Stem Cell and Growth Factor Injury and Arthritis Clinical Research Study

The investigators believe that amniotic tissue allografts may be an effective modality to
treat osteoarthritis (OA) of the knee. One important mechanism of action may be stimulation
of the synovial cells to increase production of endogenous hyaluronic acid (HA). A second
mechanism may be the increase in the anabolic factors and a decrease in degenerative factors
in the joint. The Investigators propose to quantify the concentration of HA and selected
anabolic and degradative factors in synovial fluid aspirate pre and post implantation. While
the treatment provided is designed to provide pain relief for symptoms, the purpose of this
study is to learn more information about the impact of amniotic tissue allografts on
inflammatory markers and growth factors in the knee joint.

The purpose of this study is to determine the changes in the composition of synovial fluid
resulting from implantation of amniotic tissue allograft in the knee.

This study will characterize the chemical profile of painful osteoarthritic joints and the
influence of various injections containing cells and/or growth factors on that chemical
profile. The addition of amniotic tissue allograft to HA injections may be an, effective
treatment for people with knee pain resulting from OA and furthermore may lead to
customization and/or the identification of the most efficacious combination of joint
injections.

Prior to any study-related treatment, participants will undergo an Institutional Review Board
(IRB)-approved informed consent process for aspiration of synovial fluid, followed by a
randomized injection of either A) saline only, B) hyaluronic acid, C) amnionic allograft, or
D) hyaluronic acid plus amnionic allograft, with a second aspiration performed 1 week after
injection. Synovial fluid samples from 88 participants indicated for amniotic tissue
implantation will be analyzed in vitro to determine the cellular and biochemical
characterization of the fluid obtained.

The aim of this study is to determine the changes in composition of synovial fluid resulting
from implantation of amniotic tissue allograft in the knee. There is always a possibility
that the insertion of a needle may in itself result in a change in the composition of
synovial fluid and therefore to increase the strength of the study control arm (placebo) is
necessary. The placebo controlled group is justified to provide evidence that the standard of
care and research treatments are safe and efficacious.

Participants will be randomly assigned to one of four treatment groups:

Group A: Placebo - saline Group B: Standard of care treatment - hyaluronic acid, Group C:
Standard of care treatment - amnionic allograft, or Group D: Research treatment: hyaluronic
acid plus amnionic allograft.

Prior to undergoing treatment, participants will be asked to complete a series of subjective
health questionnaires. Upon completion of the questionnaires, a 1-2mL sample of synovial
fluid will be aspirated from each subject. The collection of the synovial fluid is performed
strictly for research purposes related to this study. Treatment will be administered
according to the group the participant was randomly assigned to.

One week (+/- 3 days) following the treatment, the participant will return to the clinic, and
will complete a second set of questionnaires, after which a second aspiration of 1-2mL of
synovial fluid will be taken. If the participant received a placebo injection (saline only),
they will be given an opportunity to receive an amniotic tissue allograft injection and/or
hyaluronic acid .

Participation in this study will require that the investigators perform some procedures in
addition to the standard of care. Standard of care is defined as:

- Receipt of a therapeutic injection of hyaluronic acid or implantation of amniotic tissue
allograft

- Completion of subjective outcome questionnaires prior to treatment

Research specific procedures are defined as:

- Aspiration of knee synovial fluid during treatment

- Aspiration of knee synovial fluid one week after treatment

- Completion of subjective outcome questionnaires at one week following treatment

- Analysis of knee synovial fluid for increased levels of anabolic factors, IL1ra, TMP1,
TMP2, HA, and IGF1 as well as decreased levels of degradative factors, IL-1, TNF-alpha,
IL-10, MMP-2, MMP-9, TGF-beta

Inclusion Criteria:

1. Patients age 18 and over

2. Previous diagnosis of knee OA,

3. Kellgren-Lawrence grade of 2 - 4

4. Minimum Visual Analogue Scale (VAS) pain score of 3 on a scale of 0 - 10 where 0 is no
pain and 10 is the highest level of pain

5. Can give written informed consent

Exclusion Criteria:

1. Receipt of HA, Platelet Rich Plasma (PRP) or amniotic cell injections in the previous
6 months

2. Recent history of surgery to the same joint in the previous 3 months

3. A clinical diagnosis of inflammatory arthritis made by history, examination or
serology

4. An active or latent infection of the affected knee joint or any other systemic
infection currently under treatment or treated within the previous 3 months

5. A history of chronic alcohol or drug abuse during the six months prior to the study

6. Clinically documented acute or unstable concomitant disease, other than the condition
to be treated in this study that might be a confounding reason for the presence of
pathogens (i.e. renal, hepatic, cardiac, endocrine, hematologic, autoimmune, metabolic
bone, crystal deposition, severe degenerative joint, neoplastic diseases)

7. Systemic or intra-articular administration, within twenty days prior to the procedure,
of any type of corticosteroids, antineoplastic, immune stimulating or
immunosuppressive agents

8. Participation in any other investigational drug or device trial during the 30 days
prior to screening visit or who will receive such a drug or device during the course
of this study

9. Pregnant females

10. Subject is unable to understand verbal and/or written English