C A R T I L A G E. Order the ROCK from Joint Operations when treating cartilage and osteochondral defects. #savethejoint

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1 J O I N T O P E R AT I O N S JOINT OPERATIONS (UK) LLP Suite 20, Anchor Business Centre, Frankland Road, Blagrove, Swindon, Wiltshire SN5 8YZ TELEPHONE: +44 (0) FAX: +44 (0) service@jointoperations.co.uk JODA01/ROCK/ v2 C A R T I L A G E Order the ROCK from Joint Operations when treating cartilage and osteochondral defects R E G E N E R AT I O N S O L U T I O N S #savethejoint

2 The problem with MICRO FRACTURE for cartilage regeneration e ROCK REGENERATIVE OSTEOCHONDRAL CARTILAGE KIT ENHANCED CELLULAR CONTENT Microfracture studies demonstrate poorer results in large defects and deterioration over time: Steadman JR et al. 2003: return to sport in 76%, decreased to 36% after four and a half years Gobbi et al. 2005: decline in 80% of athletes two years after MFx Kreuz et al. 2006: improvement for 18 months followed by deterioration Mithoefer et al. 2006: initial improvement followed by deterioration at two years Knutsen et al. 2007: 23% failures at five years after MFx Mithoefer et al 2009: meta-analysis (28 studies, 3,122 patients) Improvement two years after MFx but conflicting results on durability Increased failure rates between two and five years after MFx (2-31%) Gudas et al. 2012: 38% failure rates at ten years after MFx Goyal et al. 2013: evidence-based status (15 level I and II studies) Small lesion < 3 cm²: 31% failures at three years and 38% at ten years Beyond five years post-operatively, treatment failures could be expected regardless of lesion size Solheim et al. 2014: prospective cohort of MFx (n= 110) evaluated at a median of 12 years Poor outcome (Lysholm < 64) in 45.5% of the patients at five years Additional surgery in 22% at five years (39% at ten years) Joint Operations has the comprehensive solution for cartilage regeneration within two presentations; Chondral Defects AMIC NanoFx + Chondro-Gide Osteochondral Defects AMIC combined with; Orthoss Collagen / Chips or AlloSource DBM / Chips Prochondrix Allogenic Scaffold Chondral Defects AMIC +/- NanoFx + Marrow Cellution B.M.A. or Fragmented Adipose Tissue Viable Cartilage Allograft Fresh Osteochondral Cores e ROCK REGENERATIVE OSTEOCHONDRAL CARTILAGE KIT

3 THE ROCK Smaller, Deeper, Better Regenerate damaged cartilage efficiently and effectively The instrument consists of a reusable hand instrument with thumb plate (Thumble) and a single use disposable PleuriStik TM to perform a microfracture procedure for the treatment of localised articular cartilage defects Compared to standard microfracture techniques the 1mm PleuriStik enables more channels to be placed into the site with less damage to the subchondral plate Penetrates down to a standardised 9mm depth to reach the targeted marrow cells Three times deeper than comparable microfracture techniques When tested against an awl or k-wire, NanoFx resulted in thin, fragmented cancellous bone channels without rotational heat generation. It also demonstrated deep cancellous bone perforation with a higher number of open trabecular channels THE ROCK AMIC ChondroGide and NanoFx Autologous Matrix Induced Chondrogenesis (AMIC) AMIC is the surgical treatment for chondral defects (up to 8cm outerbridge grade III to IV). Available for your hospital, the unique ROCK kit combines NanoFx with Chondro-Gide, a porcine collagen type I/III bilayer matrix. Speak with your Joint Operations representative to arrange placement. AMIC can be used on chondral and osteochondral defects. Patient age group for the treatment is targeted at years and they should have intact surrounding cartilage. Patients that have metabolic arthropathies, kissing lesions, non-correctable axial malalignment, chronic inflammatory systemic disorders and obesity (BMI >30) should be excluded from this procedure. AMIC Technique Minimally invasive, single stage technique Protection of the super clot from the Chondro-Gide scaffold Marked reduction in discomfort, even after resumption of sports activities Published clinical results (detailed overleaf) Straightforward and cost-efficient Chondro-Gide Leading natural collagen matrix for cartilage regeneration Promotes migration and adhesion of progenitor cells High-form stability Prevents intra-articular haemorrhage Easy handling and ready to use off-the-shelf Now Available NanoFx A-CURVE - Specifically curved for hard to reach ankle lesions. Reduces surface skidding for off-axis channel preparation. Fig 1: Unique bilayer structure of Chondro-Gide (100x) Fig 2: Compact, cell-occlusive surface (SEM 1500x) Fig 3: Porous, cell-adhesive surface (SEM 1500x) A randomised controlled trial demonstrating sustained benefit of Autologous Matrix-Induced Chondrogenesis over microfracture at five years. Martin Volz et al Order the ROCK from Joint Operations when treating cartilage and osteochondral defects

4 ROCKSTAR Marrow Cellution Autologous bone marrow aspiration and bone graft harvesting The Marrow Cellution TM Bone Marrow Aspiration and Cancellous Bone Graft Harvesting System is a bone marrow access and retrieval device that incorporates features designed to minimise limitations of traditional trocar needles. Marrow Cellution TM maximises stem and progenitor cell recovery and minimises peripheral blood infiltration. Trocar needles with side ports aspirate primarily through an open-ended cannula. This leads to excess blood collection, requiring additional manipulation, i.e. centrifugation or chemical separation in a laboratory. Overcome limitations and maximise cell yields Traditional Trocar Aspiration Traditional Trocars produce excess peripheral blood contamination, diminishing cellular yield, thereby requiring additional manipulation steps to achieve the cellular demand necessary for most clinical indications. ROCKSTAR Non-expanded and microfragmented adipose tissue graft LIPOGEMS is an innovative technology that harnesses the innate healing capabilities of adipose tissue. The system uses a sterile single-use medical device intended for the closedloop processing and transfering of autologous adipose tissue in a single surgical step. LIPOGEMS is a non-expanded and micro-fragmented adipose tissue graft that is injected into damaged areas of the body to provide a cushion and structural support while promoting a healing environment. LIPOGEMS preserve the natural healing properties of adipose tissue by maintaining the fats Vascular Stromal Niches. Lipogems contains more active cells than Lipoaspirate. Maximises cell yield Regulatory compliant Centrifugation not required Never leaves the sterile field Reduces blood contamination Provides substantial savings in time, effort and expense Reduces patient trauma, morbidity and risk of infection Marrow Cellution TM Marrow Cellution TM harvests high quality stem and progenitor cells from various levels within the marrow space. The system never leaves the sterile field and does not require further manipulation. Pre-seed the scaffold - ROCKSTAR

5 THE ROCK Bone Bed Orthoss Bone Regeneration Orthoss has the interconnecting pore structure of new bone Orthoss promotes rapid vascularisation and migration of osteoblasts Orthoss provides enough space for the colonisation of osteoblasts Orthoss supports natural remodelling process instead of fast resorption Allograft for ROCK and ROCKSTAR AlloFuse DBM gel, putty and pastes AlloFuse is clinically proven to be equivalent to autograft (detailed overleaf) ROCKSTAR Cell Viable Allografts Osteochondral Allografts JRF Ortho offers precut Fresh Osteochondral Allograft (OCA) Cores for the treatment of full thickness osteochondral lesions. The cores provide complete replacement; viable intact osteochondral allograft without donor site morbidity. Optimal and convenient treatment Structurally intact: contains a mature, viable, hyaline cartilage matrix with bone for a superior biomechanical and durable repair Proprietary processing methods shown to maintain 80% absolute cartilage viability 1 ProChondrix Allogenic Scaffold ProChondrix, a cellular 3D fresh osteochondral allograft, helps deliver the necessary components for cartilage restoration. This next generation of cartilage therapy provides live functional cells and other biological components, which are necessary for repair and regeneration of damaged cartilage tissues. Every lot tested to ensure the ability to grow new bone The reverse phase carrier stiffens up in situ to contain the graft Single step treatment with no patient size matching required In-house precise instrumentation Cancellous Bone Chips Stored at room temperature Great consistency of chip size Processed from donation in the United States Implanted for over 20 years, no case of disease transmission reported Making the joint solid... Indications Knee Shoulder Foot / Ankle Elbow AlloSource is a non-profit organisation and the world s leader in fresh cartilage tissue for bone and joint repair. ROCK solid 1. Data submitted for publication

6 e ROCK REGENERATIVE OSTEOCHONDRAL CARTILAGE KIT SUPPORTING CLINICAL DATA AMIC Chondro-Gide Ankle Bark et al Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction? journal World Journal of Orthopedics, 2014 September 18; 5(4): Both cartilage repair techniques (MFx & AMIC) represent an effective and safe method of treatment full-thickness chondral defects of the knee in selected cases. While results after microfracture deteriorate with time, mid-term results after AMIC seem to be enduring. Walther et al Reconstruction of focal cartilage defects in the talus with miniarthrotomy and collagen matrix (Center of Food and Ankle Surgery, Schö Klinik München Harlaching, Munich, Germany) in Oper Orthop Traumatol June Indications International Cartilage Repair Society (ICRS) grade III and IV focal cartilage defects of the talus > 1.5 cm 2. Results Follow-up of at least 30 months in 14 patients showed improvement in the Score of the American Orthopedic Foot and Ankle Society (AOFAS) from 50 to 89 points, with equal mobility on both sides of the upper ankle joint. Hip Fontana et al Sustained five-year benefit of autologous matrix-induced chondrogenesis for femoral acetabular impingement-induced chondral lesions compared with microfracture treatment. Until now, long-term comparative outcome data for the treatment of chondral defects of the hip using MFx and AMIC were not available. Our data demonstrates sustainable positive outcomes, reflected by high mhhs over a five-year period for patients who underwent AMIC compared with those who underwent MFx. Knee Gille et al Mid-term results of Autologous Matrix-Induced Chondrogenesis for treatment of focal cartilage defects in the knee. This case series study shows promising results after the AMIC procedure for the treatment of focal cartilage defects of the knee. Clinical evaluation of up to 60 months after implantation revealed an improvement of the patient s condition as documented by reliable clinical outcome scores. Martin Volz1 et al A randomised controlled trial demonstrating sustained benefit of Autologous Matrix-Induced Chondrogenesis over microfracture at five years. Purpose Autologous Matrix-Induced Chondrogenesis (AMIC ) utilising a type I/III collagen membrane was compared with microfracture (MFx) alone in focal cartilage lesions of the knee at one, two and five years. Methods Forty-seven patients (aged 37 ± 10 years, mean defect size 3.6 ± 1.6 cm2) were randomised and treated either with MFx, with sutured or glued AMIC in a prospective multicentre clinical trial. Results After improvement for the first two years in all sub-groups, a progressive and significant score degradation was observed in the MFx group, while all functional parameters remained stable for least five years in the AMIC groups. At two and five years, MRI defect filling was more complete in the AMIC groups. No treatment-related adverse events were reported. Conclusions AMIC is an effective cartilage repair procedure in the knee resulting in stable clinical results significantly better than the MFx group at five years. Supporting clinical data for e ROCK NanoFx Mona Eldracher, Patrick Orth, Magali Cucchiarini, Dietrich Pape and Henning Madry Am J Sports Med : 2741 originally published online August 28, 2014 Small subchondral drill holes improve marrow stimulation of Articular Cartilage Defects. Chen H, Hoemann CD et al. Depth of Subchondral Perforation In uences the Outcome of Bone Marrow Stimulation Cartilage Repair. J Orthop Res 29(8): , Results from quantitative histomorphometry and histological scoring showed that deeper versus shallower drilling elicited a greater fill of the cartilage defect with a more hyaline character in the repair matrix indicated by significant improvement (p = 0.021) in the aggregate measure of increased cartilage defect fill, increased glycosaminoglycan and type II collagen content and reduced type I collagen content of total soft repair tissue. Compared to microfracture at the same 2 mm depth, drilling to 2 mm produced a similar quantity and quality of cartilage repair 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: , 2011 LipoGems Human Lipoaspirate as Autologous Injectable Active Scaffold for One-Step Repair of Cartilage Defects Michela Bosetti,* Alessia Borrone, Antonia Follenzi, Fanuel Messaggio, Carlo Tremolada, and Mario Cannas On the basis of the results, which showed an induction of proliferation and ECM production of human primary chondrocytes, it was hypothesised that lipoaspirate may play a paracrine role. Moreover, the structure of a floating culture of lipoaspirate, treated for three weeks with chondrogenic growth factors, changed: tissue with a high fat component was replaced by a tissue with a lower fat component and connective tissue rich in GAG and in collagen type I, increasing the mechanical strength of the tissue. From these promising in vitro results, it may be speculated that an injectable autologous biologically active scaffold (lipoaspirate), employed intra-articularly, may 1) become a fibrous tissue that provides mechanical support for the load on the damaged cartilage; 2) induce host chondrocytes to proliferate and produce ECM; and 3) provide cells at the site of injury, which could regenerate or repair the damaged or missing cartilage. Farr J1 et al High Failure Rate of a Decellularised Osteochondral Allograft for the Treatment of Cartilage Lesions Sterilised and decellularised osteochondral allograft implant demonstrated a 72% failure rate within the first two years of implantation at these two institutions. Osteochondral Allografts Bugbee WD1 et al Return to Sport and Recreational Activity After Osteochondral Allograft Transplantation in the Knee Am J Sports Med Jun;45(7): doi: / Epub 2017 Apr 4 At a mean follow-up of six years, 75.2% of knees returned to sport or recreational activity. Among those who did not return to sport, knee-related issues and lifestyle changes were cited as reasons why. Patients who did not return to sport were more likely to be female, have injured their knee in an activity other than sport, and have a larger graft size. Conclusion OCA transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee. The majority of patients returned to sport or recreational activity. Bone Marrow Aspirate Leunig M et al Surgical Technique: Second-generation Bone Marrow Stimulation via Surgical Dislocation to Treat Hip Cartilage Lesions. Clin Orthop Relat Res Dec;470(12): Postoperative Oxford Hip Scores ranged from 13 to 17, UCLA Activity Scores ranged from 5 to 10, and MOCART scores ranged from 55 to 75. No complications occurred. De Girolamo L et al. Treatment of chondral defects of the knee with one step matrix-assisted technique enhanced by autologous concentrated bone marrow: in vitro characterisation of mesenchymal stem cells from iliac crest and subchondral bone. Injury Nov;41(11): Supporting clinical data for ROCKSTAR Matthias R. Steinwachs, M.D et al Matrix-Associated Chondroplasty: A Novel Platelet-Rich Plasma and Concentrated Nucleated Bone Marrow CelleEnhanced Cartilage Restoration Technique The advancement of marrow stimulation techniques is crucial to overcome the drawbacks of existing techniques, such as unpredictable tissue formation and intralesional osteophyte formation. The proposed MACH technique might improve the formation of regeneration tissue by providing a sufficient number of potent mesenchymal progenitor cells from BMAC and encouraging cell differentiation mediated by growth factors available in the autologous PRP. Avoiding subchondral bone injury might prevent negative subchondral effects. Jan Skowronski et al Large Cartilage Lesions of the Knee Treated with Bone Marrow Concentrate and Collagen Membrane The study presents to assess the clinical results of cartilage lesion treatment with bone marrow concentrate and collagen membrane. Material and methods. The study group comprised 54 patients with ICRS grade III or IV lesions. Lesion sizes ranged from 4 to 12 cm2. The assessment was carried out at one and five years following the surgery with the use of KOOS and Lysholm functional scales and VAS and KOOS Pain scales. Results. A significant improvement was obtained in 52 out of 54 patients across all scales. No complicating infections were noted. The average improvement at one year was 25 points in the KOOS scale and 35 points in the Lysholm scale. After five years an insignificant deterioration was noted in three patients.

7 PAIN MANAGEMENT Intra-Articular Injections CINGAL is the first and only approved combination viscosupplement formulated to provide the benefit of a cross-linked hyaluronic acid (HA) and a fast acting steroid to effectively treat the symptoms associated with osteoarthritis (OA). ORTHOVISC is an ultra-pure, high molecular weight injectable hyaluronic acid (HA) visco-supplement used to treat the joint pain caused by osteoarthritis. ORTHOVISC Mini is for small joints, available in 1ml preloaded syringe. Safely used for 20 years Natural non-avian sourced HA High concentration HA for relief of pain that lasts up to six months No confirmed pseudoseptic reactions in over 30 million injections worldwide Can extend the need for total knee replacement (TKR) up to 2.6 years MONOVISC is a single injection visco-supplement utilised to treat the joint pain caused by osteoarthritis. It is comprised of highly purified, partially cross-linked sodium hyaluronate (NaHA) in a phosphate buffered saline solution and it is both biocompatible and resorbable. With just one injection, MONOVISC may provide pain relief that lasts for up to six months. Regenerative Injections Adipose Tissue Utilises the high cellular content and availability of adipose tissue A straightforward technique without requirement for culturing, centrifuge, enzymes etc Works to support the patients natural healing mechanism Marrow Cellution Bone Marrow Aspiration POST BIOLOGY Post Biology HemiCAP implants preserve native anatomy and can be performed in conjunction with soft tissue alignments and other pathologies Intraoperative mapping, multiple convexities and trials ensure an anatomic fit across the range Inlay components preserve the joint by removing only a small amount of bone which maintains future options: no bridges burned Generally little to no activity restrictions High CFU count Smaller sample required, meaning less pain from donor site No centrifuge required saving time and money

8 CATALOGUE NUMBER DESCRIPTION SUPPORTING CLINICAL DATA LipoGems R.D. Striano, H. Chen, N. Bilbool, K. Azatullah, J. Hilado, K. Horan Non-Responsive Knee Pain With Osteoarthritis And Concurrent Meniscal Disease Treated With Autologous Micro-Fragmented Adipose Tissue Under Continuous Ultrasound Guidance. One year after the treatment, we found improvement in all measured scores. VAS pain score on a 1-10 scale, with 10 being worse, improved from 8 to 0; the KOOS (knee Injury and osteoarthritis score) outcome, with a score of 100 being perfect, improved from 45 to MRIs taken at six months post-treatment, revealed improved signal and thickness of the cartilaginous tissue over the medial femoral condyle, with a widened joint space. Radiologist initial measure of articular cartilage reported as 0.75 mm and at six months reported as 1.5 mm. R.Striano, N. Bilbool, K. Azatullah, J. Hilado Non-responsive shoulder pain with osteoarthritis, rotator cuff tear and labral tear treated with autologous micro-fragmented adipose tissue onder continuous ultrasound guidance. Single patient study Six months after Lipogems injection, all the measured scores improved (Fig 1-9). In details, VAS pain score improved from 10 to 0 (0-10 scale), ASES from to (100 being perfect), and Constant Shoulder Score from 24 to 81 (100 being perfect). Range of motion, measured with a goniometer by the same therapist, improved from abduction 53 degrees and forward exion 53 degrees to 150 degrees and 180 degrees respectively. Muscle strength, measured with instrumentation by the same therapist, improved forward exion of 8.1lb/in2 and abduction of 7.2lb/in2 to 20lb/in2 and 18lb/in2 respectively. Ultrasound imaging revealed improved homogeneity, tendon contours and internal echotexture of the supraspinatus tendon. MonoVisc Monovisc 0702 Pivotal Clinical Trial. FDA Monovisc Summary of Safety and Effectiveness Data 2014 White Paper Study conducted by Michael J. Daley, PhD Clinical Efficacy and Safety of MONOVISC TM : A lightly cross-linked highly concentrated hyaluronan specially formulated for single injection in osteoarthritis. White Paper, Post-Approval Study of MONOVISC TM, A Symptomatic Treatment of Osteoarthritis. Orthovisc Brandt KD, Block JA, Michalski JP, Moreland LW, Caldwell JR, Lavin PT. Efficacy and safety of intra-articular sodium hyaluronate in knee osteoarthritis. ORTHOVISC Study Group. Clin Orthop Relat Res 2001;(385): FDA Monovisc Summary of Safety and Efficacy Data (SSED). Application Number: P Cingal Laszlo Hangody et al May 2017 Intra-articular Injection of a cross-linked sodium hyaluronate combined with triamcinolone hexacetonide (Cingal) to provide symptomatic relief of osteoarthritis of the knee: A randomised, doubleblind, placebo-controlled multi-centre clinical trial. Of 368 patients were treated, Cingal improvement from baseline was significantly greater than saline. WOMAC Pain was reduced by 70% at 12 weeks and by 72% at 26 weeks with Cingal. Significant improvements were found in most secondary endpoints for pain and function at most time points through 26 weeks. At 1 and 3 weeks, Cingal was significantly better than Monovisc for most endpoints; Cingal and Monovisc were similar from 6 weeks through 26 weeks. A low incidence of related adverse events was reported. HemiCAP Knee Akash Patel, Zakir Haider, Amarjit Anand, and Dominic Spicer Early results of patellofemoral inlay resurfacing arthroplasty using the HemiCap Wave prosthesis "Advantages of inlay resurfacing include preservation of native geometry with minimal bone loss and soft tissue disruption, thus causing minimal disruption to natural joint biomechanics and reducing the risk of joint overstuffing. The multiple convexities of the HemiCap Wave assure anatomic fit. "Our results demonstrate that the HemiCap Wave has excellent early results, in terms of functional outcomes, radiological outcomes and low complication rates. At the very least, early results show that the HemiCap Wave is comparable to more established onlay prostheses. The HemiCap Wave thus provides a safe and effective surgical option in the treatment of isolated patellofemoral osteoarthritis in selected patients." A matched pair comparison of inlay and onlay trochlear designs for patellofemoral arthroplasty: no differences in clinical outcome but less progression of osteoarthritis with inlay designs. Matthias J. Feucht 1,2 Matthias Cotic 1 Knut Beitzel 1 Julia F. Baldini 1 Gebhart Meidinger 1,3 Philip B. Schöttle 1,4 Andreas B. Imhoff 1 Isolated PFA using either a second-generation inlay or onlay trochlear component significantly improves functional outcome scores and pain. The theoretical advantages of an inlay design did not result in better clinical outcome scores; however, progression of tibiofemoral OA was significantly less common in patients with an inlay trochlear component. This implant design may therefore improve long-term results and survival rates after isolated PFA. ORDERING INFORMATION NanoFx Handle - Knee NanoFx Handle - Talus FURS PleuriStik TM - Knee FURS PleuriStik TM - Talus FURS Thumbles ROCK-AC1 1 PleuriStik TM - Talus ROCK-PL1 1 PleuriStik TM - Knee ROCK-TM1 1 Thumble Chondro-Gide 30mm x 40mm Chondro-Gide 40mm x 50mm Orthoss 5g Orthoss Collagen 0.8cc Cancellous Chips, 15cc, 4.0mm - 9.5mm, peel pack AlloFuse DBM Putty 1cc MC-RAN-11C Marrow Cellution LG SK 60 Lipogems 60cc Surgical Kit Representative Request Prochondrix - Live Allograft Cartilage Scaffold Representative Request Osteochodral Allograft To order please contact JOINT OPERATIONS TELEPHONE: +44 (0) FAX: +44 (0) service@jointoperations.co.uk #savethejoint