is an AE that: 
1. Led to a death, 
2. Led to a serious deterioration in the health of the subject that 
a. Resulted in a life-threatening illness or injury, 
b. Resulted in a permanent impairment of a body structure or a body 
function, 
c. Required in-patient hospitalization or prolongation of existing 
hospitalization, 
d. Resulted in medical or surgical intervention to prevent permanent 
impairment to body structure or a body function. 
                                                 
1 Definition from ISO14155:2011 

 
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3. Led to fetal distress, fetal death or a congenital abnormality or birth defect 
An event that is serious must be recorded on the AE worksheet and requires 
expeditious handling to comply with regulatory requirements. 
Events NOT considered to be serious adverse events are: 
• Hospitalizations for the treatment, which was elective or pre-planned, of a pre-
existing condition that did not worsen, and 
• Treatment on an emergency, outpatient basis for an event not fulfilling any of 
the definitions of “serious” given above and not resulting in hospital admission. 
A serious adverse device effect (SADE) is an adverse device effect that has resulted 
in any of the consequences characteristic of an SAE per the ISO definition.  
An SADE which by its nature, incidence, severity or outcome has not been identified 
in the current version of the risk analysis report is defined by ISO as an unanticipated 
serious adverse device effect (USADE). Accordingly, an SADE which by its nature, 
incidence, or severity has been previously been identified in the current version of 
the risk analysis report is considered an anticipated serious adverse device effect 
(ASADE). 
Any adverse events classified as “serious” by the Investigator or the Sponsor require 
expeditious handling and reporting to the Sponsor.  All SAEs, whether or not the 
event was related to the study device or anticipated, must be immediately (within 24 
hours of becoming aware of the SAE) reported to the sponsor by telephone, email, 
or confirmed facsimile transmission: 
Kent Jones, and/or Study Manager  
Myoscience, Inc. 
(office) 
(fax) 
kjones@Myoscience.com 
11.3 
AE Severity and Relatedness 
Each AE occurring in the study will be characterized by the study Investigator as to severity 
(Table 3) and relatedness (Table 4). 
Table 3.  AE Severity Grading System. 
Severity Grade 
AE Description 
Mild 
AE is transient and easily tolerated by the subject, even if it causes discomfort 
Moderate 
AE causes the discomfort and interrupts usual activities 
Severe 
AE causes considerable interference with usual activities and may be incapacitating or 
life-threatening 
 
Table 4. AE Relatedness Grading System.* 
Grade 
Relationship of AE to 
study device or 
procedure 
Description 
5 
Definite 
An event that follows a reasonable temporal sequence from administration 
of the study device; that follows a known or expected response pattern to 
the study device; and that is confirmed by improvement on stopping. 

 
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4 
Probable 
An event that follows a reasonable temporal sequence from administration 
of the study device; that follows a known or expected response pattern to 
the study device; and that is unlikely to have been caused by 
concurrent/underlying illness or other drugs, procedures, or other causes. 
3 
Possible 
An event that follows a reasonable temporal sequence from administration 
of the study device; that follows a known or expected response pattern to 
the study device; but may have been caused by concurrent/underlying 
illness, drugs, procedure, or other causes. 
2 
Unlikely 
An event that does not follow a reasonable temporal sequence from 
administration of the study device; that does not follow a known or 
expected response pattern to the study device, or most likely was caused by 
concurrent/underlying illness, drugs, procedure, or other causes, because of 
their known effects. 
1 
Not related 
An event almost certainly caused by concurrent/underlying illness, drugs, 
procedure, or other causes. 
*Note that change in medical condition occurring between Screening and the initiation of Study Treatment will be reported as a 
change in Medical History. 
 
12. 
DEVICE TRACKING 
The Sponsor will send the investigational devices to study sites. The Investigator must house study 
devices in a secure location.  The Investigator must carefully and completely track receipt, use and 
disposition of all investigational devices. The Sponsor will track sending and receiving of devices.  
The Sponsor will monitor site device accountability periodically. 
If a Sponsor representative or designee is present at the time of use, he/she may directly take 
possession of used device(s). All devices will be returned to the Sponsor after the study is complete.  
13. 
DEVICE DEFICIENCIES AND MALFUNCTIONS 
Throughout the study, the Investigator and study staff will report and document all device 
deficiencies and malfunctions related to the identity, quality, durability, reliability, safety or 
performance of the device.  This includes reporting of device deficiencies/malfunctions that did not 
lead to an AE but could have if: 1) suitable action had not been taken, 2) intervention had not been 
made, or 3) circumstances had been less fortunate.  If possible, the Investigator should return 
devices suspected of deficiency or malfunction to the Sponsor for analysis. 
14. 
ETHICAL AND REGULATORY CONSIDERATIONS 
14.1 
Compliance with Good Clinical Research Practice 
This study will be conducted in compliance with the principles of the Declaration of 
Helsinki, with the current Good Clinical Practice (GCP) guidelines and with other 
applicable regulations. The Investigator and all study staff will conduct the study in 
compliance with this protocol. Voluntary informed consent will be given by every subject 
prior to the initiation of any study-related procedures. The rights, safety and well-being of 
the study subjects are the most important considerations and prevail over the interests of 
science and society. All personnel involved in the conduct of this study must be qualified 
by education, training and experience to perform their assigned responsibilities. 
14.2 
Institutional Review Board (IRB) and Informed Consent 
Before study initiation, the Investigator must have written and dated approval from the IRB 
for the protocol, consent form, subject recruitment materials/process (e.g., advertisements), 
and any other written information to be provided to subjects. The Investigator should also 

 
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provide the IRB with a copy of the product labeling, information to be provided to subjects 
and any updates. The Investigator will submit documentation of the IRB approval to the 
Sponsor. Copies of all correspondence with the IRB regarding this study must be sent to the 
Sponsor. 
The IRB-approved consent form must include all elements required by FDA, state, and local 
regulations, and may include appropriate additional elements. 
The Investigator/designee will explain the study to each potential subject and the subject 
must indicate voluntary consent by signing and dating the approved informed consent form. 
The Investigator must provide the subject with a copy of the consent form in a language the 
subject understands. The Investigator will maintain documentation that informed consent 
was obtained prior to the initiation of any study-specific procedures. 
Withdrawal of IRB approval of the Investigator’s part in the investigation must be reported 
to the Sponsor within 5 working days. 
14.3 
Protocol Compliance 
The Investigator will comply to the extent possible with the IRB-approved protocol.  All 
deviations from the protocol must be documented.  The Investigator will notify the Sponsor 
immediately if a deviation from the protocol was required to protect patient safety.  
14.4 
Protocol Revisions 
Revisions to the study protocol can be made only by the study Sponsor. A revised protocol 
can be put into place only after governing IRB approval.  All administrative letters must be 
submitted to the IRB for their information.  
New or altered consent forms required by the IRB due to a protocol change must be signed 
by all subjects currently enrolled in the study and must be used for any subsequent subject 
enrollment. 
14.5 
Study Monitoring 
Representatives of the Sponsor will visit all study sites intermittently to review study records 
and to directly compare them with source documents (including, but not limited to patient 
and hospital records), to discuss the study conduct with the Investigator and study staff and 
to verify that the Investigator, study staff and facilities remain acceptable for the conduct of 
the study. 
Representatives of government regulatory authorities may also evaluate the study records, 
source documents, Investigator, study staff and facilities. 
The Investigator should immediately notify the Sponsor of any audits of this study by any 
regulatory agency, and must promptly provide copies of any audit reports. 
14.6 
Safety Reporting 
The Sponsor is responsible for performing ongoing safety evaluation in this study protocol.  
Sponsor activities regarding safety include: 
• classification of all AEs, 
• review of all AEs reported in the study, 

 
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• confirm site’s classification of AEs in terms of severity and relatedness to the study 
device and/or study procedure, 
• review of severity and relatedness with the study Investigator, especially when there is 
disagreement between the Investigator and the Sponsor, 
• review of device deficiencies and malfunctions, including determination and 
documentation of whether deficiencies/malfunctions could have led to an AE or SAE, 
• ensuring the reporting of all SAEs and device deficiencies/malfunctions that could 
have led to an AE or SAE to the IRB and, if required, regulatory authorities in a timely 
fashion, 
• informing all site Investigators in writing of all SAEs at all sites in a timely fashion 
and 
• updating the risk analysis and assessment of corrective or preventive actions 
potentially required as a result of new information obtained in the investigation 
 
The Sponsor will evaluate all serious adverse events against US reporting requirements 
(Medical Device Reporting, 21 CFR 812) and Medical Device Directive (vigilance incident 
reporting) as per its standard operating procedures.  The Sponsor will investigate each SAE 
to determine whether the event represents an unanticipated serious adverse device effect 
(USADE, see Section 12.1.2).  The Sponsor will report any event to regulatory authorities, 
Investigators and reviewing IRBs/ECs as necessary. If an investigation shows that a USADE 
presents an unreasonable risk to subjects, the Sponsor will terminate all investigations or 
parts of investigations presenting that risk as soon as possible. The Sponsor will only resume 
a terminated investigation after corrective actions have taken place, site Investigators are 
informed and IRBs/ECs have been notified and given approval to resume the study. 
14.7 
Case Report Forms 
Case Report Forms (CRFs) will be provided in order to collect required data points. Data 
will be routinely monitored and collected by the sponsor, or designee, to identify 
inconsistent or missing data and to ensure compliance with the study protocol.  
An CRF is required and should be completed for each randomized Subject. The Investigator 
has ultimate responsibility for the collection and reporting of all data entered on the CRFs 
and any other data collection forms (source documents) and ensuring that they are accurate, 
authentic/original, attributable, complete, consistent, legible, timely (contemporaneous), 
enduring and available when required. The CRFs must be signed by the Investigator to attest 
that the data contained therein are true. Investigators will be responsible for the accurate and 
timely completion of CRFs during the trial. 
14.8 
Quality Assurance Audits 
Sponsor representatives or designees may conduct site quality assurance (QA) audits during 
the study.  The Investigator must agree to provide the auditor with direct access to all 
relevant documents and discuss any findings with the auditor. 
In the event of an inspection by the FDA or other regulatory authorities, the Investigator 
must give the inspector direct access to relevant documents and to discuss any findings with 
the inspector. The Investigator must notify Myoscience, Inc. in the event of a FDA site audit. 

 
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14.9 
Confidentiality 
The Investigator is responsible for ensuring the confidentiality of subjects throughout the 
trial.  A unique identification code will be assigned to each Subject participating in this 
trial.  Any data that may be published in abstracts, scientific journals, or presented at 
medical meetings will reference a unique subject code and will not reveal the subject’s 
identity.  
 
14.10 Records Retention 
The Investigator must maintain all study records (including device disposition, informed 
consents, source documents, correspondence, regulatory documents, contracts etc.) for at 
least 2 years after study completion.  At the Investigator’s discretion, all records may be 
sent to the Sponsor for permanent storage. 
The Investigator must contact the Sponsor or designee prior to destroying any records 
associated with this study.  If the Investigator withdraws from the study, all study-associated 
records must be transferred to a mutually agreed upon designee. Written notification of such 
a transfer must be given to the Sponsor or designee. 
14.11 Publication and Reporting of Study Results 
The study will be registered with clinicaltrials.gov before the first patient is treated.  Study 
results will be documented in a study report that will be signed by Myoscience 
representatives and by the Principal Investigator of the entire Study. Individual site Principal 
Investigators will not be required to sign this report. 
The results of this Myoscience sponsored study will be published in accordance with 
standard editorial and ethical practices. Results from multi-center studies must be published 
or presented at congresses only in their entirety with data pooled from all centers. Individual 
Investigators may not publish data from individual centers, unless granted specific written 
permission by Myoscience to do so. 
The list of authors of any formal publication or presentation of study results may include, 
as appropriate, representatives of Myoscience. 
15. 
SELECTED REFERENCES 

 
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