1. TECHNICAL FIELD

[001] The technical field encompasses the use of biologic compounds for therapy of the injured joint.

2. BACKGROUND

[002] In arthritis, bursitis, tendonitis, strains, sprains, dislocations and overuse joint injuries, therapy is limited usually to mild medication and rest. In more serious disease or injury, surgical procedures such as reconstruction, grafting, distraction, arthrodesis or arthroeisis are used to repair joint damage. Introduction of safe and effective agents to enhance tissue and bone healing after inflammation and joint injury will make a significant difference to recovery and quality of life of these patients. Somatotropin, or growth hormone, has long been used as a safe and effective systemic treatment for growth dysregulation. Somatotropin has been used in humans since 1958 and recombinant growth (rGH) hormone for 30 years (Saenger, 2017). Somatotropin administered systemically stimulates IGF-1 production in the liver and has multiple physiological effects.

[003] In vitro and clinical anecdotal evidence led investigators to hypothesise that Somatotropin might be effective as an aid to repair joints. Pre-clinical studies of Somatotropin into the joint directly supported this hypothesis. Clinical studies in humans demonstrated that Somatotropin introduced directly into the joint enhances repair of the damaged joint. Injection directly into the joint is a more beneficial intervention for damaged joints than systemic injection.

1. Laboratory Studies

[004] Laboratory studies demonstrated that Somatotropin stimulates tissues derived from joints. Somatotropin stimulated chondrocyte growth in culture ^1,2 . The mechanism of growth stimulation likely via enhanced production of Insulin-like Growth Factor-1 (IGF-1) and other

SUBSTITUTE SHEETS (RULE 26) growth factors ^1,3 and by stimulation of DNA synthesis. Somatotropin enhanced proteoglycan production in chondrocytes in culture ⁴ and in joint tissue explants ⁴ . Proteoglycan production is critical to joint repair.

2. Intra-articular Preclinical studies

[005] As early as the 1980’s it was recognised intra-articular injection of Somatotropin aided joint healing on pre-clinical models. Two primary reasons were forwarded to justify intraarticular injection over systemic treatment. At this time very long term large scale safety data was not extant, so it was considered more prudent to inject smaller doses locally. Secondly injection directly into the joint (intra-articular injection) was considered a better approach as the Somatotropin would not be “diluted” and cleared and consumed in the circulation ⁵ .

[006] Intra-articular injection has been effective in multiple pre-clinical models of joint healing. Chondrocytes in joints with damaged cartilage enter mitosis faster then controls on treatment with Somatotropin ⁶ . The cartilage-bone growth plate was stimulated to grow after intraarticular injection of Somatotropin into hypophysectomized rats ⁷ . Somatotropin enhanced healing of cartilage lesions in rabbits ⁸ . Somatotropin markedly enabled healing in a rabbit model of osteoarthritis, enhanced significantly in the presence of hyaluronate ⁹ . Somatotropin is however superior to hyaluronate alone as an intra-articular injection in osteoarthritis ¹⁰ . intraarticular injection of Somatotropin enhanced healing in rat jaw osteoarthritis models ⁿ .

[007] Dunn coined the term “morphoangiogenesis” to describe the process of building up new cartilage tissue after intra-articular Somatotropin injection and likened the process to stem cell stimulation during gestation ¹² . Dunn proposed that Somatotropin stimulated local formation of structures that facilitated angiogenesis and subsequent stem cell recruitment and growth.

3. Intra-articular Clinical Studies

[008] Intra-articular injection directly into the joint has been investigated for many conditions, for example knee osteoarthritis ¹³ . It is today becoming a mainstream therapy used as part of the

SUBSTITUTE SHEETS (RULE 26) standard joint clinic armamentarium. The term Prolotherapy is often used to describe any therapeutic intra-articular injection. More correctly Prolotherapy refers to an intra-articular injection of any active substance for the purposes of inducing inflammation to stimulate the healing process.

[009] To illustrate somatrotropin usage in the practice (Level 4 Study), Dunn published data from 14 patients with osteoarthritis of the ankle, 5 mg intra-articular Somatotropin weekly for 5 to 12 weeks ¹⁴ . It was observed 13 of the patients experienced reduction of pain and increases in ankle joint mobility.

[010] In another Level 3 study, 12 subjects who had prior unsuccessful treatment for bunion, had intra-articular injections of 1 IU of Somatotropin with Dextrose prolotherapy every 4 weeks for 3 to 6 treatments ¹⁵ . There were large reductions in pain and increases in joint mobility in 11 of the 12 patients.

[Oil] Thirty nine patients with chronic lower back pain were injected intra-articular with 1 mg Somatotropin together with testosterone at 2 to 4 week intervals for 4 to 5 injections total ¹⁶ . On each visit they had 3 separate injections into the lower back connective tissue. On 12 month follow up there were statistically significant decreases in pain and improvements on lower back function in this Level 4 study.

[012] In a Level 1 study of 12 elderly men, one knee was injected intra-articular with 0.1 mg Somatotropin then re-injected the next day ¹⁷ . Saline was injected into the other knee. After 6 hours, local collagen synthesis increased and local IGF-1, but not serum IGF-1, increased. This demonstrated even very low amounts of Somatotropin promote joint collagen synthesis and healing of the joint. And that these effects are local and not systemic.

[013] ALevel 1 study of 54 subjects with knee osteoarthritis showed a significant benefit for knee function ¹⁸ . Somatotropin (4 units) was added to Platelet Enriched Plasma (PRP) for intraarticular injection and the procedure repeated after one month. After one month Somatotropin with PRP was significantly better than PRP alone, in terms of joint function and pain. But after 2 months this difference was not significant. These results demonstrate Somatotropin can act rapidly on the osteoarthritic joint, accelerating healing leading to reduced healthcare costs.

SUBSTITUTE SHEETS (RULE 26) 3. SUMMARY

3.1. TECHNICAL PROBLEM

[014] In arthritis, bursitis, tendonitis, strains, sprains, dislocations and overuse joint injuries, therapy is limited usually to mild medication and rest. In more serious disease or injury, surgical procedures such as reconstruction, grafting, distraction, arthrodesis or arthroeisis are used to repair joint damage.

3.2. SOLUTION TO PROBLEMS

[015] Introduction of safe and effective agents to enhance tissue and bone healing after inflammation and joint injury will make a significant difference to recovery and quality of life of patients with joint injury. Somatotropin has a long history of safe usage and is a potent joint repair hormone. Adding Somatotropin before, during or after the joint treatment to advance healing.

3.3. ADVANTAGEOUS EFFECTS OF INVENTION

[016] Somatotropin introduced before, during or after the joint treatment will accelerate healing of the damaged joint. This will mean faster patient healing time and save costs in the health system and economy with faster return to full functioning.

4. DESCRIPTION OF DRAWINGS

None

5. DESCRIPTION OF EMBODIMENTS

5.1. EXAMPLES a. [017] A patient presents with a severely damaged ankle joint requiring surgical correction. The surgeon corrects the defect and during the surgery implants a ceramic

SUBSTITUTE SHEETS (RULE 26) bone graft to enhance healing of the bone and injects Somatotropin into the joint to heal the joint tissues. b. [018] A patient presents in the clinic with damaged and severely inflamed toe joint. Prior to surgery the surgeon injects Somatotropin into the joint to begin the joint healing process. c. [019] A patient undergoes surgery to repair a damaged 5 ^th metatarsal (Jones fracture).

A week after surgery the patient reports strong inflammation in the area of surgery. The surgeon injects Somatotropin into the joint weekly for four weeks to help heal the joint tissues. d. [020] A patient presents to a surgical clinic with damaged ankle joint that does not require surgery in hospital. To aid healing the surgeon injects Somatotropin into the joint and immediately begins a course of hyperbaric oxygen therapy. e. [021] A patient presents to a clinic with a painful damaged joint tissue that is not severe enough to require surgery. An injection of Somatotropin into the joint is given along with a course of hyperbaric therapy. f. [022] A patient presents with damaged joint not requiring surgery. The patient is injected with Somatotropin and a pro-inflammatory agent or Platelet Rich Plasma (PRP) into the joint to accelerate healing. The injections are delivered weekly for 3 weeks.

6. CITATION LIST

6.1. PATENT LITERATURE (PRIOR ART)

[021] Dunn ^19,20 has claimed the use of Somatotropin narrowly as 0.025 milligrams to 0.249 milligrams per kilogram of patient body weight dissolved in a buffer solution. Specifically, where the buffer is either phosphate or Hank’s buffer. For injection only along the joint surface. Also in combination with analgesic, anti-enzyme or anti-protease solution. Claims are for correcting malalignment, increasing joint space and smoothing bone ends.

SUBSTITUTE SHEETS (RULE 26) [022] Hojby et al. ²¹ has claimed daily subcutaneuos injection of Somatotropin for healing bone fracture. This patent was discontinued.

[023] Raschke et al. ^22,23 have claimed the use of Somaotropin secretagogues (agents that induce production of Somatotropin) for healing bone fractures. These patents were discontinued.

[024] Vad ²⁴ has claimed a formulation of Somatotropin, lubricant, polymer and release agent for treating pain and joint injury. This patent was discontinued.

6.2. BIBLIOGRAPHY

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(2) Tsukazaki, T.; Matsumoto, T.; Enomoto, H.; Usa, T.; Ohtsuru, A.; Namba, H.; Iwasaki, K.; Yamashita, S. Growth Hormone Directly and Indirectly Stimulates Articular Chondrocyte Cell Growth. Osteoarthritis Cartilage 1994, 2 (4), 259-267. https://doi.org/10.1016/sl063- 4584(05)80078-0.

(3) Izumi, T.; Shida, J.; Jingushi, S.; Hotokebuchi, T.; Sugioka, Y. Administration of Growth Hormone Modulates the Gene Expression of Basic Fibroblast Growth Factor in Rat Costal Cartilage, Both in Vivo and in Vitro. Mol Cell Endocrinol 1995, 112 (1), 95-99. https ://doi .org/10.1016/0303 -7207(95)03591 -t.

(4) Ohlsson, C.; Nilsson, A.; Isaksson, O. G.; Lindahl, A. Effect of Growth Hormone and Insulin-like Growth Factor-I on DNA Synthesis and Matrix Production in Rat Epiphyseal Chondrocytes in Monolayer Culture. J Endocrinol 1992, 133 (2), 291-300. https://doi.Org/10.1677/joe.0.1330291.

(5) Nemirovskiy, O.; Zheng, Y. J.; Tung, D.; Korniski, B.; Settle, S.; Skepner, A.; Yates, M.; Aggarwal, P.; Sunyer, T.; Aguiar, D. J. Pharmacokinetic/Pharmacodynamic (PK/PD) Differentiation of Native and PEGylated Recombinant Human Growth Hormone (RhGH and PEG-RhGH) in the Rat Model of Osteoarthritis. Xenobiotica 2010, 40 (8), 586-592. https://doi.org/10.3109/00498254.2010.488303.

(6) Hendricson, A. S.; Havdrup, T.; Telhag, H. The Effect of Growth Hormone and Thyroxine on Adult Joint Cartilage. Clin Orthop Relat Res 1982, No. 162, 270-275.

SUBSTITUTE SHEETS (RULE 26) (7) Isaksson, O. G.; Jansson, J. O.; Gause, I. A. Growth Hormone Stimulates Longitudinal Bone Growth Directly. Science 1982, 216 (4551), 1237-1239. https://doi.org/10.1126/science.7079756.

(8) Halbrecht, J.; Carlstedt, C. A.; Parsons, J. R.; Grande, D. A. The Influence of Growth Hormone on the Reversibility of Articular Cartilage Degeneration in Rabbits. Clin. Orthop. Relat. Res. 1990, No. 259, 245-255.

(9) Kim, S. B.; Kwon, D. R.; Kwak, H.; Shin, Y. B.; Han, H.-J.; Lee, J. H.; Choi, S. H. Additive Effects of Intra- Articular Injection of Growth Hormone and Hyaluronic Acid in Rabbit Model of Collagenase-Induced Osteoarthritis. J. Korean Med. Sci. 2010, 25 (5), 776-780. https://doi.Org/10.3346/jkms.2010.25.5.776.

(10) Lubis, A. M. T.; Wonggokusuma, E.; Marsetio, A. F. Intra-Articular Recombinant Human Growth Hormone Injection Compared with Hyaluronic Acid and Placebo for an Osteoarthritis Model of New Zealand Rabbits. Knee Surg Relat Res 2019, 31 (1), 44-53. https ://doi . org/ 10.5792/ksrr.18.062.

(11) Ok, S. M.; Kim, J. H.; Kim, J. S.; Jeong, E. G.; Park, Y. M.; Jeon, H. M.; Heo, J. Y; Ahn, Y. W.; Yu, S. N.; Park, H. R.; Kim, K. H.; Ahn, S. C.; Jeong, S. H. Local Injection of Growth Hormone for Temporomandibular Joint Osteoarthritis. Yonsei Med J 2020, 61 (4), 331-340. https://doi.org/10.3349/ymj .2020.61.4.331.

(12) Dunn, A. R. Morphoangiogenesis: A Unique Action of Growth Hormone. Microvasc. Res. 2002, 63 (3), 295-303. https://doi.org/10.1006/mvre.2002.2412.

(13) Nguyen, C.; Lefevre-Colau, M.-M.; Poiraudeau, S.; Rannou, F. Evidence and Recommendations for Use of Intra-Articular Injections for Knee Osteoarthritis. Ann Phys Rehahi! Med 2A \6, 59 (3), 184-189. https://doi.Org/10.1016/j.rehab.2016.02.008.

(14) Dunn, AR. Intra-Articular Growth Hormone Injections Regrow Cartilage, Increase Motion and Reduce Pain in 93 per Cent, of Arthritic Ankles. Osteoarthritis and Cartilage 2012, 20 (Supplement 1), S295-S296.

(15) Hauser, R.A.; Feister, W.A. Dextrose Prolotherapy with Human Growth Hormone to Treat Chronic First Metatarsophalangeal Joint Pain. The Foot and Ankle Online Journal 2012, 5 (9), 1. https://doi.org/doi: 10.3827/faoj.2012.0509.0001.

(16) Dubick, M. N.; Ravin, T. H.; Michel, Y; Morrisette, D. C. Use of Localized Human Growth Hormone and Testosterone Injections in Addition to Manual Therapy and Exercise for Lower Back Pain: A Case Series with 12-Month Follow-Up. J Pain Res 2015, 8, 295-302. https://doi.org/10.2147/JPR.S81078.

SUBSTITUTE SHEETS (RULE 26) (17) Vestergaard, P.; Jorgensen, J. O. L.; Olesen, J. L.; Bosnjak, E.; Holm, L.; Frystyk, J.; Langberg, H.; Kjaer, M.; Hansen, M. Local Administration of Growth Hormone Stimulates Tendon Collagen Synthesis in Elderly Men. J. AppL Physiol. 2012, 113 (9), 1432-1438. https://doi.org/10.1152/japplphysiol.00816.2012.

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(19) Dunn, A. R. Method of Treating Inflammation in the Joints of a Body. US Patent 6645485, November 11, 2003.

(20) Dunn, A. R. Method of Treating Inflammation in the Joints of a Body. US Patent Application 20040157776, August 12, 2004.

(21) Hojby, M.; liondo, M. M.; Raun, K. Use of Growth Hormone in Treatment of Long-Bone Fractures. US Patent Application 20080119819, May 22, 2008.

(22) Raschke, M.; Windhagen, H. Use of Growth Hormone or a Growth Hormone Secretagogue for Promoting Bone Formation. US Patent Application 20020128178, September 12, 2002.

(23) Raschke, M.; Windhagen, H. Use of Growth Hormone or a Growth Hormone Secretagogue for Promoting Bone Formation. US Patent Application 20040063641, April 1, 2004.

(24) Vad, V. B. Injectible Composition and Method for Treating Degenerative Animal Joints. US Patent Application 20040127402, July 1, 2004.

SUBSTITUTE SHEETS (RULE 26)