A Multicenter, Double-Blind, Randomized, Saline-Controlled Study of a Single, Intra-articular Injection of Autologous Protein Solution in Patients With Knee Osteoarthritis
Phase: NA
Conditions: Osteoarthritis
Sponsor: Zimmer Biomet

 
 
 
 
 
CLINICAL STUDY PROTOCOL 
 
 
Protocol Title: 
A Multicenter, Double-Blind, Randomized, 
Saline-Controlled Study of a Single, Intra-
Articular Injection of Autologous Protein Solution 
in Patients with Knee Osteoarthritis 
Short Title: 
Saline-Controlled Study of nSTRIDE APS for 
Knee Osteoarthritis 
Protocol Number: 
APSS-44-00 
Study Sponsor: 
Biomet Biologics, LLC 
56 East Bell Drive 
Warsaw, IN 46581 
USA 
Protocol Version: 
Version 5.0 
Version Date: 
06 August 2019 
 
 
 
 
-CONFIDENTIAL- 
This document and its contents are the property of and confidential to Zimmer 
Biomet. Any unauthorized copying or use of this document is prohibited. 
 
 
 
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INVESTIGATOR PROTOCOL AGREEMENT PAGE 
 
I agree: 
• 
To assume responsibility for the proper conduct of the study at this site and  
supervise all testing of the device involving human subjects 
• 
To conduct the study in compliance with this protocol, any future 
amendments, and with any other study conduct procedures provided by the 
Sponsor. 
• 
To ensure that the requirements for obtaining informed consent from each 
subject are met.   
• 
Not to implement any changes to the protocol without written agreement from 
the Sponsor and prior review and written approval from my institutional 
review board except where necessary to eliminate an immediate hazard to 
patients. 
• 
That I am thoroughly familiar with the appropriate use of the study device, as 
described in this protocol and any other information provided by the Sponsor. 
• 
That I am aware of, and will comply with, good clinical practice (GCP) and all 
applicable regulatory requirements. 
• 
To ensure that all persons assisting me with the study are adequately 
informed about the investigational device and have been trained on their 
study-related duties and functions as described in the protocol. 
 
 
Signature: 
 
 
Date: 
 
 
Name 
(print): 
 
  
 
 
Investigator 
 
  
 
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STUDY CONTACT INFORMATION 
 
Responsibility 
Name and Address 
Phone/E-mail Contact 
Study Sponsor  
 
Joel Higgins 
Senior Director, Biologics 
Zimmer Biomet 
56 East Bell Drive 
Warsaw, IN 46582 
USA 
Phone 
Office: 574.372.1734 
Mobile: 574.527.6964 
Email 
joel.higgins@zimmerbiomet.com 
 
Sponsor Project 
Manager 
 
Ann Blanton 
Clinical Project Lead, Biologics 
Zimmer Biomet 
56 East Bell Drive 
Warsaw, IN 46582 
USA 
Phone 
Office: 574.371.3095 
Mobile: 574.253.5556 
Email 
ann.blanton@zimmerbiomet.com 
 
Sponsor 
Regulatory 
Affairs Manager 
Susan Mack 
Regulatory Affairs Manager, 
Biologics and Sports Medicine 
Zimmer Biomet 
56 East Bell Drive 
Warsaw, IN 46582 
USA 
Phone 
Office: 574.372.6894 
Mobile : 765.490.0521 
Email 
susan.mack@zimmerbiomet.com  
 
Monitoring Lead 
Christian Barille 
Lead Clinical Research Associate 
IMARC Research, Inc. 
22560 Lunn Road 
Strongsville, OH 44149 
USA 
Phone 
Office: 440.801.1540 
Mobile: 440.823.3898 
Email 
cbarille@imarcresearch.com  
 
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STUDY SYNOPSIS 
Protocol Number: APSS-44-00 
Title: 
A Multicenter, Double-Blind, Randomized, Saline-Controlled 
Study of a Single, Intra-Articular Injection of Autologous Protein 
Solution in Patients with Knee Osteoarthritis 
Sponsor: 
Biomet Biologics, A Zimmer Biomet Company 
Name of Product: 
nSTRIDE APS Kit  
Device 
Description: 
The nSTRIDE autologous protein solution (APS) Kit with 
anticoagulant citrate dextrose solution, formula A (ACD-A) is a 
self-contained, sterile-packaged, single-use device designed to 
concentrate anti-inflammatory cytokines and growth factors 
from whole blood. The device system is to be used at the point 
of care to create an autologous solution. This device system 
consists of two parts: the nSTRIDE Cell Separator and the 
nSTRIDE Concentrator. The nSTRIDE Cell Separator 
separates the cellular components from plasma and red blood 
cells in whole blood. The cell solution is then loaded into the 
nSTRIDE Concentrator, which uses filtration through 
polyacrylamide beads to concentrate the cytokines in the 
injectable output. 
Intended Use: 
The nSTRIDE APS Kit is designed to be used for the safe and 
rapid preparation of autologous protein solution (APS) from a 
small sample of blood at the patient’s point of care. The APS is 
to be injected intra-articularly for the treatment of knee 
osteoarthritis and associated symptoms or knee pain 
associated with osteoarthritis. 
Study Center(s): 
The study will be conducted at up to 30 investigative centers in 
the United States. 
Planned Sample 
Size: 
332 subjects will be randomized (1:1) into one of two treatment 
groups (APS and Saline). 
Study Population: Patients with symptomatic osteoarthritis (OA) in one knee, who 
have not been able to get satisfactory pain relief with prior 
treatment.  
Study Objectives: Primary Objective 
The primary objective of this study is to determine whether 
nSTRIDE APS is superior to a saline with regard to the mean 
improvement from baseline to 12 months in Western Ontario 
and McMaster Universities Osteoarthritis Index (WOMAC) LK 
 
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3.1 pain score.  
Secondary and Exploratory Objectives 
Secondary objectives of this study include determining whether 
nSTRIDE APS is superior to saline in improving the WOMAC 
function subscale score (as evaluated using the percentage of 
subjects showing at least the minimal clinically important 
difference (MCID)), and the WOMAC pain subscale score (as 
evaluated using the percentage of subjects showing at least 
the minimal clinically important difference (MCID)), OMERACT-
OARSI responder rates, analyzing WOMAC pain and function 
in only the KL-II Subgroup, evaluating superiority of APS over 
saline in improving Visual Analog Scale (VAS) pain, 
assessment of the changes in WOMAC Pain scores over time, 
and evaluation of the usage of rescue and restricted 
medication.    
Additionally, this study will evaluate change in joint morphology 
and APS output characteristics. Safety of nSTRIDE APS will 
be compared to saline following intra-articular knee injections 
in subjects with early to moderate symptomatic OA. 
Study Design and 
Procedures: 
The study will compare the efficacy of nSTRIDE APS to saline 
in patients with early to moderate symptomatic osteoarthritis 
(OA) in one knee, who have failed at least one prior 
conservative OA therapy (e.g. physiotherapy, simple 
analgesics). This will be done using a double-blind, 
multicenter, randomized, controlled trial (RCT) with study 
subjects receiving either a single injection of nSTRIDE APS or 
saline. The primary efficacy measure will be pain as measured 
on the WOMAC LK 3; other measures of efficacy will include 
function, stiffness, and quality of life. In addition to clinical 
efficacy measures, safety will be assessed by tracking adverse 
events. Anatomical changes will be evaluated by magnetic 
resonance imaging (MRI) and radiographs (X-ray), and key 
factors in baseline blood and APS will be characterized. 
Laboratory characterization procedures will be performed using 
validated, prospectively defined methods. 
During the screening process, potential subjects will provide 
informed consent and then be screened for eligibility. 
Screening will consist of meeting all inclusion and exclusion 
criteria, including a WOMAC LK 3.1 pain subscale score ≥ 9 
and ≤ 19 and by providing objective physiological evidence of 
OA using the Kellgren-Lawrence scale (assessed from normal 
radiographs). Subjects will also provide demographics and 
 
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medication use information as part of this process. Baseline X-
ray (if needed) and MRI will be collected. 
Within 28 days of the screening visit, subjects will return to the 
clinic for treatment. Subjects will complete the baseline 
outcomes measurements including the EuroQol questionnaire 
(EQ-5D), and visual analog scale (VAS) for knee pain. The 
WOMAC score recorded at the screening visit will serve as the 
baseline (pre-injection) WOMAC score, and the WOMAC 
questionnaire will not be re-administered prior to treatment. 
During the treatment visit, all subjects will have a blood draw, 
from which the APS will be prepared for injection and for 
laboratory characterization. The nSTRIDE APS Kits will be 
processed for all subjects in both treatment groups. After all 
available joint fluid is aspirated and, according to 
randomization group assignment, approximately 2.5 milliliters 
(ml) of APS or saline will be injected into the joint. Needle 
placement in the joint will be verified using ultrasound. A 
blinding sleeve covering the contents of the syringe will mask 
treatment assignment from the subject and the injecting 
physician. Any adverse events associated with the blood draw 
and/or injection procedure will be recorded. All subjects will be 
instructed to refrain from exceeding the pre-injection level of 
activity for 14 days. 
Efficacy and safety will be assessed at 1, 3, 6, and 12 months 
post injection. Concomitant treatment for OA will be 
standardized to be oral acetaminophen (e.g. Tylenol) for all 
subjects during the study. Subjects will be asked to abstain 
from analgesic use for 48 hours prior to assessments. They will 
complete the WOMAC, EQ-5D, and VAS for pain.  
An X-ray and MRI will be obtained at 12 months to assess 
anatomical changes. All images will be transferred to the 
central core lab for independent review. Image acquisition, 
transfer, and analysis procedures will be performed using 
validated, prospectively defined methods.  
After each subject completes all 12 month follow-up 
evaluations, individual treatment allocation will be unblinded; 
subjects from both groups will be permitted to enter a one 
month open-label repeat treatment phase if they have had no 
major safety events due to the first injection. One month after 
the second injection, subjects will complete the WOMAC, EQ-
5D, and VAS for pain. 
 
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Study Duration: 
Maximum study duration per subject is 16 months: 12 months 
from treatment to last follow-up, 1 additional month for follow-
up after second injection, and 3 months if the maximum visit 
window time is realized. 
Inclusion Criteria: 
1. Male or female ≥ 21 and ≤ 80 years old at time of 
screening. 
2. Willingness and ability to comply with the study 
procedures and visit schedules and ability to follow oral 
and written instructions. 
3. A standing radiograph of the knee showing a Kellgren-
Lawrence grade of 2 to 4 and an absence of severe 
osteoarthritis (defined as advanced stage osteoarthritis, 
including large osteophytes, chronic fractures or bone 
remodeling, severe deformity or bone attrition, and/or 
bone-on-bone contact indicative of severe 
osteoarthritis/full thickness cartilage loss), as confirmed 
by the central imaging laboratory. 
4. Body mass index ≤ 40 kg/m2. 
5. A WOMAC LK 3.1 pain subscale total score ≥ 9 and ≤ 
19. 
6. Has undergone at least one prior conservative 
osteoarthritis treatment (e.g. physical therapy, simple 
analgesics). 
7. Signed an institutional review board approved informed 
consent. 
Exclusion 
Criteria: 
1. Presence of clinically observed active infection in the 
index knee. 
2. Presence of symptomatic osteoarthritis in the non-study 
knee; if unclear then the WOMAC LK 3.1 pain sub-scale 
for the non-index knee must be ≤ 5.0. 
3. Diagnosed with rheumatoid arthritis, Reiter’s syndrome, 
psoriatic arthritis, gout, ankylosing spondylitis, or arthritis 
secondary to other inflammatory diseases; HIV, viral 
hepatitis; chondrocalcinosis, Paget’s disease, or 
villonodular synovitis. 
4. Clinically symptomatic patellofemoral chondromalacia 
(i.e. knee pain in the anterior knee only) or diagnosis of 
isolated patellofemoral OA. 
5. Diagnosed with leukemia, known presence of metastatic 
malignant cells, or ongoing or planned 
chemotherapeutic treatment. 
6. Disease of spine, hip or other lower extremity joints 
judged by the investigator to be contributing to the pain 
in the index knee (i.e. sciatica, nerve pain, hip OA). 
Note: Patients with knee replacement at the contra-
 
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lateral knee or hip replacement in either hip may be 
enrolled provided there is sufficient pain relief after knee 
replacement or hip replacement that analgesics are not 
required. 
7. Untreated symptomatic injury of the index knee (e.g., 
acute traumatic injury, anterior cruciate ligament injury, 
clinically symptomatic meniscus injury characterized by 
mechanical issue such as locking or catching). 
8. Any condition other than OA of the index knee which, in 
the opinion of the investigator, affects the ability to 
ambulate to a sufficient degree to interfere with the 
assessment of the safety and treatment effects of the 
study injection. 
9. Presence of surgical hardware or other foreign body 
intended to treat arthritis or cartilage-related pathology 
in the index knee. 
10. Previous cartilage repair procedure on the injured 
cartilage surface (i.e., microfracture, osteoarticular 
transfer system (OATS) and autologous chondrocyte 
implantation (ACI)) of the index knee. 
11. Arthroscopy or open surgery of the index knee within 6 
months of screening. 
12. Intra-articular steroid injection in the index knee within 3 
months of screening. 
13. Intra-articular hyaluronic acid injection in the index knee 
within 6 months of screening. 
14. Other intra-articular therapy in the index knee within 6 
months prior to screening. 
15. Orally administered systemic steroid use within 2 weeks 
of screening. 
16. Planned/anticipated surgery of the index knee during the 
study period. 
17. A history of local anesthetic allergy. 
18. Use of systemic immunosuppressants within 6 weeks of 
screening. 
19. Currently on anticoagulant therapy, such as Warfarin, 
vitamin K antagonists, direct thrombin inhibitors, or 
factor Xa inhibitors or on potent anti-platelet therapy, 
such as GPIIb-IIIa antagonists, Par-1 antagonists or 
dual anti-platelet therapy, i.e. an ADP receptor 
antagonist in combination with aspirin. 
20. Any documented clinically significant degree of cognitive 
impairment or other condition, finding, or psychiatric 
illness at screening which, in the opinion of the 
investigator, could compromise patient safety or 
interfere with the assessment of the safety and 
 
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treatment effects of the study injection. 
21. Skin breakdown at the knee where the injection is 
planned to take place. 
22. Pregnant or nursing mothers or women planning on 
getting pregnant during the time they will be participating 
in the study. 
23. Known drug or alcohol dependence currently or within 
the last year. 
24. Participated in any investigational drug or device trial 
within 30 days prior to screening. 
25. Participated in any investigational biologic trial within 60 
days prior to screening. 
Schedule of 
Visits: 
• Screening 
• Procedure (within 28 days of screening) 
• 1 Month (± 7 days) 
• 3 Month (± 14 days) 
• 6 Month (± 14 days) 
• 12 Month (± 28 days) 
• (Optional) Second Injection (within 14 days of 12 Month 
visit) 
• Second Injection Follow-Up (if needed) will occur within 
1 month of second injection (± 7 days) 
Clinical 
Assessment 
Tools: 
The Western Ontario and McMaster Universities Osteoarthritis 
Index using the Likert scale, Version 3.1: 
The WOMAC LK 3.1 questionnaire is a validated tool used for 
assessing knee pain, stiffness, and function. The WOMAC LK 
3.1 has 24 items; 5 items assessing knee pain, 2 items 
assessing knee stiffness, and 17 items assessing physical 
function. Each item is answered on a 5-point Likert scale, with 
grading from 0 (none or never) to 4 (extreme or always). A 
higher score indicates worse pain, stiffness, or functional 
limitation. 
The EuroQol-5 Dimensions 
The EuroQol-5 Dimensions (EQ-5D) is a validated instrument 
which assesses an individual’s current health status and heath 
related quality of life. The EQ-5D-3L descriptive component 
assesses five dimensions: mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression over three levels of 
severity. The EQ visual analogue scale (EQ VAS) assesses 
the respondent’s self-rated overall health state on a scale from 
0 (worst imaginable health state) to 100 (best imaginable 
health state). 
Visual Analog Scale (VAS) for knee pain  
 
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The VAS is a validated measure of knee pain. The VAS is a 
nominal 100 mm line anchored by 0 “no pain” and 100 “worst 
possible pain”. Subjects rate their average pain over the last 24 
hours by indicating their level of pain with a slash mark through 
the line. 
Imaging 
Assessment 
Tools: 
Radiographs 
Standing posterior-anterior (PA) fixed flexion knee radiographs 
(X-rays) are used to assess structural features of the joint, 
including joint space width, and presence or absence of 
subchondral sclerosis, subchondral cysts, and osteophytes. X-
ray assessments will be performed by a core imaging 
laboratory. 
Magnetic Resonance Imaging 
Magnetic Resonance Imaging (MRI) has been shown to be 
sensitive to structural changes in cartilage. Specifically, 
quantitative assessment via T2 MR relaxation mapping is used 
to detect early compositional changes in cartilage.  
In addition, semi-quantitative assessment via MRI 
Osteoarthritis Knee Score (MOAKS), is used to evaluate the 
following: 
• Subchondral Bone 
• Cartilage 
• Meniscus 
• Peri-Articular Features 
Magnetic Resonance Imaging (MRI) assessments will be 
performed by a core imaging laboratory. 
Laboratory 
Characterization: 
Each subject will have an additional nSTRIDE APS Kit 
processed for laboratory characterization. The APS output from 
the additional kit, along with a baseline blood sample and 
synovial fluid (if available), will be sent to a core laboratory for 
analysis. Analyses will include quantification of cellular content 
and key cytokines and growth factors. Laboratory 
characterization procedures will be performed using validated, 
prospectively defined methods.  
Primary 
Endpoint: 
The primary endpoint will be the change in pain from baseline 
to 12 months following injection of nSTRIDE APS or saline, as 
measured by the WOMAC LK 3.1 pain subscale. 
Primary 
Hypothesis for 
nSTRIDE 
Superiority 
The primary hypothesis to be tested is that the mean 
improvement in WOMAC pain subscale score (baseline to 12 
months) in the APS group will be greater than that of the saline 
group.  
The primary hypothesis described below will be tested along 
 
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Testing: 
with the secondary hypotheses using a pre-specified order of 
hypotheses. These tests will be performed at the 0.05 level.  If 
the first null hypothesis is rejected, the second test will be 
performed at the 0.05 level. If the first hypothesis is not tested 
significantly, the second test, and all subsequent tests, will be 
performed as exploratory analyses.  
 
A two-tailed independent sample T-test will be used to test 
the primary endpoint. The hypothesis will be: 
H0: µAPS = µControl  
Versus  
HA: µAPS ≠ µControl  
Where: 
µAPS = mean change in WOMAC Pain from baseline to 12 
months in the APS group, and 
µcontrol = mean change in WOMAC Pain from baseline to 12 
months in the control group. 
 
The impact of the usage of APS on function will be evaluated 
as part of the primary endpoint; however, no formal statistical 
test will be done as a part of the study success criteria.  A 
qualitative assessment of the changes in WOMAC Function 
over time for APS and Saline will be discussed, in order to 
ensure that the impact of the treatment on function is neutral or 
positive.  The following descriptive analyses will be performed 
for this assessment of function: 
 
(1) A graphical examination of the changes in WOMAC 
Function for APS and Saline over time, including means 
and standard error bars. 
(2) Descriptive statistics for the mean changes in WOMAC 
Function over time, separately for each treatment group.  
These will include mean, median, standard deviation, 
minimum, maximum, and 95% confidence intervals. 
 
For each analysis, it is expected that the changes in WOMAC 
function will remain neutral or increase over time within the 
APS group, and also that the mean changes in WOMAC 
Function over time will be at least nominally better for the APS 
group than for Saline. 
 
A finding of nSTRIDE APS superiority on the mean 
improvement in WOMAC LK 3.1 Pain along with no 
corresponding deterioration in WOMAC Function will be 
considered evidence of nSTRIDE APS efficacy, and the device 
will be considered efficacious for the treatment of knee pain 
 
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associated with osteoarthritis. 
Secondary 
Endpoints: 
Secondary objectives of this study include determining whether 
nSTRIDE APS is superior to saline with regard to the endpoints 
shown below. These tests will be performed if the primary null 
hypothesis has been rejected. If the primary null hypothesis is 
not rejected, these analyses will be conducted as exploratory 
analyses only. 
These secondary hypotheses will be tested using a fixed-
sequence procedure, constructed using a pre-specified order 
of hypotheses, which will be tested in the order below. 
Subsequent to the rejection of the primary null hypothesis, 
these tests will be performed at the 0.05 level for each 
consecutive test until one hypothesis is tested not significantly, 
after which all subsequent tests will not be performed as 
secondary analyses, but instead will be performed as 
exploratory analyses only. 
 
Order of 
Testing 
Secondary Outcomes 
1 
WOMAC MCID Function Responder rate 
2 
WOMAC MCID Pain Responder rate 
3 
Mean WOMAC Function Δ (12 Month minus 
Baseline) 
4 
OMERACT-OARSI Responder /  
Non-responder (12 Month) 
5 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) in K-L II Subgroup 
6 
Mean WOMAC Function Δ 
(12 Month minus Baseline) in K-L II Subgroup 
7 
Use of rescue medication (acetaminophen) use 
(for index knee OA) over time 
8 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of rescue 
medication within 48 hours of the 12 month visit 
for knee OA as a covariate 
9 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of rescue 
medication within 48 hours of the 12 month visit 
for any reason as a covariate 
10 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
restricted medication within 48 hours of the 12 
month visit for knee OA as a covariate 
11 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
restricted medication within 48 hours of the 12 
month visit for any reason as a covariate 
12 
Mean VAS Pain Δ 
(12 Month minus Baseline) 
13 
Mean WOMAC Pain changes over time within 
treatment  
 
 
 
 
 
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Exploratory 
Endpoints: 
Exploratory outcomes include assessment of change in quality 
of life, pain, function, and stiffness from baseline to all post-
injection time points. 
 
Exploratory analyses will also include evaluation of changes in 
joint morphology, determined with MRI images and X-ray 
images, as well as analyses related to cell/cytokine content of 
blood and APS. 
 
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Table of Contents 
SPONSOR PROTOCOL APROVAL PAGE ........................................................................................... 2 
INVESTIGATOR PROTOCOL AGREEMENT PAGE ............................................................................ 3 
STUDY CONTACT INFORMATION ....................................................................................................... 4 
STUDY SYNOPSIS ................................................................................................................................. 5 
ABBREVIATIONS AND TERMS .......................................................................................................... 17 
1 
INTRODUCTION .......................................................................................................................... 18 
1.1  
PRECLINICAL STUDIES ............................................................................................................ 19 
1.1.1 
Mechanism of Action Cell Assays .................................................................................... 19 
1.1.2 
Cytokine Concentration Study ......................................................................................... 20 
1.1.3 
Equine Clinical Study ....................................................................................................... 20 
1.2  
CLINICAL EXPERIENCE ........................................................................................................... 20 
1.3  
DEVICE DESCRIPTION ............................................................................................................. 21 
1.3.1  
Indications ........................................................................................................................ 22 
1.3.2  
Contraindications ............................................................................................................. 22 
1.3.3  
Use and Training .............................................................................................................. 22 
1.4  
CURRENT STUDY RATIONALE ................................................................................................. 22 
1.5  
STUDY OBJECTIVES ............................................................................................................... 23 
2 
INVESTIGATIONAL PLAN .......................................................................................................... 24 
2.1 
STUDY DESIGN ...................................................................................................................... 24 
2.2 
INCLUSION CRITERIA .............................................................................................................. 24 
2.3 
EXCLUSION CRITERIA ............................................................................................................. 24 
2.4 
ELIGIBILITY FOR RE-SCREENING ............................................................................................. 25 
2.5 
CONCOMITANT TREATMENT AND MEDICATION ......................................................................... 27 
2.5.1 
Allowable Medications/Nonpharmacological Therapies .................................................. 27 
2.5.2 
Restricted Medications/Nonpharmacological Therapies ................................................. 27 
2.5.3 
Allowed Concomitant OA Medication .............................................................................. 28 
2.6 
STUDY ASSESSMENTS AND PROCEDURES ............................................................................... 29 
2.6.1 
Subject Recruitment and Screening ................................................................................ 30 
2.6.2 
Injection Procedure Visit .................................................................................................. 31 
2.6.3 
Follow-up Visits ................................................................................................................ 34 
2.6.4 
Second Injection Procedure (Optional) ............................................................................ 35 
2.6.5 
Second Injection Follow-up Assessment (If Applicable) .................................................. 35 
2.7 
SUBJECT WITHDRAWAL .......................................................................................................... 36 
2.8 
DESCRIPTION OF ASSESSMENTS AND CRFS ............................................................................ 36 
2.8.1 
Demographics .................................................................................................................. 36 
2.8.2 
Medication Use ................................................................................................................ 37 
2.8.3 
Knee Radiograph ............................................................................................................. 37 
2.8.4 
Magnetic Resonance Imaging ......................................................................................... 37 
2.8.5 
Pregnancy Test ................................................................................................................ 37 
2.8.6 
WOMAC LK 3.1 Questionnaire ........................................................................................ 37 
2.8.7 
EQ-5D .............................................................................................................................. 38 
2.8.8 
VAS Pain .......................................................................................................................... 38 
2.8.9 
Injection Procedure .......................................................................................................... 38 
2.8.10 
Ultrasound ........................................................................................................................ 38 
2.8.11 
Laboratory Characterization ............................................................................................ 38 
2.8.12 
Adverse Events ................................................................................................................ 38 
2.9 
STUDY COMPLETION .............................................................................................................. 38 
2.10 
STUDY ENDPOINTS ................................................................................................................ 39 
 
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2.10.1 
Primary Endpoint ............................................................................................................. 39 
2.10.2 
Secondary Endpoints ....................................................................................................... 39 
2.10.3 
Exploratory Endpoints ...................................................................................................... 40 
3 
PROTOCOL DEVIATION REPORTING AND MANAGEMENT .................................................. 40 
4 
ADVERSE EVENT REPORTING AND MANAGEMENT ............................................................ 40 
4.1 
DEFINITIONS .......................................................................................................................... 41 
4.2 
ADVERSE EVENT ASSESSMENTS ............................................................................................. 42 
4.3 
ADVERSE EVENT REPORTING ................................................................................................. 43 
4.4 
SERIOUS ADVERSE EVENT REPORTING ................................................................................... 43 
4.5 
UNANTICIPATED ADVERSE DEVICE EFFECT REPORTING ........................................................... 43 
5 
RISK EVALUATION .................................................................................................................... 43 
5.1 
POTENTIAL RISKS TO STUDY SUBJECTS .................................................................................. 44 
5.2 
METHODS TO MINIMIZE RISKS ................................................................................................. 44 
5.3 
MEDICAL MONITOR ................................................................................................................ 44 
5.4 
INVESTIGATION SUSPENSION OR TERMINATION ........................................................................ 45 
5.5 
POTENTIAL BENEFITS OF THE PROCEDURE .............................................................................. 45 
5.6 
BIAS MINIMIZATION................................................................................................................. 45 
5.6.1 
Randomization ................................................................................................................. 45 
5.6.2 
Blinding ............................................................................................................................ 46 
6  
CONTROL OF INVESTIGATIONAL DEVICE ............................................................................. 46 
6.1  
DESCRIPTION AND CONTROL OF SALINE COMPARATOR ............................................................ 47 
7  
DATA COLLECTION, HANDLING AND RETENTION ............................................................... 47 
7.1 
SOURCE DOCUMENTATION ..................................................................................................... 47 
7.2 
CASE REPORT FORMS ........................................................................................................... 47 
7.3 
ELECTRONIC DATA ENTRY ...................................................................................................... 48 
7.4 
RECORDS RETENTION ............................................................................................................ 48 
8  
REPORTING ................................................................................................................................ 48 
8.1 
DATA REPORTING .................................................................................................................. 48 
8.2 
OTHER REPORTING ................................................................................................................ 48 
9  
STATISTICAL ANALYSIS ........................................................................................................... 49 
9.1 
PRIMARY EFFICACY ANALYSIS ................................................................................................ 49 
9.2 
DEMOGRAPHICS AND MEDICATION USE ................................................................................... 50 
9.3 
SUBJECT REPORTED OUTCOMES ............................................................................................ 50 
9.4  
SAFETY ANALYSIS .................................................................................................................. 51 
10 
STUDY MONITORING AND QUALITY CONTROL .................................................................... 51 
11 
DEVICE LABELING ..................................................................................................................... 51 
12 
ETHICAL CONSIDERATIONS .................................................................................................... 51 
12.1 
CODE OF CONDUCT ............................................................................................................... 51 
12.2 
REGULATORY APPROVAL ........................................................................................................ 51 
12.3 
INSTITUTIONAL REVIEW BOARD APPROVAL AND PROTOCOL CHANGES ...................................... 51 
12.4 
INFORMED CONSENT .............................................................................................................. 52 
13 
LIST OF SUPPLEMENTS ............................................................................................................ 53 
14 
REFERENCES ............................................................................................................................. 54 
15  PROTOCOL REVISION HISTORY .............................................................................................. 54 
 
 
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ABBREVIATIONS AND TERMS 
ACD-A 
 
 
Anticoagulant Citrate Dextrose Solution-Formula A 
ACI  
 
 
Autologous chondrocyte implantation 
ACS  
 
 
Autologous conditioned serum 
ADE  
 
 
Adverse device effect 
ADP  
 
 
Adenosine diphosphate 
AE  
 
 
Adverse event 
APS  
 
 
Autologous protein solution 
BMI  
 
 
Body mass index 
CRF  
  
 
Case report form 
EDC  
 
 
Electronic Data Capture 
EQ-5D 
 
 
EuroQol – 5 Dimensions 
FDA  
 
 
Food and Drug Administration (US) 
GPIIb-IIIa  
 
Glycoprotein IIb and IIIa 
GCP  
 
 
Good clinical practice 
HA  
 
 
Hyaluronic acid 
ICF  
 
 
Informed consent form 
IGF-1 
 
 
Insulin-like growth factor 1 
IL-1β  
 
 
Interleukin-1 beta 
IL-1ra 
 
 
IL-1 receptor antagonist 
IRB  
 
 
Institutional Review Board 
JSN/JSW  
 
Joint Space Narrowing/Joint Space Width 
K-L  
 
 
Kellgren-Lawrence 
ml 
 
 
 
Milliliter 
MMP 
 
 
Matrix metalloproteinase 
MOAKS 
 
 
MRI Osteoarthritis Knee Score 
MRI  
 
 
Magnetic Resonance Imaging 
NSAID 
 
 
Non-steroidal anti-inflammatory drug 
OA  
 
 
Osteoarthritis 
OATS® 
 
 
Ostechondral Autograft Transfer System 
OMERACT-OARSI 
Outcome Measures in Rheumatology – Osteoarthritis 
Research Society International 
PA 
Posterior-Anterior 
Par-1 
Protease-activated receptor 1 
sIL-1RII 
 
 
Soluble form of IL-1 receptor II 
sTNF-RI,sTNF-RII 
Soluble forms of TNFα receptor I and receptor II 
SAE  
 
 
Serious adverse event 
SAP  
 
 
Statistical analysis plan 
TGF-β1 
 
 
Transforming growth factor beta 1 
TNFα 
 
 
Tumor necrosis factor alpha 
UADE 
 
 
Unanticipated adverse device effect 
VAS  
 
 
Visual Analog Scale 
WBC 
White blood cell 
WOMAC LK 3.1  
Western Ontario and McMaster Universities Osteoarthritis 
index using the Likert scale, Version 3.1 
 
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1 
INTRODUCTION 
Osteoarthritis (OA) is a degenerative and disabling articulating joint disease that 
affects both younger, more active patients (e.g., patients with trauma or who have 
prolonged participation in highly demanding sports) and the elderly (1-4). The 
disease is progressive and debilitating, eventually resulting in pain that may be so 
severe that restive sleep is impossible, along with life-altering loss of function.  
Surgical intervention is clinically successful, and widely used, in treating severe 
degenerative OA; however, treatment modalities for less advanced OA are 
associated with varying—and often disappointing—rates of success. Current 
treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), 
corticosteroid injections, and hyaluronic acid (HA) injections. Although these 
treatments can relieve pain temporarily for some OA patients, they do not address 
the biological mechanisms causing the disease (5). Most are palliative. They mask 
symptoms. 
Osteoarthritis causes chronic pain, cartilage degradation and loss, detrimental 
subchondral bone remodeling, and varying degrees of synovial inflammation. OA 
pain is a complex response resulting from the interplay between inflammation, 
anatomic pathology, innervation of articular cartilage, nerve sensitization, and 
psychological factors. Inflammation associated with OA results in joint stiffness and 
pain. Patients may experience local warmth, tenderness, and effusion (6). Although 
OA is classified as a non-inflammatory disease, inflammation is implicated in many 
symptoms and in OA progression. Pro-inflammatory cytokines are involved in OA 
development (7-12). These cytokines include interleukin-1 (IL-1), tumor necrosis 
factor alpha (TNFα), interleukin-6 (IL-6), and interleukin-8 (IL-8). These proteins are 
integral in the initiation and maintenance of inflammation by mediating cell-to-cell 
interactions. Evidence exists that these factors are out-of-balance in the OA knee 
(13). Of these cytokines, IL-1 has been proposed as playing a key role (14-16). The 
cytokines associated with inflammation in OA, primarily interleukin-1 beta (IL-1β) and 
TNFα, are also implicated in cartilage matrix breakdown (17-19). These cytokines 
induce cells in the joint to produce matrix metalloproteinases (MMPs) that in turn are 
responsible for cartilage matrix degradation (20). The interactions between 
chondrocytes in articular cartilage, synovium, IL-1 and TNFα result in a positive 
feedback loop that increases inflammation and cartilage breakdown further and is 
associated with cartilage repair attenuation. IL-1, TNFα, IL-6, and IL-8, along with 
nerve growth factor, can also lead to nerve sensitization and stimulation (21).  
Because both IL-1β and TNFα play important roles in inflammation and cartilage 
breakdown, inhibition of these cytokines may limit inflammation and matrix 
degradation. Consequently, inhibition of these proteins may constitute an effective 
OA therapy. The anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-
1ra), a competitive IL-1 receptor antagonist, blocks the signaling activity of IL-1 (and 
has no signal-inducing activity itself) (22-24). Soluble forms of the IL-1 cell receptor 
(sIL-1R) can bind with IL-1, reducing IL-1 biologic activity by preventing it from 
binding to surface receptors on the cells (25). Moreover, soluble forms of the cell 
 
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receptors for TNFα, known as sTNF-RI and sTNF-RII, can bind to TNFα, preventing 
TNF-α surface receptor binding and thus inhibiting cell signaling (26).  
These anti-inflammatory cytokines are present systemically, but not in the 
concentrations or locations that may be clinically beneficial in the treatment of knee 
OA. Autologous Protein Solution (APS), produced using the nSTRIDE APS Kit, 
contains concentrated levels of anti-inflammatory cytokines, including IL-1ra, sIL-
1RII, sTNF-RI, and sTNF-RII. APS also contains concentrated levels of anabolic 
cytokines associated with cartilage genesis, including insulin-like growth factor 1 
(IGF-I) and transforming growth factor β1 (TGF-β1) (27). Balancing these cytokines 
by autologous conditioned serum (ACS) injection has been explored. ACS is an 
autologous acellular plasma serum containing proteins. ACS contains up-regulated 
levels of anti-inflammatory cytokines and has shown promise when compared to 
hyaluronic acid (HA) and saline for OA treatment (28). APS builds upon knowledge 
gained through ACS studies. It is designed to halt and potentially reverse the OA 
disease process by rebalancing cytokine activity. 
In summary, inflammatory and catabolic cytokines are strongly implicated in the OA 
degenerative process. Inhibiting their action may be beneficial clinically. Anti-
inflammatory and anabolic cytokines found in and concentrated from whole blood 
may reduce or reverse the degenerative process. Processing whole blood using the 
nSTRIDE APS Kit can substantially increase anti-inflammatory and anabolic 
cytokine concentrations. Thus, the introduction of concentrated levels of anti-
inflammatory and anabolic cytokines in a targeted fashion with APS yields a more 
favorable intra-articular environment. A likely result is the reduction and potentially 
the reversal of the degenerative impact of out-of-balance inflammatory and catabolic 
cytokines present in the OA knee.  
The study proposed here builds upon decades of research into the causes of 
osteoarthritis. This study is designed to determine whether rebalancing of cytokines 
with APS prepared using the nSTRIDE APS Kit will, as suggested by OA literature, 
finally yield an effective treatment for early to moderate osteoarthritis of the knee that 
targets the causes of this painful and debilitating disease. 
1.1  
Preclinical Studies 
1.1.1 Mechanism of Action Cell Assays 
The proposed mechanism of action is a process of reducing OA-related upregulated 
inflammatory cytokines by introducing cytokines that inhibit inflammatory cytokine 
activity. APS has been shown to reduce production of proteins associated with 
inflammation and pain responses. In an in vitro model of inflammation and pain 
reduction, APS was incubated with IL-1-stimulated macrophages. APS decreased 
IL-8 production from these activated macrophages (29). Another study examined the 
effect of APS on cartilage degradation. APS inhibited IL-1- and TNFα-induced 
chondrocyte production of MMP-13, a known degradation enzyme of cartilage (30). 
Further, inhibition of MMP-13 activity, specifically glycosaminoglycan release, was 
also exhibited in cartilage explant cultures stimulated with IL-1 and APS (31). These 
 
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cell assay studies demonstrate that APS can inhibit deleterious enzyme production, 
consistent with the proposed mechanism of action.  
1.1.2 Cytokine Concentration Study 
Analysis of APS samples and baseline whole blood samples from 105 OA patients 
revealed that the APS device concentrates IL-1ra and other anti-inflammatory 
cytokines 3 to 5 fold over that of whole blood baseline concentrations (27).  
1.1.3 Equine Clinical Study 
An animal efficacy study was performed to evaluate the ability of APS, prepared 
using the nSTRIDE APS Kit, to alleviate OA pain in a randomized, blinded study of 
40 horses. Between April and December 2011, 20 horses were injected with APS, 
and 20 horses were injected with saline. Lameness was evaluated blindly by a single 
trained investigator at 1 week and 2 weeks post-injection. A force plate analysis was 
completed 2 weeks post-injection. At 3 months and 12 months post-injection, the 
owners completed a survey. 
At 2 weeks post-injection, lameness and quantitative force plate mean results were 
both significantly improved relative to the pre-treatment baseline, and APS results 
were statistically superior to saline-treated horse results. Similarly, owners reported 
significant improvements in lameness at 3 months and 12 months in the APS-treated 
horses. No related adverse events (AEs) were reported. Nor were there differences 
in joint swelling, as measured by joint circumference, between the APS- and saline-
treated animals. There were also no changes from baseline in total protein, total 
white blood cells (WBCs), or percent neutrophils in joint fluid aspirated from the 
APS-treated group at 2 weeks post-injection. This study provided safety and efficacy 
data showing that  APS reduces pain and improves function in horses with OA (32). 
1.2  
Clinical Experience 
An open-label feasibility study of a single intra-articular injection of APS in subjects 
with osteoarthritis of the knee was conducted at Saint Anna Hospital, Geldrop, The 
Netherlands ((33;34), NCT01773226). The primary study objective was to assess 
safety. Nine of 11 subjects (seven male) reported 22 AEs (total). There were no 
deaths or serious adverse events. The investigator deemed every AE to be 
unrelated to the device. All were rated ‘mild’ in severity. The most frequent AEs were 
joint effusion (n=9) and arthralgia (n=5). These were most likely related to the 
injection procedure and not to the device per se. One subject withdrew from the 
study subsequent to continued knee pain.  
WOMAC scores improved significantly by the second week post-injection and 
continued to improve as the study progressed. By 12 weeks, 80% of both physicians 
and subjects rated the condition under investigation as ‘very much’ or ‘much’ 
improved as determined by the Clinician and Patient Global Impression Change 
Scale. At 26 weeks follow-up, the OMERACT-OARSI high pain responder criteria 
were met by 8 of 11 subjects (73%). At final follow-up, mean WOMAC pain reduced 
by 72% (89% in the 8 responders). WOMAC stiffness and function scores improved 
 
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by 53% and by 68%, respectively. After study completion, a long-term analysis was 
performed at an average of 78 weeks (18 months) after subjects were enrolled. Six 
of the 11 subjects returned WOMAC and Patient Global Impression-Change (PGI-C) 
questionnaires and reported pain reduction from baseline measures. The data 
presented here suggest that the treatment is safe and shows a complication profile 
that is mild and consistent with similar treatments. A single injection of APS for 
treatment of early to moderate knee osteoarthritis led to symptom improvement over 
the study course. 
After completion of the open-label feasibility study, a multicenter, prospective, 
randomized, double-blind, saline-controlled trial was conducted at three enrolling 
centers in Europe ((35), NCT02138890). A total of 46 patients with unilateral OA 
(Kellgren-Lawrence 2 or 3) knee pain were randomized into two groups. Group 1 (31 
patients) received a single ultrasound-guided injection of APS, and Group 2 (15 
patients) received a single saline injection. Patient reported outcomes and adverse 
events were collected at 2 weeks, 1, 3, 6, and 12 months post-injection. The patients 
and evaluators were blinded to the treatment allocation, and the outcome was 
evaluated through VAS, WOMAC, and KOOS scores. Imaging evaluation was also 
performed with X-Ray and MRI before and after the treatment (12 months and 3 and 
12 months, respectively). 
The demographics were similar between the groups. The change from baseline to 
12 months in WOMAC pain score was 65% in Group 1 and 41% in Group 2 (p = 
0.02). Additionally, VAS pain improvement was 49% in Group 1 and 13% in Group 2 
(p = 0.07). WOMAC function change from baseline to 12 months was 55% in Group 
1 and 45% in Group 2 (p = 0.38). The safety profile was also positive, with no 
significant differences in frequency, severity, or relatedness of adverse events 
between groups. No procedure- or device-related serious adverse events were 
reported. 
This pilot study provides evidence to support the safety and clinical effectiveness of 
a single intra-articular injection of this novel autologous therapy. Long-term follow-up 
is ongoing, and this positive results obtained against saline has been used to plan 
this confirmatory trial that will be conducted to further substantiate these findings 
against those offered by other treatments for knee OA. 
 
An additional open-label study is ongoing in the United States (NCT02262364). 
Recruitment of the planned 10 patients has been completed, and follow-up is 
ongoing. All patients have completed follow-up through 6 months. There have been 
no unanticipated adverse device effects reported to date. A single serious adverse 
event has been reported, and it was unrelated to the procedure or the device. 
1.3  
Device Description 
 
The nSTRIDE APS Kit is manufactured by Biomet Biologics, LLC, 56 East Bell 
Drive, P.O. Box 587, Warsaw, IN 46581. The nSTRIDE APS Kit contains two 
polymer blood processing devices and a 30 milliliter (ml) vial of Anticoagulant Citrate 
Dextrose Solution-Formula A (ACD-A). The first of the two devices is the nSTRIDE 
 
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Cell Separator. It is a plastic tube containing a tuned-density buoy and separates 
cellular components of whole blood when appropriately cycled in a Biomet Biologics 
centrifuge. The resulting cell solution is further processed by the second of the two 
devices, the nSTRIDE Concentrator. This device is a plastic tube containing 
polyacrylamide beads to further concentrate the cell suspension and produce an 
injectable output, the APS. The nSTRIDE APS Kit is a self-contained, sterile-
packaged, single-use and disposable device used at the point of care to produce 
APS. There are no anticipated changes in the device design during this trial. 
Component Name 
Part Number 
nSTRIDE APS Kit 
800-3000US 
nSTRIDE Cell Separator (GPS III) 
800-1003-01 
nSTRIDE Concentrator 
800-3000-02 
nSTRIDE APS Kit IFU 
01-50-1497 
Anticoagulant Citrate Dextrose Solution-Formula A 
01-09-9289 
Anticoagulant Citrate Dextrose Solution-Formula A IFU 
01-05-1496 
1.3.1  Indications 
The nSTRIDE APS Kit is designed to be used for the safe and rapid preparation of 
autologous protein solution (APS) from a small sample of blood at the patient’s point 
of care. The APS is to be injected intra-articularly for the treatment of knee pain 
associated with osteoarthritis. 
1.3.2  Contraindications 
Do not inject APS in the knees of patients having knee joint infections or skin 
diseases or infections in the area of the injection site. 
nSTRIDE APS Kit is not for use in patients with systemic inflammatory conditions. 
nSTRIDE APS Kit is not intended for use in patients with leukemia, metastatic 
malignant cells or who are receiving chemotherapeutic treatment. 
1.3.3  Use and Training 
Appropriate investigative site personnel will be trained on nSTRIDE APS Kit 
processing. The investigator or other personnel who will be administering treatment 
should have the appropriate medical training to give intra-articular knee injections. 
Specifics on preparation of APS using the nSTRIDE APS Kit are given in Section 
2.6.2.3 – APS Preparation.  
1.4  
Current Study Rationale 
OA is a degenerative disease characterized by chronic pain, cartilage degradation, 
cartilage loss, subchondral bone remodeling, and varying degrees of synovial 
inflammation mediated by increased pro-inflammatory and catabolic proteins. 
Currently available OA therapies address the symptoms, but none is known to 
address the underlying pathology of this disease. Analysis of APS, prepared using 
the nSTRIDE APS Kit, clearly shows multiple fold increases (relative to whole blood) 
of anti-inflammatory and anabolic proteins. In vitro and non-human animal study 
results are consistent with the idea that APS can—in a targeted area—inhibit 
 
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deleterious proteins, increase beneficial proteins, delay cartilage breakdown, and 
deliver reduction in OA pain and improvement in joint functionality.  Moreover, 
preliminary clinical trial results in humans provide evidence that these benefits 
extend to human use as well. 
Whole blood-derived products such as ACS and platelet-rich plasma have a 
substantial history of clinical use with no report of any serious adverse events 
(SAEs). Collectively, (1) the demonstrated safety profile, (2) the evidence of clinical 
utility, and (3) the potential for disease modification by APS, justify continuing human 
clinical trials of the nSTRIDE APS Kit for OA treatment. Evidence shows that a 
pivotal human trial is a safe and reasonable next step in validating APS, prepared 
using the nSTRIDE APS Kit, as a safe and effective minimally invasive pain-
reducing therapy for OA, one that in vitro findings suggest may have the potential to 
reverse the disease process. 
1.5  
Study Objectives 
The primary objectives of this study are to determine whether nSTRIDE APS is 
superior to a saline with regard to the mean improvement from baseline to 12 
months in Western Ontario and McMaster Universities Osteoarthritis Index 
(WOMAC) LK 3.1 pain subscale score.  
 
The impact of the usage of APS on function will be evaluated as part of the 
primary endpoint; however, no formal statistical test will be done as a part of the 
study success criteria.  A qualitative assessment of the changes in WOMAC 
Function over time for APS and Placebo will be discussed, in order to ensure that 
the impact of the treatment on function is neutral or positive.  The following 
descriptive analyses will be performed for this assessment of function: 
 
(1) A graphical examination of the changes in WOMAC Function for APS and 
Placebo over time, including means and standard error bars. 
(2) Descriptive statistics for the mean changes in WOMAC Function over time, 
separately for each treatment group.  These will include mean, median, 
standard deviation, minimum, maximum, and 95% confidence intervals. 
 
Secondary and exploratory objectives of this study include determining whether 
nSTRIDE APS is superior to saline in improving patient-reported outcomes including 
function, pain, stiffness, and quality of life in subjects with early to moderate 
symptomatic OA.   
Additionally, this study will evaluate change in joint morphology and APS output 
characteristics. Safety of nSTRIDE APS will be compared to saline following intra-
articular knee injections in subjects with early to moderate symptomatic OA. 
 
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2 
INVESTIGATIONAL PLAN 
2.1 
Study Design 
This is a multicenter, double blind, randomized, saline–controlled, prospective 
evaluation of a single APS injection. The study duration for each subject will be 12 to 
16 months. A total of 332 patients will be enrolled. These patients will meet specific 
inclusion and exclusion criteria but can be generally characterized as patients with 
painful unilateral knee osteoarthritis who have not been able to get satisfactory pain 
relief with previous conservative treatment. 
2.2 
Inclusion Criteria 
Subjects must meet all inclusion criteria to be eligible for study enrollment. 
1. Male or female ≥ 21 and ≤ 80 years old at time of screening. 
2. Willingness and ability to comply with the study procedures and visit 
schedules and ability to follow oral and written instructions. 
3. A standing radiograph of the knee showing a Kellgren-Lawrence grade of 2 to 
4 and an absence of severe osteoarthritis (defined as advanced stage 
osteoarthritis, including large osteophytes, chronic fractures or bone 
remodeling, severe deformity or bone attrition, and/or bone-on-bone contact 
indicative of severe osteoarthritis/ full thickness cartilage loss), as confirmed 
by the central imaging laboratory. 
4. Body mass index (BMI) ≤ 40 kg/m2. 
5. A WOMAC LK 3.1 pain subscale total score ≥ 9 and ≤ 19. 
6. Has undergone at least one prior conservative osteoarthritis treatment (e.g. 
physical therapy, simple analgesics). 
7. Signed an institutional review board approved informed consent. 
2.3 
Exclusion Criteria 
Subjects must not meet any of the following exclusion criteria to be eligible for study 
enrollment. 
1. Presence of clinically observed active infection in the index knee. 
2. Presence of symptomatic osteoarthritis in the non-study knee; if unclear then 
the WOMAC LK 3.1 pain sub-scale for the non-index knee must be ≤ 5.0. 
3. Diagnosed with rheumatoid arthritis, Reiter’s syndrome, psoriatic arthritis, 
gout, ankylosing spondylitis, or arthritis secondary to other inflammatory 
diseases; HIV, viral hepatitis; chondrocalcinosis, Paget’s disease, or 
villonodular synovitis. 
4. Clinically symptomatic patellofemoral chondromalacia (i.e. knee pain in the 
anterior knee only) or diagnosis of isolated patellofemoral OA. 
5. Diagnosed with leukemia, known presence of metastatic malignant cells, or 
ongoing or planned chemotherapeutic treatment. 
6. Disease of spine, hip or other lower extremity joints judged by the investigator 
to be contributing to the pain in the index knee (i.e. sciatica, nerve pain, hip 
OA). Note: Patients with knee replacement at the contra-lateral knee or hip 
replacement in either hip may be enrolled provided there is sufficient pain 
 
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relief after knee replacement or hip replacement that analgesics are not 
required. 
7. Untreated symptomatic injury of the index knee (e.g., acute traumatic injury, 
anterior cruciate ligament injury, clinically symptomatic meniscus injury 
characterized by mechanical issue such as locking or catching). 
8. Any condition other than OA of the index knee which, in the opinion of the 
investigator, affects the ability to ambulate to a sufficient degree to interfere 
with the assessment of the safety and treatment effects of the study injection. 
9. Presence of surgical hardware or other foreign body intended to treat arthritis 
or cartilage-related pathology in the index knee. 
10. Previous cartilage repair procedure on the injured cartilage surface (i.e., 
microfracture, Ostechondral Autograft Transfer System (OATS®) and 
autologous chondrocyte implantation (ACI) of the index knee. 
11. Arthroscopy or open surgery of the index knee within 6 months of screening. 
12. Intra-articular steroid injection in the index knee within 3 months of screening. 
13. Intra-articular hyaluronic acid injection in the index knee within 6 months of 
screening. 
14. Other intra-articular therapy in the index knee within 6 months prior to 
screening. 
15. Orally administered systemic steroid use within 2 weeks of screening. 
16. Planned/anticipated surgery of the index knee during the study period. 
17. A history of local anesthetic allergy. 
18. Use of systemic immunosuppressants within 6 weeks of screening. 
19. Currently on anticoagulant therapy, such as Warfarin, vitamin K antagonists, 
direct thrombin inhibitors, or factor Xa inhibitors or on potent anti-platelet 
therapy, such as glycoprotein IIb and IIIa (GPIIb-IIIa) antagonists, protease –
activated receptor 1 (Par-1) antagonists or dual anti-platelet therapy, i.e. an 
adenosine diphosphate (ADP) receptor antagonist in combination with aspirin. 
20. Any documented clinically significant degree of cognitive impairment or other 
condition, finding, or psychiatric illness at screening which, in the opinion of 
the investigator, could compromise patient safety or interfere with the 
assessment of the safety and treatment effects of the study injection. 
21. Skin breakdown at the knee where the injection is planned to take place. 
22. Pregnant or nursing mothers or women planning on getting pregnant during 
the time they will be participating in the study. 
23. Known drug or alcohol dependence currently or within the last year. 
24. Participated in any investigational drug or device trial within 30 days prior to 
screening. 
25. Participated in any investigational biologic trial within 60 days prior to 
screening. 
2.4 
Eligibility for Re-Screening 
Given the binary nature and time-dependency of many of the eligibility criteria of this 
study, there are times when a patient may not initially meet the inclusion/exclusion 
criteria but may eventually become eligible due to elapsed time and/or lifestyle 
modification or resolution of a pre-existing condition. 
 
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For the following parameters, a patient may be re-screened immediately upon 
resolution of the issue leading to the initial screen failure: 
• Age; patient was initially < 21 years of age but is now ≥ 21 years of age 
• Inability to comply with the study protocol; patient previously met all study 
inclusion and no exclusion criteria but was unable to complete MRI or receive 
injection within 28 day window due to scheduling conflicts 
• BMI; patient initially had BMI > 40 kg/m2 but now has BMI ≤ 40 kg/m2 
• Active infection of index knee; patient had active infection of the index knee 
which has since resolved 
• Symptomatic OA in the non-study knee; patient has had a knee replacement 
in the non-study knee and is now fully recovered from the surgery and 
rehabilitation 
• Untreated symptomatic injury of the index knee; patient had untreated 
symptomatic injury of the index knee which has since been successfully 
treated 
• Previous treatment of index knee; patient was previously within the 3 month 
window (steroid injection) or the 6 month window (arthroscopy, open surgery, 
hyaluronic acid injection, other intra-articular injection) of previous index knee 
treatment but now is not 
• Orally administered systemic steroid use within the past 2 weeks; patient was 
previously within the 2 week window of systemic oral steroid use but now is 
not 
• Use of systemic immunosuppressants within the past 6 weeks; patient was 
previously within the 6 week window of immunosuppressant use but now is 
not 
• Skin breakdown at the knee where the injection is planned to take place; 
patient previously had skin breakdown but the skin is now intact 
• Pregnant or nursing mother; woman who was previously pregnant or nursing 
is either no longer pregnant or no longer nursing and does not plan to 
become pregnant or nurse during the study 
• Trial participation; patient was previously within the 30 day (drug or device) or 
60 day (biologic) window of clinical trial participation but now is not 
 
Given that OA is a degenerative condition, there are times when a patient may not 
initially be eligible because their OA or associated symptoms are not severe enough 
but, over time, the condition may become more severe, thereby making the patient 
eligible for participation in this study. For the following parameters, a patient may be 
re-screened upon failure of a newly administered OA therapy, provided that the 
therapy and subsequent failure are documented in the patient’s medical records: 
 
Note: Failure of a regularly administered oral or topical medication requires at least 6 
weeks of use with inadequate improvement of symptoms. 
 
 
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• Kellgren-Lawrence score; initial Kellgren-Lawrence score was 0 or 1, but 
there is now reason to believe that the joint degeneration due to the OA 
condition is more severe 
• WOMAC score; initial WOMAC pain score of the index knee was not high 
enough, but there is now reason to believe that the pain due to the OA 
condition is more severe 
• No documented prior conservative OA treatment; initial screening indicated 
that previous conservative treatment had not been attempted, but the patient 
has now failed one or more conservative treatments 
 
If the patient has failed screening for a reason other than any of those listed above, 
then the patient will not be eligible for re-screening. 
 
If a patient is re-screened, then the screening process should be done all over again, 
beginning with the informed consent, and a new subject ID should be assigned. 
2.5 
Concomitant Treatment and Medication 
2.5.1 Allowable Medications/Nonpharmacological Therapies 
The following medications and nonpharmacological therapies may be taken or used 
throughout the study: 
• Any treatment for a pre-existing condition or for an AE, outside of the study 
indication, that is not listed as restricted 
• Aspirin for cardio-protection at a maximum stable dose of 100 mg per day 
provided the dose was stabilized over 3 months prior to study entry 
• Glucosamine, chondroitin sulfate, or avocado/soya extracts if initiated and 
consistent prior to study entry 
• Physical therapy for the index knee if the program was initiated and consistent 
prior to study entry 
• Bracing of the index knee if initiated and consistent prior to study entry 
• Acetaminophen for analgesic treatment of breakthrough OA pain of the index 
knee (see Section 2.5.3) or other sources of pain that may arise (not to exceed a 
daily dose of 3000 mg) 
2.5.2 Restricted Medications/Nonpharmacological Therapies 
Patients will be advised that participation in the study will require them to abstain 
from certain medications and therapies. The following medications and 
nonpharmacological therapies should not be taken or used beginning immediately 
upon enrollment (after signing informed consent) until subject reaches the end of the 
study: 
• Oral nonsteroidal anti-inflammatory drugs (NSAIDs) 
• Topical NSAIDs (including plasters and patches) applied to the index knee 
• Other topical pain therapies applied to the index knee (e.g., capsaicin, lidocaine, 
heat patches) 
 
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• Orally administered systemic corticosteroids 
• Intra-articular corticosteroids administered to the index knee 
• Intra-articular hyaluronic acid administered to the index knee 
• Narcotics 
• Centrally acting medications for analgesia 
2.5.3 Allowed Concomitant OA Medication 
Concomitant treatment for OA will be standardized to be oral acetaminophen (e.g. 
Tylenol) for all subjects during the study. During the screening period (i.e., prior to 
the procedure visit), subjects may take acetaminophen as needed to a maximum of 
maximum of 3000 mg per day. Use of acetaminophen must be discontinued 48 
hours prior to the procedure visit and each subsequent scheduled visit. 
The use of acetaminophen for other types of pain or illness during the study (e.g., 
toothache, headache, fever) should also be recorded on the Follow-Up Visit form. 
Beginning at the procedure visit through the end of the study, each subject will be 
provided with a sufficient quantity of acetaminophen tablets at each scheduled clinic 
visit. Subjects will be asked to report the frequency of tablet consumption since the 
previous visit at each follow-up visit. 
 
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2.6 
Study Assessments and Procedures 
This table summarizes clinical study assessments, procedures, and information collected on case report forms (CRFs) 
Procedure 
Screening 
Procedure 
1 
Month 
3 
Months 
6 
Months 
12 
Months 
Optional 
APS 
Injection 
Optional 2nd 
Inj 1 Month 
F/U 
 
Within 28 days 
of completed 
Screening 
±7 days 
±14 days 
±14 days 
±28 days 
Within 14 
days of 12 
Month visit 
± 7 days 
Informed consent 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Knee radiograph 
X1 
 
 
 
 
X 
 
 
MRI 
X 
 
 
 
 
X 
 
 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
 
 
Pregnancy test (as applicable) 
X 
 
 
 
 
 
X 
 
WOMAC LK 3.1 
X 
 
X 
X 
X 
X 
 
X 
Medication use 
X 
X 
X 
X 
X 
X 
 
X 
Blood Draw and Injection Procedure  
 
X 
 
 
 
 
X 
 
Needle placement ultrasound 
 
X 
 
 
 
 
 
 
Sample preparation and shipment 
 
X 
 
 
 
 
 
 
EQ-5D 
 
X 
X 
X 
X 
X 
 
X 
VAS knee pain 
 
X 
X 
X 
X 
X 
 
X 
Adverse events (as applicable) 
 
X 
X 
X 
X 
X 
X 
X 
Study Exit2 
 
 
 
 
 
X2 
 
X2 
1 If qualifying, posterior-anterior fixed flexion radiographs were collected within the previous six months, they may be used 
2 Study exit form should be completed one time only, per subject, when any subject exits a study. It is anticipated that subjects will exit after the 12 month primary 
follow-up or after the repeat injection 1 month follow-up 
 
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2.6.1 Subject Recruitment and Screening 
Documented Institutional Review Board (IRB) approval of the protocol and informed 
consent form (ICF), and a fully executed clinical trial agreement must be obtained 
prior to subject recruitment. 
Subjects will be recruited from the population of individuals with knee OA who have 
failed at least one prior conservative OA treatment. Subjects must meet the 
requirements of inclusion and exclusion criteria at screening. 
The investigator will keep a log listing all patients who are screened and consented 
and a subject identification log listing subjects who were enrolled into the study. 
The principal investigator or officially designated site personnel will explain the study 
procedures, set expectations, and go over the informed consent with the patient. 
The patient will be given an opportunity to discuss the study with one of the 
investigators, including medical aspects of their disease and the study treatment. 
The patient will be allowed sufficient time to think about participation in the study and 
to discuss the study with family, friends, their primary care provider and/or an 
independent physician. The patient will sign the ICF only when they are satisfied 
they understand the requirements and want to participate in the study. The patient 
will sign and date the ICF before any study-required screening procedures occur. 
 
During the screening visit, the following information will be obtained and, as 
appropriate, recorded in the subject study record and CRFs for all subjects: 
• Signed and dated original ICF 
• Demographics and Medication Use 
• A standing radiograph of the knee confirming a Kellgren-Lawrence grade of 2 to 
4 and an absence of severe osteoarthritis. If a subject has qualifying knee X-rays 
performed within 6 months of screening, then they may be used without 
repeating the radiograph. Radiographs will be sent to a central imaging 
laboratory for confirmation of eligibility. 
• Pregnancy test (as applicable) 
• WOMAC LK 3.1 questionnaire for index knee 
• WOMAC LK 3.1 pain scale for non-index knee (as applicable) 
• Inclusion and exclusion criteria 
Patients who sign the ICF, satisfy the inclusion and exclusion criteria, and agree to 
the conditions of the study will be eligible to enter the study. 
Subjects will be scheduled for an MRI which will be completed prior to injection 
procedure. 
Subjects will be reminded to abstain from restricted medications and therapies as 
detailed in Section 2.5. 
Subjects will be advised to maintain a stable lifestyle with regard to physical activity 
during the study. 
 
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2.6.2 Injection Procedure Visit 
During the injection procedure visit, but prior to APS preparation and injection, 
baseline evaluations will be performed, including: 
• EuroQol 5-Dimensions (EQ-5D) 
• Visual Analog Scale for knee pain (VAS) 
• Medication Use 
2.6.2.1 
Blood Draws 
Specific instructions on how to complete the blood draws, prepare APS for 
injection, and prepare APS, whole blood, and synovial fluid for shipment for 
this study will be provided in a separate laboratory processing and shipping 
instructions document (to be provided separately at a later date). 
Note: in total, 3 samples (2 x 60 ml, 1 x 12 ml) of blood will be drawn to 
produce two APS volumes and 1 whole blood volume. For subjects randomized 
to the APS treatment group, one (processed) APS volume will be used for treatment. 
A second (processed) APS volume will be used for analytical testing, and one whole 
blood sample will be used for analytical testing. For subjects randomized to the 
saline treatment group, one (processed) APS volume will be used to determine the 
volume of saline for injection and will be used for analytical testing. A second 
(processed) APS volume will be used for analytical testing, and one whole blood 
sample will be used for analytical testing.  
If it is not possible to draw the volume of blood required for injection (1 x 60 ml), then 
that subject should be withdrawn from the study and should not be randomized. 
Multiple attempts may be made to draw the required volume of blood, provided that 
the safety of the subject is never compromised. If the volume required for injection is 
obtained, but the additional volume required for laboratory analysis cannot be drawn, 
then sample preparation and shipping for analysis should be done according to the 
instructions provided in the separate laboratory processing and shipping instructions 
document.  
2.6.2.2 
Randomization 
After the blood draw, subjects will undergo a 1:1 randomization to determine their 
treatment group. Details regarding Randomization can be found in Section 5.6.1. 
2.6.2.3 
APS Preparation 
Two nSTRIDE APS Kits should be processed for each subject as described below. If 
a second nSTRIDE APS Kit cannot be processed due to an inability to draw enough 
blood, fill the second nSTRIDE Cell Separator with water or saline equivalent to the 
volume of blood being processed in the first nSTRIDE Cell Separator (approximately 
60 ml) to act as a counterbalance. Similarly, put water or saline in the second 
nSTRIDE Concentrator (approximately 6 ml) to act as a counterbalance. 
Alternatively, if only one nSTRIDE APS Kit is being processed in the centrifuge, then 
the appropriate nSTRIDE counterbalances may be used. 
 
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To process the nSTRIDE APS Kit, using standard aseptic technique, draw 5 ml of 
ACD-A into a 60 ml syringe. Attach the syringe to an 18-gauge butterfly apheresis 
needle and prime with ACD-A. Draw 55 ml of whole blood into the syringe and gently 
mix. This will produce 60 ml of anticoagulated blood. Inject the 60 ml of 
anticoagulated whole blood into the nSTRIDE Cell Separator. Place the nSTRIDE 
Cell Separator into the centrifuge with another nSTRIDE Cell Separator so that they 
counterbalance one another, and run for 15 minutes at 3200 RPM. After 
centrifugation, using a 30 ml syringe, remove the plasma and discard appropriately. 
Then, using a 10 ml syringe, extract 2 ml of the cell solution and suspend the cells 
by vigorously shaking the syringe and nSTRIDE Cell Separator for 30 seconds while 
the nSTRIDE Cell Separator and corresponding syringe are attached to one another. 
Extract the remaining cell solution into a syringe. Detach the syringe from the 
nSTRIDE Cell Separator and inject the cell solution into the upper chamber of the 
nSTRIDE Concentrator (which contains polyacrylamide beads). Turn the paddle to 
mix the cell solution with the beads. Place the nSTRIDE Concentrators into the 
centrifuge so that they counterbalance one another and process for 2 minutes at 
2000 RPM.  
Using a new 10 ml syringe, extract the final APS product (final APS volume will be 
approximately 2.5 ml for each device processed).  
The first APS preparation should be used for the treatment injection. In the case of a 
subject randomized to the saline group, the first APS volume should be used to 
determine the volume of saline to be prepared for injection. The second APS 
preparation is reserved for testing at the central laboratory. If the subject is 
randomized to the saline group, then after using the first APS preparation to identify 
the quantity of saline to be injected, it should be prepared for shipment to the core 
laboratory for analysis along with the second APS preparation.  
Record each APS volume on the Sample Processing Form. A volume of at least 1 
ml is required for injection. If a volume of less than 1 ml is obtained from the 
nSTRIDE APS Kit, then do not inject this APS, and use the Sample Processing 
Form to record that the nSTRIDE APS Kit did not function as expected due to low 
output volume. In this circumstance, the second APS volume may be used for the 
treatment injection. If a volume of less than 1 ml is obtained from both processed 
kits, then do not perform the injection procedure. The injection procedure may be 
rescheduled, and additional kits may be used. 
For further details of preparing APS using the nSTRIDE APS Kit, consult the product 
package insert in Supplement 1, training material, or contact the sponsor directly.  
If at any point the blood and/or intermediate cell solution and/or APS is transferred 
from one facility location to another, then the syringe shall be capped with a sterile 
syringe cap or a sterile capped needle prior to transferring the syringe from one 
location to another. 
2.6.2.4 
Injection Preparation and Blinding 
Once the APS has been prepared, the delegated unblinded member of the study 
staff shall prepare a syringe for injection. If the subject has been randomized to the 
 
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nSTRIDE APS group, then the syringe containing APS output labeled for injection 
shall be placed in the blinding sleeve and provided to the injecting physician. If the 
subject has been randomized to the Saline group, then the syringe containing APS 
output labeled for injection shall be used to determine the volume of saline to draw 
up into a new 10 ml syringe. The syringe containing the appropriate volume of saline 
(equal to the volume of the APS) shall be placed in the blinding sleeve and provided 
to the injecting physician. Additional details regarding Blinding can be found in 
Section 5.6.2. 
2.6.2.5 
Injection Procedure 
Administer the contents of the masked syringe (approximately 2.5 ml) as a single 
injection into the joint. The procedure for the injection involves the following steps:  
1. Clean the injection area with an antiseptic solution. 
2. Apply a local anesthetic on the injection site (optional). If local anesthetic is used, 
then a topical anesthetic, such as ethyl chloride, is recommended. Under no 
circumstances may the anesthetic be injected intra-articularly. 
3. Position needle into the intra-articular space, and confirm needle placement with 
an ultrasound image.  
4. Attach an empty syringe to the needle, aspirate all available joint fluid (aspiration 
volume must be recorded). Retain the aspirated joint fluid for shipping to the core 
laboratory. 
5. Transfer the masked syringe that contains the injection solution (APS or saline) 
to the needle positioned at the injection site. 
6. Inject all contents of the masked syringe into the synovial space of the joint. 
Alternate technique: 
Confirm if there is any available joint fluid for aspiration via palpation or ultrasound.  
If no fluid is available for aspiration, proceed as follows: 
1.    Clean the injection area with an antiseptic solution. 
2.    Apply a local anesthetic on the injection site (optional). If local anesthetic is used, 
then a topical anesthetic, such as ethyl chloride, is recommended. Under no 
circumstances may the anesthetic be injected intra-articularly. 
3.    Attach needle (18-22 gauge) to masked syringe containing injection solution 
(APS or saline), and position needle into the intra-articular space, confirming 
needle placement with an ultrasound image.  
4.    Inject all contents of the masked syringe into the synovial space of the joint. 
  
If synovial fluid is available for aspiration, proceed as follows: 
1. Clean the injection area with an antiseptic solution. 
2. Apply a local anesthetic on the injection site (optional). If local anesthetic is used, 
then a topical anesthetic, such as ethyl chloride, is recommended. Under no 
circumstances may the anesthetic be injected intra-articularly. 
 
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3. Position needle, attached to an empty syringe, into the intra-articular space, and 
aspirate all available joint fluid (aspiration volume must be recorded). Retain the 
aspirated joint fluid for shipping to the core laboratory. 
4. Position needle (18-22 gauge), attached to the masked syringe containing 
injection solution (APS or saline), into the intra-articular space, confirming needle 
placement with an ultrasound image.  
5. Inject all contents of the masked syringe into the synovial space of the joint. 
A clear ultrasound image should be taken to document needle placement in 
the synovial space. 
The injector may choose the position of the knee (e.g., extended or bent) and the 
approach for the injection (e.g., medial or lateral). These selections must be 
recorded. 
Any adverse events associated with the blood draw or joint aspiration and injection 
procedure will be recorded. Additionally, any device processing issues will be 
recorded. 
Before discharge subjects will be instructed not to exceed their pre-injection physical 
activity level for 14 days post-injection. Subjects will also be instructed to contact 
their physician’s office if they intend to increase their activity level substantially while 
they are study subjects. 
2.6.2.6 
Sample Preparation and Shipping 
After the blood draw, device processing, and joint fluid aspiration, the samples will 
be prepared and shipped to a central laboratory for characterization. Methods for 
sample preparation, shipping, and analysis will be specified in a separate laboratory 
processing and shipping instructions document.  
2.6.3 Follow-up Visits 
Follow-up assessment visits will be at the following intervals following the injection: 
• 1 Month (±7 days) 
• 3 Months (±14 days) 
• 6 Months (±14 days) 
• 12 Months (±28 days) 
 
Follow-up windows are provided for reference only. Out of window visits will not be 
considered protocol deviations. 
 
The following assessments and information will be collected at all follow-up visits: 
• WOMAC LK 3.1 
• EQ-5D 
• VAS knee pain scale 
• Medication use  
• Adverse events 
 
 
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At the 12-month follow-up visit, a standing radiograph and MRI of the index knee will 
be acquired. Image acquisition, transfer, and analysis procedures will be performed 
using validated, prospectively defined methods. 
2.6.4 Second Injection Procedure (Optional) 
After each subject completes the 12 month follow-up visit assessments, the subject 
and study personnel may be unblinded to the treatment allocation. At that time, if 
they have had no major safety events due to the first injection, then the subject may 
choose to enter the repeat injection phase and receive an injection of APS, 
regardless of their original randomization allocation. If the subject prefers not to 
receive a second injection, then they will exit the study. If the subject chooses to 
receive a second injection, then it may be administered immediately following the 
completion of 12 month follow-up activities. Alternatively, a separate injection visit 
can be scheduled within 14 days of the 12 month follow-up visit. Prior to the second 
injection, a urine pregnancy test will be administered, where applicable. A positive 
test will render the subject ineligible for injection. 
The second injection will not require an ultrasound image. The injection 
method/approach will be documented on the Procedure Form. The procedure for the 
injection involves the following steps:  
1. Clean the injection area with an antiseptic solution. 
2. Apply a local anesthetic on the injection site (optional). If local anesthetic is 
used, then a topical anesthetic, such as ethyl chloride, is recommended. 
Under no circumstances may the anesthetic be injected intra-
articularly. 
3. Position needle into the intra-articular space (ultrasound image is not 
required). 
4. Attach an empty syringe to the needle, aspirate and discard all available 
joint fluid. (Aspiration volume must be recorded) 
5. Transfer the syringe that contains the APS to the needle positioned at the 
injection site. 
6. Inject all contents of the syringe into the synovial space of the joint. 
The injector may choose the position of the knee (e.g., extended or bent) and the 
approach for the injection (e.g., medial or lateral). These selections must be 
recorded. 
Any adverse events associated with the blood draw or joint aspiration and injection 
procedure will be recorded. Additionally, any device processing issues will be 
recorded. 
2.6.5 Second Injection Follow-up Assessment (If Applicable) 
One month (±7 days) after the second injection, a follow-up visit will be completed. 
The following assessments or information will be collected at this follow-up visit: 
• WOMAC LK 3.1 
• EQ-5D 
• VAS knee pain scale 
 
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• Medication use  
• Adverse events 
• Study Exit form 
2.7 
Subject Withdrawal 
Subjects may withdraw from the study at any time, for any reason or no reason, 
without jeopardizing their medical care. The investigative site will attempt to 
determine and document the reason(s) for discontinuation on the Study Exit form. 
Any subject who does not return for a scheduled follow-up evaluation will be 
contacted by telephone to determine the cause for the missed appointment, and an 
attempt to re-schedule the visit will be made. A subject will be withdrawn from the 
study (lost to follow-up) after a minimum of two unsuccessful attempted contacts 
were made. All subjects withdrawing from the study during the follow-up phase but 
prior to completion of the 12 month endpoint will be asked to voluntarily return for a 
final follow-up. 
Subjects may be withdrawn by the investigator prior to receiving an injection for the 
following reasons: 
• If it is not possible to withdraw the required amount of blood for nSTRIDE 
APS Kit processing (60 milliliters), then the subject will be withdrawn from the 
study and will not receive the injection. This will ensure that all treated 
subjects receive the appropriate treatment volume. 
• If, on the day of injection, it is determined by the investigator that the subject 
is no longer an appropriate candidate for injection (e.g., due to development 
of infection of the index joint) then the subject will be withdrawn from the 
study and will not receive the injection. 
Subjects who are withdrawn from the study prior to receiving an injection will be 
replaced. 
The investigator, the IRB, and the sponsor have the right to discontinue a subject for 
the following reasons: 
• Occurrence of unacceptable risk to the subjects enrolled in the study 
• Insufficient compliance with the protocol by the subject 
• AEs intolerable to the subject 
• Participation in another clinical investigation that interferes with this study 
2.8 
Description of Assessments and CRFs 
All data to be collected is described below. Sample CRFs may be found in 
Supplement 2. 
2.8.1 Demographics 
Demographic information collected will include gender, ethnicity, age, height and 
weight. 
 
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2.8.2 Medication Use 
Information regarding the subject’s allowable OA medication use, as well as use of 
acetaminophen for breakthrough pain, will be collected. 
2.8.3 Knee Radiograph 
A standing posterior-anterior (PA) fixed flexion radiograph of the index knee will be 
acquired. Joint space width (JSW) and joint space narrowing (JSN), as well as 
Kellgren-Lawrence grade, will be measured according to validated, prospectively 
defined techniques described in a signed charter produced by the Imaging Core 
Laboratory. This charter will specify the details of radiograph acquisition, transfer, 
and analysis techniques. All X-rays will be transferred to the Imaging Core 
Laboratory for independent review. Radiographs will be taken at the time of 
screening, or up to 6 months prior to screening, and at the 12 Month Follow-Up Visit. 
2.8.4 Magnetic Resonance Imaging 
MRI will be used to quantitatively assess cartilage changes via T2 relaxation 
mapping. If centers do not have T2 relaxation mapping capability, they will be 
exempt from submitting the T2-related sequences to the Imaging Core Laboratory. 
In addition, semi-quantitative assessment via MRI Osteoarthritis Knee Score 
(MOAKS) will be used to evaluate tissues including the subchondral bone, cartilage, 
meniscus, and peri-articular features. All MRIs will be transferred to the Imaging 
Core Laboratory for independent review. Image acquisition, transfer, and analysis 
procedures will be performed under the direction of a signed charter, using 
validated, prospectively defined methods. MRI will be taken at screening, following 
confirmation of eligibility, and at the 12 Month Follow-Up Visit.  
In the event that an otherwise eligible subject is unable to undergo the MRI 
procedures at screening and at the 12 Month Follow-Up Visit due to significant 
safety risk (i.e. subject has pacemaker), the Sponsor has determined that the MRI 
assessment shall be waived. This will not result in a protocol deviation. 
2.8.5 Pregnancy Test 
A urine assay will be completed, as applicable, to determine whether the subject is 
pregnant. The pregnancy test will be done for any woman less than one year post-
menopausal who is sexually active and is not actively using contraceptives. 
2.8.6 WOMAC LK 3.1 Questionnaire 
The WOMAC LK 3.1 questionnaire is a validated tool used for assessing knee pain, 
stiffness, and function. The WOMAC LK 3.1 has 24 items; 5 items assessing knee 
pain, 2 items assessing knee stiffness, and 17 items assessing physical function. 
Each item is answered on a 5-point Likert scale, with grading from 0 (none or never) 
to 4 (extreme or always). A higher score indicates worse pain, stiffness, or functional 
limitation. 
 
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2.8.7 EQ-5D 
The EuroQol-5 Dimensions (EQ-5D) is a validated instrument which assesses an 
individual’s current health status and heath related quality of life. The EQ-5D-3L 
descriptive component assesses five dimensions: mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression over three levels of severity. The EQ visual 
analogue scale (EQ VAS) assesses the respondent’s self-rated overall health state 
on a scale from 0 (worst imaginable health state) to 100 (best imaginable health 
state). 
2.8.8 VAS Pain 
The Visual Analog Rating Scale is a validated measure of knee pain. The VAS is a 
nominal 100 mm scale anchored by 0 “no pain” and 100 “worst possible pain”. 
Subjects rate their average pain over the last 24 hours by marking a slash at the 
point in the scale line representing their level of pain. 
2.8.9 Injection Procedure 
Subject will receive an injection of APS or Saline. For further information see Section 
2.6.2. 
2.8.10 Ultrasound 
The initial APS injection will be completed with a clear ultrasound image captured of 
the injection site with the needle in position. 
2.8.11 Laboratory Characterization 
Whole blood and APS will be characterized by a central laboratory for cellular 
content (red blood cells, total and differential white blood cells, and platelets) and 
key cytokine and growth factor concentrations (IL-1ra, IL-1β, sIL-1RII, sTNF-RII, 
TNFα, IGF-I, TGF-β1). Synovial fluid will also be sent to the core laboratory for 
evaluation. Laboratory characterization procedures will be performed using 
validated, prospectively defined methods.  
2.8.12 Adverse Events 
The Adverse Event form will document all adverse events reported to or identified by 
site personnel including but not limited to onset, duration, severity and relatedness to 
the device.  
2.9 
Study Completion 
Each subject will exit the study upon completion of the 12 month follow-up visit or, if 
the subject elects to enter the repeat injection phase and receive an additional 
injection of APS, then they will exit the study upon completion of the 1 Month Follow-
Up Visit after the second injection. The Study Exit form will be used to document 
study completion. 
 
This clinical investigation will be considered completed subsequent to the last 
subject last visit and after all final reports have been submitted to the Food and Drug 
Administration (FDA) and the governing IRB(s). 
 
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2.10 Study Endpoints  
2.10.1 Primary Endpoint 
The primary objective of this study is to determine whether nSTRIDE APS is 
superior to saline with regard to mean improvement in Western Ontario and 
McMaster Universities Osteoarthritis Index (WOMAC) LK 3.1 pain score (change 
from baseline to 12 months post-injection.  
Further detail is given in Section 9.1 and in the Statistical Analysis Plan (SAP) for 
this study. 
2.10.2 Secondary Endpoints 
The secondary endpoint hypothesis tests will be performed at the 0.05 level. If any 
hypothesis is not tested significantly, all subsequent tests will be performed as 
exploratory analyses. 
 
Secondary endpoints are as follows: 
Order of Testing 
Secondary Outcomes 
1 
WOMAC MCID Function Responder rate 
2 
WOMAC MCID Pain Responder rate 
3 
Mean WOMAC Function Δ (12 Month minus 
Baseline) 
4 
OMERACT-OARSI Responder /  
Non-responder (12 Month) 
5 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) in K-L II 
Subgroup 
6 
Mean WOMAC Function Δ 
(12 Month minus Baseline) in K-L II 
Subgroup 
7 
Use of rescue medication (acetaminophen) 
use (for index knee OA) over time 
8 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
rescue medication within 48 hours of the 12 
month visit for knee OA as a covariate 
9 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
rescue medication within 48 hours of the 12 
month visit for any reason as a covariate 
10 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
restricted medication within 48 hours of the 
12 month visit for knee OA as a covariate 
11 
Mean WOMAC Pain Δ 
(12 Month minus Baseline) with Usage of 
restricted medication within 48 hours of the 
12 month visit for any reason as a covariate 
 
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12 
Mean VAS Pain Δ 
(12 Month minus Baseline) 
13 
Mean WOMAC Pain changes over time 
within treatment  
2.10.3 Exploratory Endpoints 
Exploratory outcomes include assessment of change from baseline to each time 
point for quality of life, WOMAC Pain, Stiffness, and Function, and VAS pain score 
as well as the OMERACT-OARSI criteria. 
 
Exploratory analyses will also include evaluation of changes in joint morphology, 
determined with MRI images and X-ray images, as well as analyses of whole blood 
and APS cell/cytokine concentrations. 
 
Exploratory endpoints are listed in the Statistical Analysis Plan (SAP) (Supplement 
3). All analyses of exploratory endpoints will be conducted at α = 0.05 and will not be 
adjusted for multiple comparisons as these are exploratory outcomes. 
3 
PROTOCOL DEVIATION REPORTING AND MANAGEMENT 
Protocol violations will be tracked and reported by the sponsor. 
Protocol violations identified by the investigative site will be documented on the 
appropriate CRF. Protocol violations identified during monitoring visits will be 
documented on the appropriate CRF and discussed with the investigator. Where 
necessary a corrective action will be implemented. 
Protocol deviations will be classified into two severity categories: 
• Minor deviations: violations that do not impact and do not have the potential 
to impact patient safety or scientific validity of the primary endpoint. Examples 
include isolated instances of missing laboratory values or study assessments. 
• Major deviations: violations that impact patient safety or have the potential to 
do so, or have the potential to impact scientific validity of the primary 
endpoint. Examples include no ICF prior to procedure or inclusion of a subject 
who clearly did not meet eligibility criteria. 
4 
ADVERSE EVENT REPORTING AND MANAGEMENT 
All AEs reported to or identified by investigative center personnel occurring during 
the study period and after the treatment procedure will be documented. AEs will 
have the onset and resolution date(s) listed (when known), will have their 
management and outcome documented (if possible), and will be assessed for 
severity, relatedness, and whether they were anticipated. SAEs will be described in 
a narrative in the final study report. 
Anticipated AEs in this trial include, but are not limited to, those associated with any 
aspiration procedure or blood draw procedure including pain, bleeding, bruising, 
infection, deep venous thrombosis, scar tissue formation, thrombotic complications, 
or nerve/nervous system damage. Anticipated AEs associated with the injection 
procedure include worsening of knee pain and/or function, effusion, and infection.  
 
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4.1 
Definitions 
Adverse Event 
An AE is any untoward medical occurrence in a subject receiving an investigational 
medical device which does not necessarily have a causal relationship with the 
treatment. An AE can therefore be any unfavorable and unintended sign (including 
an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of an investigational device, whether or not related to the investigational device. 
Any AE that occurs during or after the blood draw will be recorded. 
Serious Adverse Event 
A serious adverse event (SAE) is an AE that:  
• Results in death 
• Is life-threatening 
• Requires inpatient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability or incapacity 
• Is a congenital anomaly or birth defect 
Adverse Device Effect 
An adverse device effect (ADE) is an AE whose causal relationship with the 
investigational device is determined to be likely or definite. The following are 
identified as possible examples of ADEs: 
• Injection site reaction – swelling, redness, burning, itching at the injection site – 
to a degree that is atypical of an intra-articular aspiration and injection procedure 
• Knee arthralgia – severe pain in the knee joint 
• Knee joint ache – to suffer dull, continued pain 
• Knee joint inflammation – a localized protective reaction of tissue to irritation, 
injury, or infection, characterized by pain, redness, swelling, and sometimes loss 
of function 
• Knee joint effusion – the escape of fluid from the blood vessels or lymphatics into 
the knee joint 
• Knee arthrosis – degenerative disease of the knee joint – beyond what is 
considered to be normal OA progression 
Unanticipated Adverse Device Effect 
An unanticipated adverse device effect (UADE) is any serious adverse effect on 
health or safety or any life-threatening problem or death caused by, or associated 
with, a device; if that effect, problem, or death was not previously identified in nature, 
severity, or degree of incidence in the investigational plan or application (including a 
supplementary plan or application), or any other unanticipated serious problem 
associated with a device that relates to the rights, safety, or welfare of subjects. 
 
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4.2 
Adverse Event Assessments 
All AEs reported to or identified by investigative center personnel will be assessed 
by the investigator and recorded in the patient’s study chart and on the Event Form, 
including but not limited to the following: 
• Observed or volunteered problems 
• Physical signs and symptoms 
• Medical condition which occurs during the study, having been absent at baseline 
• Medical condition present at baseline, which appears to worsen during the study 
All AEs will be documented on the Adverse Event Form regardless of whether the 
medical/clinical event is associated with the use of the investigational device. 
Each AE record must include a description of the event, date of onset, date of 
resolution (when known), severity, action taken, relationship to study device and 
seriousness criteria. Each AE must be recorded separately. 
An outcome which may be expected to occur following any joint aspiration and 
injection procedure (e.g. transient pain at the injection site, mild swelling of the joint) 
should not be classified as an adverse event unless it is considered to be more 
severe or of longer duration or otherwise more pronounced than is typical. 
Negative responses on follow-up questionnaires which are intended to evaluate 
clinical efficacy will not be recorded as adverse events. 
A worsening of index knee osteoarthritis (i.e. joint space narrowing observed on X-
ray) which is considered by the investigator to be part of the normal progression of 
the disease will not be recorded as an adverse event. 
Severity will be assessed by the investigator using the following definitions: 
Mild: Aware of sign or symptom, but easily tolerated 
Moderate: Discomfort enough to cause interference with usual activity 
Severe: Incapacitating with inability to work or do usual activity 
Relationship to the study device will be assessed by the investigator using the 
following definitions: 
Definitely Not: Evidence exists that the AE definitely has a cause other than 
the study device (e.g., pre-existing condition or underlying disease, intercurrent 
illness, or concomitant medication) and does not meet any other criteria listed.  
Unlikely: A temporal relationship exists between the event onset and 
preparation/administration of the investigational device (or comparator). 
Although the AE may appear unlikely to be related to the investigational device, 
it cannot be ruled out with certainty; and/or the event cannot be readily 
explained by the patient’s clinical state or concomitant therapies. 
Likely: A temporal relationship exists between the event onset and 
preparation/administration of the investigational device (or comparator) and 
appears with some degree of certainty to be related based on the known 
 
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mechanism of action of the device. It cannot be readily explained by the 
patient’s clinical state or concomitant therapies. 
Definitely: Strong evidence exists that the investigational device caused the 
AE. There is a temporal relationship between the event onset and 
preparation/administration of the investigational device (or comparator). There 
is strong mechanistic evidence that the event was caused by the investigational 
device. The patient’s clinical state and concomitant therapies have been ruled 
out as a cause. 
4.3 
Adverse Event Reporting 
All subjects will be evaluated for AEs. All AEs will be evaluated beginning with onset, 
and evaluation will continue until the last day of the study, until recovery is noted, or 
until the investigator determines that the subject’s condition is stable, whichever is 
earlier. The investigator will take all appropriate and necessary therapeutic 
measures required for resolution of the AE. Any medication necessary for the 
treatment of an AE must be recorded on the Adverse Event Form. If the medication 
necessary for treatment is on the restricted medication list, a Protocol Deviation form 
must also be completed. If more than one distinct AE occurs, each event should be 
recorded separately. The worsening of an adverse event should not be recorded as 
a new AE but as a continuation of an ongoing AE. Based on the information reported 
for the AE, if the sponsor or the sponsor’s agent determines that the reported AE is 
an unanticipated adverse device effect, then it shall be reported as an unanticipated 
adverse device effect as directed in Section 4.5 – Unanticipated Adverse Device 
Effect Reporting. 
4.4 
Serious Adverse Event Reporting 
All SAEs that occur during the study, including death, must be reported to the 
sponsor within 24 hours of occurrence or of the time the investigator becomes 
aware of the event by telephone, fax, email, or any other modality. All information on 
the AE event form must be made available to the sponsor as early as possible. 
Based on the information reported for the SAE, if the sponsor or the sponsor’s agent 
determines that the reported SAE is an unanticipated adverse device effect, then it 
shall be reported as an unanticipated serious adverse device effect as directed in 
Section 4.5 - Unanticipated Adverse Device Effect Reporting. 
4.5 
Unanticipated Adverse Device Effect Reporting 
The investigator shall submit a report of any unanticipated adverse device effect 
occurring during an investigation to the sponsor and to the reviewing IRB as soon as 
possible, but in no event later than 10 working days after the investigator first learns 
of the event. 
5 
RISK EVALUATION 
This study is designed to confirm the efficacy and safety of the nSTRIDE APS Kit 
and will weigh the benefits of the nSTRIDE APS Kit with regard to treatment of knee 
osteoarthritis and associated symptoms, or knee pain associated with osteoarthritis, 
against potential risks detected by the occurrence of adverse events. 
 
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The nSTRIDE APS Kit has a favorable risk profile. The injectable APS is processed 
from the patient’s own whole blood using the nSTRIDE APS Kit. If properly 
processed then the risk of any immunogenic reactions, disease transmission or 
adverse interactions with systemic drugs is minimal.  Because APS is delivered 
intra-articularly, there is localized anatomical impact allowing for the precise 
monitoring of adverse effects. There is little, if any, systemic introduction. Therefore, 
safety concerns with APS may be primarily related to the injection process. The most 
likely adverse effects are pain and swelling at the injection site. Such reactions 
typically resolve in one or two days with no treatment or minimal treatment. More 
serious complications of intra-articular injections include, but are not limited to, local 
infections, nerve damage, and deep vein thrombosis, all of which are extremely rare, 
and none of which have been reported in any previous clinical investigation of the 
nSTRIDE APS Kit (35;36).  
5.1 
Potential Risks to Study Subjects 
Subjects in this study are exposed to potential risks associated with aspiration of 
joint fluid, a blood draw, and solution injection into the knee. These include pain, 
bleeding, bruising, infection, deep venous thrombosis, scar tissue formation, 
thrombotic complications and nerve damage. These risks are not unique to this 
study and may occur with any aspiration, blood draw, or joint injection procedure. 
Potential risks associated with the injection of the APS include worsening of pain 
and/or knee function, effusion, and infection. Mixing up blood and/or APS samples 
from multiple donors presents a risk of injecting the APS produced from one patient 
into another patient. This would be associated with a possible inflammatory reaction 
or disease transmission to the patient receiving the injection. There are no known 
specific risks of the investigational device itself. 
5.2 
Methods to Minimize Risks 
Several procedures have been incorporated into this protocol to protect study 
subjects and to detect any injection site reactions or other AEs. Rigorous 
inclusion/exclusion criteria ensure that any patient who may be at increased risk is 
not enrolled in the study (e.g., patients with a systemic inflammatory condition). 
Appropriate investigative center personnel will be thoroughly trained on the 
processing of the nSTRIDE APS Kit.  
Sticker labels are included in each kit to identify the subject associated with each 
syringe, device and specimen. The use of these labels will reduce the risk of sample 
mix-up. Additionally, only one subject’s blood will be processed in the centrifuge at a 
time. 
5.3 
Medical Monitor 
An independent medical monitor will be available to adjudicate all serious adverse 
events and unanticipated adverse device effects with respect to severity and 
relatedness within 10 working days from the time the sponsor is made aware of the 
event. The medical monitor will have the authority to suspend or terminate the 
 
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investigation pursuant to Section 5.4. Sponsor study personnel may choose to have 
any AE independently reviewed by the medical monitor at their discretion. 
5.4 
Investigation Suspension or Termination 
The Investigator, the IRB, and the Sponsor may suspend or terminate the 
investigation at any/all investigational sites at any time if they believe: 
• There is unacceptable risk to the subjects enrolled in the study 
• A decision on the part of the sponsor to suspend or discontinue testing, 
evaluation, or development of the product (subjects already enrolled would be 
followed until they complete the study) 
• Failure of the investigator to enroll patients into the study at an acceptable 
rate 
• Failure of the investigator to comply with the protocol or appropriate 
regulations, especially with respect to subject safety 
• Site personnel knowingly submit false information from the investigative site 
to the sponsor, study monitor, IRB, or regulatory authority 
The sponsor should be notified immediately if any one of these conditions is present. 
The sponsor will determine the appropriate course of action taking into account 
medical assessments, regulatory mandates and ethical considerations. If the clinical 
investigation is suspended or terminated then the sponsor, in coordination with the 
IRB and investigator, will comply with any necessary action regarding investigation, 
documentation, and reporting. 
5.5 
Potential Benefits of the Procedure 
The potential benefit of APS is the treatment of knee OA and associated symptoms, 
or the treatment of knee pain associated with OA. This study also explores other 
potential benefits, such as knee function restoration and anatomical improvement 
within the joint. 
5.6 
Bias Minimization 
5.6.1 Randomization 
The randomization plan will be produced using SAS v 9.2 for Windows or similar 
software. Balanced, blocked randomization (1:1, APS: Saline) will be 
implemented. In the event that a screen failure occurs post-randomization, and no 
study treatment was given, randomization will not be reassigned and in this case will 
not count toward the overall sample size. Randomization will continue with the next 
case enrolled until the minimum sample size is reached in both treatment groups. 
Randomization will be stratified by site, and each site will receive separate 
randomization plans using random predetermined block sizes that will remain 
undisclosed to the sites. The randomization file will be uploaded into the electronic 
data capture (EDC) system. Once the subject is enrolled into the EDC and has been 
identified as eligible for randomization, the randomization allocation will be visible 
 
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within the EDC and viewable only by the unblinded research associate. The subject 
will be treated according to the contents of the displayed randomization allocation. 
5.6.2 Blinding 
This is a double-blind study with subjects and evaluators blinded to treatment. 
Throughout the course of the study, whether subjects receive APS or saline 
treatment, they will be cared for in the same manner in order to blind them from their 
treatment. Although saline control subjects will not receive APS treatment, they will 
undergo a blood draw, as is required for nSTRIDE APS Kit processing, in order to 
protect the blinding of the study. The nSTRIDE APS Kits will be processed 
identically for subjects randomized to both treatment groups. For subjects allocated 
to the saline treatment group, an identically sized treatment syringe will be loaded 
with a volume of saline equal to the volume of APS output from the first nSTRIDE 
APS Kit by the unblinded research associate. The unblinded research associate will 
cover the syringe to mask the contents, regardless of the treatment allocation, prior 
to presenting it to the injecting clinician. The clinician will perform the injection 
procedure, and capture an ultrasound image showing needle placement within the 
joint, taking care not to reveal the contents of the syringe. To further protect the 
blind, any recorded information specifically related to APS treatment will be kept in 
an “unblinded” file, separate from the rest of the study data, and will only be 
available to the unblinded research associate. Blinded evaluators will not have 
access to the unblinded file. 
Study-related communications between the unblinded research associate and the 
blinded evaluators will be limited to prevent breaking the blind. Study-related 
communications should be limited in scope to the subject’s pre-existing conditions 
prior to treatment or to adverse events following treatment. The unblinded research 
associate will not play a role in any follow-up visit study procedures, and unblinded 
personnel will be strictly forbidden from discussing treatment allocation with subjects 
and clinical observers. 
The subject’s randomization allocation will be viewable in the EDC by the unblinded 
research associate only. This allocation will only be communicated to blinded study 
personnel if a serious adverse event occurs and information as to which treatment 
the subject received is essential for the medical treatment of the subject and adverse 
event reporting. All sites and the sponsor will keep a record of the communication of 
the randomization allocation of any subject. 
6  
CONTROL OF INVESTIGATIONAL DEVICE 
All study devices will be provided by the sponsor at no charge. Documentation of 
receipt, disposition, and return of all investigational device materials must be 
maintained by the investigator or his/her designee on a device accountability log. It 
is the investigator’s responsibility to ensure that all investigational devices are kept in 
a secure location, with access limited to individuals authorized by the investigator. 
The device will be shipped with a confirmation of receipt form. Once signed, copies 
of the confirmation of receipt form should be maintained by the sponsor in the Trial 
Master File and in the Investigator’s files.  
 
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The nSTRIDE APS Kit with ACD-A can be stored at room temperature. The 
investigator must ensure that the study devices are used only for eligible study 
subjects who are appropriately enrolled in the study. 
At the conclusion of each procedure, and after recording all requested information 
on the Procedure Form, the investigator will discard any remaining investigational 
material which was prepared (using an acceptable disposal method for products 
potentially contaminated with blood).  
After completion of the treatment period of the study, all unopened devices will be 
returned to the sponsor in the original containers or will be destroyed at the study 
site by the study monitor. The monitor will complete an accountability form to 
document the action taken. 
The device accountability records must be readily available for inspection by the 
study monitor, independent auditor, and any regulatory authority inspector. The 
study monitor will reconcile device supplies as part of the routine monitoring visit. 
6.1  
Description and Control of Saline Comparator 
The saline comparator will be provided by the sponsor. The comparator will be 0.9% 
sodium chloride solution. The saline solution will be stored and administered in a 
consistent manner with the investigational device. 
7  
DATA COLLECTION, HANDLING AND RETENTION 
7.1 
Source Documentation 
Source documentation for this study will be maintained to capture the course of 
treatment and to substantiate the integrity of the trial data. Source documentation 
will include, but is not limited to, worksheets, hospital and/or clinic or office records 
documenting subject visits including study and other treatments or procedures, 
medical history and physical examination information, imaging results, device 
accountability records, medical consultations and laboratory results and reports. 
7.2 
Case Report Forms 
Sample CRFs are provided in Supplement 2. 
Data for this clinical trial will be collected and documented on the subject’s CRFs. 
CRFs provided may appear in paper or electronic form. Only authorized study site 
personnel or subjects will complete CRFs as appropriate to the specific CRF. CRFs 
must be reviewed and signed by the investigator or their documented designees. 
This may be done electronically within the electronic data capture system. Because 
there is a potential for errors, inaccuracies, and misinterpretation in the process of 
transcribing data onto CRFs (whether paper or electronic), the following documents 
must be available at all times for inspection and comparison to the CRFs by the 
study monitor where applicable. 
• Data query forms  
• Originals or photocopies/certified copies of all relevant records and reports  
 
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• Copies of test results and reports 
• Other records as listed in 21 CFR Part 812.140. 
Only trained study site personnel may complete and sign (or authorize) the forms. 
7.3 
Electronic Data Entry 
When using electronic data handling or remote electronic trial data systems, the 
sponsor or the sponsor’s representative will: 
• Ensure and document that the electronic data processing system(s) conforms 
to the sponsor’s established requirements for completeness, accuracy, 
reliability, and consistent intended performance (i.e., validation) 
• Maintain SOPs for using these systems 
• Ensure that systems are designed to permit changes to the data in such a 
way that the data changes are documented and there is no deletion of any 
edited or entered data (i.e., maintains an audit trail) 
• Maintain a security system to prevent unauthorized access to the data and to 
be able to uniquely identify individuals who access the data entry system 
• Maintain a list of individuals who are authorized to make data changes 
• Maintain adequate backup of the data 
7.4 
Records Retention 
Study documents will be retained by the investigator for a period of 2 years after the 
latter of the following two dates: 
• The date on which the investigation is terminated or completed 
• The date the records are no longer required for purposes of supporting a 
regulatory application 
8  
REPORTING 
8.1 
Data Reporting 
The investigator shall provide an interim progress report to the sponsor, the monitor, 
and the reviewing IRB annually following IRB approval. 
The investigator shall, within 3 months after termination or completion of the study or 
the investigator’s part of the study, submit a final report to the sponsor and reviewing 
IRB. 
8.2 
Other Reporting 
The investigator shall provide all reports in accordance with 21 CFR Part 812.150(a) 
including but not limited to: 
• Unanticipated adverse device effects 
 
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• Withdrawal of IRB approval 
• Major deviations from the investigative plan 
• Use of an investigational device without informed consent 
An investigator shall provide accurate, complete, and current information about any 
aspect of the study upon request by the Sponsor, the reviewing IRB, or FDA. 
9  
STATISTICAL ANALYSIS 
 
The complete SAP is provided in Supplement 3. Briefly, the planned analyses are 
described below. 
 
9.1 
Primary Efficacy Analysis 
The primary objectives of this study are to determine whether nSTRIDE APS is 
superior to a saline with regard to the mean improvement from baseline to 12 
months in Western Ontario and McMaster Universities Osteoarthritis Index 
(WOMAC) LK 3.1 pain subscale score.  
 
The primary hypothesis will be tested along with the secondary hypotheses listed in 
the Statistical Analysis Plan using a conventional fixed-sequence procedure, 
constructed using a pre-specified order of hypotheses. These tests will be performed 
at the 0.05 level.  If the first null hypothesis is rejected, the second test will be 
performed at the 0.05 level. If the first null hypothesis is not rejected, the second 
test, and all subsequent tests, will be performed as exploratory analyses. Since the 
order of the tests is fixed a priori, and the second hypothesis is tested only if the 
previous hypothesis has been rejected, the principle of closed testing implies that no 
adjustment to control the familywise error rate is necessary.  The Fixed-Sequence 
Method is described as an acceptable method for addressing the multiplicity problem 
in Section IV.C.5 of the FDA draft guidance entitled, “Guidance for Industry – 
Multiple Endpoints in Clinical Trials”.  
 
If the primary hypothesis is not tested significantly, all subsequent secondary tests 
will be performed as exploratory analyses only.  
 
A two-tailed independent sample T-test will be used to test the primary endpoint. 
The hypothesis will be: 
 
H0: µAPS = µControl  
Versus  
HA: µAPS ≠ µControl  
 
Where: 
µAPS = mean change in WOMAC Pain from baseline to 12 months in the APS 
group, and 
µcontrol = mean change in WOMAC Pain from baseline to 12 months in the control 
group. 
 
 
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The impact of the usage of APS on function will be evaluated as part of the primary 
endpoint; however, no formal statistical test will be done as a part of the study 
success criteria.  A qualitative assessment of the changes in WOMAC Function over 
time for APS and Placebo will be discussed, in order to ensure that the impact of the 
treatment on function is neutral or positive.  The following descriptive analyses will 
be performed for this assessment of function: 
 
(3) A graphical examination of the changes in WOMAC Function for APS and 
Placebo over time, including means and standard error bars. 
(4) Descriptive statistics for the mean changes in WOMAC Function over time, 
separately for each treatment group.  These will include mean, median, 
standard deviation, minimum, maximum, and 95% confidence intervals. 
 
For each analysis, it is expected that the changes in WOMAC function will remain 
neutral or increase over time within the APS group, and also that the mean changes 
in WOMAC Function over time will be at least nominally better for the APS group 
than for Saline. 
  
A finding of nSTRIDE APS superiority on the mean improvement in WOMAC LK 3.1 
Pain along with no corresponding deterioration in WOMAC Function will be 
considered evidence of nSTRIDE APS efficacy, and the device will be considered 
efficacious for the treatment of knee pain associated with osteoarthritis. 
 
9.2 
Demographics and Medication Use 
Analyses will be done to determine whether randomization succeeded in creating 
groups that were balanced with regards to key baseline characteristics. Planned 
tests aimed at determining this are specified in the statistical analysis plan. All tests 
will be under a null hypothesis of no difference between treatment groups.  
 
A time-course tabulation showing rescue medication (acetaminophen) use (for index 
knee OA) by treatment group will be generated. In addition the percentages of 
subjects requiring rescue medication for their index knee OA during the course of 
follow-up (up to 12 months) will be compared for APS vs. Control using a Fisher’s 
Exact test. 
9.3 
Subject Reported Outcomes 
Subject reported outcome measures, WOMAC LK 3.1, EQ-5D, and VAS knee pain, 
will be summarized and thoroughly characterized with the appropriate descriptive 
statistics including error measures. Statistics may include mean, mode, median, 
range, inter-quartile range, minimum, maximum, frequency, cumulative frequency 
percentage and cumulative percentage. Results will be presented in a narrative and 
graphically. 
These measures will also be analyzed using inferential statistics. These analyses 
are described in detail in the SAP. 
 
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9.4  
Safety Analysis 
The safety profile of APS will be characterized. AEs will be standardized using the 
Medical Dictionary for Regulatory Activities. Characterization will include narratives 
of all SAEs and descriptive statistics including AE incidence overall and per subject, 
AE severity, AE device relatedness, AE duration, and AE onset for each treatment 
group. AEs will also be used to characterize the safety of a repeat APS injection. 
10 
STUDY MONITORING AND QUALITY CONTROL 
The investigators will permit trial-related monitoring, audits, IRB review, and 
regulatory inspection(s), providing direct access to the trial site and to source 
data/documents upon request. Clinical trials sponsored by Biomet Biologics are 
conducted under standard operating procedures. The sponsor’s staff and/or 
representatives will closely monitor the conduct of the clinical investigation so that 
any questions and problems that may arise can be promptly resolved. Such 
monitoring will also ensure that the clinical investigation is conducted in accordance 
with this clinical investigation plan, including all amendments, with good clinical 
practice (GCP) guidelines, and with International Standards Organization (ISO) 
14155 stipulations. Monitoring will involve visits by the sponsor's representative to 
the investigational centers to verify good management of subjects and the clinical 
investigation devices, to observe procedures and to audit the clinical investigation for 
quality control purposes (to check device accountability and supplies, presence of 
required documents, informed consent and to compare CRFs with source data). 
There will also be frequent telephone contact and written communication between 
the monitor and clinical investigators. The Monitoring Plan is presented in 
Supplement 4. 
11 
DEVICE LABELING 
The device package insert is provided in Supplement 1. 
12 
ETHICAL CONSIDERATIONS 
12.1 Code of Conduct 
The investigator will ensure that the clinical study is conducted in accordance with: 
• The Protocol 
• Regulatory and reviewing IRB requirements 
• ISO 14155 and GCP 
12.2 Regulatory Approval 
As an Investigational Device Exemption and premarket approval study this 
investigation will be conducted under an approved IDE application from FDA. 
12.3 Institutional Review Board Approval and Protocol Changes 
The Investigator must obtain IRB approval before the study is initiated at his or her 
site. A copy of the written IRB approval and a copy of the IRB approved ICF should 
be provided to the sponsor. A list of the IRB members (including their Institution 
 
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affiliations, gender makeup, and occupations); or a statement from the IRB 
specifying that the membership complies with applicable regulations, including but 
not limited to 21 CFR Part 56, is to be provided to the sponsor by the investigator.  
Any protocol changes must be discussed and approved by the sponsor in writing 
unless the change is made to assure the safety of the subject. In the non-emergent 
setting, after agreement on the changes has been reached, an amendment to the 
protocol will be provided by the sponsor for submission to the IRB for review and 
approval prior to initiation of the change. Any change made emergently must be 
documented in the subject's medical record and reported to the sponsor within the 
time period required by local SOPs and applicable regulations.  
12.4 Informed Consent 
Prior to the performance of any study-specific procedures, subjects will be provided 
with an informed consent form (ICF) and patient information sheet and be given 
ample opportunity to review the ICF and ask questions. If the subject agrees to 
participate in the study, then the subject must sign and date the ICF. The 
Investigator or designee must also sign and date the ICF. A copy of the ICF should 
be given to the subject. 
The specific ICF used must have current IRB approval at time of use. A HIPAA 
statement must be included in the ICF or provided as a separate document.   
Subjects will be informed of new information learned during the study, if any, which 
may affect the subject’s decision to continue participation in the study.  
An Informed Consent Log will be completed to document the existence of the signed 
ICF. The log will contain: Subject ID, date ICF signed, and the version signed. The 
monitor will initial and date the log once the executed ICF has been reviewed. 
Signed ICF (or copies) are to be maintained in the study file and must be available 
for verification by monitors and inspectors. 
 
 
 
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13 
LIST OF SUPPLEMENTS 
Supplement 1 – Package Insert 
Supplement 2 – Sample Case Report Forms 
Supplement 3 – Statistical Analysis Plan 
Supplement 4 – Monitoring Plan 
 
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14 
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 15 PROTOCOL REVISION HISTORY 
 
Versi
on 
Description of Change 
Sections 
V 1.0 
Original Protocol submitted to FDA (Dated 2016-06-28) 
 
V 2.0 
Updated Study Contact Information with relevant personnel 
Study Contact 
Information  
 
Clarified concomitant OA treatment.  
Updated to reflect changes to SAP with regard to the fixed 
sequential testing of the primary and secondary endpoints.   
Revised summary of exploratory endpoints. 
Increased sample size from 246 to 332 subjects.  
Study Synopsis 
Removed extraneous reference to ultrasound guidance. 
Use and Training 
(Section 1.3.3) 
Specified version of WOMAC to be used. (i.e. LK 3.1) 
Study Objectives  
(Section 1.5) 
Increased sample size from 246 to 332 subjects. 
Study Design  
(Section 2.1) 
Added immediate re-screening criterion for inability to comply 
with the protocol (i.e. screen failure in which screening to 
injection window closes prior to MRI or injection, but subject 
otherwise remains eligible). 
Eligibility for Re-
Screening 
(Section 2.4) 
Added the Pregnancy Test requirement to the Optional 2nd 
Injection column of the clinical study assesment table. 
Study Assessments 
and Procedures  
(Section 2.6) 
Added alternative injection technique to allow for knee exam/ 
palpation or ultrasound to be used in order to determine if 
synovial fluid is available for aspiration, per standard of care. 
Injection Procedure  
(Section 2.6.2.5) 
Added the Pregnancy Test requirement prior to the optional 2nd 
Injection procedure.  
Second Injection 
Procedure (Optional) 
(Section 2.6.4) 
Added MRI waiver detail for subjects at significant safety risk. 
Magnetic Resonance 
Imaging  
Section (2.8.4) 
Updated to reflect changes to SAP with regard to the fixed 
sequential testing of the primary study hypotheses.   
Primary Endpoints 
(Section 2.10.1) 
Updated to reflect changes to SAP with regard to the fixed 
sequential testing of the secondary study hypotheses.   
Secondary Endpoints 
(Section 2.10.2) 
Updated to reflect changes to SAP with regard to the exploratory 
outcomes assessments. 
Exploratory Endpoints 
(Section 2.10.3) 
Updated to reflect changes to SAP with regard to the fixed 
sequential testing of the primary study hypotheses.   
Primary Efficacy 
Analysis 
 
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(Section 9.1) 
Updated to reflect changes to SAP to clarify the analysis of 
baseline data and medication use.  
Demographics and 
Medication Use 
(Section 9.2) 
Updated to reflect the location of the inferential statistics detail. 
Subject Reported 
Outcomes 
(Section 9.3) 
V 2.1 
Updated intended use to be the treatment of knee pain 
associated with osteoarthritis. 
Study Synopsis,  
Indications (Section 
1.3.1) 
Updated primary objective/endpoint to be WOMAC pain score, 
rather than WOMAC pain and function scores. 
Study Synopsis, 
Study Objectives 
(Section 1.5), 
Primary Endpoint 
(Section 2.10.1), 
Primary Efficacy 
Analysis (Section 9.1) 
Updated primary hypothesis to reflect one primary test (pain) 
rather than two (pain and function). 
Study Synopsis 
Updated secondary endpoints to include mean WOMAC function 
change as the first priority secondary outcome to test. 
Study Synopsis, 
Secondary Endpoints 
(Section 2.10.2) 
Updated criteria for major and minor deviations to reflect one 
primary endpoint (pain) rather than two (pain and function) 
Protocol Deviation 
Reporting and 
Management (Section 
3) 
Updated the potential benefit of APS to be treatment of knee OA 
pain. Updated other porential benefits that are explored in this 
study. 
Potential Benefits of the 
Procedure (Section 5.5) 
Updated criteria for evidence of nSTRIDE APS efficacy. 
Primary Efficacy 
Analysis (Section 9.1) 
V 3.0 
Updated intended use to be the treatment of knee osteoarthritis 
and associated symptoms or knee pain associated with 
osteoarthritis. 
Study Synopsis,  
Indications (Section 
1.3.1) 
Updated primary objective/endpoint to be WOMAC pain (mean 
improvement) and function scores (MCII responder rate), rather 
than WOMAC pain score alone. 
Study Synopsis, 
Study Objectives 
(Section 1.5), 
Primary Endpoint 
(Section 2.10.1), 
Primary Efficacy 
Analysis (Section 9.1) 
Updated primary hypothesis to reflect two sequential primary 
tests (pain and then function) rather than one (pain only). 
Study Synopsis 
Updated the potential benefit of APS to be treatment of knee OA 
and associated symptoms or knee pain associated with OA. 
Updated other potential benefits that are explored in this study. 
Potential Benefits of the 
Procedure (Section 5.5) 
Updated criteria for evidence of nSTRIDE APS efficacy. 
Primary Efficacy 
Analysis (Section 9.1) 
V  4.0 
Updated intended use to be the treatment of knee pain 
associated with osteoarthritis. 
Study Synopsis,  
Indications (Section 
1.3.1) 
Updated primary objective/endpoint to be WOMAC pain score, 
rather than WOMAC pain and function scores.   
 
Added additional detail regarding the assessment of trends on 
Study Synopsis, 
Study Objectives 
(Section 1.5), 
Primary Endpoint 
 
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WOMAC Function 
(Section 2.10.1), 
Primary Efficacy 
Analysis (Section 9.1) 
Updated secondary endpoints to reflect (1) inclusion of test of 
WOMAC MCID Function as a secondary endpoint, and (2) 
moving some exploratory endpoint to secondary in order to better 
comply with the FDA Analgesics Indications guidance document 
(https://www.fda.gov/downloads/drugs/guidancecomplianceregul
atoryinformation/guidances/ucm384691.pdf).   
Study Synopsis, 
Secondary Endpoints 
(Section 2.10.2) 
V  5.0 
Updated secondary endpoints to include (1) test of WOMAC 
MCID Pain as a secondary endpoint, and (2) specifically define 
the analyses of the impact of rescue and restricted medications 
on the primary outcome. 
Study Synopsis, 
Secondary Endpoints 
(Section 2.10.2) 
  
 
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