Conditions: Knee Osteoarthritis
Keywords: Osteoarthritis Intra-articular Injection Hyaluronic Acid Triamcinolone Hexacetonide
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 526
Healthy volunteers: no

Brief summary:
Extension study to Cingal 16-02 to obtain 39-week safety and efficacy follow-up data

Detailed description:
Extension Study to Cingal 16-02: Trial Extension to 39 Week Follow Up in the Randomized, Double-Blind, Active Comparator Controlled, Multi-Center Study of a Single Injection Cross-Linked Sodium Hyaluronate Combined with Triamcinolone Hexacetonide (Cingal) to Provide Symptomatic Relief of Osteoarthritis of the Knee

Arms:
arm 1: Cingal is a combination product consisting of 88 milligrams of crosslinked HA (hyaluronic acid) with 18 milligrams of TH (triamcinolone hexacetonide) in a 4 milliliter (mL) intra-articular injection. arm 2: Monovisc is a device that consists of 88 milligrams of cross-linked HA (hyaluronic acid) in a 4 milliliter (mL) intra-articular injection. arm 3: Triamcinolone hexacetonide (TH) is a corticosteroid supplied in a 20 milligram per 1 milliliter (20 mg/mL) intra-articular injection.

Interventions: intervention 1: Cingal intervention 2: Monovisc intervention 3: Triamcinolone Hexacetonide
Intervention descriptions: intervention 1: Hyaluronic Acid with Triamcinolone Hexacetonide intervention 2: Hyaluronic Acid intervention 3: Triamcinolone Hexacetonide

Protocol document:
Prot_000.pdf: 
 
 
ANIKA THERAPEUTICS, INC. 
32 Wiggins Avenue 
Bedford, MA 01730 
www.anikatherapeutics.com 
Cover Letter - Cingal 17-02 Protocol Version 2.0
Extension Study to Cingal 16-02: Trial Extension to 39 week Follow Up in 
the Randomized, Double-Blind, Active Comparator Controlled, Multi-Center 
Study of a Single Injection Cross-Linked Sodium Hyaluronate Combined 
with Triamcinolone Hexacetonide (Cingal®) to Provide Symptomatic Relief 
of Osteoarthritis of the Knee
NCT # 03390036
Date of Protocol: 03 January 2018




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Extension Study to Cingal 16-02: Trial Extension to 39 week Follow Up in the 
Randomized, Double-Blind, Active Comparator Controlled, Multi-Center Study of a 
Single Injection Cross-Linked Sodium Hyaluronate Combined with Triamcinolone 
Hexacetonide (Cingal®) to Provide Symptomatic Relief of Osteoarthritis of the Knee
Protocol Number: Cingal 17-02
Protocol Version 2.0
Date: 03 Janurary2018
Original Protocol (version 4.0) Cingal 16-02 Date 05 December 2017
EudraCT Number: 2017-003205-18
     Signatures for the Sponsor that have reviewed and approved the protocol
Author: 
Director of Clinical Affairs or 
Designee:
Adrian Orr
Signature
Date
Vice President of 
Regulatory/Clinical Affairs or 
Designee:
Signature
Date
Anika’s CEO or Designee: 
Charles Sherwood, Ph.D.
Signature
Date
SPONSORED BY:
Anika Therapeutics, Inc.
32 Wiggins Avenue
Bedford, MA 01730
United States of America
Phone: +1 781-457-9000
Fax: +1 781-305-9720


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PROTOCOL SIGNATURE PAGE
Title: 
Extension Study to Cingal 16-02: Trial Extension to 39 Week Follow Up in the 
Randomized, Double-Blind, Active Comparator Controlled, Multi-Center Study of a 
Single Injection Cross-Linked Sodium Hyaluronate Combined with Triamcinolone 
Hexacetonide (Cingal®) to Provide Symptomatic Relief of Osteoarthritis of the Knee
Version: 2.0 
Date: 03 January 2018
Sponsor: Anika Therapeutics, Inc.
My signature below confirms that I have read and understand the clinical protocol contained herein 
and agree to conduct the study according to this protocol and in accordance with the ethical 
principles of the Declaration of Helsinki, International Conference on Harmonization (ICH) 
Guidelines on Good Clinical Practice, Directive 2001/20/EC and Commission Directive 2005/28/EC, 
International Organization for Standardization (ISO) 14155, 21 CFR part 11, 50, 56, 312 and local 
ethical and legal requirements.
Principal Investigator:
________________________________________________________
___________
Print Name
Date
_________________________________________________________
Signature
1 
LIST OF ABBREVIATIONS...........................................................................................................6 


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2 
DEFINITIONS...............................................................................................................................8 
3 
STUDY SYNOPSIS ......................................................................................................................9 
4 
INTRODUCTION ........................................................................................................................14 
5 
PRINCIPAL INVESTIGATOR .....................................................................................................16 
6 
STUDY OBJECTIVES ................................................................................................................17 
7 
ENDPOINTS...............................................................................................................................17 
7.1 
Primary Efficacy Endpoint ....................................................................................................17 
7.2 
Secondary Efficacy Endpoints..............................................................................................17 
7.3 
Exploratory Endpoints ..........................................................................................................17 
7.4 
Safety Endpoint:...................................................................................................................18 
8 
STUDY DESIGN.........................................................................................................................19 
8.1 
Diagram................................................................................................................................19 
8.2 
Trial Design..........................................................................................................................20 
9 
ELIGIBILITY ...............................................................................................................................21 
9.1 
Enrollment Criteria................................................................................................................21 
9.1.1 
Inclusion Criteria ............................................................................................................21 
9.1.2 
Exclusion Criteria...........................................................................................................22 
9.1.3 
Screening Exclusion Criteria in Cingal 16-02 .................................................................22 
9.1.4 
Baseline Inclusion Criteria in Cingal 16-02.....................................................................24 
9.1.5 
Baseline Exclusion Criteria in Cingal 16-02....................................................................24 
10 
STUDY PROCEDURES ..........................................................................................................25 
10.1 
Schedule of Events ...........................................................................................................25 
10.2 
Procedure Description.......................................................................................................26 
10.2.1 
Informed Consent Form (ICF).....................................................................................26 
10.2.2 
Demographics ............................................................................................................26 
10.2.3 
Physical Exam (PE)....................................................................................................26 
10.2.4 
Vital Signs...................................................................................................................26 
10.2.5 
Pregnancy Test...........................................................................................................26 
10.2.6 
Chemistry/Hematology/Urinalysis ...............................................................................26 
10.2.7 
Knee X-rays/Assessment of Kellgren-Lawrence Score ...............................................27 
10.2.8 
Medical History ...........................................................................................................28 
10.2.9 
Physical Evaluation of Knee........................................................................................28 
10.2.10 
Range of Motion .........................................................................................................29 
10.2.11 
WOMAC .....................................................................................................................29 
10.2.12 
Medications ................................................................................................................29 
10.2.13 
Subject Diary ..............................................................................................................30 
10.2.14 
EuroQoL EQ-5D .........................................................................................................30 
10.2.15 
Patient Global Assessment.........................................................................................31 
10.2.16 
Evaluator Global Assessment.....................................................................................31 
10.2.17 
Blinding.......................................................................................................................31 
10.3 
Screening..........................................................................................................................32 
10.4 
Post-Treatment Follow-Up ................................................................................................33 
11 
ADVERSE EVENTS / ADVERSE REACTIONS.......................................................................34 
11.1 
Definitions – Device Adverse Events.................................................................................34 
11.2 
Definitions – Drug Adverse Events....................................................................................35 
11.3 
Relationship ......................................................................................................................35 
11.4 
Severity.............................................................................................................................36 
11.5 
Reporting ..........................................................................................................................36 
11.5.1 
Adverse Events...........................................................................................................36 
11.5.2 
Serious Adverse Events/Serious Adverse Device Effects/Serious Adverse Reactions 37 
11.5.3 
Expedited Reporting ...................................................................................................37 
11.5.4 
Independent Data Monitoring Committee....................................................................38 


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11.5.5 
Study Discontinuation .................................................................................................38 
12 
STATISTICAL CONSIDERATIONS.........................................................................................38 
12.1 
Sample Size......................................................................................................................38 
12.1.1 
Primary Efficacy Endpoint...........................................................................................39 
12.1.2 
Secondary Efficacy Endpoints ....................................................................................39 
12.1.3 
Exploratory Endpoints.................................................................................................42 
12.2 
Statistical Methods............................................................................................................43 
12.3 
Demographic and Baseline Characteristics.......................................................................44 
12.4 
Adverse Events.................................................................................................................44 
12.5 
Subject Populations ..........................................................................................................44 
12.6 
Additional Analyses...........................................................................................................45 
13 
DATA MANAGEMENT CONSIDERATIONS............................................................................45 
13.1 
Electronic Data Capture (EDC) System.............................................................................45 
13.2 
Data Collection..................................................................................................................46 
13.3 
Data Management.............................................................................................................46 
13.4 
Data Retention ..................................................................................................................47 
14 
CLINICAL SUPPLIES IN CINGAL 16-02 .................................................................................47 
14.1 
Packaging and Labeling....................................................................................................47 
14.2 
Instructions for Use ...........................................................................................................47 
14.2.1 
Contraindications........................................................................................................47 
14.2.2 
Anticipated Adverse Reactions ...................................................................................49 
14.3 
CTM Accountability ...........................................................................................................50 
14.4 
Emergency Unblinding ......................................................................................................50 
15 
DATA QUALITY ASSURANCE................................................................................................50 
16 
REGULATORY OBLIGATIONS...............................................................................................50 
16.1 
Clinical Trial Information....................................................................................................50 
16.2 
Regulatory Approval..........................................................................................................51 
16.3 
Ethics Committee (EC) Approval.......................................................................................51 
16.4 
Amendments to the Protocol .............................................................................................51 
16.5 
Pre-Study Documentation .................................................................................................52 
16.6 
Investigator Responsibilities..............................................................................................52 
16.7 
Sponsor’s Responsibilities ................................................................................................55 
16.8 
Informed Consent..............................................................................................................58 
16.9 
Protocol Adherence...........................................................................................................59 
16.10 
Adverse Event Reporting ..................................................................................................60 
16.11 
Permission to Review Subject's Source Records ..............................................................60 
16.12 
Change in Investigator ......................................................................................................61 
16.13 
Records Retention ............................................................................................................61 
16.14 
Study Monitoring ...............................................................................................................61 
16.15 
Case Report Form.............................................................................................................62 
16.16 
Auditing.............................................................................................................................63 
16.17 
Use and Publication of Study Results................................................................................63 
16.18 
Confidentiality ...................................................................................................................63 
16.19 
Early Study Discontinuation ..............................................................................................64 
16.20 
Subject Withdrawal ...........................................................................................................64 
17 
GENERAL INFORMATION .....................................................................................................66 
17.1 
Study Contact Information.................................................................................................66 
17.2 
Study Administrative Structure ..........................................................................................67 
18 
REFERENCES........................................................................................................................68 
Appendix 1 WOMAC .........................................................................................................................69 
Appendix 2 Global Assessment of Disease Activity...........................................................................75 
Appendix 3  EQ-5D ...........................................................................................................................76 


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Appendix 4 Kellgren-Lawrence Grading Scale ..................................................................................78 


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1
LIST OF ABBREVIATIONS
ACL
Anterior Cruciate Ligament
ADE
Adverse Device Effect 
AE
Adverse Event
ALT/SGPT 
Alamine Transaminase/Serum Glutamic Pyruvic Transaminase
ANOVA
Analysis of Variance
AP
Anterior Posterior
AR
Adverse Reaction
AST/SGOT
Aspartate Aminotransferase/Serum Glutamic Oxaloacetic Transaminase
BMI
Body Mass Index
CFR
Code of Federal Regulations
cm
Centimeters
CRO
Contract Research Organization
CTM
Clinical Trial Material
CV
Curriculum Vitae
D/C
Discontinued
DMP
Data Management Plan
eCRF
electronic Case Report Form 
EDC
Electronic Data Capture
EQ-5D
EuroQoL 5 Dimension
EQ VAS
EuroQoL Visual Analog Scale
EULAR
European League Against Rheumatism
FDA
Food and Drug Administration
g, mg, kg
gram, milligram, kilogram
GCP
Good Clinical Practices
GEE
Generalized Estimating Equations
h
hour(s)
HA
Hyaluronan / Sodium Hyaluronate / Hyaluronic Acid
HIPAA
Health Insurance Portability and Accountability Act
IA 
Intraarticular
ICF
Informed Consent Form
ICH
International Conference on Harmonization
ID
Identification
IDMC
Independent Data Monitoring Committee
IEC
Independent Ethics Committee
IFU
Instructions for Use
IND
Investigational New Drug
ISO
International Organization for Standardization
ITT
Intent-to-Treat
K-L
Kellgren-Lawrence classification
MedDRA
Medical Dictionary for Regulatory Activities
mL, mm, m
milliliter, millimeter, meter
NSAIDs
Non-steroidal anti-inflammatory drug
OA
Osteoarthritis
OARSI 
Osteoarthritis Research Society International
OMERACT
Outcomes Measures for Rheumatic Arthritis Clinical Trials
PA
Posterior Anterior 
PE
Physical Exam
PI
Principal Investigator
PP
Per Protocol
RBC
Red Blood Cell


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ROM
Range of Motion
SADE
Serious Adverse Device Effect
SAE
Serious Adverse Event
SAR
Serious Adverse Reaction
SAP
Statistical Analysis Plan
SOP
Standard Operating Procedure
SUSAR
Suspected Unexpected Serious Adverse Reaction 
TEAE
Treatment Emergent Adverse Events
TH
triamcinolone hexacetonide
UADE
Unanticipated Adverse Device Effect
UK
United Kingdom
US
United States
VAS
Visual Analog Scale
WBC
White Blood Cell
WOMAC
Western Ontario and McMaster Universities Osteoarthritis Index


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2
DEFINITIONS
Baseline: The assessments performed prior to the study injection after the Screening Visit.
Blinded Evaluator: The Blinded Evaluator will be a physician, research nurse, registered 
physiotherapist or physician assistant trained by the PI to perform the assessments outlined in the 
protocol. The Blinded Evaluator will complete the physical evaluation of both knees, range of motion
(ROM) assessment of both knees, and the Evaluator Global Assessment.
End of Study: End of study is defined as the last subject’s last visit.
Enrolled: A subject who has signed the informed consent form (ICF) is enrolled.
Index Knee: The knee that meets the eligibility criteria for treatment. The index knee may also be 
termed the “study knee”. In subjects with bilateral knee Osteoarthritis (OA), where both knees meet 
eligibility criteria, the more symptomatic knee is the index knee.       
Ethics Committee (EC): EC refers to an independent body (e.g. Research Ethics Boards, Independent 
Ethics Committees) whose responsibility is to ensure the protection of rights, safety and well-being of 
human subjects involved in a trial. Committees with these responsibilities will be referred to in this 
document as Ethics Committees.
Rescue Medication: Acetaminophen/paracetamol will be distributed as the rescue medication. It is
the only medication that should be taken for knee pain during the entire study. Rescue medication will 
be discontinued at least 48 hours prior to Baseline and all follow-up visits.  
Treating Physician: The Treating Physician will most often be the Principal Investigator (PI). He/she 
will administer the Cingal®, Monovisc® or steroid injection but will not participate in the efficacy 
evaluation. 
Treatment Failure: A subject who undergoes a procedure or uses a medication (other than the 
rescue medication) for the treatment of OA in the index knee at any time after the study injection 
through the 39 week visit.


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3
STUDY SYNOPSIS
Title
Extension Study to Cingal 16-02: Trial Extension to 39 Week Follow Up in the 
Randomized, Double-Blind, Active Comparator Controlled, Multi-Center Study of a Single 
Injection Cross-Linked Sodium Hyaluronate Combined with Triamcinolone Hexacetonide 
(Cingal) to Provide Symptomatic Relief of Osteoarthritis of the Knee
Study 
Objective
To evaluate the efficacy and safety of a single injection of Cingal for relief of joint pain at 
39 week follow up in subjects with Osteoarthritis (OA) of the knee who have not 
responded to conservative treatment.
Investigational 
Product
Subjects enrolled in Cingal 17-02 will not receive an injection.
For reference only, the investigational product utilized in Cingal 16-02 was:
Cingal: A chemically cross-linked sodium hyaluronate supplied as a 4-mL unit dose with 
a nominal 18 mg of triamcinolone hexacetonide (TH) in a 5-mL glass syringe.                       
Comparator 
Product
Subjects enrolled in Cingal 17-02 will not receive an injection.
For reference only, the comparator products utilized in Cingal 16-02 were:
Triamcinolone Hexacetonide (TH): 20 mg/ml supplied as 1 mL unit dose in a glass 
ampoule.
Monovisc®: A chemically cross-linked sodium hyaluronate supplied as a 4-mL unit dose 
in a 5-mL glass syringe.
Mode of 
Delivery
For reference only, the mode of delivery in Cingal 16-02 was:
Cingal, Triamcinolone Hexacetonide, or Monovisc will be injected into the intraarticular
(IA) space of the index knee using an 18-21 gauge needle.
Study Design
Multi-center, randomized, double-blind, parallel group, 3-arm, active comparator
controlled study    
Phase
Phase III
Sample Size
A total of 576 subjects will be enrolled.
This equates to 256 subjects injected with Cingal, 256 subjects injected with Monovisc
and 64 subjects injected with TH.
All subjects who meet enrollment criteria and completed the 26 week follow up in Cingal 
16-02 will have the option to participate in the sub-study.
Study Duration
The entire sub-study duration will be an additional 13 weeks. The follow up visit will be 
scheduled at 39 weeks post treatment. 
Inclusion 
Criteria
1.
Only subjects that were enrolled and met the inclusion criteria for the Cingal 16-02 
trial and signed the informed consent are eligible for Cingal 17-02 trial.
2.
Subject is able to understand and comply with the requirements of Cingal 17-02 and
voluntarily provides consent.
Patients will not be rescreened at enrollment to Cingal 17-02 as these patients were 
enrolled and met the inclusion / exclusion criteria for the Cingal 16-02 clinical trial.
For reference only, the inclusion criteria used in Cingal 16-02 were:
1.
Subject is 40-75 years old, with a Body Mass Index (BMI) NJP2.
2.
Subject has Kellgren-Lawrence (K-L) severity grade I, II or III in the index knee as 
determined by X-ray.  Contralateral knee: K-L severity grade 0, I or II.
3.
Subject has had at least two signs and at least two symptoms of OA disease (based 
on the European League Against Rheumatism (EULAR) recommendations for 
diagnosing knee OA) in the index knee for at least 6 months despite conservative 
treatment (weight reduction, physical therapy, pain medications, etc.). The EULAR 
signs and symptoms are as follows:
o
Signs: crepitus, restricted movement and bony enlargement 


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o
Symptoms: persistent knee pain, limited morning stiffness and reduced function 
4.
Subject must be willing to abstain from other IA treatments of the knee for the 
duration of the study.
5.
Subject is willing to discontinue all analgesics including NSAIDs, except 
acetaminophen/paracetamol, at least seven days before the treatment injection and 
through the completion of the study.
6.
Subject is willing to use only acetaminophen/paracetamol (up to a maximum of 4.0
grams per day per the package insert) for the treatment of joint pain for the duration 
of the study. At least forty eight hours prior to the Baseline Visit and each follow-up
visit, the subject is willing to discontinue use of acetaminophen/paracetamol. 
7.
Subject is willing to maintain a stable dose of oral glucosamine and/or chondroitin 
sulfate products throughout the study, if taken prior to signing the informed consent
form (ICF).
8.
Subject is able to understand and comply with the requirements of the study and 
voluntarily provides consent.
Exclusion 
Criteria
Patients will not be rescreened at enrollment to Cingal 17-02 as these patients were 
enrolled and met the inclusion / exclusion criteria for the Cingal 16-02 clinical trial.
Only patients enrolled in the Cingal 16-02 trial will be eligible to participate in Cingal 17-
02.
For reference only, the exclusion criteria used in Cingal 16-02 were:
1.
Subject received an IA injection of Hyaluronic Acid (HA) and/or steroid in either 
knee within 6 months of signing the informed consent form (ICF). A subject will be 
excluded if they are planning to receive an HA or steroid injection (other than the 
study injection) in either knee during the course of this study.
2.
Subject had an arthroscopy of either knee within 3 months of signing the ICF.
3.
Subject had an open surgical procedure of either knee or hip or any surgery of 
the spine within 12 months of signing ICF. Subject plans to have knee, hip or 
spine surgery within the study period. 
4.
Subject has intra-articular trauma to the index knee. Subject has concurrent multi-
system or multi-limb trauma.
5.
Subject has evidence or medical history of the following diseases in the index 
knee: septic arthritis; inflammatory joint disease; history of Reiter’s syndrome; 
gout; chondrocalcinosis associated with recurrent episodes of acute synovitis of 
the knee consistent with pseudogout; osteochondritis dissecans, Paget disease of 
the bone; ochronosis; acromegaly; hemochromatosis; primary 
osteochondromatosis; known history of Wilson disease; heritable disorders or 
collagen gene mutations.
6.
Subject has a history of cartilage repair surgery in the index knee within 3 years 
of signing the ICF.
7.
Subject has a history of ACL repair, reconstruction or injury in the index knee 
within 3 years of signing the ICF.
8.
Subject has X-ray findings of acute fractures, severe bone loss, avascular 
necrosis, severe bone or joint deformity in the index knee.
9.
Subject has significant varus or valgus deformity greater than 10 degrees in either 
knee.
10. Subject has a clinically apparent tense effusion of the index knee.
11. Subject has knee instability in either knee per the Investigator’s assessment.
12. Subject requires consistent use of an assistive device (e.g. wheelchair, walker, 
etc.) Occasional use of a cane is acceptable.
13. Subject has medical condition(s) which could affect study assessments or may 
adversely affect the safety and/or success of the study treatment. This includes 
but is not limited to the following: a. Peripheral neuropathy severe enough to 
interfere with evaluation of the subject, b. Vascular insufficiency severe enough to 


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interfere with evaluation of the subject, c. Active fibromyalgia, d. Hemiparesis 
involving either lower extremity, e. Immunocompromised or immunosuppressive 
disorder or receiving medications to treat immunosuppressive disorders, f. 
Systemic bleeding disorder(s), g. Current malignancy or treatment within the last 
5 years, except for non-melanoma skin cancer,  h. Significant psychiatric 
disorder, i. Active drug and/or alcohol abuse within the past year, j. Uncontrolled 
diabetes with a screening HbA1c of >7%.
14. Subject is taking medications at the time the subjects signs the ICF which could 
interfere with the treatment procedure, healing and/or assessments. This includes 
but is not limited to oral or injectable anticoagulant treatments, anti-aggregant 
platelet treatment, chronic opioid analgesics. Low dose aspirin used for 
cardiovascular protection is allowed if a stable regimen is maintained for the 
duration of the study.
15. Subject is receiving treatment using electromagnetic stimulation and/or low 
intensity ultrasound in the index knee at the time of signing the ICF, within 3 
months of signing the ICF or plans to receive treatment any time during the study 
period.
16. Subjects who had an oral, intramuscular, intravenous, rectal suppository or 
topical (excluded in index knee only) corticosteroid within 30 days of signing the 
ICF are excluded. Topical corticosteroid use at any site other than the index 
knee is allowed.
17. Subject has a pre-treatment contraindication to IA injections or aspiration of the 
index knee, including cutaneous infection in the injection site area, active IA 
infection (as suggested by moderate or marked effusion), knee deformity or 
condition which, in the opinion of the Investigator could jeopardize the sterility or 
delivery of the IA injection.
18. Subjects with a history of hypersensitivity to any of the ingredients in the 
hyaluronan or previous hypersensitivity to the administration of corticosteroids or 
an inability to tolerate acetaminophen/paracetamol.
19. Subject has any contraindication to the receipt of a corticosteroid.
20. Subject is receiving or in litigation for worker’s compensation.
21. Subject is a woman who is pregnant or breastfeeding at the Screening Visit or a 
woman of child bearing potential who refuses to use effective contraception 
during the course of the study.
22. Subject was involved in any other research study involving an investigational 
product, or a new application of an approved product, within 60 days of signing 
the ICF.
Baseline Inclusion Criteria
1.
Subject has a Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC) pain-sub-VFRUHPPDQGPPLQWKHDIIHFWHGNQHHDQG mm in 
the contralateral knee on a 100 mm Visual Analog Scale (VAS) scale.
Baseline Exclusion Criteria
1.
Subject KDVDGHFUHDVHRI20 mm in the WOMAC pain-sub-score (average of 5 pain 
scales) from Screening to Baseline in the index knee on a 100 mm Visual Analog 
Scale (VAS) scale.
2.
Subject has a synovial fluid aspirate volume > 20 mL in the index knee.
3.
Subject has a contraindication to continue with the study treatment injection based on 
the visual appearance of the synovial fluid aspirate unless the fluid is examined 
microscopically prior to injection with no clinically significant findings (e.g. bacteria, 
crystals or blood).
4.
Subject has range of motion of less than 100° flexion in either knee.


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Criteria for 
Evaluation
Efficacy:
Primary Endpoint:
x
The responder rate as identified by the Outcomes Measures for 
Rheumatic Arthritis Clinical Trials-Osteoarthritis Research Society
International (OMERACT-OARSI) responder index at 39 weeks post 
treatment comparing the Cingal group to the TH group.
Secondary Endpoints: 
x
The change from baseline in knee pain as measured by the WOMAC 
Pain Score (100 mm VAS) at 39 weeks post treatment comparing the 
Cingal group to the TH group. 
x
The change from baseline in WOMAC Physical Function score at 39
weeks post treatment comparing the Cingal group to the TH group.
x
The change from baseline in WOMAC Stiffness score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
x
The change from baseline in Total WOMAC score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
x
The change from baseline in the Patient Global Assessment 39 weeks 
post treatment in the Cingal group compared to the TH group.
x
The change from baseline in the Evaluator Global Assessment at 39
weeks post treatment in the Cingal group compared to the TH group.
x
The usage of rescue medication through 39 weeks post treatment in the 
Cingal group compared to the TH group.
Exploratory Endpoints: 
Any comparisons between groups (Cingal, Monovisc, TH), within groups and 
/ or time points (from baseline through to 39 weeks) not described in the 
primary or secondary endpoints may be presented in the exploratory 
endpoints including:
o
EuroQol (EQ-5D)
o
WOMAC Pain Score (100mm VAS)
o
OMERACT-OARSI
o
Total WOMAC
o
WOMAC Stiffness Score
o
WOMAC Physical Function
o
Patient Global Assessment
o
Evaluator Global Assessment
o
Range of Motion 
o
Rescue Medication Usage
o
Number of Treatment Failures due to Additional Procedure or 
Use of Disallowed Medication 
Safety:
The incidence, timing, severity, and relationship to treatment of all Adverse Events (AE) 
will be collected and coded using Medical Dictionary for Regulatory Activities (MedDRA).  
Local injection site and non-local events will be recorded separately.
Statistical 
Analysis
The primary analysis on the endpoints will be performed on the ITT (Intent to Treat) 
populations. All Primary and Secondary endpoints will be analyzed using the ITT 
population.
A secondary analysis will be conducted on the Per Protocol (PP) population.   Since the 
primary endpoint is at 39 weeks, this is all subjects who complete the 39 week visit and 
who are not major violators of the protocol.  For all other visits, this is defined as the 
subjects who complete those visits according to the protocol.
All safety analyses will be conducted on all subjects who undergo treatment in any group.


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Sites
Up to 40 clinical sites within Europe may participate.
Sponsor
Anika Therapeutics, Inc.
32 Wiggins Avenue
Bedford, MA 01730,
United States of America
Phone: + 1 781-457-9000 Fax: + 1 781-305-9720


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4
INTRODUCTION
Osteoarthritis (OA) is the most prevalent joint disorder worldwide and is associated with significant pain 
and disability [1]. It is a progressive disease that can affect any joint, but most often involves the weight 
bearing joints such as the knee. The European Project on Osteoarthritis reported on prevalence rates 
for knee OA in Europe and the United Kingdom (UK). For subjects aged 65-74 years, the rate of knee 
OA based on clinical judgment was 36.7% in Italy and 18.6 % in the UK. For subjects aged 75 years or 
older the rate, based on clinical judgment was 50.8% in Italy. In the Netherlands, the self-reported rate 
of knee OA in subjects 65-74 years was 23.6% and for subjects 75 years or older was 31.4% [2].
Because of the high prevalence of knee OA, this disease ranked as either the top or second leading 
cause of disability [3].  In particular, this disease accounted for more dependence on others in climbing 
stairs, housekeeping and walking a mile than any other disease after adjustment for age, sex and 
comorbidity [3].
Osteoarthritis is defined as a “heterogenous group of conditions that leads to joint symptoms and signs 
which are associated with defective integrity of articular cartilage in addition to related changes in the 
underlying bone and at the joint margins” [4]. OA is characterized by a decreased concentration of HA 
in synovial fluid and a slow degradation of cartilage over years [5, 6].  The decreased concentration of 
HA in the synovial fluid of an osteoarthritic joint is probably caused by dilution from exudation, a 
decreased production of hyaluronans, and increased degradation [6]. Accordingly, the average 
molecular weight is diminished resulting in a loss of the viscoelastic properties of the synovial fluid for 
which HA is responsible [5].
Corticosteroids have long been used to alleviate pain and inflammation by injecting into the intra-
articular space. Commonly used corticosteroids have been triamcinolone acetonide (TA) and 
triamcinolone hexacetonide (TH), which have been reviewed in the literature and found to be safe and 
effective for short term relief of the symptoms of osteoarthritis.[7] Standard dosing for intra-articular 
injections to the knee for triamcinolone hexacetonide (TH) have been reported as a 1 ml injection at a 
concentration of 20 mg/ml, which will be the proposed dose for the active control in this trial.[7]
Viscosupplements are believed to restore the concentration of hyaluronans in synovial fluid, elevate 
the viscosity and improve the lubricating and cushioning properties of the synovial fluid to a healthier
state to alleviate pain in OA [6].  HA in synovial fluid binds to chondrocytes, supporting a role for HA in 
healthy cartilage [5]. HA has been studied as a substance capable of restoring the normal properties 
of synovial fluid and cartilage, thereby reducing pain and stiffness in the osteoarthritic joints. 


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Exogenously administered HA immediately restores the synovial fluid’s viscoelastic (or rheologic) 
properties [6]. 
Bellamy et al (2006) conducted a systematic analysis of 76 single and double-blinded studies and 
concluded that viscosupplements are an effective treatment for OA of the knee with beneficial effects 
on pain, function and Patient Global Assessment from a 5 to 13 week post injection period showing a 
percent improvement from baseline of 28% to 54% for pain and 9% to 32% for function [8].
Because data show a delayed treatment effect of HA, Anika Therapeutics wanted to create a product 
(Cingal) that could provide quicker pain relief for subjects suffering from osteoarthritis while still 
providing the established pain relief of an HA product. 
Cingal is a sterile, biocompatible, non-pyrogenic, viscoelastic, uniform white/off white opaque solution 
composed of molecules of HA and triamcinolone hexacetonide (TH).  Cingal is indicated in the 
treatment on pain in osteoarthritis (OA) of the knee in patients who have failed to respond to 
conservative non-pharmacological therapy and to simple analgesics, e.g., acetaminophen.  Cingal 
functions as a viscoelastic supplement or a replacement for synovial fluid in human joints with short 
term pain relief is provided by triamcinolone hexacetonide. This clinical trial will evaluate the efficacy 
and safety of a single injection of Cingal for relief of joint pain in subjects with OA of the knee who have 
not responded to conservative treatment.
Anika Therapeutics, Inc are currently conducting the Cingal 16-02 study, which is a randomized, 
double-blind, active- controlled, multi-center study of a single injection of cross-linked sodium 
hyaluronate combined with triamcinolone hexacetonide (Cingal®) to provide symptomatic relief of 
osteoarthritis of the knee. Enrollment of 576 patients at up to 30 sites is being completed in a 
randomization of 4:4:1 (Cingal, Monovisc: triamcinolone hexacetonide). Subjects are currently in the 
enrollment or follow up stage of the Cingal 16-02 trial. The purpose of the Cingal 17-02 sub-study will 
be to evaluate the efficacy and safety of the treatment at 39 weeks post treatment.


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5
PRINCIPAL INVESTIGATOR
Principal Investigator
Laszlo Hangody, M.D., Ph.D., D.Sc.
Address: Uzsoki Hospital, Orthopedic and Trauma Department,
Uzsoki str. 29. Budapest, Hungary, 1145
Co-investigator
Agnes Berta M.D. 
Address: Uzsoki Hospital, Orthopedic and Trauma Department,
Uzsoki str. 29. Budapest, Hungary, 1145
Research Facilities
Uzsoki Hospital, Orthopedic and Trauma Department,
Uzsoki str. 29. Budapest, Hungary, 1145
Ethics Committee
Uzsoki Utcai Kórház Intézményi Kutatásetikai Bizottsága,
H-1145 Budapest, Uzsoki utca 29-41., 
Tel: +1-467-3750, Fax.: +1-251-5488.


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6
STUDY OBJECTIVES
The objective of this sub-study is to evaluate the efficacy and safety at 39 week follow up of a single 
injection of Cingal for relief of joint pain in subjects with OA of the knee who have not responded to 
conservative treatment (weight reduction, physical therapy, pain medications, etc.).
7
ENDPOINTS
7.1
Primary Efficacy Endpoint 
x
The responder rate as identified by the Outcomes Measures for Rheumatic Arthritis Clinical 
Trials-Osteoarthritis Research Society International (OMERACT-OARSI) responder index 
at 39 weeks post treatment comparing the Cingal group to the TH group.
7.2
Secondary Efficacy Endpoints 
x
The change from baseline in knee pain as measured by the WOMAC Pain Score (100 mm 
VAS) at 39 weeks post treatment comparing the Cingal group to the TH group. 
x
The change from baseline in WOMAC Physical Function score at 39 weeks post treatment 
comparing the Cingal group to the TH group.
x
The change from baseline in WOMAC Stiffness score at 39 weeks post treatment comparing 
the Cingal group to the TH group.
x
The change from baseline in Total WOMAC score at 39 weeks post treatment comparing
the Cingal group to the TH group.
x
The change from baseline in the Patient Global Assessment 39 weeks post treatment in the 
Cingal group compared to the TH group.
x
The change from baseline in the Evaluator Global Assessment at 39 weeks post treatment 
in the Cingal group compared to the TH group.
x
The usage of rescue medication through 39 weeks post treatment in the Cingal group 
compared to the TH group.
7.3
Exploratory Endpoints 
Any comparisons between groups (Cingal, Monovisc, TH), within groups and / or time points (from 
baseline through to 39 weeks) not described in the primary or secondary endpoints may be presented 
in the exploratory endpoints including:


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x
EuroQol (EQ-5D)
x
WOMAC Pain Score (100mm VAS)
x
OMERACT-OARSI
x
Total WOMAC
x
WOMAC Stiffness Score
x
WOMAC Physical Function
x
Patient Global Assessment
x
Evaluator Global Assessment
x
Range of Motion 
x
Rescue Medication Usage
x
Number of Treatment Failures due to Additional Procedure or Use of Disallowed Medication  
7.4
Safety Endpoint:
The incidence, timing, severity, and relationship to treatment of all Adverse Events (AE) will be collected 
and coded using Medical Dictionary for Regulatory Activities (MedDRA).  Local injection site and non-
local events will be recorded separately.


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8
STUDY DESIGN
8.1
Diagram
SCREENING
All Screening Inclusion/Exclusion Criteria Met
BASELINE
All Baseline Inclusion/Exclusion Criteria Met
RANDOMIZATION
n=576
CINGAL INJECTION
n=256
MONOVISC INJECTION
n=256
TH INJECTION
n=64
FOLLOW-UP VISITS POST TREATMENT
1, 3, 6, 12, 18, and 26 Weeks after Baseline Injection
Informed Consent
Provide subject diary & Rescue 
medications
39 Week Follow Up Visit Post 
Treatment from Cingal 16-02 
Injection.
Cingal 16-02
Cingal 17-02


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8.2
Trial Design
This sub-study is an extension of the ongoing Cingal 16-02 trial which is a multi-center, randomized, 
double-blind, parallel group, active comparator controlled trial to evaluate the efficacy and safety of a 
single injection of Cingal for the relief of joint pain in subjects with OA of the knee. 
Subjects with OA defined as Kellgren-Lawrence (K-L) I-III in the index knee were eligible for this study
[9, 10]. Felson et al 2004, encouraged the use of both OA symptoms and radiographic changes in the 
assessment of OA [11]. Cingal 16-02 study employed both methods to screen subjects.  Structural 
severity was evaluated with the K-L classification score, a composite index of the presence and severity 
of joint space narrowing, osteophytes, sclerosis, deformity and cysts (see Appendix 4) [9, 10].
For the evaluation of symptomatic severity, two main domains are important [12].  The first is pain and 
the second is functional impairment.  Other domains often used include subject’s overall assessment, 
ROM and performance.  Domains identified by OMERACT as core variables to be used in clinical trials 
involving OA are pain, function and the Patient Global Assessment which were captured as part of the 
Cingal 16-02 study [12].
Baseline and post-treatment pain, physical function and stiffness is measured using the WOMAC 
questionnaire in the Cingal 16-02 up to 26 weeks and then to 39 weeks within the Cingal 17-02 trial.
Range of Motion, Patient and Evaluator Global Assessment and the EuroQol are used to assess 
symptomatic severity throughout both studies.  In addition, the number of acetaminophen/paracetamol
pills taken is captured as an indirect measure of pain and will be done at each visit. 
Subjects meeting the inclusion/exclusion criteria for Cingal 16-02 will have been randomized to receive
a single injection of Cingal, Monovisc or triamcinolone hexacetonide (TH) in the index knee. Since there 
is a difference in volume between Cingal, Monovisc and TH, the treating physician is not considered 
blinded. To maintain the double-blind design of the study, there is a person assigned to the role of 
Treating Physician and one person assigned to the role of Blinded Evaluator. The Treating Physician,
most often the PI, will administer the injection but will not participate in the evaluation of study treatment 
effectiveness. A second individual, designated as the Blinded Evaluator, is blinded to treatment and will 
complete the pre- and post-treatment Evaluator Global Assessment, knee exams and ROM 
measurements. To maintain the subject blinding, the injection syringe will have been prepared separate 
from the patient and the injection will be masked from the subject. The blinding of the patient and the 
blinded evaluator will be maintained in both the Cingal 16-02 and Cingal 17-02 trials.
The subject will have been trained on how to complete the WOMAC, Patient Global Assessment and 


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EuroQol within the Cingal 16-02 trial. The subject should complete these questionnaires prior to any 
physical evaluation that must be done at the 39 week follow-up visit.
The Blinded Evaluator will collect and record AEs from the subjects and consult the Treating Physician 
only as needed in the management of AEs.  The Blinded Evaluator will be a physician, research nurse,
registered physiotherapist or physician assistant trained to perform the assessments outlined in the 
protocol (Section, 10.1 Schedule of Events ).
Up to 40 sites in Europe are participating in the study to enroll 576 subjects. Subject participation in 
this extension study will last approximately 13 additional weeks beyond the Cingal 16-02 trial with 
follow-up the visit scheduled at weeks 39 after the treatment injection in Cingal 16-02.
9
ELIGIBILITY
9.1
Enrollment Criteria 
9.1.1 Inclusion Criteria
1. Only subjects that were enrolled and met the inclusion criteria for the Cingal 16-02 trial and 
signed the informed consent are eligible for Cingal 17-02.
2. Subject is able to understand and comply with the requirements of Cingal 17-02 and 
voluntarily provides consent.
Patients will not be rescreened at enrollment to Cingal 17-02 as these patients were enrolled and met 
the inclusion / exclusion criteria for the Cingal 16-02 clinical trial. All patients enrolled in the Cingal 16-
02 trial will be eligible to participate in Cingal 17-02.
For reference only, the inclusion criteria used in Cingal 16-02 were:
1. Subject is 40-\HDUVROGZLWKD%RG\0DVV,QGH[%0,NJP2.
2. Subject has Kellgren-Lawrence (K-L) severity grade I, II or III in the index knee as determined 
by X-ray.  Contralateral knee: K-L severity grade 0, I or II.
3. Subject has had at least two signs and at least two symptoms of OA disease (based on the
European League Against Rheumatism (EULAR) recommendations for diagnosing knee OA
in the index knee for at least 6 months despite conservative treatment (weight reduction, 
physical therapy, pain medications, etc.). The EULAR signs and symptoms are as follows: 
a. Signs: crepitus, restricted movement and bony enlargement 
b. Symptoms: persistent knee pain, limited morning stiffness and reduced function 


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4. Subject must be willing to abstain from other intraarticular (IA) treatments of the knee for the 
duration of the study.
5. Subject is willing to discontinue all analgesics including NSAIDs, except 
acetaminophen/paracetamol, at least seven days before the treatment injection and through 
the completion of the study. 
6. Subject is willing to use only acetaminophen/paracetamol (up to a maximum of 4.0 grams per 
day per the package insert) for the treatment of joint pain for the duration of the study. At least 
forty eight hours prior to the Baseline Visit and each follow-up visit, the subject is willing to 
discontinue use of acetaminophen/paracetamol. 
7. Subject is willing to maintain a stable dose of oral glucosamine and/or chondroitin sulfate 
products throughout the study, if taken prior to signing the informed consent form (ICF). 
8. Subject is able to understand and comply with the requirements of the study and voluntarily 
provides consent.
9.1.2 Exclusion Criteria
Patients will not be rescreened at enrollment to Cingal 17-02 as these patients were enrolled and met 
the inclusion / exclusion criteria for the Cingal 16-02 clinical trial.
Only patients enrolled in the Cingal 16-02 trial will be eligible to participate in Cingal 17-02.
For reference only, the exclusion criteria used in Cingal 16-02 were:
9.1.3
Screening Exclusion Criteria in Cingal 16-02
1. Subject received an IA injection of Hyaluronic Acid (HA) and/or steroid in either knee within 6 
months of signing the ICF. A subject will be excluded if they are planning to receive an HA or 
steroid injection (other than the study injection) in either knee during the course of this study.
2. Subject had an arthroscopy of either knee within 3 months of signing the ICF.
3. Subject had an open surgical procedure of either knee or hip or any surgery of the spine 
within 12 months of signing the ICF. Subject plans to have knee, hip or spine surgery within 
the study period. 
4. Subject has intra-articular trauma to the index knee. Subject has concurrent multi-system or 
multi-limb trauma.
5. Subject has evidence or medical history of the following diseases in the index knee: septic 


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arthritis; inflammatory joint disease; history of Reiter’s syndrome; gout; chondrocalcinosis 
associated with recurrent episodes of acute synovitis of the knee consistent with pseudogout; 
osteochondritis dissecans, Paget disease of the bone; ochronosis; acromegaly; 
hemochromatosis; primary osteochondromatosis; known history of Wilson disease; heritable 
disorders or collagen gene mutations.
6. Subject has a history of cartilage repair surgery in the index knee within 3 years of signing the 
ICF.
7. Subject has a history of ACL repair, reconstruction or injury in the index knee within 3 years of 
signing the ICF.
8. Subject has X-ray findings of acute fractures, severe bone loss, avascular necrosis, severe 
bone or joint deformity in the index knee.
9. Subject has significant varus or valgus deformity greater than 10 degrees in either knee.
10. Subject has a clinically apparent tense effusion of the index knee.
11. Subject has knee instability in either knee per the Investigator’s assessment.
12. Subject requires consistent use of an assistive device (e.g. wheelchair, walker, etc.)
Occasional use of a cane is acceptable.
13. Subject has medical condition(s) which could affect study assessments or may adversely 
affect the safety and/or success of the study treatment. This includes but is not limited to the 
following:
a. Peripheral neuropathy severe enough to interfere with evaluation of the subject,
b. Vascular insufficiency severe enough to interfere with evaluation of the subject,
c. Active fibromyalgia, 
d. Hemiparesis involving either lower extremity, 
e. Immunocompromised or immunosuppressive disorder or receiving medications to treat 
immunosuppressive disorders,
f. Systemic bleeding disorder(s), 
g. Current malignancy or treatment within the last 5 years, except for non-melanoma skin 
cancer,  
h. Significant psychiatric disorder, 
i. Active drug and/or alcohol abuse within the past year, 
j. Uncontrolled diabetes with a screening HbA1c of >7%.
14. Subject is taking medications at the time of signing the ICF which could interfere with the 
treatment procedure, healing and/or assessments. This includes but is not limited to oral or 
injectable anticoagulant treatments, anti-aggregant platelet treatment, chronic opioid 
analgesics. Low dose aspirin used for cardiovascular protection is allowed if a stable regimen 


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is maintained for the duration of the study.
15. Subject is receiving treatment using electromagnetic stimulation and/or low intensity 
ultrasound in the index knee at the time of signing the ICF, within 3 months of signing the ICF
or plans to receive treatment any time during the study period. 
16. Subjects who had an oral, intramuscular, intravenous, rectal suppository or topical (excluded 
in index knee only) corticosteroid within 30 days of signing the ICF are excluded.  Topical 
corticosteroid use at any site other than the index knee is allowed.
17. Subject has a pre-treatment contraindication to IA injections or aspiration of the index knee, 
including cutaneous infection in the injection site area, active IA infection (as suggested by 
moderate or marked effusion), knee deformity or condition which, in the opinion of the 
investigator could jeopardize the sterility or delivery of the IA injection.
18. Subjects with a history of hypersensitivity to any of the ingredients in the hyaluronan or 
previous hypersensitivity to the administration of corticosteroids or an inability to tolerate 
acetaminophen/paracetamol.
19. Subject has any contraindication to the receipt of corticosteroids.
20. Subject is receiving or in litigation for worker’s compensation.
21. Subject is a woman who is pregnant or breastfeeding at the Screening Visit or a woman of 
child bearing potential who refuses to use effective contraception during the course of the 
study.
22. Subject was involved in any other research study involving an investigational product, or a 
new application of an approved product, within 60 days of signing the ICF.
9.1.4 Baseline Inclusion Criteria in Cingal 16-02
1. Subject has a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
pain-sub-VFRUHPPDQGPPLQWKHDIIHFWHGNQHHDQG0 mm in the contralateral 
knee on a 100 mm Visual Analog Scale (VAS) scale.
9.1.5 Baseline Exclusion Criteria in Cingal 16-02
1. Subject has a decrease of 20 mm in the WOMAC pain-sub-score (average of 5 pain scales) 
from Screening to Baseline in the index knee on a 100 mm Visual Analog Scale (VAS) scale.
2. Subject has a synovial fluid aspirate volume > 20 mL in the index knee.
3. Subject has a contraindication to continue with the study treatment injection based on the 
visual appearance of the synovial fluid aspirate unless the fluid is examined microscopically 
prior to injection with no clinically significant findings (e.g. bacteria, crystals or blood).
4.
Subject has ROM of less than 100° flexion in either knee.


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10 STUDY PROCEDURES
10.1 Schedule of Events
Pre-
Treatment
Treatment
Post-Treatment Follow-Up Visits
17-02 Follow-
Up Visits
Assessments
-7 to
-14 
Days
Day 0
(7-14 days after 
screening visit)
1 week
3 weeks
6 weeks
12
weeks
18
weeks
26
weeks
Consent
39
Weeks
Screening
Baseline
Treatment
±3 days
± 1 week
± 1
week
Informed Consent
X
X
Demographics
Medical History
X
Physical Exam, Vitals, BMI
X
Urine / Blood Pregnancy Test
X
Chemistry/Hematology/Urinalysis
X
Bilateral Knee X-rays
and assessment of K-L
X
Review of X-rays by Independent 
Radiologist
X
Physical Evaluation (Both Knees) 
X
X
X
X
X
X
X
X
X
ROM (Index Knee)
X
X
X
X
X
X
X
X
X
ROM (Contralateral Knee)
X
X
X
X
X
WOMAC (Both Knees)
X
X
X
X
X
X
X
X
X
Evaluation of Enrollment Criteria
X
X
X
X
Stop Analgesics/NSAIDs except 
Paracetamol
X
$VVHVV'&3DUDFHWDPROhours 
before Visit
X
X
X
X
X
X
X
X
X
Paracetamol Dispense/Pill Count
X
X
X
X
X
X
X
X
X
X
Distribute Subject Diary
X
X
Randomization
X
Aspiration/ Evaluation of Synovial Fluid
X
IA Injection
X
Evaluate Diary
X
X
X
X
X
X
X
X
EuroQol
X
X
X
X
X
X
X
X
Patient Global Assessment
X
X
X
X
X
X
X
X
Evaluator Global Assessment
X
X
X
X
X
X
X
X
Concomitant Medication Assessment
Throughout the study
Adverse Event Assessment
Throughout the study
† -Cells in grey indicate assessments conducted only during Cingal 16-02 trial.


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10.2 Procedure Description
10.2.1 Informed Consent Form (ICF)
The subject will be asked to sign the ICF prior to attending the 39 week follow up visit.
All data collected in the clinical trial Cingal 16-02 will be utilized in Cingal 17-02. The 
demographics and assessments conducted at screening and baseline for Cingal 16-02 will be 
utilized as the demographic and baseline data for Cingal 17-02.
10.2.2 Demographics
The following demographic information will have been collected at the Screening Visit of Cingal 16-02 
trial: Age, Gender, Race and Ethnicity. The demographic data for Cingal 16-02 will be used for Cingal 
17-02.
10.2.3 Physical Exam (PE)
The Physical Exam performed at the screening of Cingal 16-02 will be utilized for Cingal 17-02. The 
PE will include an assessment of general appearance, chest and lungs, heart, abdomen, skin, 
musculoskeletal system, neurologic systems and other (as applicable).  This PE will include an 
assessment of height and weight for calculation of a BMI.
10.2.4 Vital Signs
Vital signs (blood pressure, pulse, temperature) at the screening of Cingal 16-02 will be utilized for 
Cingal 17-02.
10.2.5 Pregnancy Test
For females of childbearing potential, a urine or blood pregnancy test at the screening of Cingal 16-02
will be utilized for Cingal 17-02. Women who can confirm that they are surgically sterile or have been 
postmenopausal for at least 1 year prior to signing the ICF did need not undergo a pregnancy test in 
Cingal 16-02.
10.2.6 Chemistry/Hematology/Urinalysis
For all subjects, the blood tests at the screening of Cingal 16-02 will be utilized for Cingal 17-02. A
routine and microscopic analysis of the urine at the screening of Cingal 16-02 will be utilized for Cingal 
17-02.


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Table 1 Laboratory Analytes
Hematology
Clinical Chemistry
Hematocrit
Sodium
AST/SGOT
Hemoglobin
Potassium
ALT/SGPT
RBC count
Chloride
Alkaline Phosphatase
WBC count
Glucose
Total protein
Differential WBC count
Urea nitrogen
Albumin
Platelet count
Creatinine
HbA1c (for diabetics only)
Total bilirubin
Triglycerides
Calcium
10.2.7 Knee X-rays/Assessment of Kellgren-Lawrence Score
Subjects will have completed screening within the Cingal 16-02 trial to have the following X-rays of 
both knees collected at the Screening Visit. The results of the X-rays of both knees in Cingal 16-02 
will be utilized for Cingal 17-02:
x
Long Limb Standing Anterior Posterior (AP) view
x
Fixed Flexion Posterior Anterior (PA) view 
These screening images will have been transferred to, as well as handled by, the Central Imaging Core 
lab according to their Standard Operating Procedures (SOPs). An independent radiologist from the 
Central Imaging Core lab will have evaluated the Screening plain films of both knees for osteoarthritic 
changes using the K-L scoring system (Appendix 4) and excluded subjects with K-L severity grade of
IV in the index knee or K-L severity grade III or IV in the contralateral knee. Additionally, varus/ valgus 
alignment will have been assessed in both knees and subjects with greater than 10 degrees of 
malalignment in either knee will have been excluded.
Furthermore, the independent radiologist will have evaluated the screening X-rays to determine the 
following exclusion criteria for the index knee:
x
Presence of osteochondromatosis
x
History of ACL repair, reconstruction or injury
x
History of cartilage repair surgery
x
X-ray findings of acute fracture(s)
x
Severe loss of bone density
x
Avascular necrosis


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x
Severe bone or joint deformity in the index knee
x
Advanced cases of gout
x
Advanced cases of Paget
x
Acromegaly
x
Osteochondritis dissecans
The independent radiologist will have confirmed the eligibility of screened subjects based on the 
imaging enrollment criteria. In the event the independent radiologist determined that a subject is 
ineligible based on an imaging finding, the decision of the independent radiologist would have
prevailed.
All the Screening X-rays were paid for by the Cingal 16-02 study and were free of charge to the subject. 
The images acquired for the Cingal 16-02 trial will have been transferred from the imaging site to the 
Central Imaging Core lab electronically and are available for use within Cingal 17-02. The X-rays will 
have been identified by the subject’s study identification (ID) number. No personal identifiable 
information would have been included on the image.
10.2.8 Medical History
A complete medical history will have been obtained at the Screening Visit for Cingal 16-02 and will be 
utilized for Cingal 17-02. The medical history will have included an inquiry of past medical conditions in 
the following body systems: neurological, psychological, cardiovascular, hematological, respiratory, 
endocrine/metabolic, musculoskeletal, and immunologic (including allergies). The medical history will 
also include an assessment of the subject’s history of the following:
x
History/duration of knee OA
x
History of operative arthroscopies
x
History of open surgical procedures of either knee
x
History of open surgical procedures of either hip
x
History of IA injections including HA and steroid
x
History of electromagnetic stimulation therapy
x
History of other OA surgeries
x
History of other OA procedures
x
History of other OA abnormalities
10.2.9 Physical Evaluation of Knee


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The Blinded Evaluator will perform the physical evaluation of the knee at the 39-week time point
included in Section 10.1, Schedule of Events. This will include assessment of effusion grade of both 
knees (none, mild, moderate or marked), symptoms (e.g.  persistent knee pain, limited morning stiffness 
and reduced function) and signs (crepitus, restricted movement and bony enlargement).  Knee
circumference in cm will also be measured in the index knee.
10.2.10
Range of Motion
The ROM will assess the maximum flexion and extension in degrees using a goniometer at the 39-
week time point included in Section 10.1, Schedule of Events. The ROM will be documented as a 
hyphenated number. For instance, normal ROM in the knee is about 0-140 degrees.
10.2.11
WOMAC
The WOMAC index is self-administered and assesses the three dimensions of pain, disability and 
joint stiffness in knee and hip osteoarthritis using a battery of 24 questions (5 pain, 2 stiffness,17 
physical function) [14]. This trial will utilize the VAS version of the WOMAC index. The subject will be 
trained on how to complete the WOMAC which will be collected at the 39-week time points indicated
in Section 10.1.
10.2.12
Medications
Medications that the subject may have been taking prior to enrollment in Cingal 16-02 for conditions 
unrelated to the treatment of knee osteoarthritis, other than analgesics including NSAIDs, may be 
continued through to Cingal 17-02 as long as they will not interfere with study assessments.  If the 
subject was taking oral glucosamine and/or chondroitin sulfate products for the treatment of knee 
osteoarthritis prior to signing the informed consent form for Cingal 16-02, the products may be 
continued through to Cingal 17-02, but the subject must maintain a stable regimen for the duration of 
the Cingal 16-02 and the Cingal 17-02 studies.
10.2.12.1
Restricted Medications
All analgesics other than acetaminophen/paracetamol are prohibited during the study.  This includes, 
but is not restricted to, NSAIDs, opioids and topical agents for treatment of OA in the index knee. Topical 
corticosteroids are allowed at any other site other than the index knee. The analgesic medication use 
will be monitored at each subject visit through review of the subject diary. 
The use of IA injection of steroids in any joint and the use of IA injection of viscosupplements in the 
knee joint is prohibited throughout the study.
The use of immunosuppressive agents such as 


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cyclosporine, methotrexate are prohibited throughout the study.
10.2.12.2
Rescue Medications
Acetaminophen/paracetamol (up to a maximum of 4.0 grams per day per the package insert or as per 
regional limitations) will be allowed as the rescue medication for the treatment of joint pain for the 
duration of Cingal 17-02. At least forty eight hours prior to the 39 week follow-up visit the subject should
discontinue use of the rescue medication.
At the Screening Visit for Cingal 17-02, the rescue acetaminophen/paracetamol specifically labelled for 
use within Cingal 17-02 will be dispensed. The rescue medications provided to the subject for Cingal 
16-02 should be returned to the investigational site at the Cingal 16-02 26 week follow up visit. 
The subject should be instructed to bring the rescue medication with them to 39-week follow-up visit 
for a pill count. Additional rescue acetaminophen/paracetamol will be dispensed as needed only if there 
is an unscheduled the follow-up visit before the 39 week follow up visit.
10.2.12.3
Concomitant Medications
A medication is considered concomitant if taken after signing the ICF and up to and including the 39
week follow-up visit.  Data on medications will include: medication name, dose, unit, route, frequency,
start date, stop date, indication and whether the medication was taken for an AE.
At each study visit, the subject will be asked about any new medications that were started since the 
last visit.  Indications for any new medications during the study period will be recorded as AEs, unless 
the medications are administered for a pre-existing condition.
10.2.13
Subject Diary
The subject diary will be dispensed at the Screening Visit and the subject will receive training on when 
and how to complete the diary. The subject diary will be used to collect information on medication usage
including rescue medications, concomitant therapies (e.g. physical therapy) and AEs. The subject diary 
will be reviewed by site staff to determine if there are AEs that need to be captured within the Electronic 
Data Capture (EDC) system and to assess rescue medication usage and compliance with the protocol.
10.2.14
EuroQoL EQ-5D
Outcomes information from the subject-completed EuroQol EQ-5D will be obtained at the 39-week 
follow up specified in Section 10.1, Schedule of Events.  The EQ-5D is a standardized measure of 
health status developed by the EuroQol Group which is applicable to a wide range of health conditions 


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and treatments. The EQ-5D provides a simple descriptive profile and a single index value for health 
status that can be used in the clinical and economic evaluation of health care as well as in population 
health surveys [15].
The EQ-5D is designed for self-completion by respondents and consists of 2 pages - the EQ-5D 
descriptive system and the EQ visual analog scale (EQ VAS). The EQ-5D descriptive system comprises 
the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression
[15].  The subject is asked to indicate his/her health state by ticking (or placing a cross) in the box 
against the most appropriate statement in each of the 5 dimensions. The EQ VAS records the subject’s 
self-rated health on a vertical VAS where the endpoints are labeled ‘Best health you can imagine’ and 
‘Worst health you can imagine’ as shown in Appendix 3. This information is used as a quantitative 
measure of health outcome as judged by the individual respondents [15].
10.2.15
Patient Global Assessment
The Patient Global Assessment (Appendix 2) is a VAS that will be completed by the subject at the 39
week follow up visit as specified in Section 10.1, Schedule of Events, to determine the Patient Global
Assessment of response to therapy score. “Considering all the ways the osteoarthritis in your study 
index knee affects you, what is your assessment of how much your study knee is bothering you today?”
10.2.16
Evaluator Global Assessment
The Evaluator Global Assessment (Appendix 2) will be completed by the Blinded Evaluator at the 39
week follow up visit as specified in Section 10.1, Schedule of Events. To reduce the potential for bias, 
it is important for the Blinded Evaluator to complete the Evaluator Global Assessment prior to collecting 
the Patient Global Assessment.
The Blinded Evaluator will be asked “Considering all the ways the osteoarthritis in the patient’s index 
knee affect him/her, what is your assessment of how much the patient’s knee is bothering him/her 
today?”
10.2.17
Blinding
During the Cingal 16-02 trial the Treating Physician will have been aware of the differences between 
the Clinical Trial Materials and will have been unblinded, therefore; there were two clearly defined roles
of a Treating Physician (unblinded) and a Blinded Evaluator (blinded) at each site. The site personnel 
fulfilling these roles will remain the same in Cingal 16-02 and Cingal 17-02.
x
Treating Physician: The Treating Physician is most often the PI. He/she will have administered


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the Cingal, Monovisc or Triamcinolone Hexacetonide (TH) injection but will not participated in 
the efficacy evaluations in either Cingal 16-02 or Cingal 17-02.
x
Blinded Evaluator: The Blinded Evaluator will be a physician, research nurse, registered 
physiotherapist or physician assistant trained by the PI to perform the assessments outlined in 
the Cingal 16-02 and Cingal 17-02 protocols. The Blinded Evaluator will have completed the 
physical evaluation of both knees, ROM assessments of both knees, and the Evaluator Global 
Assessment for both Cingal 16-02 and Cingal 17-02 trials.
The identity of the syringes would not have been revealed during the Cingal 16-02 trial to the patients 
or the blinded evaluator. This blinding of the treatments given to the patients in the Cingal 16-02 trial 
will be maintained for the patients and the blinded evaluators in the Cingal 17-02 trial.
10.3 Screening
Each subject will indicate his or her willingness to participate in the study by signing the ICF. Subjects
will maintain the unique subject ID (e.g., 01-001) allocated during the Cingal 16-02 trial where the first 
two digits represent the number assigned to the investigative site and the last three digits represent the 
subject number. The number will be recorded on the Enrollment Log and in the subject’s electronic 
Case Report Forms (eCRFs). Subjects will be identified by the same unique subject ID for the duration 
of their participation in both the Cingal 16-02 and the Cingal 17-02 trials.
All data collected in the clinical trial Cingal 16-02 will be utilized in Cingal 17-02. The 
demographics and assessments conducted at screening and baseline for Cingal 16-02 will be 
utilized as the demographic and baseline data for Cingal 17-02.
The following screening and eligibility data will be collected at the Screening Visit for Cingal 17-02:
x
Informed Consent
x
Eligibility Data collected in Cingal 16-02 will be utilized for Cingal 17-02
x
Distribute Subject Diary
x
Assess AEs
x
Assess Concomitant Medications
x
Dispense Rescue Medication labelled for Cingal 17-02
During the Screening Visit inform the subject about discontinuation of all analgesics including NSAIDs 
except acetaminophen/paracetamol. Acetaminophen/paracetamol will be used as a rescue pain 
medication through the completion of the study, however; acetaminophen/paracetamol should be 
discontinued at least 48 hours before each follow-up study visit. Subjects who are taking oral 


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glucosamine and chondroitin sulfate products should be informed that a stable dose of these 
supplements must be maintained for the duration of the study.
10.4 Post-Treatment Follow-Up
All study subjects will have follow-up assessments at 39 weeks after injection day in Cingal 16-02 to 
evaluate effectiveness of the treatment and to assess AEs and protocol compliance.  The Blinded 
Evaluator will evaluate the clinical status of the subject at each visit.  
More than 48 hours prior to the visit, the subject will be reminded of the visit date and time, the need to 
abstain from acetaminophen/paracetamol for at least 48 hours prior to each follow-up visit and the 
requirement to bring their subject diary and the acetaminophen/paracetamol for a pill count with them 
to the appointment.
If the subject arrives for a study visit without discontinuing acetaminophen/paracetamol for at least 48 
hours prior to the visit, the visit should be rescheduled within the allowed window of time. Study 
assessments should be performed as soon as possible and the protocol deviation, if applicable,
recorded in the source and eCRF.  The subject must be re-educated about the importance of protocol 
compliance.
If the subject does not come in at the expected time, at least three attempts will be made to contact the 
subject in order to accomplish maximum subject compliance with the follow-up schedule.  
The following post-treatment visits will be performed. The subject will be asked whether any 
concomitant medications have been taken.  All assessments will be done by the Blinded Evaluator.
39 Weeks ± 7 Days
x
Confirm Rescue Medication Washout 
x
Evaluate Subject Diary
x
Count Rescue Medication Pills (if needed)
x
Physical Evaluation (both knees)
x
ROM (both knees)
x
WOMAC (both knees)
x
Patient Global Assessment
x
Evaluator Global Assessment
x
EuroQol
x
Assess Concomitant Medications


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x
Assess AEs
11 ADVERSE EVENTS / ADVERSE REACTIONS
11.1 Definitions – Device Adverse Events
Adverse Event (AE): An AE is any untoward medical occurrence in a subject administered the CTM,
which does not necessarily have a causal relationship with the treatment.  An AE can therefore be any 
unfavorable and unintended sign, (including an abnormal laboratory finding) symptom or disease 
temporally associated with the use of the CTM, whether or not related to the CTM.
Adverse Device Effect (ADE): An AE related to the use of an investigational medical device.
NOTE 1: This definition includes Adverse Events resulting from insufficient or inadequate 
instructions for use, deployment, implantation, installation, or operation, or any malfunction of 
the investigational medical device.
NOTE 2: This definition includes any event resulting from use error or from intentional misuse 
of the investigational medical device.
Anticipated Serious Adverse Device Effect: An effect which by its nature, incidence, severity or 
outcome has been identified in the Investigator Brochure.
Serious Adverse Event (SAE): Any untoward medical occurrence that:
x
Results in death;
x
Is life-threatening ("Life-threatening" refers to an event in which the subject was at risk of 
death at the time of the event. It does not refer to an event which hypothetically might have 
caused death if it were more severe.);
x
Requires inpatient hospitalization or prolongation of existing hospitalization;
x
Results in persistent or significant disability/incapacity;
x
Is a congenital anomaly/birth defect;
x
Required intervention to prevent permanent impairment or damage.
Serious Adverse Device Effect (SADE): An ADE that has resulted in any of the consequences 
characteristic of a serious adverse event.
Unanticipated Serious Adverse Device Event: An SAE effect which by its nature, incidence, severity 
or outcome has not been identified in the current version of the Investigator’s Brochure.


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11.2 Definitions – Drug Adverse Events
Adverse Event (AE): An adverse event (sometimes referred to as an adverse experience) means any 
untoward medical occurrence associated with the use of a drug in humans, whether or not considered 
drug related.  
Suspected Adverse Reaction (SAR): A suspected adverse reaction means any adverse event for 
which there is a reasonable possibility that the drug caused the event.
Adverse Reaction (AR):  An adverse reaction means any adverse event caused by a drug.  Adverse 
reactions are a subset of all suspected adverse reactions where there is reason to conclude that the 
drug caused the event.
Unexpected AE/SAR/AR:  An adverse event, suspected adverse reaction or adverse reaction is 
considered “unexpected” if it not listed in the Investigator Brochure.
Serious AE/SAR/AR:  An adverse event, suspected adverse reaction or adverse reaction is 
considered “serious” if, in the view of either the investigator or sponsor, it results in death, a life-
threatening adverse event, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions, 
or a congenital anomaly/birth defect.  If either the investigator or sponsor believes that an event is 
serious, the event will be considered serious and evaluated by the sponsor for expedited reporting.
Suspected Unexpected Serious Adverse Reaction (SUSAR):  An adverse event, suspected adverse 
reaction or adverse reaction is considered a SUSAR if it meets the criteria of both “Unexpected” and 
“Serious” as defined in this section.  Any event believed to be a SUSAR by the investigator and/or the 
sponsor will be evaluated by the sponsor for expedited reporting.
11.3 Relationship
The Relationship between an AE and the CTM will be determined by the Investigator on the basis of 
his or her clinical judgment and the following definitions:
Definitely Related: The AE follows a reasonable temporal sequence from administration of the CTM;
the AE follows a known or expected response pattern to the CTM.


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Probably Related: The AE follows a reasonable temporal sequence from administration of the CTM;
the AE follows a known or expected response pattern to the CTM; and the AE could not be reasonably 
explained by the known characteristics of the subject’s clinical state.
Possibly Related:  The AE follows a reasonable temporal sequence from administration of the CTM;
the AE follows a known or expected response pattern to the CTM, but could readily have been produced 
by a number of other factors.
Unlikely Related: The AE which etiology is unlikely related to the CTM even if event may follow a 
known or expected response pattern to the CTM, and likely to be produced by a number of other factors.  
Sufficient information is not available at the time of the AE to determine its causality.
Not Related:  An AE for which sufficient information exists to indicate that the etiology is unrelated to 
the CTM. One or more of the following variables apply:
x
The AE does not follow a reasonable temporal sequence following administration of the CTM;
x
The AE is readily explained by the subject’s clinical state or other therapies.
For events that are determined to be definitely, probably or possibly related, additional information on 
the relationship and timing of the event in relation to the athrocentesis and study injection will be 
captured.
11.4 Severity
The severity of AEs will be assessed according to the following definitions:
Mild: The Adverse Event is noticeable to the subject, but does not interfere with routine activity.  
Moderate:  The Adverse Event interferes with routine activity but responds to symptomatic therapy or 
rest.  
Severe: The Adverse Event significantly limits the subject's ability to perform routine activities despite 
symptomatic therapy.  
11.5 Reporting  
11.5.1 Adverse Events
All AEs that occur after signing the ICF will be recorded.  At each visit during the trial, AEs that have 
occurred since the previous visit must be recorded.  All subjects will be questioned and evaluated for 


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AEs or complications associated with the procedure. Complications of the injection include, but are not 
necessarily limited to: pain, swelling and/or inflammation at the injection site. The Investigator will
determine the severity and relationship of each event, as defined above.
AEs observed during the course of this study, regardless of severity or relationship to the injection will 
be recorded on the appropriate eCRF. Each reported complication/AE will also include the duration, 
action taken to address the AE, and the resolution status (e.g. ongoing, resolved). These subjects will 
continue to be evaluated for safety and efficacy at all scheduled follow-up points. 
The sponsor must report the results of an evaluation of an unanticipated adverse device effect (UADE) 
to relevant regulatory agencies and all reviewing ECs and investigators within timelines required by the 
regulatory agencies.
11.5.2 Serious Adverse Events/Serious Adverse Device Effects/Serious Adverse Reactions
All SAE/SADE/SAR/ SUSAR must be reported to the Sponsor or designee within 24 hours of the 
investigative site becoming aware of its occurrence.  This requirement is irrespective of whether the 
SADE/SAE is thought to be possibly related to the CTM or not. 
SAE/SADE/SAR/ SUSAR Reporting Procedures 
Information such as the investigator name, study name/protocol number, subject ID number, the name 
of the SAE/SADE/SAR, the investigator’s assessment as to the relationship to the CTM, and the 
reporting source should be included in the initial report.  Any additional supporting documentation (e.g., 
autopsy report, hospital records, etc.) must be submitted to the Sponsor or designee.  This also includes 
forwarding pertinent follow-up information (e.g., hospital discharge summary) as it becomes available.  
A completed SAE/SADE/SAR/ SUSAR form needs to be submitted with each follow-up.  The subject 
must be monitored carefully until the condition disappears or the etiology is identified.
All SAE/SADE/SAR/ SUSAR will be entered into the EDC system. The EDC system will automatically 
notify the medical monitor and the Sponsor or designee.
11.5.3 Expedited Reporting
Any unexpected fatal or life-threatening AEs will be reported by the Sponsor or designee to the 
appropriate regulatory authorities in accordance with applicable expedited reporting guidelines. Any 
event considered serious by either the investigator or sponsor will be evaluated by the sponsor for 
expedited reporting.


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11.5.4 Independent Data Monitoring Committee 
An Independent Data Monitoring Committee (IDMC) will review the data to assess if the trial should be 
revised or closed.  This IDMC will be made up of individuals who have expertise in the field, experience 
in the conduct of clinical trials, and/or statistical knowledge without conflicts of interest which may affect 
objectivity.  The IDMC will operate in accordance to the IDMC Charter. A Sponsor signed and dated 
original of this document will be kept in the Sponsor’s study files.
11.5.5 Study Discontinuation
Enrollment will be suspended if a subject experiences a serious and/or life-threatening AE that is 
probably or definitely related to the study injection. The study will be stopped if in the opinion of the PI, 
medical monitor, and Sponsor that the safety of subjects is uncertain.  The decision to resume 
enrollment, permanently discontinue the trial, or otherwise modify the study will be made by the Medical 
Monitor in consultation with the IDMC.  Additionally, the triggering of the stopping rules will prompt 
notification to the appropriate regulatory agencies including the Competent Authorities and the ECs.
12 STATISTICAL CONSIDERATIONS
The statistical analysis of the study is described in detail in a separate version-controlled prospective 
Statistical Analysis Plan (SAP).  However, the statistical methodology described in this section of the 
protocol will be the basis for the detailed SAP.
12.1 Sample Size
The sample size for Cingal 16-02 was based on the primary comparison in the study between Cingal 
and triamcinolone hexacetonide with respect to the difference in the change in the WOMAC pain score 
from baseline at 26 weeks after study injection. The first secondary comparison is between Cingal and 
Monovisc with respect to the difference in the change in the WOMAC pain score from baseline at 3 
weeks after study injection.  All comparisons are made using a 5% significance level.  The primary 
comparison is powered at 90% power and in a 2:1 randomization requires 128 patients in the Cingal 
group and 64 in the triamcinolone hexacetonide group.  It is assumed that the difference in the mean 
responses for Cingal and triamcinolone hexacetonide at 26 weeks would be 10 mm based on previous 
clinical trials of similar viscosupplementation products [20, 21] and the Cingal 13-01 trial with a standard 
deviation of 20. The sample size calculation is based upon a t-test. The sample size that is necessary 
to detect that specified difference at a power of 90% with a significance level of 5% in a 2:1 enrollment 
ratio is 128 in the Cingal group and 64 in the triamcinolone hexacetonide group.  


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It is further assumed that the difference between Cingal and Monovisc at 3 weeks will be 5 mm and a 
standard deviation of 20 mm, thus it will require a minimum of 253 patients in each group to detect that 
difference at 80% power.  With the triamcinolone hexacetonide group set at 64 patients, the number of 
patients in the Cingal and Monovisc groups will be increased to provide a 4: 1 randomization ratio. This 
will yield 256 in the Cingal group, 256 in the Monovisc group and 64 in the triamcinolone hexacetonide
group. This provides a total sample size of 576 patients.
Since the primary analysis in this study is an intent to treat analysis and the missing data for a patient 
will be imputed using mixed effects models, no drop out rate will be assumed for this study.  Thus the 
total sample size for Cingal 16-02 was set at 576 patients.
12.1.1 Primary Efficacy Endpoint
The primary efficacy endpoint is the responder rate as identified by the OMERACT-OARSI 
responder index at 39 weeks post treatment comparing the Cingal group to the triamcinolone 
hexacetonide group
The response rate for the Cingal group and Triamcinolone Hexacetonide (TH) group will be calculated 
and tested using Fisher’s exact test.  Formally, the hypothesis to be tested is:
+ʌ C  ʌ T versus  HAʌ C ʌ T
:KHUHʌ C LVWKHUHVSRQGHUUDWHIRUWKH&LQJDOJURXSDQGʌ T is the responder rate for the triamcinolone 
hexacetonide group. 
12.1.2 Secondary Efficacy Endpoints
There are multiple secondary endpoints.  In order to preserve the integrity of the Type I error, these 
will be tested in a hierarchical manner.  The order of the testing is as the order presented here. 
The change from baseline in knee pain as measured by the WOMAC Pain Score (100 mm VAS) 
at 39 weeks post treatment comparing the Cingal group to the TH group. 
This secondary efficacy endpoint is the change from baseline in knee pain as measured by the WOMAC
Pain Score (100 mm VAS) at 39 weeks post treatment comparing the Cingal group to the TH group.


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Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline pain 
score as a covariate.  The primary hypothesis will be tested by a predefined contrast for comparing the 
Cingal group to the TH group.  Formally, the hypothesis to be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the mean change from baseline in the WOMAC Pain Score for the Cingal group at 39
weeks and μ DT is the mean change from baseline in the WOMAC Pain Score for the TH group at 39
weeks.  Since there are three treatment groups in this study, this hypothesis will be tested using a one 
way ANOVA and constructing a contrast for this hypothesis.  This process is the same as using a
baseline pain adjusted two-sample t-test with the common variance estimate from the ANOVA.
The change from baseline in WOMAC Physical Function score at 39 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in WOMAC Physical Function Score at 
39 weeks post treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline 
Physical Function score as a covariate.  The hypothesis will be tested by a predefined contrast for 
comparing the Cingal group to the TH group.  Formally, the hypothesis to be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the mean change from baseline in the WOMAC Physical Function Score for the Cingal 
group at 39 weeks and μ DT is the mean change from baseline in the WOMAC Physical Function Score 
for the TH group at 39 weeks.  
The change from baseline in WOMAC Stiffness score at 39 weeks post treatment comparing the 
Cingal group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in WOMAC Stiffness Score at 39 weeks 
post treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline 
Stiffness score as a covariate.  The hypothesis will be tested by a predefined contrast for comparing 
the Cingal group to the TH group.  Formally, the hypothesis to be tested is:


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H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the mean change from baseline in the WOMAC Stiffness Score for the Cingal group at 
39 weeks and μ DT is the mean change from baseline in the WOMAC Stiffness Score for the TH group 
at 39 weeks.  
The change from baseline in Total WOMAC score at 39 weeks post treatment comparing the 
Cingal group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in Total WOMAC Score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline Total 
WOMAC score as a covariate.  The hypothesis will be tested by a predefined contrast for comparing 
the Cingal group to the TH group.  Formally, the hypothesis to be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the mean change from baseline in the Total WOMAC Score for the Cingal group at 39
weeks and μ DT is the mean change from baseline in the Total WOMAC Score for the TH group at 39
weeks.  
The change from baseline in the Patient Global Assessment at 39 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group.
Since this is a secondary endpoint the data will be analyzed for each time point individually with no 
adjustment for multiplicity.  Data will be analyzed via an analysis of variance with a term for treatment
and baseline pain score as a covariate.  The primary hypothesis will be tested by a predefined contrast 
for comparing the Cingal group to the Triamcinolone Hexacetonide group.  Formally, the hypothesis to 
be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the mean change from baseline in the Patient Global Assessment Score for the Cingal 
group at 39 weeks and μ DT is the mean change from baseline in the Patient Global Assessment Score 
for the triamcinolone hexacetonide group. At 39 weeks. Since there are three treatment groups in this 
study, this hypothesis will be tested using a one way ANOVA and constructing a contrast for this 
hypothesis.  This process is the same as using a two-sample t-test with the common variance estimate 


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from the ANOVA.
The change from baseline in the Evaluator Global Assessment through 39 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group.
Since this is a secondary endpoint the data will be analyzed for each time point individually with no 
adjustments for multiplicity.  Data will be analyzed via an analysis of variance with a term for treatment
and baseline pain score as a covariate.  The primary hypothesis will be tested by a predefined contrast 
for comparing the Cingal group to the triamcinolone hexacetonide group.  Formally, the hypothesis to 
be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT
Where μ DC is the mean change from baseline in the Evaluator Global Assessment for the Cingal group 
at 39 weeks and μ DT is the mean change from baseline in the Evaluator Global Assessment for the 
triamcinolone hexacetonide group at 39 weeks.  Since there are three treatment groups in this study, 
this hypothesis will be tested using a one way ANOVA and constructing a contrast for this hypothesis.  
This process of constructing a contrast is the same as using a two-sample t-test with the common 
variance estimate from the ANOVA.
The usage of rescue medication through 39 weeks post treatment comparing the Cingal group
to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the usage of rescue medications through 39 weeks post treatment 
comparing the Cingal group to the TH group.
The hypothesis will be tested by a predefined contrast for comparing the Cingal group to the TH group.  
Formally, the hypothesis to be tested is:
H0: μ DC = μ DT versus HA: μ DC  DT.
Where μ DC is the total usage of rescue medications for the Cingal group at 39 weeks and μ DT is the 
mean change from baseline in the WOMAC Pain Score for the TH group at 39 weeks.
12.1.3 Exploratory Endpoints
Any comparisons between groups (Cingal, Monovisc, TH), within groups and / or time points (from 
baseline through to 39 weeks) not described in the primary or secondary endpoints may be presented 


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in the exploratory endpoints including:
x
EuroQoL (EQ-5D)
x
WOMAC Pain Score (100mm VAS)
x
OMERACT-OARSI
x
Total WOMAC
x
WOMAC Stiffness Score
x
WOMAC Physical Function Score
x
Patient Global Assessment
x
Evaluator Global Assessment
x
Range of Motion
x
Rescue Medication Usage: Difference in analgesic use measured by number of pills taken 
between visits will be compared between treatment groups descriptively.
x
Number of Subjects Considered Treatment Failures: Treatment Failure: A subject who 
undergoes a procedure or uses a medication (other than the rescue medication) for the 
treatment of OA in the index knee at any time after the study injection through the 39 week visit.
For the exploratory analyses, the continuous variables will be analyzed via an analysis of variance and 
contrasts used to assess the prescribed comparisons.  For the discrete variables, a Fisher’s exact test 
will be used to assess the desired comparisons.
12.2 Statistical Methods
Tabulation of summary statistics, graphical presentations, and statistical analyses will be performed 
using SAS® software 9.1.3 or higher version. Where not otherwise specified, the last pre-treatment 
observation will be used as baseline for calculating post-treatment changes from baseline. The primary 
presentations and analyses will be based on data pooled across study centers. Relevant summaries 
for individual centers, or combinations of centers, may be presented for primary data. All testing and 
confidence intervals will use a significance level of 5%.


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12.3 Demographic and Baseline Characteristics
All demographic and baseline characteristics will be tabulated by treatment group and a test of 
homogeneity between the treatment groups will be conducted. For continuous variables (e.g. age, 
height, weight) a one way ANOVA will be used. For categorical variables (e.g. gender, race), a Fisher's 
exact test or chi-squared test will be used. Medical history findings, physical examinations and 
concomitant medications will be tabulated by treatment group.
The baseline Chemistry, Hematology, Urinalysis, Vital Signs, and BMI data will be summarized via 
descriptive statistics and tested for homogeneity using a one way ANOVA.
12.4 Adverse Events
All AEs will be coded according to MedDRA. Safety assessments will include Treatment-Emergent 
Adverse Events (TEAEs) which are defined as AEs with an Investigator assessment of definitely, 
probably, or possibly related to CTM. TEAEs will be summarized with frequencies and percentages by 
system organ class and preferred term, severity, and relationship to study CTM for each treatment 
group.  In summaries of TEAEs by severity and relationship to CTM for subjects reporting multiple 
episodes, all reported events will be included, not only the worst reported case.  Serious Adverse 
Events will also be presented by relationship to the CTM.
The number of subjects with at least one AE will be tabulated for each treatment group. Differences 
between the treatment groups will be tested using Fisher's exact test. Then the number of AEs for each 
treatment group will also be tabulated.
The number of subjects and the number of AEs will be tabulated by severity, relationship, and local 
injection site specific events versus non local events.
12.5 Subject Populations  
All safety analyses will be conducted on all subjects who undergo treatment in any group.    
The primary analysis on the primary endpoint will be performed on the ITT populations using the 
Multiple Imputation Methodology.  The Multiple Imputation Methodology will use a mixed effects 
repeated measures model to predict the missing values.  All Primary and Secondary endpoints will be 
analyzed using the ITT population.
It has been determined that any missing data in this study will follow the Missing at Random (MAR) 
assumption and is justified by the following section from the guide on missing data.[25]


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Missing Data Because of Attrition in the Course of the Study The longer the planned length of a 
clinical trial, the greater the chance that participants will drop out of the trial due to their moving out of 
the area or otherwise experiencing changes in their lives that preclude or complicate further 
participation. If dropping out due to these situations is known to be unrelated to changes in health 
status, an MAR assumption for the missing values seems justified;
Since none of these patients are likely to be in a life threatening disease situation and many have had 
knee pain for a period of time, the missing data will unlikely be due to any treatment effect or lack 
thereof. Previous studies have demonstrated a missing data rate of less than 1%.  Thus, any missing 
data in this study follows that paradigm and thus should be considered MAR.  Under this MAR 
assumption, it is well known that the mixed effects repeated measures analysis yields unbiased 
estimates of the treatment effects and thus will be utilized in the analysis. However, since the primary 
and secondary analyses are being performed at a single time point using an ANCOVA model and not 
a repeated measures model, missing data will be imputed using a multiple imputation EM algorithm.  
The missing data for the WOMAC pain, WOMAC function, and PGA will be imputed in this algorithm.
A secondary analysis will be conducted on the Per Protocol (PP) population.   Since the primary 
endpoint is at 39 weeks, this is all subjects who complete the 39 week visit and who are not major 
violators of the protocol.  For all other visits, this is defined as the subjects who complete those visits
according to the protocol.  Also, to complete this sensitivity analysis, a mixed models analysis of 
variance will be performed without imputing data for missing values.
12.6 Additional Analyses
All of the analyses are performed on the data without covariates or other factors assumed in the 
model.  If it is determined that certain factors may influence the outcomes of the endpoints, then 
additional analyses will be performed.  For the continuous variables, the factors will be added to the 
ANOVA model and evaluated in a stepwise fashion for significance.  For the discrete variables, the 
data will be analyzed via a GEE model with the factors added to the model. 
13 DATA MANAGEMENT CONSIDERATIONS
13.1 Electronic Data Capture (EDC) System
The EDC system to be used in this study will be 21CFR part 11 compliant and have appropriate Quality
Management Systems in place. The same database utilized to collect the data in Cingal 16-02 will be 


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extended to collect the data for Cingal 17-02.
All sites will receive appropriate training on using the EDC System including completing the eCRF and 
responding to queries.
Each designated site participant will receive a unique electronic signature:
consisting of a user name and password, after training has been completed in order to access the EDC 
System.
13.2 Data Collection 
One eCRF will be completed for each study subject based on the source documents. Once a subject
eCRF has been completed by the site, the data management group will begin the data cleaning 
process. The details of completing the eCRF by the site can be found in the eCRF Completion 
Guidelines.
13.3 Data Management
Once the eCRF is ready for review, the data management group will complete automated and manual 
validation checks according to the Data Management Plan (DMP) to ensure the quality, consistency, 
and completeness of all data entered. Instances of incomplete, uninterpretable or inconsistent data will 
be resolved with the site through issuing a query or other means of communication as necessary. The 
site is responsible to respond and / or correct the data for all queries issued in a timely manner. All 
queries and changes to the data will be tracked.


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13.4 Data Retention
At the end of the study, an electronic transfer of all data will be provided to the Sponsor. The Contract 
Research Organization (CRO) and Sponsor will be responsible for retaining all data and documents 
pertaining to this study for a period of at least 5 years after study completion or longer depending on 
the applicable regulatory requirements. The Sponsor will be responsible for retaining the final data set 
and documents pertaining to this study for a period of at least 5 years after study completion or longer 
depending on the applicable regulatory requirements
14 CLINICAL SUPPLIES IN CINGAL 16-02
14.1 Packaging and Labeling
Clinical Trial Materials (CTM) were provided as part of Cingal 16-02. These were enclosed in a carton
containing required labeling and caution statements and a unique identifying kit number. An 
independent third party maintained the master randomization scheme. The third party shipped the CTM
to the sites as needed. 
Details on the instructions for use, contraindications and precautions remain the same as detailed in 
the Cingal 16-02 protocol and are provided for reference here.
14.2 Instructions for Use
Instructions for Use (IFU) for CTM have been supplied to each site and are contained in the Cingal 16-
02 files.  The IFU document contains the following risk information:
14.2.1 Contraindications
Cingal:
CINGAL is composed of cross-linked hyaluronic acid and an ancillary corticosteroid triamcinolone 
hexacetonide (TH). The following pre-existing conditions may constitute relative or absolute 
contraindications to the use of CINGAL:
x
Hypersensitivity to the active substance or to any of the excipients contained in CINGAL
x
Pre-existing infections of the skin region of the intended injection site
x
Infection of the index joint
x
Systemic bleeding disorders
The ancillary medicinal substance, triamcinolone hexacetonide, is contraindicated in the case of:


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x
Hypersensitivity to triamcinolone hexacetonide
x
Active tuberculosis
x
Herpes simplex keratitis
x
Acute psychoses
x
Systemic mycoses and parasitoses (strongyloid infections)
Monovisc:
Monovisc® is a sterile, non-pyrogenic, viscoelastic solution of hyaluronan contained in a single-use 
syringe. Monovisc® consists of high molecular weight, ultra-pure, natural hyaluronan, a complex 
sugar of the glycosaminoglycan family. The hyaluronan in Monovisc® is derived from bacterial cells 
and is cross-linked with a proprietary cross-linker.
The following pre-existing conditions may constitute relative or absolute contraindications to the use 
of Monovisc:
x
Hypersensitivity (allergy) to hyaluronate preparations
x
Hypersensitivity (allergy) to gram positive bacterial proteins
x
Infections or skin diseases in the area of the infection site or joint
x
Systemic bleeding disorders 
Triamcinolone hexacetonide:
Lederlon® 20 mg is a glucocorticoid (adrenal cortex hormone) that acts on the metabolism, the salt 
(electrolyte) balance and tissue functions. Glucocorticoids have anti-inflammatory and other 
therapeutic properties. The glucocorticoid in Lederlon® 20 mg is called triamcinolone hexacetonide.
Lederlon® 20 mg may NOT be used in the event of:
x
Known hypersensitivity to triamcinolone hexacetonide or one of the following other ingredients 
in this medication: benzyl alcohol (9 mg per 1 ml), polysorbate 80, sorbitol (Ph. Eur.)
x
Infections within or in direct proximity of the joint to be treated
x
Joint inflammation due to bacterial infections (bacterial arthritis)
x
Instability of the joint to be treated
x
Tendency toward bleeding, either spontaneously or due to taking medications to inhibit 
coagulation (anticoagulants)
x
Calcium deposits around joints
x
Bone necrosis due to sporadic or persistent perfusion disorders (non-vascularized bone 
necrosis)
x
Ruptured tendon
x
Joint disease due to decreased pain perception in the joint (neuropathic arthropathy)


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14.2.2 Anticipated Adverse Reactions
Reported adverse reactions associated with the IA use of hyaluronic acid:
Intra-articular injection of sodium hyaluronate preparations has occasionally been associated with 
allergic/anaphylactic reactions
and transient hypotension, which have generally resolved 
spontaneously or after conservative treatment.
The most common reported adverse events associated with Monovisc are the following: arthralgia, joint 
swelling and injection site pain.
Incidences of rash, headache, dizziness, chills, hives, itching, nausea, muscle cramps, peripheral 
edema, and malaise have also been reported in association with intra-articular injections.
A study conducted by Anika Therapeutics, Inc. on Monovisc recorded information on AEs that were 
possibly, probably and definitely related to the study injection. Patients who received Monovisc had 
7.1% of AEs related to the study injection and 5.4% of patients who received saline had an AE related 
to the study injection. Most of the AEs were minor complications that required little or no treatment. 
These included injection site events, joint swelling, joint pain, and limb pain. The rate of joint pain and 
limb pain not related to the study injection was higher than the rate related to the study injection [26].
Reported adverse reactions associated with the IA use of corticosteroids:
Dermatologic: Whitening of the skin at the injection site, local fat atrophy.
Musculoskeletal: Joint infection, joint swelling and pain several hours after injection, tendon rupture, 
pain, swelling, ligament damage.
Neurological: Nerve damage.
General: Infection, local bleeding, allergic reactions.


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14.3 CTM Accountability
Clinical Trial Material (CTM) accountability was completed within the Cingal 16-02 trial. 
A batch of acetaminophen / paracetamol rescue medication will be provided for the Cingal 17-02 trial 
and will be labelled accordingly. These rescue medications are not investigational and are considered 
as clinical supplies. However, the use of rescue medications will be recorded as previously described.
14.4 Emergency Unblinding
Unblinding should only occur when a SAE requires the allocation code in order to enable clinical 
treatments to be planned. The PI, in consultation with the clinical team and medical monitor should 
assess the need for unblinding as time permits. The allocation details can then be provided. Upon 
unblinding, the site personnel should record withdrawal of the subject and the allocation in the clinical 
trial notes. 
15 DATA QUALITY ASSURANCE
Anika Therapeutics, Inc. performs quality assurance checks on all clinical trials that it sponsors.
Investigational sites have been qualified and initiated within the Cingal 16-02 trial. Before enrollment of 
a subject in this extension study, a monitor (from Anika or designee) and the site staff will review the 
protocol, the eCRFs and instructions for completing them, the procedure for obtaining informed 
consent, the procedure for reporting AEs and all other relevant study procedures and forms.  Site 
monitoring visits will be performed on a regular basis according to the Monitoring Plan which will be an 
extension of the Cingal 16-02 Monitoring Plan.
16 REGULATORY OBLIGATIONS
The Principal Investigator agrees that the study will be conducted according to the principles of the ICH 
E6 (R1) Guideline for Good Clinical Practice (GCP) Step 6, ISO 14155:2011, Directive 2001/20/EC and 
Commission Directive 2005/28/EC, 21 CFR part 11, 50, 56, 312 and the ethical principles that have 
their origins in the World Medical Association Declaration of Helsinki, and local ethical and legal 
requirements. To ensure compliance the Investigator agrees, by written consent to this protocol, to fully 
cooperate with compliance checks by allowing access to all documentation by authorized individuals.  
The Investigator must conduct the trial as outlined in the protocol and in accordance with Declaration 
of Helsinki, as well as all applicable government regulations.  
16.1 Clinical Trial Information


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The Investigator’s Brochure for Cingal 16-02 will apply for Cingal 17-02 as this extension study does 
not relate any new information on the investigational product.  If the Investigator’s Brochure is revised 
during the study, the Investigator will receive a copy of the revised version. The Investigator’s Brochure 
and the protocol are confidential communications of Anika Therapeutics, Inc. Acceptance constitutes 
the agreement by the recipient that no unpublished information therein contained will be published or 
disclosed without Anika Therapeutics Inc.’s prior written approval except that these documents must 
be submitted in accordance with the SOPs of the EC and other applicable oversight committees with 
the agreement that these committees are required to keep the information confidential.
16.2 Regulatory Approval
The study outlined in this protocol will only be conducted following written approval by the appropriate 
regulatory authorities for sites located in the European Union (EU).
16.3 Ethics Committee (EC) Approval
The protocol and the ICF must have the approval of a properly constituted EC responsible for approving 
clinical trials for each investigational site.  Any additional requirements imposed by the EC shall be 
addressed in the protocol amendments. The signed EC approval letter must identify that the documents 
approved, list the Investigator's name, the Anika Therapeutics, Inc. protocol title, and the date of 
approval of the protocol and the ICF.  Any advertisements used to recruit subjects or any subject
handouts should also be reviewed and approved by the EC.  Anika Therapeutics, Inc. or designee will 
not ship any CTM to a site until an approval letter has been received from the EC and a Clinical Trial 
Agreement has been fully executed.
The Investigator is committed in accordance with local requirements to inform the EC of any emergent 
problem, SADEs/SAEs, and/or protocol amendments. 
16.4 Amendments to the Protocol
Any amendment to the study protocol must be agreed upon between the Investigator(s) and Anika 
Therapeutics, Inc.  Once a protocol amendment has received approval from Anika Therapeutics Inc., 
the Investigators will submit it to the EC and regulatory agencies (as required) for written approval.  The 
approval letter, signed by the EC, should refer specifically to the Investigator, Anika Therapeutics, Inc., 
protocol title, the protocol amendment number, and the date of the protocol amendment.  Anika 
Therapeutics, Inc. will submit a copy of the protocol amendment to the appropriate regulatory agencies.
The protocol amendment may be implemented after it has been approved by the EC and the 


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appropriate regulatory agencies, unless immediate implementation of the change is necessary for 
subject safety in which case a protocol change must be documented in an amendment and reported to 
the EC and regulatory agencies, as required within the required timeframe.
16.5 Pre-Study Documentation
The Investigators in Cingal 16-02 will have enrolled subjects into that study having provided the 
following documents prior to the enrollment of any subjects as appropriate to local country regulation:
x
Completed and signed Investigator Agreement/Form FDA 1572 signed by Principal Investigator. 
x
Signed and dated protocol signature page by the Principal Investigator (Investigator) and all 
Sub-Investigators (including Blinded Evaluator).
x
Signed and dated protocol amendment(s) signature page by the Investigator and all Sub-
Investigators (including Blinded Evaluator), when applicable.
x
Current curriculum vitae (CV) for the Investigator and all Sub-Investigators (including Blinded 
Evaluator)
x
Current medical license for the Principal Investigator and all Sub-Investigators (if applicable).
x
Financial disclosure statements signed and dated by the Investigator and all Sub-Investigator 
(including Blinded Evaluator).
x
Copy of the EC approval letter for the protocol and any other pertinent documents.
x
List of EC committee members. 
x
Copy of the EC-approved ICF to be used.
x
Fully executed Clinical Trial Agreement.
x
Delegation of Authority form.
x
Certified translations of EC approval letters, and approved ICF document (when applicable).
x
Insurance certificate as required.
16.6 Investigator Responsibilities
x
The Investigator should be qualified by education, training, and experience to assume 
responsibility for the proper conduct of the clinical study.
x
The Investigator must have knowledge on the use, application, implementation or administration 
of the CTM in Cingal 16-02 and the requirements for clinical, efficacy and safety follow-up. 


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x
The Investigator should be familiar with and trained on the appropriate use of CTM as described 
in the Cingal 16-02 protocol and in the Cingal 16-02 Investigator's Brochure.
x
The Investigator should disclose any potential conflicts of interest, including financial, that 
interfere with the conduct of the clinical investigation or interpretation of the results.
x
The Investigator should be trained on and comply with GCP regulations and the applicable 
regulatory requirements.
x
The Investigator should demonstrate that the proposed Clinical Trial Site has the following:
o
One or more qualified Investigators; 
o
Qualified site staff;
o
Adequate facilities for the foreseen duration of the clinical study;
o
Required number of eligible subjects needed within the agreed recruitment period.
x
The Investigator must create and maintain source documentation throughout the clinical study 
and make it available as requested during monitoring visits and audits.
x
The Investigator should permit monitoring and auditing by the Sponsor or Sponsor’s designee
and inspection by the appropriate regulatory authorities. Investigator should be accessible 
(when possible) to the monitor to respond to questions.
x
The Investigator should have sufficient time to conduct and oversee the trial.
x
The Investigator should ensure the EC has the most up to date study related documentation 
(e.g. Investigator’s Brochure, Protocol).
x
The Investigator should inform the subject’s primary physician about the subject’s participation 
in the trial if permitted to do so by the subject.
x
The Investigator will provide the Sponsor with copies of any clinical-investigation-related 
communications between the Investigator and the EC.
x
The Investigator will continue to utilize the alert card given to each subject participating in the 
Cingal 16-02 trial, which has been previously agreed by the Sponsor and approved by the EC, 
containing at minimum the name of the subject, the investigator contact number and blinded 
information regarding the medical treatment.
x
The Investigator must be aware of the AE and adverse reaction reporting process, including 
reactions related to application of the CTM used in Cingal 16-02.


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x
The Investigator shall ensure accuracy, completeness legibility and timeliness of the data 
reported to the Sponsor in the eCRFs and in all required reports. 
x
The Investigator must have knowledge of the risk analysis of the CTM utilized in Cingal 16-02,
knowledge of the requirements for storage, handling, administration, and destruction or disposal 
of the CTM including any hazard to those handling the product and close contacts and the risk 
to the environment. 
x
The Investigator shall ensure maintenance and calibration of the equipment relevant for the 
assessment of the clinical study is appropriately performed and documented, when applicable.
x
The Investigator must be knowledgeable with the method of obtaining informed consent.
x
The Investigator shall ensure and document appropriate training if any authorized designee is 
appointed to conduct the informed consent process. 
x
The Investigator must inform the trial subject of the particular issues that arise for the CTM used 
in Cingal 16-02. In particular, both the ICF and any other written information to be provided to 
the subjects should include an explanation of the following:
o
Provisions for subject data protection and confidentiality;
o
The arrangements for follow-up before and after the end of the trial, including after 
subjects withdraw from the study and including the information (alert card) to be provided 
to the subject for use in the event of problems arising after the end of the trial;
o
The length of follow-up;
o
The definition of the end of the trial and its relationship to the follow-up after the end of 
the trial;
o
The need to keep an accurate subject diary;
o
The irreversible nature of the CTM;
o
The need, where applicable, for the presence of a representative of the Sponsor for 
assistance during the administration of the CTM and the rationale for this.
x
The Investigator shall provide adequate medical care to a subject during and after subject’s 
participation in a clinical study in the case of AEs.
x
The Investigator shall ensure that clinical records are clearly marked to indicate that the subject 
is enrolled in a particular clinical study.
x
The Investigator must provide the subject with the following:


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o
Any necessary instructions on the proper use, handling, storage, and return of the 
rescue medications. Investigator shall retain all clinical-investigation-related records;
o
Information on any new significant findings occurring during the clinical study, including 
the need for additional medical care that may be required;
o
Well-defined procedures for possible emergency situations to the clinical study and 
make arrangements for emergency treatment, including decoding procedures for 
blinded/masked clinical studies;
o
Some means of showing the subjects participation in the clinical study, together with 
identification and compliance information for the concomitant treatment measures (If 
appropriate).
x
The Investigator shall sign the Clinical Investigation Report at the close-out of the clinical study.
16.7 Sponsor’s Responsibilities
x
Anika Therapeutics, Inc. may delegate some of the responsibilities to a CRO but will maintain 
oversight of the clinical study. Anika shall define, establish and allocate all the roles and 
responsibilities related to the clinical study in one or more written agreements. 
x
Anika Therapeutics, Inc. shall implement and maintain written clinical quality procedures to 
ensure that the clinical study is designed, conducted and monitored, and that data are 
generated, documented, recorded and reported in compliance with ISO 14155:2011 and ICH 
E6, this protocol, any subsequent amendments, and any other applicable standards and 
regulatory requirements.
x
Anika Therapeutics, Inc. will ensure that there is written agreement with the 
Investigator/institution and any other parties involved with the clinical study. 
x
Anika Therapeutics, Inc. will designate appropriately qualified medical personnel to advise on 
medical questions or problems.
x
Anika Therapeutics Inc. will utilize appropriately qualified individuals to supervise the overall 
conduct of the trial, to handle the data, to verify the data, to conduct the statistical analyses, and 
to prepare the trial reports. 
x
Anika Therapeutics, Inc. will select Investigators/institutions that are qualified by training and 
experience with adequate resources to properly conduct this trial for which the Investigator is 
selected. Anika will also select a coordinating Investigator, if appropriate.  Anika Therapeutics, 


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Inc. will ensure members of the site staff and their designated authorization(s) are identified in 
a log with details.
x
Anika Therapeutics, Inc. will ensure that all Investigators and all other parties involved are given 
instructions on uniformly assessing and documenting clinical and laboratory findings.
x
Anika Therapeutics, Inc. will designate or appoint one or more monitors, or otherwise assume
the responsibilities of the monitor(s) and ensure documentation of training, experience and 
scientific or clinical knowledge for all the relevant parties involved in order to adequately conduct 
the clinical study. This includes training on the following:
o
Accountability procedures
o
Investigator’s Brochure
o
Protocol
o
eCRFs and instructions for completion
o
The written ICF and informed consent process as well as other written information 
provided to subjects
o
Sponsors written procedures; ISO 14155:2011; and any other applicable regulatory 
procedures.
x
Anika Therapeutics, Inc. will receive disclosures of conflicts of interest from PIs and 
Investigators.
x
Anika Therapeutics, Inc. will assure the accuracy of any translations, as applicable.
x
Anika Therapeutics, Inc. will establish an IDMC to assess the progress of a clinical study, 
including the safety data and the critical efficacy endpoints at intervals, and to recommend to 
the Sponsor whether to continue, modify, or stop a trial.
x
Anika Therapeutics, Inc. will ensure that any electronic trial data handling and/or remote 
electronic trial data systems, are validated with the following characteristics:
o
Data changes are allowed with an audit trail;
o
System is secure and does not allow for unauthorized access to the data;
o
A list of the individuals who are authorized to make data changes is maintained;
o
Adequate backup of the data is maintained; 


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o
An unambiguous subject ID is used to allow identification of all the data reported for 
each subject.
x
Anika Therapeutics, Inc. will ensure maintenance of sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved, and/or where the sponsor intends to apply for 
approval(s). 
x
Anika Therapeutics, Inc. will inform the Investigator/institution in writing of the need for record 
retention and will notify the Investigator/institution in writing when the trial related records are 
no longer needed. 
x
Anika Therapeutics, Inc. will provide insurance or indemnify the Investigator/institution against 
claims arising from the trial, except for claims that arise from malpractice and/or negligence. 
x
Anika Therapeutics, Inc. will obtain the following information documentation from each 
participating EC: 
o
The name and address of the EC. 
o
A statement obtained from the EC that it is organized and operates according to GCP 
and the applicable laws and regulations. 
o
Documented EC approval/favorable opinion for the protocol and any subsequent 
amendments (as applicable) and re-approvals.
x
Anika Therapeutics, Inc. will update the Investigator's Brochure as significant new information 
becomes available. 
x
Anika Therapeutics, Inc. will ensure the CTM is transported at the acceptable storage 
temperatures and transport conditions. 
x
Anika Therapeutics, Inc. will verify that each subject has consented, in writing, to direct access 
to his/her original medical records for trial-related monitoring, audit, EC review, and regulatory 
inspection. 
x
Anika Therapeutics, Inc. is responsible for the ongoing safety evaluation of the CTM.
x
Anika Therapeutics, Inc. will notify all concerned Investigators/institutions and the regulatory 
authority(ies) of findings that could affect adversely the safety of subjects, impact the conduct
of the trial, or alter the EC approval/favorable opinion to continue the trial. 


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x
Anika Therapeutics, Inc. will submit any required application(s) to the appropriate authority(ies) 
for review, acceptance, and/or permission (as required by the applicable regulatory 
requirement(s)) to begin the trial(s). 
x
Anika Therapeutics, Inc. will ensure that all required EC, or other regulatory approvals are 
obtained and documented; and that appropriate provisions are made to meet any specific 
conditions imposed by the EC. Anika will ensure that any modification(s) required by the EC or
other regulatory authority are made and documented by the PI and have gained the approval 
of the EC or other regulatory authority.
x
Anika 
Therapeutics, 
Inc. 
will 
expedite 
the 
reporting 
to 
all 
concerned 
Investigator(s)/institutions(s), to the EC, where required, and to the regulatory authority(ies) of 
all ADEs that are both serious and unexpected. 
x
Anika Therapeutics, Inc. will submit to the regulatory authority(ies) all safety updates and 
periodic reports, as required by applicable regulatory requirement(s).
x
Anika Therapeutics, Inc. will ensure that an ongoing risk analysis, based on existing knowledge 
of the type of product and its intended use, is performed and provided to the Investigator 
involved in a clinical study with the CTM, through the Investigator’s Brochure or updates to it 
and to the subject through the ICF or updates to it.
x
Anika Therapeutics, Inc. will also incorporate the risk analysis and risk management plan of the 
CTM and share this with the Investigators;
x
Anika Therapeutics, Inc. shall be responsible for:
o
Documenting correspondence with all parties involved in the clinical study, including the 
EC and regulatory authorities;
o
Ensuring that the clinical study is appropriately monitored by determining the extent and 
nature of the monitoring;
o
Reviewing the monitoring reports and follow-up on actions required in the monitoring
report;
o
Taking prompt action to secure compliance with all clinical study requirements;
o
Submitting progress reports, including safety summary deviations, when requested, to 
all reviewing EC’s and the regulatory authorities.
16.8 Informed Consent


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All subjects in this study are to be completely informed, in accordance with local EC or other regulatory 
authority requirements, concerning the pertinent details and purpose of the study. Informed consent for 
each subject will be obtained in accordance with ICH Guidance for Industry E6 Good Clinical Practice:  
Consolidated Guidance (ICH Topic E 6 (R1) Guideline for Good Clinical Practice). One copy of the 
signed ICF document must be given to each subject in his/her native language and one signed copy 
must be retained in the subject’s file.
All subjects must sign and personally date an approved ICF after receiving detailed written and verbal 
information about the reason, the nature and the possible risks associated with the administration of 
the CTM. An ICF will be required for all subjects.
All foreseeable risks and potential benefits which might occur with the use of the CTM will have been
discussed with the subject. The subject will be informed that, should an unanticipated adverse product-
related event occur, which presents an unreasonable risk to participating subjects, he/she will be 
notified. The subject will be informed that his/her medical records are subject to review by 
representatives of the Sponsor, EC, or the appropriate regulatory authorities, as necessary. The subject
will be informed that the information obtained during the study will be used to evaluate the safety and 
efficacy of the CTM. However, his/her confidentiality will be maintained at all times. The subject will be 
told that he/she is free to refuse study participation or to withdraw from the study at any time without 
compromising future medical care.
The subject must be made aware and agree that personal information may be scrutinized during an
audit by competent authorities and properly authorized persons. However, personal information will be 
treated as strictly confidential and will not be publicly available.  
A sample ICF template with standard wording suggested for this study will be provided to each 
Investigator. Prior to EC submission, the Investigator must send a copy of the ICF to be used at their 
institution to Anika Therapeutics Inc. or designee for review to assure compliance with the ICH 
requirements. The approved written consent form is to be supplied by the Investigator and will be 
understood and signed by each subject prior to enrolling in the study. An ICF will be required for all 
subjects. The Investigator is responsible for maintaining each subject's ICF in the study file and 
providing each subject with a copy of the ICF.
16.9 Protocol Adherence
The Investigator agrees to conduct the study according to the protocol and agrees that all persons 
delegated to perform study procedures will do so as well. The Investigator must read the protocol 


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thoroughly and must follow the instructions exactly. Investigators shall propose to Anika Therapeutics, 
Inc. any appropriate modifications to the Protocol. Any change should be agreed to by prior discussion 
between Anika Therapeutics Inc. and the Investigator, with written protocol amendments made prior to 
affecting the changes agreed upon. The Investigator is not to conduct any protocol modifications 
without prior written permission from Anika Therapeutics Inc. Investigator will refrain from implementing 
any modifications to the protocol without agreement from the Sponsor, EC and regulatory authorities, 
if applicable. Each Investigator will be responsible for enrolling only those subjects who have met 
protocol eligibility criteria.
Deviations from the protocol include, but are not limited to, the use of prohibited medications or 
therapies, out of window visits, etc.  All protocol deviations should be documented and explained.  Major 
protocol violations are defined as those that could impact the efficacy evaluation such as a subject is 
ineligible, missing key data, received an unauthorized treatment, etc.  All subjects with protocol 
deviations will continue to be followed for safety and efficacy assessments.  Analysis of study data will 
be done on both the ITT and PP populations.
16.10 Adverse Event Reporting
The Investigator agrees to document and report all AEs / ARs to Anika Therapeutics, Inc. or its 
designee.  The Investigator is further responsible for ensuring that any Sub-Investigator promptly brings 
AEs / ARs to the attention of the Investigator.  The Investigator is also responsible for informing the 
participating EC and other regulatory authorities (as applicable) of any reportable events and adhering 
to local EC requirements. The Investigator agrees to supply Anika Therapeutics Inc., upon request, any 
additional information related to the safety reporting of a particular event. The Investigator shall inform 
the subject of the nature and possible cause of any AEs/ ARs experienced.
16.11 Permission to Review Subject's Source Records
The Investigator agrees that Anika Therapeutics, Inc., its employees or agents, and the respective 
Competent Authorities will have the right from time to time, both during and after this trial, to audit and 
review pertinent medical records related to the clinical study.  A signed statement will be obtained from 
each subject who participates in the trial that permits the release of his or her medical records as 
necessary for inspection by authorized personnel from Anika Therapeutics, Inc., its designee or 
participating Competent Authority.  Subjects will not be identified by name, and confidentiality of 
information in medical records will be preserved.


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16.12 Change in Investigator
If any Investigator retires, relocates, or withdraws from an investigation, the responsibility for conducting 
the study and maintaining records may be transferred to another person who will accept the 
responsibility at the same institution. Anika Therapeutics, Inc. must be notified of and agree to the 
change. 
16.13 Records Retention
All documents related to this clinical study should be kept in appropriate study files.  Copies of the 
protocol, subject ID, eCRF, source data, ICF and other documents pertaining to the study conduction 
must be retained until at least 5 years after study completion or longer depending on the applicable 
regulatory requirements. It is the responsibility of the Sponsor to inform the Investigator/institution as 
to when these documents no longer need to be retained. No study document will be destroyed without 
prior written agreement between Anika Therapeutics, Inc. and the Investigator.
16.14 Study Monitoring
An appropriate representative of Anika Therapeutics, Inc. or designee (Study Monitor) will maintain 
contact with the Investigator and will contact the Clinical Trial Site for the purpose of overseeing the 
progress of the study, and ensuring it is conducted, recorded and reported in accordance with the 
protocol, SOPs, GCP and applicable regulatory requirements.
An initiation visit will have been made by the Study Monitor to discuss the Cingal 16-02 protocol and 
the obligations of both the Sponsor and the Investigator.  The Investigator must allow the Study Monitor 
to perform periodic, interim monitoring visits.  The purposes of these visits are:
x
Verify that written informed consent was obtained prior to each subject’s participation in the trial
x
Ensure the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), with GCP, and with the applicable regulatory requirement(s)
x
Ensure the rights and well-being of human subjects are protected 
x
Ensure the reported trial data are accurate, complete, and verifiable from source documents. 
x
Assess the progress of the study
x
Review the compliance with the study protocol


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x
Determine whether the Investigator is maintaining the essential documents
x
Discuss any emergent problem(s)
x
Act as the main line of communication between the Sponsor and the Investigator
x
Ensure that the Investigator receives the current Investigator's Brochure, all documents, and all 
trial supplies needed to conduct the trial properly and to comply with the applicable regulatory 
requirement(s) 
x
Ensure that the Investigator and the Investigator's site staff are adequately informed about the 
trial 
x
Verify that the Investigator and the Investigator's site staff are performing the specified trial 
functions, in accordance with the protocol and any other written agreement between the 
Sponsor and the Investigator/institution, and have not delegated these functions to unauthorized 
individuals 
x
Verify that the Investigator is enrolling only eligible subjects
x
Inform the Investigator of any eCRF entry error, omission, or illegibility 
x
Determine whether all AEs are appropriately reported within the time periods required by GCP, 
the protocol, the EC, the Sponsor, and the applicable regulatory requirement(s) 
x
Communicating deviations from the protocol, SOPs, GCP, and the applicable regulatory 
requirements to the Investigator and ensuring that the site staff takes appropriate action 
designed to prevent recurrence of the detected deviations 
All data required by the protocol must be reported accurately on the eCRFs and must be consistent 
with the source documents. Source documents are original documents, data and records (e.g., hospital 
records, clinical and office charts, laboratory notes, memoranda, subjects' diaries or evaluation 
checklists, pharmacy dispensing records, recorded data from automated instruments, copies or 
transcriptions certified after verification as being accurate and complete, microfiches, photographic 
negatives, microfilm or magnetic media, X-rays or other diagnostic images, subject’s files, pharmacy 
records and laboratory records).  The Investigator will make available the source documents for 
inspection.  This information will be considered as confidential.
The Study Monitor will perform a closeout visit at the conclusion of the Investigator’s involvement in the 
study.
16.15 Case Report Form


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Electronic Case Report Forms must be completed for each subject in accordance with the DMP and
any eCRF Completion Guidelines.  The Investigator must ensure data are reported into the eCRF in a 
timely fashion and that data recorded in the eCRF is consistent with the source documents or the 
discrepancies should be explained. Any change or correction should have an audit trail and explanation 
of the change.
16.16 Auditing
The Investigator will make all pertinent records available including source documentation for inspection 
by regulatory authorities and for auditing by the Sponsor. This information will be considered as 
confidential. The Sponsor's audit will be independent of and separate from routine monitoring or quality 
control function and will serve to evaluate the trial conduct and compliance with the protocol, SOPs, 
GCP, and the applicable regulatory requirements.
16.17 Use and Publication of Study Results
All unpublished documentation (including the protocol, eCRF and Investigator's Brochure) given to the 
Investigator is strictly confidential.  All recipients must agree not to disclose the information herein 
contained to any person without the prior written authorization of Anika Therapeutics, Inc. The 
submission of these documents to the EC is expressly permitted. The Investigator agrees that Anika 
Therapeutics, Inc. maintains the right to use the results of this study in their original form and/or in a 
global report for submission to governmental and regulatory authorities of any country.
The results of the study may be presented during scientific symposia or published in a scientific journal 
only after review by Anika Therapeutics, Inc. in accordance with the guidelines set forth in the applicable 
publication or the Investigator agreement. 
16.18 Confidentiality
All information that is provided to the Investigator dealing with the CTM is regarded as confidential. 
Subjects will be told that data will be handled in compliance with Health Insurance Portability and 
Accountability Act (HIPAA), European Union Data Protection Directive and other national laws on the 
protection of personal data.  Subjects will be informed that the Anika Therapeutics, Inc. or designee will 
have access to their medical records. Subject’s participation in the study will be treated as confidential 
and subject’s will not be referred to by name in any report of the study.   The identity of the subjects will 
not be disclosed in any study records and subjects’ data will be described with a unique subject


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identifier. Subject data will be processed electronically to determine the outcome of this study, and to 
provide to health authorities. Subjects will be advised that all data may be transferred to other countries.
16.19 Early Study Discontinuation
If the Sponsor, Investigator, or Study Medical Monitor discover conditions during the study that indicate 
that the study or Clinical Trial Site should be terminated, this action may be taken after appropriate 
consultation between the Sponsor, Investigator, and Study Medical Monitor.
Conditions that may warrant termination of the Clinical Trial Site include, but are not limited to:
• The discovery of any unexpected, serious, or unacceptable risk to subjects enrolled in the study,
• The decision on the part of the Sponsor to suspend or discontinue testing, evaluation, or development 
of the CTM.
• Failure of the Investigator to comply with GCP guidelines,
• Submission of knowingly false information from the research facility to the Sponsor,
Clinical Monitor, or regulatory authorities,
• Insufficient adherence to protocol requirements.
If Anika Therapeutics, Inc. and/or the Investigator should discover conditions arising during the study 
that indicate it should be terminated, an appropriate schedule for termination will be instituted. Anika 
Therapeutics, Inc. also reserves the right to discontinue this study for administrative reasons at any 
time. 
If a trial is suspended, Anika Therapeutics Inc. will promptly inform the Investigators/institutions, and 
the regulatory authority(ies) of the termination or suspension and the reason(s) for the termination or 
suspension. The Investigator should notify the EC promptly and provided the reason(s) for the 
termination or suspension by the Sponsor or by the Investigator/institution.
16.20 Subject Withdrawal
Each subject is free to discontinue from the study at any time, for any reason. If a subject discontinues 
the study, the Investigator will record the reason for withdrawal on the eCRF. Examples of reasons for 
premature withdrawal of a subject from the study include:
• Inter-current illness that would, in the judgment of the Investigator, affect study assessment to a 
significant degree
• Subject noncompliance with follow-up assessments 


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• Subject request to withdraw
• Subject lost to follow-up
• Termination of the site’s study participation by Anika Therapeutics, Inc., the institution, EC or other 
regulatory authority
• Other (reason to be documented in the eCRF)
Every effort shall be made to have withdrawn subjects return for the required safety evaluations as 
detailed in the protocol.


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17 GENERAL INFORMATION
17.1 Study Contact Information
Sponsor:
Anika Therapeutics, Inc.
32 Wiggins Avenue
Bedford, MA 01730
Phone: 781-457-9000
Fax: 781-305-9720
Medical Monitor EU:
During Office Hours:
Dr. Josep-Maria Badenas
Address: SynteractHCR Iberica, SL 
Príncep Jordi, 21-23, Esc. B, Entlo. 1-B
08014 Barcelona, Spain
Tel: + 34 674 746 106
Contract Research Organization (CRO):
SynteractHCR
5909 Sea Otter Place 
Carlsbad, CA 92010
Phone:  +1 760 268 8200 
Fax:    +1 760 929 1419 
Central Core Imaging Laboratory:
Qmetrics Technologies
1250 Pittsford-Victor Road
Suite 110, Building 200
Pittsford, NY 14534
Phone: 585.301.4300
Fax: 585-301-4300 X250


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17.2 Study Administrative Structure
Name/Affiliation
Address/Phone Number
Responsibility
Adrian Orr
Director of Clinical Affairs
Anika Therapeutics Inc. 
32 Wiggins Avenue 
Bedford, MA 01730 USA 
Tel: (781) 457-9226
Fax: (781) 305-9720 
Email: aorr@anikatherapeutics.com
Sponsor Project 
Manager
Josep-Maria 
Badenas M.D.
SynteractHCR Iberica, SL 
Príncep Jordi, 21-23, Esc. B, Entlo. 1-B
08014 Barcelona, Spain
Phone: + 34 674 746 106
Medical Monitor
EU
SynteractHCR, 
Inc.
CRO
5909 Sea Otter Place 
Carlsbad, CA 92010
Phone: 760.268.8200
Safety, Site 
Management and 
Monitoring
Qmetrics Clinical 
Services
Core Imaging Laboratory
1250 Pittsford-Victor Road, Bldg 2, Suite 110
Pittsford, NY 14534
Phone: 585.301.4300
Imaging
Axiom Real-Time 
Metrics Inc.
EDC Vendor 
50 Ronson Drive, Suite 190
Toronto, ON M9W 1B3
Phone: 416.804.1110
EDC and Data 
Management
In case of emergency, refer to the study manual of operations for alternate contact information.


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18 REFERENCES
1.
Bellamy, N., et al., Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database of 
Systematic Reviews, 2006( 2).
2.
Schaap, L.A., et al., European Project on OSteoArthritis (EPOSA): methodological challenges in harmonization 
of existing data from five European population-based cohorts on aging. BMC musculoskeletal disorders, 2011. 
12: p. 272.
3.
Guccione, A.A., et al., The effects of specific medical conditions on the functional limitations of elders in the 
Framingham Study. American journal of public health, 1994. 84(3): p. 351-8.
4.
Altman, R., et al., Development of criteria for the classification and reporting of osteoarthritis. Classification of 
osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism 
Association. Arthritis and rheumatism, 1986. 29(8): p. 1039-49.
5.
Moreland, L.W., Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: 
mechanisms of action. Arthritis research & therapy, 2003. 5(2): p. 54-67.
6.
Stitik, T.P. and J.A. Levy, Viscosupplementation (biosupplementation) for osteoarthritis. American journal of 
physical medicine & rehabilitation / Association of Academic Physiatrists, 2006. 85(11 Suppl): p. S32-50.
7.
Neustadt, D.H., Intra-articular injections for osteoarthritis of the knee. Cleve Clin J Med, 2006. 73(10): p. 897-8, 
901-4, 906-11.
8.
Bellamy, N., et al., Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of 
Systematic Reviews 2006(2).
9.
Kellgren, J.H. and J.S. Lawrence, Radiological assessment of osteo-arthrosis. Annals of the rheumatic diseases, 
1957. 16(4): p. 494-502.
10.
Kellgren, J. and J. Lawrence, Atlas of standard radiographs:  The epidemiology of chronic rheumatism.  , in 
Blackwell Scientific Publications. 1963, Oxford.
11.
Felson, D.T. and M.C. Nevitt, Epidemiologic studies for osteoarthritis: new versus conventional study design 
approaches. Rheumatic diseases clinics of North America, 2004. 30(4): p. 783-97, vii.
12.
Bellamy, N., et al., Recommendations for a core set of outcome measures for future phase III clinical trials in 
knee, hip, and hand osteoarthritis. Consensus development at OMERACT III. The Journal of rheumatology, 1997. 
24(4): p. 799-802.
13.
Zhang, W., et al., EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum 
Dis, 2010. 69(3): p. 483-9.
14.
WOMAC.  [cited 2012 December 12]; Available from: http://www.womac.org/womac/index.htm.
15.
Cheung, K., et al. EQ-5D User Guide-Basic Information on how to use the EQ-5D, 2009. 2009; Available from: 
www.euroqol.org.
16.
Brooks, R., EuroQol: the current state of play. Health Policy, 1996. 37(1): p. 53-72.
17.
Knoop, J., et al., Proprioception in knee osteoarthritis: a narrative review. Osteoarthritis Cartilage, 2011. 19(4): 
p. 381-8.
18.
Jackson, D.W., N.A. Evans, and B.M. Thomas, Accuracy of needle placement into the intra-articular space of the 
knee. J Bone Joint Surg Am, 2002. 84-A(9): p. 1522-7.
19.
Toda, Y. and N. Tsukimura, A comparison of intra-articular hyaluronan injection accuracy rates between three 
approaches based on radiographic severity of knee osteoarthritis. Osteoarthritis Cartilage, 2008. 16(9): p. 980-5.
20.
Strand, V., et al., A multicenter, randomized controlled trial comparing a single intra-articular injection of Gel-
200, a new cross-linked formulation of hyaluronic acid, to phosphate buffered saline for treatment of 
osteoarthritis of the knee. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society, 2012. 20(5): p. 
350-6.
21.
Day, R., et al., A double blind, randomized, multicenter, parallel group study of the effectiveness and tolerance of 
intraarticular hyaluronan in osteoarthritis of the knee. The Journal of rheumatology, 2004. 31(4): p. 775-82.
22.
Pham, T., et al., OMERACT-OARSI initiative: Osteoarthritis Research Society International set of responder 
criteria for osteoarthritis clinical trials revisited. Osteoarthritis Cartilage, 2004. 12(5): p. 389-99.
23.
Pham, T., et al., Outcome variables for osteoarthritis clinical trials: The OMERACT-OARSI set of responder 
criteria. J Rheumatol, 2003. 30(7): p. 1648-54.
24.
Pham, T., et al., Outcome variables for osteoarthritis clinical trials: The OMERACT-OARSI set of responder 
criteria. The Journal of rheumatology, 2003. 30(7): p. 1648-54.
25.
The Preventions and Treatment of Missing Data in Clinical Trials. 2010, Washington, DC: The National 
Academies Press.
26.
Monovisc Study Data: "A Randomized, Double-Blind, Placebo Controlled, Multi-Center Study of a Single 
Injection Cross-linked Sodium Hyaluronate to Provide Symptomatic Relief of Osteoarthritis of the Knee". 2009.


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Appendix 1 WOMAC


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Appendix 2 Global Assessment of Disease Activity
A VAS is to be completed by the subject and the evaluating physician at time points specified in 
Section 7.1 for determining the Patient’s and the Evaluator’s Global Assessment of response to 
therapy score.
EVALUATOR GLOBAL ASSESSMENT (VAS SCALE)
Record your response with an “X”: 
“Considering all the ways the osteoarthritis in the patient’s index knee affect him/her, what is your 
assessment of how much the patient’s knee is bothering him/her today?” 
                          No pain
Extreme pain
PATIENT GLOBAL ASSESSMENT (VAS SCALE)
Record your response with an “X”: 
Think about the pain you felt in your STUDY knee caused by your osteoarthritis during the last 24 
hours.  
“Considering all the ways the osteoarthritis in your STUDY index knee affects you, what is your 
assessment of how much your STUDY knee is bothering you today?” 
                          No pain
Extreme pain


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Appendix 3 EQ-5D


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Appendix 4 Kellgren-Lawrence Grading Scale
Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
Grade 2: definite osteophytes, definite narrowing of joint space
Grade 3: moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and 
possible deformity of bone contour
Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity 
of bone contour


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Change History


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Location of 
Change 
Original Text
Changed Text
Reason
Title Page & 
Throughout
Protocol version 1.0 Date 08 August 2017
Original Protocol version 3.0 Cingal 16-02 Date 05 May 
2017
Protocol version 2.0 Date 28 December 2017
Original Protocol version 4.0 Cingal 16-02 Date 05 December 2017
Protocol revision.
Cingal 16-02 amended to 
version 4.0 
Study Synopsis 
Investigational Product
Cingal: A chemically cross-linked sodium hyaluronate 
supplied as a 4-mL unit dose with a nominal 18 mg of 
triamcinolone hexacetonide (TH) in a 5-mL glass 
syringe.
Investigational Product
Subjects enrolled in Cingal 17-02 will not receive an injection.
For reference only, the investigational product utilized in Cingal 16-02
was:
Cingal: A chemically cross-linked sodium hyaluronate supplied as a 
4-mL unit dose with a nominal 18 mg of triamcinolone hexacetonide 
(TH) in a 5-mL glass syringe.
Clarification that no injection 
performed in Cingal 17-02
trial.
Study Synopsis 
Comparator Product
Triamcinolone Hexacetonide (TH): 20 mg/ml supplied 
as 1 mL unit dose in a glass ampoule.
Monovisc®: A chemically cross-linked sodium 
hyaluronate supplied as a 4-mL unit dose in a 5-mL 
glass syringe.
Comparator Product
Subjects enrolled in Cingal 17-02 will not receive an injection.
For reference only, the comparator products utilized in Cingal 16-02
were:
Triamcinolone Hexacetonide (TH): 20 mg/ml supplied as 1 mL unit 
dose in a glass ampoule.
Monovisc®: A chemically cross-linked sodium hyaluronate supplied 
as a 4-mL unit dose in a 5-mL glass syringe.
Clarification that no injection 
performed in Cingal 17-02
trial.
Study Synopsis 
Mode of Delivery
Cingal, Triamcinolone Hexacetonide, or Monovisc will 
be injected into the intraarticular (IA) space of the index 
knee using an 18-21 gauge needle.
Mode of Delivery
For reference only, the mode of delivery in Cingal 16-02 was:
Cingal, Triamcinolone Hexacetonide, or Monovisc will be injected into 
the intraarticular (IA) space of the index knee using an 18-21 gauge 
needle.
Clarification that no injection 
performed in Cingal 17-02
trial.
Study Synopsis 
Section 9.1 
Inclusion Criteria
1.
Subjects meet the inclusion criteria for Cingal 
16-02 and signed the informed consent.
Inclusion Criteria
1
Only subjects that met the inclusion criteria for the Cingal 
16-02 trial and signed the informed consent are eligible for 
Cingal 17-02 trial.
Clarification that only Cingal 
16-02 subjects will be 
enrolled in Cingal 17-02 trial.
Study Synopsis 
Section 9.1 
Exclusion Criteria
Patients will not be rescreened at enrollment to Cingal 
17-02 as these patients met the inclusion / exclusion 
criteria for the Cingal 16-02 clinical trial. 
All patients enrolled in the Cingal 16-02 trial will be 
eligible to participate in Cingal 17-02.
Exclusion Criteria
Patients will not be rescreened at enrollment to Cingal 17-02 as 
these patients were enrolled and met the inclusion / exclusion criteria 
for the Cingal 16-02 clinical trial. 
Only patients enrolled in the Cingal 16-02 trial will be eligible to 
participate in Cingal 17-02.
Clarification that only Cingal 
16-02 subjects will be 
enrolled in Cingal 17-02 trial.


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Study Synopsis 
Section 7.2,
12.1.2 & 12.1.3
Secondary Endpoints
•The change from baseline in knee pain as measured 
by the WOMAC Pain Score (100 mm VAS) at 39 
weeks post treatment comparing the Cingal group to 
the TH group. 
•The change from baseline in the Patient Global 
Assessment 39 weeks post treatment in the Cingal 
group compared to the TH group.
•The change from baseline in the Evaluator Global 
Assessment at 39 weeks post treatment in the Cingal 
group compared to the TH group
Exploratory Endpoints: 
•
EuroQol (EQ-5D)
•
Total WOMAC
•
WOMAC Stiffness Score
•
WOMAC Physical Function
•
Range of Motion 
•
Rescue Medication Usage
•
Number of Treatment Failures due to 
Additional Procedure or Use of Disallowed Medication  
Secondary Endpoints
•The change from baseline in knee pain as measured by the 
WOMAC Pain Score (100 mm VAS) at 39 weeks post treatment 
comparing the Cingal group to the TH group. 
•The change from baseline in WOMAC Physical Function score at 39 
weeks post treatment comparing the Cingal group to the TH group.
•The change from baseline in WOMAC Stiffness score at 39 weeks 
post treatment comparing the Cingal group to the TH group.
•The change from baseline in Total WOMAC score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
•The change from baseline in the Patient Global Assessment 39 
weeks post treatment in the Cingal group compared to the TH group.
•The change from baseline in the Evaluator Global Assessment at 39 
weeks post treatment in the Cingal group compared to the TH group.
•The usage of rescue medication through 39 weeks post treatment in 
the Cingal group compared to the TH group.
Exploratory Endpoints:
Any comparisons between groups (Cingal, Monovisc, TH), within 
groups and / or time points (from baseline through to 39 weeks) not 
described in the primary or secondary endpoints may be presented in 
the exploratory endpoints including:
o
EuroQol (EQ-5D)
o
WOMAC Pain Score (100mm VAS)
•o
OMERACT-OARSI
o
Total WOMAC
o
WOMAC Stiffness Score
o
WOMAC Physical Function
o
Patient Global Assessment
•o
Evaluator Global Assessment
o
Range of Motion 
o
Rescue Medication Usage
o
Number of Treatment Failures due to Additional Procedure 
or Use of Disallowed Medication  
Aligned secondary and 
exploratory endpoints with 
latest version of Cingal 16-02
protocol.
Section 10.1
Post-Treatment Follow-Up Visits:
Reconsent
Post-Treatment Follow-Up Visits:
Consent
Clarified the Cingal 17-02
Visit as a consent and not re-
consent visit.
Section 10.1
Post-Treatment Follow-Up Visits
Addition of header:
Post-Treatment Follow-Up Visits
17-02 Follow-Up Visits
Clarification of 17-02
assessments


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Section 17.1 & 
17.2
Study Contact Information:
Contract Research Organization (CRO):
SynteractHCR
5759 Fleet Street, Suite 100 
Carlsbad, CA 92008 USA
Study Contact Information:
Contract Research Organization (CRO):
SynteractHCR
5909 Sea Otter Place 
Carlsbad, CA 92010
Change of address for CRO

SAP_001.pdf: 
 
 
ANIKA THERAPEUTICS, INC. 
32 Wiggins Avenue 
Bedford, MA 01730 
www.anikatherapeutics.com 
Cover Letter - Cingal 17-02 Statistical Analysis Plan 
for Protocol Version 2.0
Extension Study to Cingal 16-02: Trial Extension to 39 week Follow Up in 
the Randomized, Double-Blind, Active Comparator Controlled, Multi-Center 
Study of a Single Injection Cross-Linked Sodium Hyaluronate Combined 
with Triamcinolone Hexacetonide (Cingal®) to Provide Symptomatic Relief 
of Osteoarthritis of the Knee
NCT # 03390036
Date of SAP: 25 May 2018




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Statistical Analysis Plan
Extension Study to Cingal 16-02: Trial Extension to 39 
week Follow Up in the Randomized, Double-Blind, Active 
Comparator Controlled, Multi-Center Study of a Single 
Injection Cross-Linked Sodium Hyaluronate Combined 
with Triamcinolone Hexacetonide (Cingal®) to Provide 
Symptomatic Relief of Osteoarthritis of the Knee
Protocol Number:  CINGAL 17-02 Version 2.0
Protocol Issue Date:  03 January 2018
SAP Date:25 May 2018
Anika Therapeutics, Inc.
Prepared by:
Gary Stevens, Ph.D.
DynaStat Consulting, Inc.
Approved by:
Gary Stevens, Ph.D.
Anika Therapeutics, Inc.
Dynastat Consulting, Inc.


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Table of Contents
Contents
Table of Contents............................................................................................................................ 2 
1.0 
Introduction.......................................................................................................................... 3 
2.0 
Study Design........................................................................................................................ 3 
3.0 
Objectives ............................................................................................................................ 4 
3.1 Primary Efficacy Endpoint ................................................................................................... 4 
3.2 Secondary Efficacy Endpoints.............................................................................................. 4 
3.3 Exploratory Endpoints .......................................................................................................... 5 
3.4 Safety Endpoint..................................................................................................................... 5 
4.0 
Statistical Methods in Protocol............................................................................................ 6 
4.1 Statistical Methods................................................................................................................ 6 
4.1.1Sample Size..................................................................................................................... 6 
4.1.2 Primary Efficacy Endpoint ............................................................................................ 6 
4.1.3 Secondary Efficacy Endpoints....................................................................................... 7 
4.1.4 Exploratory Endpoints ................................................................................................. 12 
4.2 Statistical Methods.............................................................................................................. 12 
4.3 Demographic and Baseline Characteristics ........................................................................ 12 
4.4 Adverse Events ................................................................................................................... 13 
4.5 Subject Populations............................................................................................................. 13 
4.6 Additional Analyses............................................................................................................ 14 


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1.0
Introduction
This document presents the statistical analysis plan (SAP) for the Anika Therapeutics, Inc. 
protocol Cingal 17-02.  This incorporates the data listings, summary tables, and statistical 
analyses.  This document is based on the original final protocol and case report forms (CRFs).
2.0
Study Design
This sub-study is an extension of the ongoing Cingal 16-02 trial which is a multi-center, 
randomized, double-blind, parallel group, active comparator controlled trial to evaluate the 
efficacy and safety of a single injection of Cingal for the relief of joint pain in subjects with OA 
of the knee. 
Subjects with OA defined as Kellgren-Lawrence (K-L) I-III in the index knee will be eligible for 
this study. Felson, et al 20041, encouraged the use of both OA symptoms and radiographic changes 
in the assessment of OA.  This study will employ both methods to screen subjects.  Structural 
severity will be evaluated with the K-L classification score, a composite index of the presence and 
severity of joint space narrowing, osteophytes, sclerosis, deformity and cysts
.
For the evaluation of symptomatic severity, two main domains are important.  The first is pain and 
the second is functional impairment.  Other domains often used include subject’s overall 
assessment, ROM and performance.  Domains identified by OMERACT as core variables to be 
used in clinical trials involving OA are pain, function and the Patient Global Assessment which 
will be captured as part of this study.
Baseline and post-treatment pain, physical function and stiffness will be measured using the 
WOMAC questionnaire.  Range of Motion, Patient and Evaluator Global Assessment and the 
EuroQol will be used to assess symptomatic severity throughout the study.  In addition, the number 
of acetaminophen/paracetamol pills taken will be captured as an indirect measure of pain and will 
be done at each visit. 
Subjects meeting the inclusion/exclusion criteria will be randomized to receive a single injection 
of Cingal, Monovisc or triamcinolone hexacetonide (TH) in the index knee. Since there is a 
difference in volume between Cingal, Monovisc and TH, the treating physician will not be 
considered blinded.  To maintain the double-blind design of the study, there will be a person 
assigned to the role of Treating Physician and one person assigned to the role of Blinded Evaluator. 
The Treating Physician, most often the PI, will administer the injection but will not participate in 
the evaluation of study treatment effectiveness. A second individual, designated as the Blinded 
Evaluator, is blinded to treatment and will complete the pre- and post-treatment Evaluator Global 
Assessment, knee exams and ROM measurements. To maintain the subject blinding, the injection 
syringe will be prepared separate from the patient and the injection will be masked from the 
subject.
1 Felson, DT, Nevitt MC.  Epidemiologic studies for osteoarthritis: new versus conventional study design 
approaches.  Rheumatic Diseases Clinics of North America 2004. 30(4):783-97.


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The subject will be trained on how to complete the WOMAC, Patient Global Assessment and 
EuroQol.  The subject should complete these questionnaires prior to any physical evaluation that 
must be done at each follow-up visit.
The Blinded Evaluator will collect and record AEs from the subjects and consult the Treating 
Physician only as needed in the management of AEs.  The Blinded Evaluator will be a physician, 
research nurse, registered physiotherapist or physician assistant trained to perform the assessments 
outlined in the protocol.
Up to 40 sites in Europe are participating in the study to enroll 576 subjects.  Subject participation 
in this extension study will last approximately 13 additional weeks beyond the Cingal 16-02 trial 
with follow-up the visit scheduled at weeks 39 after the treatment injection in Cingal 16-02.
3.0
Objectives
The objective of this sub-study is to evaluate the efficacy and safety at 39 week follow up of a 
single injection of Cingal for relief of joint pain in subjects with OA of the knee who have not 
responded to conservative treatment (weight reduction, physical therapy, pain medications, etc.).
3.1 PRIMARY EFFICACY ENDPOINT 
x
The responder rate as identified by the Outcomes Measures for Rheumatic Arthritis 
Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) 
responder index at 39 weeks post treatment comparing the Cingal group to the TH 
group.
3.2 SECONDARY EFFICACY ENDPOINTS 
x
The change from baseline in knee pain as measured by the WOMAC Pain Score (100 
mm VAS) at 39 weeks post treatment comparing the Cingal group to the Triamcinolone 
Hexacetonide (TH) group. 
x
The change from baseline in WOMAC Physical Function score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
x
The change from baseline in WOMAC Stiffness score at 39 weeks post treatment 
comparing the Cingal group to the TH group.
x
The change from baseline in Total WOMAC score at 39 weeks post treatment 
comparing the Cingal group to the TH group.
x
The change from baseline in the Patient Global Assessment 39 weeks post treatment in 
the Cingal group compared to the TH group.
x
The change from baseline in the Evaluator Global Assessment at 39 weeks post 
treatment in the Cingal group compared to the TH group. 
x
The usage of rescue medication through 39 weeks post treatment in the Cingal group 
compared to the TH group.


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3.3 EXPLORATORY ENDPOINTS 
Any comparisons between groups (Cingal, Monovisc, TH), within groups and / or time points 
(from baseline through to 39 weeks) not described in the primary or secondary endpoints may be 
presented in the exploratory endpoints including:
x
EuroQol (EQ-5D)
x
WOMAC Pain Score (100mm VAS)
x
OMERACT-OARSI
x
Total WOMAC
x
WOMAC Stiffness Score
x
WOMAC Physical Function
x
Patient Global Assessment
x
Evaluator Global Assessment
x
Range of Motion 
x
Rescue Medication Usage
x
Number of Treatment Failures due to Additional Procedure or Use of Disallowed 
Medication  
3.4 SAFETY ENDPOINT 
The incidence, timing, severity, and relationship to treatment of all Adverse Events (AE) will be 
collected and coded using Medical Dictionary for Regulatory Activities (MedDRA).  Local 
injection site and non-local events will be recorded separately.


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4.0
Statistical Methods in Protocol
4.1 STATISTICAL METHODS
This Statistical Analysis Plan provides the details of the statistical analysis of the study data that 
is described in the protocol.
4.1.1Sample Size
The primary comparison in the study will be between Cingal and triamcinolone hexacetonide with 
respect to the difference in the change in the WOMAC pain score from baseline at 26 weeks after
study injection.
It is assumed that the difference in the mean responses for Cingal and triamcinolone hexacetonide 
at 26 weeks would be 10 mm based on previous clinical trials of similar viscosupplementation 
products and the Cingal 13-01 trial with a standard deviation of 20. The sample size calculation is 
based upon a t-test. The sample size that is necessary to detect that specified difference at a power 
of 90% with a significance level of 5% in a 2:1 enrollment ratio is 128 in the Cingal group and 64 
in the triamcinolone hexacetonide group.  If a 15% drop out rate is assumed then enrolling in a 
24:4:1 (Cingal: Monovisc :triamcinolone hexacetonide ratio) a total of 576 evaluable subjects, 256 
subjects in the Cingal arm, 256 subjects in the Monovisc arm and 64 subjects in the triamcinolone 
hexacetonide arm is needed. This will provide 90% power to detect the difference between Cingal 
compared to triamcinolone hexacetonide at 26 weeks at a 5% significance level.   
4.1.2 Primary Efficacy Endpoint
4.1.2.1 The responder rate as identified by the OMERACT-OARSI responder index at 39 
weeks post treatment comparing the Cingal group to the triamcinolone hexacetonide
group.
The response rate for the Cingal group and Triamcinolone Hexacetonide (TH) group will be 
calculated and tested using Fisher’s exact test.  Formally, the hypothesis to be tested is:
+ʌC  ʌT YHUVXV+ʌC ʌT
:KHUH ʌC LV WKH UHVSRQGHU UDWH IRU WKH &LQJDO JURXS DQG ʌT is the responder rate for the 
triamcinolone hexacetonide group. 
This will be estimated and tested using PROC FREQ with the EXACT option.  The results will be 
displayed similar to:
Summary of the OMERACT-OARSI Responder Rates at 39 Weeks
Parameter
Cingal
Monovisc
TH
Estimate n/N (%)
Cingal vs TH (Primary) (p-value)


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Parameter
Cingal
Monovisc
TH
Cingal vs Monovisc (p-value)
Monovisc vs TH (p-value)
4.1.3 Secondary Efficacy Endpoints
There are multiple secondary endpoints.  In order to preserve the integrity of the Type I error, these will 
be tested in a hierarchical manner.  The order of the testing is as the order presented here. 
The change from baseline in knee pain as measured by the WOMAC Pain Score (100 mm VAS) at 39 
weeks post treatment comparing the Cingal group to the TH group. 
This secondary efficacy endpoint is the change from baseline in knee pain as measured by the WOMAC 
Pain Score (100 mm VAS) at 39 weeks post treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline 
pain score as a covariate.  The primary hypothesis will be tested by a predefined contrast for 
comparing the Cingal group to the triamcinolone hexacetonide group.  Formally, the hypothesis to 
be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the mean change from baseline in the WOMAC Pain Score for the Cingal group at 
39 weeks and μDT is the mean change from baseline in the WOMAC Pain Score for the 
triamcinolone hexacetonide group at 39 weeks.  Since there are three treatment groups in this
study, this hypothesis will be tested using a one way ANOVA and constructing a contrast for this 
hypothesis.  This process is the same as using a baseline pain adjusted two-sample t-test with the 
common variance estimate from the ANOVA.
The anticipated SAS code for this analysis is given as:
The mean difference will be estimated and tested using the contrasts from PROC GLM on the 
responses at the 39 week time period.
PROC GLM DATA=EFF;
WHERE VISITNO = 39;
CLASS TRT;
MODEL WOMDIFF = BASEWOM TRT / TYPE3 ALPHA=0.05;
ESTIMATE ‘CINGAL VS MONOVISC’ TRT 1 -1 0 ;
ESTIMATE ‘CINGAL VS TH’       TRT 1 0 -1 ;
ESTIMATE ‘MONOVISC VS TH’     TRT 0 1 -1 ;
LSMEANS TRT / DIFF CL ALPHA=0.05;
FORMAT TRT TRTF. ;
RUN;
In this model, the WOMDIFF is the difference in WOMAC Pain Scores from baseline.  The 
variable TRT is a categorical variable where 1 = Cingal, 2=Monovisc, and 3=TH.  The variable 


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BASEWOM is the baseline WOAMC scores and the variable VISITNO is the visit number 
identifier.  ODS statements will be used to output the contrasts and the mean differences into  
data sets that can be easily displayed using PROC REPORT.  The primary analysis will be 
comparing Cingal to TH.
The tables for this analysis will be displayed as:
Summary of Least Squares Means at 39 weeks – WOMAC Pain Score
Treatment
Group
Mean Percent
Improvement
LS Mean
Standard
Error
Cingal
Monovisc
TH
Summary of Differences in Mean Responses at 39 Weeks – WOMAC Pain Score
Treatment
Group
Mean Percent
Improvement
Standard
Error
Lower
Confidence
Limit
Upper
Confidence
Limit
p-value
Cingal – Monovisc
Cingal – TH 
Monovisc - TH


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The change from baseline in WOMAC Physical Function score at 39 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in WOMAC Physical Function Score at 39 
weeks post treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline Physical 
Function score as a covariate.  The hypothesis will be tested by a predefined contrast for comparing the 
Cingal group to the TH group.  Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the mean change from baseline in the WOMAC Physical Function Score for the Cingal group 
at 39 weeks and μDT is the mean change from baseline in the WOMAC Physical Function Score for the TH
group at 39 weeks.  
The change from baseline in WOMAC Stiffness score at 39 weeks post treatment comparing the Cingal 
group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in WOMAC Stiffness Score at 39 weeks post 
treatment comparing the Cingal group to the TH group.
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline Stiffness 
score as a covariate.  The hypothesis will be tested by a predefined contrast for comparing the Cingal group 
to the TH group.  Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the mean change from baseline in the WOMAC Stiffness Score for the Cingal group at 39 
weeks and μDT is the mean change from baseline in the WOMAC Stiffness Score for the TH group at 39 
weeks.  
The change from baseline in Total WOMAC score at 39 weeks post treatment comparing the Cingal 
group to the triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the change from baseline in Total WOMAC Score at 39 weeks post 
treatment comparing the Cingal group to the TH group.


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Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline Total 
WOMAC score as a covariate.  The hypothesis will be tested by a predefined contrast for comparing the 
Cingal group to the TH group.  Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the mean change from baseline in the Total WOMAC Score for the Cingal group at 39 weeks 
and μDT is the mean change from baseline in the Total WOMAC Score for the TH group at 39 weeks.  
The change from baseline in the Patient Global Assessment at 39 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group.
Since this is a secondary endpoint the data will be analyzed for each time point individually with 
no adjustment for multiplicity.  Data will be analyzed via an analysis of variance with a term for 
treatment and baseline PGA score as a covariate.  The primary hypothesis will be tested by a 
predefined contrast for comparing the Cingal group to the Triamcinolone Hexacetonide group.  
Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the mean change from baseline in the Patient Global Assessment Score for the Cingal 
group and μDT is the mean change from baseline in the Patient Global Assessment Score for the 
triamcinolone hexacetonide group.  Since there are three treatment groups in this study, this 
hypothesis will be tested using a one way ANOVA and constructing a contrast for this hypothesis.  
This process is the same as using a two-sample t-test with the common variance estimate from the 
ANOVA.
The mean difference will be estimated and tested using the contrasts from PROC GLM on the 
responses by week with the 39 week time period being the time point of interest for the analysis 
of this secondary endpoint.
4.1.3.4 The change from baseline in the Evaluator Global Assessment through 39 weeks 
post treatment comparing the Cingal group to the triamcinolone hexacetonide group.
Since this is a secondary endpoint the data will be analyzed for each time point individually with 
no adjustments for multiplicity.  Data will be analyzed via an analysis of variance with a term for 
treatment and baseline EGA score as a covariate.  The primary hypothesis will be tested by a 
predefined contrast for comparing the Cingal group to the triamcinolone hexacetonide group.  
Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT


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Where μDC is the mean change from baseline in the Evaluator Global Assessment for the Cingal 
group at 39 weeks and μDT is the mean change from baseline in the Evaluator Global Assessment 
for the triamcinolone hexacetonide group at 39 weeks.  Since there are three treatment groups in 
this study, this hypothesis will be tested using a one way ANOVA and constructing a contrast for 
this hypothesis.  This process of constructing a contrast is the same as using a two-sample t-test 
with the common variance estimate from the ANOVA.
The usage of rescue medication through 39 weeks post treatment comparing the Cingal group to the 
triamcinolone hexacetonide group. 
This secondary efficacy endpoint is the usage of rescue medications through 39 weeks post treatment 
comparing the Cingal group to the TH group.
The hypothesis will be tested by a predefined contrast for comparing the Cingal group to the TH group.  
Formally, the hypothesis to be tested is:
H0: μDC = μDT versus HA: μDC DT.
Where μDC is the total usage of rescue medications for the Cingal group at 39 weeks and μDT is the mean 
change from baseline in the WOMAC Pain Score for the TH group at 39 weeks.


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4.1.4 Exploratory Endpoints
Any comparisons between groups (Cingal, Monovisc, TH), within groups and / or time points (from 
baseline through to 39 weeks) not described in the primary or secondary endpoints may be presented in the 
exploratory endpoints including:
x
EuroQoL (EQ-5D)
x
WOMAC Pain Score (100mm VAS)
x
OMERACT-OARSI
x
Total WOMAC
x
WOMAC Stiffness Score
x
WOMAC Physical Function Score
x
Patient Global Assessment
x
Evaluator Global Assessment
x
Range of Motion
x
Rescue Medication Usage: Difference in analgesic use measured by number of pills taken 
between visits will be compared between treatment groups descriptively.
x
Number of Subjects Considered Treatment Failures: Treatment Failure: A subject who 
undergoes a procedure or uses a medication (other than the rescue medication) for the 
treatment of OA in the index knee at any time after the study injection through the 12 week 
visit.
For the exploratory analyses, the continuous variables will be analyzed via an analysis of variance 
and contrasts used to assess the prescribed comparisons.  For the discrete variables, a Fisher’s 
exact test will be used to assess the desired comparisons.
4.2 STATISTICAL METHODS
Tabulation of summary statistics, graphical presentations, and statistical analyses will be 
performed using SAS® software 9.1.3 or higher version. Where not otherwise specified, the last 
pre-treatment observation will be used as baseline for calculating post-treatment changes from 
baseline. The primary presentations and analyses will be based on data pooled across study centers. 
Relevant summaries for individual centers, or combinations of centers, may be presented for 
primary data. All testing and confidence intervals will use a significance level of 5%.
4.3 DEMOGRAPHIC AND BASELINE CHARACTERISTICS
All demographic and baseline characteristics will be tabulated by treatment group and a test of 
homogeneity between the treatment groups will be conducted. For continuous variables (e.g. age, 
height, weight) a one way ANOVA will be used. For categorical variables (e.g. gender, race), a 
Fisher's exact test or chi-squared test will be used. Medical history findings, physical examinations 
and concomitant medications will be tabulated by treatment group.


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The baseline Chemistry, Hematology, Urinalysis, Vital Signs, and BMI data will be summarized 
via descriptive statistics and tested for homogeneity using a one way ANOVA.
4.4 ADVERSE EVENTS
All AEs will be coded according to MedDRA. Safety assessments will include Treatment-
Emergent Adverse Events (TEAEs) which are defined as AEs with an Investigator assessment of 
definitely, probably, or possibly related to CTM.  TEAEs will be summarized with frequencies 
and percentages by system organ class and preferred term, severity, and relationship to study CTM 
for each treatment group.  In summaries of TEAEs by severity and relationship to CTM for subjects 
reporting multiple episodes, all reported events will be included, not only the worst reported case.  
Serious Adverse Events will also be presented by relationship to the CTM. 
The number of subjects with at least one AE will be tabulated for each treatment group. Differences 
between the treatment groups will be tested using Fisher's exact test. Then the number of AEs for 
each treatment group will also be tabulated.
The number of subjects and the number of AEs will be tabulated by severity, relationship, and 
local injection site specific events versus non local events.
4.5 SUBJECT POPULATIONS  
All safety analyses will be conducted on all subjects who undergo treatment in any group. 
The primary analysis on the primary endpoint will be performed on the ITT populations using the 
Multiple Imputation Methodology.  The Multiple Imputation Methodology will use a mixed effects 
repeated measures model to predict the missing values.  All Primary and Secondary endpoints will 
be analyzed using the ITT population.
It has been determined that any missing data in this study will follow the Missing at Random 
(MAR) assumption and is justified by the following section from the guide on missing data.
Missing Data Because of Attrition in the Course of the Study The longer the planned length of 
a clinical trial, the greater the chance that participants will drop out of the trial due to their moving 
out of the area or otherwise experiencing changes in their lives that preclude or complicate further 
participation. If dropping out due to these situations is known to be unrelated to changes in health 
status, an MAR assumption for the missing values seems justified;
Since none of these patients are likely to be in a life threatening disease situation and many have 
had knee pain for a period of time, the missing data will unlikely be due to any treatment effect or 
lack thereof.  Previous studies have demonstrated a missing data rate of less than 1%.  Thus, any 
missing data in this study follows that paradigm and thus should be considered MAR.  Under this 
MAR assumption, the mixed effects repeated measures analysis yields unbiased estimates of the 
treatment effects and thus will be utilized in the analysis.


Anika Therapeutics, Inc.
Page 14 of 14
Confidential 
Date 25 May 2018
A secondary analysis will be conducted on the Per Protocol (PP) population.   Since the primary 
endpoint is at 39 weeks, this is all subjects who complete the 39 week visit and who are not major 
violators of the protocol.  For all other visits, this is defined as the subjects who complete those 
visits according to the protocol.  
4.6 ADDITIONAL ANALYSES
All of the analyses are performed on the data with the specified covariates or other factors 
assumed in the model.  If it is determined that certain factors may influence the outcomes of the 
endpoints, then additional analyses will be performed.  For the continuous variables, the factors 
will be added to the ANOVA model and evaluated in a stepwise fashion for significance.  For the 
discrete variables, the data will be analyzed via a GEE model with the factors added to the 
model.