1. Regenerative Options for Knee Osteoarthritis Cellular Medicine Chris Evans PhD REHABILATATION MEDICINE RESEARCH CENTER

2. DISCLOSURES Orthogen AGSupervisory Board TissueGene IncScientific Advisory Board (IP; licensing fee; honorarium) Aldabra LLCCo-Founder Research funded by NIH, DoD, AO Foundation

3. OSTEOARTHRITIS HAS ALWAYS BEEN INCURABLE AND DIFFICULT TO TREAT “Osteoarthritis is an easy disease to take care of. When the patient walks in the front door, I walk out the back door”. Sir William Osler (1849 – 1919)

4. Normal Joint

5. Osteoarthritic Joint

6. PATHOLOGIES Synovial thickening and inflammation Changes to bone Osteophytes Sub-chondral sclerosis Cysts Loss of articular cartilage SYMPTOMS Pain Loss of Function

7. PATHOLOGY POTENTIAL SynovitisHigh Osseous ChangesPotentially High Cartilage LossVery Difficult POTENTIAL INTERVENTION IN MAJOR OA PATHOLGIES

8. Unlike many other tissues in the body, such as bone, articular cartilage has no intrinsic repair capacity. WHY?

9. LOW MAG. MEDIUM MAG. HIGH MAG.

10. Articular cartilage has no intrinsic repair capacity because: Avascular Aneural Alymphatic Complex architecture No stem cells (?)

12. SEVERELY OSTEOARTHRITIC CARTILAGE

13. INTRA-ARTICULAR THERAPY Intuitively attractive for OA – No systemic sequelae – Limited number of affected joints – Higher local drug concentration – Reduced extra-articular side-effects – Reduced cost But more difficult than robbing banks* *Evans CH: Drug delivery to chondrocytes Osteoarthritis Cartilage, 2015

15. HALF LIVES OF MOLECULES IN JOINTS Acridine orange (MW 370 Da) 0.23 h NSAIDs and soluble steroids 1- 4 h Anakinra (MW 17 kDa) ~ 4 h Albumin (MW 67 kDa) 1.23 h HA (MW 3x10 6 Da) 26.3 h

16. CELLULAR MEDICINE Do cells remain in joint after intra-articular injection? Do they provide therapeutic effect? Do they provide regenerative effect?

17. CANDIDATES FOR INTRA-ARTICULAR CELL THERAPY Synovial fibroblasts Chondrocytes Mesenchymal stem/stromal cells (MSCs)

18. WHAT IS A STEM CELL? STEM CELLS HAVE TWO IMPORTANT PROPERTIES: 1. They undergo assymetric cell division and thereby self-renew 2. They give rise to other cell types

19. Mesenchymal Stem (Stromal) Cell

20. MSCs AS A SOURCE OF TROPHIC FACTORS

21. MSCs ARE ALSO IMMUNOSUPPRESSIVE CAN THEY BE SUCCESSFULLY ALLOGRAFTED? UNIVERSAL DONOR?

22. Visited 10/01/15 Allogeneic 6 Autologous10 Marrow MSCs 11 (BMC* 1) Adipose MSCs 2 (SVF** 1) Umbilical Cord MSCs 3 Phase I or I/II15 Phase II 3 * Bone marrow concentrate ** Stromal vascular fraction Commercialized in Veterinary Medicine

23. Recombinant Transforming Growth Factor-  1 Pellet of marrow MSCs Pellet of cartilage IN VITRO CHONDROGENESIS ~ 1 month

24. Recombinant TGF-  1 Adenovirus TGF-  1 Adenovirus TGF-  1 Pellet of marrow MSCs Pellet of cartilage IN VITRO CHONDROGENESIS BY GENE TRANSFER ~ 1 month

25. OA gene therapy protocol of TissueGene* Phase III trials in USA and Korea Uses allograft chondrocytes expressing TGF-  *CHE is on SAB

26. * CHE on SAB of TissueGene * INVOSSA™

27. Current Surgical Repair Methods Mosaicplasty (OATS) (osteochondral plugs) Allograft (osteochondral plugs) Allograft (living cartilage fragments) AUTO/ALLO-GRAFTING CELL THERAPY Autologous Chondrocyte Implantation (ACI) Microfracture BUT NOT IN OSTEOARTHRITIS

28. Interleukin-1  Inhibition of Chondrogenesis Brackets: p<0.05 (n=4)

29. INTERLEUKIN-1 (IL-1) A Mediator of Pathology in OA Inflammatory Promotes destruction of cartilage Inhibits chondrogenesis Alters bone turnover Involved in pain

30. AAV.IL-1Ra IL-1Ra

31. REGENERATION CELLS MORPHOGENS MECHANICAL FACTORS SCAFFOLDS

33. REGENERATIVE REHABILITATION

34. THANK YOU REHABILATATION MEDICINE RESEARCH CENTER