Randomized, Multi-center Phase II Clinical Trial for the Regeneration of Cartilage Lesions in the Knee Using Nasal Chondrocyte-based Tissue (N-TEC) or Nasal Chondrocyte-based Cell (N-CAM)-Therapies
Phase: NA
Conditions: Tear; Knee, Cartilage, Articular
Sponsor: University Hospital, Basel, Switzerland

Interventional study with investigational medicinal 
product (IMP)  
Clinical Study Protocol
Randomized, multi-center phase II clinical trial for 
the regeneration of cartilage lesions in the knee 
using nasal chondrocyte-based tissue (N-TEC) or 
nasal chondrocyte-based cell (N-CAM)-therapies  
Short Title: 
 Nose to Knee II 
Study Type: 
Clinical trial phase II with Investigational Medicinal Product (IMP) 
Study Categorization: 
C 
Study Registration: 
ClinicalTrial.Gov   Registration number: NCT02673905 
EudraCT 
 Registration number: 2015-005162-34 
Study Identifier: 
n.a. 
Sponsor, Sponsor-Investigator or 
Principal Investigator: 
Prof. Dr. med. Marcel Jakob 
Department of Traumatology, University Hospital Basel 
Spitalstrasse 21, CH-4031 Basel, Switzerland 
email:       Marcel.Jakob@usb.ch 
Tel.:          +41 61 328 72 40 
Investigational Product: 
N-TEC (nasal chondrocyte tissue engineered cartilage) 
N-CAM (nasal chondrocyte cell activated matrix)  
Protocol Version and Date: 
Version number 07, 10.04.2018 
CONFIDENTIAL 
The information contained in this document is confidential and the property of the Tissue Engineering 
group / Dept. of Traumatology (“sponsor” rep. by Prof. M. Jakob). The information may not - in full or in 
part - be transmitted, reproduced, published, or disclosed to others than the applicable Competent 
Ethics Committee(s) and Regulatory Authority(ies) without prior written authorization from the sponsor 
except to the extent necessary to obtain informed consent from those who will participate in the study. 

Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
7 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 7 of 80 
Table of Contents 
STUDY SYNOPSIS ............................................................................................................................... 10
STUDY SUMMARY IN LOCAL LANGUAGE ....................................................................................... 17
ABBREVIATIONS ................................................................................................................................. 20
STUDY SCHEDULE .............................................................................................................................. 22
1.
STUDY ADMINISTRATIVE STRUCTURE .................................................................................... 23
1.1 Sponsor, Sponsor-Investigator .....................................................................................................23
1.2 Principal Investigator(s) ................................................................................................................23
1.3 Statistician ("Biostatistician") ........................................................................................................24
1.4 Laboratory ....................................................................................................................................24
1.5 Monitoring institution ....................................................................................................................25
1.6 Data Safety Monitoring Committee ..............................................................................................25
1.7 Any other relevant Committee, Person, Organisation, Institution ................................................26
2.
ETHICAL AND REGULATORY ASPECTS .................................................................................. 27
2.1 Study registration .........................................................................................................................27
2.2 Categorization of study.................................................................................................................27
2.3 Competent Ethics Committee (CEC) ...........................................................................................27
2.4 Competent Authorities (CA) .........................................................................................................27
2.5 Ethical Conduct of the Study ........................................................................................................28
2.6 Declaration of interest ..................................................................................................................28
2.7 Patient Information and Informed Consent ..................................................................................28
2.8 Participant privacy and confidentiality ..........................................................................................28
2.9 Early termination of the study .......................................................................................................29
2.10 Protocol amendments ..................................................................................................................29
3.
BACKGROUND AND RATIONALE .............................................................................................. 30
3.1 Background and Rationale ...........................................................................................................30
3.2 Investigational Product (treatment, device) and Indication ..........................................................31
3.3 Preclinical Evidence .....................................................................................................................34
3.4 Clinical Evidence to Date .............................................................................................................36
3.4.1Safety ...................................................................................................................................40
3.4.2Efficacy .................................................................................................................................40
3.5 Dose Rationale / Medical Device: Rationale for the intended purpose in study (pre-market MD)41
3.6 Explanation for choice of comparator (or placebo) ......................................................................41
3.7 Risks / Benefits .............................................................................................................................42
3.8 Justification of choice of study population ....................................................................................46
4.
STUDY OBJECTIVES ................................................................................................................... 47
4.1 Overall Objective ..........................................................................................................................47
4.2 Primary Objective .........................................................................................................................47
4.3 Secondary Objectives ..................................................................................................................47
4.4 Safety Objectives .........................................................................................................................47
5.
STUDY OUTCOMES ..................................................................................................................... 48
5.1 Primary Outcome .........................................................................................................................48
5.2 Secondary Outcomes ...................................................................................................................48
5.3 Other Outcomes of Interest ..........................................................................................................48
5.4 Safety Outcomes ..........................................................................................................................48

 
Document: 
Clinical Study Protocol 
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V07 
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Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 8 of 80 
6. STUDY DESIGN ............................................................................................................................ 49
6.1 General study design and justification of design ..........................................................................49
6.2 Methods of minimizing bias ..........................................................................................................49
6.2.1Randomization .....................................................................................................................49
6.2.2Blinding procedures .............................................................................................................49
6.2.3Other methods of minimizing bias ........................................................................................49
6.3 Unblinding Procedures (Code break) ...........................................................................................49
7. STUDY POPULATION .................................................................................................................. 50
7.1 Eligibility criteria ............................................................................................................................50
7.2 Recruitment and screening ..........................................................................................................51
7.3 Assignment to study groups .........................................................................................................52
7.4 Criteria for withdrawal / discontinuation of participants ................................................................52
8. STUDY INTERVENTION ............................................................................................................... 53
8.1 Identity of Investigational Products (treatment / medical device) .................................................53
8.1.1Experimental Intervention (treatment / medical device) .......................................................53
8.1.2Secondary study arm (treatment / medical device) .............................................................53
8.1.3Packaging, Labelling and Supply (re-supply) ......................................................................53
8.1.4Storage Conditions...............................................................................................................53
8.2 Administration of experimental and control interventions ............................................................54
8.2.1Experimental Intervention ....................................................................................................54
8.2.2Control Intervention ..............................................................................................................54
8.3 Dose / Device modifications .........................................................................................................54
8.4 Compliance with study intervention ..............................................................................................54
8.5 Data Collection and Follow-up for withdrawn participants ...........................................................54
8.6 Trial specific preventive measures ...............................................................................................54
8.7 Concomitant Interventions (treatments) .......................................................................................54
8.8 Study Drug / Medical Device Accountability ................................................................................55
8.9 Return or Destruction of Study Drug / Medical Device ................................................................55
9. STUDY ASSESSMENTS ............................................................................................................... 56
9.1 Study flow chart(s) / table of study procedures and assessments ...............................................56
9.2 Assessments of outcomes ...........................................................................................................56
9.2.1Assessment of primary outcome ..........................................................................................56
9.2.2Assessment of secondary outcomes ...................................................................................57
9.2.3Assessment of other outcomes of interest ...........................................................................57
9.2.4Definition of treatment failure ...............................................................................................57
9.2.5Assessment of safety outcomes ..........................................................................................57
9.2.6Assessments in participants who prematurely stop the study .............................................58
9.3 Procedures at each visit ...............................................................................................................58
9.3.1Visit 1: Screening visit (-240 days or less) ...........................................................................58
9.3.2Visit 2: Screening visit (Day -60 or less) ..............................................................................58
9.3.3Visit 3: Harvesting of nasal cartilage biopsy and blood (Day -14 or -28) .............................58
9.3.4Visit 4: Implantation (Day 0-5) ..............................................................................................58
9.3.5Visit 5: Clinical follow up (day 42 (6w)) ................................................................................58
9.3.6Visit 6: Clinical follow-up and efficacy assessment (Day 90 (3m)) ......................................58
9.3.7Visit 7-8: Clinical follow-up and efficacy assessment (Day 360 (12m), Day 720 (24m)) .....59

 
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Clinical Study Protocol 
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Acronym 
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Page 9 of 80 
10.SAFETY ......................................................................................................................................... 60
10.1 Drug studies .................................................................................................................................60
10.1.1Definition and assessment of (serious) adverse events and other safety related events ...60
10.1.2Reporting of serious adverse events (SAE) and other safety related events ......................61
10.1.3Follow up of (Serious) Adverse Events ................................................................................61
11.STATISTICAL METHODS ............................................................................................................. 62
11.1 Hypothesis ....................................................................................................................................62
11.2 Determination of Sample Size ......................................................................................................62
11.3 Statistical criteria for termination of trial .......................................................................................63
11.4 Planned Analyses .........................................................................................................................63
11.4.1Datasets to be analysed, analysis populations ....................................................................63
11.4.2Primary Analysis ..................................................................................................................63
11.4.3Secondary Analyses ............................................................................................................63
11.4.4Interim analyses ...................................................................................................................63
11.4.5Safety analysis .....................................................................................................................63
11.4.6Deviation(s) from the original statistical plan .......................................................................64
11.5 Handling of missing data and drop-outs.......................................................................................64
12.QUALITY ASSURANCE AND CONTROL .................................................................................... 65
12.1 Data handling and record keeping / archiving ..............................................................................65
12.1.1Case Report Forms ..............................................................................................................65
12.1.2Specification of source documents ......................................................................................66
12.1.3Record keeping / archiving ..................................................................................................66
12.2 Data management ........................................................................................................................66
12.2.1Data Management System ..................................................................................................67
12.2.2Data security, access and back-up ......................................................................................67
12.2.3Analysis and archiving .........................................................................................................67
12.2.4Electronic and central data validation ..................................................................................68
12.3 Monitoring .....................................................................................................................................68
12.4 Audits and Inspections .................................................................................................................68
12.5 Confidentiality, Data Protection ....................................................................................................68
12.6 Storage of biological material and related health data .................................................................69
13.PUBLICATION AND DISSEMINATION POLICY.......................................................................... 70
14.FUNDING AND SUPPORT ............................................................................................................ 71
14.1 Funding ........................................................................................................................................71
14.2 Other Support ...............................................................................................................................71
15.INSURANCE .................................................................................................................................. 71
16.REFERENCES ............................................................................................................................... 72
17.APPENDICES ................................................................................................................................ 73
18.HISTORY OF CHANGES .............................................................................................................. 74
 
 
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
10 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 10 of 80 
STUDY SYNOPSIS  
 
Sponsor / Sponsor-
Investigator 
University Hospital Basel / Prof. Dr. med. Marcel Jakob 
Study Title: 
Randomized, multi-center phase II clinical trial for the regeneration of 
cartilage lesions in the knee using nasal chondrocyte-based tissue (N-
TEC) or nasal chondrocyte-based cell (N-CAM)-therapies 
Short Title / Study ID: 
Nose to Knee II  
Protocol Version and 
Date: 
Version 07, 10.04.2018   
Trial registration: 
EudraCT Registration-Number: 2015-005162-34 . Date: 12.11.15. 
ClinicalTrials.Gov Registration-Number: NCT02673905. Date: 1.2.2016 
Study category and 
Rationale 
This study is an investigator initiated, interventional phase II trial with two 
IMPs considered “Advanced Therapy Medicinal Product (ATMP)”, intended 
to evaluate the efficacy and compare different maturation stages of a 
tissue engineered product. Since the IMPs have no market authorization in 
any country this trial is considered category C. 
Clinical Phase: 
Clinical trial phase II 
Background and 
Rationale: 
Cartilage tissue has a limited capacity for self-repair due to its avascular 
and aneural nature. Articular cartilage injuries that are not properly treated 
are associated with pain and disability, and are known to double the 
incidence of degenerative joint disorders in the elderly.  
Cartilage repair treatments have the potential not only to relieve pain and 
improve the quality of life for younger patients, but also to slow down or 
eliminate the need for joint replacement in the elderly. However, current 
therapeutic options such as arthroscopic debridement, micro fracture, 
autologous osteochondral grafting and use of allografts suffer from major 
drawbacks, such as defect-size limitations, long and complex rehabilitation 
times, donor-site morbidity and limited availability of graft material. Even 
the more advanced cell-based therapies, in addition to involving technically 
challenging operations associated with donor-site morbidity and highly 
variable outcome, provide no fully satisfactory treatment, especially for 
elderly patients. Moreover, these therapies, comprising mainly the 
implantation of cells, lack the complex biological and mechanical signals 
which can be delivered via a more developed (mature) graft. In this trial we 
will introduce two innovations: 1) the use of autologous nasal chondrocytes 
(NC) as a cell source superior to articular chondrocytes (AC), thus 
exploiting the already proven higher and more reproducible properties of 
NCs regarding proliferation and differentiation capacity, which are less 
dependent on the age of the donor as compared to AC and 2) the delivery 
of a mature graft as opposed to an immature graft.  

 
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Objective(s): 
The goal of this trial is to compare the clinical efficacy of a mature graft 
(i.e., nasal chondrocyte tissue engineered cartilage, N-TEC) with that of an 
immature graft (i.e., nasal chondrocyte cell actived matrix, N-CAM) for the 
treatment of cartilage lesions in the knee. This proposed phase II trial will 
evaluate whether implantation of a mature cartilage graft improves the 
clinical efficacy, leading to an increase of at least 10 points in the main 
primary outcome (KOOS (mean of subscores)). In addition, the integration 
of the grafts with the surrounding tissues as well as the quality of the repair 
tissue will be assessed. Retrospectively data will be analyzed to possibly 
identify the most suitable treatment (mature or immature graft) in relation to 
the onset of symptoms (acute vs chronic cartilage lesions).This will require 
enrolling a total of 108 patients in a multicenter, prospective study involving 
5 clinical centers. 
Outcome(s): 
Primary endpoint: 
• KOOS score: The primary endpoint is the KOOS subjective score at the 
24-month visit. The difference in the KOOS-score will be compared 
between the two groups (Comparison of Efficacy of treatment) 
Secondary endpoints: 
• MOCART and 3D MOCART Scores (MRI): The MRI will be performed at 
3, 12, 24 months follow-up visits and MOCART and 3D MOCART scores 
calculated. (Assessment of stability and integration) 
• dGEMRIC evaluation (MRI): The relative delta R1 will be evaluated by 
dGEMRIC and recorded at 3, 12, 24 months follow-up visits and 
referenced to the native cartilage of the treated knee. (Assessment of 
quality of the repair tissue)  
• A further questionnaire (EQ-5d) at 12 and 24 month and an additional 
time point (12 month) for KOOS will allow the more detailed analysis of the 
clinical development of the patient’s recovery and elucidate changes in the 
perceived quality of life before and after treatment. 
• Additional secondary endpoint is the number of treatment failure at 24 
months. The difference will be compared between the two groups. 
 
Other outcomes: 
• Retrospective analysis of primary and secondary endpoint data with 
regard to the onset of symptoms to identify a possible selection of 
treatment of acute (onset < 1 years) or chronic (onset >1 years) lesions 
• Subgroup analysis to compare the outcome with regard to the localization 
of the defect (patella vs. femoral condyle/trochlea) 
Safety: 
• Any AE and SAEs will be recorded regarding event descriptions, onset, 
resolution dates and relationship to the IMP. All SADR or SUSAR will be 
reported to Basel as leading center and the respective authorities. 

 
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Clinical Study Protocol 
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Study design: 
The study will be designed as an unblinded multicenter, randomized phase 
II study for the comparison of a therapy with a mature versus a therapy 
with an immature graft. 
•  mature graft (N-TEC): 
1) Nasal cartilage biopsy, performed by Ear-Nose-Throat (ENT) / 
Plastic surgeon 
2) Expansion of cells (2 weeks), seeding onto the collagen scaffold 
(Chondro-Gide®) , followed by 2 weeks of in vitro culture 
3) Implantation of the cartilage graft into the knee joint via 
arthrotomy/mini-arthrotomy, debridement down to subchondral 
lamella and stable cartilage rim, fixation by sutures (e.g. Monocryl 
5-0), no drainage 
•  immature graft (N-CAM): 
1) Nasal cartilage biopsy, performed by ENT/Plastic surgeon  
2) Expansion of cells (2 weeks) and seeding into the collagen scaffold 
(Chondro-Gide ®), followed by 2 days of in vitro culture 
3) Implantation of the cell-seeded scaffold into the knee joint via 
arthrotomy/mini-arthrotomy, debridement down to subchondral 
lamella and stable cartilage rim, fixation by sutures (e.g. Monocryl 
5-0) , no drainage 
This phase II study will be performed as a prospective, randomized and 
unblinded study. Patients will be enrolled at 5 clinical centers in Basel 
(CH), Freiburg (D), Zagreb (HR), Milan (I) and Wuerzburg (D). The multi-
center study, enrolling a total of 108 patients, is planned for the duration of 
4 years including follow-up times of two years for each patient. The study 
will start with the signature of the informed consent by the first patient and 
end with the two-year follow up of the last patient. Patients may be asked 
to participate in a further follow-up up to 5 years based on questionnaires 
on a voluntary basis.  

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
1 3 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 1 3 of 8 0 
I n cl u si o n / E x cl u si o n 
crit eri a: 
P ati e nt s b et w e e n 1 8 - 6 5 y e ar s ol d wit h s y m pt o m ati c f ull-t hi c k n e s s 
c artil a g e l e si o n s o n t h e f e m or al c o n d yl e a n d/ or tr o c hl e a a n d/ or p at ell a of 
t h e k n e e will b e e nr oll e d i n t hi s tri al. 
K e y i n cl u si o n crit eri a: 
•   
P ati e nt h a s o n e or t w o s y m pt o m ati c c artil a g e d ef e ct of gr a d e III or 
I V ( a c c or di n g t o t h e I C R S cl a s sifi c ati o n) o n t h e f e m or al c o n d yl e 
a n d/ or t h e tr o c hl e a a n d/ or p at ell a of t h e k n e e. 
•   
P ati e nt h a s a m a xi m u m b a s eli n e s c or e of ≤7 5/ 1 0 0 o n t h e K O O S 
s u bj e cti v e k n e e e v al u ati o n.  
•   
T ot al si z e of c artil a g e d ef e ct s i s ≥2 c m 2  a n d ≤ 8 c m 2  ( a s s e s s e d b y 
M R I) 
K e y e x cl u si o n crit eri a: 
•   
Pr e s e n c e of > 2 s y m pt o m ati c c artil a g e d ef e ct s Gr a d e III/I V 
( a c c or di n g t o t h e I C R S cl a s sifi c ati o n) 
•   
Pri or s ur gi c al tr e at m e nt of t h e t ar g et k n e e wit hi n 1 2 m o nt h s u si n g 
m o s ai c pl a st y a n d/ or mi cr ofr a ct ur e ( N ot e: pri or di a g n o sti c 
art hr o s c o p y wit h d e bri d e m e nt a n d l a v a g e ar e a c c e pt a bl e wit hi n 1 2 
m o nt h s).  
•   
I n st a bilit y of t h e k n e e or a xi s d e vi ati o n of ≥5° ( N ot e: A nt eri or 
cr u ci at e li g a m e nt r e p air a n d/ or r e ali g n e m e nt s ur g er y i s a c c e pt e d if 
p erf or m e d wit hi n 6 w e e k s of t h e pl a n n e d c artil a g e tr e at m e nt.) 
•   
P ati e nt h a s r a di ol o gi c all y a p p ar e nt d e g e n er ati v e j oi nt di s e a s e i n 
t h e t ar g et k n e e a s d et er mi n e d b y K ell gr e n a n d L a wr e n c e gr a d e > 2. 
 
M e a s ur e m e nt s a n d 
pr o c e d ur e s: 
Aft er writt e n i nf or m e d c o n s e nt t o t h e st u d y, t h e p ati e nt i s c h e c k e d f or 
eli gi bilit y a c c or di n g t o t h e i n cl u si o n a n d e x cl u si o n crit eri a d efi n e d.  
I n or d er t o a c q uir e b a s eli n e d at a, st a n d ar d M RI will b e p erf or m e d b ef or e 
i nt er v e nti o n, if n ot alr e a d y d o n e d uri n g di a g n o si s b y a n e xt er n al r a di ol o g y 
d e p art m e nt. T h e p ati e nt will b e gi v e n t h e r el e v a nt q u e sti o n n air e s i n or d er 
t o c oll e ct t h e b a s eli n e d at a f or t h e cli ni c al s c or e s a n d a s si g n e d t o a 
tr e at m e nt gr o u p b y r a n d o mi z ati o n. 
3- 5 w e e k s b ef or e t h e s ur g er y, d e p e n di n g o n t h e tr e at m e nt gr o u p, a n a s al 
c artil a g e bi o p s y a n d a ut ol o g o u s bl o o d ( 7 2 ml), n e e d e d f or t h e 
m a n uf a ct uri n g, ar e h ar v e st e d u n d er l o c al a n e st h e si a. Aft er 3- 5 w e e k s of 
m a n uf a ct uri n g t h e gr aft or c ell- s e e d e d s c aff ol d i s i m pl a nt e d.  
Cli ni c al f oll o w- u p will b e d o n e at 6 w e e k s a s w ell a s at 3, 1 2 a n d 2 4 
m o nt h s t o a s s e s s r e c o v er y. Aft er 3, 1 2 a n d 2 4 m o nt h s a n M RI will b e 
p erf or m e d i n a d diti o n t o t h e cli ni c al a s s e s s m e nt, a n d q u e sti o n n air e s fill e d 
o ut b y t h e p ati e nt ( 1 2 u n d 2 4 m o nt h s) t o c oll e ct t h e cli ni c al d at a.   
St u d y Pr o d u ct / 
I nt er v e nti o n:  
T h e a cti v e c o m p o n e nt s of t h e ti s s u e e n gi n e er e d c artil a g e gr aft ( N- T E C ) 
ar e e x p a n d e d h u m a n  a ut ol o g o u s n a s al c h o n dr o c yt e s a n d c artil a g e 
m atri x pr ot ei n s  pr o d u c e d b y t h e c ell s. T h e N- T E C i s g e n er at e d u si n g 
a ut ol o g o u s n a s al c h o n dr o c yt e s i s ol at e d b y e n z y m ati c di g e sti o n fr o m a 
6 m m di a m et er bi o p s y of t h e n a s al s e pt u m  a n d e x p a n d e d f or 2 w e e k s i n 
m o n ol a y er. Aft er e x p a n si o n, 5 0 milli o n c ell s ar e s e e d e d o n a 3 0 x 4 0 m m 
c oll a g e n m e m br a n e ( C h o n dr o- Gi d e ® ) a n d c ult ur e d f or t w o a d diti o n al w e e k s 
t o all o w f or e xtr a c ell ul ar m atri x d e p o siti o n b y t h e c ell s. T h e gr aft i s c ut a n d 
s h a p e d b y t h e s ur g e o n s a c c or di n g t o t h e d ef e ct si z e a n d i m pl a nt e d i n t h e 
k n e e u si n g s ut uri n g. T h e gr aft i s e x p e ct e d t o h e al i n t h e d ef e ct a n d 
i nt e gr at e wit h t h e a dj a c e nt ti s s u e. 

 
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Clinical Study Protocol 
Version: 
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Dept. of Biomedicine 
Acronym 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 14 of 80 
Secondary treatment 
arm: 
The active component for the cell-seeded scaffold (N-CAM) is expanded 
human autologous nasal chondrocytes. The product for the secondary 
treatment arm is generated in the same way as the study product, but only 
cultured for 2 days after cell seeding onto the scaffold. Therefore the cells 
are attached to the scaffold, but no extracellular matrix produced. The graft 
is cut and shaped by the surgeons according to the defect size and 
implanted in the knee using suturing. The graft is expected to heal in the 
defect and integrate with the adjacent tissue. 
Number of 
Participants with 
Rationale: 
The total number of Patients is 108 trial participants considering an overall 
drop-out rate of 10%. Each group will consist of 54 patients. The patients 
will be recruited and treated by five centers in Switzerland, Germany, 
Croatia and Italy to achieve a defined number of patients per center. This 
sample size is estimated to be able to show the superiority of N-TEC to N-
CAM regarding the primary endpoint and is based on the study of Saris et 
al., 2008. 
Study Duration: 
Estimated duration is 4 years for the main investigational plan (i.e. from 
start of screening of first participant to last participant processed and 
finishing the study) 
Study Schedule: 
01/2017: Treatment of first patient 
10/2019: Treatment of last patient 
01/2019: 24 months (final) follow-up of first patient 
10/2021: 24 months (final) follow-up of last patient 

 
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Investigator(s): 
Sponsor Investigator / 
Principal Investigator 
(CH) 
 
 
 
 
 
Principal Investigator / 
study coordinator (CH) 
 
 
 
 
 
Principal Investigator 
(D) 
 
 
 
 
 
 
Principal Investigator 
(HR) 
 
 
 
 
 
Principal Investigator (I) 
 
 
 
 
Principal Investigator 
(D) 
 
 
 
 
 
Prof. Dr. med. Marcel Jakob 
Department of Traumatology, University Hospital Basel,  
Spitalstrasse 21, CH-4031 Basel, Switzerland 
Tel.: +41 61 328 72 40 
Fax : +41 61 265 7322 
email: Marcel.Jakob@usb.ch 
 
Dr. Marcus Mumme 
Department of Traumatology, University Hospital Basel.  
Spitalstrasse 21, CH-4031 Basel, Switzerland  
Tel.: +41 61 556 5885 
Fax : +41 61 265 3990 
email: Marcus.Mumme@usb.ch 
 
Dr. Tayfun Yilmaz 
Medical 
Center 
- 
University 
of 
Freiburg, 
Germany 
Department of Orthopedics and Trauma Surgery  
Hugstetter Strasse 49, 79106 Freiburg, Germany 
Tel: +49 761 270  24010 
Fax: +49 761 270 25200 
Email: tayfun.yilmaz@uniklinik-freiburg.de 
 
Prof. Dr. Alan Ivkovic  
Department of Orthopaedic Surgery, University Hospital Sveti Duh,  
Sveti Duh 64, 10000 Zagreb, Croatia 
Tel: +38513712320 
Email: alan.ivkovic@gmail.com 
 
Prof. Dr. Giuseppe Peretti  
Istituto Ortopedico Galeazzi (IOG) 
Via Galeazzi 4, 20161 Milano, Italy  
Tel: +39 02 50319967 
Email: gperetti@iol.it  
 
Dr.Lothar Seefried 
Orthopedic Clinic König-Ludwig-Haus 
Lehrstuhl für Orthopädie der Universität Würzburg 
Brettreichstrasse 11, 97074 Würzburg, Germany 
Tel: +49 931 803 3575 
Fax: +49 931 803 1598  
Email: l-seefried.klh@uni-wuerzburg.de 
 
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
16 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 16 of 80 
Other investigators 
Dr. Sebastian Müller (CH) 
PD Dr. Kaywan Izadpanah (D) 
Dr. Damir Hudetz (HR) 
Dr. Laura Mangiavini (I) 
Dr. Franca Genest (D) 
Study Centre(s): 
5 Centers: 
University Hospital Basel (Basel, Switzerland) 
University Hospital Freiburg (Freiburg, Germany) 
University Hospital Sveti Duh (Zagreb, Croatia)  
Istituto Ortopedico Galeazzi (IOG) (Milano, Italy) 
Orthopedic Clinic König-Ludwig-Haus (Würzburg, Germany) 
Statistical 
Considerations: 
The primary endpoint is the Knee injury and Osteoarthritis Outcome Score 
(KOOS) measured 24 months after surgery. The score ranges from 0–100; 
the higher the score, the better the outcome. The null hypothesis is that 
there is no difference in the primary endpoint between N-TEC and N-CAM 
(H0 : KOOSN–TEC – KOOSN–CAM = 0). The alternative hypothesis is that N-
TEC and N-CAM differ significantly in terms of the primary endpoint (HA : 
KOOSN–TEC – KOOSN-CAM =   0). Absolute differences () of 10 score 
points or more are considered clinically relevant. 
Sample size was estimated to be able to show the superiority of N-TEC to 
N-CAM regarding the primary endpoint. Assumptions for sample size 
calculation were based on the study of Saris and colleagues (Saris et al., 
2008), who reported an increase in a mean overall KOOS score after 18 
months of 18 points to a final value of 74.73 with a standard deviation of 
17.01. We have assumed that the effect size after 24 months will be at 
least as large.  
Sample size was calculated using a resampling method. Each sample size 
(ni=1,...,21 = 40, ..., 160) was evaluated by sampling R = 999 times, ni/2 
KOOS scores from a normal distribution with  = 75 and  = 17 for the N-
CAM group, and ni/2 KOOS scores from a normal distribution with  = 75 + 
 and  = 17 for the N-TEC group. The size of  was varied between 5 and 
15. Values that exceeded 100 were set to 100.  
N-CAM and N-TEC will be tested for a difference in KOOS score using a 
two-sided t-test. Superiority of N-TEC to N-CAM is declared when the test 
shows a significant result. Sample size was set to ensure at least 80% 
power (1 -  = 0.8), at a significance level of  = 5%. 
For this study, 108 patients should be recruited to ensure 97 evaluable 
patients at a power of 80%, considering an overall drop-out rate of 10%.  
GCP Statement: 
This study will be conducted in compliance with the protocol, the current 
version of the Declaration of Helsinki, the ICH-GCP or ISO EN 14155 (as 
far as applicable) as well as all national legal and regulatory requirements  
 
 
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
17 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 17 of 80 
STUDY SUMMARY IN LOCAL LANGUAGE  
Obwohl Gelenkknorpelschäden häufig bei älteren Menschen als Folge langjähriger Abnutzung 
entstehen, treten sie auch regelmässig bei jüngeren Menschen als Folge von Unfällen auf. 
Insbesondere bei grösseren Knorpeldefekten erfolgt so gut wie nie eine spontane Selbstheilung. 
Wenn diese Defekte unbehandelt bleiben, ist das Risiko für die Entstehung einer Arthrose in späteren 
Jahren deutlich erhöht. Allerdings erfordern die heutigen Strategien zur Heilung dieser Defekte 
komplizierte Operationstechniken, langwierige Rehabilitationsmassnahmen und sind limitiert bezüglich 
der Anwendung bei sehr grossen Verletzungen und der Verfügbarkeit/Qualität des Spendergewebes. 
Zudem führen sie nach wie vor oft zu unbefriedigenden klinischen Ergebnissen aufgrund der 
geringeren Qualität des Reparaturgewebes. Häufig bleiben dauerhafte Schmerzen und eine 
eingeschränkte Beweglichkeit bzw. Funktion des Gelenkes bestehen. Selbst die Anwendung der 
neueren Zelltherapien konnte noch keine auf Dauer befriedigenden Resultate zeigen. Ein innovativer, 
vielversprechender Ansatz ist die Gewebezüchtung, bei der im Labor ein Stück Knorpel aus 
körpereigenen Zellen hergestellt wird. Erste Resultate einer klinischen Studie Phase I zeigen, dass 
der Einsatz von gezüchtetem Nasenknorpel für die Regeneration von Gelenkknorpel sicher und 
machbar ist. Zudem sind auch die ersten klinischen Resultate bezüglich der Wirksamkeit 
vielversprechend. 
Das Ziel dieser klinischen Phase II Studie ist, die Wirksamkeit eines reifen Gewebes (mit 
knorpelspezifischen 
Proteinen) 
mit 
jener 
eines 
unreifen 
Gewebes 
(wenig 
bis 
keine 
knorpelspezifischen Proteine) zu vergleichen. Dazu werden 108 Patienten in die Studie aufgenommen 
und in zwei Gruppen unterteilt, von denen die eine das unreife und die andere das reife Gewebe 
erhält. Die Patienten müssen eine oder zwei symptomatische, isolierte Knorpelläsion der Stufe III-IV 
(nach Einstufung durch die International Cartilage Repair Society (ICRS)) von 2 bis zu 8cm2 an der 
Kniegelenksfläche vom Oberschenkelknochen und/oder der Trochlea und/oder der Kniescheibe 
aufweisen, unter 65 Jahren sein sowie mündlich und schriftlich ihr Einverständnis erklärt haben, um in 
die Studie aufgenommen zu werden. Nach Erhalt der schriftlichen Einverständniserklärung, werden 
die Patienten getestet, ob sie alle weiteren Ein- und Ausschlusskriterien erfüllen. Anschließend wird 
dem Patienten Blut (72ml) sowie eine Knorpelbiopsie (Gewebeprobe) aus der Nasenscheidewand 
entnommen. Die Knorpelzellen (Chondrozyten) werden aus dem Gewebe isoliert, 2 Wochen vermehrt 
und dann auf eine Kollagenmatrix aufgebracht. Für das unreife Gewebe wird das entstandene 
Konstrukt weitere 2 Tage kultiviert, damit sich die Zellen an das Gewebe anheften können. Für das 
reife Gewebe wird weitere 2 Wochen kultiviert, damit die Zellen ein Knorpelgewebe bilden können. 
Nach Prüfung der Qualität des Implantates durch die Herstellung erfolgt die Freigabe basierend auf 
der Sterilität, Zellviabilität und im Falle des reifen Gewebes der Matrixbildung. Im Anschluss wird das 
Konstrukt in das Knie implantiert. 6 Wochen, sowie 3, 12 und 24 Monate nach der Operation wird eine 
Nachsorge durchgeführt. Hierbei werden bei den 3,12 und 24 Monatskontrollen MRTs durchgeführt, 
sowie bei den 12 und 24 Monatskontrollen Fragebögen (KOOS, EQ-5d) durch den Patienten 
ausgefüllt.  
Während die Fragebögen (insbesondere der Knee injury and Osteoarthritis Outcome Score (KOOS-
Score)) einen Aufschluss über die Wirksamkeit der Behandlung aus der subjektiven Sicht des 
Patienten geben, ist mit Hilfe der MRTs eine Aussage über die Integration des Implantates in den 
Defekt sowie die Qualität des Reparaturgewebes möglich. Im Nachhinein werden die Daten zudem im 
Zusammenhang mit dem Status des Defektes zum Zeitpunkt der Behandlung (akut (Symptome seit 
weniger als 2 Jahren) oder chronisch (Symptome seit mehr als zwei Jahren)) analysiert. Dieses gibt 
einen Aufschluss darüber, ob eine bestimmte Behandlung (unreifes oder reifes Gewebe) für eine 
bestimmte Indikation (akut oder chronisch) effektiver ist. 
 
English version 
Although cartilage damages in the joint develop mostly in older people due to degeneration of the 
cartilage, they also occur regularly in young people due to accidents. Especially in large cartilage 
defects there is no spontaneous self-healing. If these defects are left untreated, the risk of the 
development of osteoarthritis later on is significantly increased. However, the current treatment 
options for these defects involve difficult operation techniques, require tedious rehabilitation and are 
limited in the application for large injuries and the availability/quality of the donor material. Furthermore, 
they often lead to not entirely satisfactory clinical results due to the low quality of the repair tissue. In 
many cases permanent pain and restricted mobility persist. Even the use of the new cell therapies has 
not led to satisfactory results in the long term. An innovative promising approach is tissue engineering, 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
18 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 18 of 80 
where cartilage is manufactured in the laboratory using the body’s own cells. First results of a clinical 
phase I study show that the use of engineered nasal cartilage for the regeneration of articular cartilage 
(knee joint) is feasible and safe. In addition the preliminary clinical results regarding the efficacy are 
also promising. 
The goal of this phase II clinical study is to compare the efficacy of a mature graft (with cartilage 
specific proteins) with the one of an immature graft (little to no cartilage specific proteins). In order to 
achieve this we will enroll 108 patients in the study and divide them in two groups, one receiving the 
immature graft and the other the mature graft. Patients must display a symptomatic, isolated cartilage 
lesion grade III-IV (according to the grading by the International Cartilage Repair Society (ICRS)) from 
2 to 8 cm2 on the femoral condyle and/or the trochlea and/or patella, have to be between 18-65 years 
old and must consent in oral and written manner in order to be enrolled in the study. After written 
informed consent has been obtained, the patients will be tested to see if they comply with all other 
inclusion and exclusion criteria. Subsequently blood (72ml) and a cartilage biopsy (tissue sample) 
from the nasal septum of the patient will be taken. The cartilage cells (Chondrocytes) are isolated from 
the tissue, expanded for 2 weeks and placed on a collagen matrix. For the immature graft the resulting 
construct will be cultured for 2 more days to allow the cells to adhere to the matrix. For the mature 
graft the construct will be cultured for 2 more weeks, to allow the cells to form cartilage tissue. After 
performing the quality tests the implant will be released by the manufacturer based on the sterility, cell 
viability and in case of the mature graft the deposition of matrix. Subsequently, the construct will be 
implanted in the knee. At 6 weeks as well as 3, 12 and 24 months after the operation follow-ups will be 
performed. During the follow-ups at 12 and 24 months questionnaires (KOOS, EQ-5d) will be filled out 
by the patient and MRIs will be performed at 3,12 and 24 months.  
While the questionnaires (especially the Knee injury and Osteoarthritis Outcome Score KOOS-
Score)) provide subjective information about the efficacy of the treatment, the MRIs will shed light on 
the integration of the implant in the defect and give information about the quality of the repair tissue. 
Retrospectively the data will be analyzed in correlation to the status of the defect at time of treatment: 
acute (symptoms since less than 2 years) or chronic (symptoms since more than 2 years). This will 
give an indication whether one treatment (immature or mature graft) is more effective for a defined 
indication (acute or chronic) than the other. 
 
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Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
19 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 19 of 80 
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1< 
I questionari, specialmente il KOOS-Score (Knee injury and Osteoarthritis Outcome Score), forniranno 
informazioni soggettive riguardo l'efficacia del trattamento, mentre la RMN consentirà di valutare il 
grado di integrazione dell'impianto nella lesione e darà informazioni sulla qualità del tessuto di 
riparazione. In retrospettiva, i dati saranno analizzati in correlazione allo stato della lesione, definito 
come acuto (sintomi presenti da meno di due anni) o cronico (sintomi presenti da più di due anni), al 
momento del trattamento. Tutto ciò chiarirà quale trattamento (innesto più immaturo o di alto livello di 
maturazione) sia più efficace per una specifica situazione (acuta o cronica). 
 
Croatian version 
Iako se ošte=enja zglobne hrskavice razvijaju prvenstveno kod starijih ljudi uslijed degenerativnih 
procesa, tako>er se redovito pojavljuju i kod mla>ih ljudi kao posljedica akutne traume. Pogotovo kod 
velikih ošte=enja hrskavice ne postoji spontano zacijeljivanje. Ukoliko se ovakva ošte=enja ne lije?e 
zna?ajno je pove=an rizik od kasnijeg razvoja osteoartitisa. Me>utim, trenutne mogu=nosti za lije?enje 
ovih ošte=enja uklju?uju komplicirane kirurškte tehnike, zahtijevaju dugotrajn rehabilitaciju, a postoje i 
zna?ajna ograni?enja u dostupnosti / kvaliteti materijala donora. Nadalje, ovakvi postupci ?est ne 
rezultiraju zadovoljavaju=im klini?kim rezultatom zbog relativno loše kvalitete repariranog tkiva. U 
mnogim slu?ajevima bol i ograni?ena pokretljivost ostaju kao trajne posljedice. @ak i primjena novih 
stani?nih terapija ne dovodi do dugoro?nih zadovoljavaju=ih rezultata. Tkivni inženjering predstavlja 
inovativni obe=avaju=i pristup, gdje se hrskavica proizvodi u laboratoriju uz pomo= vlastitih stanica. 
Prvi rezultati faze I klini?ke istraživanja pokazuju da je korištenje nosne hrskavice (potrebom tkivnog 
inženjeringa) za regeneraciju hrskavice (zgloba koljena) izvedivo i sigurno. Osim toga preliminarni 
klini?ki rezultati u pogledu u?inkovitosti su tako>er vrlo obe=avaju=i. 
Cilj faze II klini?ke studije jest usporedba u?inkovitosti-lije?enja zrelim presatkom (koji sadrži proteine 
specifi?ne za zglobnu hrskavicu) i nezrelim presatkom (koji sadrži malo ili nimalo proteina specifi?nih 
za zglobnu hrskavicu). Kako bi postigli taj cilj u studiju =e biti uklju?eno 108 pacijenata koji =e biti 
podijeljeni u dvije skupine, jedna skupina =e biti lije?ena nezrelim presatkom a druga zrelim presatkom. 
Potencijalni pacijenti za studiju moraju imai simptomatsku, izoliranu hrskavi?nu lezija stupnja III-IV 
(prema ocjenskoj ljestvici Me>unarodnog društva za popravak hrskavice (ICRS)), veli?ine od 2 do 8 
cm2 na kondilu i / ili trohleji i /ili pateli femura, moraju biti izme>u 18-65 godina i moraju u pismenom i 
usmenom obliku dati pristanak za sudjelovanje u studiji. Nakon što je dobiven pismeni informirani 
pristanak, pacijenti =e biti obra>eni kako bi se utvrdilo da li su u skladu sa svim drugim kriterijima 
uklju?ivanja i isklju?ivanja. Potom =e im se uzeti uzorak krvi (72 ml) i hrskavice (uzorak tkiva) iz 
nosnog septuma. Stanice hrskavice (hondrociti) izoliraju se iz tkiva, umnažaju tijekom 2 tjedna te 
nasa>uju na  kolagenski nosa?. U slu?aju nezrelog presatka stanica =e biti uzgajane još 2 dana kako 
bi stanice prianjale na nosa?. Kod zrelog presatka on =e se uzgajati još 2 tjedna, kako bi se omogu=ilo 
da stanice stvore hrskavi?no tkivo. Nakon provedenog ispitivanja kvalitete presadak =e biti isporu?en 
od strane proizvo>a?a na temelju sterilnosti, vijabilnosti stanica, a u slu?aju tkivne terapije i proizvodnji 
izvanstani?nog matriksa. Nakon toga, presadak se ugra>uje u koljeno. Nakon 6 tjedana, kao i nako 3, 
12 i 24 mjeseci nakon operacije provoditi =e se pra=enje pacijenata. Tijekom vremena pra=enja od 12 i 
24 mjeseca upitnici (KOOS, EQ-5d) =e biti ispunjeni od strane pacijenta a MR slikovna obrada =e biti 
napravljen nakon 3, 12 i 24 mjeseca. 
I dok nam upitnici (osobito KOOS-Score) pružaju subjektivnu informacije o u?inkovitosti lije?enja, 
magnetska rezonancija =e rasvijetliti kvalitetu integracije implantata u ošte=enje i dati informacije o 
kvaliteti repariranog tkiva. Retrospektivno podaci =e se analizirati u korelaciji sa statusum ošte=enja u 
trenutku operacije: akutna (simptomi traju kra=e od 2 godine) ili kroni?nih simptoma (ve= više od 2 
godine). To =e nam ponuditi objašnjenje da li je jedna ovih opcija (zreli i nezreli presadak), u?inkovitija 
kod razli?itih indikacija (akutni ili kroni?ni). 
 

 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 20 of 80 
ABBREVIATIONS 
 
AC 
Articular Chondrocytes 
ACI 
Autologous Chondrocyte Implantation 
AE 
Adverse Event  
ASR 
Annual Safety Report 
ATMP  
Advanced Therapy Medicinal Product 
CA 
Competent Authority (e.g. Swissmedic) 
CEC 
Competent Ethics Committee 
CRF 
Case Report Form  
CTU 
Clinical Trial Unit 
CRO 
Contract Research Organization 
ClinO 
Ordinance on Clinical Trials in Human Research (in German: KlinV, in French: 
OClin) 
eCRF 
Electronic Case Report Form  
ENT 
Ear-Nose-Throat 
FACS 
Fluorescence Activated Cell Sorter 
CTCAE 
Common terminology criteria for adverse events 
DSUR 
Development safety update report 
DSMC 
Data Safety Monitoring Committee 
dGEMRIC 
delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage 
GAG 
Glycosaminoglycan 
GCP 
Good Clinical Practice  
GDP 
Good Distribution Practice 
GMP 
Good Manufacturing Practice 
GFP 
Green Fluorescent Protein 
IB 
Investigator’s Brochure 
Ho 
Null hypothesis 
H1 
Alternative hypothesis 
HFG 
Humanforschungsgesetz (Law on human research) 
HMG 
Heilmittelgesetz   
HRA 
Federal Act on Research involving Human Beings 
ICRS 
International Cartilage Repair Society 
IMP 
Investigational Medicinal Product 
IIT 
Investigator-initiated Trial 
ISO 
International Organisation for Standardisation 
ITT 
Intention To Treat 
KlinV 
Verordnung über klinische Versuche in der Humanforschung (in English: ClinO, in 
French OClin) 

 
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Page 21 of 80 
KOOS 
Knee injury and Osteoarthritis Outcome Score (unless mentioned otherwise, the 
KOOS will be a mean of all 5 subscores) 
LPTh 
Loi sur les produits thérapeutiques 
LRH 
Loi fédérale relative à la recherche sur l’être humain 
MACI 
Matrix Assisted Chondrocyte Implantation 
MD 
Medical Device 
MRI 
Magnetic Resonance Imaging 
MOCART 
Magnetic resonance Observation of CARTilage repair tissue 
NC 
Nasal Chondrocytes 
N-TEC 
Nasal chondrocyte - Tissue Engineered Cartilage 
N-CAM 
Nasal chondrocyte – Cell Activated Matrix 
OClin 
Ordonnance sur les essais cliniques dans le cadre de la recherche sur l'être humain 
(in German : KlinV, in English : ClinO) 
Patient ID 
Patient Identification number 
PEI 
Paul-Ehrlich-Institute, Federal Competent authority, Germany 
PI 
Principal Investigator  
QP 
Qualified Person 
SAE 
Serious Adverse Event 
SADR 
Serious Adverse Drug Reaction 
SDV 
Source Data Verification  
SOP 
Standard Operating Procedure 
SPC 
Summary of Product Characteristics 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TMF 
Trial Master File  
IL-1A 
Interleukin-1A 
3D 
Three Dimensional 
Mature tissue 
This term is used in the protocol for the IMP with a prolonged culture time allowing 
the autologous cells to produce extracellular matrix. The term refers to the active 
ingredient: cells and extracellular matrix.  
Immature 
tissue 
This term is used in the protocol for the IMP with a short culture time allowing the 
autologous cells to adhere. The term refers to the active ingredient: cells. Therefore 
the final form of the IMP is a cell-seeded scaffold with little to no extracellular matrix. 
 
 
 

 
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STUDY SCHEDULE  
Study Periods 
Screening 
Treatment 
Follow-up 
Visit 
1 
2 
3 
4 
5 
6 
7 
8 
Time (hour, day, 
week) 
8m 
2m 
- 3-4.3 w 
Day 0 
6 w 
3m 
12m 
24m 
Day 
240 
 60 
- 19-30 
0 
42 
90 
360 
720 
Acceptable time delay 
 
 
0d 
1d 
2w 
2w 
6w 
8w 
Patient Information 
and Informed Consent 
x 
 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
 
In- /Exclusion Criteria 
x 
 
 
 
 
GFR 
GFR 
GFR 
Laboratory Tests 
(Serology) 
x 
 
x 
 
 
 
 
 
Pregnancy Test 
x 
 
 
 
 
 
 
 
Randomisation 
 
x 
 
 
 
 
 
 
MRI 
x 
x***** 
 
 
 
x 
x 
x 
Questionnaires 
x 
x**** 
 
 
 
 
x 
x 
Harvesting of biopsy 
and blood 
 
 
x 
 
 
 
 
 
Surgery (implantation) 
 
 
 
x 
 
 
 
 
Clinical examination  
x 
x 
x 
x 
x 
x 
x 
x 
Physiotherapy* 
 
 
 
 
x 
x 
x*** 
 
Adverse Events** 
x 
x 
x 
x 
x 
x 
x 
x 
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Clinical Study Protocol 
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Dept. of Biomedicine 
Acronym 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 23 of 80 
1. STUDY ADMINISTRATIVE STRUCTURE  
1.1 Sponsor, Sponsor-Investigator  
Prof. Dr. med. Marcel Jakob 
Department of Traumatology, University Hospital Basel 
Spitalstrasse 21, CH-4031 Basel, Switzerland 
Tel.:          +41 61 328 72 40 
Fax : 
     +41 61 265 7322 
email:       Marcel.Jakob@usb.ch 
 
The Sponsor-Investigator will assume all the responsibilities of the Sponsor, University Hospital Basel 
in accordance with the ClinO and the ICH-guideline E6 (R1). Furthermore, the Sponsor-Investigator 
will act as Principal Investigator and also assume those responsibilities as indicated in chapter 1.2. He 
has been involved in the design of the study and will perform the implantation during the course of the 
study. He will also take part in the interpretation of the data and writing of the report. 
1.2 Principal Investigator(s)  
The Principal Investigators are responsible for the conduct of the clinical trial in accordance with GCP-
regulations and ICH-guideline E6 (R1). They are involved in the design and planning of the clinical trial 
and are responsible for all trial related medical decisions at their site. Furthermore they have the 
responsibility of training all further staff involved in the performance of the clinical trial at their site and 
reporting of all SAEs to the Sponsor-Investigator. 
 
Dr. Marcus Mumme 
Department of Traumatology, University Hospital Basel 
Spitalstrasse 21, CH-4031 Basel, Switzerland  
Tel.:          +41 61 704 2808 
Fax.: 
     +41 61 265 3990 
email:       Marcus.Mumme@usb.ch 
 
In addition to the other responsibilities, Dr. Mumme, as PI of University Hospital Basel, will be in 
charge of coordinating the clinical trial among partners and ensure harmonization of the procedures. 
 
Dr. Tayfun Yilmaz 
Medical Center - University of Freiburg, Germany  
Department of Orthopedics and Trauma Surgery  
Hugstetter Strasse 49, 79106 Freiburg, Germany 
Tel: :+49 270 24010 
Fax: +49 270 25200 
Email: tayfun.yilmaz@uniklinik-freiburg.de 
 
Prof. Dr. Alan Ivkovic  
Department of Orthopaedic Surgery, University Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, 
Croatia  
Tel: +38513712320 
Email: alan.ivkovic@gmail.com 

 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 24 of 80 
Prof. Dr. Giuseppe Peretti  
IRCC Istituto Ortopedico Galeazzi (IOG)  
Via R. Galeazzi 4, 20161 Milano, Italy  
Tel: +39 02 50319967 
Email: gperetti@iol.it 
 
Dr.Lothar Seefried 
Orthopedic Clinic König-Ludwig-Haus 
Lehrstuhl für Orthopädie der Universität Würzburg 
Brettreichstrasse 11, 97074 Würzburg, Germany 
Tel: +49 931 803 3575 
Fax: +49 931 803 1598  
Email: l-seefried.klh@uni-wuerzburg.de 
 
1.3 Statistician ("Biostatistician")  
Power analysis has been performed by the CTU Basel. 
 
!	
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Department klinische Forschung, Clinical Trial Unit  
Schanzenstrasse 55, 4031 Basel, Switzerland 
Tel.: +41 61 556 52 04 
Email: deborah.vogt@usb.ch 
1.4 Laboratory 
Test on serology will be performed by the laboratories of the dedicated hospitals at the clinical sites. 
Switzerland: 
 
Klinische Mikrobiologie 
First serology   
Universitätsspital Basel 
Petersgraben 4, 4031 Basel  
Schweiz 
 
Second serology:  
Institut für Virologie und Immunologie 
(day of harvesting)  
Universität Würzburg,  
Versbacher Strasse 7, 97078 Würzburg  
Germany 
 
Germany:  
 
Institute of Virology 
(Freiburg) 
Hermann-Herder-Str. 11 
79104 Freiburg 
Germany 
 
Germany:  
 
MVZ für Laboratoriumsmedizin und Mikrobiologie Würzburg 
(Würzburg) 
 
Grombühlstr. 12 
97080 Würzburg 
Germany 
 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
2 5 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 2 5 of 8 0 
It al y:  
  
L a b or at ori o A n ali si  
 
  
I R C C S I stit ut o Ort o p e di c o G al e a z zi  
 
  
Vi a R. G al e a z zi 4, 2 0 1 6 1 Mil a n o,  
 
  
It ali a 
 
Cr o ati a:  
  
D e p art m e nt of cli ni c al mi cr o bi ol o g y 
 
  
U ni v er sit y H o s pit al f or I nf e cti o u s Di s e a s e s 
 
  
Mir o g oj s k a 8, 1 0 0 0 0 Z a gr e b 
 
  
Cr o ati a 
1. 5 
M o nit ori n g i n stit uti o n 
M o nit ori n g will b e p erf or m e d b y t h e C T U at t h e cli ni c al sit e s i n B a s el ( S wit z erl a n d), Fr ei b ur g a n d 
W ü r z b ur g ( G er m a n y) a n d a C R O i n Mil a n o (It al y) a n d Z a gr e b ( Cr o ati a).  
S witz erl a n d:  
U ni v ersit ätss pit al B as el 
 
D e p art m e nt Kli ni s c h e F or s c h u n g, Cli ni c al Tri al U nit  
 
S c h a n z e n str a s s e 5 5, 4 0 3 1 B a s el, S wit z erl a n d 
 
G er m a n y:  
 M e di c al C e nt er - U ni v er sit y of Fr ei b ur g, G er m a n y  
Cli ni c al Tri al s U nit  
El s a e s s er Str. 2 
7 9 1 1 0 Fr ei b ur g 
G er m a n y 
 
It al y: 
C o n s or zi o It ali a n o p er l a Ri c er c a i n M e di ci n a ( CI R M),  
 
Vi al e Z ar a, 8 1, 2 0 1 5 9 Mil a n o, It al y 
 
Cr o ati a:  
S m art M e di c o d. o. o.,  
 
Ž u p a n o v a 5, 1 0 0 0 0 Z a gr e b, Cr o ati a 
 
1. 6 
D at a S af et y M o nit ori n g C o m mitt e e  
T h e d at a s af et y m o nit ori n g c o m mitt e e i s a n i n d e p e n d e nt gr o u p of e x p ert s w hi c h m o nit or p ati e nt’ s 
s a f et y a n d tr e at m e nt effi c a c y d at a w hil e a cli ni c al tri al i s o n g oi n g. T h e y c a n a s s e s s at c ert ai n i nt er v al s 
t h e pr o gr e s s of a cli ni c al tri al, t h e s af et y d at a a n d t h e criti c al effi c a c y e n d p oi nt s a n d r e c o m m e n d t o t h e 
s p o n s or w h et h er t o c o nti n u e, m o dif y or st o p a tri al. T h e s p o n s or of t hi s m ulti c e nt er cli ni c al tri al, h a s 
a s s e s s e d t h e 
n e e d f or 
a 
d at a 
s af et y 
m o nit ori n g 
c o m mitt e e 
a c c or di n g t o t h e 
g ui d eli n e s 
( E M E A/ C H M P/ E W P/ 5 8 7 2/ 0 3 
C orr) t a ki n g i nt o 
c o n si d er ati o n t h e f oll o wi n g 
p ar a m et er s: t h e 
c h ar a ct eri sti c s of t hi s cli ni c al st u d y, cli ni c al i n di c ati o n, st u d y e n d p oi nt s a n d st u d y d ur ati o n, a s w ell a s 
st u d y p o p ul ati o n. 
Aft er e x a mi n ati o n, t h e s et- u p of a D S M C w a s n ot c o n si d er e d n e c e s s ar y d u e t o t h e f oll o wi n g a s p e ct s:  
-  
T h e cli ni c al st u d y i s n ot d o u bl e bli n d  
-  
F oll o w u p of 2 y e ar s 
-  
Cli ni c al i n di c ati o n: n ot a lif e t hr e at e ni n g di s e a s e, n o pri or k n o wl e d g e or s u s pi ci o n  t h at t h e 
I M P s h a v e t h e p ot e nti al t o h ar m p ati e nt s 
-  
St u d y p o p ul ati o n: d o e s n ot i n v ol v e v ul n er a bl e p o p ul ati o n s u c h a s a p a e di atri c p o p ul ati o n or 
m e nt all y di s a bl e d p ati e nt s. 
-  
Bi o st ati sti c al e x p erti s e pr o vi d e d b y t h e C T U ( cli ni c al tri al u nit s) 
I n a d diti o n, alt h o u g h t h e fi n al r e s p o n si bilit y f or t h e c o n d u ct of a cli ni c al tri al li e s wit h t h e st u d y s p o n s or 
a n d t h e i n v e sti g at or s, diff er e nt gr o u p s will o v er s e e v ari o u s a s p e ct s of t h e cli ni c al tri al:  
•   
Et hi c al c o m mitt e e s fr o m 4 c o u ntri e s ( D: Et hi c al c o m mitt e e of t h e Al b ert- L u d wi g s- U ni v er sit y 
Fr ei b ur g; Et hi c al c o m mitt e e of t h e m e di c al f a c ult y of t h e U ni v er sit y W ür z b ur g, I: S a n R aff a el e 
H o s pit al 
Et hi c al 
C o m mitt e e;  
Hr: 
Sr e di š nj e eti č k o p o vj er e n st v o; 
C H: 
Et hi k k o m mi s si o n 
N or d w e st- u n d Z e ntr al s c h w ei z ( E K N Z)) 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
2 6 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 2 6 of 8 0 
•   
Et hi c s a n d cli ni c al r e g ul at or y c o m mitt e e: e st a bli s h e d wit hi n t h e c o nt e xt of a n H ori z o n 2 0 2 0 
E ur o p e a n gr a nt, t hi s c o m mitt e e will b e c h air e d b y E C RI N- E RI C ( E ur o p e a n Cli ni c al R e s e ar c h 
I nfr a str u ct ur e N et w or k), hi g hl y e x p eri e n c e d i n t h e c o n d u ct of cli ni c al tri al s a c c or di n g t o G C P 
r e g ul ati o n s a s w ell a s t h e i nt er a cti o n s wit h E C a n d r e g ul at or y a ut h oriti e s i n diff er e nt c o u ntri e s 
t hr o u g h t h e E C RI N- E RI C p art n er s. 
 
1. 7 
A n y ot h er r el e v a nt C o m mitt e e, P er s o n, Or g a ni s ati o n, I n stit uti o n  
D at a m a n a g e m e nt will b e c arri e d o ut b y: 
 
M e d a ct a i nt er n ati o n al  S A 
D a ri o B er g a d a n o 
M e di c al Aff air s Dir e ct or 
Str a d a R e gi n a, 6 8 7 4 C a st el S a n Pi etr o, S wit z erl a n d 
 
 

 
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2. ETHICAL AND REGULATORY ASPECTS  
The study will be carried out in four countries. The decision of the respective ethical committees and 
competent authorities concerning the conduct of the study will be made in writing to the Sponsor-
Investigator before commencement of this study. The clinical study in the respective country can only 
begin once approval from all required authorities has been received.  
2.1 Study registration  
The study will be registered at EudraCT, Swiss Federal Complementary Database and 
ClinicalTrials.gov. Results of the study will be posted in the database as well, if possible. 
2.2 Categorization of study  
According to the „Ordinance on Clinical Trials in Human Research (ClinO)“ of September, 20th 2013, 
Article 19: “Categorisation of clinical trials of medicinal products” and Article 21: “Clinical trials of 
transplant products” this trial is category C since the medicinal products are not authorised in 
Switzerland. 
2.3 Competent Ethics Committee (CEC)  
The responsible investigator/PI at each site ensures that consenting vote from the respective 
Competent Ethics Committee (CEC) (EKNZ (CH), San Raffaele Hospital Ethical Committee (I), Ethical 
committee of the Albert-Ludwigs-University Freiburg and Ethical committee of the medical faculty of 
the University Würzburg, (D), Central Ethics Committee (HR)) is obtained for the clinical study.  
It is the duty of the PI to report all changes in the research activity and all unanticipated problems 
involving risks to humans; including the planned or premature study end and the final report. No 
changes will be made to the protocol without prior Sponsor/investigator and CEC approval, except 
where necessary to eliminate apparent immediate hazards to study participants. 
Premature study end or interruption of the study shall be reported within 15 days. The regular end of 
the study will be reported to the CEC within 90 days, the final study report shall be submitted within 
one year after study end. Amendments are reported according to chapter 2.10. 
2.4 Competent Authorities (CA)  
As CA approval is necessary for all studies in category B or C, the Sponsor-Investigator and the PI of 
each site will obtain approval from the respective competent authority (Swissmedic (CH), Agenzia 
Italiana del Farmaco (AIFA) (I), Paul-Ehrlich-Institut (NCA) and Regierungspräsidium Freiburg and 
Regierungspräsidium Oberfranken (Würzburg) (D) (Competent local authority) and Croatian Ministry 
of Health (HR)) before the start of the clinical trial. 
All adverse drug reactions that are both serious and unexpected are subject to expedited reporting. 
They will be reported to the local authority of the country where they occurred by the PI of the site as 
well as by the sponsor to Swissmedic, as authority of the Sponsor’s country. All other events from all 
sites will be reported in the annual safety report. 
For events occurring in Switzerland reporting will be made to the local regulatory authority 
(Swissmedic). The description and the severity of the event, anticipated or not, causal association and 
dosing variable will be included in the reporting. Fatal or life-threatening unexpected adverse drug 
reactions will be reported as soon as possible but no later than 7 calendar days, all others no later 
than 15 calendar days. 
Events in Germany will be reported to PEI and the ethical committee as well as to local authorities, if 
applicable, within the same time limits as in Switzerland. Croatia also applies the same time limits for 
reporting to Croatian Ministry of Health and the ethical committee. Italy also applies the same time 
limits for reporting. 
The regular end of the study will be reported to the authorities within 90 days (CH) and the final study 
report will be submitted within one year after study end. Amendments will be reported according to 
chapter 2.10. 
All SUSARs or SADR’s or lethal SAEs occurring in all centers will be reported to Swissmedic within 
the respective time lines. 

 
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2.5 Ethical Conduct of the Study  
The study will be carried out in accordance with the protocol and the principles enunciated in the 
current version of the Declaration of Helsinki, the guidelines of Good Clinical Practice (GCP) issued by 
ICH, the Swiss Law and Swiss regulatory authority’s requirements. The CEC and regulatory 
authorities will receive annual safety and interim reports and be informed about study stop/end in 
agreement with local requirements.  
Additionally this study will be carried out in accordance to the German Arzneimittelgesetz and 
Transplantationsgesetz.  
For the manufacturing of the IMPs the guidelines of GMP and GDP will be adhered to. 
2.6 Declaration of interest  
The investigators have no conflict of interest. 
2.7 Patient Information and Informed Consent 
The principal investigators at each site will explain to each patient the nature of the study, its purpose, 
the procedures involved, the expected duration, the potential risks and benefits and any discomfort it 
may entail in an oral and written way (Patient Information). Each patient will be informed that its 
participation in the study is voluntary and that he/she may withdraw from the study at any time, and 
such withdrawal of consent will not affect his/her subsequent medical assistance and treatment. 
His/Her data will be anonymized upon withdrawal of informed consent. The patient will also be 
informed about alternative treatments. Patients will not be coerced to participate. 
The patient must be informed that his/her medical records may be examined by authorized individuals 
other than their treating physician. 
All participants for the study will be provided with the patient information and a consent form 
describing the study and providing sufficient information for the patient to make an informed decision 
about their participation in the study. Patients will be given the opportunity to discuss the treatment 
options and study participation with relatives or other close persons. Each participant will be given a 
minimum of 24 hours to decide whether to participate or not.  
The patient information sheet and the consent form will be submitted to the respective CEC and to the 
competent authority to be reviewed and approved. Patient information and consent form will be written 
in the local language of the respective country. The formal consent of a participant, using the 
approved consent form, must be obtained before the participant is submitted to any study procedure.   
The participant should read and consider the statement before signing and dating the informed 
consent form, and will be given a copy of the signed document. The consent form must also be signed 
and dated by the investigator (or his designee) and it will be retained as part of the study records. 
2.8 Participant privacy and confidentiality  
The investigator affirms and upholds the principle of the participant's right to privacy and that they 
shall comply with applicable privacy laws. Especially, anonymity of the participants shall be 
guaranteed when presenting the data at scientific meetings or publishing them in scientific journals.  
Individual subject medical information obtained as a result of this study is considered confidential and 
disclosure to third parties is prohibited. Subject confidentiality will be further ensured by utilizing 
subject identification code numbers to correspond to treatment data in the computer files. 
For data verification purposes, authorised representatives of the Sponsor (-Investigator), a competent 
authority (Swissmedic (CH), Agenzia Italiana del Farmaco (AIFA) (I), Paul-Ehrlich-Institut (NCA) and 
Regierungspräsidium Freiburg and Regierungspräsidium Oberfranken (Würzburg)  (Competent local 
authority) (D) and Croatian Ministry of Health (HR)), or an ethics committee (EKNZ (CH), San Raffaele 
Hospital Ethical Committee (I), Ethical committee of the Albert-Ludwigs-University Freiburg and Ethical 
committee of the medical faculty of the University Würzburg, (D), Središnje eti?ko povjerenstvo (HR)) 
may require direct access to parts of the medical records relevant to the study, including participants’ 
medical history. 
 
 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
2 9 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 2 9 of 8 0 
2. 9 
E arl y t er mi n ati o n of t h e st u d y  
T h e S p o n s or-I n v e sti g at or m a y t er mi n at e t h e st u d y pr e m at ur el y a c c or di n g t o c ert ai n cir c u m st a n c e s, f or 
e x a m pl e: 
•   
et hi c al c o n c er n s, 
•   i n s uffi ci e nt p arti ci p a nt r e cr uit m e nt, 
•   if t h e s af et y of t h e p arti ci p a nt s i s d o u btf ul or at ri s k, r e s p e cti v el y, 
•   
alt er ati o n s i n a c c e pt e d cli ni c al pr a cti c e t h at m a k e t h e c o nti n u ati o n of a cli ni c al tri al u n wi s e,  
•   
e arl y e vi d e n c e of b e n efit or h ar m of t h e e x p eri m e nt al i nt er v e nti o n  
2. 1 0 Pr ot o c ol a m e n d m e nt s 
T h e S p o n s or-i n v e sti g at or ( Pr of. M. J a k o b) a n d t h e Pri n ci p al i n v e sti g at or/ st u d y c o or di n at or ( Dr. M. 
M u m m e) ar e all o w e d t o a m e n d t h e pr ot o c ol. All Pri n ci p al i n v e sti g at or s fr o m e a c h si d e ar e all o w e d t o 
pr o vi d e s u g g e sti o n s f or a pr ot o c ol a m e n d m e nt.  
I m p ort a nt pr ot o c ol 
m o difi c ati o n s ( e. g., c h a n g e s t o eli gi bilit y crit eri a, o ut c o m e s, a n al y s e s) will b e 
c o m m u ni c at e d ( wit hi n 5 d a y s) t o r el e v a nt p arti e s ( e. g., i n v e sti g at or s, C E C, c o m p et e nt a ut h oriti e s, tri al 
p arti ci p a nt s, tri al r e gi stri e s, j o ur n al s, r e g ul at or s). 
S u b st a nti al a m e n d m e nt s ar e o nl y i m pl e m e nt e d aft er a p pr o v al of t h e C E C a n d C A r e s p e cti v el y. 
U n d er e m er g e n c y cir c u m st a n c e s, d e vi ati o n s fr o m t h e pr ot o c ol t o pr ot e ct t h e ri g ht s, s af et y a n d w ell-
b ei n g of h u m a n s u bj e ct s m a y pr o c e e d wit h o ut pri or a p pr o v al of t h e s p o n s or a n d t h e C E C/ C A. S u c h 
d e vi ati o n s s h all b e d o c u m e nt e d a n d r e p ort e d t o t h e s p o n s or a n d t h e C E C/ C A a s s o o n a s p o s si bl e. 
All n o n- s u b st a nti al a m e n d m e nt s ar e c o m m u ni c at e d t o t h e C A a s s o o n a s p o s si bl e if a p pli c a bl e a n d t o 
t h e C E C wit hi n t h e D e v el o p m e nt S af et y U p d at e R e p ort ( D S U R).  
 
 
 

 
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3. BACKGROUND AND RATIONALE  
3.1 Background and Rationale  
Articular cartilage injuries remain a clinical challenge, and are associated with pain, disturbed function 
and disability. The number of articular cartilage defects diagnosed each year in the EU and USA 
reaches about 2 million (Hambly et al., 2009). When not properly treated, such lesions predispose to 
osteoarthritis and may finally result in total replacement of the joint, with massive costs for the 
healthcare system. Cartilage repair treatments have the potential not only to relieve pain and improve 
the quality of life for younger patients, but also to slow down or eliminate the need for joint 
replacement in the elderly. However, there is still no universally accepted and successful treatment 
approach for articular cartilage defects. As a first step conservative treatment with physical therapy in 
conjunction with activity modification and weight loss, if necessary, is applied. Surgical intervention 
should be considered if a full-thickness cartilage defect grade III or IV is diagnosed and if conservative 
treatment has not provided acceptable pain relief. The ultimate goal in the treatment is to achieve the 
regeneration of organized functional hyaline cartilage. However, current therapeutic options such as 
arthroscopic debridement, microfracture, autologous osteochondral grafting and use of allografts 
suffer from major drawbacks, such as defect-size limitations, long and complex rehabilitation times, 
donor-site morbidity and limited graft material (Gomoll et al, 2010). Even the more advanced cell-
based therapies, in addition to involving technically challenging operations associated with donor-site 
morbidity and highly variable outcome, do not provide entirely satisfactory treatment. Moreover, due to 
the use of Articular Chondrocytes (AC) in these therapies, their applicability for older patients is limited, 
due to the age-dependent properties of articular chondrocytes. Such techniques, although improving 
symptoms in short-term follow-up, cannot offer predictable and reproducible restoration of cartilage 
structure and function and have yet to prove cost effectiveness.  
However, a tissue-therapy based on the use of autologous Nasal Chondrocytes (NC) could overcome 
these drawbacks and lead to a measurable benefit for the patient. A phase-I study using an 
engineered nasal cartilage tissue performed to evaluate the safety and feasibility of the procedure, 
showed promising clinical results (see Chapter 3.4). Despite the known advantages and 
disadvantages (Table 3.1.1) a direct comparison of the efficacy of a mature graft (active ingredient is 
cells and matrix) vs an immature graft (active ingredient only cells) is difficult due to the paucity of well-
designed randomized and controlled trials, especially for the more recently developed techniques such 
as ACI, MACI and Tissue Engineering. Thus in this trial we aim at carrying out a phase II clinical trial 
for cartilage repair, introducing the following two main innovations: 1) the use of autologous nasal 
chondrocytes (NC) as cell source superior to articular chondrocytes (AC) (see chapter 3.2) and 2) the 
delivery of a mature graft as opposed to an immature graft (see chapter 3.2). 
The main objective is the comparison of a mature versus an immature graft in order to determine the 
impact of graft maturation on the clinical outcome: 
=> Determine whether implantation of a more mature graft is beneficial for the quality and 
durability of the repair tissue and the clinical outcome, measured by a superiority of at least 
10 points in the main primary outcome (self-assessed KOOS score) 
In addition, since the integration with the surrounding cartilage might be less efficient for a mature graft 
than for an immature graft (cell-seeded scaffold) as described in vitro by Obradovic et al, 2001, we 
want to assess this integration using the non-invasive MRI technique. Further we want to evaluate the 
quality of the repair tissue in order to determine its influence on the clinical outcome as experienced by 
the patient. 
=> Determine the potential of the mature graft to integrate with the adjacent cartilage 
(MOCART) and the formation of hyaline cartilage as repair tissue as assessed by dGEMRIC 
analysis 
Recent studies have indicated that ‘acute’ cartilage lesions have a more favorable prognosis following 
cellular therapy than those defined as ‘chronic’. Although a threshold time to distinguish between 
acute and chronic defects after onset of the traumatic event has not yet been defined, there is 
increasing consensus on the fact that 2-3 years after the trauma the joint starts displaying homeostatic 
changes and possible traits of early degeneration. On one hand, a more mature cartilage graft, due to 
the higher mechanical stability and superior cell protection, could play a critical role in the repair of 
chronic cartilage lesions. On the other hand, an immature graft could be sufficient to trigger anabolic 
regenerative processes in the case of acute defects. Therefore, it is necessary to compare efficacy of 
N-TEC and N-CAM in the clinical settings of acute (defined as <1 years) vs chronic (defined as >1 and 

 
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< 5 years) cartilage lesions. This analysis will be performed retrospectively.  
=> determine whether the efficacy of each treatment has a correlation to the characteristics of 
the defect (e.g. “acute” versus “chronic” setting) possibly allowing the most promising 
treatment in relation to the time after the initial cartilage injury (onset of symptoms) to be 
selected 
 
Therapy  
Grafted material 
Advantages 
Disadvantages 
Existing 
tissue 
engineere
d products 
Spherox® 
Spheroids of 
human autologous 
matrix-associated 
chondrocytes for 
implantation 
suspended in 
isotonic sodium 
chloride solution. 
  
Only autologous 
cells implanted (no 
scaffold) 
  
Arthroscopic 
implantation possible 
- 
Variability of ACs  
- 
Cells directly exposed 
to inflammatory and 
mechanical assaults 
(self-synthesizing 
extracellular matrix) 
- 
Issues linked to cell 
retention in the defects 
- 
Long rehabilitation 
protocol 
*MACI® 
(Matrix-induced 
autologous 
chondrocyte 
implantation) 
 
autologous AC 
seeded in 
collagen type I/III 
membrane 
 
  
Better retention of 
cells in the defect 
  
Initial mechanical 
stability  
  
Partial chondrogenic 
re-differentiation 
- 
Rather fibroblastic cell 
phenotype in repair 
tissue 
- 
Variability of ACs  
- 
Possible foreign body 
reaction to the scaffold 
- 
Cells directly exposed 
to inflammatory and 
mechanical assaults 
(no newly formed 
extra-cellular matrix) 
- 
Long rehabilitation 
protocol 
Nose to 
Knee II 
immature 
graft 
N-CAM 
 
 
autologous NC 
seeded in 
collagen type I/III 
matrix 
  
Same as MACI® 
  
More potent and 
more reproducible 
cell source (NC vs 
AC) 
  
Higher cell density 
as compared to 
MACI  
- 
Limited 
chondrogenicity  
- 
Cells directly exposed 
to inflammatory and 
mechanical assaults 
(no newly formed 
extra-cellular matrix) 
- 
Long rehabilitation 
protocol 
Nose to 
Knee II 
mature 
graft 
N-TEC  
 
tissue engineered 
cartilage from 
autologous 
expanded NC 
cultured in 
collagen type I/III 
matrix 
  
Good cell protection 
(presence of ECM) 
  
More reproducible 
tissue quality (NC vs 
AC) 
  
Mechanical stability, 
easier implantation/ 
fixation 
- 
Possible problem of  
integration with the 
surrounding cartilage 
- 
Longer production 
time 
- 
Higher production 
costs 
Table 3.1.1 Comparison of existing tissue engineered products (with market authorization) with the approach 
used in the Nose to Knee II study.  
*The marketing authorisation for MACI has been suspended at the recommendation of the Agency's Committee 
for Medicinal Products for Human Use since 17.12.2014 
3.2 Investigational Product (treatment, device) and Indication  
The investigational medicinal product is considered a combined ATMP (Tissue engineered product). 
The active components of the tissue engineered cartilage graft (N-TEC) are expanded human 
autologous nasal chondrocytes and cartilage matrix proteins produced by the cells. The N-TEC 

 
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is generated using autologous nasal chondrocytes isolated by enzymatic digestion from a 6mm 
diameter biopsy of the nasal septum and expanded for 2 weeks in monolayer. After expansion, 50 
million cells are seeded on a 30 x 40 mm collagen membrane (Chondro-Gide®) and cultured for two 
additional weeks to allow for production of extracellular matrix by the cells. The graft is cut and shaped 
by the surgeons according to the defect and implanted in the knee using suturing. The graft is 
expected to heal the defect and integrate with the adjacent tissue maturing further in the process. 
 
Suitability of cell source 
In contrast to articular cartilage, harvesting of nasal cartilage, also characterized as hyaline cartilage, 
is less invasive and can be performed as an outpatient procedure under local anaesthesia. This 
procedure leads to minimal donor site morbidity due to the fact that the donor site is more easily 
accessible and not subjected to high levels of physical force. The number of nasal chondrocytes which 
can be collected from a small biopsy of 6mm diameter is sufficient for the generation of an autologous 
cartilage graft of clinically relevant size (e.g. 12 cm2) (Tay et al, 2004; Fulco et al, 2014). Moreover this 
donor site can also be used in older patients (>70 years) or patients with limited availability of healthy 
articular cartilage. 
In addition, the properties of NC are less age dependent (Rotter et al, 2002). Importantly, the NC not 
only proliferate faster than articular chondrocytes (AC) but have a higher and more reproducible 
chondrogenic capacity (Kafienah et al, 2002). Isolated chondrocytes from nasal cartilage tissue have 
been used to successfully engineer in vitro and/or in vivo 3D cartilaginous tissues (Pelltari K, 2014; 
Fulco I, 2014; Scotti C, 2014; Candrian C, 2008; Farhadi J, 2006; Miot S, 2005; Kafienah W, 2002). As 
shown in figure 3.2.1, the contents of GAG and Collagen type II and, consequently, the mechanical 
properties are superior in tissues engineered from NC as compared to those from AC.  
 
Fig. 3.2.1. Properties of engineered cartilage tissue generated by nasal chondrocytes (ECN) or articular 
chondrocytes (ECA) prior to mechanical loading. A and B, Safranin O and type II collagen immunohistochemical 
staining of representative ECN or ECA after 2 weeks of culture in chondrogenic medium. Top rows (bar = 500 
Bm) show lower-magnification views of bottom rows (bar = 100 Bm). C, Glycosaminoglycan (GAG) and type II 
collagen content of ECN and ECA. D, Equilibrium modulus (EEQ, left y-axis) and pulsatile dynamic modulus (EPD, 
right y-axis) of ECN and ECA. Values are the mean and SEM results from 5 independent experiments. o = 
significant difference versus ECA. 
Despite the numerous advantages of NC over AC in the generation of cartilage grafts, the use of NC 
to treat articular lesions has raised questions regarding the compatibility of these cells with the joint 
environment. Therefore in vitro experiments have been conducted to study the response of NC to 
experimental conditions mimicking the mechanical and inflammatory joint environment. Although NC 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
3 3 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 3 3 of 8 0 
ar e n ot s u bj e ct e d t o hi g h m e c h a ni c al f or c e s i n t h eir n ati v e e n vir o n m e nt, t h e y ar e a bl e t o r e s p o n d t o 
p h y si c al f or c e s a n d s urf a c e m oti o n r e s e m bli n g j oi nt l o a di n g si mil arl y t o arti c ul ar c h o n dr o c yt e s, a n d 
c a n u p-r e g ul at e m ol e c ul e s t y pi c all y i n v ol v e d i n j oi nt l u bri c ati o n ( C a n dri a n et al., 2 0 0 8).  
Ti s s u e s g e n er at e d fr o m N C al s o h a v e a hi g h er c a p a cit y t o r e c o v er aft er a s h ort e x p o s ur e t o I L- 1 β  
( si m ul ati n g i nfl a m m ati o n f oll o wi n g s ur g er y) a s c o m p ar e d t o ti s s u e s g e n er at e d fr o m A C ( S c otti et al., 
2 0 1 2). 
Fi n all y, t h e c a p a cit y of N C ( 1) t o a c q uir e t h e 
m ol e c ul ar i d e ntit y of A C f oll o wi n g i m pl a nt ati o n i n 
e x p eri m e nt al arti c ul ar c artil a g e d ef e ct s i n a n a ut ol o g o u s s etti n g a n d ( 2) t o c o ntri b ut e t o t h e r e p air of 
t h e d a m a g e d c artil a g e h a s b e e n s h o w n i n a l ar g e a ni m al st u d y i n g o at s ( P eltt ari K, 2 0 1 4). 
 
Bi ol o gi c al pr o p erti e s 
A n al y si s of t h e bi ol o gi c al pr o p erti e s of gr aft s pr e vi o u sl y m a n uf a ct ur e d a c c or di n g t o t h e s e pr ot o c ol s 
di s pl a y a b u n d a nt c artil a gi n o u s m atri x e m b e d di n g w ell diff er e nti at e d c h o n dr o c yt e s ( F ul c o et al, 2 0 1 4) 
(fi g ur e 3. 2. 2), i n di c ati n g t h at r e- diff er e nti ati o n of t h e c h o n dr o c yt e s aft er e x p a n si o n h a s b e e n a c hi e v e d.  
 
 
 
 
 
 
 
Fi g. 3. 2. 2  Hi st ol o gi c al i m a g e of a ti s s u e e n gi n e er e d c artil a g e gr aft. C ell m or p h ol o g y a n d m atri x d e p o siti o n ar e 
s h o w n i n hi st ol o gi c al S afr a ni n O st ai ni n g.  
 
H e m at o x yli n a n d E o si n ( H & E st ai ni n g, fi g ur e 3. 2. 3) s h o w e d t h e pr e s e n c e of li vi n g c ell s. El a sti c a v o n 
Gi e s o n (fi g ur e 3. 2. 3) r e v e al e d t h e pr e s e n c e of c oll a g e n a n d el a sti c fi b er s i n t h e c artil a g e gr aft. 
M u c o p ol y s a c c ari d e s, a c h ar a ct eri sti c of c artil a g e, c o ul d b e d et e ct e d b y al ci a n bl u e- P A S (fi g ur e 3. 2. 3). 
F urt h er m or e i m m u n o hi st o c h e mi str y st ai ni n g i n di c at e d t h at t h e e n gi n e er e d n a s al c artil a g e gr aft s w er e 
p o siti v e f or c oll a g e n t y p e II, pr o- c oll a g e n t y p e I, S 1 0 0, p o d o pl a ni n a n d S o x- 9, b ut n e g ati v e f or p 5 3 
i n di c ati n g a h e alt h y st at u s of t h e c ell s wit hi n t h e e n gi n e er e d ti s s u e (fi g ur e 3. 2. 3, s e e i n v e sti g at or’ s 
br o c h ur e f or d et ail s). T hi s br o a d c h ar a ct eri z ati o n c o nfir m e d t h at t h e N C- e n gi n e er e d ti s s u e e x hi bit s 
t y pi c al c h ar a ct eri sti c s of n ati v e h y ali n e c artil a g e. 

 
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Fig. 3.2.3 Histological and Immunohistochemical characterization of N-TEC 
 
Mechanical properties 
In order to be used in a clinical setting for the repair of articular cartilage defects, sufficient mechanical 
properties at the time of implantation (stable enough for suturing, while still flexible enough to be fitted 
to the curvature of the site) could be a possible advantage of engineered cartilage grafts. By the time 
that fixation is dissolved, mechanical stability is required to resist contraction by scar tissue formation 
and exposure to local or external forces in the recipient bed (i.e., compression, tensile and bending 
forces). 
Preclinical investigations support this theory having shown in vitro (Farhadi et al, 2006) as well as in 
vivo in an orthotopic large animal model (Miot et al, 2012; Pelttari et al, 2014) that pre-cultivation of 
engineered human nasal cartilage enhances the mechanical properties relevant for use in a clinical 
setting.  
3.3 Preclinical Evidence  
Several in vitro experiments have shown that nasal chondrocytes are a suitable cell source for the 
production of tissue engineered cartilage grafts to treat articular cartilage injuries in the knee. This is 
not only due to their advantageous properties as compared to articular chondrocytes, but also due to 
the facts that nasal chondrocytes can adapt to the environment of the knee regarding weight loading 
and their resistance to inflammatory responses (see chapter 3.2). 
Furthermore several animal studies have been performed to investigate the behavior of tissue 
engineered nasal cartilage in the environment of the joint.  
 
 
 
H&E 
Elastica von Gieson 
Alcian blue-PAS
Collagen type II
Pro-Collagen type I
Sox-9
S100
Podoplanin
P53

 
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Migration study (see IB for details) 
To answer the question whether implanted nasal chondrocytes are still detectable in the repair tissue 
and/or migrating in surrounding articular tissues, we performed two experiments in a goat animal 
model where autologous articular chondrocytes, labelled using GFP lentivirus for tracking purposes, 
were cultured in Chondro-Gide® and implanted in a joint defect. 
After 
4 
weeks, 
3 
months 
and 
6 
months 
respectively, 
animals 
were 
sacrificed 
and 
immunohistochemical analysis of reparative tissue showed that GFP positive chondrocytes were still 
detected in the tissue, indicating that the implanted chondrocytes remained at the site of implantation. 
In addition, the reparative tissue was cartilaginous, as demonstrated by positive Safranin-O staining 
specific for cartilage extracellular matrix. After 3 months chondrocytes were exhibiting typical shape 
within lacuna but were not displaying a columnar organization.  
No GPF-positive chondrocytes could be detected by FACS analyses in any of the tissues surrounding 
the joint/implantation site (fat pad, patella, meniscus, cruciate ligaments, and synovium; n = 3 goats). 
Therefore, it could be concluded that the implanted chondrocytes, either from articular or from nasal 
origin, did not migrate into the tissues surrounding the joint up to 3 months after implantation (Mumme 
et al, 2016). 
 
Tumorigenicity (see IB for details) 
Different groups have reported that chondrocytes from different cell sources showed no signs of 
malignant transformation after cell expansion in 2D, assessed by different techniques (Kamil et al, 
2002 and 2003, Brandl et al, 2010, Trimborn et al, 2011). 
The N-TEC, composed of autologous nasal chondrocytes and the Chondro-Gide® membrane, has 
been used in a previous clinical trial “Tissue engineered nasal cartilage for reconstruction of the alar 
lobule” (TpP-I-2010-002) for reconstructive purposes following resection of a non-melanoma skin 
cancer and thus implanted in a tumor site. Second look biopsies were analyzed 6 months after 
implantation and histological analysis performed by a pathologist. There was no evidence of tumor 
formation. The one year follow-up also showed no indication of tumor formation in any of the patients. 
The same nasal cartilage graft was used in a second clinical trial “Tissue engineered nasal cartilage 
for the regeneration of articular cartilage in the knee after traumatic injury- phase I clinical trial” (TpP-I-
2012-001). There was no indication of local tumor formation detected in the MRI of the 1 or 2 year 
follow-up for the first patients. 
In addition an animal study (mouse) was performed to assess the tumor potential of constructs 
generated with nasal chondrocytes from 3 patients of the previous trial expanded in 2D in the 
presence of growth factors. After implantation none of the operated mice showed weight loss or 
abnormalities with palpation indicating absence of tumor at the implantation site. After 6 months 
constructs were explanted and assessed histologically. In addition, five different organs (lung, liver, 
the kidneys, spleen, and local lymph nodes) were harvested from the same mice, No signs of tumor 
formation could be found in any of the explanted tissues, Therefore it can be concluded that the 
expanded nasal chondrocytes do not have any tumor potential when used for cell based constructs. 
 
Capacity for cartilage repair (see IB for details) 
A long-term study in goats was performed to obtain preclinical evidence of the suitability of NC for the 
repair of articular cartilage defects. Tissue-engineered constructs were generated using autologous 
NC (and AC to serve as controls) and implanted into experimental defects created at a clinically 
relevant location, namely load-bearing sites of the articular condyle. The results of this study (Pelttari 
et al., 2014) show, per the semi quantitative O’Driscoll scoring system, that the quality of the repair 
tissue significantly improved from 3 to 6 months after implantation only when using NCs, such that at 6 
months the repair quality achieved by NCs was statistically superior to AC controls. The improved 
quality of the repair tissue using NC compared with AC was confirmed histologically by a stronger and 
more uniform staining for glycosaminoglycans at 6 months (figure 3.3.1). 
 

 
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Fig. 3.3.1 Goat nasal chondrocytes (NC) in articular cartilage repair. (A) O’Driscoll scores of the repair quality of 
the NC- or AC-treated goat articular defects at 3 and 6 months (n = 3 animals per time point) after implantation. * 
= p<0.05. (B) Safranin O and Alcian blue staining of representative repair tissues at the defect site (d) and of 
adjacent native articular cartilage (n) 6 months after implantation of NC or AC. Lower Alcian blue images show 
higher magnification (scale bar, 50 Bm) of the regions framed in the respective upper panels (scale bar, 1mm)  
In summary, the results of these animal studies support the compatibility and efficacy of nasal 
chondrocytes for articular cartilage repair. 
3.4 Clinical Evidence to Date  
The two IMPs have been used in a number of clinical trials. A summary of all clinical trials is given in 
the table below.  
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Table 3.4.1 Summary of clinical trial to date with N-TEC and N-CAM respectively 
One of the proposed IMPs (N-TEC) has been used in phase I trials for two clinical indications, the 
reconstruction of the alar lobule after tumor excision and the regeneration of articular cartilage lesions 
in the knee after traumatic injury. 
Clinical trial Phase I: Nose to Nose (TpP-I-2010-002) 
N-TEC was first used in a prospective single center phase I clinical trial for the reconstruction of the 
alar lobule after tumor excision (Clinical-trials.gov (NCT 01242618), Swissmedic TpP-I-2010-002) and 
the results were recently published in “The Lancet” (Fulco et al, 2014). Five patients (76-88 years) with 
two-layer defects from non-melanoma skin cancer in the alar lobule accepted the novel procedure. 
The engineered cartilage grafts (25 x 25 x 2 mm) were shaped intra-operatively and implanted after 
tumor excision under paramedian forehead or nasolabial flaps, as in the standard reconstruction using 
native cartilage. After six months, during flap refinement, second look biopsies of repair tissues were 
harvested and histologically analyzed. At least one year after implantation, when reconstruction is 
typically stabilized, patients were assessed for safety, aesthetic (figure 3.4.1) and functional outcomes. 
Monofilament and rhinomanometry tests were used to quantify alar cutaneous sensibility, mechanical 
stability and respiratory flow rate. All engineered grafts contained a mixed hyaline-fibrous cartilage 
matrix. Six months after implantation, reconstructed tissues displayed fibro-muscular-fatty structures 
typical of the alar lobule. After one year, all patients were satisfied with the aesthetic and functional 
outcome and no adverse events were recorded. The procedure resulted in sensibility and structural 
stability of the reconstructed area, with adequate respiratory function and no donor site morbidity.  
 
 
 
 
 
Fig. 3.4.1 Photographs of the affected alar lobule (patient Nr.1) before (left: skin tumor with margins contouring) 
and 1 year after reconstruction (right)  
 
These results indicate that engineered autologous nasal cartilage tissues can be safely used in clinical 
applications such as reconstruction in replacement of native cartilage grafts. 
 
Clinical trial Phase I: Nose to Knee (TpP-I-2012-001) 
A similar nasal cartilage graft, larger in size (30 x 40mm), is currently used in a prospective phase I 
clinical trial. In this study (Clinical-trials.gov: NCT01605201, Swissmedic TpP-I-2012-001) a total of 25 
patients (initially 10, extended to 25) between 18 and 55 years suffering from traumatic articular 
cartilage injuries in the knee are being treated with N-TEC. The goal is to test the safety and feasibility 
of this approach for the regeneration of articular cartilage. Patients are enrolled if they display a 
maximum of two defects with a total size of 2-8cm2, Grade III-IV according to the ICRS scale on the 
femoral condyle and/or trochlea femoris. Corresponding lesions or advanced osteoarthritis are 
currently exclusion criteria. The primary endpoint (safety) is assessed by the number of (serious) 
Adverse Reactions. In addition, data are collected on efficacy based on the biochemical composition 
of the repair tissue (GAG-content as assessed by delayed Gadolinium enhanced MRI of Cartilage 

 
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(dGEMRIC), radiological outcome (structure and integration of the cartilage as assessed by MOCART 
scoring of MRI), clinical scores (KOOS, LYSHOLM & IKDC) and questionnaires of patient satisfaction. 
The results from the first 10 patients have been published in “The Lancet” (Mumme et al, 2016) 
Safety and stability 
So far 18 patients (15 having completed the 2 year follow-up) have been treated with no occurrence of 
serious adverse reactions. Two patients were excluded due to multiple accidents (after 23 months) 
and intraoperative findings (defect size too large). The graft was stable in situ in all patients but one, 
where the transplant was destroyed due to another unrelated accident occurring during sports 
exercise (patient excluded due to multiple accidents). Adverse events reported so far are summarized 
in the table below. 
 
Adverse Events/reactions Patients (n=18) 
No. 
events 
Patient # 
Time point after 
implantation 
Serious Adverse Reactions 
0 
 
 
Adverse Reaction 
3 
 
 
- Hematoma due to surgery  
1 
#17 
0 month 
- Partial graft delamination (no intervention necessary) 
1 
#15 
12 months 
- saphenous nerve irritation 
1 
#17 
13 months 
Serious Adverse Events 
5 
 
 
Additional injuries with hospitalization & surgery (same knee) 
2 
 
 
- new cartilage lesions in the afflicted knee at other location  with 
hospitalization and re-surgery (deterioration) 
1 
#2 
12 months 
- knee instability due to ACL insufficiency 
1 
#17 
7 months 
Additional injuries with hospitalization & surgery (other location) 
3 
 
 
- new sports injury in the contralateral knee  
1 
#9 
17 months 
- distortion of the contralateral knee (accident) 
1 
#14 
1 month 
- acute appendicitis 
1 
#18 
0 month 
Adverse Events 
4 
 
 
- meniscus lesion of contralateral knee 
1 
#8 
11 months 
- ankle distorsion (sports injury) 
1 
#9 
11 months 
- new sports injury of the afflicted knee without hospitalization or 
surgery 
2 
#7 & #9 
20 months (#7) 
11 months (#9) 
Table 3.4.1: Summary of adverse events reported so far for 16 patients (two patients excluded) 
Preliminary clinical efficacy 
The early clinical observations indicate not only safety and feasibility of the procedure, but together 
with Magnetic Resonance Imaging (MRI) data also show promising results for efficacy of the treatment 
(15 patients have completed the 24 months follow-up, 2 are excluded, 1 has not yet reached the 24 
months follow-up). Clinical scores (average and range have been summarized in the table below 
(Table 3.4.1).  
 
 
 
 
 
 
 

 
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Page 39 of 80 
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Table 3.4.2 Preliminary clinical scores of the phase I study  
An improvement of more than 10 points in the KOOS sub-scores is considered a clinically relevant 
improvement. The average improvement of all scores is always above 10 points, but with large 
standard deviations since results vary from one patient to another. On an individual basis, more than 
half of the patients (15 evaluated so far) benefited from the treatment (see below). 
 

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Table 3.4.3: Improvement of clinical scores: Average and individual basis  
The radiological evaluation of N-TEC treatment is promising (figure 3.4.2). The quantification of 
glycosaminoglycan by dGEMRIC indicates hyaline cartilage tissue formation. More precisely, by 
comparison of the repair tissue with native healthy cartilage from radiological measurements, the 
relative CR1 has been calculated (1.0 indicating no difference detectable between repair tissue and 
native healthy cartilage). With the resulting relative CR1 of 1.9 (0.89 – 4.13) after 6 months, 1.5 (0.78 – 
2.17) after 12 months and 1.20 (0.71 - 1.51) after 24 months, a progressive additional maturation of 
the tissue over time can be observed. This is further supported by histological data (figure 3.4.3). 
When compared to literature, N-TEC treatment might result in even more hyaline tissue compared to 
MACI (relative CR1 2.18, Trattnig et al 2008) or ACT (2.40, Trattnig et al 2007) or microfracture (3.39, 
Trattnig et al 2008). The morphological MOCART score after 6 months was 61 (25-80), after 12 
months 56 (25-80) and after 24 months 48 (10-80). This might be due to occasional cleft formation at 
the interface between native and repair cartilage. 

 
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.  
Fig. 3.4.2 Sagittal MRI of the knee before surgery (A) indicating the cartilage defect (red circle). Maturation of the 
repair tissue after 6 months (B) and 12 months (C), demonstrating the repair tissue in situ. 
 
 
 
 
 
 
 
Fig. 3.4.3 Histological analysis indicates chondrogenic differentiation of the graft at time of implantation (A). 18 
months after surgery, the repair tissue is more mature with abundant deposition of glycosaminoglycans (B) and 
with positive collagen type II (C) and widely negative collagen type I immunohistochemistry (D) typical for hyaline 
cartilage.  
Clinical trial Phase II: Nose to Knee II (2016TpP2004, EudraCT: 2015-005162-34)  
The current clinical trial “Nose to Knee II” described in this study protocol is a phase II multicenter 
clinical trial based on the phase I study described above, which focuses on efficacy and the 
comparison of grafts in different maturation stages and therefore requires higher patient numbers to 
be statistically significant. Patients, between 18 and 65 years old, suffering from articular cartilage 
lesions not related to an inflammatory state,  are treated in four different countries: Croatia, Germany, 
Italy and Switzerland and will be followed up for 2 years. At 6 weeks as well as 3, 12 and 24 months 
after the operation, follow-ups are performed. During the follow-ups at 12 and 24 months 
questionnaires (KOOS, EQ-5d) are filled out by the patient and MRIs will be performed at 3,12 and 24 
months. 
3.4.1 
Safety 
So far, 23 grafts have been produced at two manufacturing sites, 12 N-TEC (3 in Basel, 9 in 
Wurzburg) and 11 N-CAM (2 in Basel, 9 in Wurzburg). All batches produced passed the release 
criteria and were within specifications (see IMPD). The first IMP manufactured was a N-TEC graft 
produced in Basel and implanted the 09.01.2017. No adverse reactions have been recorded up to now. 
One AE was observed for patient USB01197001 (plate removal after osteotomy) and one SAE for 
patient USB08197702 (scrotal atheroma). For regular updates and further information, please consult 
the Investigator’s Brochure (IB). 
3.4.2 
Efficacy 
Nineteen patients had the three months MRI showing all grafts to be in place and integrated within the 
surrounding cartilage. Two patients have so far reached the one year follow-up. KOOS sub-scores 
were improved for both patients (one N-TEC and one N-CAM). For regular updates and further 
information, please consult the Investigator’s Brochure (IB). 
 
 
 

 
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Patient 
USB01197001 (N-TEC) 
USB03198803 (N-CAM) 
KOOS 
preop 
12 
months 
Change 
from 
baseline 
preop 
12 months 
Change 
from 
baseline 
Symptoms 
42.9 
100 
57.1 
53.6 
89.3 
35.7 
Pain 
44.4 
100 
55.6 
47.2 
91.7 
44.5 
ADL 
57.4 
98.5 
41.2 
67.7 
100.0 
32.4 
Sport 
5.0 
90.0 
85.0 
25.0 
85.0 
60 
QoL 
12.5 
75.0 
62.5 
25.0 
62.5 
37.5 
Table 3.4.5: Clinical scores at baseline (preop), after 12 months and change from baseline. (ADL: 
Activities of daily life, QoL: Quality of Life). All scores are from 0-100, with 100 being the best score. 
In summary, the clinical data indicate that engineered nasal cartilage grafts are safe for use in clinical 
applications for reconstructive as well as orthopedic purposes. 
Taking into account all scientific and clinical data, the use of the engineered nasal cartilage graft is 
feasible and safe. 
3.5 Dose Rationale / Medical Device: Rationale for the intended purpose in 
study (pre-market MD)  
Previous studies have shown that the cell seeding density has a significant impact on the generation 
of cartilaginous constructs in terms of GAG content and collagen type II expression (Francioli et al. 
2010). High seeding densities (8.3 Million/cm2) lead to an increase in GAG and collagen type II 
expression and thus a cartilaginous tissue of higher quality as compared to low seeding densities (2.1 
Million/cm2). However, the amount of cells that can be isolated from a reasonable sized biopsy has 
also to be taken in consideration, since large biopsies could be unavailable and/or increase donor site 
morbidity. Therefore a seeding density of 50 Million cells per construct (size 30 x 40 mm, seeding 
density of 4.2 Million cells/cm2) has been selected for preclinical animal studies (Pelttari et al. 2014, 
see IB for details) and the previous and ongoing clinical trials (Fulco et al, 2014, Nose to Knee (TpP-I-
2012-001) see above). The chosen cell seeding density leads to cartilaginous tissues suitable for 
regenerative medicine.  
3.6 Explanation for choice of comparator (or placebo)  
As the most promising approach currently, and reported to provide clinical improvement to young 
patients with focal cartilage defects in mid-term follow-up (Kon et al, 2009), we have selected cell-
therapy techniques as the most appropriate comparator. The established cell-based technique MACI® 
has been used in clinical applications since 1998 and is a standard product with marketing 
authorization in Europe since 2013 (currently suspended). In order to eliminate differences due to the 
cell source and allow a more appropriate evaluation of the impact of graft maturation on the clinical 
outcome, nasal chondrocytes instead of articular chondrocytes will be used (figure. 3.6.1), therefore 
exploiting the concept of cellular therapies, not using a licensed product. Since nasal chondrocytes 
have been proven in vitro to have superior properties as compared to articular chondrocytes, results at 
least comparable to the standard MACI® procedure can be expected.  
Fig. 3.6.1 Illustration of the procedures to generate the NC-based IMPs and of their main characteristics  

 
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We believe that in this setting, where a mature and immature graft is manufactured in a similar way 
using nasal chondrocytes, the superiority of the mature graft in comparison to the immature graft can 
be shown. 
3.7 Risks / Benefits  
The spontaneous healing capacity of cartilage is poor and untreated defects predispose to 
osteoarthritis. Common current strategies such as arthroscopic debridement, microfracture, 
autologous osteochondral grafting, cartilage allografts and autologous chondrocytes implantation 
(ACI/MACI) still have drawbacks or produce unsatisfactory long term results. These drawbacks could 
be overcome using a tissue based therapy. 
Potential risks and benefits 
During this trial all patients will be treated according to current hospital standards. Nasal cartilage 
biopsies will be harvested by an experienced plastic or ENT-surgeon. The manufacturing of the graft 
will be performed in a GMP-facility with given manufacturing authorization from Regierung von 
Oberfranken, Ansbach, Germany in consultation with PEI (NCA) or from Swissmedic, Switzerland 
depending on the manufacturing site. Manufacturing will be performed in compliance with GMP-
guidelines and according to verified protocols. In-Process controls will be conducted at defined points 
during the process to ensure absence of microbiological, endotoxin or mycoplasma contamination. 
The quality of the graft will be tested before implantation according to verified protocols. Experienced 
orthopedic surgeons will implant the graft into the knee and perform the follow-up. Technically the 
operation is no more challenging than standard procedures as ACI, and the follow-up includes all 
standard procedures with the addition of an MRI analysis. Since autologous cells are implanted and 
autologous serum is used instead of bovine serum, the risk of immune reaction or of disease 
transmission is minimal. Furthermore, in vitro and in vivo studies have already proven that nasal 
chondrocytes can survive in the joint environment and respond to mechanical loading similar to 
articular chondrocytes. The certified Chondro-Gide® membrane is already in clinical use. The 
combination of nasal chondrocytes cultured in this matrix has already successfully been used in two 
other clinical trials, for the reconstruction of the alar lobule after tumor resection and for the treatment 
of cartilage defects in the knee.  
From standard therapies it is known that localized defects on the patella on average have higher 
complication rates and clinically inferior outcomes as compared to defects on the femoral condyle or 
trochlea. For N-CAM and N-TEC treatment, there are no clinical data available yet concerning the 
outcome of treatment for patella defects. 
Taking into account the pre-clinical results and safety measures, the risk for the patient is not 
increased as compared to the standard procedures. 
However, several benefits can be expected from the implantation of cartilage grafts into focal cartilage 
defects as compared to state-of-the-art surgical treatments: 
1. Shorter rehabilitation times 
Implantation of a more mature tissue should lead to shorter rehabilitation times, earlier postoperative 
joint loading and a faster return of the patient to daily life activities and sports. 
2. Possibility to treat larger defects 
This technique can be used for cartilage defects up to 8 cm2 in size. 
3. More durable regeneration 
We assume that in the long term the repair tissue will be hyaline cartilage instead of fibrocartilage and 
will therefore have better durability and stability as compared to the outcome of current methods.  
4. Reduced donor-site morbidity 
When AC are used for cartilage repair currently, harvesting of autologous cartilage plugs or biopsies 
from a low weight bearing site generate an additional defect in the joint, which has been reported to be 
detrimental to the surrounding healthy articular cartilage. Biopsies taken from the nasal septum lead to 
negligible donor-site morbidity. Safety of harvesting procedure was previously reported in a first trial in 
which similar nasal cartilage biopsies were taken to generate tissue engineered grafts for the 
reconstruction of alar lobule after tumor resection (Clinicaltrials.gov: NCT01242618, Fulco et al, 
Lancet 2014). 
5. Superior graft quality 
Articular cartilage has to be harvested from a healthy, low weight bearing area, therefore limiting the 

 
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availability of material. In case of some diseases harvesting of healthy cartilage might not even be 
possible. Furthermore, it has been shown that properties of articular chondrocytes are dependent on 
age, while those of nasal chondrocytes are less age dependent and show greater proliferation and 
differentiation capacity. This might allow this technique to be applied to older patients or those with 
insufficient amounts of healthy articular cartilage. 
 
Overall the risk for the patient is not considered to be higher as compared to standard procedures, but 
the benefits might have a significant impact especially for large defects. 
Expected Adverse Reactions 
Based on the experience of the phase I study, no major risks are expected. Expected adverse 
reactions are mostly related to the tissue withdrawal and implantation: 
Expected Adverse Reaction related to nose cartilage withdrawal 
  Local hematoma 
  Local bleeding 
  Local pain 
Expected Adverse Reaction related to tissue implantation 
Local: 
  Pain 
  Swelling and/or hematoma 
  Plate removal in case of necessary osteotomy 
Systemic: 
  Post-anesthetic nausea  
  vomiting  
  fever 
No adverse reactions are expected to follow-up procedures such as MRI/dGEMRIC. These expected 
adverse reactions are common for the standard treatment and therefore will only be classified 
according to chapter 10.1.1 and recorded in the CRF. They are not subject to reporting.  
 
Risk assessment 
Risks could be related to the manufacturing, the quality of the product itself or the implantation of the 
product. Due to the use of a certified, clinically used matrix with autologous cells, the adherence to 
GMP- and GCP-regulation and a close follow-up schedule, the overall risk for the patient is expected 
to be low. Possible risks have been identified, evaluated and appropriate measures to reduce the risk 
described (Table 3.7.1). For residual risk a contingency plan is available. If, during the process, further 
risks are identified or other measures have to be taken, the plan will be adapted. Microbiological, 
Endotoxin and Mycoplasma testing will be carried out as in process controls. In case of serious 
adverse events related to the IMP, the respective ethical commissions and national authorities will be 
informed. Along with the patient information, the patient receives the contact details of the responsible 
doctor along with the instruction to contact the doctor at any time for any ambiguities, emergencies, 
unexpected or adverse events during or after the study. 
In summary, this procedure contains no expected additional risks as compared to the standard 
procedure for these cases.  
Major 
High chance of occurrence, critical for the trial  
Medium 
Medium chance of occurrence, critical for the trial  
Minor 
Low chance of occurrence, may be critical for the trial  
Acceptable 
No contingency plan required 

 
D o c u m e nt: 
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P a g e n u m b er: 
4 4 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 4 4 of 8 0 
T a bl e 3. 7. 1:  Ri s k f a ct or s i n t h e u s e of a ti s s u e e n gi n e er e d pr o d u ct s f or c artil a g e r e g e n er ati o n. 
Ri s k 
I niti al 
ri s k 
Ri s k C o ntr ol/ Miti g ati o n 
R e si d u al 
Ri s k 
C o nti n g e n c y 
Pl a n 
C o n str u ct 
C o nt a mi n ati o n of 
bi o p s y  
m e di u m 
•  
Bi o p s y h ar v e sti n g 
a c c or di n g t o G o o d Cli ni c al 
Pr a cti c e 
•  
C h e c k f or mi cr o bi ol o gi c al 
c o nt a mi n ati o n i n t h e 
s u p er n at a nt of t h e bi o p s y 
aft er tr a n s p ort 
•  
Tr ai ni n g of pl a sti c s ur g e o n s 
•  
A d diti o n of a nti bi oti c s i n t h e 
tr a n s p ort m e di u m a n d fir st 
w e e k of e x p a n si o n 
a c c e pt a bl e  
 
C o nt a mi n ati o n 
d uri n g m e di a 
c h a n g e 
m e di u m 
•  
C h e c k f or mi cr o bi ol o gi c al & 
e n d ot o xi n c o nt a mi n ati o n 
a n d m y c o pl a s m a i n t h e 
m e di a aft er e x p a n si o n a n d 
pr e- c ult ur e p h a s e 
•  
U s e of cl e a n r o o m 
•  
W or k a c c or di n g t o S O P s 
mi n or  
a b ort of t h e 
tr a n s pl a nt 
g e n er ati o n if 
t h er e ar e 
p o siti v e r e s ult s 
f or 
c o nt a mi n ati o n 
C o nt a mi n ati o n 
d uri n g tr a n s p ort 
mi n or 
•  
P a c k a gi n g a c c or di n g t o t h e 
n or m f or st eril e p a c ki n g 
•  
W or k a c c or di n g t o S O P 
a c c e pt a bl e  
 
F ail ur e t o 
g e n er at e a gr aft 
m e di u m 
•  if t h e st a n d ar d s ur gi c al 
m et h o d h a s t o b e u s e d, 
t h er e i s n o di s a d v a nt a g e 
a c c e pt a bl e  
 
C ell n u m b er f or 
s e e di n g n ot 
r e a c h e d 
m e di u m 
•  
w or ki n g a c c or di n g t o S O P s  
•  
c orr e ct bi o p s y si z e 
mi n or  
I n c a s e of < 5 0 M 
a n d > 3 8 M c ell s, 
≥9 5 %  
vi a bilit y 
a n d  
a d e q u at e 
m or p h ol o g y 
s e e di n g 
of 
a 
s m all er s c aff ol d  
 
C o nt a mi n ati o n of t h e c o n str u ct i s a criti c al ri s k. 
Si n c e 
m o st c ult ur e s s h o w si g n s of 
c o nt a mi n ati o n wit hi n 4 8 h, t h e s a m pl e of t h e l a st m e di a c h a n g e i s t a k e n 4 8 - 7 2 h pri or t o 
i m pl a nt ati o n. T h e l a st r e s ult will b e r etr o s p e cti v e r e g ar di n g mi cr o bi ol o gi c al c o nt a mi n ati o n.  
Ri s k 
I niti al ri s k  
Ri s k C o ntr ol/ Miti g ati o n 
R e si d u al Ri s k 
C o nti n g e n c y 
Pl a n 
S af et y f or p ati e nt 
I nf e cti o n d uri n g 
s ur gi c al 
i nt er v e nti o n at 
t h e bi o p s y sit e  
mi n or 
•  
st a n d ar d pr e p ar ati o n 
of p ati e nt f or o p er ati o n 
•  
a d diti o n al tr e at m e nt of 
t h e bi o p s y sit e t o a v oi d 
i nf e cti o n 
•  r o uti n e pr e c a uti o n s a s 
i n a n y o p er ati o n 
a c c e pt a bl e  
 
I nf e cti o n t hr o u g h 
tr a n s pl a nt 
mi n or 
•  
n o p o siti v e t e st s 
r e g ar di n g 
m y c o pl a s m a, 
e n d ot o xi n or 
mi cr o bi ol o gi c al 
c o nt a mi n ati o n (l a st 
r e s ult r etr o s p e cti v e) 
a c c e pt a bl e  
 
I nf e cti o n aft er 
o p er ati o n 
mi n or 
•  
s a m e a s f or st a n d ar d 
o p er ati o n 
a c c e pt a bl e  
 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
4 5 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 4 5 of 8 0 
•  
cl o s e f oll o w u p of 
p ati e nt  
C o m pli c ati o n s 
aft er i m pl a nt ati o n 
mi n or 
•  
s a m e a s f or st a n d ar d 
o p er ati o n 
•  
art hr o s c o p y t o 
d et er mi n e c a u s e a n d 
f urt h er tr e at m e nt 
a c c e pt a bl e  
 
L o s s of i m pl a nt  
mi n or 
•  
s a m e a s f or st a n d ar d 
o p er ati o n 
a c c e pt a bl e  
 
R ej e cti o n s a n d 
i m m u n e r e a cti o n 
mi n or 
•  
a ut ol o g o u s c ell s a n d 
s er u m ar e u s e d  
a c c e pt a bl e  
 
C o ntr a st a g e nt 
( D ot ar e m® ) a s s o ci
at e d wit h 
n e p hr o g e ni c 
s y st e mi c fi br o si s 
mi n or 
•  
e x cl u si o n of p ati e nt s 
wit h r e n al i m p air m e nt 
a c c e pt a bl e  
 
All er gi c or 
h y p er s e n siti v e 
r e a cti o n s t o 
c o ntr a st a g e nt 
( D ot ar e m® ) 
mi n or 
•  
p ati e nt s wit h k n o w n 
all er gi e s or a st h m a will 
r e c ei v e a nti- all er g y 
m e di c ati o n b ef or e 
o p er ati o n 
a c c e pt a bl e  
 
All er gi c r e a cti o n 
t o a nti bi oti c s 
u s e d p arti all y 
d uri n g pr o d u cti o n 
mi n or 
•  
e x cl u si o n of p ati e nt s 
wit h k n o w n all er gi e s 
a c c e pt a bl e  
 
U nf or e s e e n si d e 
eff e ct s 
mi n or 
•  i m m e di at e c o nt a ct wit h 
st u d y d o ct or f or f urt h er 
i n v e sti g ati o n a n d 
tr e at m e nt 
a c c e pt a bl e  
 
Ri s k 
I niti al ri s k  
Ri s k C o ntr ol/ Miti g ati o n 
R e si d u al Ri s k 
C o nti n g e n c y 
Pl a n 
P ati e nt’ s ri g ht s 
I n s uffi ci e nt 
p ati e nt 
i nf or m ati o n 
mi n or 
•  
n o p arti ci p ati o n of 
p ati e nt wit h o ut si g n e d 
i nf or m e d c o n s e nt s 
a c c e pt a bl e 
 
Pr ot e cti o n of 
p er s o n al ri g ht s 
mi n or 
•  
n o p er s o n al d at a 
b e si d e s t h o s e r el e v a nt 
f or t h e st u d y ( a g e a n d 
s e x) gi v e n t o p e o pl e 
i n v ol v e d i n t h e 
pr o d u cti o n 
•  
d at a tr e at e d a c c or di n g 
t o u s u al h o s pit al 
pr a cti c e  
a c c e pt a bl e 
 
I n ci d e nt al 
fi n di n g s d uri n g 
s cr e e ni n g or 
f oll o w- u p 
m e di u m 
•  
p ati e nt will b e a s k e d 
a s p art of i nf or m e d 
c o n s e nt w h et h er 
h e/ s h e w o ul d li k e t o b e 
i nf or m e d of t h e s e 
a c c e pt a bl e  
 
 
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
46 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 46 of 80 
Potential threats to the study 
Beyond our studies, no engineered cartilage has been used in patients for cartilage regeneration. 
Even though several products have been claimed as engineered cartilage implants, histological 
analyses have shown limited matrix deposition. (figure 3.7.1). 
 
 
 
 
 
 
 
 
Fig. 1.4.1 Histological images of the four different scaffolds types. Cell morphology and matrix 
deposition are shown in histological alcian  blue stainings (A, C, D), hematoxylin and eosin staining (B), 
or in Safranin-O staining (E) Note the presence of chondrocytes but no matrix deposited. (A-D) From 
Albrecht C et al, 2011. 
 
Fig. 3.7.1 Histological images of the four different scaffolds types. Cell morphology and matrix deposition are 
shown in histological alcian blue stainings (A, C, D), hematoxylin and eosin staining (B), or in Safranin-O staining 
(E). Note the presence of chondrocytes but no matrix deposited. (A-D) From Albrecht C et al, 2011. 
Post-trial care 
Patients will be followed-up on a voluntary basis up to 5 years after implantation and can contact study 
doctors at any time during or after the study. 
3.8 Justification of choice of study population  
Patients between 18 - 65 years of age with one or two symptomatic full-thickness cartilage lesions 
from 2 cm2 to 8 cm2 (per lesion, however, not exceeding a total size of 8 cm2 for all lesions) on the 
femoral condyle and/or trochlea and/or patella of the knee due to a traumatic injury will be enrolled in 
this trial. The patients cannot display signs of advanced osteoarthritis, since this would lead to an 
inhomogeneous patient group: several not yet fully understood factors influence the clinical outcome 
and would therefore render the clinical results difficult to interpret. The proposed inclusion and 
exclusion criteria however, will lead to a patient cohort conform with the clinical indications of the  
standard therapies.  
Patients will be selected from those attending normal consultations in the 5 clinical centers. 
 
 
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
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N-TEC 
Existing technologies 
Nose to Knee II 
technology 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
47 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 47 of 80 
4. STUDY OBJECTIVES  
4.1 Overall Objective 
The study aims at the comparison of a therapy with a mature graft versus a therapy with an immature 
graft for the regeneration of articular cartilage lesions in the knee after injury. Two main innovations 
are introduced: 1) the use of autologous nasal chondrocytes (NC) as cell source superior to articular 
chondrocytes (AC) and 2) the delivery of a mature graft as opposed to an immature graft. Data will 
also be analyzed retrospectively to identify the possibility of treatment selection in relation to the time 
after the initial cartilage injury (acute vs chronic cartilage lesions as defined by onset of symptoms). 
4.2 Primary Objective 
This proposed phase II trial seeks to primarily define whether a mature graft will improve the clinical 
efficacy for the patient, leading to an increase of at least 10 points in the main primary outcome (self-
assessed score KOOS) after 24 months as compared to the group receiving the immature graft. 
Comparison between groups will allow assessment of whether the mature graft is superior to the 
immature graft. 
4.3 Secondary Objectives 
The secondary objective is to assess the stability and integration of the graft with the adjacent tissues 
as well as the remodeling of the implanted graft towards native cartilage. 
Furthermore another questionnaire (EQ-5d) and an additional time point (12 month) for the KOOS will 
allow the more detailed analysis of the clinical development of the patient’s recovery and elucidate 
changes in the perceived quality of life before and after treatment. 
Additionally the number of treatment failure at 24 months will be analyzed. Treatment failure is defined 
as objective pathological clinical findings by the investigator directly correlated with subjective patients 
complaints resulting in a deterioration of the subjective clinical outcome assessed by KOOS and the 5 
KOOS subscores. In case of treatment failure, a root cause analysis will be performed. A clinical 
deterioration is defined as reduction in the KOOS score of > 10 compared to baseline. A non-
responding to treatment is defined as improvement of < 10 in the KOOS score. 
 
4.4 Safety Objectives 
Safety of the procedure will be assessed by the number of SADRs and SUSARs within the 2 year 
time-frame of the trial related to the implants. Reoperations due to new accidents or incidents at other 
sites than the operated site will be recorded, but not counted as related to the implant. 
 
 

 
Document: 
Clinical Study Protocol 
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V07 
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Dept. of Biomedicine 
Acronym 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 48 of 80 
5. STUDY OUTCOMES  
5.1 Primary Outcome 
The KOOS score will be used to measure the primary outcome. The primary endpoint is the difference 
in the KOOS at 24 months between the two techniques (comparison of the efficacy of the technique). 
The KOOS score, covering the fields of Symptoms, Pain, Activities of daily life, Sport activities and 
Quality of life, is suitable for assessing the improvement for the patient. This validated questionnaire is 
widely used to assess efficacy of cartilage repair therapies.  
5.2 Secondary Outcomes 
The stability and integration as well as the morphological properties of the graft will be assessed by 
the MOCART and 3D MOCART Scores (magnetic resonance observation of cartilage repair tissue) 
derived from the MRI. The secondary endpoint will be the 24-month assessment. MRI will be 
performed at 3, 12, 24 months follow-up. 
The remodeling of the tissue after implantation towards native cartilage will be assessed by dGEMRIC 
evaluation (MRI) from the 24-month assessment of the relative CR1. The dGEMRIC evaluation will be 
recorded at 3, 12, 24 months follow-up.  
The KOOS will be recorded for patients at baseline visit 1 or 2 and at the 12- and 24-month follow-up 
assessments. Variations over time will be recorded through completion of the questionnaires at 
enrolment and at each follow-up visit (12 and 24 months after treatment). An increase of at least 10 
points after 2 years in the KOOS is considered a relevant improvement for the patient, thus proving 
the efficacy of the treatment. 
 
5.3 Other Outcomes of Interest 
Retrospectively data will be analyzed to identify the possibility of treatment selection (mature graft vs. 
immature graft) in relation to the time after onset of symptoms (acute vs chronic cartilage lesions) in 
order to determine if one treatment is more beneficial than the other (e.g. higher stability, better 
integration etc.).  
In addition a subgroup analysis to compare the outcome with regard to the localization of the defect 
(patella vs. femoral condyle/trochlea) will be performed after the study. 
 
5.4 Safety Outcomes 
The study will evaluate the safety of the implantation of an immature or a mature graft by the number 
of SADRs or SUSARs from baseline assessment up to 60-months follow-up assessment.  
Adverse events/adverse drug reaction will be graded according to severity, expectedness, and 
relationship to trial treatment and reported according to the regulations. 
No adverse events are expected except for those associated with any operation (see chapter 3.7) 
 
 

 
Document: 
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Page 49 of 80 
6. STUDY DESIGN  
6.1 General study design and justification of design  
This study is an interventional phase II study comparing the efficacy of a mature graft vs. an immature 
graft in cartilage repair after traumatic injury. 108 patients will be enrolled in 5 clinical centers in order 
to determine the possible benefits and superiority of a mature graft as compared to an immature graft. 
Patients will be randomized to ensure equal numbers in each treatment group at each center, but 
there will be no blinding in this study due to the fact that the manufacturing processes for the two IMPs 
have a different duration. The implantation date, thus the time after biopsy harvesting required for 
manufacturing of the graft, will disclose to both patient and surgeons to which treatment group the 
patient was assigned.  
After the initial screening procedures, including MRI and blood tests, the patient is asked to fill out the 
baseline questionnaires and a biopsy is taken from the nasal septum. Either about three or five weeks 
later, depending on the treatment group, the IMP is implanted in the cartilage defect in the knee. The 
follow-ups at week 6 include only clinical issues such as wound healing. After 3, 12 and 24 months 
patients are additionally assessed by MRI and given validated questionnaires (12 and 24 month) to 
self-assess their condition. Patients are enrolled in the trial for 2 years, but will be asked to volunteer 
for further assessment by questionnaires for up to 5 years (see study schedule in summary). 
In addition to the follow-ups, the patients will receive continuous physiotherapy starting shortly after 
implantation and lasting up to 1 year post-operatively if necessary.  
A potential limitation in this trial is the fact that surgeons and patients are aware which IMP is 
implanted in the defect due to the properties and appearance of the IMP (surgeons) and the time 
between biopsy and implantation date (patient). However, although the assessment for the primary 
outcome is subjectively performed by the patient using validated questionnaires, the secondary 
outcome is assessed by independent medical personnel.  
6.2 Methods of minimizing bias  
6.2.1 
Randomization  
A permuted-block (2, 4 and 6 size) randomisation method will be performed. This method will prevent 
confounding of the treatment effect with "disease duration". For each centre there will be a 
randomisation list. The list will be generate by Sealed Envelope online software application 
(https://www.sealedenvelope.com/) and provided to database manager in order to implement and 
allow the automatic group assignation. 
6.2.2 
Blinding procedures  
The study will be unblinded. Manufacturing of immature grafts is performed in a shorter time than for 
the mature grafts and therefore the operation date is at an earlier time point, thus disclosing the type 
of IMP implanted. In addition the physical properties of the two IPMs are different in terms of handling 
and appearance and thus can be easily identified by the surgeons. Therefore, it is not feasible to blind 
the study.  
6.2.3 
Other methods of minimizing bias  
Patients will fill out validated questionnaires, widely used in clinical assessment for the efficacy of 
cartilage repair treatment. 
All MRIs of all clinical centers will be analyzed at the University Hospital Basel by medical personnel 
with special focus on cartilage MRI. They will be blinded to assess for MOCART and 3D MOCART 
scores and dGEMRIC evaluation. 
6.3 Unblinding Procedures (Code break)  
Not applicable 
 

 
Document: 
Clinical Study Protocol 
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Page 50 of 80 
7. STUDY POPULATION  
Patients presenting at hospitals will be treated in five clinical centers (Switzerland, Germany, Italy and 
Croatia) by the respective PIs as mentioned in Chapter 1.2. Harvesting of the starting material (nasal 
cartilage biopsy and blood) will be performed as an outpatient procedure, while the implantation will be 
performed as an in-patient procedure in the respective hospital. At each clinical center a defined 
number of patients should be enrolled (half for therapy with an immature graft, half for therapy with a 
mature graft). In case that less patients are enrolled in one of the centers, another center would have 
the possibility to enroll more patients than initially planned. 
7.1 Eligibility criteria  
Participants fulfilling all of the following inclusion criteria are eligible for the study: 
• 
Patient is 18 and 65 years old at time of screening. 
• 
Patient has a localized articular cartilage defect of the femoral condyle and/or the trochlea 
and/or patella of the knee. 2 localized cartilage defects are accepted if the total defect size is  
8 cm2, both cartilage defects are located at the femoral condyle and/or the trochlea and/or 
patella and both cartilage defects are to be treated with N-CAM or N-TEC. 
• 
Patient has a defect of grade 3 or 4 according to the ICRS classification. 
• 
Patient has a defect size 2 and 8 cm2 as assessed by MRI/arthroscopy. 
• 
Patient has an opposite intact (ICRS Grade 2) articulating joint surface (no "kissing lesions"). 
• 
Patient has an intact meniscus (maximum 1/2-resection). 
• 
Patient has a stable knee joint or sufficiently reconstructed ligaments. If not, ligament repair 
has to be done during the operation or within 6 weeks of the planned cartilage treatment. 
• 
Patient has a maximum baseline score of 75/100 in the KOOS subjective knee evaluation. 
• 
Patient is willing and able to give written informed consent to participate in the study and to 
comply with all study requirements, including attending all follow-up visits and assessments 
and to complete postoperative rehabilitation regimen. 
 
The presence of any one of the following exclusion criteria will lead to exclusion of the participant: 
• 
Patient is the investigator or any sub-investigator, research assistant, pharmacist, study 
coordinator, other staff or relative thereof directly involved in the conduct of the protocol or in a 
dependency or employment with the sponsor. 
• 
Patient is unable to understand the patient information  
• 
Patient is unable to undergo magnetic resonance imaging (MRI) or is sensitive to gadolinium 
• 
Patient has had prior surgical treatment of the target knee within 12 months using 
mosaicplasty and/or microfracture (Note: prior diagnostic arthroscopy with debridement and 
lavage are acceptable within 12 months). Anterior cruciate ligament repair is accepted, if the 
target knee is stable or a primary ACL reconstruction is performed within 6 weeks of the 
planned cartilage treatment. 
• 
Patient has free range of motion of the affected knee joint or  10° of extension and flexion 
loss. 
• 
Patient has a relevant meniscus tear. Partial meniscal removal allowed, if not exceeding 1/2. 
Suture of meniscocapsular separation is allowed. Suture of meniscus tear is allowed if the 
same compartment is not afflicted by symptomatic cartilage injury, and the graft is planned for 
trochlea and /or patella and /or contralateral compartment. If the same compartment is 
afflicted, suture is not allowed in parallel, but if successful, cartilage treatment might be added 
12 months later. 
• 
Patient has radiologically apparent degenerative joint disease in the target knee as 
determined by Kellgren and Lawrence grade >2. 
• 
Patient has evidence of joint disease e.g. chronic inflammatory arthritis, and/or infectious 
arthritis. 
• 
Patient has an unstable knee joint or insufficiently reconstructed ligaments. If ligament repair 
is necessary, the repair has to be performed during the operation or within 6 weeks of the 
planned cartilage treatment. 
• 
Patient has malalignment (no valgus- or varus-deformity) in the target knee  5°. In suspected 
cases, the mechanical axis must be established radiographically through complete leg 
imaging during standing and in a.p. or rather p.a. projection. If alignment surgery is necessary, 
surgery has to be performed within 6 weeks of the planned cartilage treatment. 

 
Document: 
Clinical Study Protocol 
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Dept. of Biomedicine 
Acronym 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 51 of 80 
• 
Patient has an osteochondral defect which cannot be reconstructed (bony substance defect of 
>3mm depth need to be reconstructed with autologous bone graft from tibia or iliac crest). 
Bone marrow edema is allowed. 
• 
Any concomitant painful or disabling disease of the spine, hips, or lower limbs that would 
interfere with evaluation of the afflicted knee. 
• 
Patient has a known systemic connective tissue disease. 
• 
Patient has a known autoimmune disease. 
• 
Patient has a known immunological suppressive disorder or is taking immunosuppressives. 
• 
Patient is currently systemically or intra-articularly taking steroids and/or has used steroids 
within the 30 days prior to the planned treatment. 
• 
The patient has a known history of HIV/AIDS. (Protection of staff) 
• 
The patient has a known history of Treponema pallidum (syphilis). (Protection of staff) 
• 
The patient has an active hepatitis B or C infection with verified antigens. Patients with a 
cured hepatitis B or C infection and/or verified antibodies are not excluded. (Protection of 
staff) 
• 
The patient has at the site of surgery an active systemic or local microbial infection, 
eczematization or inflammable skin alterations (including Protozoonosis: Babesiosis, 
Trypanosomiasis (e.g. Chagas-Disease), Leishmaniasis, persistent bacterial infections, such 
as Brucellosis, spotted and typhus fever, other Rickettsiosis, Leprosy, Recurrent Fever, 
Melioidosis or Tularaemia). 
• 
Patient has a known history of cancer. 
• 
Patient has a known history of primary hyperparathyroidism, hyperthyroidism, reduced kidney 
function (GFR < 80 ml/min), or prior pathological fractures, independent of the genesis. 
• 
Patient has any degenerative muscular, vascular or neurological condition that would interfere 
with evaluation of outcome measures including but not limited to Parkinson's disease, 
amyotrophic lateral sclerosis (ALS), or multiple sclerosis (MS). 
• 
Patient has a body mass index (BMI) >35 kg/m2. 
• 
Patient is pregnant, lactating or anticipates becoming pregnant within 24 months after surgery. 
• 
Patient is currently participating, or has participated in any other clinical study within 3 months 
prior to the screening visit. 
• 
Patient has known current or recent history of illicit drug or alcohol abuse or dependence 
defined as the continued use of alcohol or drugs despite the development of social, legal or 
health problems. 
• 
Patient has psychiatric or cognitive impairment that, in the opinion of the investigator, would 
interfere with the patient's ability to comply with the study requirements, e.g., Alzheimer's 
disease. 
• 
Patient has any other condition, which, in the opinion of the investigator, would make the 
patient unsuitable for the study. 
• 
Patient is unable to tolerate local anesthesia 
• 
Any known allergies, especially for porcine collagen, penicillin or streptomycin  
• 
Patient is unwilling and/or unable to give written informed consent to participate in the study 
and to comply with all study requirements, including attending all follow-up visits and 
assessments and to complete postoperative rehabilitation regimen. 
Intraoperative Exclusion Criteria: 
• 
Patient has a total defect size <2 or defect size extends graft size and could therefore not be 
treated in total. 
• 
Patient has >2 independent cartilage lesions 
• 
Patient has symptomatic full-thickness (ICRS Grade 3 or 4) of tibial plateau. 
7.2 Recruitment and screening  
There is no advertisement for recruitment, since no healthy volunteers are eligible for the trial. No 
compensation or payment will be given to the participants. Patients attending for normal consultation 
at the 5 clinical centers will be screened for participation. If diagnosed with one or two symptomatic, 
cartilage lesions on the femoral condyle and/or trochlea and/or patella, patients will be informed of the 
trial and asked to participate. Before enrollment in the study the patient will receive information in an 
oral and written manner by the PI of the respective center and will be given time to discuss the 
treatment options and study participation with relatives or close persons. Patients will not be coerced 
into participating and will not suffer any disadvantage in treatment by declining to participate: they will 
be treated according to current standards. On signing the informed consent, the patient will be 

 
Document: 
Clinical Study Protocol 
Version: 
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investigated, to see if they are eligible for the clinical trial and meet the inclusion and exclusion criteria 
defined in the study protocol. A baseline MRI will be performed, the questionnaires filled out by the 
patient and screening for pregnancy, if applicable, as well as for viruses and other parameters listed in 
the exclusion criteria carried out. If the patient complies with the eligibility criteria, they will be assigned 
to a treatment group, noted in the enrolment log and given a Patient-ID. 
7.3 Assignment to study groups  
The study group is assigned in phase of patient acceptance to the trial by the MyClinical Data 
database. Once the investigator creates the patient schedule and confirm that the patient is eligible for 
the study, according to inclusion and exclusion criteria and following consent form signed by the 
patient, the software will attribute to study group based on random algorithm.  
7.4 Criteria for withdrawal / discontinuation of participants  
Patients can be excluded from the study by the respective PIs at any point for the following reasons: 
• 
Medical reasons where a continuation of the trial would jeopardize the health of the patient 
• 
Withdrawal of informed consent (final medical follow-up mandatory for patient safety) 
• 
Non-compliance with the required procedures as stated in the patient information and  
informed consent or refusal of the follow-up examinations which are necessary to assess the 
safety and efficacy of the treatment 
• 
Abortion of the clinical study 
• 
Contamination of the IMP during manufacturing  
• 
IMP manufacturing not successful 
• 
Patient fulfills intraoperative exclusion criteria (section 7.1) 
In case patients are excluded from the study, the PI will inform the patient and discuss a final medical 
follow-up date with them. The treatment cannot be terminated, since the intervention is an implantation. 
In case patients are excluded before implantation due to manufacturing issues or intraoperative 
exclusion criteria the surgeon will decide for a suitable treatment. The patient will be marked as 
excluded/study aborted in the enrolment log signed by the PI.  
Patients excluded from the study after implantation will not be replaced, since a drop-out rate of 10% 
has been included in the power-calculation.  
 
 

 
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8. STUDY INTERVENTION  
8.1 Identity of Investigational Products (treatment / medical device)  
8.1.1 
Experimental Intervention (treatment / medical device) 
Name:  
N-TEC 
Sources: 
 GMP production unit at Fraunhofer Institute, Germany (QP: PD Dr. Oliver Pullig) or 
DBM clean room at University Hospital Basel, Switzerland (QP: PD Dr. Werner 
Krenger) 
Composition: 
Chondro-Gide® combined with autologous nasal chondrocytes and extracellular matrix 
containing cartilage specific proteins produced by the cells during preculture 
Appearance: 
glossy-white (cartilaginous) 
 
Size: 
 
30x40 mm 
Dose:  
50 million cells 
Route:  
Implantation in the cartilage defect of the knee and fixation by sutures  
No commercial product available on the market. 
8.1.2 
Secondary study arm (treatment / medical device)  
Name:  
N-CAM 
Sources: 
 GMP production unit at Fraunhofer Institute, Germany (QP: PD Dr. Oliver Pullig) or 
DBM clean room at University Hospital Basel, Switzerland (QP: PD Dr. Werner 
Krenger) 
Composition: 
Chondro-Gide® combined with autologous nasal chondrocytes and minimal to no 
extracellular matrix deposited 
Appearance: 
comparable to appearance of the Chondro-Gide® membrane alone 
 
 
 
Size: 
 
30x40 mm 
Dose:  
50 million cells 
Route:  
Implantation in the cartilage defect of the knee and fixation by sutures  
The commercial product comparable to the IMP is MACI®. This is also based on a matrix of porcine 
collagen Type I/III combined with autologous cells such as Chondro-Gide®. The difference is that for 
MACI®, articular chondrocytes are used, while here nasal chondrocytes will be seeded in order to 
eliminate differences related to the cell source. 
8.1.3 
Packaging, Labelling and Supply (re-supply)  
Labels for both products will be designed in accordance with the EU-GMP-guidelines, Volume 4 
Annex 13. The labels will be in the local language of the country where the IMP will be used. The IMPs 
will be packed individually for each patient in a primary container (tube) within a secondary transport 
container and shipped by overnight courier to the respective clinic. 
8.1.4 
Storage Conditions  
The product will be used immediately on receipt for implantation. Therefore no storage is intended. 

 
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8.2 Administration of experimental and control interventions  
8.2.1 
Experimental Intervention  
After manufacturing, the engineered tissue will be sent to the respective clinic, cut and shaped 
according to the defect size by the surgeon and immediately implanted using sutures for fixation until 
the graft heals in. The sutures are bioresorbable and dissolve with time. No additional preparations are 
necessary. Any unused part of the generated graft will be sent to the research lab (Tissue 
Engineering) in Basel involved in the clinical trial for research provided the patient has given prior 
consent. 
8.2.2 
Control Intervention 
After manufacturing, the cell-seeded graft will be sent to the respective clinic, cut and shaped 
according to the defect by the surgeon and immediately implanted using sutures for fixation until the 
graft heals in. The sutures are bioresorbable and dissolve with time.  No additional preparations are 
necessary. Any unused part of the generated graft will be sent to the research lab (Tissue 
Engineering) in Basel involved in the clinical trial for research provided the patient has given prior 
consent. 
8.3 Dose / Device modifications  
Not applicable. 
8.4 Compliance with study intervention  
Since the treatment itself (implantation) will be done by the surgeons and is a one-time application 
there is no risk of non-compliance. Surgical procedures will be harmonized by training and written 
SOPs. 
In case of missed follow-up appointments, the surgeons will contact the patients and reschedule the 
visit. Questionnaires will be filled in by the patient directly at the time of follow-up using an eCRF. 
Adherence to recommendations regarding sport activities cannot be monitored; performance at 
physiotherapy will be asked of the patient, but not monitored.  
8.5 Data Collection and Follow-up for withdrawn participants  
Data will be collected until the time of withdrawal using the questionnaires and MRIs at the time of 
follow-up. No data will be collected afterwards. A final medical visit is recommended for the safety of 
the patient after withdrawal (minimum 1 year after treatment). 
8.6 Trial specific preventive measures 
There are no specific preventive measures for this trial apart from the ones taken for standard 
operations. Pregnancy tests will be performed at time of enrolment. Contraception using a reliable 
method such as hormonal in combination with a mechanical contraception or double mechanical 
contraception such as diaphragm in combination with condom is advised during study participation. 
Immunosuppressive medication is not allowed during study participation, as it could increase infection 
rate and/or mask signs of inflammation/infection.  
Steroidal medication is not allowed during study participation as it could compromise repair tissue 
formation. 
8.7 Concomitant Interventions (treatments)  
Physiotherapy will be given to the patient after implantation to restore mobility and muscle formation. 
This is part of the study protocol. Patients need to follow a rehabilitation program to ensure proper 
reintegration into daily activities, work and sports and leisure. This process is be accompanied by 
physiotherapists.  
The rehabilitation program includes restriction of weight-bearing and range of motion. Critical limits in 
weight bearing and range of motion are defined as follows: 
- Partial weight bearing (15kg) with use of crutches for 6 weeks. Afterwards stepwise increase as 
tolerated till total weight bearing.  
- Immobilization of the knee in extension for the first week. Limitation of range of motion Ext/Flex 

 
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0/0/30° for the second week, Ext/Flex 0/0/60° for the third and fourth week, Ext/Flex 0/0/90° for the 
fifth and sixth week. Afterwards free range of motion.  
The rehabilitation program is complemented with passive continuous motion application and amongst 
others with strength and proprioceptive training. Due to the different possibilities for postsurgical 
physiotherapy in the different countries with different health insurance coverage, a supporting web-
based rehabilitation platform will be integrated (VideoReha.com). Patients and physiotherapists have 
the possibility to follow instructive videos suggesting appropriate exercises in the different phases of 
rehabilitation. This is an optional offer for patients and physiotherapists. 
8.8 Study Drug / Medical Device Accountability  
The immature and mature grafts will be prepared, produced, tested, packed and shipped to the 
respective clinic according to GMP and GDP standards and reviewed by the National Competent 
Authorities (D, CH). The IMPs will be implanted immediately on arrival according to the study protocol 
reviewed and approved by the competent authorities of the respective countries and will not be stored. 
Each IMP will be individually produced for the patient: therefore the batch size is one and the batch 
number will equal the patient ID. The remains of the IMPs will not be used further in the clinic, but will 
be sent to the Tissue Engineering Lab, University Hospital Basel, for further scientific research 
purposes, provided the patient has given prior consent, and will be destroyed in this process.  
8.9 Return or Destruction of Study Drug / Medical Device  
Remains of the IMP after implantation as well as excess cells from production will be sent to the 
Tissue Engineering Lab, University Hospital Basel, 4031 Basel, Switzerland for research purposes if 
the patient has given prior consent. Remains of the IMPs will be destroyed during analysis. If the 
patient does not consent to donating samples for research, they will be discarded according to the 
individual hospital’s policies. 
 
 

 
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9. STUDY ASSESSMENTS  
9.1 Study flow chart(s) / table of study procedures and assessments 
Study Periods 
Screening 
Treatment 
Follow-up 
Visit 
1 
2 
3 
4 
5 
6 
7 
8 
Time (hour, day, 
week) 
8m 
2m 
- 3-4.3 w 
Day 0 
6 w 
3m 
12m 
24m 
Day 
240 
 60 
- 19-30 
0 
42 
90 
360 
720 
Acceptable time delay 
 
 
0d 
1d 
2w 
2w 
6w 
8w 
Patient Information 
and Informed Consent 
x 
 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
 
In- /Exclusion Criteria 
x 
 
 
 
 
GFR 
GFR 
GFR 
Laboratory Tests 
(Serology) 
x 
 
x 
 
 
 
 
 
Pregnancy Test 
x 
 
 
 
 
 
 
 
Randomisation 
 
x 
 
 
 
 
 
 
MRI 
x 
x***** 
 
 
 
x 
x 
x 
Questionnaires 
x 
x**** 
 
 
 
 
x 
x 
Harvesting of biopsy 
and blood 
 
 
x 
 
 
 
 
 
Surgery (implantation) 
 
 
 
x 
 
 
 
 
Clinical examination  
x 
x 
x 
x 
x 
x 
x 
x 
Physiotherapy* 
 
 
 
 
x 
x 
x*** 
 
Adverse Events** 
x 
x 
x 
x 
x 
x 
x 
x 
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9.2 Assessments of outcomes  
9.2.1 
Assessment of primary outcome  
The primary outcome is the KOOS subjective score at 24-month follow-up visit and it will be assessed 
by the KOOS questionnaire. The KOOS questionnaire is a self-assessment by the patient and covers 
the areas of symptoms, pain, activities of daily life, sport activities and quality of life. The patient will 
complete the questionnaire online during each visit, i.e. at time of enrolment (baseline) as well as at 24 
month follow-up visit. Additional questionnaires can be filled out on a voluntary basis at month 60. The 
score is automatically calculated according to the equation defined in the questionnaire. This validated 
questionnaire is widely used for clinical assessment of cartilage repair and therefore will also provide a 
high comparability to other studies.  

 
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9.2.2 
Assessment of secondary outcomes 
The secondary outcome is related to the stability, integration and remodeling of the graft to assess the 
quality of the repair tissue in order to determine whether there is a correlation to the primary outcome. 
Stability and integration are assessed using MRI, where the pictures will be interpreted by experienced 
and independent medical personnel. The MOCART (magnetic resonance observation of cartilage 
repair tissue) score will be used to assess the integration, stability and morphological properties of the 
graft at 24 month follow-up. The score parameters include: filling of the defect, integration of the 
border zone to the adjacent cartilage, intactness of the subchondral lamina, intactness of the 
subchondral bone, relative signal intensities of the repair tissue compared to the adjacent native 
cartilage, and others. 
Since the harvesting of second look biopsies is not planned as standard for ethical reasons, dGEMRIC 
is chosen as an alternative non-invasive method to assess the quality of the repair tissue. This method 
will give a quantification of glycosaminoglycan content of the repair tissue in relation to the healthy 
native cartilage.  
The KOOS Score is also collected after 12 month to evaluate the development of the patient’s health 
status. An additional self-assessment questionnaire used is the EQ-5d questionnaire. These 
questionnaires provide additional information for comparability with other studies. 
9.2.3 
Assessment of other outcomes of interest 
Retrospectively the data collected in the primary and secondary outcome will be used for analysis with 
regard to the onset of symptoms. The patients will be classified regarding the onset of symptoms as 
acute (onset < 2 years) or chronic (onset > 2 years) and differences between the treatment groups as 
well as within the treatment groups will be analyzed in order to identify possible correlation between 
the efficacy of the IMP treatment and the time of onset of symptoms. 
In addition a subgroup analysis to compare the outcome with regard to the localization of the defect 
(patella vs. femoral condyle/trochlea) will be performed in order to evaluate, how the outcome of 
patella defects, which are known to have an inferior clinical outcome in standard therapies, is in case 
of treatment with N-TEC and N-CAM. 
 
9.2.4 
Definition of treatment failure 
Treatment failure is defined as: “Objective pathological clinical findings by the investigator, which are 
directly correlated with subjective patients complaints resulting in a deterioration of the subjective 
clinical outcome assessed by KOOS and the 5 KOOS subscores.” 
Clinical deterioration is defined as reduction in the KOOS score of > 10 compared to baseline. A non-
responding to treatment is defined as improvement of < 10 in the KOOS score.  
Furthermore, revision surgery rate independent of cause and deterioration of the subjective clinical 
outcome assessed by KOOS and the 5 KOOS subscores independent of correlation with IMPs will be 
assessed and analyzed. 
9.2.5 
Assessment of safety outcomes 
9.2.5.1 
Adverse events  
All AEs (see Chapter 10 for definition) will be recorded in the eCRF. Among the expected adverse 
events are those associated with the application of the IMP (anesthesia & operation) as described in 
Chapter 3.7 under “Risks & Benefits”. Other adverse events can be associated with surgical and 
medical procedures, arthralgia, joint effusion, decreased joint range of motion, and infections (joint, 
wound) or related to the IMP itself. These parameters will be checked at each follow-up visit or if the 
patient reports any kind of indisposition in between the visits. 
All SAEs will be reported to the Sponsor-investigator or his designee according to the SOP of the 
Sponsor. Information in the reporting form includes: reporting center, Patient-ID, Information on 
surgery, other treatments already performed and details of the adverse event (affected site, symptoms, 
time of onset/end, time course, diagnosis and expected outcome (if possible)). The PI of the 
respective clinic as well as the Sponsor-investigator or his designee will perform an assessment on 
causality and decide on the necessary reporting.  
All SAEs resulting in death will be reported to the ethical committee and the national competent 
authority as well as to Swissmedic within 7 days.  

 
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All SUSARs and SADRs will be reported by the Sponsor-Investigator to Swissmedic, the respective 
national competent authorities and the local ethical committee within 7 days in case of death; 
otherwise within 15 days, as well as to all investigators involved in the trial. Reports to local ethical 
committees will be performed by the PI of the respective site. 
 
 
 
 
 
Any occurring adverse event will be documented and treated during and after the trial. The patients 
will be followed until side effects are resolved or stable for at least 3 months. 
9.2.5.2 
Laboratory parameters 
Not applicable 
9.2.5.3 
Vital signs 
Not applicable 
9.2.6 
Assessments in participants who prematurely stop the study 
Depending on the time of withdrawal, participants prematurely leaving the study might enter the 
normal follow-up schedule for patients after knee operations performed with the standard procedure or 
will be scheduled for a final medical consultation for their own safety.  
9.3 Procedures at each visit 
9.3.1 
Visit 1: Screening visit (-240 days or less) 
The screening visit will take place after the informed consent has been signed. Blood will be taken 
from the patient and sent to the respective laboratories for analysis of the parameters listed in the 
inclusion and exclusion criteria. MRI can be performed if not available from a recent visit to an external 
physician. Questionnaires will be filled to see, if the patient fulfills inclusion and exclusion criteria. The 
visit should take place maximal 8 months before the treatment start (Biopsy harvesting). If all inclusion 
and exclusion criteria are met, the patient can be randomized. 
9.3.2 
Visit 2: Screening visit (Day -60 or less) 
The baseline data for the questionnaires regarding the clinical scores (KOOS, EQ-5d) and an MRI will 
be acquired, if not already available. A physical examination of the knee joint will be performed 
according to the ICRS knee examination form. Provided that the patient fulfills all inclusion/exclusion 
criteria, the patient is accepted for the clinical trial and randomly assigned to a treatment group. The 
elapsed time between visit one and two should be a maximum of 6 months. Questionnaires must not 
be older than 6 months before start of treatment (biopsy harvesting). Otherwise they must be repeated. 
Screening visit 1 and 2 can be combined.  
9.3.3 
Visit 3: Harvesting of nasal cartilage biopsy and blood (Day -14 or -28) 
The nasal cartilage and the blood will be harvested during an out-patient procedure, with the patient 
returning for a check-up and removal of the tamponade the next day. Additional serology testing (HIV 
1 and 2, Hepatitis B, Hepatitis C, Syphilis) have to be performed. 
9.3.4 
Visit 4: Implantation (Day 0-5) 
The patient will be admitted to the hospital on the day of implantation and will stay in hospital for an 
average of 5 days after their operation. During this time follow-up will be performed according to the 
standard post-operative procedures and results will be controlled and recorded in the patient’s dossier. 
All AE will be recorded in the eCRF and graded. 
9.3.5 
Visit 5: Clinical follow up (day 42 (6w)) 
The recovery and clinical course will be checked and the patient will be asked about any AEs. The 
threads will be removed after 2 weeks. In addition, the patient will be asked about any consequences 
from the harvesting procedure of the nasal cartilage. Furthermore the patient will be asked about the 
ongoing physiotherapy. 
9.3.6 
Visit 6: Clinical follow-up and efficacy assessment (Day 90 (3m)) 
The wound healing will be checked and the patient asked about any AEs. In addition the patient will be 
asked about any consequences from the harvesting procedure of the nasal cartilage and the ongoing 
or completed physiotherapy. Furthermore an MRI/dGEMRIC will be performed to assess the stability 

 
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and remodeling of the graft. The renal function will be assessed before the contrast agent (Dotarem®) 
is given. 
9.3.7 
Visit 7-8: Clinical follow-up and efficacy assessment (Day 360 (12m), Day 720 (24m)) 
The wound healing will be checked and the patient asked about any AEs. In addition the patient will be 
asked about any consequences from the harvesting procedure of the nasal cartilage and the ongoing 
or completed physiotherapy. Furthermore the patient will be asked to fill out the questionnaires 
regarding the clinical scores (KOOS, EQ-5d) and an MRI/dGEMRIC will be performed to assess the 
stability and remodeling of the graft. The renal function will be assessed before the contrast agent 
(Dotarem ®) is given. 
 
 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
6 0 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 6 0 of 8 0 
1 0. S A F E T Y  
1 0. 1 Dr u g st u di e s 
T h e S p o n s or’ s S O P s pr o vi d e m or e d et ail o n s af et y r e p orti n g. 
D u ri n g t h e e ntir e d ur ati o n of t h e st u d y ( c at e g or y C), all a d v er s e e v e nt s ( A E) a n d all s eri o u s a d v er s e 
e v e nt s ( S A E s) ar e c oll e ct e d, f ull y i n v e sti g at e d a n d d o c u m e nt e d i n s o ur c e d o c u m e nt s ( p ati e nt’ s 
r e c or d s) a n d c a s e r e p ort f or m s ( C R F s). St u d y d ur ati o n e n c o m p a s s e s t h e ti m e fr o m w h e n t h e 
p arti ci p a nt si g n s t h e i nf or m e d c o n s e nt u ntil t h e l a st pr ot o c ol- s p e cifi c pr o c e d ur e h a s b e e n c o m pl et e d, 
a n d i n cl u d e s a s af et y f oll o w- u p p eri o d of u p t o 2 y e ar s a n d p o st-tri al u p t o 5 y e ar s. 
1 0. 1. 1 
D efi niti o n a n d a s s e s s m e nt of ( s eri o u s) a d v er s e e v e nt s a n d ot h er s af et y r el at e d e v e nt s 
A n A d v er s e E v e nt ( A E)  i s a n y u nt o w ar d m e di c al o c c urr e n c e i n a p ati e nt or a cli ni c al i n v e sti g ati o n 
p arti ci p a nt a d mi ni st er e d a p h ar m a c e uti c al pr o d u ct a n d w hi c h d o e s n ot n e c e s s aril y h a v e a c a u s al 
r el ati o n s hi p wit h t h e st u d y pr o c e d ur e. A n A E c a n t h er ef or e b e a n y u nf a v or a bl e a n d u ni nt e n d e d si g n 
(i n cl u di n g a n a b n or m al l a b or at or y fi n di n g), s y m pt o m, or di s e a s e t e m p or all y a s s o ci at e d wit h t h e u s e of 
a m e di ci n al (i n v e sti g ati o n al) pr o d u ct, w h et h er or n ot r el at e d t o t h e m e di ci n al (i n v e sti g ati o n al) pr o d u ct.  
A S eri o u s A d v er s e E v e nt ( S A E)  i s cl a s sifi e d a s a n y u nt o w ar d m e di c al o c c urr e n c e t h at: 
•   
r e s ult s i n d e at h, 
•   i s lif e-t hr e at e ni n g, 
•   
r e q uir e s i n- p ati e nt h o s pit ali z ati o n or pr ol o n g ati o n of e xi sti n g h o s pit ali z ati o n, 
•   
r e s ult s i n p er si st e nt or si g nifi c a nt di s a bilit y/i n c a p a cit y, or 
•   i s a c o n g e nit al a n o m al y/ birt h d ef e ct. 
I n a d diti o n, i m p ort a nt m e di c al e v e nt s t h at m a y n ot b e i m m e di at el y lif e-t hr e at e ni n g or r e s ult i n d e at h, or 
r e q uir e h o s pit ali z ati o n, b ut m a y j e o p ar di z e t h e p ati e nt or m a y r e q uir e i nt er v e nti o n t o pr e v e nt o n e of t h e 
ot h er o ut c o m e s li st e d a b o v e s h o ul d al s o u s u all y b e c o n si d er e d s eri o u s. [I C H E 2 A] 
E x a m pl e s of s u c h e v e nt s ar e i nt e n si v e tr e at m e nt i n a n e m er g e n c y r o o m or at h o m e f or all er gi c 
br o n c h o s p a s m, bl o o d d y s cr a si a or c o n v ul si o n s t h at d o n ot r e s ult i n h o s pit ali z ati o n, or d e v el o p m e nt of 
dr u g d e p e n d e n c y or dr u g a b u s e.  
S A E s s h o ul d b e f oll o w e d u ntil r e s ol uti o n or st a bili z ati o n. P arti ci p a nt s wit h o n g oi n g S A E s at st u d y 
t er mi n ati o n (i n cl u di n g s af et y vi sit) will b e f urt h er f oll o w e d u p u ntil r e c o v er y or u ntil st a bili z ati o n of t h e 
di s e a s e aft er t er mi n ati o n.  
 
A s s e s s m e nt of C a u s alit y 
B ot h I n v e sti g at or a n d S p o n s or-i n v e sti g at or m a k e a c a u s alit y a s s e s s m e nt of t h e e v e nt i n r el ati o n t o t h e 
I M P. T h e c a u s alit y i s b a s e d o n t h e q u e sti o n, w h et h er t h er e i s a “r e a s o n a bl e p o s si bilit y” or “ n o 
r e a s o n a bl e p o s si bilit y” t h at t h e st u d y tr e at m e nt c a u s e d t h e e v e nt. 
 
U n e x p e ct e d A d v er s e Dr u g R e a cti o n 
A n “ u n e x p e ct e d” a d v er s e dr u g r e a cti o n i s a n a d v er s e r e a cti o n, t h e n at ur e or s e v erit y of w hi c h i s n ot 
c o n si st e nt wit h t h e a p pli c a bl e pr o d u ct i nf or m ati o n ( e. g. I n v e sti g at or’ s Br o c h ur e f or dr u g s t h at ar e n ot 
y et a p pr o v e d a n d Pr o d u ct I nf or m ati o n f or a p pr o v e d dr u g s, r e s p e cti v el y).  
 
S u s p e ct e d U n e x p e ct e d S eri o u s A d v er s e R e a cti o n s ( S U S A R s) 
T h e S p o n s or-I n v e sti g at or e v al u at e s a n y S A E t h at h a s b e e n r e p ort e d r e g ar di n g s eri o u s n e s s, c a u s alit y 
a n d e x p e ct e d n e s s. If t h e e v e nt i s r el at e d t o t h e i n v e sti g ati o n al pr o d u ct a n d i s b ot h s eri o u s a n d 
u n e x p e ct e d, it i s cl a s sifi e d a s a S U S A R.  
 
A s s e s s m e nt of S e v erit y 
All A E s will b e cl a s sifi e d a c c or di n g t o t h e N ati o n al C a n c er I n stit ut e C o m m o n T er mi n ol o g y Crit eri a 
f or A d v er s e E v e nt s ( C T C A E) V er si o n 4. 0 3 ( 2 0 1 0) a s Gr a d e 1 mil d, 2 m o d er at e, 3 s e v er e, 4 lif e 
t hr e at e ni n g. 
 

 
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10.1.2 Reporting of serious adverse events (SAE) and other safety related events  
Reporting of SAEs 
All SAEs must be reported immediately and within a maximum of 24 hours to the Sponsor-Investigator 
of the study or his substitute. The Sponsor-Investigator will re-evaluate the SAE. 
SAEs resulting in death are reported to the local Ethics Committee (via local Investigator) within 7 
days. 
The other Ethics Committees involved in the trial as well as Swissmedic receive SAEs resulting in 
death via Sponsor-Investigator within 7 days. 
 
Reporting of SUSARs 
A SUSAR needs to be reported to the local Ethics Committee (local event via local Investigator) and to 
Swissmedic for category B and C studies (via Sponsor-Investigator) within 7 days, if the event is fatal, 
or within 15 days (all other events). 
The Sponsor-Investigator must inform all Investigators participating in the clinical study of the 
occurrence of a SUSAR. All Ethics Committees involved in the trial will be informed about SUSARs in 
Switzerland via Sponsor-Investigator according to the same timelines. 
All SAEs having a suspected link to the IMP administered (Serious adverse drug reaction (SADR)) 
must be reported in the same way as SUSARs. 
 
Reporting of Safety Signals 
All suspected new risks and relevant new aspects of known adverse reactions that require safety-
related measures, i.e. so called safety signals, must be reported to the Sponsor-Investigator within 24 
hours. The Sponsor-Investigator must report the safety signals within 7 days to the local Ethics 
Committee (local event via local Investigator) and to Swissmedic in case of a category B or C study. 
The Sponsor-Investigator must immediately inform all participating Investigators about all safety 
signals. The other Ethics Committees involved in the trial will be informed about safety signals via the 
Sponsor-Investigator. 
 
Reporting and Handling of Pregnancies 
Pregnant participants will be followed-up in the normal way, but will not be subjected to the dGEMRIC 
MRI due to the need to apply a contrast agent (Dotarem®). Further follow-up after the end of the study 
and the outcome of the pregnancy is not necessary. 
 
Periodic reporting of safety 
A development safety update report (DSUR) is submitted once a year to the local Ethics Committees 
and to the national authorities via Sponsor-Investigator. 
For multicenter studies the DSUR contains information from all sites including information from sites 
outside Switzerland. The Sponsor-Investigator prepares it, and then submits it to the National 
Competent Authorities and participating Investigators.   
10.1.3 Follow up of (Serious) Adverse Events 
Any SAE or AE initiated within the study period (ongoing, completed or withdrawn) shall be followed 
until considered as resolved by the investigator. All efforts shall be made to gather laboratory and 
clinical data which will be reported in the CRF and the SAE narrative. 
 
 

 
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11. STATISTICAL METHODS  
11.1 Hypothesis 
The primary endpoint is the Knee injury and Osteoarthritis Outcome Score (KOOS) measured 24 
months after surgery. The score ranges from 0–100; the higher the score, the better the outcome. The 
null hypothesis is that there is no difference in the primary endpoint between N-TEC and N-CAM (H0 : 
KOOSN–TEC – KOOSN–CAM = 0). The alternative hypothesis is that N-TEC and N-CAM differ significantly 
in terms of the primary endpoint (HA : KOOSN–TEC – KOOSN–CAM =   0). An absolute difference () of 
10 score points or more is considered clinically relevant. These hypotheses will determine whether the 
primary objective, namely that therapy with a mature graft will improve the clinical efficacy for the 
patient, is met. 
11.2 Determination of Sample Size  
Sample size was estimated to be such that it would be able to show the superiority of N-TEC to N-
CAM regarding the primary endpoint. Assumptions for sample size calculation were based on a study 
(Saris et al., 2008), in which an increase in a mean overall KOOS score after 18 months of 18 points 
to a final value of 74.73 with a standard deviation of 17.01 was reported. We have assumed that the 
effect size after 24 months will be at least as big.  
Sample size was calculated using a resampling method. Each sample size (ni=1,...,21 = 40, ..., 160) 
was evaluated by sampling R = 999 times, ni/2 KOOS scores from a normal distribution with  = 75 
and  = 17 for the N-CAM group, and ni/2 KOOS scores from a normal distribution with  = 75 +  and 
 = 17 for the N-TEC group. The size of  was varied between 5 and 15. Values that exceeded 100 
were set to 100.  
N-CAM and N-TEC were tested for a difference in KOOS score using a two-sided t-test. Superiority of 
N-TEC to N-CAM was declared when the test showed a significant result. Sample size was set to 
ensure at least 80 % power (1 -  = 0.8), at a significance level of  = 5 %. 
For this study, 108 patients should be recruited to ensure 97 evaluable patients at a power of 80%, 
considering an overall drop-out rate of 10% (Figure 11.2.1). 
 
Fig. 11.2.1: Sensitivity of the sample size with regard to absolute difference in KOOS after 24 months (N-TEC vs. 
N-CAM), assuming a mean KOOS of 75 for N-CAM. An example is given based on an expected absolute 
difference of 10 score points (Curves are smoothed and are for illustrative purpose only) 
 

 
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11.3 Statistical criteria for termination of trial  
Not applicable 
11.4 Planned Analyses  
11.4.1 Datasets to be analysed, analysis populations 
The full analysis set (FAS) consists of all patients who were randomized, regardless of treatment 
conclusion or loss of follow-up (Intention To Treat principle – ITT).  
The per protocol set (PPS) consists of all patients who have at least one follow-up measure. Patients 
in the PPS will be analyzed according to the treatment received without randomization. 
The FAS will be used for the primary analysis and the secondary analyses as described. The PPS will 
be used for sensitivity analyses of the primary analysis and the secondary analyses as described. 
Demographics and relevant baseline variables will be summarized for the FAS. Categorical data will 
be presented as frequencies and percentages. For continuous variables, the lower and upper quartile, 
the median, the mean and the standard deviation will be presented. 
11.4.2 Primary Analysis 
The primary objective is to demonstrate in patients younger than 65 years with articular knee cartilage 
injuries the superiority of N-TEC to N-CAM, assessing by KOOS measured 24 months after surgery. 
The primary endpoint will be analyzed with a linear mixed effects model, including therapy (N-TEC vs. 
N-CAM; categorical variable) as single explanatory variable (fixed effect), and including study center 
as random effect variable to account for the multicenter study design. 
Sensitivity analyses: As a sensitivity analysis, we will analyze the primary endpoint by adjusting for 
covariates and testing for interactions. The linear mixed-effects model will include therapy (N-TEC vs. 
N-CAM; categorical variable), onset of symptoms (stratified categorical: acute: <= 1 years; chronic: > 1 
years) and the covariate baseline KOOS (continuous variable) as explanatory variables (fixed effects). 
In addition, the model will include the interaction between therapy and onset of symptoms. A 
significant interaction would indicate that the outcome of the therapy depends on how long the 
symptoms have been present. Further, study center will be included as a random effect variable in the 
model to account for the multicenter study design.  
11.4.3 Secondary Analyses 
The following secondary endpoints will be analyzed: 
• KOOS score at 12 months after surgery 
• relative GAG-content (rel. CR1) by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) 3, 12 
and 24 months after surgery 
• MOCART score at 3,12 and 24 months after surgery 
• EQ-5d score at 12 and 24 months after surgery 
All secondary endpoints will be analyzed with a linear mixed effects model as described for the 
sensitivity analysis of the primary endpoint (with the corresponding baseline scores as covariate). If 
necessary, endpoints will be transformed in order to fulfill assumption of a normal residual distribution, 
or, if no reasonable transformation can be found, generalized linear mixed-effects models will be 
applied. 
11.4.4 Interim analyses 
Adjustments are not necessary in this trial, since the application is a one-time procedure and there are 
no stopping guidelines foreseen for this trial. It is not expected, that the implant will have a negative 
systemic effect. 
11.4.5 Safety analysis 
All SARs and SUSARs are recorded. The annual safety report summarizes all SAEs, SARs and 
SUSARs. No other safety analysis is planned. 

 
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11.4.6 Deviation(s) from the original statistical plan  
If substantial deviations of the analysis as outlined in this chapter are needed for whatever reason the 
protocol will be amended. All deviations of the analysis from the protocol or from the detailed analysis 
plan will be listed and justified in a separate chapter of the final statistical report.  
11.5 Handling of missing data and drop-outs  
Careful trial planning and conduct should minimize the occurrence of missing data as far as possible. 
We will consider bootstrap multiple imputation procedures for the analyses of the FAS. No imputation 
of missing values is planned for the PPS. Thus, if there are patients lost to follow-up visits, they will not 
be included in analyses of endpoints measured at later follow ups. 
A drop-out rate of 10% was considered for sample size estimation. 
All primary and secondary analyses described above will be repeated with the PPS and included as 
sensitivity analyses.  
 
 
 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
6 5 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 6 5 of 8 0 
1 2. Q U A LI T Y A S S U R A N C E A N D C O N T R O L  
T h e S p o n s or- PI or hi s d e si g n e e i s r e s p o n si bl e f or i m pl e m e nti n g a n d m ai nt ai ni n g q u alit y a s s ur a n c e 
a n d q u alit y c o ntr ol s y st e m s wit h writt e n S O P s a n d w or ki n g i n str u cti o n s at all sit e s of t h e m ulti c e nt er 
st u d y. All S O P s a n d w or ki n g i n str u cti o n s will b e writt e n i n E n gli s h t o e n s ur e u n d er st a n di n g a n d 
h ar m o ni z e d pr o c e d ur e s f or tr e at m e nt, r e h a bilit ati o n a n d f oll o w- u p at all sit e s. T h e PI of e a c h sit e i s 
r e s p o n si bl e f or pr o p er tr ai ni n g of all i n v ol v e d st u d y p er s o n n el at hi s sit e. 
T h e K O O S- q u e sti o n n air e a s a m e a s ur e f or t h e pri m ar y o ut c o m e will b e i n cl u d e d i n t h e el e ctr o ni c C R F 
t o b e fill e d o ut b y t h e p ati e nt dir e ctl y at t h e sit e.  
All i n v e sti g at or s dir e ctl y i n v ol v e d i n t h e p ati e nt’ s i nf or m ati o n, st u d y i nt er v e nti o n a n d f oll o w- u p will h a v e 
t o pr o vi d e t h e c ertifi c at e of G C P-tr ai ni n g a n d/ or f oll o w a d diti o n al n ati o n al a n d l o c al r e q uir e m e nt s o n 
i n v e sti g at or q u alifi c ati o n. 
1 2. 1 D at a h a n dli n g a n d r e c or d k e e pi n g / ar c hi vi n g  
D at a will b e c oll e ct e d o nl y fr o m p ati e nt s w h o h a v e gi v e n t h eir writt e n c o n s e nt t o o ur st u d y. T h eir 
m e di c al r e c or d s will b e h a n dl e d c o nfi d e nti all y. O nl y m e m b er s of t h e st u d y t e a m, m o nit or s a n d t h e 
r e s p e cti v e a ut h oriti e s ( et hi c al c o m mitt e e s, c o m p et e nt a ut h oriti e s) will h a v e a c c e s s t o t h e d at a. 
A n e nr ol m e nt l o g will b e k e pt at e a c h sit e a s w ell a s a c o d e li st t o li n k t h e p ati e nt’ s n a m e wit h t h eir 
p ati e nt I D. D o c u m e nt s will b e st or e d a c c or di n g t o t h e h o s pit al r e g ul ati o n s, b ut f or a mi ni m u m of 3 0 
y e ar s.  
1 2. 1. 1 
C a s e R e p ort F or m s  
All d at a c oll e ct e d d uri n g t hi s st u d y will b e dir e ctl y r e c or d e d i n a n e C R F s p e cifi c f or t h e p ati e nt. T hi s 
a p pli e s t o f oll o w- u p d at a a s w ell a s t o t h e q u e sti o n n air e s c o m pl et e d b y t h e p ati e nt. D at a t h at n e e d t o 
b e e nt er e d aft er a f oll o w- u p vi sit ( e. g. l a b r e s ult s fr o m s cr e e ni n g) will b e e nt er e d i n t h e e C R F b y si n gl e 
d at a e ntr y. All M RI d at a will b e e nt er e d a s a d o u bl e d at a e ntr y b y B a s el. E a c h p h y si ci a n of t h e tri al will 
a c c e s s t h e e C R F vi a t h e I nt er n et u si n g hi s o w n l o gi n a n d t h er e b y b e i d e ntifi e d b y t h e s y st e m. O nl y 
a ut h ori z e d p er s o n n el will r e c ei v e a l o gi n. T h e e C R F will c o nt ai n t h e f oll o wi n g i nf or m ati o n: 
1. 
B a s eli n e c h ar a ct eri sti c s 
•   
P ati e nt I D a n d birt h d at e 
•   
Hi st or y of i nj ur y 
•   
P ati e nt d at a ( a g e, B MI et c.) 
•   
C artil a g e d ef e ct cl a s sifi c ati o n 
•   
M e di c al hi st or y (i n cl u si o n/ e x cl u si o n crit eri a) 
•   
L a b or at or y r e s ult s 
•   
S c or e s fr o m q u e sti o n n air e s 
 
2. I nt er v e nti o n v ari a bl e s 
•   
D at a f or h ar v e sti n g of t h e n a s al bi o p s y a n d bl o o d 
•   
D at a f or i m pl a nt ati o n ( a s s e s s m e nt of gr aft, c artil a g e d ef e ct cl a s sifi c ati o n)  
•   
F oll o w- u p r e g ar di n g cli ni c al e x a mi n ati o n  
 
3. 
O ut c o m e v ari a bl e s 
a) 
Cli ni c al effi c a c y 
•   
Q u e sti o n n air e s ( e. g. K O O S) at m o nt h s 1 2, 2 4 
 
b) 
Gr aft st a bilit y a n d r e m o d eli n g 
•   
M RI a n d d G E M RI C d at a at m o nt h s 1 2, 2 4 
 
c) 
S af et y 
•   
A d v er s e e v e nt s/ a d v er s e dr u g r e a cti o n s: gr a d e d a c c or di n g t o s e v erit y ( C T C A E V er si o n 
4. 0 3/ 2 0 1 0 a s gr a d e 1 mil d, 2 m o d er at e, 3 s e v er e, 4 lif e t hr e at e ni n g, 5 d e at h), 
e x p e ct e d n e s s, a n d r el ati o n s hi p t o tri al tr e at m e nt 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
6 6 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 6 6 of 8 0 
1 2. 1. 2 
S p e cifi c ati o n of s o ur c e d o c u m e nt s  
S o ur c e d at a will b e a v ail a bl e at all sit e s t o d o c u m e nt t h e e xi st e n c e of t h e st u d y p arti ci p a nt s o n e a c h 
sit e. S o ur c e d at a will i n cl u d e t h e f oll o wi n g d o c u m e nt s: 
•   
m e di c al r e c or d s of e a c h p ati e nt ( alt h o u g h f or t h e m o st of t h e m n ot p art of t h e e C R F, t h e s e 
r e c or d s ar e u s e d t o r e c or d all d at a r o uti n el y a s s o ci at e d wit h t h e p ati e nt’ s tr e at m e nt). 
T h e s e c a n b e p a p er d o c u m e nt s or el e ctr o ni c.  
•   i nf or m e d c o n s e nt s of t h e p ati e nt f or t h e st u d y a n d a n y r e g ul ar i nf or m e d c o n s e nt s  
•   l a b or at or y r e s ult s ( e nt er e d i n e C R F aft er a vi sit) 
•   
M RI r e s ult s ( e nt er e d i n e C R F aft er a vi sit) 
•   
D at a dir e ctl y r e c or d e d i n t h e e C R F ( e. g. q u e sti o n n air e s, p ati e nt d at a, i nt er v e nti o n d at a). 
T h e s e c a n al s o b e r e c or d e d o n p a p er a n d e nt er e d i n t h e e C R F l at er b y si n gl e e ntr y. 
L o c ati o n of S o ur c e d at a: 
S wit z erl a n d:  
S o ur c e d at a i n p a p er f or m will b e k e pt i n t h e offi c e of t h e PI u n d er l o c k a n d k e y. S o ur c e d at a will al s o 
b e st or e d el e ctr o ni c all y i n t h e h o s pit al s y st e m. 
G er m a n y:  
S o ur c e D at a will b e k e pt i n t h e offi c e of t h e St u d y C o or di n at or, u n d er l o c k a n d k e y. S o ur c e d at a will 
al s o b e st or e d el e ctr o ni c all y i n t h e h o s pit al s y st e m. ( Fr ei b ur g) 
S o ur c e D at a will b e k e pt i n t h e offi c e of t h e St u d y C o or di n at or, u n d er l o c k a n d k e y ( W ür z b ur g). 
It al y:  
S o ur c e d at a i n p a p er f or m, a s i nf or m e d c o n s e nt, will b e k e pt i n t h e Pr oj e ct M a n a g er offi c e, u n d er l o c k 
a n d k e y. T h e m e di c al r e c or d s of p ati e nt s will b e st or e d i n t h e h o s pit al p a p er ar c hi v e (l o c at e d o ut si d e 
t h e h o s pit al). S o ur c e d at a will al s o b e st or e d el e ctr o ni c all y i n t h e h o s pit al s y st e m. 
Cr o ati a:  
St u d y s p e cifi c s o ur c e d o c u m e nt s will b e st or e d at PI’ s offi c e wit h r e stri ct e d a c c e s s. 
1 2. 1. 3 
R e c or d k e e pi n g / ar c hi vi n g  
S wit z erl a n d: 
All st u d y d at a m u st b e ar c hi v e d f or a mi ni m u m of 2 0 y e ar s aft er st u d y t er mi n ati o n or pr e m at ur e 
t er mi n ati o n of t h e cli ni c al tri al. Ar c hi vi n g will b e c arri e d o ut a c c or di n g t o h o s pit al r e g ul ati o n s. 
G er m a n y: 
All St u d y D at a m u st b e ar c hi v e d f or a mi ni m u m of 3 0 y e ar s (r e g ar di n g tr a n s pl a nt ati o n a ct) aft er st u d y 
t er mi n ati o n or pr e m at ur e t er mi n ati o n of t h e cli ni c al tri al. Ar c hi vi n g of st u d y r el at e d d o c u m e nt s will b e 
p erf or m e d i n t h e h o s pit al s ar c hi v e. 
It al y:  
All st u d y d at a m u st b e ar c hi v e d f or a mi ni m u m of 1 0 y e ar s aft er st u d y t er mi n ati o n or pr e m at ur e 
t er mi n ati o n of t h e cli ni c al tri al. Ar c hi vi n g will b e c arri e d o ut a c c or di n g t o h o s pit al r e g ul ati o n s. 
Cr o ati a: 
All st u d y d at a m u st b e ar c hi v e d f or a mi ni m u m of 2 0 y e ar s aft er st u d y t er mi n ati o n or pr e m at ur e 
t er mi n ati o n of t h e cli ni c al tri al. Ar c hi vi n g will b e c arri e d o ut a c c or di n g t o h o s pit al r e g ul ati o n s. 
1 2. 2 D at a m a n a g e m e nt  
D at a c oll e ct e d d uri n g t h e st u d y, a c c or di n g t o t h e st u d y fl o w c h art, will b e st or e d i n a n el e ctr o ni c 
d a t a b a s e “ M y Cli ni c al D at a” pr o vi d e d b y t h e s p o n s or, g e n er at e d a n d a d mi ni st er e d b y 
M e d a ct a 
I nt er n ati o n al S A ( S wit z erl a n d). D at a e ntri e s ar e e x p o s e d t o t h e r e stri ct e d u s er s t hr o u g h a w e b 
a p pli c ati o n. E a c h i n v e sti g at or will h a v e a c c e s s t o t h e d at a b a s e t hr o u g h hi s/ h er p er s o n al p a g e. T h e 
d at a b a s e l et t h e i n v e sti g at or t o cr e at e p ati e nt c a s e s c h e d ul e a n d fill o ut t h e e C R F pr e vi e w e d b y t h e 
st u d y pr ot o c ol.  
All t h e cli e nt i nt erf a c e d at a c o n si st s i n H T M L p a g e s, pr e vi o u sl y g e n er at e d b y ar m o ur e d s er v er si d e 
pr o gr a m mi n g l e v el s. T hi s ar c hit e ct ur e all o w s s hi el di n g t h e d at a b a s e a c c e s s o p er ati o n s. 
D u e t o t h e s e n siti vit y of h e alt h i s s u e s, e x c h a n gi n g a n d c oll e cti n g i nf or m ati o n bri n g s al o n g s e v er al 
c o n c er n s r e g ar di n g pri v a c y a n d c o nfi d e nti alit y.  

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
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Dept. of Biomedicine 
Acronym 
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Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 67 of 80 
According to the Swiss Federal Law 235.1, about Protection of Personal Data, Medacta International 
SA has taken every measure possible to guarantee that the information, with which we are entrusted, 
is not misused or accessed, by accident or by malice, by any unauthorized persons. Medacta 
International has the right to treat only clinical data, following a written consent by the person involved 
and properly stored by the investigator(s) in charge. For details about the security access see ref 
chapter 12.2.2. 
Several error preventing actions are implemented at each level of the software, increasing the data 
quality along with all the technical choices, which are oriented to provide a lean, topical and easily 
accessible tool. Further validation information is listed in chapter 12.2.4. 
12.2.1 Data Management System  
The system is used to collect clinical data with the purpose of monitoring medical devices, medicinal 
products, in compliance with European Directives. Medacta is responsible of the development and the 
maintenance of the software through internal developer and administrator profiles, along with the 
management of the internal functionality operations through internal clinical data operator profiles. 
Regarding the database system administration the responsibility is assigned to the external hosting 
provider SecurityLab. The software will be functionally checked by Medacta staff on an isolated 
environment during a test phase that previews the verification of all interface functionality for each 
user profile, analysing the tracing logs.     
For hosting details ref. chapter 12.2.3. 
12.2.2 Data security, access and back-up  
The access to the data is strictly channelled through a limited set of user groups. Users can access the 
system data through a user-password authentication. Medacta staff manages the user creation and 
generates one-time codes to let the user complete his/her registration. Since the registration operation 
has been completed, the user login is active and can access the web application. The user can any 
time modify his/her personal password by accessing the web application. 
Whenever a study person leaves the study, the study surgeon must notify it to the Medacta staff in 
order to block the related login and blinding all the data. 
The physical and network security of the web service is left up to a hosting entity (SecurityLab) (see E 
Security Procedure 2015-05-28). 
All the communication with the My Clinical data is encrypted (https). The users of the web application 
have to identify themselves to the system before accessing the data, several rules have been set up to 
limit the data that each user can view, to the strict necessary. 
The web application is regularly checked for security flaws by a specialized company and multiple 
backup files that are treated by the security measures of the hosting company. 
The physical and network security of My Clinical Data web service is maintained by SecurityLab 
(Switzerland). The server is physically housed in a datacenter in Ticino (Switzerland) in a dedicated 
rack. The provided service has carrier redundancy with the major national providers to guarantee 
continuity of service. The physical access to the server room is limited by badge. A video surveillance 
of the room is present. An alarm system with central monitoring 24/7 against intrusion, fire (RAS) and 
flooding is also present. 
The network is protected by a firewall and a web application firewall which analyses the traffic against 
intrusions. 
The firewall only allows web access to the server from outside via port 443 (https).  
Web security is controlled by Symantec VeriSign certified SSL web server certificate with 256-bit 
encryption on the server. 
The logs of the server are continuously monitored for suspicious traffic.  
Web application maintenance access is restricted to the Medacta network. 
12.2.3 Analysis and archiving 
The entered data can be extracted any time by the users in electronic format attuo for statistic and 
planning purpose. In particular, the user can extract the calendar sheet with patient code list and 
related visit plan, and the data related to the eCRF previously filled out. The Administrator, Medacta 
International, may on specific demand provide a full data extraction of the study. 

 
D o c u m e nt: 
Cli ni c al St u d y Pr ot o c ol 
V er si o n: 
V 0 7 
P a g e n u m b er: 
6 8 of 8 0 
D e pt. of Bi o m e di ci n e 
A cr o n y m 
N o s e t o K n e e II 
 
St u d y Pr ot o c ol N o s e t o K n e e II, A pril 1 0, 2 0 1 8, V er si o n 0 7 
P a g e 6 8 of 8 0 
T h e d at a ar e st or e d i n t h e o nli n e d at a b a s e i nt er n all y d e v el o p e d b y M e d a ct a. T h e t y p e a n d fr e q u e n c y 
of cli ni c al d at a c oll e cti o n i s i n a c c or d a n c e wit h t h e r el ati v e st u d y pr ot o c ol s a p pr o v e d b y c o m p et e nt 
a ut h oriti e s. T h e cli ni c al d at a of t h e p ati e nt s ar e st or e d i n a M e d a ct a d e di c at e d virt u al s er v er h o st e d 
a n d m ai nt ai n e d b y S e c urit y L a b. T h e st or e d d at a ar e r ef er e n c e d u si n g p s e u d o a n o n y m o u s c o d e s. T h e 
cli ni c al d at a f or a n I M P pr o d u ct h a s t o b e st or e d f or 3 0 y e ar s.  
T h e cli ni c al d at a c o ul d b e eli mi n at e d fr o m t h e d at a b a s e i n a d v a n c e, a c c or di n g t o a s u bj e ct s p e cifi c 
r e q u e st. T h e i n v e sti g at or will i nf or m M e d a ct a I nt er n ati o n al of c a s e c o d e cli ni c al d at a t o b e r e m o v e d b y 
t h e s p e cifi c f or m.  T h e cli ni c al d at a of a s p e cifi c c a s e c o d e or of t h e cli ni c al st u d y will b e i m m e di at el y 
n ot u s a bl e o n t h e d at a b a s e b ut t h e cli ni c al d at a r e m o v al pr o c e d ur e n e e d s a t e c h ni c al d el a y of 3 0 d a y s 
d u e t o t h e c o m pl et e eli mi n ati o n of all b a c k u p s.  
I n c a s e of d a m a g e of p h y si c al s u p p ort, t h e h o sti n g e ntit y ( S e c urit y L a b) f oll o w s a n o w n pr o c e d ur e f or 
p h y si c al d e str u cti o n of t h e s u p p ort. 
1 2. 2. 4 
El e ctr o ni c a n d c e ntr al d at a v ali d ati o n  
T h e d at a s u b mitt e d t o t h e M y Cli ni c al D at a i s s y st e m ati c all y v erifi e d f or it s c o n si st e n c y a n d if a n err or 
o c c ur s n o i n s erti o n will b e m a d e. Al s o t h e o ut p ut d at a ar e c h e c k e d f or t h eir c o n si st e n c y, t o li mit 
err o n e o u s d at a r etri e v al. 
D u pli c ati o n s, d at a t y p e i n c o n gr u e n c e, 
m a n d at or y fi el d c h e c k et c ar e 
pr e v e nti v el y a v oi d e d b y cli e nt si d e v e hi c ul a nt fi el d s, c h e c k c o ntr ol s, i nt erf a c e 
m e s s a g e s, d at a 
r el ati o n al c o n str ai nt s a n d a r o b u st pr o gr a m mi n g c or e 
1 2. 3 M o nit ori n g  
M o nit ori n g i s t h e a ct of o v er s e ei n g t h e pr o gr e s s of a cli ni c al tri al, a n d of e n s uri n g t h at it i s c o n d u ct e d, 
re c or d e d, a n d r e p ort e d i n a c c or d a n c e wit h t h e pr ot o c ol, St a n d ar d O p er ati n g Pr o c e d ur e s ( S O P s), 
G o o d Cli ni c al Pr a cti c e ( G C P), G o o d M a n uf a ct uri n g Pr a cti c e ( G M P) a n d t h e a p pli c a bl e r e g ul at or y 
r e q uir e m e nt s.  
T h e p ur p o s e i s t o v erif y t h at: 
•   
T h e ri g ht s a n d w ell- b ei n g of t h e h u m a n s u bj e ct s ar e pr ot e ct e d 
•   
T h e r e p ort e d tri al d at a ar e a c c ur at e, c o m pl et e a n d v erifi a bl e fr o m s o ur c e d o c u m e nt s 
•   
T h e c o n d u ct of t h e tri al i s i n c o m pli a n c e wit h t h e c urr e ntl y a p pr o v e d pr ot o c ol/ a m e n d m e nt s, 
G C P, G M P a n d r e g ul at or y r e q uir e m e nt s 
•   
T h e o n g oi n g q u alit y of t h e tri al i s c o nti n u o u sl y v erifi e d. 
T h e m o nit ori n g will b e p erf or m e d b y t h e r e s p e cti v e C T U s ( Cli ni c al Tri al U nit s) at t h e sit e s or b y l o c al 
C R O s u n d er t h e c o or di n ati o n a n d s u p er vi si o n of E C RI N- E RI C, wit h t h e C T U B a s el a s t h e l e a d C T U. 
A m o nit ori n g pl a n a s w ell a s S O P s, d e s cri bi n g i n d et ail t h e d o c u m e nt s a n d d at a t o b e m o nit or e d, will 
b e e st a bli s h e d t o g u ar a nt e e a h ar m o ni z e d m o nit ori n g. 
A n i niti ati o n vi sit b ef or e t h e st art of t h e tri al, i nt eri m vi sit s a n d a cl o s e- o ut vi sit at t h e e n d of t h e tri al ar e 
f or e s e e n f or e a c h sit e. R e g ul ar t el e p h o n e c o nf er e n c e s b et w e e n t h e C T U s/ C R O s s h all e n s ur e 
h ar m o ni z ati o n of t h e pr o c e d ur e s.  
All s o ur c e d at a a n d d o c u m e nt s will b e a c c e s si bl e t o m o nit or s a n d q u e sti o n s ari si n g fr o m m o nit ori n g 
c a n b e a n s w er e d b y a n y p arti ci p a nt. 
1 2. 4 A u dit s a n d I n s p e cti o n s  
T h e r e s p o n si bl e et hi c s- c o m mitt e e s, a ut h oriti e s a n d t h e s p o n s or h a v e t h e ri g ht t o a n d m a y i n s p e ct t h e 
s tu d y a n d/ or m a n uf a ct uri n g sit e at a n y ti m e pri or t o, d uri n g or aft er t h e cli ni c al c o n d u ct. T h er e will b e 
n o a u dit s i n a d diti o n t o t h e m o nit ori n g a n d i n s p e cti o n s. St u d y d o c u m e nt ati o n a n d t h e s o ur c e 
d at a/ d o c u m e nt s ar e a c c e s si bl e t o a u dit or s/i n s p e ct or s ( al s o C E C a n d C A) a n d q u e sti o n s will b e 
a n s w er e d d uri n g i n s p e cti o n s. All i n v ol v e d p arti e s m u st k e e p t h e p arti ci p a nt d at a stri ctl y c o nfi d e nti al. 
1 2. 5 C o nfi d e nti alit y, D at a Pr ot e cti o n  
Dir e ct a c c e s s t o s o ur c e d o c u m e nt s will b e gr a nt e d f or p ur p o s e s of m o nit ori n g ( 1 2. 3), a u dit s a n d 
in s p e cti o n s ( 1 2. 4) (I C H E 6, 6. 1 0) t o t h e C T U a n d S wi s s m e di c w h o will al s o h a v e a c c e s s t o pr ot o c ol, 
d at a s et, st ati sti c al c o d e, et c. d uri n g a n d aft er t h e st u d y. Ot h er p er s o n s wit h a c c e s s t o s o ur c e 
d o c u m e nt s will b e t h e tr e ati n g p h y si ci a n s. S o ur c e d o c u m e nt s will n ot b e u s e d f or di s s e mi n ati o n a n d 
p u bli c ati o n s a n d n o p ati e nt d at a all o wi n g t h e i d e ntifi c ati o n of t h e p ati e nt will b e p u bli s h e d. 

 
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12.6 Storage of biological material and related health data  
Consent of the patient has to be obtained for the use of excessive cells and remains of the implants. 
Remains of IMPs (implants) after transplantation will be used for research if the patient has consented 
to this and will therefore be destroyed during analysis. Excessive cells not used for the generation of 
the implant will be transferred to Basel and used for research to study this and similar diseases. All 
biological materials given to the lab will be encoded. Only the Principal Investigators have access to 
the code. No connection is made between the biological material and patient data. 
 
 

 
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13. PUBLICATION AND DISSEMINATION POLICY  
Information on the study will be disseminated through the public website of the project. 
The publication of the results is planned to be by the submission of papers to peer-reviewed journals. 
In addition the results will be communicated at national and international conferences and seminars as 
well as through presentations for lay persons.  
The results will also be published on educational platforms such as VUMEDI for clinical personnel.  
Study results will be published in the registered databases. 
 
 

 
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14. FUNDING AND SUPPORT  
14.1 Funding  
The clinical study will be performed within the framework of the EU-H2020 Project BIO-CHIP (No. 
681103) and mainly funded through the project. Partners in Switzerland will be funded through the 
contribution by SERI (State Secretariat for Education, Research and Innovation). There will be no 
additional costs for the patient and insurance companies. 
14.2 Other Support  
Personnel are in addition funded by the respective hospitals. Facilities and equipment are also partly 
funded by the respective hospitals. 
15. INSURANCE  
Insurance will be provided by the Sponsor. A copy of the certificate is filed in each investigator site file 
and the trial master file. 
 
 
 

 
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16. REFERENCES  
Declaration of Helsinki, Version October 2013, (http://www.wma.net/en/30publications/10policies/b3/index.html )  
 
International Conference on Harmonization (ICH, 1996) E6 Guideline for Good Clinical Practice. 
(http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6_R1/Step4/E6_R1__Guidelin
e.pdf ) 
 
International Conference on Harmonization (ICH, 1997) E8 Guideline: General Considerations for Clinical Trials 
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E8/Step4/E8_Guideline.pdf) 
 
Humanforschungsgesetz, HFG Bundesgesetz über die Forschung am Menschen (Bundesgesetz über die 
Forschung am Menschen, HFG) vom 30. September 2011/ Loi fédérale relative à la recherche sur l’être humain 
(loi relative à la recherche sur l’être humain, LRH) du 30 septembre 2011.  
(http://www.bag.admin.ch/themen/medizin/00701/00702/07558/index.html?lang=de) 
 
Verordnung über klinische Versuche in der Humanforschung (Verordnung über klinische Versuche, KlinV) vom 
20. September 2013 / Ordonnance sur les essais cliniques dans le cadre de la recherche sur l’être humain 
(Ordonnance sur les essais cliniques, OClin) du 20 septembre 2013. 
(http://www.bag.admin.ch/themen/medizin/00701/00702/12310/index.html?lang=de) 
 
Heilmittelgesetz, HMG Bundesgesetz über Arzneimittel und Medizinprodukte (Heilmittelgesetz, HMG) vom 15. 
Dezember 2000/Loi fédérale sur les médicaments et les dispositifs médicaux (Loi sur les produits thérapeutiques, 
LPT) du 15 décembre 2000. (http://www.admin.ch/ch/d/sr/8/812.21.de.pdf) 
 
ISO 14155:2011 Clinical investigation of medical devices for human subjects -- Good clinical practice 
(www.iso.org) 
 
ISO 10993 Biological evaluation of medical devices (www.iso.org) 
 
WHO, International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/)  
 
Gomoll AH, Farr, j, Gillogly, SD et al. Surgical Management of articular cartilage defects of the knee. The Journal 
of Bone & Joint Surgery 2010; 92:2470-2490. 
 
Miot S, Brehm W, Dickinson S, Sims T, Wixmerten A, Longinotti C, Hollander AP, Mainil-Varlet P, Martin I 
Influence of in vitro maturation of engineered cartilage on the outcome of osteochondral repair in a goat model. 
Eur Cell Mater. 2012 (5);23:222-36. 
 
Pelttari K, Pippenger B, Mumme M, Feliciano S, Scotti C, Mainil-Varlet P, Procino A, von Rechenberg B, 
Schwamborn T Jakob M, Cillo C, Barbero A, Martin I. Adult human neural crest-derived cells for articular cartilage 
repair. Sci Transl Med. 2014 Aug 27;6(251):251ra119. 
 
Candrian C, Vonwil D, Barbero A, Bonacina E, Miot S, Farhadi J, Wirz D, Dickinson S, Hollander A, Jakob M, 
Li Z, Alini M, Heberer M, Martin I. Engineered cartilage generated by nasal chondrocytes is responsive to physical 
forces resembling joint loading. Arthritis Rheum. 2008 Jan;58(1):197-208. 
 
Obradovic B, Martin I, Padera RF, Treppo S, Freed LE, Vunjak-Novakovic G. Integration of engineered cartilage. 
J Orthop Res. 2001 Nov;19(6):1089-97. 
 
Fulco I, Miot S, Haug MD, Barbero A, Wixmerten A, Feliciano S, Wolf F, Jundt G, Marsano A, Farhadi J, 
Heberer M, Jakob M, Schaefer DJ, Martin I Engineered autologous cartilage tissue for nasal reconstruction after 
tumour resection: an observational first-in-human trial. Lancet. 2014 Jul 26;384(9940):337-46 
 
Kafienah W, Jakob M, Démarteau O, Frazer A, Barker MD, Martin I, Hollander AP. Three-dimensional tissue 
engineering of hyaline cartilage: comparison of adult nasal and articular chondrocytes. Tissue Eng. 2002 
Oct;8(5):817-26. 
 
Miot S, Woodfield T, Daniels AU, Suetterlin R, Peterschmitt I, Heberer M, van Blitterswijk CA, Riesle J, Martin 
I. Effects of scaffold composition and architecture on human nasal chondrocyte redifferentiation and cartilaginous 
matrix deposition. Biomaterials. 2005 May;26(15):2479-89. 
 
 
M. Mumme, A. Barbero, S. Miot, A. Wixmerten, S. Feliciano, F. Wolf, MA. Asnaghi, D. Baumhoer, O. Bieri, M. 
Kretzschmar, G. Pagenstert, M. Haug, D. J. Schaefer, I. Martin, M. Jakob Nasal chondrocytes-based engineered 
autologous cartilage tissue for the repair  of articular cartilage defects: an observational first-in-human trial. Lancet 
388:1985-94 (2016). 

 
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Mumme M, Steinitz A, Nuss KM, Klein K, Feliciano S, Kronen P, Jakon M, Von Rechenberg B, Martin I, Barbero 
A, Pelttari K. Regenerative potential of tissue engineered nasal chondrocytes in goat articular cartilage defects. 
Tissue Eng-A 22:1286-1295 (2016) 
 
Rotter N, Bonassar LJ, Tobias G, Lebl M, Roy AK, Vacanti CA. Age dependence of biochemical and 
biomechanical properties of tissue-engineered human septal cartilage. Biomaterials 2002 Aug;23(15):3087-94. 
 
Kon E, Gobbi A, Filardo G, Delcogliano M, Zaffagnini S, Marcacci M. Arthroscopic second-generation autologous 
chondrocyte implantation compared with microfracture for chondral lesions of the knee: prospective 
nonrandomized study at 5 years. Am J Sports Med. 2009 Jan;37(1):33-41. 
 
Scotti C, Osmokrovic A, Wolf F, Miot S, Peretti GM, Barbero A, Martin I. Response of human engineered cartilage 
based on articular or nasal chondrocytes to interleukin-1A and low oxygen. Tissue Eng Part A. 2012 
Feb;18(3-4):362-72. 
 
Albrecht C, Tichy B, Nürnberger S, Hosiner S, Zak L, Aldrian S, Marlovits S. Gene expression and cell 
differentiation in matrix-associated chondrocyte transplantation grafts: a comparative study. 
Osteoarthritis Cartilage. 2011 Oct;19(10):1219-27. 
 
Farhadi J, Fulco I, Miot S, Wirz D, Haug M, Dickinson SC, Hollander AP, Daniels AU, Pierer G, Heberer M, 
Martin I. Precultivation of engineered human nasal cartilage enhances the mechanical properties relevant for use 
in facial reconstructive surgery. Ann Surg. 2006 Dec;244(6):978-85. 
 
Trattnig S, Mamisch TC, Pinker K, Domayer S, Szomolanyi P, Marlovits S, Kutscha-Lissberg F, Welsch GH. 
Differentiating normal hyaline cartilage from post-surgical repair tissue using fast gradient echo imaging in 
delayed gadolinium-enhanced MRI (dGEMRIC) at 3 Tesla. Eur Radiol. 2008 Jun;18(6):1251-9. 
 
Trattnig S, Marlovits S, Gebetsroither S, Szomolanyi P, Welsch GH, Salomonowitz E, Watanabe, A, Deimling M, 
Mamisch TC. Three-dimensional delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) for in vivo evaluation 
of reparative cartilage after matrix-associated autologous chondrocyte transplantation at 3.0T: Preliminary results. 
J Magn Reson Imaging. 2007 Oct;26(4):974-82. 
 
Tay AG, Farhadi J, Suetterlin R, Pierer G, Heberer M, Martin I. Cell yield, proliferation, and postexpansion 
differentiation capacity of human ear, nasal, and rib chondrocytes. Tissue Eng. 2004 May-Jun;10(5-6):762-70. 
 
Kamil SH, Woda M, Bonassar IJ, Novitsky YW, Vacanti CA, Eavey RD, Vacanti MP. Normal features of tissue-
engineered auricular cartilage by flow cytometry and histology: patient safety. Otolaryngol head neck surg. 2003 
Oct;129(4):390-6. 
 
Brandl A, Angele P, Roll C, Prantl L, Kujat R, Kinner B. Influence of the growth factors PDGF-BB, TGF-beta1 and 
bFGF on the replicative aging of human articular chondrocytes during in vitro expansion. J Orthop Res. 2010 
Mar;28(3):354-60. 
 
Kamil SH, Aminuddin BS, Bonassar LJ, Silva CA, Weng Y, Woda M, Vacanti CA, Eavey RD, Vacanti MP. Tissue-
engineered human auricular cartilage demonstrates euploidy by flow cytometry. Tissue Eng. 2002 
Feb;8(1):85-92. 
 
Trimborn M1, Endres M, Bommer C, Janke U, Krüger JP, Morawietz L, Kreuz PC, Kaps C. Karyotyping of human 
chondrocytes in scaffold-assisted cartilage tissue engineering. Acta Biomater. 2012 Apr;8(4):1519-29. 
 
Hambly K. Knee articular cartilage repair for athletes. SportEx Medicine (2009) 39(1): 17-21. 
 
Francioli S., Candrian C., Martin K., Heberer M., Martin I., Barbero A. Effect of three-dimensional expansion and 
cell seeding density on the cartilage-forming capacity of human articular chondrocytes in type II collagen sponges. 
J Biomed Mater Res-A 95:924-931 (2010) 
17. APPENDICES 
1. IMP: IB  
2. Case Report Form (CRF) 
3. Patient Information and informed consent 
4. Questionnaires if relevant for outcome (KOOS) 

 
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18. HISTORY OF CHANGES  
Changes from the accepted version (V03) to the study protocol include the following: 
page 
old 
new 
Page 3/ Page 14 / Page 22/ 
Page 24  
 
Universitätsklinikum Freiburg 
Clinic 
for 
Orthopedic 
and 
Trauma Surgery 
 
Medical Center - University of 
Freiburg, 
Germany 
Department of Orthopedics and 
Trauma Surgery  
 
Page 23 (laboratory) 
 
Institut für Klinische Chemie und 
Laboratoriumsmedizin 
Universitätsklinikum Freiburg 
Hugstetter Str. 49 
79106 Freiburg, Germany  
Institute 
of 
Virology
Hermann-Herder-Str. 
11
79104 
Freiburg
Germany 
Page 24 (Monitoring) 
 
Universitätsklinikum Freiburg 
Studienzentrum, 
Projektkoordination 
Klinische 
Studien 
Elsässer 
Strasse 
2, 
79110 
Freiburg, Germany 
 
Medical Center - University of 
Freiburg, 
Germany 
Clinical 
Trials 
Unit 
Elsaesser 
Str. 
2
79110 
Freiburg
Germany 
Throughout 
the 
document 
pages 25-26 
Landesbehörde 
Competent local authority 
Page 25 
Bundesoberhörde 
National Competent Authority 
 
Page 35 (results of 10 first 
patients published) 
 
The results from the first 10 
patients 
are 
accepted 
for 
publication 
in 
“The 
Lancet” 
(Mumme et al, 2016) 
Page 
37 
(inclusion 
of 
2nd 
authority ) 
 
manufacturing 
authorization 
from 
Regierung 
von 
Oberfranken, 
Ansbach, 
Germany in consultation with 
PEI (Bundesoberbehörde) 
manufacturing 
authorization 
from 
Regierung 
von 
Oberfranken, 
Ansbach, 
Germany in consultation with 
PEI 
(Bundesoberbehörde) 
or 
from Swissmedic, Switzerland 
depending on the manufacturing 
site.   
Page 
49 
(inclusion 
of 
2nd 
manufacturing site ) 
 
 
 
GMP 
production 
unit 
at 
Fraunhofer Institute, Germany 
(QP: Dr. Oliver Pullig) 
GMP 
production 
unit 
at 
Fraunhofer Institute, Germany 
(QP: Dr. Oliver Pullig) or DBM 
clean 
room 
at 
University 
Hospital 
Basel, 
Switzerland 
(QP: PD Dr. Werner Krenger) 
 
Page 50/51  
Not existing 
Include 
paragraph 
on 
Rehabilitation 
Page 51 (NCA in Switzerland) 
 
reviewed 
by 
the 
National 
Competent Authorities (GER) 
reviewed 
by 
the 
National 
Competent Authorities (GER, 
Switzerland) 

 
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Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 75 of 80 
page 
old 
new 
 
 
 
Page 
53: 
9.2.4.1 
Adverse 
events 
 
Adapted to SOP 
Page 
55: 
Assessment 
of 
causality 
Table with causality grading 
deleted 
and 
causality 
assessment simplified 
The causality is based on the 
question, whether there is a 
“reasonable possibility” or “no 
reasonable possibility” that the 
study treatment caused the 
event 
Page 56 
An annual safety report is 
submitted… 
An annual safety report or 
development 
safety 
update 
report (DSUR) is submitted… 
Page 61 (Data handling and 
record keeping, archiving)   
Minimum of 20 years 
Minimum of 30 years 
Page 67-68 
 
 
Inclusion of a new reference 
Mumme et al 2016 
 
Changes from the accepted version (V04) to the study protocol include the following: 
Due to both products (N-TEC and N-CAM) being classified as Tissue engineered products from a 
regulatory point of view the terms “tissue therapy” and “cell therapy” have been replace throughout the 
protocol with the terms reflecting the maturation stage of the cartilaginous tissue: “immature” (N-CAM) 
and “mature” (N-TEC). 
 
page 
old 
new 
3/14/22 
Prof. Dr. Philipp Niemeyer 
Dr. Tayfun Yilmaz 
10 
MOCART Score (MRI): The MRI 
will be performed at 3, 12, 24 
months 
follow-up 
visits 
and 
MOCART scores calculated. 
MOCART and 3D MOCART 
Scores (MRI): The MRI will be 
performed at 3, 12, 24 months 
follow-up visits and MOCART 
and 
3D 
MOCART 
scores 
calculated. 
10 
 
• Additional secondary endpoint 
is the number of treatment 
failure 
at 
24 
months. 
The 
difference will be compared 
between the two groups. 
40/54/55/57 
 
Dotarem® 
43 
 
Additionally 
the 
number 
of 
treatment failure at 24 months 
will be analyzed. Treatment 
failure is defined as objective 
pathological clinical findings by 
the 
investigator 
directly 
correlated 
with 
subjective 
patients complaints resulting in 
a deterioration of the subjective 
clinical outcome assessed by 
KOOS 
and 
the 
5 
KOOS 
subscores. In case of treatment 
failure, a root cause analysis 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
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Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 76 of 80 
page 
old 
new 
will be performed. A clinical 
deterioration 
is 
defined 
as 
reduction in the KOOS score of 
> 10 compared to baseline. A 
non-responding to treatment is 
defined as improvement of < 10 
in the KOOS score. 
44/45 
…the MOCART Score…  
…the 
MOCART 
and 
3D 
MOCART Scores… 
46 
- Patient has an opposite intact 
(ICRS Grade 1) articulating joint 
surface (no "kissing lesions"). 
- Patient has an intact meniscus 
(maximum 1/3-resection). 
- 
Patient 
has 
an 
onset 
of 
symptoms of < 5 years 
 
- Patient has an opposite intact 
(ICRS Grade 2) articulating 
joint 
surface 
(no 
"kissing 
lesions"). 
- Patient has an intact meniscus 
(maximum 1/2-resection). 
- deleted 
- Patient has free range of 
motion of the affected knee joint 
or  10° of extension and 
flexion loss 
47 
Patient has a body mass index 
(BMI) >30 kg/m2 
Patient has a body mass index 
(BMI) >35 kg/m2 
53 
 
9.2.4 Definition of treatment 
failure 
Treatment failure is defined as: 
“Objective pathological clinical 
findings by the investigator, 
which are directly correlated 
with 
subjective 
patients 
complaints 
resulting 
in 
a 
deterioration of the subjective 
clinical outcome assessed by 
KOOS 
and 
the 
5 
KOOS 
subscores.” 
Clinical deterioration is defined 
as reduction in the KOOS score 
of > 10 compared to baseline. A 
non-responding to treatment is 
defined as improvement of < 10 
in the KOOS score.  
Furthermore, revision surgery 
rate independent of cause and 
deterioration of the subjective 
clinical outcome assessed by 
KOOS 
and 
the 
5 
KOOS 
subscores 
independent 
of 
correlation with IMPs will be 
assessed and analyzed. 
54 
…(KOOS, 
EQ-5d) 
and 
an 
MRI/dGEMRIC will be acquired, 
if not already… 
…(KOOS, EQ-5d) and an MRI 
will be acquired, if not already…
69 
In press. The lancet 2016 
. Lancet 388:1985-94 (2016).
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
77 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 77 of 80 
Changes from the accepted version (V05) to the study protocol include the following: 
page 
old 
new 
6/12/14/15/16/24/25/27/45/48/50
(the new center/ethic committee 
has been added throughout the 
protocol) 
 
Clinical center 
Orthopädische Klinik König-
Ludwig-Haus 
Julius-Maximilians-Universität 
Würzburg 
Brettreichstrasse 11 
97074 Würzburg 
Germany 
Ethics committee: 
Ethical committee of  the 
medical faculty of the university 
of Würzburg 
14 
01/2019: Treatment of last 
patient 
01/2021: 
24 
months 
(final) 
follow-up of last patient 
10/2019: Treatment of last 
patient 
10/2021: 
24 
months 
(final) 
follow-up of last patient 
16 
Amir Steinitz 
Sebastian Müller 
22/55 
First visit: 8 months (2w delay) 
Second visit: 2 months (2w 
delay) 
needs to be filled at visit 2, if not 
done, but minimal 2 months 
before implantation 
First visit: 8 months  
Second visit:  2 months  
 
needs to be filled at visit 2, if 
not done, but not older than 6 
months before implantation 
24 (labs added for serology for 
Switzerland (second serology) 
and Germany (Würzburg) 
 
Switzerland: 
 
 
Second serology: (day of 
harvesting) 
 
Institut für Virologie und 
Immunologie, Universität 
Würzburg,  
Versbacher Strasse 7, 97078 
Würzburg  
 
Germany (Würzburg):   
Institut für Virologie und 
Immunologie, Universität 
Würzburg,  
Versbacher Strasse 7, 97078 
Würzburg  
Germany 
29 
…within 
the 
Annual 
Safety 
Report (ASR). 
…within 
the 
Development 
Safety updated report (DSUR). 
31 
Chondro-Celect ® 
Spherox® 
37/38  
 
Results 
phase 
I 
updated 
(Clinical 
and 
radiological 
scores, addition of Table with 
Adverse events) 
41 (added) 
 
Plate 
removal 
in 
case 
of 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
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Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 78 of 80 
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new 
necessary osteotomy 
42 
Risk control/mitigation: 
• Check for microbiological and 
endotoxin contamination and 
mycoplasma in the supernatant 
of the biopsy after transport 
 
 
Risk: minor 
Mitigation: abort of the transplant 
generation 
Risk control/mitigation: 
• Check for microbiological 
contamination in the 
supernatant of the biopsy after 
transport 
• Addition of antibiotics in the 
transport medium and first 
week of expansion 
Risk: acceptable 
Mitigation: -  
57 (added) 
Visit 1: Screening visit (-240 
days) 
 
 
 
 
 
 
 
1.1.1 
Visit 2: Screening visit 
(Day -60) 
 
Visit 1: Screening visit (-240 
days or less) 
Questionnaires will be filled to 
see, if the patient fulfills 
inclusion and exclusion criteria. 
The visit should take place 
maximal 8 months before the 
treatment start (Biopsy 
harvesting). If all inclusion and 
exclusion criteria are met, the 
patient can be randomized. 
Visit 2: Screening visit (Day -60 
or less) 
The elapsed time between visit 
one and two should be a 
maximum of 6 months. 
Questionnaires must not be 
older than 6 months before 
start of treatment (biopsy 
harvesting). Otherwise they 
must be repeated. Screening 
visit 1 and 2 can be combined. 
60 
An annual safety report or 
development 
safety 
update 
report (DSUR) is submitted once 
a year to the local Ethics 
Committee via local Investigator 
and to Swissmedic in case of a 
category B or C study via 
Sponsor-Investigator. 
For 
multicenter 
studies 
the 
annual safety report contains 
information 
from 
all 
sites 
including information from sites 
outside 
Switzerland. 
The 
Sponsor-Investigator prepares it, 
and then submits it to the 
National Competent Authorities 
and participating Investigators 
who will submit it to their local 
committees. 
 
A development safety update 
report (DSUR) is submitted 
once a year to the local Ethics 
Committees and to the national 
authorities 
via 
Sponsor-
Investigator. 
For multicenter studies the 
DSUR contains information 
from all sites including 
information from sites outside 
Switzerland. The Sponsor-
Investigator prepares it, and 
then submits it to the National 
Competent Authorities and 
participating Investigators.   
 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
79 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 79 of 80 
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old 
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65 
medical records of each patient 
…  
 
• Data directly recorded in the 
eCRF (Questionnaires, patient 
data, intervention data).  
• medical records of each 
patient … These can be paper 
documents or electronic.  
• Data directly recorded in the 
eCRF (e.g. questionnaires, 
patient data, intervention data). 
These can also be recorded on 
paper and entered in the eCRF 
later by single entry. 
72 (added) 
 
Mumme M, Steinitz A, Nuss 
KM, Klein K, Feliciano S, 
Kronen 
P, 
Jakon 
M, 
Von 
Rechenberg 
B, 
Martin 
I, 
Barbero 
A, 
Pelttari 
K. 
Regenerative potential of tissue 
engineered nasal chondrocytes 
in 
goat 
articular 
cartilage 
defects. Tissue Eng-A 22:1286-
1295 (2016) 
 
 
Changes from the accepted version (V06) to the study protocol-V07 include the following: 
 
page 
old 
new 
13/17/18/19/45/49/50 
 
 
cartilage lesions on the femoral 
condyle and/or trochlea of the 
knee 
cartilage lesions on the femoral 
condyle and/or trochlea and/or 
patella of the knee 
11/56 
 
 
 
Subgroup analysis to compare 
the outcome with regard to the 
localization 
of 
the 
defect 
(patella 
vs. 
femoral 
condyle/trochlea) 
 
40 
 
 
 
From standard therapies it is 
known that localized defects on 
the patella on average have 
higher complication rates and 
clinically inferior outcomes as 
compared to defects on the 
femoral condyle or trochlea. For 
N-CAM and N-TEC treatment, 
there 
are 
no 
clinical 
data 
available yet concerning the 
outcome of treatment for patella 
defects. 
 
36/37 
 
Inclusion of table summarizing 
all clinical studies with N-TEC 
and N-CAM 
40/41 
 
Inclusion of preliminary results 
from current phase II study and 

 
Document: 
Clinical Study Protocol 
Version: 
V07 
Page number: 
80 of 80 
Dept. of Biomedicine 
Acronym 
Nose to Knee II 
 
Study Protocol Nose to Knee II, April 10, 2018, Version 07 
Page 80 of 80 
page 
old 
new 
reference to IB 
49 
Patient has a relevant meniscus 
tear. Partial meniscal removal 
allowed, if not exceeding 1/2. 
Suture is not allowed in parallel, 
but 
if 
successful, 
cartilage 
treatment might be added 12 
months later. 
Suture 
of 
meniscocapsular 
separation is allowed. Suture of 
meniscus tear is allowed if the 
same 
compartment 
is 
not 
afflicted 
by 
symptomatic 
cartilage injury, and the graft is 
planned for trochlea and /or 
patella and /or contralateral 
compartment. 
If 
the 
same 
compartment is afflicted, 
50 
Patient has an osteochondral 
defect (bony substance defect of 
>3mm 
depth). 
Bone 
marrow 
edema is allowed. 
 
Patient has an osteochondral 
defect 
which 
cannot 
be 
reconstructed (bony substance 
defect of >3mm depth need to 
be 
reconstructed 
with 
autologous bone graft from tibia 
or iliac crest). Bone marrow 
edema is allowed.