A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament Reconstruction Using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior Cruciate Ligament Reconstruction
Phase: NA
Conditions: ACL Tear
Sponsor: Andrews Research & Education Foundation

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
Version Date: 16AUG2022 
 
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Title: A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care 
Anterior Cruciate Ligament Reconstruction 
 
Principal Investigator:  
Adam Anz, M.D.  
 
Co-Investigators:  
 
Steve Jordan, MD 
Roger Ostrander, MD 
Jessica Truett, MA, BCBA 
Nicholas A. Ott, MD 
Travis Roth, M.D. 
 
Research Team:  
 
Chandler Bridges, MS 
Joshua Cook, BS 
Victoria Williams 
 
 
Funding Mechanism:   
State of Florida Grant 
 
Institution(s):   
 
Andrews Research & Education Foundation (AREF) 
 
 
 
 
1020 Gulf Breeze Pkwy 
 
 
 
 
Gulf Breeze, FL 32561 
 
 
 
 
(850) 916- 8590 
 

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
Version Date: 16AUG2022 
 
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Contents 
1 
Background / Scientific Rationale ..................................................................................................... 5 
2 
Objectives ............................................................................................................................................. 7 
2.1 Primary Objective ............................................................................................................................... 7 
2.2 Primary Effectiveness Endpoint .......................................................................................................... 7 
3  
Hypotheses ........................................................................................................................................... 7 
3.1 Null Hypothesis .................................................................................................................................. 7 
3.2 Alternative Hypothesis ........................................................................................................................ 7 
4 
Study Design and Procedures ............................................................................................................ 8 
4.1 Intraoperative Tissue Harvest and Application ................................................................................... 8 
4.2 Post-operative Evaluation and Treatment Plan ................................................................................... 8 
4.3 Magnetic Resonance Imaging ............................................................................................................. 9 
4.4 Functional Testing Algorithm ............................................................................................................. 9 
5 Patient Reported Outcome Measures (PROMs) ................................................................................... 9 
5.1 Tampa Kinesiophobia Scale (TKS): ................................................................................................. 10 
5.2 International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC): ........... 10 
5.3 Patient Reported Outcomes Measurements Information Systems (PROMIS): ................................ 10 
5.4 Single Assessment Numeric Evaluation (SANE): ............................................................................ 10 
6 
Participant Recruitment ................................................................................................................... 10 
6.1 Screening Process ............................................................................................................................. 11 
6.2 Participant Eligibility ........................................................................................................................ 11 
6.2.1 Inclusion Criteria: ...................................................................................................................... 11 
6.2.2 Exclusion criteria: ...................................................................................................................... 11 
6.3 Benefits ............................................................................................................................................. 11 
6.4 Compensation ................................................................................................................................... 12 
7 
Informed Consent 21 CFR 50 .......................................................................................................... 12 
7.1 Consent Withdrawal: ........................................................................................................................ 12 
8  
Review of Safety ................................................................................................................................ 12 
8.1 Adverse Event (AE) .......................................................................................................................... 12 

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
Version Date: 16AUG2022 
 
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8.2 Serious Adverse Event (SAE) ........................................................................................................... 13 
8.3 Unanticipated Problem (UP) ............................................................................................................. 13 
8.4 AE & SAE Collection and Reporting ............................................................................................... 14 
8.5 Expected Risks and Discomforts ...................................................................................................... 14 
9 
Data Management Procedures ......................................................................................................... 14 
10 
Data Analysis ................................................................................................................................. 15 
11 
Statistical Considerations ............................................................................................................. 15 
12  
Quality Control and Assurance ................................................................................................... 15 
12 
References ...................................................................................................................................... 16 
 
 
 

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
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Version Date: 16AUG2022 
 
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Abbreviations and Definitions 
ACL Anterior Cruciate Ligament 
AE Adverse Event 
AREF Andrews Research and Education Foundation  
BTB Bone-Patellar Tendon-Bone 
FTA Functional Testing Algorithm  
HIPAA Health Insurance Portability and Accountability Act 
ICF Informed Consent Form 
IRB Institutional Review Board 
LDSC Ligament Derived Stem Cell 
MRI Magnetic Resonance Imaging 
MSC Mesenchymal Stem Cell 
PCL Posterior Cruciate Ligament 
PI Principal Investigator  
PRP Platelet Rich Plasma 
SAE Severe Adverse Event  
SOC Standard of Care 
TDSC Tendon Derived Stem Cell 
Tg Transgenic 
UP Unanticipated Problem  
 

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
Version Date: 16AUG2022 
 
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1 
Background / Scientific Rationale 
The anterior cruciate ligament (ACL)’s anatomical importance is to act as a stabilizer of the knee 
joint during physical activity. This ligament is vitally important during high intensity sports. It is 
estimated that 250,000 ACL injuries occur in the United States per year (1, 2). Leathers Et. AL. 
found that patients who elect to undergo ACL reconstruction are at a six times greater risk of 
tearing the reconstructed graft within the first two years of ACL reconstruction surgery or within 
their return to sports in comparison to uninjured counterparts (3). This translates to 
approximately 8.5% of females and 10.5% of males having a tear of the ipsilateral ACL graft 
within two years of repair or their return to sports. With such high recurrence rates, it is 
paramount to develop methods to improve outcomes in patients who undergo ACL 
reconstruction. Bioaugmentation of ACL reconstruction may provide a method to achieve 
improved outcomes in this patient population.   
Orthopedic clinicians and researchers have taken interest in the underlying biology of healing, 
specifically regarding the application of orthobiologics to improve patient outcomes. 
Orthobiologics are a class of therapies that originate from biological products that can be applied 
at the point of care. Recent studies have focused on using a patient’s own tissues to improve 
current clinical and surgical methods (4, 5). With an increased focus on cell therapy to adjunct 
current practices, the orthopedic community is determined to develop the least-invasive, 
convenient, and cost-effective methods to harvest and use stem cells.  
Mesenchymal stem cells (MSCs) were first isolated from bone marrow, but they also can be 
isolated and are contained in synovial tissue, adipose tissue, injured ACL stump tissue, cartilage, 
and the ACL injury effusion (6-9). MSCs have shown exceptional promise regarding cellular 
proliferative potential, multipotentiality, and the ability to improve healing in animal models (10-
17). In humans, harvesting stem cells from tissues inside the knee joint has recently become a 
method of interest. Utilizing already available tissues which contain stem cells during 
arthroscopic knee surgery is particularly beneficial compared to trying to use cells from bone 
marrow, as bone marrow aspiration for harvest would require patients to undergo a longer 
duration of anesthesia and positional readjustment over the course of an operation.   
During surgery, injury effusion fluid, synovial tissue, and fat tissue found inside the knee are 
typically removed in order to visualize and repair structures. We recently evaluated this waste 
tissue in 30 individuals undergoing ACL reconstruction surgery. Culture analysis showed that 
the knee effusion contained 181 progenitor cells per ml, byproduct tissue contained a 
concentration of 429 progenitor cells per ml of tissue, and the byproduct fluid contained a 

 
 
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Cruciate Ligament Reconstruction 
 
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concentration of 14 cells per ml (14). Animal and human trials are emerging to suggest that 
autologous augmentation of ACL reconstruction deserves further development (21, 22). We 
recently completed a study describing the quantity of stem cell available from various waste 
tissues of ACL surgery: ACL stump, fat pad, bone debris, and cartilage debris. We determined 
that ACL stump tissue has the most potential to augment ACL reconstruction surgery.  
A review of recent studies shows that there is growing evidence in support of bioaugmentation 
for ACL repairs. Berdis Et. Al. recently published their results for 109 knees in 101 adolescent 
patients who underwent hamstring ACL reconstruction with bioaugmentation with PRP 
contained in a porous bovine collagen matrix carrier (23). A total of 132 patients (92%) returned 
to their preinjury level of competition, while 7 patients sustained a reinjury requiring revision 
surgery (5%). They concluded that biologic augmentation with hamstring autograft in ACL 
reconstruction led to a decreased rate of subsequent ACL injury, specifically regarding ACL 
revision surgery. Patients in this study also showed the ability to return to preinjury level of 
competition at a faster rate when compared to data from other studies (23, 24).  
The desired benefit of MSC therapy is to promote improved bone-to-tendon healing with better 
biomechanical properties and increased tissue maturity (25). Ligament derived stem cells 
(LDSC), such as those found in the ACL stump, and tendon derived stem cells (TDSC) have 
shown better tendon/ligament lineage-specific differentiation when compared to bone marrow 
counterparts (26). Studies on MSC-based therapies have provided growing evidence that 
damaged tissues express signaling molecules that act as chemoattractants to aid in the migration, 
adhesion, and infiltration of MSCs to sites of injury (27). Takeuchi Et. Al. studied the fate of 
endogenous cells in ACL graft infiltration in transgenic (Tg) pigs. They determined that 
eventually the endogenous cells proceeded to differentiate into spindle-shaped fibroblast-like 
cells with a uniform distribution, closely resembling the natural histology of the ACL (28). 
Nonetheless, future studies tracking MSC differentiation into fibroblasts and other cell types 
remain necessary.   
A key to determining the efficacy of bioaugmentation methods for ACL reconstruction is 
possessing the ability to accurately evaluate the healing and rehabilitation processes of the 
patient. Functional testing algorithms (FTA) are used for clinical decision making based on 
quantitative and qualitative testing and assessment to make clinical judgements to safely return 
patients back to pre-injury activity and strength. Therapists have developed a systematic 
guideline and criteria to return to sport based on systematic literature reviews and clinical 
experience (29). Evaluation with FTA provides the quantitative and qualitative criteria needed to 

 
 
A Randomized, Single Blinded Study of the Augmentation of Anterior Cruciate Ligament 
Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
Version Date: 16AUG2022 
 
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make an informed decision on progress towards returning to sports activity. In addition to FTA, 
magnetic resonance imaging (MRI) is a key analytical method used to provide quantifiable data 
on the quality of the ACL graft following reconstruction. Evaluation with MRI enables the 
physician to assess the integrity of the graft, placement within the tunnel, tunnel healing, and 
healing of the donor site. This information coupled with the functional assessment enables the 
healthcare team to determine a patient’s readiness to return to activity.    
2 
Objectives 
2.1 Primary Objective 
The primary objective of this study is to develop a cost-effective, autologous biologic 
augmentation technique for ACL reconstruction. The technique involves applying tissue 
harvested with the GraftNet from the patient’s ACL stump to an ACL autograft. This 
study is key to determining a reproducible and effective autologous biologic 
augmentation technique that can be utilized at the point-of-care during ACL 
reconstruction surgery.  
2.2 Primary Effectiveness Endpoint 
FTA results as well as measurements from MRI evaluation will be recorded and utilized 
to quantify the healing and ACL graft maturation processes. MRI evaluation will be 
performed in accordance with accepted ACL imaging protocols. This data will then be 
compared to FTA results and MRI evaluation from patients who did not undergo the 
bioaugmentation technique for ACL reconstruction.  
3  
Hypotheses 
3.1 Null Hypothesis 
H0 – Participants undergoing the proposed bioaugmentation technique for ACL 
reconstruction will not have improved healing times and graft maturation as evidenced by 
functional assessment scores and MRI evaluation when compared to matched participants 
who only underwent ACL reconstruction without bioaugmentation.  
3.2 Alternative Hypothesis  
H1 – Participants undergoing the proposed bioaugmentation technique for ACL 
reconstruction will have improved healing times and graft maturation as evidenced by 
functional assessment scores and MRI evaluation when compared to matched participants 
who only underwent ACL reconstruction without bioaugmentation. 

 
 
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Reconstruction using Stump-Derived Mesenchymal Stem Cells Versus Standard of Care Anterior 
Cruciate Ligament Reconstruction 
 
Version: 1.0 
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Study Design and Procedures 
Study design will be a prospective, single-blinded, randomized, single-center trial. Patients at the 
Andrews Institute who meet the inclusion criteria will have the study explained in detail and 
informed consent will be obtained as outlined below. Fifty patients will be blinded, randomized, 
and undergo an ACL reconstruction surgery. Twenty-Five randomized patients will receive 
standard of care (SOC) ACL reconstruction surgery. Twenty-Five randomized patients will 
receive ACL reconstruction surgery augmented with the patient’s ACL stump tissue harvested 
with the GraftNet device (Arthrex, Naples, Fl).  
4.1 Intraoperative Tissue Harvest and Application 
A tissue sample will be harvested from each participant with the GraftNet device (one per 
surgery) during ACL reconstruction from the ACL stump. During the intra-articular 
preparation phase of the reconstruction, the tissue sample collected from the ACL stump 
will be applied to the ACL graft on the back table during the graft preparation phase.   
 
4.2 Post-operative Evaluation and Treatment Plan 
Each of the participants will be qualified for the study due to falling within all inclusion 
criterion and no exclusion criterion. The screening of the inclusion criterion will occur at 
visit one of the study. Visit one will take place prior to or at the same time as surgery. At 
this time, the AREF Research Team will review and collect informed consent from each 
participant. Visit two will occur three (3) months after each participant’s ACL 
reconstruction surgery. At this time, an evaluation by the treating physician will occur 
along with functional movement assessment and MRI. Visit three will occur six (6) 
months after each participant’s ACL reconstruction surgery. At this time, an evaluation 
by the treating physician will occur along with functional movement assessment and 
MRI. Visit four will occur nine (9) months after each participant’s ACL reconstruction 
surgery. At this time, an evaluation by the treating physician will occur along with 
functional movement assessment and MRI. Visit five will occur twelve (12) months after 
each participant’s ACL reconstruction surgery. At this time, an evaluation by the treating 
physician will occur along with functional movement assessment and MRI. Visit six will 
occur eighteen (18) months after each participant’s ACL reconstruction surgery. At this 
time, an evaluation by the treating physician will occur along with functional movement 
assessment and MRI. Visit seven will occur twenty-four (24) months after each 
participant’s ACL reconstruction surgery. At this time, an evaluation by the treating 
physician will occur along with functional movement assessment and MRI. At each time 
point, the treating physician or the therapist performing the functional movement 

 
 
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assessment can choose to limit the functional movement assessment if there are concerns 
that the patient may not be ready for the expected load of one or more elements of the 
functional movement assessment.  
At each follow up visit after ACL reconstruction, patient reported outcome measures 
(PROMs) will be collected by the research team in written or electronic format to assist 
in assessing the overall health and rehabilitation of each participant. A complete list of 
PROMs to be collected can be found in section 5.  
4.3 Magnetic Resonance Imaging 
Magnetic Resonance Imaging (MRI) will be used as a noninvasive assessment tool to 
obtain quantitative measures to assess progress in graft maturity and rehabilitation 
towards safe return to sport. As the injured ACL undergoes ligamentization, MRI will be 
used to monitor the progress of each participant through T2* analysis and volume at the 
following time intervals:  3months, 6months, 9months, 12months, 18months, and 
24months. MRIs will review the integrity of each graft, placement within the tunnel, and 
tunnel healing, and healing of the donor site (30).  
4.4 Functional Testing Algorithm 
Using the Davies Functional Algorithm (29), the following tests will be performed: Basic 
Measurements, Sensorimotor System Testing: Balance/Proprioceptive Testing, Closed 
Kinetic Chain Testing, Open Kinetic Chain Testing, Functional Jump Tests, Functional 
Hop Tests, Lower Extremity Functional Tests, and Sport-Specific/Position-Specific 
Testing. Each test will be performed incrementally, and participants will not advance to 
the next series of tests until the prior assessment has been completed at a satisfactory 
level. The participants’ results from the Functional Testing Algorithm (FTA) and the time 
required to complete the progression during the rehabilitation period will be quantified 
and analyzed according to demographic data and pre-injury activity level. The 
participants will be stratified according to activity level. Participant groups will include 
general orthopedic patients, recreational athletes, and competitive athletes and will be 
tested by the FTA accordingly.  
5 Patient Reported Outcome Measures (PROMs) 
Patient reported outcome measures will be used to quantify physical and psychological aspects 
of rehabilitation after ACL reconstruction monthly after informed consent has been obtained and 
surgery has occurred. The patient reported outcomes can be collected in paper format or through 
the REDCap system. The patient reported outcomes will follow the presented follow up visit 
schedule: 3months, 6months, 9months, 12months, 18months, and 24months. 

 
 
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5.1 Tampa Kinesiophobia Scale (TKS): 
The fear of reinjury can be a barrier to the rehabilitation of competitive athletes after 
ACL reconstruction. To quantify the fear associated with reinjury, the Tampa 
Kinesiophobia (TSK) scale will be provided monthly to participants in the study (31). 
Kinesiophobia is defined as the fear of movement (31). This measure will be collected to 
evaluate progression in rehabilitation to take into account not only the physical health of 
the injured athlete but also the psychological effects and rehabilitation.  
5.2 International Knee Documentation Committee Subjective Knee Evaluation Form 
(IKDC): 
The International Knee Documentation Committee Subjective Knee Evaluation (IKDC) 
form will contribute to the comprehensive data set to evaluate each participant’s 
confidence in performance on a monthly schedule. IKDC has 19 questions that will take 
approximately 3-5 minutes for each participant to complete monthly. IKDC data will be 
collected by the AREF research team and reviewed with the primary investigator. 
5.3 Patient Reported Outcomes Measurements Information Systems (PROMIS): 
The patient reported outcomes measurement information system (PROMIS) is a 
measurement system used monthly in this project to assess monthly the overall health 
functioning and rehabilitation levels of each participant (32). AREF will collect this data 
and alert the primary investigator if any adverse outcomes are found. The addition of the 
PROMIS data is required to ensure that a comprehensive assessment of overall 
functioning is reviewed in the determination of athlete readiness to return to sport.  
 
5.4 Single Assessment Numeric Evaluation (SANE): 
The SANE assessment is a single question patient reported outcome from a rating of 0-
100 for each participant to score their current functioning in comparison to their pre-
injury functioning level (33). This assessment will be collected monthly after ACL 
reconstruction by the AREF research team for each participant.  
6 
Participant Recruitment 
A total of 50 participants will be recruited through the Andrews Institute physician practices. A 
recruitment flyer will be posted within the physicians’ offices, on social media platforms and 
posted in community locations. Potential participants will be prescreened for inclusion and 
exclusion criteria through standard of care medical evaluations. Participants meeting the 

 
 
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inclusion criteria will have the study explained to them by one of the members of the research 
team, and they will be given an opportunity to participate if they are interested. Once a potential 
participant has agreed to be involved in the study, they will go through the described informed 
consent process.  
6.1 Screening Process 
Once interested patients are identified and prescreened, a screening visit (visit 1) will be 
scheduled. During the screening visit, a screening form will be completed which includes 
the inclusion and exclusion criterion below. If an individual answers "yes" to any of the 
initial screening exclusion questions, they will be informed that they do not qualify for 
the study, and they will be informed that they can keep their screening form and their 
medical care will not be adversely affected by not enrolling in the study. If all answers 
are "no" then the form will be placed in the study documents and the enrollment process 
will continue. 
Once the screening requirements are met, the informed consent form will be provided to 
the participant or electronically via REDCap for review ensure the volunteer understands 
the details of the study including the benefits and risk factors. The patient will be 
provided sufficient time to consent and sign the informed consent form (ICF). The 
principal investigator (PI) and study/research team will be available to answer any 
questions or provide clarifications during the informed consent process.  
6.2 Participant Eligibility 
6.2.1 Inclusion Criteria:  
Patients between the ages of 14 and 50 who are scheduled to have ACL 
reconstruction by one of the investigating physicians will be pre-screened for 
participation in this study. 
6.2.2 Exclusion criteria:  
Exclusion criteria will include patients requiring ACL and posterior cruciate 
ligament (PCL) combined surgery, patients with a history of an autoimmune 
disease, diabetes, a blood/clotting disorder, or history of previous surgery on the 
injured knee. Patients will undergo informed consent and an unidentifiable patient 
study number will be created.  
6.3 Benefits 
Direct benefit to the intervention group participant may include improved outcome following 
the ACL reconstruction and earlier return to baseline functioning level. Indirect benefits to the 

 
 
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Cruciate Ligament Reconstruction 
 
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participant include increased surgical follow-up, and additional post-surgery monitoring. This 
study may also help direct clinical practice in developing preferred techniques to augment 
orthopedic surgical procedures (aspirational benefit). 
 
6.4 Compensation 
Compensation will not be provided to participants in this study.  
7 
Informed Consent 21 CFR 50 
In adherence to the 21 CFR 50, Protection of Human Subjects Guidelines, the informed consent 
process will be performed by one of the study investigators or staff, in the research office on 
paper or electronically via REDCap. REDCap is a secure web application for building and 
managing online surveys and databases. While REDCap can be used to collect virtually any type 
of data in any environment (including compliance with 21 CFR Part 11, FISMA, HIPAA, and 
GDPR), it is specifically geared to support online and offline data capture for research studies 
and operations. The REDCap Consortium, a vast support network of collaborators, is composed 
of thousands of active institutional partners in over one hundred countries who utilize and 
support their own individual REDCap systems. All participants will have the study described to 
them and will give as much time as they require to read an approved, stamped version of the 
informed consent document. After physical or electronic signing of the informed consent 
document, participants will be given a copy for their records. This process will take place only 
after the patient has consented to proceed with the study. 
7.1 Consent Withdrawal: 
During the informed consent procedure, participants will be informed that if at any point 
during the study, consent may be withdrawn. To withdraw consent, participants can 
request in writing to withdraw HIPAA authorization and the research site will not use or 
provide any health information to researchers. At this time, the link between the 
participant’s health information will be severed with the research team. This process for 
consent withdrawal will be reviewed with each participant and identified barriers will be 
addressed at the time of informed consent. 
8  
Review of Safety 
8.1 Adverse Event (AE) 
An adverse event is any untoward or unfavorable medical occurrence in the human 
subject, including any abnormal sign, symptom, or disease, temporally associated with 

 
 
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the subject’s participation in the research, whether considered related to the subject’s 
participation in the research. 
8.2 Serious Adverse Event (SAE) 
Serious adverse events are any events that: 
• 
Result in death 
• 
Is life threatening, or places the participant at immediate risk of death from the 
event as it occurred 
• 
Requires or prolongs hospitalization 
• 
Causes persistent or significant disability or incapacity 
• 
Results in congenital anomalies or birth defects 
• 
Is another condition which investigators just to represent significant hazards 
8.3 Unanticipated Problem (UP) 
Defined by DHHS 45 CFR part 46 as any incident, experience, or outcome that meets the 
following criteria.  
• 
Unexpected, in terms of nature, severity, or frequency, given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the study population.  
• 
Related or possibly related to participation in the research (in this guidance 
document, possibly related means there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures 
involved in the research); 
• 
Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 

 
 
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8.4 AE & SAE Collection and Reporting 
Throughout the study the research team will monitor the occurrence of AE and SAE. 
Data will be collected if an instance occurs, and the PI will be notified. All AE data, such 
as onset date, resolution date, outcome and treatments given will be documented in the 
source documents and will be recorded in the electronic data capture system (EDC) and 
analyzed for severity to follow reporting protocol if severity level. 
Follow-up will occur using the provided safety monitoring form if AE occurs. The follow 
up will end either when the symptoms resolve or up to 30 days past the end of the study 
participation. 
8.5 Expected Risks and Discomforts 
Risks and Discomforts: As with any research involving human subjects there is the 
inherent risk of a breach in patient confidentiality. This will be minimized using 
participant code numbers and adhering to all HIPAA guidelines. Standard sterile 
precautions for surgical procedures will be utilized for all ACL surgeries. With any 
surgery there remains the risk of infection, bleeding, and swelling. The collection of soft 
tissue samples with the GraftNet device does not increase the risk associated with the 
surgical procedure. MSC transplantation has been deemed safe by the Food and Drug 
Administration (FDA) (34). However, as with all stem cell therapy, there is the inherent 
risk of tumorigenicity (35) (36). Long-term follow up is needed to further elucidate these 
risks. Use of the bovine collagen matrix presents minimal risk to the participant. Other 
studies utilizing this implant did not report any discomforts or adverse events attributed 
to the collagen matrix implant (23).  
9 
Data Management Procedures 
All personal information is strictly confidential, and no names will be disclosed except as 
required by law. All information and data collected including patient reported outcomes 
measures during this research will be compiled into an Excel spreadsheet. This spreadsheet will 
not contain protected health information. The spreadsheet will be stored in a secure password 
protected folder on a laptop that only the study investigators will have access to and will be 
permanently deleted following publication of all manuscripts, if any, written as a result of this 
research. Records related to this study will be securely retained in a secure location for a period 
of 3 years after the completion of the study or longer as required by law. At that time, all records 
will be properly destroyed.  

 
 
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Data Analysis 
Data will be compiled in Microsoft Excel and REDCap. All compiled data will be de-identified.  
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Statistical Considerations 
Statistical analysis will be performed in excel and SAS Studio (Version 3.8 on SAS 9.4, SAS 
Institute Inc., Cary, NC). Descriptive statistics will be compiled for all numeral measures 
(outcomes).  
12  
Quality Control and Assurance 
All protocols will be monitored and analyzed data will be checked for accuracy by the principal 
investigator and /or a designated AREF research team member. All medical data will be kept in 
compliance with HIPAA guidelines. 
 
 

 
 
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References 
 
1. 
Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, et al. Noncontact 
anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop 
Surg. 2000;8(3):141-50. 
2. 
Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior cruciate ligament 
injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 
2009;12(6):622-7. 
3. 
Leathers MP, Merz A, Wong J, Scott T, Wang JC, Hame SL. Trends and Demographics 
in Anterior Cruciate Ligament Reconstruction in the United States. J Knee Surg. 2015;28(5):390-
4. 
4. 
Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, et al. 
Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy 
improves healing and prevents further tears: a case-controlled study. Int Orthop. 
2014;38(9):1811-8. 
5. 
Ullah I, Subbarao RB, Rho GJ. Human mesenchymal stem cells - current trends and 
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