Prospective, Randomized, Single-Center Study to Compare Clinical Outcomes Between Cryopreserved and Lyopreserved Stravix as an Adjunct to NPWT in the Treatment of Complex Wounds
Phase: PHASE4
Conditions: Diabetic Wound
Sponsor: University of Texas Southwestern Medical Center

Official title: PROSPECTIVE, RANDOMIZED, SINGLE-CENTER STUDY TO COMPARE
CLINICAL OUTCOMES BETWEEN CRYOPRESERVED AND LYOPRESERVED
STRAVIX AS AN ADJUNCT TO NPWT IN THE TREATMENT OF COMPLEX WOUNDS
NCT number: NCT04405765
IRB Approved date: 04/10/2023

STU2020-0293, Lavery, FormA3-Protocol, Mod_11, 04-10-23
7.19.21
i
PROSPECTIVE, RANDOMIZED, SINGLE-CENTER STUDY TO COMPARE CLINICAL OUTCOMES BETWEEN
CRYOPRESERVED AND LYOPRESERVED STRAVIX AS AN ADJUNCT TO NPWT IN THE TREATMENT OF
COMPLEX WOUNDS
PROTOCOL NUMBER:
STU-2020-0293
SPONSOR:
OSIRIS THERAPEUTICS (SUBSIDIARY OF SMITH & NEPHEW)
7015 ALBERT EINSTEIN DRIVE
COLUMBIA, MD 21046
ISSUE DATE:
19 July 2021

STU2020-0293, Lavery, FormA3-Protocol, Mod_11, 04-10-23
7.19.21
ii
SPONSOR SIGNATURE PAGE
PROSPECTIVE, RANDOMIZED, SINGLE-CENTER STUDY TO COMPARE CLINICAL OUTCOMES BETWEEN
CRYOPRESERVED AND LYOPRESERVED STRAVIX AS AN ADJUNCT TO NPWT IN THE TREATMENT OF
COMPLEX WOUNDS
PROTOCOL NUMBER:
STU-2020-0293
SPONSOR:
OSIRIS THERAPEUTICS (SUBSIDIARY OF SMITH & NEPHEW)
7015 ALBERT EINSTEIN DRIVE
COLUMBIA, MD 21046
ISSUE DATE:
19 Jul 2021
Print Name, Title, Company: __________________________________
Signature:  __________________________________
Date:  __________________

STU2020-0293, Lavery, FormA3-Protocol, Mod_11, 04-10-23
7.19.21
iii
INVESTIGATOR SIGNATURE PAGE
PROSPECTIVE, RANDOMIZED, SINGLE-CENTER STUDY TO COMPARE CLINICAL OUTCOMES BETWEEN
CRYOPRESERVED AND LYOPRESERVED STRAVIX AS AN ADJUNCT TO NPWT IN THE TREATMENT OF
COMPLEX WOUNDS
PROTOCOL NUMBER:
STU-2020-0293
SPONSOR:
OSIRIS THERAPEUTICS (SUBSIDIARY OF SMITH & NEPHEW)
7015 ALBERT EINSTEIN DRIVE
COLUMBIA, MD 21046
ISSUE DATE:
19 JUL 2021
Site Name:
Print Investigator Name:  ________________________________
Investigator Signature:  __________________________________  Date:  _______________

STU2020-0293, Lavery, FormA3-Protocol, Mod_11, 04-10-23
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iv
Table of Contents
Primary Study Contacts..................................................................................................................................................................... 2
UT Southwestern Medical Center.................................................................................................................................................... 2
Osiris Therapeutics ......................................................................................................................................................................... 2
Executive Summary........................................................................................................................................................................... 3
1.
Introduction........................................................................................................................................................................ 4
Background and Rationale............................................................................................................................................................... 4
Benefits and Risks .......................................................................................................................................................................... 4
2.
Trial Objectives................................................................................................................................................................... 5
3.
Selection and Withdrawal of Subjects ................................................................................................................................ 6
Inclusion Criteria: ........................................................................................................................................................................... 6
Exclusion Criteria:.......................................................................................................................................................................... 6
Withdrawal of Subjects ................................................................................................................................................................... 6
4.
Trial Design......................................................................................................................................................................... 7
Description of Trial Design ............................................................................................................................................................. 7
Trial Endpoints............................................................................................................................................................................... 7
Sample Size.................................................................................................................................................................................... 7
Duration of Subject Participation..................................................................................................................................................... 8
Screening and Enrollment ............................................................................................................................................................... 8
Randomization................................................................................................................................................................................ 8
Visit Schedule................................................................................................................................................................................. 8
Audits and Inspections...................................................................................................................................................................18
5.
Assessment of Efficacy.......................................................................................................................................................18
Effectiveness Endpoints .................................................................................................................................................................18
6.
Assessment of Safety ..........................................................................................................................................................18
Primary Safety Endpoint ................................................................................................................................................................18
7.
Statistics.............................................................................................................................................................................18
Analysis Plan.................................................................................................................................................................................18
Sample Size Justification................................................................................................................................................................19
8.
Data Management..............................................................................................................................................................19
9.
Deviations from the Investigational Plan...........................................................................................................................19
10.
Product Accountability......................................................................................................................................................19
11.
Ethics..................................................................................................................................................................................19
Trial Conduct.................................................................................................................................................................................19
Institutional Review Board Review.................................................................................................................................................20
Informed Consent ..........................................................................................................................................................................21
Coverage of Expenses....................................................................................................................................................................21
Confidentiality...............................................................................................................................................................................21
12.
Data Handling and Record Keeping..................................................................................................................................22
Source Documents .........................................................................................................................................................................22
Data Collection..............................................................................................................................................................................22
Record Retention ...........................................................................................................................................................................22
13.
Quality Control and Quality Assurance ............................................................................................................................23
Site Training..................................................................................................................................................................................23
Investigator Training......................................................................................................................................................................23
14.
Adverse Events and Serious Adverse Events.....................................................................................................................24
General..........................................................................................................................................................................................24
Adverse Event Reporting ...............................................................................................................................................................24
Definition of an Adverse Event (AE) ..............................................................................................................................................24
Definition of Serious Adverse Event (SAE) ....................................................................................................................................25

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v
Causality Assessment of Adverse Events........................................................................................................................................25
Adverse Event Severity Assessment ...............................................................................................................................................25
Withdrawal Due to Adverse Events (See Also Section on Subject Withdrawal)................................................................................26
Eliciting Adverse Event Information...............................................................................................................................................26
Reporting Requirements.................................................................................................................................................................26
Serious Adverse Event Reporting Requirements .............................................................................................................................26
Non-Serious Adverse Event Reporting Requirements......................................................................................................................27
Reporting Requirements to Regulatory Authorities..........................................................................................................................27
15.
Publication Policy ..............................................................................................................................................................27

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
Primary Study Contacts
UT Southwestern Medical Center
Principal Investigator
Lawrence A Lavery
email
Larry.lavery@utsouthwestern.edu
phone
214.648.7284
Clinical Research Manager
Debby Noble
email
Debby.noble@utsouthwestern.edu
phone
214.648.8686
Osiris Therapeutics
Sponsor Contact
Sharron E. McCulloch
email
Sharron.McCulloch@smith-nephew.com
phone
443-545-1830
Clinical Ops
Molly Saunders
email
Molly.saunders@smith-nephew.com
phone
443-545-1821

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
Executive Summary
Title of Study
Prospective, Randomized, Single-Center Study to Compare Clinical Outcomes between
Cryopreserved and Lyopreserved Stravix as an Adjunct to NPWT in the Treatment of
Complex Wounds
Protocol Number
TBD
Study Purpose
The purpose of this study is to evaluate the clinical outcomes using lyopreserved Stravix
as compared to cryopreserved Stravix when used as an adjunct to NPWT.
Study Design
Prospective, 2-arm parallel assignment, randomized clinical trial. Stravix will be applied
at initial visit with NPWT and will only be reapplied after 4 weeks if wound is not ready
for grafting unless debridement is indicated.
Enrollment
40 subjects will complete the study.
Investigational Sites
UT Southwestern and Parkland Hospitals
Study Duration
12 weeks
Efficacy Endpoints
Primary Endpoint: To compare the incidence of complete wound closure of lyopreserved
vs cryopreserved Stravix treated groups at 12 weeks post initial application.
Secondary Endpoints: To evaluate the outcomes noted below between lyopreserved and
cryopreserved Stravix.
1.
Time to 100% granulation of deep structures (bone, tendon, etc)
2.
Duration of NPWT
3.
Time to surgical grafting to cover the wound.
4.
Time to complete wound closure (complete epithelization with no drainage)
5.
Level of infection
6.
Resource utilization
7.
Quality of Life – SF36, EQD5 and PROMISE
Safety Endpoints
Ulcer-related adverse events
Study Groups
Subjects will all receive NPWT and be randomized to either lyopreserved or cryopreserved
Stravix.

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
1.
Introduction
Background and Rationale
Negative Pressure Wound Therapy (NPWT) has dramatically changed the care of complex foot wounds.
Compared to standard wound care, patients with diabetic foot wounds that are treated with NPWT are 5.9
times more likely to heal and 4.4 times less likely to require amputation [1, 2]. NPWT involves the
delivery of sub-atmospheric pressure through a vacuum pump connected to a specialized dressing to
maintain a closed environment. NPWT increases perfusion to the wound, accelerates granulation tissue
formation, reduces edema, and reduces bio-burden [1-3].
Stravix® is a cryopreserved human placental tissue composed of umbilical amnion and Wharton’s jelly.
Stravix retains the native collagen and hyaluronic acid-rich extracellular matrix (ECM), endogenous
growth factors, and endogenous cells including epithelial cells, fibroblasts, and mesenchymal stem cells
(MSCs) found in placental tissue. Stravix is a living placental tissue for surgical applications. As a viable
wrap for surgical procedures, Stravix conforms to injured tissue, can be sutured, and is arthroscopic and
robotic procedure friendly. Stravix is manufactured using a proprietary process allowing the tissue to
retain its native components.
Historically, cryopreservation was the only available method that allowed for long-term preservation of
living cells and tissues. However, cryopreservation requires ultra-low-temperature freezers and dry ice or
liquid nitrogen for storage, which limits the widespread use of cellular therapies. To address this
limitation, Osiris has developed PrestigeTM Lyotechnology. Unlike all other known lyophilization
methods, PrestigeTM Lyotechnology enables the preservation of living cells within tissues while stored at
ambient temperatures. Moreover, the manufacturing of lyopreserved living tissues with PrestigeTM
Lyotechnology is scalable and can be applied to many different cell and tissue types.
Benefits and Risks
Potential Benefits to the Subjects
Previous studies of clinical cases demonstrate potential benefit of Stravix use in surgical treatment of
complex wounds.
Potential Risk
Participation in this clinical investigation presents low risk to subjects. Stravix is defined by FDA as an
HCT/P under Section 361 of the Public Health Service Act and 21 CFR Part 1271. This category of
products considered low risk (ref FDA documents). Some general risks associated with any new wound
dressing or skin-contact devices are listed in the table below.
Risks
Disorders/Conditions
Skin and
Subcutaneous Tissue
Reaction/Allergy

Skin rash, irritation, blistering

Pruritus/itching

Skin excoriation/breakdown

Skin scarring if significant skin irritation were to
occur

Skin hyper/hypo-pigmentation at and/or around
dressing application area

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020

Erythema/redness, edema, inflammation, or
swelling at and/or around dressing application
area
Mild Pain or
Discomfort

Tenderness/minor ache at and/or around dressing
application area

Decreased sleep or sleep quality

Paresthesia (numbness, tingling, prickling,
creeping sensation)
Other

Risks to privacy

Loss of data confidentiality
Potential Risks of a Blood Draw

Discomfort

Fainting

Dizziness

Bruising at the puncture site (hematoma)

Nerve injury

Arterial puncture or laceration
Protection Against Risks
Protected health information (PHI) of subjects in clinical investigations are kept as confidential as possible
in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However,
confidentiality cannot be assured.  The table below lists the entities granted access to protected health
information (PHI).
Entity
Reason for Access
Sponsor’s Clinical
Representative (Monitor)
Assess data for accuracy and completeness
Institutional Review Board
(IRB)
Ensure protection of research subjects
Regulatory Authorities (e.g.
Food and Drug
Administration
Audit clinical trial for Subject protection and data
integrity
Investigator/Site Staff
Collection and assessment of data for accuracy and
completeness
Alternatives to Participation:
Subjects are not required to participate in this research study. As an alternative to study participation,
subjects will receive wound care treatment per physician discretion.
2.
Trial Objectives
The primary objective of this trial is to compare the clinical outcomes between cryopreserved and lyopreserved
Stravix adjunct to NPWT in the treatment of diabetes-related lower extremity complex wounds.

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
3.
Selection and Withdrawal of Subjects
Inclusion Criteria:

Diagnosis of a diabetes mellitus

Men/women ≥21 years old

Post-operative foot or ankle wounds sized >4cm2 that have presented for <1 year

ABI ≥0.5 or toe pressures >30 mmHg

Wounds indicated for treatment with NPWT
Exclusion Criteria:

Active Charcot arthropy

Unable to use NPWT

Untreated bone or soft tissue infection

Is pregnant or plans to become pregnant

Is nursing or actively lactating

Developmental disability/significant psychological disorder that in the opinion of the
investigator could impair the subject’s ability to provide informed consent, participate in the
study protocol or record study measures, including untreated schizophrenia, bipolar disorder
and psychiatric hospitalization within the last 2 years.

Active alcohol or substance abuse in the opinion of the investigator that could impair the
subject’s ability to provide informed consent, participate in the study protocol or record study
materials
Withdrawal of Subjects
Subjects may withdraw from the study at any time at their own request, or they may be withdrawn at any
time at the discretion of the PI for safety, behavioral, or administrative reasons. If a subject does not return
for a scheduled visit, every effort should be made to contact the subject, per institutional protocol. In any
circumstance, every effort should be made to document subject outcome. The Investigator should inquire
about the reason for withdrawal, request that the subject return for a final visit, if applicable, and follow
up with the subject regarding any unresolved AE's.
Any related SAE occurring within 14 days following subject discontinuation must be reported to Osiris
Therapeutics and be followed up until stabilization or resolution. If the Subject withdraws from the study,
and also withdraws consent for disclosure of future information, no further study evaluations will be
performed, and no additional data will be collected. The PI may retain and continue to use any data
collected before such withdrawal of consent.
The Investigator may choose to withdraw their own participation or discontinue a Subject from study with

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
or without their consent for any of the following:

Adverse Events

Non-compliance

Safety

Complications

Unforeseen events
A patient who experiences the noted changes, relative to previous measures, in the following parameters
will be terminated early from study participation

An increase in wound size by 50% or more prior to debridement.

An increase in pain rating by 50% or more

Presence of infection as determined by 2 more bacterial infection indicators that requires
treatment outside the study scope

Need for wound management outside the study scope

Or for any reason that may, in the opinion of the Investigator, affect negatively the wellbeing of
the subject.
If for any reason the subject is withdrawn from the clinical investigation, the Investigator will inform the
subject accordingly.
4.
Trial Design
Description of Trial Design
This study is a prospective, 2-arm parallel assignment, randomized clinical trial to compare lyopreserved
vs cryopreserved Stravix as an adjunct therapy to NPWT.
Trial Endpoints
Primary Endpoint: To compare the incidence of complete wound closure of lyopreserved vs cryopreserved
Stravix treated groups at 12 weeks post initial application.
Secondary Endpoints: To evaluate the outcomes noted below between lyopreserved and cryopreserved
Stravix.
1.
Time to 100% granulation of deep structures (bone, tendon, etc)
2.
Duration of NPWT
3.
Time to surgical grafting to cover the wound.
4.
Time to complete wound closure (complete epithelization with no drainage)
5.
Level of infection
6.
Quality of Life – SF36, EQ-5D and PROMIS®
Sample Size
For this study, 40 patients from UT Southwestern and Parkland hospitals will complete the study (no cap
on screening/enrollment).

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
Duration of Subject Participation

Screening: Within 7 days of therapy start

Treatment period: Up to 12 weeks from therapy start

Total duration of subject participation: Up to 13 weeks
Screening and Enrollment
Patients who present to the investigator's institution (through clinic admission, direct transfer from another
facility, or through the emergency room) may be recruited to participate in the study. No direct marketing
for subject recruitment will be done.
Patients approached for study participation will be at least 21 years of age at the time of consent, will
undergo wound assessment, and meet all eligibility requirements. Those meeting eligibility criteria for
the study will have the study explained to them by the Investigator. An Informed Consent Form will be
provided to sign according to Section 11 prior to undergoing any study procedures. Patients will be
encouraged to ask questions of the investigators. It will be made clear to the patient that not participating
in the study will in no way influence the treatment plan or the relationship with the physician.
There is no cap on the number of subjects that can be screened/enrolled. Additional subjects will continue
to be recruited as needed to reach the minimum number of 20 treated per protocol, per arm (40 in total).
Wound Selection
Subjects with only one wound will be included in the study. Subjects with multiple wounds will have each
wound measured for volume. The wound with the largest volume meeting all eligibility requirements will
be chosen for inclusion in the study as the primary wound. The etiology of the chosen wound, its
classification, and if it is a new or recurring, will be documented. All other wounds will be documented
as secondary wounds and will be followed throughout the study.
Randomization
Randomization will be performed using www.randomizer.org. Subjects who meet all inclusion and no
exclusion criteria will be randomized in a 1:1 ratio to be treated with NPWT and either lyopreserved
Stravix or cryopreserved Stravix. Study staff will use the randomization number labels contained in the
envelope.  The number will become the subject ID.  The research staff will note treatment assignment
number on the CRF.  
Visit Schedule
Study procedures for each phase of study are outlined below.  In a later section, details on each study
procedure are described, including equipment designation.
Screening
1.
Explain purpose and nature of the study and obtain signature on the informed consent document.
2.
Screen the subject against protocol inclusion and exclusion criteria, including all pertinent tests

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
(ex. ABIs), including pregnancy test
3.
Complete SF-36, EuroQol 5 dimensions (EQ-5D) and PROMIS®
4.
Perform neuropathy assessment
5.
Randomize subject if all inclusion and exclusion criteria are met.
Baseline (-within 7 days -after screening)
1.
Obtain general medical history and demographic information and social history
2.
Complete a physical examination, body weight, height, BMI and vital signs, including
measurement of resting heart rate, respiratory rate, and blood pressure while seated.
3.
Select target study ulcer
4.
Obtain complete history pertinent to DFU disease including duration of the target ulcer, previous
and current treatment. Document ulcer classification.
5.
Perform debridement and obtain tissue collection (up to 4 tissues and 1 bone if applicable).
6.
Collect blood sample at baseline visit (approximately 10mL at each collection) for Ribonucleic
Acid (RNA) gene expression.
7.
Perform standardized photography and measurement of the primary study wound and, if
applicable, secondary study wounds (eKare or available camera with ruler if eKare is not
available) pre-debridement. Assess the post-debridement ulcer area (cm2), perimeter (cm), and
greatest depth (cm) using the inSight device (eKare, Fairfax, VA).  These values are the baseline
measurements for calculating wound closure rate at the two-week run-in visit.
8.
Perform hyperspectral imaging of dorsal and plantar aspects of the foot.
9.
Collect all relevant concomitant medication (antibiotics, antifungals and other anti-infective
therapies)
10. Collect all relevant clinical lab values
11. Place Stravix (lyo or cryo per randomization schedule) and dress wound for NPWT therapy
(typically within 24 hours post-operatively for NPWT placement).
12. Document size of Stravix used.
13. Disburse subject stipend
Therapy/Treatment Phase (Weekly visits +/- 4 days)
Study Visit 1-11:
1.
Assess target ulcer (if wound has closed, document as such, skip to step 5).
2.
Document time on/off NPWT if applicable. NPWT removal/discontinuation will be per Principal
Investigator discretion.
3.
Perform standardized photography (eKare) of the study primary wound when NPWT is removed.
4.
Assess the ulcer(s) area (cm2), perimeter (cm), and greatest depth (cm) using the inSight device
(eKare) and document if the primary wound and, if applicable secondary wound(s), document if
subject has investigational product in place or no investigational product- if the wound is deemed
closed by the physician, skip to EOS visit.
5.
Perform hyperspectral imaging of the dorsal and plantar aspects of the foot if wound is active or
closed.
6.
Debride wound if indicated. Re-measure primary wound and, if applicable, secondary wounds
with the inSight device (eKare) if surgical debridement is performed prior to dressing the wound.
7.
Collect tissue and/or bone samples at weeks 4, and 8. If at any visit the subject has an infection,
collect tissue and/or bone.
8.
Collect blood sample at week 4 (approximately 10mL at each collection) for Ribonucleic Acid

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
(RNA) gene expression. Will also collect blood if patient develops and recovers from an infection
during the study timeframe. Blood will be collected once clinical signs of infection are resolved.
9.
Collect all relevant concomitant medication.
10. If wound is still active, redress the wound with assigned Stravix (if removed for debridement)
and NPWT. Document all dressings applied including size of Stravix.
11. Disburse subject stipend
12. Note: at week 4, if wound is not ready for grafting, remove existing Stravix and replace with new
piece of Stravix (per randomization schedule)
13. Assess for AE/SAEs and/or follow up on previous AE/SAEs.
Study Visit Closed
1.
When a subject’s study wound has closed, they will perform the EOS evaluation.
Study Visit 12/EOS:
1.
At the time of wound closure, subjects will perform EOS visit.
2.
A subject whose wound is not deemed closed (epithelialized with no drainage) by physician at
week 12 will exit from the study after the week 12 wound evaluation.
3.
Assess index ulcer.
4.
If the wound is still open and large enough, collect tissue and/or bone samples along with a blood
sample.
5.
Assess the ulcer(s) area (cm2), perimeter (cm), and greatest depth (cm) using the inSight device
(eKare) and document if the primary wound and, if applicable, secondary wound(s) and if subject
has investigational product in place or no investigational product.
6.
Perform hyperspectral imaging of the dorsal and plantar aspects of the foot if wound is active or
healed.
7.
If wound has not closed, redress the wound per physician-directed standard of care.
8.
Administer Patient Reported Outcome (PRO) (questionnaires).
9.
Collect all relevant concomitant medication
10. Perform EOS visit documentation
11. Follow up on AE/SAEs that have been reported that have not yet been resolved.
Study Visit Follow-up:
1.
If the wound heals during the treatment phase or if the wound is not healed after 12 weeks, data
from their electronic medical record will be evaluated to identify healing, time to heal, adverse
events related to the wound.
Detailed Study Operations
Medical Status/History

The New York Heart Association (NYHA) Functional Classification System: This system will be
used to classify stage of heart failure. The New York Heart Association (NYHA) functional
classification system is used to classify the stage of heart failure from Class I to IV (as shown in
the table below). This system relates symptoms to everyday activities and the patient's quality of
life.

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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #: STU-2020-0293
Version04 November 2020
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe
Unable to carry out any physical activity without discomfort. Symptoms of
cardiac insufficiency at rest. If any physical activity is undertaken, discomfort
is increased.

Body Mass Index (BMI): BMI is calculated as the ratio of body weight in kilograms (kgs) to
height in meters squared (m²).

Medical History: The following information will be collected from each subject
Co-Morbidities
Clinical Lab Values

BUN

Creatinine

Estimated GFR (glomerular
filtration rate)

Hemoglobin A1c

Prealbumin (transthyretin)

Albumin

CRP (C-reactive protein)

ESR (Erythrocyte Sed Rate)

White blood cell count

RBC

Hemoglobin

Hematocrit

Pregnancy test if subject is child
bearing potential
Cardiac
MI < 6mos
MI > 6mos
None
Coronary  Artery  Bypass
Surgery
Yes/No
Cardiac Angioplasty
Yes/No
Stroke
< 6mos
> 6mos
None
Liver Disease
Hepatitis A
Active
Not Active
None
Hepatitis B
Active
Not Active
None
Hepatitis C
Active
Not Active
None
Cirrhosis
Active
Not Active
None
Vision
Retinopathy
proliferative
background
none
Glaucoma
Yes/No/Not Known
Specify Eye:
Cataracts
Yes/No/Not Known
Specify Eye:
Blindness
Yes/No/Not Known
Specify Eye:
Bone  Tumors
Yes/No
Arthritis
Yes/No
Osteoporosis
Yes/No
Malignancy
Yes/No

STU2020-0293, Lavery, FormA3-Protocol, Mod_11, 04-10-23
All information contained in this document is confidential
4/19/2023
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Osiris: Cryo vs Lyo Stravix with NPWT
PI: Lavery
Protocol #:  STU-2020-0293
Version: April 23
Blood Collection
Whole blood will be collected and the cells lysed. RNA will be isolated and preserved, then
analyzed for gene expression. The blood, tissue samples and some clinical data will be sent to
Ingham Institute of Applied Clinical Research. These samples and the clinical data will be de-
identified and will only contain an assigned study ID number, visit number and date of the visit.
Concomitant Medications
All antibiotics, antifungals and other anti-infective therapies engaged in by the subject will be
recorded at screening visits and treatment visits.
Social Factors
The following social factors will be recorded:

marital status

years of education

occupation

tobacco use history: number of years of smoking, current or previous smoker, use of chewing
tobacco, average daily number of cigarettes for current smokers

alcohol and drug use history: current and/or previous history, types of alcohol/drugs consumed in
the past and/or present; frequency and amount of alcohol/drugs consumed in the past and/or
present
Demographic Variables
The following demographics will be recorded for each subject:

Gender: male or female.

Age

Language Spoken: English, Spanish, English and Spanish, other(specify)

Ethnicity: Caucasian, Hispanic, African American, American Indian, Asian/Pacific Islander.
Wound History and Assessment

Wound History and Evaluation: We will use the University of Texas Ulcer Classification to
document ulcer severity. Our group developed and validated this classification system. This
classification system is a 4 x 4 matrix that includes the depth of the ulcer or the ulcer Grade: (1.)
pre-ulcerative site, (2.) full thickness, (3.) extends to tendon or capsule, (4.) extends to bone and
the Stage of the ulcer that identifies if there is infection and/or PAD: (A.) No PAD or infection,
(B.) infection, (C.) PAD (D.) infection and PAD.

Wound Measurements and Debridement: Debridement will be performed per physician discretion
using a scalpel or bone curette to remove all surrounding callus, wound debris, necrotic tissue,
fibrin, eschar and non-viable tissue to create a bleeding wound bed. Debridement may also take
place in a surgical setting in which case tissue samples will be collected. Tissue and bone samples
– the doctor will take 4 small samples of tissue from the subject’s wound after debridement

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(removal of dead or unhealthy tissue) and 1 sample of bone (if applicable) and these tissue
samples will be kept and tested for the amount and type of bacteria that are present (qPCR
analysis/laboratory analysis). We will objectively measure ulcer debridement and changes in
wound size using changes in wound volume and area from wound measurements with the inSight
digital 3D measurement device (eKare, Fairfax, VA). Digital photos will be taken after
debridement. We will take post-debridement measurements of wound volume and area. Gardner
et al reported that volume measurements with a digital image evaluation system was reliable.

Safety Measures: Each of the following measures will be rated on the following 5-point Likert
scale, as well as a descriptive evaluation being recorded, as applicable, for the study wound: 1)
absence or 2) presence of the following:

Erythema

Discharge/drainage

Malodor

Tissue necrosis
Vascular Assessment
We will assess perfusion with three approaches; Arterial dopplers (bedside may be done for screening
if formal ABIs have not yet been performed/resulted), and Hyperspectral Imaging. Hyperspectral
imaging (HyperMed, Nashville, TN or Kent Imaging, Calgary, AB, Canada) will be used to evaluate
the peri-wound tissue surrounding the ulcer and the angiosomes on the dorsum and plantar aspect of
the foot.
Neurological Assessment
Semmes-Weinstein monofilament evaluation will be performed. We will assess light touch and
pressure sensation at five sites on the study foot using a 10-gram monofilaments. We will perform
Vibration Perception Threshold VPT; a device that uses vibration to test how well your feet can detect
gentle pressure.
Infection Evaluation
This system first divides wounds by whether they are clinically infected on the basis of the
presence of purulent secretions or local or systemic signs of inflammation or infection. Infected
wounds are further divided into those that are considered to be mild, moderate, or severe, on the
basis of the size (especially of any cellulitis) and depth (or level of tissue involved) of the
infection and presence of systemic manifestations of infection or metabolic instability
[4]. Additionally, the subjects will have the following monitored: temperature, heart rate,
respirations and WBC.
Description
International Working Group Infection
Severity
no infection: no pus no inflammation
1
2 or more signs of infection (pus, pain, warmth, swelling.
2
cellulitis < 2cm
infection limited to the skin or subcutaneous tissue

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No systemic signs of infection
2 or more signs of infection (pus, pain, warmth, induration.
3
cellulitis > 2 cm
lymphangistis, abscess
infection extends to deep fascia, tendon muscle
No systemic signs of infection
same as 3 with systemic toxicity
4
meets SIRS criteria fever >38C, tachycardia >90, respiration >12,
leukocytosis >12,000
osteomyelitis
5
Patient Reported Outcomes
The Medical Outcomes Study (MOS) 36-item Short Form (SF-36) is one of the most commonly
utilized instruments in assessing diabetic foot disease and provides information on overall physical
and mental quality of life. The SF-36 provides a physical component summary (PCS) score as well
as a mental component summary (MCS) score, which are derived from eight different sub- scales.
The PCS and MCS are standardized so that a score of 50 represents the normative score for the general
population, and a higher score is indicative of better HRQOL (20). Excellent correlation has been
found between PCS and MCS scores calculated from the SF-36 in patients with diabetic foot disease
[5].
The EuroQol-5-dimension (EQ-5D-5L) questionnaire is a generic instrument which is commonly
used for the assessment of QoL in various diseases. The 5-level version, EQ--5D-5L, consists of 2
pages – the EQ-5D-5L descriptive system, and the EQ visual analogue scale (EQ VAS). The
descriptive system comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort,
and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate
problems, severe problems, and extreme problems. The digits for the 5 dimensions can be combined
in a 5-digit number describing the respondent’s health state. The questionnaire item results will be
converted to an index score using the conversion tool provided by EuroQoL for EQ-5D-5L.
The EQ VAS records the respondent’s self-rated health on a 20 cm vertical, visual analogue scale
with endpoints labeled ‘the best health you can imagine’ and “the worst health you can imagine”. This
information may be used as a quantitative measure of health as judged by the individual respondents.
PROMIS® is a publicly available system of highly reliable, precise measures of patient-reported
health status for physical, mental, and social well-being. This web-based resource can be used to
measure health symptoms and health-related quality of life domains such as pain, fatigue, depression,
and physical function, which are relevant to a variety of chronic diseases.
Offloading

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All subjects who can be offloaded will wear the DH OffLoading Walker or a Total Contact Cast.
Subjects who have dorsal wounds or who cannot wear a boot/cast will be placed in a diabetic shoe.
Offloading method may be dependent on wound location and postural positioning of the subject.
12 Month Retrospective Follow-up:
We will collect 12 month follow-up data to extend the length of follow up to adequately capture the
time period with highest incidence of recurrent ulceration and infection.

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Schedule of Events Table – Treatment Phase
The table below shows the schedule of planned events for each subject in this study.
Schedule of Events
Weekly Visits (4 days)
SC
BL/0
1
2
3
4
5
6
7
8
9
10
11
*EOS
FUP
@6mo
Informed Consent
X
Inclusion/Exclusion
X
Randomization
X
Medical History, Social,
Demographics, PE, Vitals
X
Lab Values
X
Blood Collection for RNA#
X
X
X
Pregnancy test if needed
X
ABI, monofilament, VPT
X
Wound Assessment,
Debridement, Tissue Collection if
Applicable+
X
X
X
X
Stravix Application**
X
**X
Wound Photography and
Measurements, HSI Camera
X
X
X
X
X
X
X
X
X
X
X
X
X
Offloading
X
X
X
X
X
X
X
X
X
X
X
X
Adverse Events
X
X
X
X
X
X
X
X
X
X
X
X
X
Concomitant Medication
X
X
X
X
X
X
X
X
X
X
X
X
X
Administer SF-36, EuroQol 5
dimensions (EQ-5D) and
PROMIS®
X
X
Subject Stipend
X
X
X
X
X
X
X
X
X
X
X
X
X
EMR Reference
X
*if subject closes prior to week 12, subject will perform EOS visit and enter the FUP phase

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**Stravix should only be removed and replaced if the physician deems it necessary for wound outcomes.  If Stravix is not changed until week 4 and at week 4 the
wound is not ready for surgical closure, it will be replaced.
+Only to be collected if surgical debridement is required.
#will also collect blood if subject develops and recovers from an infection during the study timeframe. Blood will be collected once clinical signs of infection are
resolved.

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Audits and Inspections
Internal audits are done periodically to assure regulations, guidelines and protocols are adhered to
appropriately. Patient binders are reviewed for proper informed consent process documentation, case
report forms are compared to the source documents and reviewed for accuracy and an independent review
of the inclusion and exclusion criteria using a checklist. Additionally, the use of an auditing and
monitoring tool which includes sections on consent, HIPAA, on study/treatment, off treatment/off study
and a general section. Weekly meetings occur to go over each study. If there are any issues that arise, they
are brought up and discussed at the meeting.
5.
Assessment of Efficacy
Effectiveness Endpoints
Primary Endpoint: To compare the incidence of complete wound closure of lyopreserved vs cryopreserved
Stravix treated groups at 12 weeks post initial application.
Secondary Endpoints: To evaluate the outcomes noted below between lyopreserved and cryopreserved
Stravix.
1.
Time to 100% granulation of deep structures (bone, tendon, etc)
2.
Duration of NPWT
3.
Time to surgical grafting to cover the wound.
4.
Time to complete wound closure (complete epithelization with no drainage)
5.
Level of infection
6.
Quality of Life – SF36, EQD5 and PROMISE
6.
Assessment of Safety
Primary Safety Endpoint
Number of index wound related adverse events
7.
Statistics
Analysis Plan
We will summarize study variables as means and standard deviations (SD) for continuous variables and
proportions or percentages for categorical variables. Continuous variables will be presented as median,
mean ± standard deviation and dichotomous variables presented as percent. We will use Analysis of
Variance (ANOVA) to test for differences in continuous variables. For categorical variables, we will use
chi square to compare the proportion of outcomes in each treatment arm with an alpha of 0.05, and we
will use Kaplan Meier analysis to compare closure rates of the treatment groups. p-values were reported
using the step-up Bonferroni method of Hochberg. We will use an adjusted two-sided analysis with an
alpha of 0.05. In the intent to treat analysis, we will use the last observation carried forward to define the
clinical outcomes for patients that were lost to follow up.

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Tissue samples will be extracted and used for molecular biology analyses. These may include, gene
and protein expression of the wound tissue, histological analyses of tissue morphology and pathology,
and analyses of bacterial genes to determine levels of infection. All sample analyses will be
performed in a de-identified manner and tissue samples WILL NOT be used for genetic sequencing
that can be used to deduce the subject’s identity.
Sample Size Justification
This is a pilot exploratory study so no sample size justification will be provided.
8.
Data Management
Standardized CRFs will be used. Investigators are responsible for the accurate completion and timely
submission of the data collected during the trial. All data from the trial will be entered from the CRFs into a
central database. Incoming data will be frequently reviewed to identify inconsistent or missing data and any
adverse events. Any data issues are to be promptly addressed with the investigator by the Sponsor. Quality
assurance procedures will be established to ensure that complete, accurate and timely data are submitted, that
protocol requirements are followed and that complications, adverse events and adverse device effects are
correctly reported and investigated, as appropriate. Investigators are to maintain all source documents as
required by the protocol, including laboratory results, supporting medical records, and signed Informed
Consent Forms. The source documents will be used during the regular monitoring visits to verify information
from the database against data contained on the completed CRFs.
9.
Deviations from the Investigational Plan
Any deviations from the study protocol will be documented as Protocol Deviations in the Source
Documentation.
10. Product Accountability
The Sponsor will ship investigational product directly to the site once IRB approval has been obtained. The
investigator is responsible for providing a secure storage location for the investigational product, supervising
product use, as well as the disposal and/or return of the product as instructed by the Sponsor. In addition, the
investigator shall maintain records to document the receipt, use and disposition of all investigational product
received by their site.
11. Ethics
Trial Conduct
The study will be conducted according to the Declaration of Helsinki, Protection of Human Volunteers
(21 CFR 50), Institutional Review Boards (21 CFR 56), and Obligations of Clinical Investigators (21 CFR
812).
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other records will be
identified by a coded number only.  All study records will be kept in a locked research office with limited

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access to study personnel and code sheets linking a patient’s name to a patient identification number will
be stored separately in a secured area within the research office.  Clinical information will not be released
without written permission of the subject, except as necessary for monitoring by the FDA.  The
Investigator must also comply with all applicable privacy regulations (e.g., Health Insurance Portability
and Accountability Act of 1996, EU Data Protection Directive 95/46/EC).
Good clinical practice (GCP) is an international quality standard that is provided by International
Conference of Harmonization (ICH), an international body that defines a set of standards, which
governments can then transpose into regulations for clinical trials of medications as well as medical
devices involving human subjects.
GCP guidelines are important as they provide the necessary enforcement of ethics of a clinical study,
protection of human rights for the subjects (such as voluntariness) and assurance of the safety and efficacy
of investigational products. High standards are required in terms of comprehensive documentation for the
clinical protocol, record keeping (paper and electronic which includes computers and software), training,
and facilities. Quality assurance and inspections ensure that these standards are achieved and maintained.
GCP guidelines include standards on how clinical trials should be conducted, define the roles and
responsibilities of clinical trial sponsors, clinical research investigators, and monitors. As a research site,
we follow the ICH-GCP guidelines. Our GCP includes review of each case to determine whether or not
the patient would be a good candidate for a clinical trial and if there is an appropriate clinical trial for the
patient. Important aspects include adequate time for the person to review the consent form and have all
questions answered, voluntarily give consent and know that they can withdraw at any time. Maintaining
the subject’s privacy and confidentiality is handled by assigning a subject number for each study
participant. Research staff responsibilities include: adherence to the protocol, proper documentation,
accuracy of data and appropriate handling of the study product.
Institutional Review Board Review
The protocol and consent form will be reviewed and approved by the IRB/IEC prior to study initiation.
Serious adverse experiences regardless of causality will be reported to the IRB/IEC in accordance with
the standard operating procedures and policies of the IRB/IEC, and the Investigator will keep the IRB/IEC
informed as to the progress of the study.  The Investigator will obtain assurance of IRB/IEC compliance
with regulations.
Any documents that the IRB/IEC may need to fulfill its responsibilities (such as protocol, protocol
amendments, Investigator’s Brochure, consent forms, information concerning patient recruitment,
payment or compensation procedures, or other pertinent information) will be submitted to the IRB/IEC.
The IRB/IECs written unconditional approval of the study protocol and the informed consent form will
be in the possession of the Investigator before the study is initiated.  The IRB/IECs unconditional approval
statement will be transmitted by the Investigator to Osiris Therapeutics contact prior to the shipment of
study supplies to the site.  This approval must refer to the study by exact protocol title and number and
should identify the documents reviewed and the date of review.
Protocol and/or informed consent modifications or changes may not be initiated without prior written
IRB/IEC approval except when necessary to eliminate immediate hazards to the patients or when the
change(s) involves only logistical or administrative aspects of the study.  Such modifications will be
submitted to the IRB/IEC and written verification that the modification was submitted and subsequently

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approved should be obtained.
The IRB/IEC must be informed of revisions to other documents originally submitted for review; serious
and/or unexpected adverse experiences occurring during the study in accordance with the standard
operating procedures and policies of the IRB; new information that may affect adversely the safety of the
patients of the conduct of the study; an annual update and/or request for re-approval; and when the study
has been completed.
Any amendment to the protocol will be written by the investigator and Osiris Therapeutics contact.
Protocol amendments cannot be implemented without prior written IRB/IEC approval except as necessary
to eliminate immediate safety hazards to patients.  A protocol amendment intended to eliminate an
apparent immediate hazard to patients may be implemented immediately, provided the IRBs are notified
within five working days.
Informed Consent
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH GCP, US Code of
Federal Regulations for Protection of Human Subjects (21 CFR 50.25 [a,b], CFR 50.27, and CFR Part 56,
Subpart A), the Health Insurance Portability and Accountability Act (HIPAA, if applicable), and local
regulations.
Subjects cannot be asked to sign the Informed Consent form until the study has been fully approved by
the investigational site’s IRB and the Sponsor has received and reviewed the specific IRB approved
Informed Consent form to be used by the site. The potential subject shall be given adequate time to read
the consent form, have the study procedures explained, including risks and benefits, as well as alternative
procedures, prior to signing the Informed Consent form. An example of the Informed Consent form for
this study is provided in Appendix 1: Informed Consent Form. The consent form must be read by the
subject, the subject’s questions answered, and the form signed by the subject before the treatment can be
performed. All subjects are to receive copies of their signed consent form. The date the subject signs the
consent form is to be recorded on CRF.
Coverage of Expenses
Subject Compensation
Subjects will be paid 35 dollars for each week of participation in the study at the completion of their
participation in the study. Payment will be made after each visit or within 30 days of the ending of their
participation in the study. The study sponsor will not pay for transportation to and from the wound care
clinic for the follow-up visit requirements.
Cost to Subjects
There will be no cost incurred by the subject for participating in this study. All noted procedures are
considered standard of care (SOC) and will be billed to the patient’s insurance or whatever program the
patient uses.
Confidentiality

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Protected health information (PHI) of clinical investigation Subjects are kept as confidential as possible
in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Members
of the study team who will have access to the PHI information include the following: Research staff at
UT Southwestern and Parkland Hospitals, Sponsor (Osiris Therapeutics), and any outside labs/facilities
that may handle specimens. When appropriate, specimens and data will only have subject ID. However,
confidentiality cannot be assured.
12. Data Handling and Record Keeping
Source Documents
The investigator must maintain detailed source documents on all subjects who are enrolled or who
undergo screening in the study. Source documents include subject medical records, hospital charts, clinic
charts, investigator subject trial files, as well as the results of diagnostic tests (e.g., laboratory tests,
hemodynamic studies).
The following minimum information should be entered into the subject’s medical record:

The date the subject entered the trial and the subject number

The trial protocol number and the name of the Sponsor

The date that Informed Consent was obtained

Evidence that the subject meets the trial eligibility requirements (e.g., medical history, study
procedures and/or evaluations)

The dates of all trial related subject visits

Evidence that required procedures and/or evaluations were completed

Use of any concomitant medications

Documentation of specific device used

Occurrence and status of any adverse events (AEs)

The date the subject exited the trial and a notation as to whether the subject completed the trial or
was discontinued, including the reason for discontinuation
Data Collection
The investigator must maintain detailed records on all subjects who sign the Informed Consent Form and
begin the pre-procedure evaluation. Data for enrolled subjects will be transcribed on to CRFs provided
by the Site. All data should be transcribed completely, promptly and legibly. Corrections should be made
in a manner that does not obscure or eliminate the original error, by striking through the original data with
one line, and initialing and dating the change, along with the reason for the change (if not obvious). The
investigator should maintain a copy of all completed CRFs from this trial.
Trial exit forms will be completed for all enrolled subjects, regardless if they did or did not complete the
trial (e.g., subject discontinuation, trial termination).
Record Retention
All records relating to the conduct of this trial are to be retained by the investigator for a minimum of 2
years or until notified by the Sponsor or Sponsor’s designee that the records may be destroyed, whichever

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is longer.
13. Quality Control and Quality Assurance
Site Training
Training records shall be kept for all study-related training.
Investigator Training
Investigator Responsibilities
The investigators are responsible for ensuring that this study is conducted according to this protocol and
applicable regulations and that signed Informed Consent is obtained from each subject prior to his
inclusion in this study. It is the investigator’s responsibility to ensure that all staff assisting with this study
have the appropriate qualifications and are fully instructed on the study procedures and respect subject
confidentiality, as specified in the Investigator Agreement with the Sponsor
Investigator Records
Standardized Case Report Forms (CRFs) will be used to collect complete and accurate records of the
clinical data generated from this study according to Good Clinical Practices (GCP) requirements. The
investigators are responsible for collecting and accurately recording the clinical data generated for this
study. Investigators are also responsible for maintaining records for at least 7 years per UTSW rules.
Investigator Reports
The investigator will be responsible for providing the following reports, in accordance with
CFR§812.150, to the Sponsor for this study:

Serious Adverse Events (SAEs) and Unanticipated Adverse Device Effects (UADEs): The
investigators will report by telephone, email or fax any SAEs or UADEs as soon as possible,
within 24 hours of the investigator becoming aware of the event, to the Sponsor and the IRB. The
Serious Adverse Event form is to be completed to document the SAE and it is to be faxed or
express mailed to the Sponsor and the IRB within ten working days of the event.

Withdrawal of Approval: If an IRB withdraws the approval to conduct this study for any reason,
the investigator will notify the Sponsor as soon as possible, but in no event later than five working
days after the withdrawal of the approval

Progress Reports: The investigator will submit progress reports on the investigation to the
Sponsor and the reviewing IRB at regular intervals, but in no event less often than yearly.

Deviations from the Investigational Plan: The investigator must notify the Sponsor and the
reviewing IRB of any deviation from the Investigational Plan to protect the life or physical well-
being of a subject in an emergency. This notice must occur as soon as possible, but in no case
longer than five working days following the occurrence of the deviation.

Informed Consent: If the investigator uses a device without obtaining informed consent, the
investigator shall report the use to the Sponsor and the IRB within 5 working days after the use
occurs.

Final Report: Within three months after the termination or completion of the study or the

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investigator’s part in the study, the investigator shall submit a final report to the Sponsor and the
IRB.

Other Reports: Upon request from the IRB or the FDA, the investigator shall provide accurate,
complete and current information about any aspect of the study.
The investigator is responsible for ensuring that the study is conducted according to this protocol and that
signed Informed Consent is obtained from each subject prior to their inclusion in this study.
14. Adverse Events and Serious Adverse Events
General
All observed or volunteered adverse events regardless of treatment group or suspected causal relationship
to the investigational product(s) will be reported as described in the following sections.
For all adverse events, the investigator must pursue and obtain information adequate both to determine
the outcome of the adverse event and to assess whether it meets the criteria for classification as a serious
adverse event requiring immediate notification to the Osiris Therapeutics contact.  For all adverse events,
sufficient information should be obtained by the investigator to determine the causality of the adverse
event.  The investigator is required to assess causality.  For adverse events with a causal relationship to
the device, follow-up by the investigator is required until the event or its sequelae resolve or stabilize at a
level acceptable to the investigator, and the Osiris Therapeutics contact concurs with that assessment.
Protocol Specific AE Definition/Collection: For the purposes of this study, only AEs that are directly
related to the study product, diabetes (including labs & kidney function) or wound healing (including
infections related to the wound) will be collected and reported as these events may effect outcomes and
analysis of data. AEs not related to the aforementioned product or diagnoses are not relevant to the subject
outcomes of this research or data analysis (such as nausea, emesis, pain, constipation, diarrhea, mood
disorders, respiratory diagnoses, etc). AEs that do not fall under this protocol specific definition will be
assessed and treated as per standard of care. SAEs will be collected as per the usual SAE guidelines (see
section on reporting SAEs). In addition, planned procedures related to the study wound for a subject
during the same hospitalization (as these subjects will be recruited while in the hospital because they have
an infection in their foot wound/ulcer) for incision/debridement/amputation will be considered part of
their continuation of SOC and not adverse events unless a complication, new infection or new wound
occurs.
Adverse Event Reporting
For serious adverse events, the reporting period to Osiris Therapeutics or its designated representative
begins from the time that the subject provides informed consent, which is obtained prior to the subject’s
participation in the study, i.e., prior to undergoing any study-related procedure and/or receiving
investigational product, through and including 28 calendar days after the last administration of the
investigational product.  Any serious adverse event occurring any time after the reporting period must be
promptly reported if a causal relationship to investigational product is suspected. Adverse events (serious
and non-serious) should be recorded on the CRF from the time the subject has undergone one treatment
through last subject visit.
Definition of an Adverse Event (AE)

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An adverse event is any untoward medical occurrence in a clinical investigation subject administered a
product or medical device; the event need not necessarily have a causal relationship with the treatment or
usage.  Examples of adverse events include but are not limited to:

Abnormal test findings;

Clinically significant symptoms and signs or diagnosis;

Changes in physical examination findings;

Hypersensitivity;

Progression/worsening of wound.
Definition of Serious Adverse Event (SAE)
A Serious Adverse Event (SAE) is any AE that has any serious unfavorable and unintended sign,
symptom, or disease temporally associated with the use of the devices, whether or not considered related,
including those that:

results in death

is life-threatening

requires inpatient hospitalization or causes prolongation of existing hospitalization

results in persistent or significant disability/incapacity

is a congenital anomaly/birth defect

requires intervention to prevent permanent impairment or damage
Medical and scientific judgment should be exercised in determining whether an event is an important
medical event.  An important medical event may not be immediately life-threatening and/or result in death
or hospitalization.  However, the important medical event should be reported as serious, if it is determined
that the event may jeopardize the subject and/or may require intervention to prevent one of the other
adverse event outcomes.
Causality Assessment of Adverse Events
The investigator’s assessment of causality must be provided for all adverse events (serious and non-
serious); the investigator must record the causal relationship in the CRF, as appropriate, and report such
an assessment in accordance with the serious adverse reporting requirements if applicable.  An
investigator’s causality assessment is the determination of whether there exists a reasonable possibility
that the cleared medical device caused or contributed to an adverse event.  If the investigator does not
know whether or not medical device caused the event, then the event will be handled as “related to medical
device” for reporting purposes. (see Section on Reporting Requirements).  If the investigator's causality
assessment is "unknown but not related to investigational product", this should be clearly documented on
study records.
In addition, if the investigator determines a serious adverse event is associated with study procedures, the
investigator must record this causal relationship in the source documents and CRF, as appropriate, and
report such an assessment in accordance with the serious adverse event reporting requirements, if
applicable.
Adverse Event Severity Assessment
The Investigator will provide an assessment of the severity of each adverse reaction by recording a

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severity rating on the appropriate SAE reporting page of the subject’s file. Severity, which is a description
of the intensity of manifestation of the SAE, is distinct from seriousness, which implies a patient outcome
or SAE-required treatment measure associated with a threat to life or functionality.  Severity will be
assessed according to the following scale.
If required on the adverse event case report forms, the investigator will use the adjectives MILD,
MODERATE, or SEVERE to describe the maximum intensity of the adverse event.  For
purposes of consistency, these intensity grades are defined as follows:
MILD
Does not interfere with subject's usual function.
MODERATE
Interferes to some extent with subject's usual function.
SEVERE
Interferes significantly with subject's usual function.
Note the distinction between the severity and the seriousness of an adverse event.  A severe event is not
necessarily a serious event.  For example, a headache may be severe (interferes significantly with subject's
usual function) but would not be classified as serious unless it met one of the criteria for serious adverse
events, listed above.
Withdrawal Due to Adverse Events (See Also Section on Subject Withdrawal)
Withdrawal due to adverse event should be distinguished from withdrawal due to insufficient response,
according to the definition of adverse event noted earlier, and recorded on the appropriate adverse event
CRF page.
When a subject withdraws due to a serious adverse event, the serious adverse event must be reported in
accordance with the reporting requirements defined below.
Eliciting Adverse Event Information
The investigator is to report all directly observed adverse events and all adverse events spontaneously
reported by the study subject.  In addition, each study subject will be questioned about adverse events by
a member of the research staff.
Reporting Requirements
Each adverse event is to be assessed to determine if it meets the criteria for serious adverse events.  If a
serious adverse event occurs, expedited reporting will follow local and international regulations, as
appropriate.
Serious Adverse Event Reporting Requirements
If a serious adverse event occurs, Osiris Therapeutics is to be notified within 24 hours of awareness of the
event by the investigator.  In particular, if the serious adverse event is fatal or life-threatening, notification
to Osiris Therapeutics must be made immediately, irrespective of the extent of available adverse event
information.  This timeframe also applies to additional new information (follow-up) on previously
forwarded serious adverse event reports as well as to the initial and follow-up reporting of Exposure
during pregnancy cases.

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In the rare event that the investigator or member of the research team does not become aware of the
occurrence of a serious adverse event immediately (e.g., if an outpatient study subject initially seeks
treatment elsewhere), the investigator or member of the research team is to report the event within 24
hours after learning of it and document the time of his/her first awareness of the adverse event.
For all serious adverse events, the investigator is obligated to pursue and provide information to Osiris
Therapeutics in accordance with the timeframes for reporting specified above.  In addition, an investigator
may be requested by Osiris Therapeutics to obtain specific additional follow-up information in an
expedited fashion.  This information may be more detailed than that captured on the adverse event case
report form.  In general, this will include a description of the adverse event in sufficient detail to allow
for a complete medical assessment of the case and independent determination of possible causality.
Information on other possible causes of the event, such as concomitant medications and illnesses must be
provided.  In the case of a subject death, a summary of available autopsy findings and/or a copy of the
death certificate must be submitted as soon as possible to Osiris Therapeutics or its designated
representative.
All AEs/SAEs should be followed until resolution.
Non-Serious Adverse Event Reporting Requirements
All adverse events will be reported on the adverse event page(s) of the CRF.  It should be noted that the
form for collection of serious adverse event information is not the same as the adverse event CRF.  Where
the same data are collected, the forms must be completed in a consistent manner.  For example, the same
adverse event term should be used on both forms.  Adverse events should be reported using concise
medical terminology on the CRFs as well as on the form for collection of serious adverse event
information.
Reporting Requirements to Regulatory Authorities
Adverse events reporting, including suspected serious unexpected adverse reactions, will be carried out
in accordance with applicable local regulations.
15. Publication 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 investigator and the Osiris Therapeutics
contact.  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.
References
1.
Armstrong, D.G. and L.A. Lavery, Negative Pressure Wound After Partial Diabetic Foot
Amputation: a Multicentre, Randomised controlled trial. The Lancet, 2005. 366: p. 1704-1710.

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2.
Blume, P.A., et al., Comparison of negative pressure wound therapy using vacuum-assisted
closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter
randomized controlled trial. Diabetes Care, 2008. 31(4): p. 631-6.
3.
Saxena, V., et al., Vacuum-assisted closure: microdeformations of wounds and cell proliferation.
Plast Reconstr Surg, 2004. 114(5): p. 1086-96; discussion 1097-8.
4.
Lipsky, B.A., et al., Diagnosis and treatment of diabetic foot infections. Clin Infect Dis, 2004.
39(7): p. 885-910.
5.
Wukich, D.K., et al., Correlation of SF-36 and SF-12 Component Scores in Patients With
Diabetic Foot Disease. J Foot Ankle Surg, 2016. 55(4): p. 693-6.