A Prospective, Randomized, Controlled Trial Comparing Cytal Wound Matrix 1-Layer to Standard of Care (SOC) in the Management of Diabetic Foot Ulcers (DFUs)
Phase: NA
Conditions: Diabetes, Diabetic Foot, Diabetes Mellitus, Type 2, Diabetes Mellitus, Type 1
Sponsor: Integra LifeSciences Corporation

 
 
A Prospective, Randomized, Controlled Trial Comparing Cytal® Wound Matrix 1-
Layer to Standard of Care (SOC) in the management of Diabetic Foot Ulcers 
(DFUs) 
 
 
Unique Protocol ID: CR2017-006 
 
NCT03626623 
 
 
 
Version 3.0 
27 August 2019 

ACell Confidential 
 
Page 1 of 59 
 
 
 
 
 
A Prospective, Randomized, Controlled Trial Comparing Cytal® Wound Matrix 1-
Layer to Standard of Care (SOC) in the management of Diabetic Foot Ulcers 
(DFUs) 
 
 
CR2017-006   
 
 
 
ACell, Inc. 
6640 Eli Whitney Drive 
Columbia, MD  21046 
 
 
 
 
 
Version 3.0 
27 August 2019 
 
 
 
 
 
 

ACell Confidential 
 
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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS ....................................................................................................................................... 5 
PROTOCOL SUMMARY ........................................................................................................................................... 6 
1 
KEY ROLES .................................................................................................................................................. 14 
2  
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ...................... 15 
2.1 
Background Information and rationale ............................................................................. 15 
2.2 
Potential Risks and Benefits .............................................................................................. 16 
2.2.1 
Potential Risks ............................................................................................... 16 
2.2.2 
Potential Benefits ........................................................................................... 16 
3 
OBJECTIVES ................................................................................................................................................ 17 
4 
STUDY DESIGN AND ENDPOINTS ......................................................................................................... 17 
4.1 
Description of the Study Design ....................................................................................... 17 
4.2.1 
Primary Endpoint ........................................................................................... 18 
4.2.2 
Secondary Endpoints .................................................................................... 18 
4.2.3 
Health Economic Outcomes ......................................................................... 18 
5 
STUDY ENROLLMENT AND WITHDRAWAL ......................................................................................... 19 
5.1 
Participant Inclusion Criteria .............................................................................................. 19 
5.2 
Participant Exclusion Criteria ............................................................................................ 19 
5.3 
Strategies for Recruitment and Retention ....................................................................... 20 
5.4 
Participant Withdrawal or termination .............................................................................. 21 
5.4.1 
Reasons for Withdrawal or Termination ..................................................... 21 
5.4.2 
Handling of Participant Withdrawals or termination ................................. 21 
5.5 
Premature Termination or Suspension of Study ............................................................ 22 
6 
STUDY Device .............................................................................................................................................. 22 
6.1 
Study Device Description ................................................................................................... 22 
6.1.1 
Device Description......................................................................................... 22 
6.1.2 
Device Configuration ..................................................................................... 23 
6.1.3 
Product Storage and accountability ............................................................ 23 
6.1.4 
Return or Destruction of Study Device ....................................................... 23 
7 
STUDY PROCEDURES AND SCHEDULE .............................................................................................. 24 
7.1 
Study Schedule ................................................................................................................... 24 
7.1.1 
Run-In Period (2 Weeks) (Day -14 and -7) ................................................... 24 
7.1.2 
Baseline/Randomization (Study Visit 1) ...................................................... 25 
7.1.3  
Study Visits (2-13 and confirmation visits) ................................................. 28 
7.1.4 
Final Study Visits (WEEK 26 AND 52 ±2 WEEKS) ...................................... 31 
7.1.5 
Unscheduled Visit .......................................................................................... 32 
7.1.6 
Missed Visit .................................................................................................... 33 
7.1.7 
Description of systems/outcome measurements ...................................... 33 
7.2 
Concomitant Medications .................................................................................................. 35 
8 
ASSESSMENT OF SAFETY ...................................................................................................................... 35 
8.1 
Specification of Safety Parameters .................................................................................. 35 
8.1.1 
Definition of Adverse Events (AE) ............................................................... 35 
8.1.2 
Definition of Serious Adverse Events (SAE) .............................................. 36 

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8.1.3 
Definition of Unanticipated Adverse Device Effect (UADE) ..................... 36 
8.2 
Classification of an Adverse Event ................................................................................... 37 
8.2.1 
Severity of Event ............................................................................................ 37 
8.2.2 
Relationship to Study Agent ........................................................................ 37 
8.2.3 
Expectedness ................................................................................................. 38 
8.3 
Time Period and Frequency for Event Assessment and Follow-Up ........................... 38 
8.4 
Reporting Procedures ........................................................................................................ 38 
8.4.1 
Adverse Event Reporting .............................................................................. 39 
8.4.2 
Serious Adverse Event (SAE) Reporting .................................................... 39 
8.4.3 
Unanticipated Adverse Device Effect (UADE) Reporting.......................... 39 
8.4.4 
Reporting of Pregnancy ................................................................................ 39 
9 
CLINICAL MONITORING ............................................................................................................................ 40 
10 
STATISTICAL CONSIDERATIONS .......................................................................................................... 40 
10.1 
Statistical and Analytical Plans ......................................................................................... 40 
10.2 
Statistical Hypotheses ........................................................................................................ 41 
10.3 
Analysis Datasets................................................................................................................ 43 
10.4 
Description of Statistical Methods .................................................................................... 43 
10.4.1 
 General Approach ......................................................................................... 43 
10.4.2 
 Analysis of the Primary Efficacy Endpoint(s) ........................................... 44 
10.4.3  
Analysis of the Secondary AND TERTIARY Endpoint(s) .......................... 44 
10.4.4 
 Safety Analyses ............................................................................................ 46 
10.4.5  
Adherence and Retention Analyses ............................................................ 48 
10.4.6 
Baseline Descriptive Statistics .................................................................... 48 
10.4.7 
 Planned Interim Analyses ............................................................................ 48 
10.4.9 
Multiple Comparison/Multiplicity ................................................................. 49 
10.4.10 
Tabulation of Individual Response Data ..................................................... 49 
10.4.11 
Exploratory Analyses .................................................................................... 49 
10.5 
Sample Size ......................................................................................................................... 49 
10.6 
Measures to Minimize Bias ................................................................................................ 50 
10.6.1 
Randomization ............................................................................................... 50 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS ................................... 50 
12 
QUALITY ASSURANCE AND QUALITY CONTROL .............................................................................. 51 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS ................................................................................... 51 
13.1 
Ethical Standard .................................................................................................................. 51 
13.2   Laws and Regulations............................................................................................................... 52 
13.3 
Institutional Review Board ................................................................................................. 52 
13.4 
Informed Consent Process ................................................................................................ 52 
13.5 
Participant and data Confidentiality .................................................................................. 53 
14 
DATA HANDLING AND RECORD KEEPING .......................................................................................... 53 
14.1 
Study Records Retention ................................................................................................... 53 
14.2 
Protocol Deviations ............................................................................................................. 53 
14.3 
Publication and Data Sharing Policy ................................................................................ 54 
15 
CONFLICT OF INTEREST POLICY .......................................................................................................... 54 

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16  
LITERATURE REFERENCES.................................................................................................................... 55 
APPENDIX I: SCHEDULE OF EVENTS ............................................................................................................... 57 
APPENDIX II: STATEMENT OF COMPLIANCE ................................................................................................. 58 
APPENDIX III: OPTIMA DIAB BOOTS USER’S GUIDE .................................................................................... 59 
 

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LIST OF ABBREVIATIONS 
 
ABI 
Ankle Brachial Index 
AE 
Adverse Event 
Alb 
Albumin 
BMI 
Body Mass Index 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CMP 
Complete Metabolic Panel 
CMS 
Centers for Medicare and Medicaid Services 
CRF 
Case Report Form 
DFU 
Diabetic Foot Ulcer 
DFS-SF 
Diabetic Foot Ulcer Scale- Short Form 
DM 
Diabetes Mellitus 
eCRF 
Electronic Case Report Form  
GCP 
Good Clinical Practice 
HbA1C 
Glycated Hemoglobin Level 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
KATZ ADL 
Katz Index of Independence in Activities of Daily Living 
PAB 
Pre-albumin 
PAD 
Peripheral Artery Disease 
QC 
Quality Control 
SAE 
Serious Adverse Event  
SAP 
Statistical Analysis Plan 
SAS 
Statistical Analysis System 
SF 
Short Form  
SF-20 
The SF-20® Health Survey 
SID 
Subject Identification Number  
SOC 
Standard of Care 
UADE 
Unanticipated Adverse Device Effect 
VAS/VPS 
Visual Analogue Scale or Visual Pain Scale 
Intervention and treatment are used interchangeably for the purpose of this protocol.  
Wound and ulcer are also used interchangeably for the purpose of this protocol.    
 
 
 

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PROTOCOL SUMMARY 
Title: 
A prospective, randomized, controlled trial comparing Cytal® 
Wound Matrix 1-Layer to Standard of Care (SOC) in the 
management of Diabetic Foot Ulcers (DFUs) 
Protocol 
Number: 
CR2017-006   
 
Study Design: 
Multi-site, prospective, randomized study comparing Cytal® Wound 
Matrix 1-Layer (Group 1) to Standard of Care (Group 2) in the 
management of diabetic foot ulcers.   
 
Subjects who meet the inclusion and exclusion criteria for the study 
will be randomized (2:1) to Group 1 or Group 2 using a permuted 
block randomization scheme.   
 
Study DFUs will be treated up to 10 times in a 12 week period and 
must be located on a single foot.     
 
Study 
Objectives: 
 
Primary Objective 
1. To compare the incidence of complete wound closure (defined 
as 100% epithelialization) by 12 weeks between randomized 
groups. 
Secondary Objective(s) 
1. To compare the rate of wound healing over time in cm2/week 
between randomized groups. 
2. To compare the time to complete wound closure between 
randomized groups. 
3. To compare DFU recurrence after healing between randomized 
groups. 
4. To compare subject reported outcomes between randomized 
groups. 
5. To compare the intervention-emergent adverse event (AE) 
safety profile between randomized groups. 
Health Economic Objectives 
1. Perform a health economics and cost effectiveness analysis 
between randomized groups. 
 

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Endpoints: 
Primary Endpoint 
1. Measure incidence of complete wound closure (defined as 
100% epithelialization) by 12 weeks between randomized 
groups. 
Secondary Endpoint(s) 
1. Measure changes in wound size, measured in cm2 per week 
between randomized groups by 12 weeks. 
2. Measure time to complete wound closure, in days, between 
randomized groups by 12 weeks. 
3. Measure wound recurrence after healing is complete at 26 
weeks and 52 weeks (6 & 12 months post intervention initiation) 
between randomized groups.    
4. Changes in subject reported outcomes including quality of life 
and pain (quality of life surveys & visual analogue scale), pre- 
intervention to post-intervention between randomized groups 
over time and by 12 weeks. 
5. Measure frequency of adverse events related to DFU including 
unexpected adverse device events or serious adverse 
experiences throughout the duration of the study and evaluate 
between randomized groups. 
Health Economic Outcomes 
1. Any changes from baseline in the prescription of narcotics 
related to the DFU(s) by subject and between randomized 
groups. 
2. Any changes in ambulatory status (i.e. bed, wheel chair, walk w/ 
assistance, or walk independent) by subject and between 
randomized groups. 
3. Any changes in “return to work/reported work status”, activities 
of daily living, or disability status by subject and between 
randomized groups. 
4. Health economics analysis, as measured by direct costs as 
measured by total cost per subject stratified by healed vs. non 
healed DFU. 
 
Population: 
A maximum of 150 subjects who present to the participating 
Investigator(s) in the in-patient or out-patient facility with at least a 
single diabetic foot ulcer that is characterized as Wagner Grade 1 
or Grade 2 will be enrolled and randomized.  An interim 
assessment will be performed after 60 subjects complete the 12 

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week intervention and evaluation period or withdraw prematurely.  
The conditional power will be estimated by an independent 
biostatistician at the interim assessment to ensure the observed 
incidence of response is commensurate with the planning 
estimates.  The biostatistician may recommend that enrollment be 
increased from the target population of 120 subjects (80 subjects in 
Group 1 vs. 40 subjects in Group 2) to a maximum of 150 subjects 
(100 subjects in Group 1 vs. 50 subjects in Group 2).  Given the 
primary 
endpoint 
is 
dichotomous, 
subjects 
who 
withdraw 
prematurely (<12 weeks) from their randomized intervention 
assignment without complete wound closure will be considered in 
the analysis as not having met the definition for closure. 
 
Study Criteria: 
Inclusion Criteria:   
1. Provision of signed and dated informed consent form by 
subject or legally authorized representative.  
2. Stated willingness to comply with all study procedures and 
availability for the duration of the study. Subject is able and 
willing to tolerate non-removable offloading device for the 
duration of the run-in and intervention phases of the study. 
3. Subject is male or female and ≥22 years of age. 
4. Subject has a clinical diagnosis of type 1 or type 2 diabetes. 
5. Subject’s current foot ulcer(s) has been present for ≥ 30 days 
and ≤ 365 days.  
6. Subject’s current foot ulcer(s), post-debridement is/are 
predominantly below the malleoli and on the plantar surface of 
the foot. 
7. Subject’s foot ulcer(s) must be Wagner Grade 1 or  2.  
8. Post debridement, subject’s ulcer(s) are free of necrotic debris 
and appear to be comprised of healthy, vascularized tissue. 
9. All qualifying ulcers are ≥ 5cm away from any other ulcer on 
the same foot. 
10. Subject’s ulcer(s) surface area is ≥ 1cm2 and ≤ 20cm2 at 
randomization. 
11. Subject’s HbA1C reading is ≤10%. 
12. Subject’s Serum Creatinine ≤ 3.0mg/dL.  
13. Subject has adequate circulation to the foot as measured by 
Ankle-Brachial Index (ABI) ≥ 0.7 
14. Negative pregnancy test at randomization for women of 

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childbearing potential. 
Exclusion Criteria:  
1. Subject is pregnant, breastfeeding, or unwilling to practice 
birth control during participation in the study, if applicable. 
2. Allergy or hypersensitivity to materials in porcine-based study 
products (per subject report) or personal preference. 
3. Subject report of concurrent participation in another clinical 
trial that involves a drug or device.  
4. The subject has any condition that, in the Investigator’s 
opinion, would warrant exclusion from the study or prevent the 
subject from completing the study. 
5. Subject has clinical evidence of gangrene on any part of the 
affected foot. 
6. The subject’s ulcer(s) is/are definitively due to a non-diabetic 
etiology, ulcers of arterial, venous stasis, pressure, radiation, 
traumatic, rheumatoid, vasculitis, collagen vascular disease, 
or other non-diabetic etiologies in the opinion of the 
Investigator.   
7. Subject has unstable Charcot foot, Charcot foot with a bony 
prominence(s) or Charcot amputation.    
8. Qualifying wound(s) is connected to another ulcer via a fistula.  
9. Subject has one or more medical condition(s) including renal, 
hepatic, hematological, neurologic, or immune disease that in 
the opinion of the Investigator would make the subject an 
inappropriate candidate for this wound healing study. 
10. Subject has or has had a malignant disease (other than basal 
cell carcinoma) that has not been in remission for at least five 
years. 
11. Subject is receiving oral or parenteral corticosteroids, 
immunosuppressive or cytotoxic agents, or is anticipated to 
require such during the course of the study. 
12. Subject has acute osteomyelitis of the affected foot. 
13. Subject’s ulcer(s) is accompanied by active cellulitis. 
14. Subject has received growth factor or enzymatic therapy in 
the area of the wound, within 2 weeks of consent.  
15. Subject has ever received radiation or radiologic implants in 
the area of the wound OR chemotherapy within the past 5 
years. 
16. Subject is allergic to any of the primary or secondary dressing 

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materials, including occlusive dressings and the adhesives on 
such dressings. 
17. Subject’s ulcer(s) surface area has decreased in size by > 
30% during the run-in phase. 
18. Subject’s ulcer(s) surface area has increased in size by > 
50% during the run-in phase. 
19. Subject’s ulcer(s) has tunnels or sinus tracts that cannot be 
completely debrided. 
20. Subject has severe malnutrition as evidenced by albumin <2.0 
g/dL. 
21. Subject has a bleeding disorder that would make the subject 
unsuitable for serial bedside sharps or chemical cautery 
debridement.   
22. Subject is on dialysis. 
23. Any DFU(s) is actively infected and has not been treated for 
any clinically suspected infection prior to application of any 
product. 
 
Number of Sites 
enrolling 
participants: 
3-6  
 
ACell Study 
Products: 
 
1. Cytal® Wound Matrix 1-Layer   
 
Participant & 
Study Duration: 
The maximum number of subjects expected to be enrolled and 
randomized in this trial is 150; the target sample size to detect a 
25% difference between the 2 randomized intervention groups is 
120 subjects.  Subjects will undergo a 2 week run-in phase and a 
12 week intervention phase. For wounds that are treated during the 
intervention phase and subsequently heal, subjects will be followed 
for 3 weeks to confirm complete epithelization. For healed wounds, 
additional study visits will be conducted at 6 and 12 months from 
intervention initiation to evaluate the state of healing or the 
reoccurrence of the DFU(s). The duration of participation for each 
subject will be up to a maximum of 54 weeks. 
 
Eligible subjects will be recruited and enrolled, under the 
responsibility of the participating Investigators. The actual overall 
study duration or subject recruitment period may vary. 
 

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Statistical 
Methodology: 
Baseline is defined as the observations recorded immediately prior 
to the application of study intervention.  Continuous demographic 
parameters, such as the subject’s age at the time of enrollment, will 
be summarized for the ITT population using descriptive statistics 
(N, mean, median, standard deviation, minimum and maximum 
value, and 95% two-sided confidence limits) and compared 
between 
groups 
using 
a 
two-sample 
t-test. 
Categorical 
demographic parameters, such as gender, will be summarized as a 
proportion of the ITT population and compared using a two-tailed 
Fisher’s Exact test.  Co-morbid risk factors will be summarized for 
the ITT population by intervention assignment and according to the 
type of variable (categorical, continuous) and compared between 
groups.  Kaplan-Meier estimates for time-to-event analyses will be 
prepared based on the ITT population.  Separate tables containing 
subject counts, percentages, and 95% binomial confidence limits 
will be prepared based on individual risk factors.   
 
The primary efficacy analysis population will be subjects in the ITT 
population who have any wound measurement data following 
randomization. For data analyses, complete wound closure 
requires confirmation at 3 weeks (≥21 days) post clinically apparent 
wound closure.  
 
The primary efficacy analysis will compare the proportion of 
subjects who achieve complete target ulcer closure within 12 
weeks after the first study intervention using a random-effects 
generalized linear model specifying the distribution of the 
dependent variable as binomial.  Statistical significance will be 
declared if the two-sided probability value is <0.05; tests for 
interaction will be performed at the 0.1 alpha level.  Asymptotic 
confidence limits will be presented based on the normal 
approximation to the binomial distribution for differences in 
proportions.  Exact confidence intervals will be used for all other 
presentations.  
 
For the secondary efficacy endpoints, the change in the wound 
size, measured in cm2, will be calculated on an intra-subject basis 
for each post-baseline measurement.  The mean change per week 

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will be calculated for each subject and compared between the 
intervention and standard of care groups using a random-effects 
generalized linear model specifying the distribution of the 
dependent variable as continuous.  The time to complete wound 
closure will be calculated in days from the date of the initial study 
intervention and compared between the intervention and standard 
of care groups using a log-rank test.  Subjects who fail to achieve 
complete wound closure will be censored using the last date of 
examination in the study.  Wound recurrence after healing is 
complete at 26 weeks and 52 weeks will be tabulated by 
intervention group and the proportions will be compared between 
intervention and standard of care groups using a 2-tailed Fisher’s 
Exact test.  Changes in subject reported outcomes will be 
summarized and compared between the intervention and standard 
of care groups based on the distribution of the data.  A random-
effects generalized linear model, specifying the distribution of the 
dependent variable based on the type of data, will be used to 
compare the results over time between the intervention and 
standard of care groups.    All computations will be performed using 
SAS® (Version 9.4 or higher).   
 
Adverse events will be coded according to the MedDRA system 
dictionary. The percentage of subjects experiencing adverse events 
will be summarized by body system and preferred term.  Subject 
counts will be tabulated for all adverse events for the ITT 
population.  Adverse events will also be tabulated for events that 
occurred following initial treatment application through final study 
visit.  The incidence of subjects with 1 or more adverse events, and 
restricted to serious adverse events, will be summarized using 
counts and percentages.  The incidence will be compared using a 
generalized linear model specifying the distribution as binomial. 
The maximum number of subjects to be enrolled into this clinical 
investigation is 150 subjects; the target sample size is 120 subjects 
with a 2:1 randomization ratio to detect a difference in the 
proportion of responders of 25% with a power approaching 80% 
(assumes an asymptotic normal distribution and a normal 
approximation).  A sample size re-estimation will be performed 
when 60 of the subjects have completed the 12 week intervention 
and evaluation period or withdrawn prematurely to establish the 

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primary endpoint results (confirmed complete wound closure or no 
confirmed wound closure). 
 
 
 
 
 

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1 
KEY ROLES 
Elizabeth A. Smith  
Senior Director of Clinical Research 
ACell Inc.  
(443) 283–2768  
elizabethsmith@acell.com 
 
Tejal Gambhir 
Clinical Research Manager 
ACell, Inc.  
(443) 283-7961 
tejalgambhir@acell.com 
 
Becky Seufert 
Clinical Research Project Manager 
ACell, Inc. 
410-953-8549 
rebeccaseufert@acell.com 
 
Mike Anibaba 
Clinical Research Associate 
ACell, Inc.  
(443) 283-2798 
mikeanibaba@acell.com 
 
Elizabeth Okeke 
Clinical Research Assistant 
ACell, Inc.  
(443) 283-7960 
elizabethokeke@acell.com 
 
Cindy Mattingly 
Clinical Data Manager 
ACell Inc. 
(410) 953-8539 
cindymattingly@acell.com 
 
Bruce C. Stouch, Ph.D. 
Biostatistician 
(610) 787-0742 
BCSSTATS@aol.com 
 
 
 
 

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2  
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE  
2.1 
BACKGROUND INFORMATION AND RATIONALE 
Diabetes mellitus (DM) is a chronic disease that causes elevated glucose levels in the 
blood and, if left untreated, can lead to a number of short and long-term health 
complications. In 2015, the American Diabetes Association estimated 30.3 million 
Americans, or 9.4% of the population, are affected by this disease, with the incidence 
expected to dramatically increase over the next 25 years[1,11]. There has been much 
success in treating diabetes, which has led to improvements in the life expectancy of 
those affected by the disease[3]. However, the increased prevalence coupled with the 
extended amount of time people live with the disease has led to an increase in the 
number of diabetes-related complications[3]. These subjects are at risk for a number of 
health problems, with diabetic foot ulcers (DFUs) being one of the most common and 
serious complications, affecting roughly 15-25% of diabetes subjects in their 
lifetime[4,5,12]. 
Diabetic foot ulcerations present as an open wound or sore and are commonly located 
on the bottom of the foot or lower extremities of people with diabetes. The most 
common contributing factors leading to the development of DFUs are ischemic, 
neuropathic, or combined neuroishcemic abnormalities, peripheral artery disease (PAD), 
foot deformity, and minor trauma [3,5,12]. However, when the ulcer appears, the 
progression is often exacerbated by other risk factors and comorbidities such as gender, 
duration of diabetes longer than 10 years, advanced age of subjects, high Body Mass 
Index (BMI), retinopathy, diabetic peripheral neuropathy, glycated hemoglobin level 
(HbA1C), high plantar pressure, infections, and inappropriate foot self-care habits[12]. 
Regardless of etiology, DFUs require clinical treatment to prevent further progression of 
the ulcer and other sequelae that have the potential to result in severe and costly 
outcomes[8]. Due to the chronic nature of these wounds and the characteristically poor 
healing response, DFU(s) require extensive healing time and are a major source of 
morbidity and mortality in diabetes subjects, with a 3-year mortality rate of 28% and 
amputation rates 15 times higher than subjects without the disease[8,12]. These wounds 
are also a leading cause of hospitalization in diabetes subjects; it is estimated that 20% 
of hospitalizations for subjects with diabetes are due to complications associated with 
foot ulceration[8,12]. Aside from these complications, the development of DFUs can lead 
to physical and mental distress as well as productivity and financial losses that lower the 
quality of life of subjects[12].  
The economic burden associated with people with diabetes is significant, with medical 
expenditures 2.3 times higher in subjects with diabetes compared to those without the 

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disease[6]. In 2012, the annual cost of diabetes was estimated to be $245 billion, which 
included health care expenditures and productivity losses[8]. A substantial amount of 
these expenditures were related to managing comorbidities and chronic complications 
such as DFU and lower-extremity amputation[8]. The current Standard of Care (SOC) for 
DFU(s) as highlighted in the literature includes debridement, pressure offloading, moist 
wound therapies, and adequate education and nutritional support. The incidence of 
closure for DFUs treated with SOC alone has been reported to be between 20-
38%[9,10,13]. Thus, with the prevalence of diabetes and diabetes-related complications on 
the rise, there is a need for an intervention that has the ability to increase the incidence 
of DFU healing. Such an intervention may provide a cost-effective means of decreasing 
morbidity and mortality and improve the quality of life for subjects who suffer from 
diabetic foot ulceration(s). This clinical investigation will assess the efficacy of Cytal® 
Wound Matrix 1-Layer as a potential therapy for the management of chronic, non-
healing DFUs compared to SOC over a 12 week period. 
2.2 
POTENTIAL RISKS AND BENEFITS  
 
2.2.1 POTENTIAL RISKS  
Cytal® Wound Matrix 1-Layer 
Complications and reactions are possible with any soft tissue repair, including but not 
limited to: infection, increased chronic inflammation, allergic reaction, unexplained fever 
or chills, excessive redness, pain, or swelling. 
2.2.2 POTENTIAL BENEFITS  
Cytal® Wound Matrix 1-Layer 
Cytal® Wound Matrix 1-Layer is constructed of a naturally-occurring biomaterial 
designed to manage wounds.  The devices may be cut to size and must be hydrated 
prior to placement by immersion in room temperature sterile saline.  The biomaterial is a 
resorbable extracellular matrix scaffold containing basement membrane which facilitates 
constructive remodeling of host tissue by integration. 
 
 

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3 
OBJECTIVES  
 
The primary objective of the study is: 
1. To compare the incidence of complete wound closure (defined as 100% 
epithelialization) by 12 weeks between randomized groups. 
The secondary objectives of the study are: 
1. To compare the rate of wound healing over time in cm2/week between randomized 
groups. 
2. To compare the time to complete wound closure between randomized groups. 
3. To compare DFU recurrence after healing between randomized groups. 
4. To compare subject reported outcomes between randomized groups. 
5. To compare the intervention-emergent adverse event (AE) safety profile between 
randomized groups.  
The health economic objective of the study is: 
1. Perform a health economics analysis between randomized groups. 
4 
STUDY DESIGN AND ENDPOINTS 
 
4.1 
DESCRIPTION OF THE STUDY DESIGN 
Multi-site, prospective, randomized study comparing Cytal® Wound Matrix 1-Layer 
(Group 1) to Standard of Care (Group 2) in the management of diabetic foot ulcers. 
Subjects who meet the inclusion and exclusion criteria for the study will be randomized 
(2:1) to Group 1 or Group 2 using a permuted block randomization scheme. 
Study DFUs will be treated up to 10 times in a 12 week period and must be located on a 
single foot.     
The target number of subjects to be enrolled and randomized in this trial is 120, with 
150 being the maximum number of subjects based on the interim sample size re-
estimation.  Subjects will undergo a 2 week run-in phase and a 12 week intervention 
phase. For wounds that are treated during the intervention phase and subsequently 
heal, subjects will be followed for 3 weeks to confirm complete epithelization. For healed 
wounds, additional study visits will be conducted at 6 and 12 months from intervention 
initiation to evaluate the state of healing or the reoccurrence of the DFU(s). 
The duration of participation for each subject will be up to a maximum of 54 weeks. 

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Eligible subjects will be recruited and enrolled, under the responsibility of the 
participating Investigators. The actual overall study duration or subject recruitment 
period may vary. 
4.2.1 PRIMARY ENDPOINT 
Measure incidence of complete wound closure (defined as 100% epithelialization) by 12 
weeks between randomized groups. 
4.2.2 SECONDARY ENDPOINTS 
The secondary endpoints of the study, comparing measurements between randomized 
groups, include: 
1. Measure changes in wound size, measured in cm2 per week between randomized 
groups by 12 weeks. 
2. Measure time to complete wound closure, in days between randomized groups by 
12 weeks. 
3. Measure wound recurrence after healing is complete at 26 weeks and 52 weeks (6 & 
12 months post intervention initiation).   
4. Changes in subject reported outcomes including quality of life and pain (quality of life 
surveys & visual analogue scale), pre- intervention to post- intervention over time 
and by 12 weeks. 
5. Measure frequency of adverse events related to DFU including unexpected adverse 
device events or serious adverse experiences throughout the duration of the study. 
4.2.3 HEALTH ECONOMIC OUTCOMES 
The health economic outcomes of the study include: 
1. Any changes in the prescription of narcotics related to the DFU(s) by subject and 
between randomized groups. 
2. Any changes in ambulatory status (i.e. bed, wheel chair, walk w/ assistance, or walk 
independent) by subject and between randomized groups. 
3. Any changes in “return to work/reported work status”, activities of daily living, or 
disability status by subject and between randomized groups. 
4. Health economics analysis, as measured by direct costs as measured by total cost 
per subject stratified by healed vs. non healed  DFU.  
 
 

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5 
STUDY ENROLLMENT AND WITHDRAWAL 
5.1 
PARTICIPANT INCLUSION CRITERIA 
In order to be eligible to participate in this study, an individual must meet all of the 
following criteria:  
1. Provision of signed and dated informed consent form by subject or legally authorized 
representative.  
2. Stated willingness to comply with all study procedures and availability for the 
duration of the study. Subject is able and willing to tolerate non-removable offloading 
device for the duration of the run-in and intervention phases of the study. 
3. Subject is male or female and ≥22 years of age. 
4.   Subject has a clinical diagnosis of type 1 or type 2 diabetes.  
5. Subject’s current foot ulcer(s) has been present for ≥ 30 days and ≤365 days. 
6. Subject’s current foot ulcer(s), post-debridement is/are predominantly below the 
malleoli and on the plantar surface of the foot. 
7. Subject’s foot ulcer(s) must be Wagner Grade 1 or  2.  
8. Post debridement, subject’s ulcer(s) are free of necrotic debris and appear to be 
comprised of healthy, vascularized tissue. 
9. All qualifying ulcers ≥ 5cm away from any other ulcer on the same foot. 
10. Subject’s ulcer(s) surface area is ≥ 1cm2 and ≤ 20cm2 at randomization. 
11. Subject’s HbA1C reading is ≤10%. 
12. Subject’s Serum Creatinine ≤ 3.0mg/dL.  
13. Subject has adequate circulation to the foot as measured by Ankle-Brachial Index 
(ABI) ≥ 0.7. 
14. Negative pregnancy test at randomization for women of childbearing potential.  
5.2 
PARTICIPANT EXCLUSION CRITERIA 
An individual who meets any of the following criteria will be excluded from participation 
in this study: 
1. Subject is pregnant, breastfeeding, or unwilling to practice birth control during 
participation in the study, if applicable. 
2. Allergy or hypersensitivity to materials in porcine-based study products (per 
subject report) or personal preference. 
3. Subject report of concurrent participation in another clinical trial that involves a 
drug or device. 
4. The subject has any condition that, in the Investigator’s opinion, would warrant 
exclusion from the study or prevent the subject from completing the study. 

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5. Subject has clinical evidence of gangrene on any part of the affected foot. 
6. The subject’s ulcer(s) is/are definitively due to a non-diabetic etiology, ulcers of 
arterial, venous stasis, pressure, radiation, traumatic, rheumatoid, vasculitis, 
collagen vascular disease, or other non-diabetic etiologies in the opinion of the 
Investigator.   
7. Subject has unstable Charcot foot, Charcot foot with a bony prominence(s) or 
Charcot amputation.    
8. Qualifying wound(s) is connected to another ulcer via a fistula.  
9. Subject has one or more medical condition(s) including renal, hepatic, 
hematological, neurologic, or immune disease that in the opinion of the 
Investigator would make the subject an inappropriate candidate for this wound 
healing study. 
10. Subject has or has had a malignant disease (other than basal cell carcinoma) that 
has not been in remission for at least five years. 
11. Subject is receiving oral or parenteral corticosteroids, immunosuppressive or 
cytotoxic agents, or is anticipated to require such during the course of the study. 
12. Subject has acute osteomyelitis of the affected foot. 
13. Subject’s ulcer(s) is accompanied by active cellulitis. 
14. Subject has received growth factor or enzymatic therapy in the area of the wound, 
within 2 weeks of consent.  
15. Subject has ever received radiation or radiologic implants in the area of the wound 
OR chemotherapy within the past 5 years. 
16. Subject is allergic to any of the primary or secondary dressing materials, including 
occlusive dressings and the adhesives on such dressings. 
17. Subject’s ulcer(s) surface area has decreased in size by > 30% during the run-in 
phase. 
18. Subject’s ulcer(s) surface area has increased in size by > 50% during the run-in 
phase. 
19. Subject’s ulcer(s) has tunnels or sinus tracts that cannot be completely debrided. 
20. Subject has severe malnutrition as evidenced by albumin <2.0 g/dL. 
21. Subject has a bleeding disorder that would make the subject unsuitable for serial 
bedside sharps or chemical cautery debridement.  
22. Subject is on dialysis. 
23. Any DFU(s) is actively infected and has not been treated for any clinically 
suspected infection prior to application of any product. 
5.3 
STRATEGIES FOR RECRUITMENT AND RETENTION 
Eligible subjects will be recruited and enrolled, under the responsibility of the 
participating Investigators.   

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5.4 
PARTICIPANT WITHDRAWAL OR TERMINATION 
5.4.1 REASONS FOR WITHDRAWAL OR TERMINATION 
A subject may be discontinued from the study at any time if the subject, the Investigator, 
or the Sponsor feels that it is not in the subject’s best interest to continue.  The following 
is a list of possible reasons for study and/or intervention discontinuation (including but 
not limited to):  
• Screen Failure/Subject does not continue to meet eligibility  
• Subject withdrawal of consent  
• Subject is not compliant with study procedures 
• Adverse Event that in the opinion of the Investigator would be in the best interest 
of the subject to discontinue study participation and/or study intervention 
• Protocol deviation  
• Lost to follow-up 
• Sponsor request for early termination of study 
• Subject death 
All subjects are free to withdraw from participation at any time, for any reason, specified 
or unspecified, and without prejudice. Reasonable attempts will be made by the 
Investigator to provide a reason for subject withdrawals.  The reason for the subject’s 
withdrawal from the study will be specified in the subject’s source documents and the 
Case Report Form (CRF).   
If a subject is withdrawn from intervention due to an AE, the subject will be followed and 
treated by the Investigator until the abnormal parameter or symptom has resolved or 
stabilized. 
The Investigator (study staff) must make every effort to contact subjects who are lost to 
follow-up.  Three (3) attempted contacts should be documented by research personnel 
prior to considering the subject lost to follow-up. Attempts to contact such subjects must 
be documented in the subjects’ records (e.g. dates of attempted telephone contact).  
5.4.2 HANDLING OF PARTICIPANT WITHDRAWALS OR TERMINATION 
Although subjects may withdraw from the study at any time and for any reason, (or may 
be withdrawn at the Investigator’s discretion), subject withdrawal should be avoided as 
much as reasonably possible.  In any case, appropriate follow-up for endpoints should 
be continued.  The reason for study discontinuation will be recorded on the subject’s 
source document and CRF.   

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Subjects who do not continue to meet eligibility criteria following the 2 week run-in 
phase will be withdrawn from the study. The reason for study discontinuation will be 
recorded on the subject’s source document and CRF.   
Subjects who prematurely discontinue following initial treatment are not to be replaced.   
Randomized subjects who terminate their clinical trial participation for any reason post 
randomization will not be replaced and their randomization number will not be re-
assigned. 
For subjects considered lost to follow-up, the CRF must be completed up to the last visit 
performed.  
5.5 
PREMATURE TERMINATION OR SUSPENSION OF STUDY 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to the Investigator, 
the Sponsor and the Institutional Review Board (IRB), as appropriate.  If the study is 
prematurely terminated or suspended, the Investigator will promptly inform the IRB and 
will provide the reason(s) for the termination or suspension.  
Circumstances that may warrant termination or suspension include, but are not limited 
to:  
• Determination of unexpected, significant, or unacceptable risk to participants  
• Demonstration of efficacy that would warrant stopping  
• Insufficient compliance to protocol requirements  
• Data that are not sufficiently complete and/or evaluable  
• Determination of futility  
Study may resume once concerns about safety, protocol compliance, data quality are 
addressed and satisfy the Sponsor and/or the IRB. 
6 
STUDY DEVICE 
 
6.1 
STUDY DEVICE DESCRIPTION  
6.1.1 DEVICE DESCRIPTION  
Cytal® Wound Matrix 1-Layer 

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Cytal® Wound Matrix 1-Layer is composed of a porcine-derived extracellular matrix 
known as urinary bladder matrix and is intended for the management of wounds 
including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic 
ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor 
sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), 
trauma wounds (abrasions, lacerations, second-degree burns, skin tears), and draining 
wounds. The (individual) device is intended for one time use. 
6.1.2 DEVICE CONFIGURATION 
Cytal® Wound Matrix 1-Layer  
The study devices are supplied in a fenestrated sheet configuration in sizes up to 10 cm 
x 15 cm and packaged in double peel-open pouches. 
Standard of Care Products 
Fibracol™  
The standard of care primary dressing is standardized under this protocol to be 
Fibracol™.  The devices are supplied in a sheet configuration in sizes up to 10 cm x 11 
cm. 
The standard of care secondary dressings used by treating Investigator which are part 
of his/her standard of care will be used per their approved labelling and as packaged 
per their manufacturer. 
Please note: Silver impregnated products may not be used under this protocol as SOC 
treatments. Silver impregnated products may be used at the investigator’s discretion 
when a patient presents with an emergent wound condition, such as a local wound 
infection. Products used must be documented on the AE CRF. 
6.1.3 PRODUCT STORAGE AND ACCOUNTABILITY 
Cytal® Wound Matrix 1-Layer should be stored in a clean, dry environment, between 15-
35°C (59-95°F), in the unopened and undamaged package. The products should be 
protected from freezing temperatures, excessive heat, and high humidity. 
Regular study device reconciliation will be performed to document study product 
assigned to each eligible participant, if applicable.  This reconciliation will be logged on 
the Device Accountability Log, and signed and dated by the PI at the end of the study.   
Fibracol™ should be stored per manufacturer’s instructions. 
6.1.4 RETURN OR DESTRUCTION OF STUDY DEVICE 

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All unused Cytal® Wound Matrix 1-Layer devices will be retrieved by the Sponsor, if 
applicable. A detailed Device Accountability Log and a Storage Attestation Form of the 
returned study product(s) will be provided to the Sponsor at the end of the study. 
7 
STUDY PROCEDURES AND SCHEDULE 
7.1 
STUDY SCHEDULE 
A Schedule of Events representing the required testing procedures to be performed for 
the duration of the study is diagrammed in Appendix I. 
7.1.1 RUN-IN PERIOD (2 WEEKS) (DAY -14 AND -7) 
1. The run-in period will be for two consecutive weeks (Day -14 and Day -7 +/-2 days) 
prior to intervention initiation. Subjects should return for two weekly visits during this 
period. All eligibility criteria are to be confirmed prior to randomization and 
intervention at Study Visit 1. Subjects are considered enrolled in the study once 
randomized.  Confirmation of continued eligibility at treatment visit allows for subject 
randomization.  Obtain informed consent from the potential subject, or legally 
authorized representative. 
2. Assign subject a Subject ID (SID). Subject IDs will be assigned in consecutive order 
and cannot be re-used. 
3. Collect demographic data including: date of birth, gender, race, and ethnicity only at 
Run-In Visit 1.    
4. Document weight (pounds), height (inches), and calculated BMI.  BMI will be 
calculated using the National Institutes of Health BMI calculator. 
5. Collect blood sample(s) for  albumin, pre-albumin, serum creatinine and Hemoglobin 
HbA1C (only required at one of the two Run-In visits).   
6. Record ABI to confirm appropriate perfusion per Inclusion/Exclusion criteria (only 
required at one of the two Run-In visits).                                                                                             
7. Perform physical exam and evaluation needed to determine eligibility based on 
inclusion/exclusion criteria.  
8. Record concomitant medication use (type, dose, frequency, duration, indication) for 
the following (including but not limited to): pain medication related to DFU, any anti-
hypertensives, medication or supplements to control diabetes, nutritional 
supplements, and antibiotics.   
9. Record the anatomic location of the wound(s), date of onset, and any previous 
interventions. 
10. Record 
wound 
characteristics 
pre-debridement. 
Wound 
appearance 
and 
characteristics including but not limited to: presence of epibole, eschar, undermining, 

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tunneling, sinus tracts, slough, and/or adverse odor; Appearance of Exudate: 
serous, serosanguinous, purulent, and bloody.  
11.  Record Appearance of Wound Bed : Beefy Red, Red, Pink, White, or Yellow.  If 
debridement is performed, record appearance of wound bed post-debridement. 
12. Use the Silhouette system to capture at least one image per wound pre-
debridement at the first run-in visit only (this is a reference picture and 
measurements will not be recorded).  
• Images should be captured in a manner where no identifiable information is 
contained in the photograph (i.e. tattoos, full body, etc.). Refer to the 
SilhouetteConnect User Guide and the SilhouetteStar Quick Reference Guide 
for detailed instructions on how to use the Silhouette system.  
13. Use the Silhouette system to capture at least one image per wound post-
debridement at the first and second run-in visit and record the length, width, and 
depth of the diabetic foot ulcer(s) in centimeters (surface area, volume, and percent 
changes from baseline will be auto-calculated). If debridement is not performed, at 
least one image per wound must be captured and measured as noted above.   
14. Treat the DFU(s) with SOC to include debridement (if necessary), moist wound 
therapy, the appropriate secondary dressing, and off-loading (per SOC) for 2 
consecutive weeks prior to randomization. This 2 week run-in period is required to 
determine continued eligibility in the study. No advanced wound dressings (i.e. 
Fibracol™) should be used prior to the initiation of the treatment phase as SOC 
treatment. 
7.1.2 BASELINE/RANDOMIZATION (STUDY VISIT 1) 
Baseline/Randomization visit should occur 1 week following second run-in visit (+/- 2 
days) for all subjects. 
1. Verify and document inclusion/exclusion criteria continue to be met. Subjects whose 
DFU(s) surface area decreases in size by > 30% or increases by > 50% from the 
initial run-in visit will not be eligible for study intervention and will be considered a 
screen failure. Qualifying subjects will be randomized to either Group 1 or Group 2.    
2. Record subject’s employment status, disability status, ambulatory status, medical 
history (including duration of diabetes disease, past diabetes complications, and 
DFUs), and surgical history per available medical reports and/or patient self-report. 
3. Record social information including alcohol and tobacco use.  
4. Confirm concomitant medication use (type, dose, frequency, duration, indication) for 
the following (including but not limited to): pain medication related to DFU, any anti-
hypertensives, medication or supplements to control diabetes, nutritional 
supplements, and antibiotics. 
5. Perform urinary pregnancy test for women of childbearing potential.  

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6. Administer the SF-20 Health Survey, DFS-SF, Visual Analogue Scale for Pain 
(VAS), and KATZ ADL prior to intervention.  
7. Record the following information for the eligible wound(s) (record wound 
characteristics pre-debridement, if debridement at this visit is deemed necessary by 
the investigator). Wound appearance and characteristics including but not limited to: 
Presence of epibole, eschar, undermining, tunneling, sinus tracts, slough, and/or 
adverse odor; Appearance of Exudate: Serous, serosanguinous, purulent, and 
bloody; Appearance of Wound Bed: Beefy Red, Red, Pink, White, or Yellow. 
8. Record the following information for each of the eligible ulcer(s) (record size and 
classification post-debridement, if the ulcer(s) was debrided at this visit): 
• If debridement is performed:  Use the SilhouetteStar and SilhouetteConnect 
system to capture at least one wound image post debridement and prior to 
product application.. Capture images in a manner where no identifiable 
information is contained in the photograph (i.e. tattoos, full body, etc.).  Use 
SilhouetteConnect to trace one image in order to calculate and record the 
length, width, depth, surface area and volume.  
• If 
debridement 
is 
not 
performed: 
 
Use 
the 
SilhouetteStar 
and 
SilhouetteConnect system to capture at least one wound image prior to 
product application. Capture images in a manner where no identifiable 
information is contained in the photograph (i.e. tattoos, full body, etc.). Use 
SilhouetteConnect to trace one image in order to calculate and record the 
length, width, depth, surface area and volume.    
• Additional images beyond the requirements stated above may be taken 
however are not required under this protocol. Additional images should not be 
measured within ARANZ SilhouetteConnect.      
• Categorize the wound using the Wagner Classification System 
9. If all eligibility criteria continue to be met, perform randomization and proceed with 
intervention procedures as outlined below, depending on randomization assignment. 
If there is more than one qualifying wound, randomize by subject so all wounds are 
in the same intervention group.. 
Group 1 (ACell products) Procedures 
i. 
Wash the wound using saline prior to debridement, as needed. 
ii. 
Sharps debride the eligible diabetic foot ulcer(s) to remove all non-
viable tissue, callus, epibole at wound edges, slough, and debris (at 
the physician’s discretion). The wound margins should be excised to 
healthy bleeding tissue.  
iii. 
Wash the wound(s) once more with saline to remove remaining 
debris and confirm hemostasis is achieved, as needed.  
iv. 
Refer to section 7.1.2 Number 8 above for wound image and 
measurement instructions for the eligible wound(s) post-debridement.  

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v. 
Place an appropriately sized Cytal® Wound Matrix 1-Layer sheet 
(previously hydrated in sterile saline per the manufacturer’s 
Instructions for Use) into the wound bed. The hydrated sheet should 
be cut to fit the interior of the wound, with no overlap onto healthy 
skin. Record appropriate wound care time inclusive of product 
preparation, debridement and dressing. 
vi. 
Secure product with a non-adherent, contact layer.  
vii. 
Apply a water-based surgical lubricant of physician choice as 
necessary to maintain a moist wound environment.  
viii. 
Apply the appropriate secondary dressing based on wound 
characteristics and physicians discretion. 
ix. 
Apply the OPTIMA® Diab boot with the appropriate insole kit based 
on subject weight and wound size and make the boot non-removable 
by using the locking system. 
x. 
In cases of AEs/SAEs in the ACell arm, the PI may treat subjects 
with any other primary wound contact layer as per the Investigator’s 
discretion except for any FibracolTM devices, so as to not confound 
study arms and results.   
 
Group 2 (Standard of Care Only) Procedures 
i. 
Wash the wound using saline prior to debridement. 
ii. 
Sharps debride the eligible diabetic foot ulcer(s) to remove all non-
viable tissue, callus, epibole at wound edges, slough, and debris (at 
the physician’s discretion). The wound margins will be excised to 
healthy bleeding tissue.  
iii. 
Wash the wound(s) once more with saline to remove remaining 
debris and confirm hemostasis achieved.  
iv. 
Refer to section 7.1.2 Number 8 above for wound image and 
measurement instructions for the eligible wound(s) post-debridement.  
xi. 
Place an appropriately sized Fibracol™ sheet (per the manufacturer’s 
Instructions for Use) into the wound bed.  Record appropriate wound 
care time inclusive of product preparation, debridement and dressing. 
v. 
Apply a water-based surgical lubricant of physician choice as 
necessary to maintain a moist wound environment.  
vi. 
Apply the appropriate secondary dressing based on wound 
characteristics and physicians discretion. 
vii. 
Apply the OPTIMA® Diab boot with the appropriate insole kit based 
on subject weight and wound size and make the boot non-removable 
by using the locking system. 

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viii. 
In cases of AEs/SAEs in the SOC arm, the PI may treat subjects with 
any other primary wound contact layer per the Investigator’s 
discretion except for Cytal ® Wound Matrix 1-Layer, so as to not 
confound study arms and results. 
10. Record wound-related AEs and all SAEs as reported by participant or observed by 
the Investigator.  In cases of AEs/SAEs in either study arm, use of oral antibiotics, 
topical antimicrobials, or the use of silver infused primary contact layers is 
acceptable. For subjects in the ACell arm, use of any FibracolTM devices is 
prohibited per protocol so as to not confound study arms and results.  For subjects 
in the SOC arm, use of Cytal ® Wound Matrix 1-Layer is prohibited so as to not 
confound study arms and results. Corresponding documentation should be included 
in submitted AE reporting as appropriate.   
11. Provide instructions to subject regarding maintenance of adequate nutrition and 
diabetes control as per SOC. 
12. Provide instructions to subject regarding off-loading. The boot should not be 
removed between visits.  Relevant information provided by the manufacturer of the 
boot may be found in the Appendix of this protocol. 
13. Confirm date of next visit with the subject.   
7.1.3  STUDY VISITS (2-13 and confirmation visits) 
Study visits at which the wound(s) is evaluated should occur every 7 days (± 2 days) for 
all subjects. 
1. Record written documentation of off-loading per protocol requirements 
(compliance to off-loading instructions). 
2. Record wound-related AEs and all SAEs as reported by subject or observed by 
Investigator. In cases of AEs/SAEs in either study arm, use of oral antibiotics, 
topical antimicrobials, or the use of silver infused primary contact layers is 
acceptable. For subjects in the ACell arm, use of any FibracolTM devices is 
prohibited per protocol so as to not confound study arms and results. For 
subjects in the SOC arm, use of Cytal ® Wound Matrix 1-Layer is prohibited so 
as to not confound study arms and results. Corresponding documentation should 
be included in submitted AE reporting as appropriate.   
3. Record any changes to activities of daily living, employment, disability, and 
primary ambulatory status.  For confirmation visits, this is required at the third 
and final confirmation visit only.   
4. If the subject is unable to work due to their DFU(s), record whether or not the 
subject could be released to return back to work independent of their current 
work status based on the status of the wound and physicians discretion.  

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5. Confirm concomitant medication use for the following (including but not limited 
to): pain medication use relating the DFU(s), any anti-hypertensives, medications 
or supplements to control diabetes, nutritional supplements, and antibiotics, if 
applicable. 
6. Administer VAS for pain-overall body pain and DFU foot pain prior to intervention 
weekly, as appropriate.  
7. Record weight (pounds) and BMI at wound healing.  
8. Collect blood samples for Hemoglobin HbA1C at Visit 13 and Albumin at Visit 3, 
Visit 6, Visit 9 and Visit 13.  For confirmation visits, collect blood sample at the 
third and final confirmation visit only.      
9. Record ABI to confirm appropriate perfusion PRN for non-healing wounds.  
10. Administer DFS-SF at the last closure confirmation visit.   
11. Administer SF-20 Health Survey and the Katz ADL prior to intervention at Visit 7 
& 13 and at the third and final confirmation visit if the wound heals prior to Visit 
13.   
12. Record the following information for all treated wound(s) pre-debridement, if 
debridement at this visit is deemed necessary by the Investigator. Wound 
appearance and characteristics including, but not limited to: Presence of epibole, 
eschar, undermining, tunneling, sinus tracts, slough and/or adverse odor; 
Appearance of Exudate: Serous, serosanguinous, purulent, and/or bloody; 
Appearance of Wound Bed: Beefy Red, Red, Pink, White, or Yellow. 
13. Record the following information for all treated wound(s) post-debridement, if 
debridement at this visit is deemed necessary by the Investigator: 
a. Use the SilhouetteStar and SilhouetteConnect system to capture at least 
one wound image and record measurements including length, width, and 
depth of the diabetic foot ulcer(s) in centimeters (surface area, volume, 
and percent changes from baseline will be auto-calculated). Capture 
images in a manner where no identifiable information is contained in the 
photograph (i.e. tattoos, full body, etc.).  If debridement is not performed, 
capture at least one wound image and record measurements as noted. 
b.  If wound(s) is healed, Use the SilhouetteStar and SilhouetteConnect 
system to capture at least one wound image of the healed wound area. 
c. Additional images beyond the requirements stated above may be taken 
however are not required under this protocol. Additional images should 
not be measured within ARANZ.     
14. Proceed with treatment procedures as outlined below (Note, a maximum of 10 
treatments within the 12 week period or until wound has completely closed, 
whichever occurs first, is allowed.  These applications may be made per the 
discretion of the Investigator.)   
a. Group 1 Procedures (ACell Products) 

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i. Do not remove or disrupt any residual ACell product (Group 1) 
when preparing the wound bed for reapplication. 
ii. Minimal “spot” sharps debrides and gentile saline washes may be 
performed at subsequent treatment visits as determined by the 
investigator. 
iii. Apply weekly applications of Cytal® Wound Matrix 1-Layer until 
wound closure or up to, and including, week 12, whichever occurs 
first.  Record appropriate wound care time inclusive of product 
preparation, debridement and dressing if additional study devices 
are applied. 
iv. Secure product with a non-adherent, primary contact layer.  
v. Apply a water-based surgical lubricant of physician choice as 
necessary to maintain a moist wound environment.  
vi. Apply the appropriate secondary dressing based on wound 
characteristics and physicians discretion. 
vii. Apply the OPTIMA® Diab boot with the appropriate insole kit based 
on subject weight and wound size and make the boot non-
removable by using the locking system. 
viii. In cases of AEs/SAEs in the ACell arm, the PI may treat subjects 
with any other primary wound contact layer as per the Investigator’s 
discretion except for any FibracolTM devices, as to not confound 
study arms and results.   
b. Group 2 Procedures (SOC Only) 
i. Minimal “spot” sharps debrides and gentile saline washes may be 
performed at subsequent intervention visits as determined by the 
investigator. 
ii. Place 
an 
appropriately 
sized 
Fibracol™ 
sheet 
(per 
the 
manufacturer’s Instructions for Use) into the wound bed Record 
appropriate wound care time inclusive of product preparation, 
debridement and dressing as appropriate. Apply a water-based 
surgical lubricant of physician choice as necessary to maintain a 
moist wound environment.  
iii. Apply the appropriate secondary dressing based on wound 
characteristics and physicians discretion. 
iv. Apply the OPTIMA® Diab boot with the appropriate insole kit based 
on subject weight and wound size and make the boot non-
removable by using the locking system. 
v. In cases of AEs/SAEs in the SOC arm, the PI may treat subjects 
with any other primary wound contact layer per the Investigator’s 

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discretion except for Cytal ® Wound Matrix 1-Layer, so as to not 
confound study arms and results. 
15. Confirm date of next visit.  Visits should be completed every 7 days (± 2 days).  If 
wound re-opens at one of the closure confirmation visits, resume weekly study 
visits and treatment as appropriate for a maximum of 10 treatments in a 12 week 
period.    
a. If complete wound healing is observed by, or prior to, Visit 13: Subject 
will return for 3 consecutive visits to confirm complete wound closure and to 
perform the procedures outlined above, sections 1-11 as applicable.  
For example, if the wound heals at Visit 13, subject is to return for Study Visit 
14, 15, and 16; if wound heals at Visit 8, subject is to return for Study Visit 9, 
10, and 11. The maximum number of study visits in this phase of the study is 
16 and is dependent on wound healing. Subjects will be evaluated for DFU 
recurrence.  
b. If treatment is administered at Visit 13:  Subjects will complete an 
Unscheduled visit to evaluate treatment effect.  If healing is noted at the 
Unscheduled visit, subject should return for 3 confirmation visits. 
7.1.4 FINAL STUDY VISITS (WEEK 26 AND 52 ±2 WEEKS) 
The Final Study Visits will occur 26 and 52 weeks (± 2 weeks) after the initial 
intervention visit (Day 0). The Final Study Visits are required ONLY for subjects with at 
least 1 healed wound noted following treatment during the intervention phase.  
1. Record weight (pounds) and BMI. 
2. Record any changes to subject’s employment status, disability status, ambulatory 
status, medical history, and surgical history. 
3. Record changes to concomitant medication use for the following (including but 
not limited to): pain medication use relating the DFU(s), any anti-hypertensives, 
medications or supplements to control diabetes, nutritional supplements, and 
antibiotics, if applicable.  
4. Administer SF-20 Health Survey, DFS-SF, VAS for pain (overall body pain and 
DFU foot pain), and KATZ ADL. 
5. Record diabetes and/or wound-related AEs and all SAEs as reported by 
participant or observed by Investigator. 
6. Collect blood samples for Hemoglobin HbA1C and albumin. 
7. Record off-loading as applicable. 
8. Record ABI to confirm perfusion PRN for non-healing wounds.. 
9. Record if there has been recurrence at the original anatomical location of the 
wound.   
10.  If recurrence is noted following Visit 13, record the following information: 

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a. Wound appearance and characteristics including, but not limited to: 
Presence of epibole, eschar, undermining, tunneling, sinus tracts, slough 
and/or adverse odor; Appearance of Exudate: Serous, serosanguinous, 
purulent, and/or bloody; Appearance of Wound Bed: Beefy Red, Red, 
Pink, White, or Yellow 
b. Using the SilhouetteStar and SilhouetteCentral, obtain at least one wound 
image and measurements including length, width, and depth of the 
diabetic foot ulcer(s) in centimeters (surface area, volume, and percent 
changes will be auto-calculated). Capture images in a manner where no 
identifiable information is contained in the photograph (i.e. tattoos, full 
body, etc.). If debridement is performed, images must be post-
debridement.    
c. If wound(s) remains healed, use the SilhouetteStar and SilhouetteConnect 
system to capture at least one wound image of the healed wound area. 
d. Additional images beyond the requirements stated above may be taken 
however are not required under this protocol. Additional images should not 
be measured within ARANZ.     
7.1.5 UNSCHEDULED VISIT 
Unscheduled visits may occur at any time between Study Visit 1 and Visit 13,  in the 
event of an adverse event (i.e. recurrence, infections, etc.) related to the original, 
qualifying DFU(s) up to week 52; or in the event that product is applied at Visit 13. 
Reasons for an Unscheduled Visit include, but are not limited to: diabetic foot ulcer 
events, assessment or follow-up of adverse events, etc.  
1. Document reason for the unscheduled visit.  
2. Review and record any changes to subject’s employment status, disability status, 
ambulatory status, medical history, and surgical history, if applicable. 
3. Record changes to concomitant medication use for the following (including, but 
not limited to): pain medication use relating the DFU(s), any anti-hypertensives, 
medications or supplements to control diabetes, nutritional supplements, and 
antibiotics, if applicable.  
4. Record diabetic and wound-related AEs and all SAEs as reported by participant 
or observed by Investigator.  
5. As applicable: 
a. Confirm closure or record if there has been a recurrence at the original 
anatomic location of the diabetic foot ulcer(s).    
b. Record wound appearance and characteristics including but not limited to: 
Presence of epibole, eschar, undermining, tunneling, sinus tracts, slough, 
and/or adverse odor; Appearance of Exudate: Serous, serosanguinous, 

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purulent, and bloody; Appearance of Wound Bed: Beefy Red, Red, Pink, 
White, or Yellow. 
c. Using the SilhouetteStar and SilhouetteCentral, obtain at least one wound 
image and record measurements including length, width, and depth of the 
diabetic foot ulcer(s) in centimeters (surface area, volume, and percent 
changes will be auto-calculated). Capture images in a manner where no 
identifiable information is contained in the photograph (i.e. tattoos, full 
body, etc.).  If debridement is performed, images must be post-
debridement. 
d. Record ABI to confirm perfusion PRN for non-healing wounds. 
6. Record actions taken to treat the wound(s), if applicable. 
7.1.6 MISSED VISIT 
If a subject misses a visit, the site is to make every effort to have the subject return as 
soon as possible for the missed visit. Once the subject is seen, he/she is to return to 
his/her original weekly visit schedule (window +/- 2 days). For example: 
• If a subject was seen regularly on Mondays but missed a scheduled Monday visit 
and came in on Wednesday, he/she should return the next Monday to maintain 
his/her weekly Monday Visit.  
• 
If the same subject was not able to come in until Friday, the subject would still 
come in the next Monday to maintain the weekly schedule.  
7.1.7 DESCRIPTION OF SYSTEMS/OUTCOME MEASUREMENTS 
Wagner Ulcer Classification System 
GRADE LESION 
0 
No open lesions; may have deformity or cellulitis 
1 
Superficial diabetic ulcer (partial or full thickness) 
2 
Ulcer extension to ligament, tendon, joint capsule, or deep fascia without abscess or 
osteomyelitis 
3 
Deep ulcer with abscess, osteomyelitis, or joint sepsis 
4 
Gangrene localized to portion of forefoot or heel 
5 
Extensive gangrenous involvement of the entire foot 
 
The SF-20® Health Survey (SF-20) 
The SF-20 is a 20-item questionnaire used to assess generic health outcomes from the 
subject’s perspective. Generic subject-reported outcome (PRO) measures like the SF-

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20 assess general health and well-being [or health-related quality of life (HRQOL)], 
including the impact of any and all illnesses on a broad range of functional domains. 
The SF-20 consists of a subset of 20 items from the SF-36® Health Survey (SF-36), 
covering the same eight domains of health outcomes, including physical functioning, 
role functioning, mental health, current health perceptions, and pain.  
Diabetic Foot Ulcer Scale- Short Form (DFS-SF) 
The DFS-SF is a 29-item questionnaire is a specific instrument designed to assess the 
impact of diabetic foot ulcers and their intervention on quality of life in people with 
diabetes. The short form is based on the original Diabetic Foot Ulcer Scale; this 
questionnaire reduces the burden of a lengthy survey on subjects and has been shown 
to have good internal consistency, reliability, construct validity, and demonstrated 
sensitivity to ulcer healing14.  
Visual Analogue Scale for Pain (VAS) 
The visual analogue scale or visual analog scale (VAS) is a psychometric response 
scale which can be used in patient-based outcome questionnaires. It is a measurement 
instrument for subjective characteristics or attitudes that cannot be directly/objectively 
measured. The VAS is anchored by two verbal descriptors, one for each symptom 
extreme measured from the zero mark, indicating “no pain” (score of 0) to the mark of 
10 on the 10-cm line, indicating “pain as bad as it could be” or “worst imaginable 
pain.”  Respondents are asked to report current pain intensity or pain intensity in the last 
24 hours. 
When responding to a VAS item, respondents specify their level of agreement to a 
statement by placing a vertical line perpendicular to the VAS line at the point that 
represents their pain intensity.  After the patient has marked, using a ruler, the score is 
determined by measuring the distance (mm) on the 10-cm line between the “no pain” 
anchor and the patient’s mark. 
Katz Index of Independence in Activities of Daily Living (KATZ ADL) 
The Katz Index of Activities of Daily Living, formerly referred to as the Katz Activities of 
Daily Living Scale15, is a validated measure used to quantify independence in activities 
of daily living.  These activities include bathing, dressing, toileting, transfers, feeding, 
and continence. The Katz ADL is a 6-item questionnaire where each item is 
dichotomized as either having a score of zero (i.e. dependence) or one (i.e. 
independence). A score of 2 or less indicates a dependent subject, 3-5 for partially 
dependent and 6 for independent.   
ARANZ Medical Silhouette 

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Silhouette® is an easy to use wound imaging, 3D measurement, and documentation 
system using non-invasive laser technology. As an FDA approved medical device, 
Silhouette has been proven to provide accurate, precise, and repeatable wound 
assessments for all phases of clinical research in more than 70 studies globally.  
• 
SilhouetteStar™ + SilhouetteConnect™: The SilhouetteStar camera is used with 
the SilhouetteConnect application software for fast and easy imaging, 3D wound 
measurement and clinical notes capture. SilhouetteStar connects via USB to a 
computer with SilhouetteConnect installed.  
• 
SilhouetteCentral™ (central server) is an integrated electronic wound 
information management system that enables trial managers to review, report, 
securely share, and analyze data collected by Silhouette point-of-care devices. 
7.2 
CONCOMITANT MEDICATIONS 
At the discretion of the Investigator, the subject may be administered any necessary 
medications, provided such medications are not listed under the study exclusion criteria. 
Concomitant medications that will be documented in the subject’s source documents 
and CRFs at all of the intervention and follow-up visits as well as recorded on the 
Medications Log include but not limited to: pain medication use relating the DFU(s), any 
anti-hypertensives, medications or supplements to control diabetes, nutritional 
supplements, and antibiotics, if applicable.  
8 
ASSESSMENT OF SAFETY 
8.1 
SPECIFICATION OF SAFETY PARAMETERS 
8.1.1 DEFINITION OF ADVERSE EVENTS (AE) 
Adverse Event means any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention-related. 
Adverse events of interest under this protocol are those to be considered related to 
diabetes or the DFU.  They include but are not limited to: 
• Infection 
• Increased chronic inflammation 
• Allergic reaction 
• Unexplained fever or chills 
• Excessive redness 
• Pain – excessive or exacerbated 
• Swelling - excessive or exacerbated 

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• Non-characteristic wound odor not associated with product degradation (odor or 
suspected infection of wound) 
• Pus drainage from the treated wound 
• Serosanguinous drainage from the wound- excessive or exacerbated 
• Bleeding- excessive or exacerbated 
• Hematoma 
• Seroma 
• Diabetes related, specify 
• Diabetic foot ulcer – newly developed or worsening 
• Necrotic Tissue-excessive or exacerbated 
• Gangrene 
• Wound dehiscence 
• Osteomyelitis 
• Cellulitis 
• Periwound maceration 
• Wound recurrence (after closure) 
• Hypergranulation of treated wound(s) 
• Amputation  
• Death  
8.1.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 
An AE or suspected adverse reaction is considered "serious" if, in the view of either the 
Investigator or Sponsor, it results in any of the following outcomes:  
• Death 
• A life-threatening adverse event 
• In-patient hospitalization or prolongation of existing hospitalization 
• A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
• A congenital anomaly/birth defect 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the subject or  may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. All SAEs are 
required to be collected following randomization through the final study visit for this 
study. 
8.1.3 DEFINITION OF UNANTICIPATED ADVERSE DEVICE EFFECT 
(UADE) 

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Unanticipated adverse device effect is any serious adverse effect on health or safety, 
any life-threatening problem or death caused by, or associated with a device, if that 
effect, problem, or death was not previously identified in nature, severity, or degree of 
incidence in the application; or any other unanticipated serious problem associated with 
a device that relates to the rights, safety, or welfare of subjects. 
8.2 
CLASSIFICATION OF AN ADVERSE EVENT 
8.2.1 SEVERITY OF EVENT 
The Investigator will be asked to assess the severity of the AE using the following 
categories: 
 
Mild: 
Events require minimal or no intervention and do not interfere with the 
participant’s daily activities. 
 
Moderate: 
Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference 
with functioning. 
Severe: 
Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other intervention. Severe events are usually 
potentially life-threatening or incapacitating. 
8.2.2 RELATIONSHIP TO STUDY AGENT 
For all collected AEs, the clinician who examines and evaluates the participant will 
determine the AE’s causality based on temporal relationship and his/her clinical 
judgment. The degree of certainty about causality will be graded using the categories 
below.  
 
Definitely: 
The relationship of the AE and the study device or the study procedure 
can definitely be established. 
 
Probably: 
While a clear relationship to the study device or to the study procedure 
cannot be established, the AE is associated with an expected AE or 
there is no other medical condition or intervention, which could explain 
the occurrence of such an event. 
 
Possibly: 
There is no clear relationship between the AE and the study device or 
study procedure; however, one cannot definitely conclude that there is 

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no relationship. 
 
Unrelated: 
There is no relationship between the AE and the study device or study 
procedure.  This may include but is not limited to the incident being an 
expected outcome of a previously existing or concurrent disease, 
concomitant medication or procedure the subject experienced. 
 
8.2.3 EXPECTEDNESS  
The Investigator will be responsible for determining whether an AE is expected or 
unexpected. An AE will be considered unexpected if the nature, severity, or frequency 
of the event is not consistent with the risk information previously described for the study 
products. 
8.3 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP 
The occurrence of an AE or SAE may come to the attention of study personnel during 
study visits or upon review by a study monitor.  All AEs (per Investigator discretion) 
that are deemed ‘Possibly’, ‘Probably’ or ‘Definitely’ related  to the development or 
healing of the DFU(s) and those including local and systemic reactions not meeting 
the criteria for an SAE, will be captured on the appropriate CRF. Information to be 
collected includes, but is not limited to, event description, date of onset, clinician’s 
assessment 
of 
severity, 
relationship 
to 
study 
products, 
and 
date 
of 
resolution/stabilization of the event.  All AEs will be followed to adequate resolution.  
Any medical condition that is present at the time that the participant is screened will 
be considered as baseline and not reported as an AE.  However, if the study 
participant’s condition deteriorates at any time during the study, it will be recorded as 
an AE.  
Changes in the severity of an AE will be documented to allow an assessment of the 
duration of the event at each level of severity to be performed.  AEs characterized as 
intermittent require documentation of onset and duration of each episode.  
The PI will record all reportable events with start dates occurring any time following 
initial treatment application through final study visit.  At each study visit, the Investigator 
will inquire about the occurrence of AE/SAEs since the last visit.  Events will be followed 
for outcome information until resolution or stabilization. 
8.4 
REPORTING PROCEDURES 
 

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8.4.1 ADVERSE EVENT REPORTING  
Adverse Events will be documented on the appropriate Case Report Form (CRF) as the 
Investigator learns of the event.  All AEs, not serious in nature, will be reviewed by the 
Sponsor during scheduled Interim Monitoring Visits (IMVs).  The Investigator will follow 
all AEs until adequate resolution is achieved or until AE returns to baseline status, at 
which point the AE would be considered resolved.  The IRB should be notified of all AEs 
according to their notification policies. 
All AEs will be reported to ACell Quality Assurance and reported under the appropriate 
regulatory consideration.   
8.4.2 SERIOUS ADVERSE EVENT (SAE) REPORTING  
In the case of an SAE, the Investigator must immediately notify (within 1 working day of 
becoming aware of the event) the study Sponsor (contact information is provided in 
Section 1, Key Roles).  The IRB must also be notified according to their notification 
policies.   
All SAEs will be followed until satisfactory resolution or until the site Investigator deems 
the event to be chronic or the appearance to be stable. Other supporting documentation 
of the event may be requested by the study Sponsor and should be provided as soon as 
possible. The study Sponsor will be responsible for notifying the FDA of any unexpected 
fatal or life-threatening suspected adverse reaction as soon as possible but in no case 
later than 7 calendar days after the Sponsor's initial receipt of the information. 
8.4.3 UNANTICIPATED ADVERSE DEVICE EFFECT (UADE) REPORTING  
The study Investigator shall submit to the  Sponsor and to the reviewing IRB as soon as 
possible, but in no event later than 10 working days after the Investigator first learns of 
the effect. The  Sponsor contact information is provided in Section 1, Key Roles. The 
study Sponsor is responsible for conducting an evaluation of an UADE and shall report 
the results of such evaluation to the FDA, all reviewing IRB(s) and  Investigator(s) within 
10 working days after the Sponsor first receives notice of the effect.  
This study is not being conducted under an IDE; therefore, Sponsor reporting timelines 
may differ from those defined above.   
8.4.4 REPORTING OF PREGNANCY  
If a female subject becomes pregnant during the trial, she must be followed until the 
outcome of the pregnancy is known. 

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If pregnancy occurs, the Investigator must contact the Sponsor immediately for further 
instruction.  Both the detection and the outcome of the pregnancy must be reported to 
the Sponsor. 
9 
CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of human 
subjects are protected, that the reported trial data are accurate, complete, and 
verifiable, and that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), with Good Clinical Practice (GCP), and with applicable 
regulatory requirement(s). 
A Clinical Monitoring Plan will describe in detail who will conduct the monitoring, at what 
frequency monitoring will be done, at what level of detail monitoring will be performed, 
and the distribution of monitoring reports.  
10 
STATISTICAL CONSIDERATIONS  
10.1 STATISTICAL AND ANALYTICAL PLANS 
A Statistical analysis Plan (SAP) will be written and signed-off prior to the first subject 
being enrolled in the study.  The SAP will include a comprehensive description of the 
statistical methods and analyses to be included in the final study report.  Any change 
to the analysis methods described in the protocol will require an amendment only if it 
changes a principal feature of the protocol. Any other change to the analysis methods 
described in the protocol, and the justification for making the change, will be 
described in the SAP. 
Tabulations of summary statistics, graphical presentations, and statistical analyses 
will be performed using SAS software version 9.4.  The statistical analyses will be 
based on data pooled across subject and wound characteristics and presented in 
aggregate; a separate series of analyses will retain specific subject and wound 
characteristics found to be significant covariates in response.  All subset summary 
tables and data listings will be sorted by subject. The pre-procedure observations will 
be used as the baseline value for calculating post-procedural changes from baseline. 
Statistical significance will be declared if the two-sided probability value is <0.05; tests 
for interaction will be performed at the 0.1 alpha level.  Asymptotic confidence limits will 
be presented based on the normal approximation to the binomial distribution for 
differences in proportions.  Exact confidence intervals will be used for all other 
presentations. All computations will be performed using SAS® (Version 9.4 or higher).   

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10.2 STATISTICAL HYPOTHESES 
Primary Efficacy Endpoint(s):  
The primary endpoint of the study is the incidence of complete wound closure by 12 
weeks between Group 1 and Group 2.  The comparison between the randomized 
groups will be based on the overall incidence of complete closure.  
Ho: Incidence of complete wound closure by 12 weeks in Group 1 = Incidence 
of complete wound closure by 12 weeks in Group 2 
Ha: Incidence of complete wound closure by 12 weeks in Group 1 ≠ Incidence  
of complete wound closure by 12 weeks in Group 2 
Secondary Efficacy Endpoint(s):  
The first secondary endpoint is the change in wound size, measured in cm2 per week.  
The null and alternative hypotheses are presented below. 
Ho: Change in the wound surface area in Group 1 = Change in the wound 
surface area in Group 2 
Ha: Change in the wound surface area in Group 1 ≠ Change in the wound 
surface area in Group 2 
The second secondary endpoint is the time to complete wound closure, in days, 
between Group 1 and Group 2.  The null and alternative hypotheses are presented 
below. 
Ho: Median time to complete closure in Group 1 = Median time to complete 
closure in Group 2 
Ha: Median time to complete closure in Group 1 ≠ Median time to complete 
closure in Group 2 
The third secondary endpoint is the incidence of wound recurrence after healing is 
complete at 26 weeks and 52 weeks (6 & 12 months post intervention initiation).  The 
null and alternative hypotheses are presented below. 
Ho: Incidence of wound recurrence after healing at 26 weeks in Group 1 = 
Incidence of wound recurrence after healing at 26 weeks in Group 2 
Ha: Incidence of wound recurrence after healing at 26 weeks in Group 1 ≠ 
Incidence of wound recurrence after healing at 26 weeks in Group 2 

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Ho: Incidence of wound recurrence after healing at 52 weeks in Group 1 = 
Incidence of wound recurrence after healing at 52 weeks in Group 2 
Ha: Incidence of wound recurrence after healing at 52 weeks in Group 1 ≠ 
Incidence of wound recurrence after healing at 52 weeks in Group 2 
The fourth secondary endpoint is the changes in subject reported outcomes (quality of 
life surveys & visual analogue scale), pre- intervention to post- intervention. The null 
and alternative hypotheses are presented below. 
Ho: Change in the subject reported outcomes in Group 1 = Change in subject 
reported outcomes in Group 2 
Ha: Change in the subject reported outcomes in Group 1 ≠ Change in the 
subject reported outcomes in Group 2 
The fifth secondary endpoint is the incidence of adverse events (serious and non-
serious) related to DFU throughout the duration of the study and compared between 
randomized groups.  The null and alternative hypotheses are presented below. 
Ho: Change in the overall incidence of DFU-related adverse events in Group 1 
= Change in the overall incidence of DFU-related adverse events in Group 
2 
Ha: Change in the overall incidence of DFU-related adverse events in Group 1 
≠ Change in the overall incidence of DFU-related adverse events in Group 
2 
Ho: Change in the incidence of serious DFU-related adverse events in Group 1 
= Change in the incidence of serious DFU-related adverse events in Group 
2 
Ha: Change in the incidence of serious DFU-related adverse events in Group 1 
≠ Change in the incidence of serious DFU-related adverse events in 
Group 2 
Health Economic Outcome(s):  
There are 4 specific outcomes that will be summarized in this clinical investigation.  
The summary statistics that will be calculated will facilitate a comparison of the point 
estimates and variability. No formal hypothesis testing will be conducted to compare 
the 2 groups.  However, the summary statistics and appropriate confidence intervals 
will be presented in a graphical format to examine the differences between the 
intervention and standard of care groups.   

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A summary of the 4 health economic outcome parameters is presented below. 
• Summary of the changes in the prescription of  narcotics related to the DFU(s) by 
subject and between randomized groups 
• Summary of the changes in ambulatory status (i.e. bed, wheel chair, walk w/ 
assistance, or walk independent) by subject and between randomized groups 
• Summary of the changes in “return to work/reported work status”, activities of 
daily living, or disability status by subject and between randomized groups 
• Summary of the direct costs  as measured by total cost per subject stratified by 
healed vs. non-healed DFU 
 
10.3 ANALYSIS DATASETS 
Safety Population - The Safety population will include all subjects receiving any 
investigational product. The safety population will be used for the safety analysis.  
Intention-to-Treat (ITT) Population - The ITT population will include all subjects in the 
Safety population with at least one post-baseline efficacy data point. The ITT population 
will be used for the primary efficacy analysis.  
Per Protocol (PP) Population - The PP population will consist of subjects in the ITT 
population who did not have major protocol violations. The review of protocol violations, 
which will be defined in the statistical analysis plan (SAP), will be performed and signed 
off prior to study database lock. The primary efficacy analysis and the secondary 
analysis will be conducted on the PP population as part of a sensitivity analysis.  
Specific algorithms for imputing missing or partially missing dates will be discussed in 
the Statistical Analysis Plan.  Derived data will be identified in the individual subject data 
listings. Imputed data for dates will not be incorporated into the case report form 
datasets.  Imputed data for dates will be used in the preparation of the derived datasets.  
All recorded data will be presented in the individual data listings. 
10.4 DESCRIPTION OF STATISTICAL METHODS 
10.4.1 
 GENERAL APPROACH 
The observed data will be used for analysis.  Specific algorithms for imputing missing or 
partially missing dates will be discussed in the Statistical Analysis Plan.  Derived data 
will be identified in the individual subject data listings. Imputed data for dates will not be 
incorporated into the case report form datasets.  Imputed data for dates will be used in 
the preparation of the derived datasets.  All recorded data will be presented in the 
individual data listings. 

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The pre-procedure observations will be used as the baseline value for calculating post-
procedural changes from baseline.   
Continuous demographic parameters, such as the age of the subject at the time of 
enrollment, will be summarized for the ITT population using descriptive statistics (N, 
mean, median, standard deviation, minimum and maximum value, and 2-sided 95% 
confidence limits). Categorical demographic parameters, such as gender, will be 
summarized as a proportion of the ITT population using Clopper-Pearson 2-sided 95% 
confidence limits. 
Adverse events will be coded according to the MedDRA system dictionary. The 
percentage of subjects experiencing adverse events will be summarized by body 
system and preferred term.  Subject counts will be tabulated for all adverse events for 
the ITT population.  Adverse events will also be tabulated for events that occurred 
following initial treatment application through final study visit.  Tabulated subject counts 
will be presented as a proportion of the ITT population with 95% binomial confidence 
intervals.   
10.4.2 
 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
The primary efficacy analysis population will be subjects in the ITT population who have 
any wound measurement data following randomization. For all statistical and data 
analyses, wound measurement data and confirmation of wound closure will be obtained 
from an independent wound core lab or clinical assessor based on the photograph of 
the wound and the assessment of the investigator (closed vs. not closed). For data 
analyses, complete wound closure requires confirmation at 3 weeks(≥ 21 days) post 
clinically apparent wound closure.   The date of complete wound closure for those that 
have confirmed closure will be the date that it was clinically apparent (up to and 
including 12 weeks post Randomization Day).   
The primary efficacy analysis will compare the proportion of subjects who achieve 
complete target ulcer closure within 12 weeks after the first study intervention using a 
random-effects generalized linear model specifying the distribution of the dependent 
variable as binomial. Results from this analysis are expected to approach the test 
statistic used to derive the sample size estimates. 
10.4.3  
ANALYSIS OF THE SECONDARY AND TERTIARY ENDPOINT(S) 
For the secondary efficacy endpoints, the change in the wound size, measured in cm2, 
will be calculated on an intra-subject basis for each post-baseline measurement.  The 
mean change per week will be calculated for each subject and compared between the 
intervention and standard of care groups using a random-effects generalized linear 

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model specifying the distribution of the dependent variable as continuous.  The time to 
complete wound closure will be calculated in days from the date of the initial study 
intervention and compared between the intervention and standard of care groups using 
a log-rank test.  Subjects who fail to achieve complete wound closure will be censored 
using the last date of examination in the study.  Wound recurrence after healing is 
complete at 26 weeks and 52 weeks will be tabulated by group and the proportions will 
be compared between intervention and standard of care groups using a 2-tailed Fisher’s 
exact test.  The time to wound recurrence will also be compared between the 
intervention and standard of care groups.  Changes in subject reported outcomes will be 
summarized and compared based on the distribution of the data.  A random-effects 
generalized linear model, specifying the distribution of the dependent variable based on 
the type of data, will be used to compare the results over time between the intervention 
and standard of care groups. 
The incidence of adverse events related to DFU recorded during the course of the study 
will be totaled by intervention group and compared between randomized groups using a 
generalized linear model and specifying the distribution as binomial.  A separate 
tabulation will be prepared comparing the overall incidence of all adverse events, and 
restricted to serious adverse events.  
The first health economic outcome parameter to be summarized is the change from 
baseline in the prescription of narcotics related to the DFU(s) by subject and between 
randomized groups.  The summary statistics will be calculated using the daily dosage 
converted into morphine equivalent units, averaged over successive 7-day intervals 
from the time of study enrollment until week 52.  The average 7-day changes will be 
summarized by group assignment. 
The second health economic outcome parameter is the intra-subject change in 
ambulatory status (i.e. bed, wheel chair, walk w/ assistance, or walk independent).  
The distribution of subjects by ambulatory status (improved, no change, worse) at 12, 
26 and 52 weeks will be summarized by group.  The 2-sided 95% exact binomial 
confidence intervals will be summarized by ambulatory status category and treatment 
group.  The time to a change in status (improved status and worsening status) will 
also be summarized using K-M estimates and compared between the intervention and 
standard of care groups using a log-rank test.  
The third health economic outcome includes work status, disability status, and 
activities of daily living.  The change in “return to work/reported work status” or 
disability status as defined by the investigator’s evaluation of the subject’s ability to 
return to work related to their DFU status will be derived for each subject and 
compared between randomized groups.  It is expected a measureable proportion of 
the subjects may not be employed at the time of enrollment for reasons not related to 

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their DFU.  Shift tables will be prepared by intervention and standard of care only 
assignment based on sequential 30 day intervals to categorize the proportion of 
subjects who transition from not working because of the DFU to working following 
study intervention  for the DFU.  Separately, the time to return to work will be 
summarized using descriptive statistics and Kaplan-Meier estimates.  Finally, the 
investigator will be asked to provide the date of the examination where the subject is 
cleared to return to work, independent of the subject’s actual work status.  Using this 
date, the number of days from the date of enrollment will be summarized by 
intervention assignment using descriptive statistics and summarized by intervention 
group using Kaplan-Meier estimates.  This tabulation will include all subjects, 
independent of the subject being employed prior to enrollment into the study. 
The scores from the Activities of Daily Living questionnaire will be summarized each 
time the questionnaire is administered.  The actual scores, and the changes from 
scores recorded at baseline, i.e., prior to study intervention, will be summarized using 
descriptive statistics and compared between the intervention and standard of care 
only groups using an analysis of variance test.  
The fourth health economic outcome is the total direct cost per DFU by intervention and 
standard of care only group assessed during the treatment period.  The total intra-
subject direct cost will include the wound care time (physician time, nursing time, 
procedural time, application of products dressing time, application of off-loading device, 
etc.) and will be modeled over sequential 30 day intervals culminating at the end of the 
intervention phase; additional factors that are known predictors of healing, along with 
specific data about the size, depth, and location of the ulcer will be added to the model 
to derive an estimated direct intervention cost.  
10.4.4 
 SAFETY ANALYSES 
Safety will be assessed by physical examinations, clinical laboratory tests and collection 
of AEs as outlined in the Schedule of Events.  All summaries of AEs will be based on 
intervention-emergent adverse events, which will be coded according to the MedDRA 
system dictionary. The number and percentage of subjects experiencing adverse events 
will be summarized by body system organ class and description.  Subject counts will be 
tabulated for all intervention- emergent adverse events for the ITT population.  Adverse 
events will also be tabulated for events that occurred following initial treatment 
application through final study visit. Summaries by maximum severity and relationship to 
the study intervention will also be provided.  SAEs and AEs leading to discontinuation 
from the study will be presented by system organ class and preferred term.  Tabulated 
subject counts will be presented as a proportion of the ITT population with 95% binomial 
confidence intervals.   

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Adverse events will be coded using MedDRA.  Verbatim description of the adverse 
events and the MedDRA System Organ Class (SOC) and Preferred Term (PT) for all 
AEs will be contained in the subject data listings.  A separate listing sorted by MedDRA 
SOC and PT will include all verbatim descriptions associated with each SOC/PT 
category.  All reported AEs  will be included in by-subject AE listings.  A separate listing 
will be created with all the distinct levels of SOC, Preferred Terms and the verbatim 
investigator description reported in the study. Sorting will be alphabetically by SOC, 
Preferred Term and then verbatim description.  
The incidence of  AEs will be presented using counts and percentages of subjects with 
AEs and tabulated by SOC and PT. SOC will be sorted alphabetically and PT within 
SOC will be sorted by descending frequency based on the incidence across subjects 
overall. If a subject has multiple occurrences (start and stop) of an event associated 
with a specific SOC or PT within a SOC, a subject will only be counted once in the 
incidence count for the SOC or PT within SOC respectively. 
The following specific summary tables may be generated: 
• Overall incidence of adverse events 
• Incidence of AEs by SOC overall and by PT within each SOC  
• Incidence of  AEs related to Intervention by SOC overall and by PT within each 
SOC 
• If a subject reports two or more adverse events that code to the same PT, the 
event with the maximum relationship will be included in the table. AEs with a 
missing relationship will be assumed to be intervention related. 
• Incidence of AEs by Maximum Severity, SOC overall and by PT within each 
SOC 
• If a subject reports two or more adverse events that code to the same PT, the 
event with the maximum severity will be included in the table. AEs with a 
missing severity will be assumed to be severe. 
• Incidence of  AEs occurring in ≥ 5% of subjects in at least one intervention group 
by SOC overall and by PT within each SOC 
• Incidence of intervention-related AEs occurring in ≥ 5% of subjects in at least 
one intervention group by SOC overall and by PT within each SOC 
• Incidence of Serious  AEs by SOC overall and by PT within each SOC 
• Incidence of AEs leading to treatment discontinuation by SOC overall and by PT 
within each SOC 
Deaths, other SAEs, and AEs leading to treatment discontinuation, dose interruption, or 
dose reduction will be listed including the intervention group and dosing information (if 
applicable), start and stop dates/times of the AE, and days on study relative to the day 
of exposure to the study product.   

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10.4.5  
ADHERENCE AND RETENTION ANALYSES 
The number and proportion of subjects eligible for and compliant with each follow-up 
examination will be presented.  Subjects who withdraw from the study will be tabulated 
with reasons for withdrawal.  The primary presentation of the results for the ITT 
population will be based on the observed data with imputation for missing endpoint data 
using the last recorded observation.  Compliance and device duration will be 
summarized using descriptive statistics (N, mean, median, standard deviation, minimum 
and maximum value, and 2-sided 95% confidence limits). 
10.4.6 
BASELINE DESCRIPTIVE STATISTICS 
Baseline is defined as the observations recorded  prior to the application of study 
intervention.  Continuous demographic parameters, such as the subject’s age at the 
time of enrollment, will be summarized for the ITT population using descriptive statistics 
(N, mean, median, standard deviation, minimum and maximum value, and 95% two-
sided confidence limits) and compared between groups using a two-sample t-test.  
Categorical demographic parameters, such as gender, will be summarized as a 
proportion of the ITT population and compared using a two-tailed Fisher’s exact test.  
Co-morbid risk factors will be summarized for the ITT population by intervention 
assignment and according to the type of variable (categorical, continuous) and 
compared between groups.  Kaplan-Meier estimates for time-to-event analyses will be 
prepared based on the ITT population.  Separate tables containing subject counts, 
percentages, and 95% binomial confidence limits will be prepared based on individual 
risk factors.   
10.4.7 
 PLANNED INTERIM ANALYSES  
A sample size re-estimation will be performed when 50% of the target population or 60 
subjects have completed the intervention / evaluation period (confirmed complete 
wound closure or no confirmed wound closure by Visit 13) of the study to derive the 
primary endpoint results.  
10.4.7.1 
SAFETY REVIEW 
The clinical investigator will be responsible for monitoring the safety of the subjects on 
an ongoing basis. 
10.4.7.2 
EFFICACY REVIEW 
Efficacy will be based on the results from the final analysis of the primary endpoint. 
10.4.8 
ADDITIONAL SUB-GROUP ANALYSES 

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All sub-group analyses will be described in the SAP. 
10.4.9 
MULTIPLE COMPARISON/MULTIPLICITY 
There is a single primary endpoint and no multiple testing will be performed. 
10.4.10 
TABULATION OF INDIVIDUAL RESPONSE DATA 
The method for presenting the individual response data will presented in the SAP. 
10.4.11 
EXPLORATORY ANALYSES 
All exploratory analyses will be described in the SAP. 
10.5 SAMPLE SIZE 
The maximum number of subjects to be enrolled into this clinical investigation is 150 
subjects; the target sample size is 120 subjects, based on a difference in the proportion 
of responders of 25% and a power approaching 80%.   
Estimates were prepared based on the primary endpoint considering a type 1 error rate 
of 5%.  A 25% difference in the incidence of response was used to estimate the 
statistical power over a range of sample sizes from 100 to 150 subjects.  To address 
concerns regarding the reliability of the estimates of intervention effectiveness, an 
adaptive mid-course sample size re-estimation procedure will be performed when 50% 
of the subjects have completed the 12 week study or withdrawn prematurely.  The data 
for the re-estimation of sample size will be unblinded for the independent biostatistician; 
the sample size will be increased based on promising conditional power; therefore, 
there will be no inflate of the type I error[2].  
Table 1 presented below contains 6 scenarios considering total sample sizes from 100 
to 150 subjects.   
Table 1: Power Estimates based on a Type 1 Error Rate of 5% and a 2:1 
Randomization Ratio (active: control) 
Scenario 
Power 
Total 
Sample 
Size 
Sample 
Size / 
Active 
Intervention 
Sample 
Size / 
Control 
Incidence 
of Closure / 
Active 
Intervention 
(%) 
Incidence 
of Closure 
/ Control 
(%) 
1 
0.700 
100 
67 
33 
45% 
20% 
2 
0.740 
110 
73 
37 
45% 
20% 
3 
0.787 
120 
80 
40 
45% 
20% 
4 
0.818 
130 
86 
44 
45% 
20% 
5 
0.844 
140 
93 
47 
45% 
20% 

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6 
0.874 
150 
100 
50 
45% 
20% 
With a target sample size of 120 subjects, if the difference in the incidence of response 
was 25% with exactly 45% of the subjects in Group 1 responding and 20% of the 
subjects in Group 2 responding, the power would be just under 80%.  The re-estimation 
of the sample size by the independent biostatistician is designed to ensure adequate 
power for the final analysis if the results are promising at the interim assessment.  
10.6 MEASURES TO MINIMIZE BIAS 
The methods for assessing bias will be described in the SAP. 
10.6.1 
RANDOMIZATION 
Subjects will be randomized using a permuted block randomization scheme in a 2:1 
ratio of Cytal to SOC.   
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE 
DATA/DOCUMENTS 
Data collection is the responsibility of the clinical trial staff at the site under the 
supervision of the site Principal Investigator.  The Investigator is responsible for 
ensuring the accuracy, completeness, legibility, and timeliness of the data reported.  
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.  When making changes or corrections, cross out the original entry 
with a single line, and initial and date the change. DO NOT ERASE, OVERWRITE, OR 
USE CORRECTION FLUID OR TAPE ON THE ORIGINAL. 
Study personnel at each site will enter data from source documents corresponding to a 
subject’s visit into the protocol-specific CRF when the information corresponding to that 
visit is available.  Subjects will not be identified by name in the study database or on any 
study documents to be collected by the Sponsor (or designee), but will be identified by a 
subject number and initials. 
It is the responsibility of the Investigator to maintain adequate and accurate eCRFs 
designed by the Sponsor to record all observations and other data pertinent to the 
clinical investigation. All paper documentation should be completed in their entirety in a 
neat, legible manner to ensure accurate interpretation of data; black or blue ink should 
be used to ensure the clarity of the reproduced copy of all documentation. Should a 
correction be made, the information to be modified must not be overwritten. The 
corrected information will be transcribed by the authorized person next to the previous 

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value, initialed and dated, and the corrected documentation should be verified again by 
the monitor. 
The handling of the data by the Sponsor after review of the eCRFs may generate 
additional requests to which the Investigator is obliged to respond by confirming or 
modifying the data questioned. 
Participating site(s) will maintain appropriate medical and research records for this trial, 
in compliance with ICH E6 and regulatory and institutional requirements for the 
protection of confidentiality of participants. Each site will permit authorized 
representatives of the Sponsor or designee, and regulatory agencies to examine (and 
when permitted by applicable law, to copy) clinical records for the purposes of quality 
assurance reviews, audits, and evaluation of the study safety, progress, and data 
validity.   
Source data are all information, original records of clinical findings, observations, or 
other activities in a clinical trial necessary for the reconstruction and evaluation of the 
trial. Examples of these original documents and data records include, but are not limited 
to: hospital records, clinical and office charts, laboratory notes, memoranda, 
participants’ memory aids or evaluation checklists, pharmacy records, recorded data 
from automated instruments, , and participant files and records kept at the pharmacy, at 
the laboratories, and medico-technical departments involved in the clinical trial.  
The SF-20 Health Survey, DFS-SF, and VAS for Pain will be considered source 
documents and also act as the original CRFs. 
12 
QUALITY ASSURANCE AND QUALITY CONTROL 
Quality Control (QC) procedures will be implemented beginning with the data entry 
system and data QC checks that will be run on the database.  Any missing data or 
data anomalies will be communicated to the site for clarification/resolution.  
Following written Standard Operating Procedures, the monitors will verify that the 
clinical trial is conducted and data are generated, documented (recorded), and reported 
in compliance with the protocol and GCP.    
The site will provide direct access to all trial related materials, including source 
data/documents, electronic medical records (if applicable), CRFs, and reports for the 
purpose of monitoring and auditing by the Sponsor and/or the IRB. 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS  
13.1 ETHICAL STANDARD  

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The Investigator will ensure that this study is conducted in full conformity with 
Regulations for the Protection of Human Subjects of Research codified in 45 CFR Part 
46, 21 CFR Part 50, 21 CFR Part 56, and/or the ICH E6.  
13.2   LAWS AND REGULATIONS 
This clinical study will be conducted in compliance with all national laws and regulations 
of the countries in which the clinical trial is performed, as well as any applicable 
guidelines. The trial will be registered on www.clintrials.gov and on other sites, as 
appropriate. 
13.3 INSTITUTIONAL REVIEW BOARD  
The protocol, informed consent form(s), and all participant materials will be submitted to 
the IRB for review and approval.  Approval of both the protocol and the consent form 
must be obtained before any participant is enrolled.  Any amendment to the protocol will 
require review and approval by the IRB before the changes are implemented to the 
study.  All changes to the consent form will be IRB approved; a determination will be 
made regarding whether previously consented participants need to be re-consented. 
13.4 INFORMED CONSENT PROCESS  
Informed consent is a process that is initiated prior to the individual’s agreeing to 
participate in the study and continues throughout the individual’s study participation.  
Extensive discussion of risks and possible benefits of participation will be provided to 
the participants and their families.  Consent forms will be IRB approved and the 
participant will be asked to read and review the document.  The Investigator will explain 
the research study to the participant and answer any questions that may arise.  All 
participants will receive a verbal explanation in terms suited to their comprehension of 
the purposes, procedures, and potential risks of the study and of their rights as research 
participants.  Participants will have the opportunity to carefully review the written 
consent form and ask questions prior to signing.  The participants should have the 
opportunity to discuss the study with their surrogates or think about it prior to agreeing 
to participate.  The participant will sign the informed consent document prior to any 
procedures being done specifically for the study.  The participants may withdraw 
consent at any time throughout the course of the trial.  A copy of the informed consent 
document will be given to the participants for their records.  The rights and welfare of 
the participants will be protected by emphasizing to them that the quality of their medical 
care will not be adversely affected if they decline to participate in this study. 
If a consent document is revised due to changes in study procedures, subjects who 
were enrolled prior to the change, but are affected by the change, will be informed of the 

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changes and will sign the amended consent document.  If a consent document is 
revised due to changes in the risks or safety of the study, all active participants must 
sign the revised consent. 
13.5 PARTICIPANT AND DATA CONFIDENTIALITY  
Participant confidentiality is strictly held in trust by the participating Investigator(s), their 
staff, the Sponsor and their agents.  The study protocol, documentation, data, and all 
other information generated will be held in strict confidence.  No information concerning 
the study or the data will be released to any unauthorized third party without prior 
written approval of the Sponsor. 
The study monitor, other authorized representatives of the Sponsor, and/or 
representatives of the IRB may inspect all documents and records required to be 
maintained by the Investigator for the participants in this study.  The clinical study site 
will permit access to such records.  
The study participant’s contact information will be securely stored at the clinical site 
for internal use during the study.  At the end of the study, all records will continue to 
be kept in a secure location for as long a period as dictated by the local IRB and 
Institutional regulations.  
14 
DATA HANDLING AND RECORD KEEPING  
14.1 STUDY RECORDS RETENTION  
All study documents (subject files, signed informed consent forms, Study Regulatory 
Binder, etc.) must be kept secured for a period of two years following completion of the 
study.  There may be other circumstances for which the Sponsor is required to maintain 
study records and, therefore, the Sponsor should be contacted prior to removing study 
records for any reason.  It is the responsibility of the Sponsor to inform the Investigator 
when these documents no longer need to be retained. 
14.2 PROTOCOL DEVIATIONS  
A protocol deviation is any noncompliance with the clinical trial protocol or GCP 
requirements. The noncompliance may be either on the part of the participant, the 
Investigator, or the study site staff. As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly.   
All protocol deviations/violations should be documented using the Protocol 
Deviations/Violations CRF and submitted to the IRB according to their reporting 
guidelines.   

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14.3 PUBLICATION AND DATA SHARING POLICY 
The preparation and submittal for publication of manuscripts containing the study results 
shall be in accordance with a process determined by mutual written agreement among 
the study Sponsor and participating institutions.  The publication or presentation of any 
study results shall comply with all applicable privacy laws, including, but not limited to, 
the Health Insurance Portability and Accountability Act of 1996.  
 
15 
CONFLICT OF INTEREST POLICY 
The independence of this study from any actual or perceived influence, such as by the 
device industry, is critical. Therefore any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed.  Furthermore, persons who have a perceived conflict of 
interest will be required to have such conflicts managed in a way that is appropriate to 
their participation in the trial.  The study leadership has established policies and 
procedures for all study group members to disclose all conflicts of interest and will 
establish a mechanism for the management of all reported dualities of interest. 
 
 

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16  
LITERATURE REFERENCES  
1. American Diabetes Association (ADA). (2017). Statistics about diabetes: Overall 
numbers, diabetes and prediabetes. Retrieved from: 
http://www.diabetes.org/diabetes-basics/statistics/ 
2. Chen, Y. N., DeMets, D. L., Lann, K. K. (2004). Increasing the sample size when the 
unblended interim result is promising. Statistics in Medicine, 23(1), 1023-1038. 
3. Dumville, J. C., O’Meara, S., Deshpande, S., & Speak, K. (2013). Hydrogel dressing 
for healing diabetic foot ulcers (review). Cochrane Database of Systematic Reviews, 
7(1), 1-52. doi: 10.4002/14651858.CD009101.pub3. 
4. Gordon, K. A., Lebrun, E. A., Tomic-Canic, M., & Kirsner, R. (2012). The role of 
surgical debridement in healing of diabetic foot ulcers. SKINmed, 10(1), 24-26.  
5. Iraj, B., Khorvash, F., Ebneshahidi, A., & Askari, G. (2013). Prevention of diabetic foot 
ulcer. International Journal of Preventative Medicine, 4(3), 373-376. 
6. Margolis, D. J., Malay, S., Hoffstad, O. J., Leonard, C. E., MaCurdy, T., Tan, Y., 
Molina, T., Lopez de Nava, K., & Siegel, K. L. (2011). Economic burden of diabetic 
foot ulcers and amputations: Data points #3. Data Points Publication Series [Internet]. 
Rockville, MD: Agency for Healthcare Research and Quality (US). 
7. Margolis, D. J., Kantor, J., Berlin, J. A. (1999). Healing of diabetic neuropathic foot 
ulcers receiving standard treatment. Diabetes Care, 22(5), 692-695. 
8. Rice, J. B., Desai, U., Cummings, A. K., Birnbaum, H. G., Skornicki, M., & Parson, N. 
B. (2014). Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes 
Care, 27(1), 651-658. 
9. Veves, A, Sheehan, P., Pham, H. T. (2002). A randomized, controlled trial of 
Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard 
treatment in the management of diabetic foot ulcers. Archives of Surgery, 137(7), 
822-827.  
10. Veves, A., Falanga, V., & Armstrong, D. G. (2001). Graftskin, a human skin 
equivalent, is effective in the management of noninfected neuropathic diabetic foot 
ulcers: A prospective randomized multicenter clinical trial. Diabetes Care, 24(2), 290-
295. 
11. Wu, L., Norman, G., Dumville, J. C., O’Meara, S., Bell-Syer, S. E. (2015). Dressing 
for treating foot ulcers in people with diabetes: An overview of systematic reviews 
(review). Cochrane Database of Systemic Reviews, 7(1), 1-62.  

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12. Yazdanpanah, L., Nasiri, M., Adarvishi, S. (2015). Literature review on the 
management of diabetic foot ulcer. World Journal of Diabetes, 6(1), 37-53. 
13. Zelen, C. M., Orgill, D. P., Serena, T., Galiana, R., Carter, M. J., DiDomenico, L. A., 
Keller, J., Kaufman, J., & Li, W. W. (2017). A prospective, randomized, controlled, 
multicenter clinical trial examining healing rates, safety and cost to closure of an 
acellular reticular allogenic human dermis versus standard of care in the treatment of 
chronic diabetic foot ulcers. International Wound Journal, 14(2), 307-315. doi: 
10.1111/iwj.12 
14. Bann, C. M., Fehnel, S. E., & Gagnon, D. D. (2003). Development and validation of 
the diabetic foot ulcer scale-short form (DFS-SF). Pharmacoceconomics, 21(17), 
1277-1290. 
15. Bann, C. M., Fehnel, S. E., & Gagnon, D. D. (2003). Development and validation of 
the diabetic foot ulcer scale-short form (DFS-SF). Pharmacoceconomics, 21(17), 
1277-1290.  
16.  Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., & Jaffe, M.W., 1963. Studies of 
illness in the age. The index of ADL: a standardized measure of biological and 
psychological function. Journal of the American Medical Association, 185, 914–919. 
 
 
 
 
 
 
 

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APPENDIX I: SCHEDULE OF EVENTS 
Parameters 
Run-In  
Visit 1 
Day -14 (+/- 
2 days)  
Run-In 
Visit 2 
Day -7 (+/- 
2 days) 
V1 
Enrollment/ 
Randomization  
Day 0 (+/- 2 days) 
 
 
V2  
7 days (+/- 2 days) 
V3 
14 days (+/- 2 days) 
V4  
21 days (+/- 2 days) 
V5  
28 days (+/- 2 days) 
V6  
35 days (+/- 2 days) 
V7 
42 days (+/- 2 days) 
V8  
49 days (+/- 2 days) 
V9  
56 days (+/- 2 days) 
V10  
63 days (+/- 2 days) 
V11  
70 days (+/- 2 days) 
V12  
77 days (+/- 2 days) 
V13 
84 days (+/- 2 
days) 
Confirmation 
Closure 1 
Confirmation 
Closure 2 
Confirmation 
Closure 3 
Final Visit 1 
26 Weeks 
(+/- 2 weeks) 
Final Visit 2 
52 Weeks 
(+/- 2 weeks) 
Informed Consent  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assign Subject ID 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inc/Exc Criteria 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Employment/ Disability/Ambulatory  
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
Height, Weight1, BMI 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Med/Surg/Social History 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Con Meds Log 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Wagner Ulcer Classification 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum Creatinine 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HbA1C Draw 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
X 
X 
Pre-Albumin Draw  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Albumin Draw 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
 
X 
X 
X 
Randomization  
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test  
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AEs/SAE Eval  
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ABI Eval2 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Product Application 
 
 
10 Applications in a 12 Week (84 day) Period 
 
 
 
 
 
DFS-SF Admin 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
KATZ-ADL Admin 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
X 
X 
SF-20 Admin 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
X 
X 
VAS Admin 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Offloading Instruction and Documentation 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Closure Assessment 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Recurrence Assessment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
1Record weight and BMI at study visit wound healing is initially observed.    
Closure Confirmation Visit 1 – Within 7 days to 91 Days Post Initial Product App After Healing 
 
2Record ABI PRN for non-healing wounds.  Laboratory tests as well as ABIs performed during 
the Run In period may be used at Study Visit 1 for confirmation of eligibility.  
Closure Confirmation Visit 2 – Within 14 days to 98 Days Post Initial Product App After Healing 
 
. 
Closure Confirmation Visit 3 – Within 21 days to 105 Days Post Initial Product App After Healing 
 

ACell Confidential  
 
Page 58 of 59 
APPENDIX II: STATEMENT OF COMPLIANCE 
The trial will be conducted in accordance with the ICH E6, the United States (US) Code of Federal 
Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, and 21 
CFR Part 812. 
The Principal Investigator will assure that no deviation from, or changes to the protocol will take place 
without prior agreement from the Sponsor and documented approval from the Institutional Review Board, 
except where necessary to eliminate an immediate hazard(s) to the trial participants. All personnel 
involved in the conduct of this study have completed Human Subjects Protection Training. 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitments. 
 
Signature of Principal Investigator 
Date (mm/dd/yy) 
 
 
Printed Name 
 
 
Name of Institution 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Protocol # CR2017-006                                                                                                          Version 3.0 27 AUG 2019 
ACell Confidential 
 
Page 59 of 59 
 
APPENDIX III: OPTIMA DIAB BOOTS USER’S GUIDE 
 
 
 
 
 
See attachment.