Conditions: Non-healing Wound Non-healing Diabetic Foot Ulcer Diabetic Foot Infection
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 32
Healthy volunteers: no

Brief summary:
It is hypothesized that application of the human placental umbilical cord tissue TTAX01 to the surface of a well debrided, complex diabetic foot ulcer will, with concomitant management of infection, result in a higher proportion of wounds showing complete healing within 16 weeks of initiating therapy.

Detailed description:
The hypothesis under study is that one or more applications of TTAX01 to the wound surface of a well debrided, complex diabetic foot ulcer managed with appropriate antibiotic therapy will result in a higher probability of complete healing than would be expected from management with standard care alone. In this open label Phase 2 pilot trial, all subjects will receive the intervention over a maximum period of 16 weeks. Eligible consenting subjects will undergo a baseline aggressive debridement in the operating room to remove infected and devitalized bone and soft tissue. TTAX01 will be applied to the debrided wound bed at baseline, and if healing is not evident, it will be applied again at 4 week intervals. At each weekly visit the wound will be further debrided as necessary.

Consenting subjects who qualify for enrollment will undergo an aggressive surgical debridement at the baseline visit, including biopsies of bone for histology and microbiologic testing at the start and completion of debridement. Systemic antibiotics will be given empirically, with adjustments made on the basis of culture and sensitivity results. New or recurrent infections will be managed with additional debridement and adjustment or addition of appropriate systemic antibiotics. The test article, TTAX01, will be sutured to the debrided wound bed at baseline and again at 4 week intervals over the 16 week treatment period for wounds that do not show evidence of healing. For wounds that do show evidence of healing, additional applications of TTAX01 will be withheld, based on observations from retrospective case series.

Subjects whose wounds close prior to 16 weeks will move directly to a 2 week confirmation of closure period. Subjects whose wounds have not closed by the end of 16 weeks will exit the trial.

Arms:
arm 1: Eligible consenting subjects will undergo a baseline aggressive debridement in the operating room to remove infected and devitalized bone and soft tissue. A six week course of systemic antibiotics will be used to resolve baseline infection. TTAX01 will be applied to the debrided wound bed at baseline, and if healing is not evident, it will be applied again at 4 week intervals. At each weekly visit the wound will be further debrided as necessary.

Interventions: intervention 1: TTAX01 intervention 2: Surgical resection and debridement intervention 3: Systemic antibiotics intervention 4: Off-loading
Intervention descriptions: intervention 1: TTAX01 will be applied directly to the wound surface and retained with non-absorbable sutures. A single layer of the test article should cover the entire open surface of the wound. The material is to be applied once every 4 weeks unless the wound shows evidence of healing, in which case dosing is suspended; or, if the test article has been accidentally dislodged, it may be replaced at any time. intervention 2: Perform surgical sharp debridement in the OR, to remove:

* infectious agents and biofilms (purulence),
* all debris, eschar, callus and macerated non-viable tissue from the wound base, and
* dead (suprabasal epidermis), scarred (elevated/edematous) and necrotic/macerated tissue from the wound edge.

Surgical Resection will be performed to remove as much of the necrotic bone detected by the radiographic evidence as is appropriate. intervention 3: Six (6) weeks of systemic antibiotic therapy is required. A definitive therapy will be guided by the microbiological results based on bone biopsy. intervention 4: Provide off-loading device appropriate to the location of wound with full length boot or total contact cast

Protocol document:
Prot_000.pdf: 
 
 
 
 
 
 
Study Protocol: TTCRNE-1501: A Multicenter, Open Label Phase 2 Pilot Trial of Subjects with 
Complex Non-healing Diabetic Foot Ulcers Treated with Standard Care plus Cryopreserved 
Umbilical Cord Allograft (TTAX01) 
 
NCT03230175 
 
Version 1.1 (05Feb2018) 


A Multicenter, Open Label Phase 2 Pilot Trial of 
Subjects with Complex Non-healing Diabetic Foot 
Ulcers Treated with Standard Care plus 
Cryopreserved Umbilical Cord Allograft (TTAX01) 
 
Protocol Number: TTCRNE-1501 
IND Sponsor:   TissueTech, Inc. 
7300 Corporate Center Dr STE 700 
Miami, FL 33126 
 
Version Number:  v.1.1 
05-FEB-2018 
 
 
Summary of Changes from Previous Version: 
Affected 
Section(s) 
Summary of Revisions Made 
Rationale 
1.1 
Updated study population to 36 patients with 
approximately 12 sites 
Adjusted study population based on the 
projected number of clinical sites to 
participate, and to enroll 3 patients/site 
3.0, 8.1.1 
Updated safety endpoint to include proportion of 
subjects who experience subsequent limb 
amputation 
Updated safety endpoint to distinguish initial 
amputation completed at the Initial Procedure 
Visit and any subsequent limb amputation that 
would discontinue the subject per section 7.2 
5.2 
Removed previous exclusion #1 ‘the subject has 
another ulcer within 3cm of the index ulcer 
 
Removed previous exclusion #10 ‘The subject 
has tested positive for HIV or has AIDS’ 
Since there is no worsening criterion of the 
index ulcer, any ulcer within close proximity 
to the index ulcer would be surgically 
addressed at the Initial Procedure Visit. 
Allowing patients with HIV or AIDS since 
there are no contraindications with TTAX01 


 
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Added sepsis definition to previous exclusion 
#20, which is now exclusion #18 
Added 
sepsis 
criteria 
to 
ensure 
site 
consistency when evaluating new patients 
6.1.2, 8.1.2 
Added clarity that TTAX01 should be surgically 
fixed by either sutures or staples 
Added TTAX01 must be fenestrated 
Provided additional means to surgically fix 
TTAX01 with staples 
TTAX01 must be fenestrated to avoid 
possible seromas or hematomas after tissue 
placement on the woundbed 
8.1.2, 
8.1.3, 
8.1.4, 8.1.5  
Allowing total contact casts for off-loading 
Some sites use total contact casts as their 
standard care so allowing both full length boot 
or total contact cast for off-loading methods 
8.4.1, 
8.4.2, 
8.4.3.2, 8.4.6 
Updated adverse event (AE) definition, reporting 
AEs, updating related terminology, updated 
Medical Monitor email 
Provided clarity on AE definition, reporting of 
AEs in the electronic data capture system, and 
updated medical monitor email for SAE  
9.4.7 
Updated sub-group analysis by race 
Updated sub-group analyses per FDA 
recommendation 


  
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Table of Contents 
STATEMENT OF COMPLIANCE .............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ................................................................................................................................ 2 
1.1 
Synopsis ................................................................................................................................................. 2 
1.2 
Schema ................................................................................................................................................... 4 
1.3 
Schedule of Activities (SoA) .................................................................................................................. 6 
2 
INTRODUCTION ............................................................................................................................................ 7 
2.1 
Study Rationale ...................................................................................................................................... 7 
2.2 
Background ............................................................................................................................................ 8 
2.3 
Risk/Benefit Assessment ...................................................................................................................... 11 
2.3.1 
Known Potential Risks ..................................................................................................... 11 
2.3.2 
Known Potential Benefits ................................................................................................. 11 
2.3.3 
Assessment of Potential Risks and Benefits ..................................................................... 11 
3 
OBJECTIVES AND ENDPOINTS ................................................................................................................ 12 
4 
STUDY DESIGN ............................................................................................................................................ 13 
4.1 
Overall Design ...................................................................................................................................... 13 
4.2 
Scientific Rationale for Study Design .................................................................................................. 14 
4.3 
Justification for Dose............................................................................................................................ 14 
4.4 
End of Study Definition ....................................................................................................................... 14 
5 
STUDY POPULATION ................................................................................................................................. 14 
5.1 
Inclusion Criteria .................................................................................................................................. 15 
5.2 
Exclusion Criteria ................................................................................................................................. 15 
5.3 
Lifestyle Considerations ....................................................................................................................... 16 
5.4 
Screen Failures ..................................................................................................................................... 16 
5.5 
Strategies for Recruitment and Retention ............................................................................................. 17 
6 
STUDY INTERVENTION ............................................................................................................................. 17 
6.1 
Study Intervention(s) Administration ................................................................................................... 17 
6.1.1 
Study Intervention Description ......................................................................................... 17 
6.1.2 
Dosing and Administration ............................................................................................... 17 
6.2 
Preparation/Handling/Storage/Accountability ...................................................................................... 18 
6.2.1 
Acquisition and accountability ......................................................................................... 18 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ........................................................ 18 
6.2.3 
Product Storage and Stability ........................................................................................... 19 
6.2.4 
Preparation ........................................................................................................................ 19 
6.3 
Measures to Minimize Bias .................................................................................................................. 20 
6.4 
Study Intervention Compliance ............................................................................................................ 20 
6.5 
Concomitant Therapy ........................................................................................................................... 21 
6.5.1 
Rescue Medicine ............................................................................................................... 21 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ................................................................................................................... 21 
7.1 
Discontinuation of Study Intervention ................................................................................................. 21 
7.2 
Participant Discontinuation/Withdrawal from the Study...................................................................... 21 
7.3 
Lost to Follow-Up ................................................................................................................................ 22 
8 
STUDY ASSESSMENTS AND PROCEDURES .......................................................................................... 22 
8.1 
STUDY ACTIVITIES BY VISIT ........................................................................................................ 22 
8.1.1 
Screening Period (within -7 Days from Initial Procedure Visit) ....................................... 22 
8.1.2 
Initial Procedure Visit (Visit BL/baseline) ....................................................................... 25 


  
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8.1.3 
Treatment Period [Visit 01 through Visit 15 (7 +/- 2 days)] ............................................. 27 
8.1.4 
Treatment Period [Visit 16 (7 +/- 2 days)] ........................................................................ 31 
8.1.5 
Confirmatory Period [Visit 17 and Visit 18 (7 +/- 2 days)] .............................................. 31 
8.1.6 
End of Treatment Period Visit (Visit 19) (14 +/- 2 days) ................................................. 32 
8.2 
Efficacy Assessments ........................................................................................................................... 32 
8.3 
Safety and Other Assessments .............................................................................................................. 32 
8.4 
Adverse Events and Serious Adverse Events ....................................................................................... 32 
8.4.1 
Definition of Adverse Events (AE)................................................................................... 32 
8.4.2 
Definition of Serious Adverse Events (SAE) ................................................................... 33 
8.4.3 
Classification of an Adverse Event ................................................................................... 33 
8.4.4 
Time Period and Frequency for Event Assessment and Follow-Up ................................. 34 
8.4.5 
Adverse Event Reporting .................................................................................................. 35 
8.4.6 
Serious Adverse Event Reporting ..................................................................................... 35 
8.4.7 
Reporting Events to Participants ....................................................................................... 36 
8.4.8 
Events of Special Interest ................................................................................................. 36 
8.4.9 
Reporting of Pregnancy .................................................................................................... 36 
8.5 
Unanticipated Problems ....................................................................................................................... 36 
8.5.1 
Definition of Unanticipated Problems (UP)...................................................................... 36 
8.5.2 
Unanticipated Problem Reporting ..................................................................................... 36 
8.5.3 
Reporting Unanticipated Problems to Participants ........................................................... 36 
9 
STATISTICAL CONSIDERATIONS ............................................................................................................ 37 
9.1 
Statistical Hypotheses ........................................................................................................................... 37 
9.2 
Sample Size Determination .................................................................................................................. 37 
9.3 
Populations for Analyses ...................................................................................................................... 37 
9.4 
Statistical Analyses............................................................................................................................... 37 
9.4.1 
General Approach ............................................................................................................. 37 
9.4.2 
Analysis of the Primary Efficacy Endpoint(s) .................................................................. 38 
9.4.3 
Analysis of the Secondary Endpoint(s) ............................................................................. 38 
9.4.4 
Safety Analyses ................................................................................................................ 39 
9.4.5 
Baseline Descriptive Statistics .......................................................................................... 39 
9.4.6 
Planned Interim Analyses ................................................................................................. 39 
9.4.7 
Sub-Group Analyses ......................................................................................................... 40 
9.4.8 
Tabulation of Individual participant Data ......................................................................... 40 
9.4.9 
Exploratory Analyses ........................................................................................................ 40 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .................................. 40 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ................................................................... 40 
10.1.1 
Informed Consent Process ................................................................................................ 40 
10.1.2 
Study Discontinuation and Closure .................................................................................. 42 
10.1.3 
Confidentiality and Privacy .............................................................................................. 42 
10.1.4 
Future Use of Stored Specimens and Data........................................................................ 43 
10.1.5 
Key Roles and Study Governance .................................................................................... 43 
10.1.6 
Safety Oversight ............................................................................................................... 43 
10.1.7 
Clinical Monitoring .......................................................................................................... 44 
10.1.8 
Quality Assurance and Quality Control ............................................................................ 44 
10.1.9 
Data Handling and Record Keeping ................................................................................. 44 
10.2 
Additional Considerations .................................................................................................................... 46 
10.3 
Abbreviations ....................................................................................................................................... 47 


  
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10.4 
Protocol Amendment History ............................................................................................................... 48 
11 
REFERENCES................................................................................................................................................ 49 
12 
Sponsor Signatures .......................................................................................................................................... 55 
13 
Investigator Signature ..................................................................................................................................... 56 
 


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STATEMENT OF COMPLIANCE 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (21 CFR 
Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
Investigators and clinical trial site staff who are responsible for the conduct, management, or 
oversight of this trials have completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is screened or enrolled.  
Any amendment to the protocol will require review and approval by the IRB before the changes 
are implemented to the study.  In addition, all changes to the consent form will be IRB-approved; 
a determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form. 
 
 
 
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1 
 
PROTOCOL SUMMARY 
1.1 SYNOPSIS  
Title: 
A Multicenter, Open Label Phase 2 Pilot Trial of Subjects with 
Complex Non-healing Diabetic Foot Ulcers Treated with Standard Care 
plus Cryopreserved Umbilical Cord Allograft (TTAX01) 
 
Study Description: 
It is hypothesized that application at 4-week intervals of the human 
placental umbilical cord tissue TTAX01 to the surface of a well 
debrided, complex diabetic foot ulcer will, with concomitant 
management of infection, result in a higher proportion of wounds 
showing complete healing within 16 weeks of initiating therapy. This 
open label pilot study provides a framework for a larger, controlled 
study. The purpose for conducting this study is to evaluate the 
functionality of the protocol, and to obtain an estimate of product safety 
and efficacy when applied according to the protocol instructions, and 
measured according to the stated endpoints.  
 
Objectives: 
 
Primary Objective:  To examine the safety and estimate the efficacy of 
TTAX01 plus standard care (SC) in achieving complete wound closure 
of complex non-healing diabetic foot ulcers with high risk factors of [1] 
ulcer depth indicating exposed bone, tendon, muscle, and/or joint 
capsule and [2] clinical suspicion of osteomyelitis. 
 
 
Summary of Secondary Objectives: To examine alternative measures 
of wound healing, progress towards healing, and healing among stated 
subsets, as well as to estimate the influence of treatment on rates of 
amputation. 
 
Endpoints: 
Primary Endpoint: Proportion of subjects with complete wound healing 
by Treatment Week 16 
 
Secondary Endpoints: Various associated measures such as time to 
heal, proportion healed by week, and wound area reduction.  
 
Study Population: 
Approximately 36 adults aged 18 years and older, with diabetes mellitus 
types 1 or 2, and non-ischemic, non-dorsal diabetic foot ulcer 
measuring 1-10 cm2 inclusive with evidence of exposed bone, tendon, 
muscle and/or joint capsule and presumptive evidence of osteomyelitis. 
 
Phase: 
2 
 
Description of 
Sites/Facilities 
Enrolling 
Participants: 
Approximately twelve sites specializing in care of diabetic foot ulcers, 
including inpatient hospital and outpatient based wound practices to 
include podiatric office practices, wound care centers, dermatology and 
vascular surgery clinics. 


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Description of Study 
Intervention: 
All subjects will receive aggressive debridement at baseline, followed 
by standard care supplemented with TTAX01, a cryopreserved human 
umbilical cord product derived from human placental tissue. Test article 
is applied and surgically fixed in direct contact with the wound surface, 
at 4 week intervals unless healing is evident, or when replacement of 
dislodged material is necessary.  
 
Study Duration: 
Estimated time from first subject eligible and enrolled to completion of 
statistical analysis is 18 months. 
 
Participant Duration: 
The maximum time in study for any subject will be 21 weeks, with 1 
week in screening and assuming wound healing occurs at week 16 
followed by 2 weeks of observation for confirmation of closure, and a 
final exit visit 14 days later. 
 
 
 
 


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1.2 SCHEMA 
 
Figure 1. Flow diagram  
 
 
Prior to  
Enrollment 
 
 
 
Baseline 
Visit, 
1st Procedure 
Enrollment 
 
 
 
 
 
Treatment 
Visits 
 
 
 
 
Verification 
Visits 
 
 
 
Exit Visit 19 
 
 
 
 
 
 
 
 
 
 
 
Obtain informed consent. Screen potential participants by inclusion and exclusion criteria; 
obtain history, document. Perform baseline assessments and lab tests (Table 2). Obtain 
imaging to aid in diagnosis of osteomyelitis. 
Perform aggressive debridement in the operating room to remove infected and devitalized 
tissue. Obtain biopsies for histopathology testing and microbiology culture. Begin 
systemic antibiotics. Administer initial TTAX01 plus standard care. 
Follow-up assessments of study endpoints and safety 
Final Assessments 
Enrollment 
target N=36 
Observe wound for evidence of healing at weekly intervals, with wound cleaning, 
debridement, and management of any infection. Repeat study intervention at 4-week 
intervals if the wound is not infected and is not showing signs of healing. 


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Figure 2. Process diagram  
 
 
 
 
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Screening
Visit SCR
• Total estimated screened n=47 (30% screen failure rate)
• Obtain informed consent, screen potential participants by inclusion and exclusion criteria
• Obtain history, document
• Obtain baseline laboratory and imaging studies for osteomyelitis
• Initiate empiric systemic antibiotics
BL/Initial Procedure
• Perform aggressive debridement in the operating room, obtain biopsies for histopathology and culture
• Verify that subject meets all criteria for enrollment
• Apply first TTAX01 
Baseline debridement, Qualification
Visits 1-16 (7±2 d)
• Observe wound weekly for healing or stalled, infected
• Re-treat at 4 week intervals if not infected, not healing
• Perform weekly cleaning and debridement; observe and interview for adverse events
• If the wound has closed, proceed to Visit 17. If the wound remains open at Visit 16, proceed to Visit 19
Follow-up assessments of study endpoints and safety
Visits 17, 18 (7±2 d)
• For subjects whose wound has closed, determine again if the wound remains healed or has re-opened
End of Study Exit Visit
Visit 19 (14±2 d)
• Verify wound healing, resolution of AEs,  assess vascular perfusion, obtain final lab tests (Table 2)
Evaluations and re-treatments 


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1.3 SCHEDULE OF ACTIVITIES (SOA) 
 
 
 
 
 
 
 


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2 
 
INTRODUCTION 
 
2.1 STUDY RATIONALE  
 
According to the United States (US) Centers for Disease Control, there were 29.1 million 
Americans of all ages or 9.3% of the population in 2014 who had diabetes (1) either diagnosed or 
undiagnosed, a figure that has increased by fivefold since 1980 (2). An estimated 21 million 
persons were diagnosed with the disease, while an additional 8.1 million remain undiagnosed (1). 
By 2050, as many as 1 out of every 3 adults in the US could have diabetes if the trend continues 
(2).  
One of the most prevalent complications of diabetes is the diabetic foot ulcer. Diabetic persons 
have approximately 25% risk of developing a foot ulcer in their lifetime (3) with an estimated 
annual incidence rate of 0.5-3.0% (4-8). When the ulcer is non-healing, the dermal first line of 
defense is compromised for a prolonged period and the patient is susceptible to tissue loss that 
leads to limb amputation. Indeed, foot ulceration is the most common single precursor of lower 
extremity amputations among persons with diabetes and is a precursor to approximately 85% of 
the lower extremity amputations within this population (3, 9-20). In the US, diabetes has been the 
most common underlying cause of non-traumatic lower extremity amputations (21, 22); more than 
60% of non-traumatic lower extremity amputations occur in diabetic persons (1). 
Over 73,000 non-traumatic lower-limb amputations are performed in the US for people with 
diabetes annually (1). Unfortunately, after one major lower extremity amputation, the 5-year 
survival rate is estimated to be 50% (14, 15), worse than those of most malignancies and second 
only to that of lung cancer (14, 16). Moreover, once amputation occurs, 50% of the patients will 
develop an ulcer in the contralateral limb within 5 years (15). For amputation survivors, day-to-
day functioning is greatly impaired.  Many cannot walk, with or without the use of a cane or 
walker. A study found that in 2010, 22.8% of patients undergoing amputation of a lower extremity 
in the US were readmitted to the hospital within 30 days, the highest rate of re-admission among 
the procedures considered in the study (23). Moreover, even with the best of medical care, 
amputation and its aftermath are traumatic experiences that can be expected to produce depression 
as the patient copes with the social and financial consequences of disfigurement and loss of 
function. Collectively, one can envision a grave picture of the seriousness of the complex non-
healing foot ulcers that carry these high risks that may lead to amputation in this country and 
worldwide. 
Three major risk factors, i.e., [1] ulcer depth, [2] infection, and [3] ischemia, have been recognized 
to complicate non-healing foot ulcers leading to limb amputation (17). The first risk factor is “ulcer 
depth”. This clinical trial will enroll patients with the ulcer depth exhibiting exposed bone, tendon, 
muscle and/or joint capsule. It has been well known that these deep ulcers with extensive tissue 
loss are at high risk for infection-related ulcer complications including osteomyelitis (24). 


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The second risk factor is “infection”. While infection is not often implicated in the pathway leading 
to ulceration, it is a major risk factor in the causal pathway to amputation (25, 26). Contiguous 
spread of any infection of adjacent soft tissue into the bone of the foot will complicate the ulcer, 
predisposing the patient to risk of osteomyelitis (18),(19). Foot ulcers accompanied by limb-
threatening infections such as osteomyelitis have reported amputation rate as high as 51% (27-29). 
Indeed, the presence of an infection is a major predisposing factor for diabetic foot amputations, 
as 85% of these amputations are preceded by an infection (21, 30, 31). The risk of amputation 
increases by four times when the foot ulcer is complicated by osteomyelitis compared to soft tissue 
infection alone (32).  
The third risk factor is “ischemia”. Critical limb ischemia (CLI) has been used to denote a subgroup 
of patients with a threatened lower extremity primarily due to chronic ischemia. Foot ulcers 
complicated by ischemia have been reported to have an amputation rate of between 17-23% and a 
mortality rate of 33% (33, 34). Because CLI will compromise wound healing and because the 
standard of care calls for vascular consultation as well as potential revascularization procedures to 
address limb ischemia (17), clinical trials conducted under the Sponsor’s IND exemption will only 
enroll those patients with diabetic foot ulcer in which the vascular perfusion status is adequate to 
support healing.  
Collectively, the Inclusion and Exclusion criteria stated in this protocol allow us to enroll patients 
with a chronic diabetic foot ulcer that carries the severity of Wagner Grade 3 or worse (on a scale 
of 0 to 5 based on Wagner Classification System). This open label pilot study is intended to 
examine the operational aspects of a proposed Phase 3 pivotal trial, including ease of compliance 
with various decision points in the protocol (e.g., antibiotic use, debridement in the operating room, 
whether to treat with TTAX01 or withhold treatment), and to provide a refined estimate of 
treatment response.  
 
2.2 BACKGROUND  
 
Although new advances in wound care products include advanced skin substitutes and 
recombinant growth factors such as platelet-derived growth factor, none of these products are 
indicated for treating complex wounds presenting with osteomyelitis. In addition, the vast 
majority have not been demonstrated to be safe or effective in the treatment of complex non-
healing ulcers that have a depth exhibiting exposed bone, tendon, muscle, and/or joint capsule. 
Apligraf® and Dermagraft® are not indicated for ulcers with exposed bone, tendon, muscle, and/or 
joint capsule and are contraindicated for use on clinically infected ulcers or manifesting ischemia 
(e.g., Ankle Brachial Index (ABI) less than 0.60) or infection (e.g., osteomyelitis). Exposure of 
bone, tendon, muscle, and/or joint capsule, ischemic wounds (e.g., ABI less than 0.60), clinically 
infected ulcers and osteomyelitis are the exclusion criteria in clinical trials of various advanced 
skin substitutes approved for chronic foot ulcers of various etiologies. Only Theraskin® carries 
indication for use in exposed tendon, joint and/or bone. It should be noted that the approval of 
Theraskin® is supported by a retrospective observational study or clinical case studies (35-37) 
rather than a prospective randomized and controlled clinical trial. In one study of 188 patients 






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muscle and/or joint capsule and [2] clinical suspicion of osteomyelitis, so as to reduce the 
likelihood of ulcer-related complications including limb amputation. 
 
2.3 RISK/BENEFIT ASSESSMENT   
 
2.3.1 KNOWN POTENTIAL RISKS  
 
The major risk associated with use of human tissue as a temporary, non-engrafting therapeutic is 
the transmission of infectious agents. (63) This risk is minimized though careful donor screening 
and Good Tissue Practices. Decellularization removes any risk of potential graft vs. host reactions. 
A review of the literature indicates that various cell and tissue based products tested as therapeutics 
for non-healing wounds show no differences in adverse event profile compared with standard care 
(SC). Two ongoing controlled trials of NEOX® CORD 1K® for treatment of DFU show no pattern 
of treatment emergent adverse events associated with use of the product (NCT02166294, 
NCT02707406). The procedures required by the protocol are standard practice in the care of 
diabetic foot ulcers. 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
 
Three published retrospective case series provide an estimate of the complete healing rate when 
treating chronic DFU with NEOX® CORD 1K®, a marketed HCT/P 361 product identical to the 
test article TTAX01, with the exception that TTAX01 will be released against identity, potency 
and purity specifications put in place under Good Manufacturing Practices. 
 
Ref 
Patients 
Baseline wound 
area 
Number 
of 
applications 
Complete 
healing 
Mean time 
to heal 
(64) 
Retro case 
series 
31 patients, 33 wounds; 
complex 
DFU 
with 
osteomyelitis 
15.6 ± 17.7 cm2  
1.24 ± 0.44 
26/33 (78.8%) 
16.0 ± 9.3 
weeks 
(65) 
Retro case 
series 
29 patients, 32 wounds; 
DFU 
10.6 ± 2.15cm2  
1.68 ± 0.18 
28/32 (87.5%) 
13.8 ± 1.95 
weeks 
(66) 
Retro case 
series 
57 patients, 64 wounds of 
the lower extremity 
6.85 ± 16.29 cm2  
3.43 ± 2.42 
51/64 (79.7%) 
5.53 ± 3.93 
weeks 
 
The anticipated immediate benefit is healing of the open diabetic foot ulcer. The associated long 
term benefit is expected to be a reduced risk of amputation. In the published experience of Caputo 
(64), only one of 15 planned amputations was necessary following intervention with NEOX® 
CORD 1K®. 
 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
 
The standard care provided in this protocol is based on guidelines and recommendations from 
experts in the field of diabetic foot ulcer care. The initial aggressive debridement in an operating 
room is considered best practice for the type of wounds being studied, which extend to deep 
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5.1 INCLUSION CRITERIA 
 
In order to be eligible to participate in this study, an individual must meet all of the following 
criteria: 
1. The subject has signed the informed consent form 
2. The subject is male or female, at least 18 years of age inclusive at the date of Screening 
3. The subject has confirmed diagnosis of Type I or Type II diabetes 
4. The subject’s index ulcer is located on the plantar surface, inter digital, heel, or lateral or 
medial surface of the foot 
5. The subject has an index ulcer with visible margins having an area ≥1.0 cm2 to ≤ 10.0 cm2 
when measured by the electronic measuring device at Screening 
6. The subject’s index ulcer extends beyond the dermis, into subcutaneous tissue with 
evidence of exposed bone, tendon, muscle and/or joint capsule 
7. The subject presents with history, signs or symptoms leading to a clinical suspicion of 
osteomyelitis in the opinion of the Investigator supported by positive Probe to Bone (PTB) 
and any of the following: radiographic (x-ray, Magnetic Resonance Imaging (MRI), or 
bone scan) or evidence of bone necrosis 
8. The subject has an ABI ≥ 0.7 to ≤ 1.3 or TcPO2 ≥ 40 mmHg on the dorsum of the affected 
foot, or Great Toe Pressure ≥ 50 mmHg 
9. The subject is under the care of a physician for the management of Diabetes Mellitus  
10. The subject is willing to return for all mandatory visits as defined in the protocol  
11. The subject is willing to follow the instructions of the trial Investigator 
 
5.2 EXCLUSION CRITERIA 
 
An individual who meets any of the following criteria will be excluded from participation in this 
study: 
1. The subject’s index ulcer is primarily located on the dorsal surface of the foot 
2. The subject’s index ulcer can be addressed by primary closure through the completion of 
the initial or staged surgical procedure 
3. The subject has a glycated hemoglobin A1c (HbA1c) level of > 12% 
4. The subject has a serum albumin level ≤ 2.0 g/dL 
5. The subject has a white blood cell count < 2.0 x109/L, neutrophils < 1.0 x109/L, or platelets 
< 100 x109/L 
6. The subject has been on oral steroid use of > 7.5 mg daily for greater than seven (7) 
consecutive days in 30 days before Screening 


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7. The subject has been on parenteral corticosteroids, or any cytotoxic agents for seven 
consecutive days in the period of 30 days before Screening  
8. The subject is currently taking the type 2 diabetes medicine canagliflozin (Invokana™, 
Invokamet™, Invokamet XR™) 
9. The subject has malignancy or a history of cancer, other than non-melanoma skin cancer, 
in five years before Screening  
10. The subject is pregnant  
11. The subject is a nursing mother 
12. The subject is a woman of child-bearing potential who is unwilling to avoid pregnancy or 
use an appropriate form of birth control (adequate birth control methods are defined as: 
topical, oral, implantable, or injectable contraceptives; spermicide in conjunction with a 
barrier such as a condom or diaphragm; IUD; or surgical sterilization of partner). 
13. The subject is unable to sustain offloading as defined by the protocol 
14. The subject has an allergy to primary or secondary dressing materials used in this trial 
15. The subject has an allergy to Amphotericin B, Dulbecco’s Modified Eagle Medium 
(DMEM) or glycerol 
16. The subject’s index ulcer is over an acute Charcot deformity 
17. The subject has had previous use of NEOX®, CLARIX®, or TTAX01 applied to the index 
ulcer 
18. Per Investigator’s discretion the subject is not appropriate for inclusion in the trial, e.g., 
undergoing surgical treatments listed in the protocol or the subject currently has sepsis, i.e., 
life-threatening organ dysfunction caused by a dysregulated host response to infection 
 
5.3 LIFESTYLE CONSIDERATIONS 
 
Subjects are expected to maintain ongoing care and management of their diabetes under the 
supervision of a qualified diabetologist, endocrinologist or internist with appropriate specialty 
training and experience. The need for offloading of the wound requires compliance with daily 
wearing of the offloading device, which may limit ambulation to some degree. 
 
5.4 SCREEN FAILURES 
 
Screen failures are defined as potential subjects who consent to participate in the trial but are not 
subsequently entered. Screen failure information will be captured to ensure transparent reporting 
of screen failure participants, to meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements and to respond to queries from regulatory authorities. Minimal 
information includes demography, screen failure details, eligibility criteria, and any serious 
adverse event (SAE). 
 
Individuals who do not meet the criteria for participation in this trial because of an abnormal lab 
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Handling Instructions for the test article are as follows: 
  
1. If frozen, allow TTAX01 to sit at controlled room temperature in its original unopened 
packaging for at least 5 minutes. 
2. Open the outer foil peel pouch and present the clear inner peel pouch to the sterile field 
using aseptic techniques. 
3. Open the inner clear peel pouch to retrieve the TTAX01. 
4. Secure the TTAX01 on the wound bed. 
 
6.3 MEASURES TO MINIMIZE BIAS 
 
The trial is open label, with no blinding of the site staff. All eligible subjects will be enrolled into 
a single active treatment arm. The determination of wound closure will be made by the Investigator 
based on visual and tactile assessment of the wound. High quality photographic images will be 
taken at each visit, from an angle and distance recommended for optimum computerized 
calculation of wound area. In the event that the Investigator determines that a wound is completely 
healed, several additional images will be acquired at different angles in order to observe surface 
reflection of light from newly formed epithelium, and the absence of exudate. An independent 
reviewer will examine the first photographic image in order to make a determination of wound 
closure. If this opinion is concordant with the Investigator’s opinion, the wound will be recorded 
as healed. If the independent reviewer finds reason to disagree with the Investigator, a third 
independent reviewer will examine all of the photographs for the purpose of breaking the tie.  
 
6.4 STUDY INTERVENTION COMPLIANCE 
 
The Investigator is responsible for ensuring that the treatment and follow-up procedures are 
followed as laid out in this protocol, unless a deviation is needed to protect the health and welfare 
of a subject.  Such deviations should promptly be reported to the Sponsor or their designee and 
may also require reporting to the IRB.   
 
Protocol compliance by the Investigator and site staff will be monitored by routine site visits 
conducted by the Sponsor, the frequency of which will be determined by any findings of issues as 
outlined in a separate detailed monitoring plan. All subjects will be provided with instructions 
which may include written materials on how to off-load correctly. Subject compliance will be 
based on observation of the offloading device at each visit for evidence of wear, by queries 
regarding excluded concomitant medications / therapies, and queries regarding dosing of any 
antibiotics. No blood testing or other test procedure will be utilized for determination of 
compliance. Diaries will not be used. 
 
 


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6.5 CONCOMITANT THERAPY 
 
Systemic anti-microbials may be used as prescribed. Wound cleansing with a neutral, non-
irritating and non-toxic solution is recommended at the discretion of the Investigator. Sterile saline, 
non-ionic cleanser, or hypochlorous acid are recommended. 
Canagliflozin, a type 2 diabetic medication, also referred to as Invokana, Invokamet, and 
Invokamet XR, is not permitted throughout the duration of the screening, treatment and 
confirmation of closure periods. 
Concomitant therapies for treating the index ulcer other than those defined in the protocol will not 
be permitted during the treatment and confirmation of closure period. They include topical 
antibiotics, antiseptic agents including hydrogen peroxide, acetic acid, chlorhexidine, 
povidone/iodine, and cetrimide, enzymes, negative pressure wound therapy, hyperbaric oxygen, 
growth factors, living skin, dermal substitutes, silver-containing products, amniotic membrane or 
umbilical cord products or other advanced biological therapies, or revascularization procedures 
(e.g., endoscopic perforator surgery, superficial venous ablation, endovenous laser ablation, 
valvuloplasty, free flap transfer with microvascular anastomoses), and Achilles tendon 
lengthening. 
6.5.1 RESCUE MEDICINE 
 
Not applicable. 
 
7 
STUDY 
INTERVENTION 
DISCONTINUATION 
AND 
PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
  
7.1 DISCONTINUATION OF STUDY INTERVENTION 
 
Given that the manufacturing method of the test article is similar to the commercial product 
NEOX® CORD 1K®, which has an outstanding safety record, there is no a priori expectation of 
needing to suspend or terminate the trial for unexpected adverse events.  
 
7.2 PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
 
All subjects have the right to discontinue the trial at any time. The Investigator may also withdraw 
a subject from the trial at any time if they deem it medically necessary. The reason for 
discontinuation should be documented and trial staff should attempt to bring the subject in for an 
Early Termination Visit and perform all applicable assessments as appropriate listed under the End 
of Treatment Period Visit (Visit 19) for discontinuations that occur during the Treatment Period. 
Subjects may be discontinued from the trial for the following reasons: 
• 
Adverse Event (including illness) 


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• 
Subject withdrawal of consent 
• 
The Sponsor or Investigator terminates the trial 
• 
Lost to follow-up 
• 
Product-related > Grade 2 skin or systemic allergic reaction 
• 
Ulcer-related complications (i.e., life-threatening, infection-related sepsis complications) 
• 
Subsequent limb amputation (i.e., full amputation involving the index ulcer anatomic 
location) 
 
In the event of a subject’s withdrawal, the Investigator will promptly notify the medical monitor 
and will make every effort to complete all procedures at either the End of Treatment Period Visit. 
Even if removed subjects have been removed from the trial or if an adverse event remains ongoing, 
Investigators should follow up with subjects as per their standard medical practice. 
Discontinued subjects will not be replaced.  Simultaneous screening at multiple sites may result in 
an allowable modest over-enrollment. 
7.3 LOST TO FOLLOW-UP 
 
If a subject is lost to follow-up, a minimum of three documented contact attempts including one 
certified letter should be in the records. If there is not contact made by the subject after sending 
the certified letter, the next of kin and the physician responsible for managing the subject’s diabetes 
should be contacted to obtain information about the subject’s current health status. 
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 STUDY ACTIVITIES BY VISIT 
 
8.1.1 SCREENING PERIOD (WITHIN -7 DAYS FROM INITIAL PROCEDURE 
VISIT) 
 
[Purpose]: To determine the trial eligibility by assessing all inclusion/exclusion criteria based on 
the medical information available, clinical assessment, clinical laboratory testing, imaging studies 
and interview with subject. 
Each subject who enters Screening will be assigned a subject ID number for traceability.  The 
subject ID will consist of a 2-digit site number and a 3-digit subject number (i.e. 01-001, etc.). 
Any subject who signs an informed consent, but fails to meet the required eligibility criteria is 
considered to be a Screen Failure. Screen Failure subjects should have their demographic 
information captured with the reason for screen failure specified. If a subject fails to meet all 
criteria after two screening attempts, the subject may not be enrolled into the trial. A new informed 
consent is required for each screening attempt. All procedures, excluding qualifying lab and 
















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Figure 3. Treatment if there is no SSTI observed 
 
 
 
 
 
Figure 4.  Treatment if SSTI is observed without recurrence of clinical suspicion of osteomyelitis 
 
 
Figure 5. Treatment if SSTI is observed with clinical suspicion of osteomyelitis 
 
 






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An Adverse Event is any untoward medical occurrence temporally associated with the use of an 
investigational medicinal product, whether or not considered causally related to that product. An 
AE can be any unfavorable and unintended sign (for example, an abnormal laboratory finding), 
symptom, or disease. The Investigator, or his/her designee, will document AEs.  AE data will be 
entered onto the appropriate source and electronic case report form (eCRF). Adverse events will 
be coded using Medical Dictionary for Regulatory Activities (MedDRA). 
All AEs should be followed during the trial period. The Investigator should use his/her discretion 
in ordering additional tests as necessary to monitor the resolution of such events. Event outcome 
at resolution or at time of last follow up will be recorded as event resolved, resolved with sequelae, 
ongoing at discontinuation, or death. Investigators should continue to follow up events of concern 
outside of the trial per their standard of care. The trial database may be finalized in these cases 
with events noted as ongoing. 
The Investigator should consider adverse events both as they relate to the investigational product 
and as they relate to the procedures involved in the trial such as debriding tissue. The Investigator 
is responsible for determining initial relationship, expectedness, and severity of adverse events. 
All adverse events must be reported regardless of whether or not they are considered to be related 
to the test article. 
 
8.4.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
 
A serious adverse event (SAE) is defined by federal regulation as any AE occurring at any dose 
that results in any of the following outcomes: death, life-threatening AE, requires hospitalization 
or prolongation of existing hospitalization, a persistent or significant disability/incapacity, or a 
congenital anomaly/birth defect. 
Important medical events that may not result in death, be life threatening, or require hospitalization 
may be considered an SAE when, based upon appropriate medical judgment, they may jeopardize 
the subject and may require medical or surgical intervention to prevent one of the outcomes listed 
in this definition. Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in subject hospitalization, or the development of drug dependency or drug abuse. 
 
8.4.3 CLASSIFICATION OF AN ADVERSE EVENT 
 
8.4.3.1 SEVERITY OF EVENT 
 
The severity of all AE, will be assessed by the Investigator and should be classified as mild, 
moderate, or severe.  Severity will be graded according to the following definitions: 


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• Mild: The subject experiences awareness of symptoms but these are easily tolerated or 
managed without specific treatment. 
• Moderate: The subject experiences discomfort enough to cause interference with usual 
activity, and/or the condition requires specific treatment. 
• Severe: The subject is incapacitated with inability to work or do usual activity, and/or the 
event requires significant treatment measures. 
 
8.4.3.2 RELATIONSHIP TO STUDY INTERVENTION 
The relationship of the event to the investigational product should be determined by the Principal 
Investigator according to the following criteria: 
Not Related: The event is most likely produced by other factors such as the subject’s clinical 
condition, intercurrent illness, or concomitant drugs, and does not follow a known response 
pattern to the trial product which makes a causal relationship unlikely. 
Related: The event follows a temporal relationship or known response pattern to the trial 
product, and cannot be reasonably explained by other factors such as the subject's clinical 
condition, intercurrent illness, or concomitant drugs.   
 
8.4.3.3 EXPECTEDNESS  
 
As with the use of any human tissue, the possibility of infectious agent transmission cannot be 
completely eliminated although all screening and microbial testing results were satisfactory for the 
tissue and tissue donor. Possible significant adverse events include microbial infection and 
transmission of viral disease. 
 
Expected adverse events non-related to the product are those post-surgical conditions consistent 
with any dermal debridement and excoriation of an ulcer. Potential adverse events for all research 
subjects in this trial intrinsic to the nature of DFUs: bleeding, hematoma, cellulitis, pain, 
deteriorating ulcer exudation, erythema, edema, infections including deep tissue infections 
(osteomyelitis), and occurrence of new ulcers. 
8.4.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention 
of study personnel during study visits and interviews of a study participant presenting for medical 
care, or upon review by a study monitor. 
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured 
on the appropriate case report form (CRF). Information to be collected includes event description, 
date of onset, clinician’s assessment of severity, relationship to study product (assessed only by 
those with the training and authority to make a diagnosis) confirmed by the Principal Investigator, 


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and date of resolution/stabilization of the event. All AEs occurring while on study must be 
documented appropriately regardless of relationship.  
 
Any medical condition that is present at the time that the participant is screened will be considered 
as baseline medical history and not reported as an AE. However, if the study participant’s condition 
deteriorates at any time during the study, it will be recorded as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the 
event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
 
The Investigator will record all reportable events with start dates occurring any time after informed 
consent is obtained until the final study visit.  At each study visit, the investigator will inquire 
about the occurrence of AE/SAEs since the last visit.  Event outcome at resolution or at time of 
last follow up will be recorded as “event resolved”, “resolved with sequelae”, “ongoing at 
discontinuation”, or “death”. 
 
8.4.5 ADVERSE EVENT REPORTING  
 
Disease Related Events expected in this population (angina, neuropathy, nephropathy, urinary tract 
infection, erectile dysfunction, retinopathy, hypoglycemic events) may be reported by the 
investigator if they differ in nature or frequency from what is expected, or if they appear to have a 
causal relationship to the test article. All adverse events must be reported in the subject’s source 
documents, and recorded on an Adverse Event Case Report Form regardless of whether or not they 
are considered to be related to the test article.    
 
8.4.6 SERIOUS ADVERSE EVENT REPORTING  
 
In the event of any SAE reported or observed during the trial, whether or not attributable to the 
trial product, the Investigator, or designee, shall report the event to the medical monitor within 24 
hours being made aware of the event.  An initial report should be made with the understanding that 
it may be lacking in details.   
A Serious Adverse Event Form must be completed for all serious adverse events and submitted 
within 24 hours of the Investigator's knowledge of the event and to the Institutional Review 
Board/Independent Ethics Committee, according to their reporting requirements. When new 
significant information is obtained as well as when the outcome of an event is known, the 
Investigator must provide this information as soon as it becomes available. Depending on the 
nature of the adverse event, copies of the subject’s medical records as well as results of any relevant 
laboratory tests performed maybe required to be submitted. If the subject was hospitalized, a copy 
of the discharge summary should be forwarded as soon as it becomes available. In certain cases, a 
letter from the Investigator that summarizes the events related to the case may be required. 
Serious adverse events must be reported using the eCRF system (preferred), or via telephone or 
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Not applicable. 
 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 STATISTICAL HYPOTHESES 
 
This pilot study will utilize descriptive statistics in the analysis and reporting of observed 
outcomes, to be described in greater detail in a separate Statistical Analysis Plan. 
 
9.2 SAMPLE SIZE DETERMINATION 
 
It is expected that 47 potential subjects will be screened in order to find 36 who qualify for this 
trial (screen failure rate 30%). The target number 36 is selected based on the law of large numbers, 
which holds that sample sizes less than 25 are more likely to produce skewed distributions of 
observed values, while sample sizes greater than 25 should generate a bell shaped distribution of 
observed values whose mean approaches the expected value as sample size increases.  
The dropout rate is expected to be ~10%. As numbers between 25 and 30 should yield reasonably 
equivalent estimates of efficacy, there is no plan to replace dropouts. 
 
9.3  POPULATIONS FOR ANALYSES 
 
The Intent-to-Treat (ITT) population will consist of all enrolled subjects. The ITT population is 
the primary efficacy population and will be used to conduct all analyses on primary and secondary 
efficacy endpoints. 
The Per Protocol (PP) population is a subset of subjects in the ITT and is the secondary efficacy 
population.  The PP population will be defined as all qualified and treated subjects meeting 
inclusion and exclusion criteria and completing the study treatment as planned in the protocol, 
with no major protocol deviations during the 16-week Treatment Period. Major protocol deviations 
will be determined by the trial clinical team prior to database lock. Subjects found to have major 
protocol deviations will be excluded from the PP population. 
The Safety Population includes all subjects who underwent treatment, regardless of protocol 
compliance. The Safety Population will be used for the analysis of safety endpoints. 
 
9.4 STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
 
Categorical data will be presented as percentages. Continuous data will be presented as means ± 
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(f) Those aspects of the trial that are experimental. 
 
(g) The reasonably foreseeable risks or inconveniences to the subject and, when applicable, to an 
embryo, fetus, or nursing infant. 
 
(h) The reasonably expected benefits. When there is no intended clinical benefit to the subject, the 
subject should be made aware of this. 
 
(i) The alternative procedure(s) or course(s) of treatment that may be available to the subject, and 
their important potential benefits and risks. 
 
(j) The compensation and/or treatment available to the subject in the event of trial-related injury. 
 
(k) The anticipated prorated payment, if any, to the subject for participating in the trial. 
 
(l) The anticipated expenses, if any, to the subject for participating in the trial. 
 
(m) That the subject’s participation in the trial is voluntary and that the subject may refuse to 
participate or withdraw from the trial, at any time, without penalty or loss of benefits to which the 
subject is otherwise entitled. 
 
(n) That the monitor(s), the auditor(s), the IRB/IEC, and the regulatory authority(ies) will be 
granted direct access to the subject’s original medical records for verification of clinical trial 
procedures and/or data, without violating the confidentiality of the subject, to the extent permitted 
by the applicable laws and regulations and that, by signing a written informed consent form, the 
subject or the subject’s legally acceptable representative is authorizing such access. 
 
(o) That records identifying the subject will be kept confidential and, to the extent permitted by 
the applicable laws and/or regulations, will not be made publicly available. If the results of the 
trial are published, the subject’s identity will remain confidential. 
 
(p) That the subject or the subject’s legally acceptable representative will be informed in a timely 
manner if information becomes available that may be relevant to the subject’s willingness to 
continue participation in the trial. 
 
(q) The person(s) to contact for further information regarding the trial and the rights of trial 
subjects, and whom to contact in the event of trial-related injury. 
 
(r) The foreseeable circumstances and/or reasons under which the subject’s participation in the 
trial may be terminated. 
 
(s) The expected duration of the subject’s participation in the trial. 
 
(t) The approximate number of subjects involved in the trial. 
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 


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Consent forms will be Institutional Review Board (IRB)-approved and the participant will be asked 
to read and review the document. The investigator will explain the research study to the participant 
and answer any questions that may arise. A verbal explanation will be provided in terms suited to 
the participant’s comprehension of the purposes, procedures, and potential risks of the study and 
of their rights as research participants.  Participants will have the opportunity to carefully review 
the written consent form and ask questions prior to signing. The participants will have the 
opportunity to discuss the study with their family or surrogates or think about it prior to agreeing 
to participate. Participants will be informed that participation is voluntary and that they may 
withdraw from the study at any time, without prejudice. A copy of the informed consent document 
will be given to the participants for their records. The informed consent process will be conducted 
and documented in the source document (including the date), and the form signed, before the 
participant undergoes any study-specific procedures. The rights and welfare of the participants will 
be protected by emphasizing to them that the quality of their medical care will not be adversely 
affected if they decline to participate in this study. 
 
 
Only authorized trial staff should obtain consent and the most currently approved IRB consent 
form must be used. 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
 
The trial may be terminated at any time by the Sponsor if serious side effects occur, if the 
Investigator does not adhere to the protocol, or if, in the Sponsor’s judgment, there are no further 
benefits to be achieved from the trial. In the event that the clinical development of the 
investigational product is discontinued, the Sponsor shall inform all trial Investigators/institutions 
and regulatory authorities. 
To ensure subject safety, the following approach is included to allow suspension or termination of 
the trial should a serious unforeseen risk arise: in the event that there are 2 reports of the same 
serious, unexpected and related adverse event, the Medical Monitor will within 5 calendar days of 
notification of the second event make a recommendation to Sponsor senior management  whether 
to enhance surveillance, suspend enrollment, halt all further exposures, terminate the trial or 
continue without change. 
If suspended, the trial may resume once concerns about safety, protocol compliance, and data 
quality are addressed, and satisfy the sponsor, IRB and/or FDA. 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
 
Subject confidentiality and privacy is strictly held in trust by the participating investigators, their 
staff, and the sponsor. This confidentiality is extended to cover testing of biological samples in 
addition to the clinical information relating to subjects. Therefore, the study protocol, 
documentation, data, and all other information generated will be held in strict confidence. No 
information concerning the study or the data will be released to any unauthorized third party 
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Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site investigator. Refer to the eCRF completion guidelines for eCRF completion, correction, and 
transmission procedures. The investigator is responsible for ensuring the accuracy, completeness, 
legibility, and timeliness of the data reported.  
 
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data. Hardcopies of study visit worksheets may be provided for use as source 
document worksheets for recording data for each participant enrolled in the study.  Data recorded 
in the electronic case report form (eCRF) derived from source documents should be consistent 
with the data recorded on the source documents.  
 
Clinical data (including adverse events (AEs), concomitant medications, and expected adverse 
reactions data) and clinical laboratory data will be entered via eDC into iMedNet, a 21 CFR Part 
11-compliant data capture system provided by MedNet Solutions. The data system includes 
password protection and internal quality checks, such as automatic range checks, to identify data 
that appear inconsistent, incomplete, or inaccurate. Clinical data will be entered directly from the 
source documents. 
 
10.1.9.2 STUDY RECORDS RETENTION  
 
All records and documents pertaining to the trial including, but not limited to, data and source 
documents, will be maintained by the Investigator for a period of 10 years after completion of the 
trial or for a period of at least 2 years following the removal of an IND, whichever is longer. If the 
Investigator retires, relocates, or for any other reason withdraws from responsibility of keeping the 
study records, custody must be transferred to the Sponsor or to a person who will accept 
responsibility and is approved by the Sponsor. In order to avoid any possible errors, the 
Investigator will contact the Sponsor prior to the destruction of any trial records.  The Investigator 
will promptly notify the Sponsor in the event of accidental loss or destruction of any trial records. 
 
10.1.9.3 PROTOCOL DEVIATIONS  
 
A protocol deviation is any noncompliance with the clinical trial protocol or ICH GCP 
requirements. The noncompliance may be either on the part of the participant, the investigator, or 
the study site staff. As a result of serious or repeated deviations, corrective and preventative actions 
are to be developed by the site and implemented promptly.  
 
It is the responsibility of the site investigator to use continuous vigilance to identify and report 
deviations. The Investigator may not deviate from the protocol without a formal protocol 
amendment having been established and approved by the Sponsor and an appropriate IRB, except 
when necessary to eliminate imminent hazards to the patient or when the change(s) involve only 
logistical or administrative aspects of the trial. A deviation may result in the patient having to be 
withdrawn from the trial, rendering that patient non-evaluable. 
 
10.1.9.4 PUBLICATION AND DATA SHARING POLICY 
 


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Agreements regarding publication and data sharing are found in the individual Clinical Trial 
Agreements between the Sponsor and each Investigator. At a minimum, the trial and its results 
will be posted on ClinicalTrials.Gov. 
 
10.1.9.5 CONFLICT OF INTEREST POLICY 
 
Each investigator will be asked to complete a financial disclosure prior to the initiation of this 
study, and one year following database lock. 
 
10.2 ADDITIONAL CONSIDERATIONS 
 
None. 
 
 
 


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10.3 ABBREVIATIONS 
 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CONSORT Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DRE 
Disease-Related Event 
EC 
Ethics Committee 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FFR 
Federal Financial Report 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
HIPAA 
Health Insurance Portability and Accountability Act  
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation  
ICMJE 
International Committee of Medical Journal Editors 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
MedDRA 
Medical Dictionary for Regulatory Activities 
MSDS 
Material Safety Data Sheet 
NCT 
National Clinical Trial 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SC 
Standard Care 
SMC 
Safety Monitoring Committee 
SOA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
SSTI 
Skin & Soft Tissue Infections 
UP 
Unanticipated Problem 
US 
United States 
 
 
 


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10.4 PROTOCOL AMENDMENT HISTORY 
 
Version 
Date 
Description of Change  
Brief Rationale 
1.0 
01JUN2017 Original issue 
 
1.1 
24Jan2018 
Amendment #1 
Updates to the protocol were 
made 
to 
improve 
the 
implementation 
and 
execution of the pilot trial 
across all clinical sites 
 
 
 
















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13 INVESTIGATOR SIGNATURE 
Study Title: 
A Multicenter, Open Label Phase 2 Pilot Trial of Subjects with 
Complex Non-healing Diabetic Foot Ulcers Treated with Standard 
Care plus Cryopreserved Umbilical Cord Allograft (TTAX01) 
Study Number: 
TTCRNE- 1501 
 
Amendment Version 
Date: 
 
05 February 2018 
By my signature, I confirm that my staff, and I have carefully read and understand this protocol, 
and agree to comply with the conduct and terms of the trial specified herein.  In particular, I/we 
have agreed to: 
 
1. 
Abide by all obligations stated in the Clinical Trial Agreement (Contract) 
2. 
Maintain confidentially and assure security of all confidential documents such as the 
protocol, product information documents, final trial reports, manuscript drafts, unpublished 
data, correspondence, etc. 
3. 
Assure access by the Sponsor representatives to original source documents and medical 
records.  
4. 
Obtain Institutional Review Board approval of trial, any amendments to the trial, recruitment 
advertisements, informed consent document, and periodic re-approval as required. 
5. 
Keep the Institutional Review Board and Sponsor informed of serious adverse events and 
periodically report status of the trial to them as required. 
6. 
Obtain written informed consent from each participant or his/her legal representative. 
7. 
Make immediate reports of serious adverse events (SAE) to the Sponsor or designee. 
8. 
Cooperate fully with any trial-related Good Clinical Practice audit as performed by the 
Sponsor’s representatives. 
9. 
Abide by manuscript preparation/authorship guidelines established at the outset of the trial. 
 
 
Investigator’s Signature: 
___________________________________________ 
Investigator’s Name (please print):  ___________________________________________ 
Date: 
___________________________________________ 
 

SAP_001.pdf: 
 
 
 
 
 
 
SAP: TTCRNE-1501: A Multicenter, Open Label Phase 2 Pilot Trial of Subjects with Complex Non-
healing Diabetic Foot Ulcers Treated with Standard Care plus Cryopreserved Umbilical Cord 
Allograft (TTAX01) 
 
NCT03230175 
 
Version 1.0 (08Nov2017) 




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STATISTICAL ANALYSIS PLAN 
 
ABBREVIATIONS AND DEFINITIONS ................................................................................. 4 
1 
INTRODUCTION .......................................................................................................... 5 
1.1 
Trial Objectives ....................................................................................................... 5 
1.2 
Background Information .......................................................................................... 5 
2 
STUDY DESIGN ........................................................................................................... 6 
2.1 
Rationale................................................................................................................. 6 
2.2 
Description of Trial Design ...................................................................................... 6 
2.3 
Schedule of Assessments ....................................................................................... 7 
2.4 
Randomization .......................................................................................................10 
2.5 
Sample Size Estimation .........................................................................................10 
2.6 
Efficacy and Safety Measurements ........................................................................10 
2.6.1 
Primary efficacy measure .......................................................................................10 
2.6.2 
Secondary efficacy measure ..................................................................................10 
2.6.3 
Safety measures ....................................................................................................11 
2.6.4 
Other measures .....................................................................................................12 
2.7 
Drug Concentration and PK Measurements ...........................................................12 
2.8 
Handling of Missing, Incomplete, and Repeat Data ................................................12 
2.9 
Statistical Methods .................................................................................................13 
2.9.1 
Primary efficacy analysis ........................................................................................14 
2.9.2 
Secondary efficacy analysis ...................................................................................15 
2.9.3 
Planned Interim Analysis ........................................................................................15 
2.9.4 
Safety analysis .......................................................................................................16 
2.9.5 
Other analysis ........................................................................................................17 
3 
STUDY POPULATION ................................................................................................18 
3.1 
Definition of Subject Populations ............................................................................18 
3.2 
Screening and Enrollment ......................................................................................18 
3.3 
Population Demography .........................................................................................18 
3.4 
Disease Characteristics and Prior Treatment .........................................................18 
3.5 
Medical History ......................................................................................................19 
3.6 
Disposition of Study Participants ............................................................................19 
3.7 
Protocol Deviations and Violations .........................................................................19 
4 
EFFICACY EVALUATION ...........................................................................................19 
4.1 
Datasets Analyzed .................................................................................................19 
4.2 
Treatment Compliance ...........................................................................................19 
4.3 
Data Missing and Imputation ..................................................................................19 
4.4 
Baseline Measures ................................................................................................20 
4.5 
Efficacy Results and Tabulations ...........................................................................20 
4.5.1 
Results of primary efficacy analysis .......................................................................20 
4.5.2 
Results of secondary efficacy analyses ..................................................................20 
5 
SAFETY EVALUATION ..............................................................................................20 
5.1 
Extent of Drug Exposure ........................................................................................20 
5.2 
Early Termination ...................................................................................................21 
5.3 
Adverse Events ......................................................................................................21 
5.4 
Physical Examination .............................................................................................21 


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5.5 
Clinical Laboratory Evaluation ................................................................................22 
5.6 
Concomitant Medication .........................................................................................22 
6 
REFERENCES ............................................................................................................23 
7 
LIST OF STATISTICAL TABLE SHELLS ...................................................................24 
8 
LIST OF KEY LISTING SHELLS .................................................................................26 
9 
LIST OF FIGURES ......................................................................................................27 
10 
LIST OF CRF DATA TABULATIONS .........................................................................27 
 
 


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ABBREVIATIONS AND DEFINITIONS  
 
AE 
Adverse Event 
ANOVA 
Analysis of Variance 
ANCOVA 
Analysis of Covariance 
BS 
Baseline 
CI 
Confidence Interval 
CMH 
Cochran-Mantel-Haenszel Test 
CRF 
Case Report Form 
DFU 
Diabetic Foot Ulcers 
EOS 
End of Study 
EOT 
End of Treatment 
ET 
Early Termination 
HRQoL 
Heath-Related Quality of Life 
IWRS 
Interactive Web-Based Response System  
ITT 
Intention to Treat 
LOCF 
Last Observation Carried Forward 
LS 
Least Square 
MedDRA 
Medical Dictionary for Regulatory Activities 
PK 
Pharmacokinetics 
PP 
Per protocol 
SAE 
Serious Adverse Event 
SD 
Standard Deviation 
SC 
Standard Care 
TEAE 
Treatment Emergent Adverse Event 
WC 
Worst-Case 
 
 
 


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1 
INTRODUCTION 
1.1 
Trial Objectives 
The primary objective of this study is to examine the safety and estimate the efficacy of 
TTAX01 plus standard care (SC) in achieving complete wound closure of complex non-
healing diabetic foot ulcers (DFU) with high risk factors of [1] ulcer depth indicating exposed 
bone, tendon, muscle, and/or joint capsule and [2] clinical suspicion of osteomyelitis.   
 
This document describes the statistical analysis methods and data presentations for the data 
analyses of Protocol TTCRNE-1501. Related documents to this SAP are the study protocol 
and case report form (CRF).  Data analysis will be based on the final dataset(s) provided by 
Sponsor or designee Data Management group. The study database(s) includes all of the 
CRF-based clinical data and all of central laboratory data.   
 
1.2 
Background Information 
One of the most prevalent complications of diabetes is the diabetic foot ulcer in the lower 
extremity. Foot ulceration is the most common single precursor of lower extremity 
amputations among persons with diabetes and is a precursor, especially the non-healing foot 
ulcers, to approximately 85% of the lower extremity amputations within this population. 
 
Three major risk factors, including (1) ulcer depth, (2) infection, and (3) ischemia, have been 
recognized to complicate non-healing foot ulcers leading to limb amputation. Contiguous 
spread of any infection of adjacent soft tissue into the bone of the foot may complicate the 
ulcer, predisposing the patient to risk of osteomyelitis. 
 
Cell- or tissue-based skin substitutes are able to initially cover the non-healing foot ulcer 
while the cellular or tissue components may secrete or provide growth factors or structures 
that stimulate the host’s cells, thereby promoting healing activity. Currently marketed cell- or 
tissue-based treatment therapies include Apligraf® and Dermagraft®, with both products 
combining allogeneic human epidermal and dermal cells.  
 
TissueTech, Inc. is developing a tissue-based skin therapy (code named as TTAX01). 
TTAX01 is a cryopreserved human umbilical cord (UC) product aseptically processed with 
the patented CRYOTEK® process in compliance with current Good Tissue Practices (cGTP) 
from donated human placenta tissues following healthy, live, caesarian section, full-term 
births after determination of donor eligibility and placenta suitability. The CRYOTEK® process 
inactivates the cell activity in the tissue1 to eliminate the possibility of graft rejection while 
retaining the natural properties. In clinical, this cryopreserved human UC product has been 
used for the treatment of chronic non-healing wounds. 
 
This Phase II single-arm and open-label pilot trial will focus on the subgroup of diabetic foot 
ulcers that are defined as complex with the ulcer depth showing exposed bone, tendon, 
muscle and/or joint capsule, as well as infection as indicated by clinically suspicious 
osteomyelitis defined by positive probe-to-bone and positive radiographic (X-ray, MRI, or 
bone scan) of adjacent bone necrosis. 
 


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2 
STUDY DESIGN 
2.1 
Rationale 
Cell- or tissue-based skin substitutes are able to initially cover the wound while the cellular or 
tissue components may secrete or provide growth factors or cellular structures that stimulate 
or support the host’s cells, thereby promoting healing activity. TTAX01 is a tissue-based skin 
therapy for treatment of DFU. 
 
2.2 
Description of Trial Design 
This is a multi-center, Phase 2, open-label and single-arm pilot study of the safety and 
efficacy with TTAX01 plus SC treatment in subjects with a complex diabetic foot ulcer (DFU), 
ranging in size from 1.0 o 10.0 cm2, with exposed bone, tendon, muscle and/or joint capsule 
and clinically suspicious osteomyelitis defined as positive probe to bone (PTB) and positive 
radiographic (x-ray, MRI, or bone scan) evidence of adjacent bone necrosis. 
 
The study consists of a screening visit and two periods, including a 16-week open-label 
treatment period with an Initial Procedure Visit/baseline and 16 weekly visits (Visit 01 through 
Visit 16), and a 4-week confirmatory assessment period of closed wound with 2 weekly visits 
(Visits 17 and 18) and a bi-weekly visit (Visit 19, which also serves as the end-of-treatment 
visit for the efficacy evaluation).   
 
Following the screening visit, approximately 36 subjects meeting entry criteria will be enrolled 
in the study at the Initial Procedure Visit (Visit BS/baseline) to receive the care for the index 
ulcer of TTAX01 plus SC for 16 weeks (Visits 01 thru 16).  At each visit, all subjects will 
receive the SC treatment, and will receive the TTAX01 application on the baseline visit (Visit 
BS) or following the last surgical sharp debridement and bone resection, if a staged surgical 
procedure is performed; and, subjects will receive the TTAX01 application(s) on the 
subsequent visits (Visits 01 thru 15) per the guidelines of TTAX01 treatment described in 
details in the study protocol. 
 
Subjects’ identified index ulcer will be assessed over the course of the treatment visits (Visit 
BS and Visits 1 through 16) or until their ulcers close. Subjects whose ulcers have closed, as 
assessed by the investigator and verified by an independent blinded evaluator using the 
images collected via the electronic wound imaging and measurement device, prior to the 16th 
week of treatment (or Visit 15) will stop treatment and return for two consecutive weekly visits 
(i.e., Visits 17, and 18) to verify if the target ulcer remains closed at these two visits following 
the initial observation of ulcer closure, which is defined as the complete ulcer closure in this 
study. Two weeks after the 2nd confirmatory visit (Visit 18), subjects with index ulcer 
remained as closed at Visits 17 and 18 will return and complete an End of Treatment Period 
visit (Visit 19). Subjects whose ulcers have not closed at the end of the 16-week treatment 
(i.e., Visit 16) or whose ulcers have re-opened during the confirmatory visits (Visits 17 and 
18) will move on directly to complete the assessments of Visit 19.  Visit 19 will serve as the 
study’s End of Treatment (EOT) visit for the treatment and ulcer closure confirmatory period 
and will also serve as study exit visit.   
 
For those subjects who are enrolled and discontinue from the treatment prior to Visit 16 due 
to any reasons other than target ulcer closure, Visit 19 will serve as the early termination 
(ET) visit. 
 


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The total duration of study starting from enrollment to the end of the treatment period is 16 
weeks, during which time adverse events and ulcer-related complications, including limb 
amputation are assessed. 
 
The status and size of the index ulcer will be assessed for each subject at screening visit, 
initial visit (Visit BS), Visits 01 thru 15, Visit 16 (for the ulcer assessment only), Visits 17 and 
18 (confirmation of complete ulcer closure).  At the initial visit (Visit BS), eligible subjects will 
receive ulcer care of TTAX01 plus SC performed by the Investigator or a designated 
physician at the clinic unit. The test article consists of validated inner clear pouch that is 
placed inside an outer foil pouch that is pre-packaged. The open-label treatment period 
consists of 16 weeks, during which the subject will return to the clinic for 16 visits (Visits 01 to 
16). At each visit of Visit BS and Visits 01 to 15, all subjects will receive the SC treatment 
and will receive the TTAX01 application on the Initial Visit (Visit BS) or following the last 
surgical sharp debridement and bone resection, if a staged surgical procedure is performed; 
and, subjects will receive the TTAX01 application(s) on the subsequent visits (Visits 01 thru 
15) per the guidelines of TTAX01 treatment described in details in the study protocol. 
 
2.3 
Schedule of Assessments 
The complete schedule of assessments for this study is shown in table below. With reference 
to the Initial Procedure Visit (Visit BS), study visits are allowed to have a window of ±2 days 
for the weekly treatment and confirmatory visits (Visits 01 thru 19).   
 
At Screening, eligible subjects will be assessed for ulcer measurements (i.e., size, perimeter, 
and depth) and duration of the index ulcer. At the initial visit (Visit BS/baseline), eligible 
subjects will receive the ulcer care of TTAX01 plus SC. At each of the study visits from Visit 
01 through Visit 19, the subject’s ulcer measurements (i.e., size, perimeter, and depth) will 
be assessed, evaluated, and images collected via the electronic wound imaging and 
measurement device.  All of the subjects will receive SC treatment at the clinic at Visit BS 
and Visits 01 thru 18, and will receive the TTAX01 application at Visit BS or at the last 
surgery for a staged surgical procedure, and will receive the TTAX01 application(s) at 
subsequent visits of Visits 01 thru 15 per the guidelines of TTAX01 treatment described in 
details in the study protocol.  
 
The assessment schedule over the entire study is outlined in the table below. 
 






















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3 
STUDY POPULATION 
3.1 
Definition of Subject Populations 
All subjects who have procedures completed at Visit BS are considered study participants. 
The following subject populations are defined to assess the safety and efficacy of TTAX01 
with SC. 
 
Safety Population 
The safety population is defined as all subjects who are enrolled and who have received at 
least one treatment of the investigational product.  
Intention-to-treat (ITT) Population 
This population is defined as all subjects who are enrolled to receive treatment. The ITT 
population is the primary population for efficacy evaluation in this study. The ITT population 
will be identified and finalized before the database is locked.  
Per-Protocol (PP) Population 
This population is defined as sub-population of the ITT population. The PP population is the 
secondary population for efficacy evaluation in this study.  The detailed criteria of the PP 
population will be provided in a separate “Data Standards” document completed prior to data 
base lock. 
3.2 
Screening and Enrollment 
An enrollment summary including the number of subjects screened, enrolled, and completed 
treatment will be presented for all screened subjects and by site (Table 1.1.1). The number of 
subjects enrolled (i.e., study participants or ITT population) will be summarized for each post-
debridement ulcer size group and overall (Table 1.1.2). The number of subjects treated (i.e., 
the safety population) will be summarized for each post-debridement ulcer size group and 
overall (Table 1.1.3). The number of treated subjects terminating from treatment will be 
summarized for each group (Table 1.1.4). 
3.3 
Population Demography 
For ITT and safety populations, descriptive summaries of demography and baseline 
characteristics will be presented for each group and overall to establish baseline 
comparability (Tables 1.2.1 to 1.2.2). 
 
Demography includes age in years (continuous and categorical 18 to 39, 40 to 49, 50 to 59, 
60 to 69, 70+), gender, race, ethnicity, weight, and height. Demography will also be listed for 
all study participants (Listing 1). 
3.4 
Disease Characteristics and Prior Treatment 
For ITT and safety populations, descriptive summaries of baseline index ulcer characteristics 
will be presented for each group and overall to establish baseline comparability (Tables 1.3.1 
to 1.3.2). 
 


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The size and duration and other characteristics of index ulcer will be listed for all subjects 
(Listing 1). 
 
Primary therapy used for treatment of DFU prior to participating in the study will be listed for 
all subjects (Listing 1). 
3.5 
Medical History 
Medical history will be listed in CRF data tabulation. 
3.6 
Disposition of Study Participants 
Subject disposition including completion and discontinuation along with CRF-based 
termination reason will be summarized for ITT population and safety population (Tables 1.4.1 
to 1.4.2). Subjects’ early termination details will be listed for all subjects (Listing 2). 
  
Subjects’ TTAX01 treatment and date will be listed for all subjects enrolled (Listing 3). 
3.7 
Protocol Deviations and Violations 
A summary of protocol deviation and violations will be provided for ITT population (Table 
1.5.1). Subjects who are enrolled to receive treatment in the study and included in the ITT 
population, but do not have post-baseline status of ulcer closure will be listed for subjects 
enrolled (Listing 4). 
 
Subjects who are included in the ITT population, but not included in the PP population due to 
either protocol violations or other documented reasons will be listed for all subjects excluded 
from the PP population (Listing 5). Major protocol violations may include the following: 
 
• 
The subject fails to meet all inclusion/exclusion criteria and receives no waiver for 
entering into the study; 
• 
The subject is terminated for protocol violations. 
 
4 
EFFICACY EVALUATION 
4.1 
Datasets Analyzed 
The ITT population is defined as the primary efficacy population, and the PP population as 
the secondary efficacy population. Both populations will be identified and finalized before the 
database is locked. The definitions of the two populations are provided in Section 3.1. 
 
4.2 
Treatment Compliance 
The compliance rate of SC treatment will be summarized by treatment group and 
demographic parameters for the ITT and safety populations (Tables 1.5.2 and 1.5.3). 
 
4.3 
Data Missing and Imputation 
Summary of the observed data missing and imputation performed will be reported for index 
ulcer closure status, the primary efficacy measure, of the ITT population in Table 1.6.1. 


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4.4 
Baseline Measures 
Descriptive statistics of the index ulcer area, depth, and volume at baseline will be 
summarized by treatment for the ITT and safety populations (Tables 1.3.1 and 1.3.2).  
 
4.5 
Efficacy Results and Tabulations 
4.5.1 
Results of primary efficacy analysis 
Descriptive and inferential statistics on the ITT population of the proportion of subjects with 
complete ulcer closure over the treatment period will be presented in Table 2.1.1. 
 
For the PP population, the results of the same proportion analysis on the number of subjects 
with complete ulcer closure will be presented in Table 2.1.2.   
 
The by-site summary of descriptive statistics of the number of subjects with complete ulcer 
closure will be presented in Table 2.1.3 for pooled sites and in Table 2.1.4 for original sites. 
 
Individual subjects’ primary efficacy data (i.e., complete ulcer closure), ulcer area measure 
and ulcer closure status at each visit, with and without imputation, will be listed by treatment 
for the ITT population (Listing 6). 
 
4.5.2 
Results of secondary efficacy analyses 
Descriptive and inferential statistics on the ITT population of the number of days to complete 
ulcer closure will be presented in Table 2.3.1 for Cox regression analysis.  The resultant 
probability of subjects with index ulcer open over the 16-week treatment period and 
estimated median time to ulcer closure will be reported in Table 2.3.2.  For the PP 
population, the results of the same Cox regression analysis on the number of days to 
complete ulcer closure will be presented in Table 2.3.3 and Table 2.3.4.   
   
Descriptive and inferential statistics on the ITT population of the proportion of subjects with 
complete ulcer closure for each post-baseline treatment week will be presented in Table 
2.1.1. 
 
Descriptive and inferential statistics on the ITT population of percent change of index ulcer 
parameters (ulcer area, depth, and volume) and percent of granulation tissue coverage at 
each treatment visit will be presented in Tables 2.4.1 thru 2.4.4. 
 
5 
SAFETY EVALUATION 
For safety evaluation, the safety population as defined in Section 3.1 will be utilized to 
conduct safety analyses among treatment groups. 
 
5.1 
Extent of Drug Exposure 
Exposure to study medication will be tabulated by treatment in Table 3.1.1 for total number of 
SC treatments received and in Table 3.1.2 for TTAX01 application received, using the 
following categories: 1-2 applications, 3-4 applications, 5-6 applications, 7-8 applications, 9-


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10 applications, 11-12 applications, 13-14 applications, and 15-16 applications. The 
tabulations will be done for the safety population, and for man and woman, separately. 
 
Individual subjects’ treatment exposure (applications) will be listed by treatment regimen for 
the safety population (Listing 3). 
 
5.2 
Early Termination 
Early termination will be categorically summarized for the ITT population in Table 1.5.1, and 
for the safety population in Table 1.5.2. Subjects’ study termination details will be listed 
(Listing 2). 
 
5.3 
Adverse Events 
An overall summary of AE reported in this study will provided in Table 4.1.1 for study 
participants and in Table 4.1.2 for safety population. The incidences of subjects reporting 
pre-treatment AE will be reported in Table 4.2.1 for the pre-randomization period and in 
Table 4.2.2 for the treatment-emergent AE by post-debridement ulcer size group. Those 
treatment-emergent AE by preferred terminology that are reported by more than 3% of 
subjects in any treatment will be tabulated in Table 4.2.3. 
 
Incidences of subjects reporting treatment-emergent AE will also be tabulated by onset time 
Table 4.3.1. 
 
The severity of the treatment-emergent AE and the relationship to the investigational product 
will be summarized in Table 4.4.1. 
 
Treatment-emergent AE associated with early terminations and serious AE will be 
summarized by preferred term in Table 4.4.2 and Table 4.4.3.   
 
Details of AE associated with both index ulcer and non-index foot ulcers will be listed for 
each subject (Listing 7) 
 
Details of AE associated with early terminations will be listed for each subject (Listing 8).  
SAE, including deaths, will be listed for each event (Listing 9).     
 
Narratives will be presented for all deaths, non-fatal serious adverse events, and subjects 
withdrawn due to adverse events. 
 
5.4 
Physical Examination 
Abnormal findings of physical examination will be recorded as adverse events in this study, if 
so determined by the investigator. 
 
Qualitative findings in terms of abnormal, normal, and not done at both screening and end-of-
treatment visits will be tabulated by group in Table 5.1.1 for the safety population. 
 


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5.5 
Clinical Laboratory Evaluation 
Descriptive statistics of laboratory parameters will be presented by group at the screening 
and end-of-treatment visits for the safety population in Tables 6.1.1 to 6.1.3 for hematology 
and chemistry as well as other laboratory tests, respectively. 
 
Qualitative findings in terms of abnormal low, normal, and abnormal high at both screening 
and end-of-treatment visits will be tabulated by group in Tables 6.2.1 to 6.2.2 for the safety 
population for hematology and chemistry, respectively. 
 
Any clinically meaningful abnormalities observed during the study will be listed for 
hematology (Listing 10) and chemistry (Listing 11), as well as pregnancy test (Listing 12). 
 
5.6 
Concomitant Medication 
Number and percent of subjects who take pre-baseline concomitant medications will be 
reported in Table 7.1.1. Number and percent of subjects who take post-baseline concomitant 
medications will be reported by group in Table 7.1.2.   
 
Number and percent of subjects who take pre-baseline concomitant medications for ulcer 
treatment will be reported in Table 7.2.1 for index ulcer and in Table 7.2.2 for non-index 
ulcer.  Number and percent of subjects who take post-baseline concomitant medications for 
ulcer treatment will be reported by group in Table 7.3.1 for index ulcer and Table 7.3.2 for 
non-index ulcer. 
 


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6 
REFERENCES 
 
Study protocol.