Safety and performance of the intra-articular injection of animal-free chitosan biomaterial (viscosupplementation) in patients with symptomatic knee osteoarthritis: a pre-market study

• Male or female with age >= 40 years and <= 85 years except in Stage 1 cohort where age is limited to <= 70 years.
• Body mass index (BMI) <= 35 kg/m².
• Uni- or bilateral femorotibial knee OA associated or not with femoropatellar knee OA.
• Primary knee osteoarthritis responding to the clinical and radiological criteria of the American College of Rheumatology (ACR)
• Radiological Kellgren and Lawrence (K&L) grade II to III from a standing knee radiograph taken less than 6 months previously.
• Symptomatic pain at least 6 months in the treatment knee not or poorly responding to first line non-opioid analgesics and non-steroidal anti-inflammatory drug in oral uptake.
• Pain criteria assessed prior to injection at V1 on both knees using the 5-graded Likert WOMAC pain score after mandatory 48-hour wash-out:
o Treatment knee: 7-17 points of the 5-graded Likert WOMAC pain score and at least 2 points on the WOMAC pain subscore A1 in the most affected knee.
o Non-treatment knee: not more than 6 points of the 5-graded Likert WOMAC pain score in the contralateral knee.
• Fully ambulatory patient for functional evaluation
• Willing NOT to take any pain medication for 48 hours prior to study visit.
• For female NOT surgically sterile (tubal ligation or hysterectomy) or NOT postmenopausal for at least one year, must have an effective contraception (pill, patch, ring, diaphragm, implant and intrauterine device).
• Able to understand and follow the instructions of the study.
• Having signed a written informed consent.

• Related to the OA pathology and related symptoms:
o Radiological K&L grade 0, I or IV from a standing knee radiograph taken less than 6 months previously.
o Exclusively patellofemoral osteoarthritis where the symptoms, including pain, are principally of patellofemoral origin (Patellar syndrome).
o Chondromatosis or villonodular synovitis of the knee.
o Clinically-apparent knee effusion, inflammation or flare-up of the knee or abnormal synovial fluid macroscopy or volume upon arthrocentesis on the day of injection.
o History of injury to the treatment knee during the 6 months before inclusion or recent trauma (<1 month) of the knee responsible of pain that is not directly related to OA symptoms.
o Significant clinically-assessed or radiographic varus or valgus deformation of the selected knee at the judgment of the investigator.
o Inflammatory disease, i.e., rheumatoid arthritis, psoriatic rheumatism, articular chondrocalcinosis, gouty arthritis, ankylosing spondylitis, lupus, acute calcium pyrophosphate arthritis, or infectious arthritis, and, articular disease resulting from articular dysplasia, aseptic osteonecrosis, acromegaly, Paget*s disease, hemophilia, hemochromatosis.
o Pathologies interfering with the evaluation of OA pain for the knee to be treated, i.e., homolateral coxarthrosis, radiculalgia, femoral or sciatic nerve root pain, venous or lymphatic stenosis, arteritis, tendinopathy (e.g. hip periarthritis). ;• Related to treatments:
o Contraindications: hypersensitivity or allergy to the product components of KIO014, including chitosan, sorbitol and/or other mushroom-derived products, or to hyaluronic acid-based products.
o Corticosteroids or PRP or cell-based therapy injection in the treatment knee in the last 3 months before injection.
o Hyaluronic acid injection in the treatment knee in the last 6 months before injection.
o Arthroscopy and surgery in the treatment knee in the last 6 months before injection.
o Oral corticotherapy >=5 mg/day (in prednisone equivalent) in the last 3 months before injection.
o Change in the dosage regimen of symptomatic slow-acting drugs (SYSAD) or dietary supplement, i.e., curcuma extract, chondroitin, glucosamine, diacerein or avocado-soya unsaponifiables in the last 3 months before injection.
o Change in physiotherapy of the treatment knee in the last 3 months.
o Anticipated need for any surgical or other invasive procedure during the trial including prosthesis in the treatment knee.
o Anticipated need for any forbidden OA treatments during the trial except for rescue treatment as defined in the study protocol.
o Anticoagulants: coumarin-based compounds or heparin. ;• Related to associated diseases:
o Any Investigator-assessed clinically significant condition that may represent a substantial risk to the patient or may have an impact on the study assessments.
o History of recurrent bacterial infection, defined as at least 3 major infections resulting in hospitalization and/or requiring intravenous antibiotic treatment within the past 2 years or history of synovial infection or infections or skin diseases in the area of the injection site.
o History of symptomatic hip OA
o History of autoimmune disease.
o Severe, ongoing and uncontrolled diseases such as malignancy or history of malignancy, type I diabetes, liver failure, renal failure, lung/heart disease, neoplasia, malignant blood disease, tumor, HIV, or other major disease (e.g. systemic fungal infection), or other severe uncontrolled conditions.
o Subject addicted to alcohol (for example, more than 2 glasses/day of strong alcohol) or drugs or ongoing or recently recovered (<6 months) depression or psychiatric disorders or any other disorder and/or that may pose a health risk to the subject in the study and/or may have an impact on the study assessments.
o Severe alteration of mobility preventing any functional evaluation.
o High risk of hemorrhage.;• Related to patients:
o Participation in a therapeutic clinical trial in the last 3 months before injection.
o Patient under guardianship or judicial protection.
o Pregnancy, breastfeeding, planned conception, or premenopausal women without effective contraception (pill, patch, ring, diaphragm, implant and intrauterine device), tubal ligation or hysterectomy.