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Autologous Tenocyte Implantation (ATI)

Cultured tendon-cell injection (OrthoATI) for chronic tendinopathy — how it is made and given, what the published evidence does and does not show, and its regulatory standing in Australia.

25 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Autologous tenocyte implantation (ATI) is a cultured-cell injection for chronic tendinopathy. A needle biopsy is taken from a healthy tendon — the patellar tendon in every published series — the tendon-derived cells are expanded in a GMP facility over three to five weeks, and a single suspension of those cells is injected into the tendinopathic lesion under ultrasound guidance. In Australia the technology is supplied commercially as OrthoATI (Orthocell, Perth). It is not listed on the Australian Register of Therapeutic Goods; patients are treated under the TGA's Special Access Scheme.

It is marketed for recalcitrant tendinopathy at several sites — lateral epicondylitis, rotator cuff, gluteal, Achilles and patellar tendon — but the published clinical evidence is concentrated almost entirely on the elbow, and it is small. A 2025 independent systematic review searched 174 records and included five studies containing 50 patients in total: three case series and two case reports, all conducted in Australia between 2013 and 2018 [1]. No controlled trial of ATI has been published, at any site, in any indication.

The randomised evidence that is claimed for the technology exists outside the peer-reviewed literature: a 48-patient trial against surgery for lateral epicondylitis, announced by the manufacturer to the ASX in November 2023 and presented at the Australian Orthopaedic Association ASM, which remains unpublished. The one properly blinded, placebo-controlled trial ever registered — 90 patients, Achilles tendinopathy, Erasmus MC — completed in June 2014 and has never reported.

That combination is the whole picture in one paragraph: a consistent uncontrolled signal, a large positive result that no one outside the sponsor has been able to appraise, and a silent placebo-controlled trial.

How It Works

The rationale is specific and biologically reasonable. Chronic tendinosis is not an inflammatory state but a failed healing response, and in the extensor carpi radialis brevis of chronic lateral epicondylitis both apoptosis and autophagic cell death are demonstrable in the resident tenocyte population [2]. Ageing tenocytes show oxygen-tension-dependent Rac1 signalling that drives the tendinotic phenotype [3]. If the lesion is depopulated of functional collagen-producing cells, repopulating it with healthy autologous tendon cells is a coherent thing to attempt.

The cells delivered are characterised, not merely aspirated. In the index elbow series, flow cytometry and quantitative real-time PCR were used to confirm a tendon-cell phenotype distinguishable from mesenchymal stem cells, and 2 mL of suspension at 2–5 × 10⁶ cells/mL in 10% autologous serum was injected through an 18-gauge needle into the tendinosis or tear on one or two passes — deliberately not a peppering technique [4]. The manufacturer's laboratory reports that growth and bioactivity of the harvested cells are not degraded by donor age or donor site [5], which matters because the target population is late-middle-aged.

The preclinical work is mixed rather than uniformly supportive, and the negative result is the interesting one. Autologous tenocytes seeded on a biodegradable collagen scaffold improved biomechanical outcomes in sheep tendon-bone reconstruction [6]. Tenocyte-seeded nanofibrous scaffolds in rotator cuff repair improved healing in juvenile and aged animals but had no effect in adult animals [7]. Human dermal fibroblasts, which behave comparably to tenocytes and are far cheaper to obtain, enhanced healing of chronic rotator cuff tears in rabbits [8] and, in a randomised human trial, reduced the retear rate after arthroscopic repair of full-thickness tears larger than 2 cm [9]. If cell delivery is what matters, the cell may not have to be a cultured tenocyte.

What the Evidence Shows

The published lateral epicondylitis series

Connell et al. treated 12 patients with refractory common extensor origin tendinosis using skin-derived tenocyte-like cells — the precursor technique, not ATI proper. PRTEE fell from a median of 78 before injection to 12 at six months (p = 0.003); 11 of 12 expressed satisfaction and 10 of 12 said they would undergo it again; there were no adverse events [10].

Wang et al. reported the index ATI series: 20 patients enrolled, 17 treated, 16 analysed. Maximum-pain VAS improved from 5.94 by 57% at four weeks, 77% at six months and 86% at 12 months; QuickDASH improved from 45.88 by 91%; the combined MRI tendinopathy-and-tear score improved from 4.31 to 2.88 (all p < 0.001), and MRI score correlated with QuickDASH (R = 0.545), pain (R = 0.448) and grip (R = −0.494). One patient failed at three months after re-injuring the elbow lifting a patient at work and went on to surgery [4].

The same cohort was reassessed at a mean 4.51 years (range 3.08–5.17). Fifteen of 16 were available. VAS remained 78% better than baseline, QuickDASH 84% better, UEFS 64% better, and grip strength continued to rise beyond the one-year value (19.85 kg baseline → 37.38 kg at one year → 46.60 kg at final). The MRI score held at 2.87 against 2.88 at one year, with all but two patients scoring identically. There were no infections, ruptures, haematomas, nerve injuries or heterotopic ossification, and no donor-site complications [11].

For comparison within cell therapy, allogeneic adipose-derived MSC injection in 12 patients with chronic lateral epicondylosis reduced VAS from 66.8 mm to 14.8 mm and improved the modified Mayo elbow performance index from 64.0 to 90.6 over 52 weeks, with two minor elbow effusions [12].

The trial that is claimed but not published

Orthocell announced on 14 November 2023 the final results of a randomised, multicentre, open-label, non-inferiority trial comparing OrthoATI with surgery in severe, chronic, treatment-resistant lateral epicondylitis. Forty-eight participants were randomised 24:24; all had MRI-verified disease with more than six months of symptoms, a mean symptom duration of 25.7 months, and 90% had failed at least one corticosteroid injection. The primary endpoint was QuickDASH at 12 months with a 15-point non-inferiority margin. The announced result was that the ATI arm was 15.7 points better than surgery at 12 months (p = 0.0028), with return to work at 19 versus 51 days, VAS falling 5.6 → 1.6 versus 6.5 → 2.7, and grip strength reaching parity with the unaffected side at six months versus 12 months.

This result should not be treated as established, and the reasons are structural rather than a matter of taste.

  1. It has not been peer reviewed. The only public account is a sponsor announcement written for investors and a conference presentation. There is no protocol, no CONSORT flow diagram, no confidence intervals, no intention-to-treat versus per-protocol comparison, and no adverse-event table. As of August 2026 — nearly three years on — no publication of the trial is indexed in PubMed or Europe PMC.
  2. It is open-label with patient-reported primary and secondary endpoints. QuickDASH and VAS are entirely subjective, and every participant knew whether they had received an operation or a novel regenerative injection. This is exactly the setting in which expectation effects dominate: in lateral epicondylitis, a double-blinded placebo-controlled trial found that surgical excision of the degenerative ECRB conferred no additional benefit over placebo surgery [13].
  3. A superiority claim is being made from a non-inferiority design. The trial was powered to show ATI was not more than 15 QuickDASH points worse. A 15-point margin is roughly the entire minimal clinically important difference, so the design would have declared success even had ATI been meaningfully worse. Announcing a 15.7-point advantage is a different inference from the one the trial was built to support.
  4. Forty-eight patients is small, and this literature is fragile. An analysis of randomised trials of non-operative management of lateral epicondylitis found that reversing as few as three patient outcomes would overturn the reported statistical significance in these studies [14].
  5. The sponsor ran it. Orthocell's co-founder and Chief Scientific Officer was an investigator, and the announcement's stated next step was appointing a US corporate adviser to find a strategic partner. In lateral epicondylitis specifically, industry affiliation is associated with more favourable results in randomised trials of platelet-rich plasma [15]. In the closely comparable mesenchymal stromal cell literature, spin is documented in most trials [16] and abstracts report a significantly higher proportion of significant p-values than the main texts of the same papers [17]. Adherence to the Minimum Information for Studies Evaluating Biologics in Orthopedics reporting standard is poor across biologics research generally [18] and in lateral epicondylitis specifically [19] — so cell dose, viability and passage number are usually unrecoverable from what is published.
  6. The comparator does not establish biological activity. Surgery for tennis elbow is no more effective than non-operative treatment [20] and no more effective than placebo surgery [13]. Matching, or even beating, an intervention that has not itself beaten sham is not evidence that a treatment is biologically active. It is evidence that two interventions produce similar trajectories in a condition in which about 90% of untreated patients resolve by one year [21].

In fairness to the technology, three points cut the other way. The cohorts are genuinely chronic and refractory rather than incident cases, which weakens — though does not remove — spontaneous resolution as the explanation. The MRI endpoint in the elbow series is scored by a radiologist against a defined tendinopathy-and-tear scale rather than self-reported, and it moved and then held for five years [4, 11]. And the safety record is consistent across every series and the systematic reviews: cell therapy at multiple tendon sites has produced no serious adverse events [22].

Against that last point, the gluteal series is a useful corrective: clinical scores improved and were sustained to 24 months, but MRI tendon appearance did not significantly change [23] — so the structural claim is not reproduced away from the elbow.

The trial that would settle it

NCT01343836 was an investigator-initiated, quadruple-blind (participant, care provider, investigator and outcomes assessor) randomised trial of autologous tenocyte implantation versus intratendinous saline placebo, both with eccentric exercise, in chronic Achilles tendinopathy. Erasmus Medical Center was the sponsor, the primary outcome was VISA-A at 24 weeks, and 90 patients were actually enrolled. It completed in June 2014. No results have been posted, the registration record was last updated in February 2015, and no publication is indexed.

That is the single most important fact about this evidence base. The only placebo-controlled test of ATI ever conducted finished twelve years ago and has never reported.

Other sites

Twelve women with chronic recalcitrant gluteal tendinopathy improved on Oxford Hip Score, VAS and SF-36 out to 24 months after a single injection; three had mild biopsy-site pain that settled with topical NSAID [23]. A case report described healing of a partial-thickness rotator cuff tear [24]. A conference abstract reports a randomised comparison of ATI against subacromial corticosteroid for interstitial supraspinatus tears in 30 patients (19:11) with ASES 93.3 versus 62.9 at 12 months and 7 of 11 corticosteroid patients withdrawing for worsening symptoms [25] — an abstract, from the same group, with the same design limitations, and not a substitute for a paper.

Practical Considerations

Regulatory and funding. OrthoATI is not on the ARTG. It is supplied under the TGA Special Access Scheme, which places the responsibility for the decision on the treating practitioner and requires the patient to be informed that the product is unapproved. It is not a listed Medicare benefit, and the cell-processing component is paid for privately. Any patient or third-party funder should be given that in writing before a biopsy is taken.

What the patient goes through. Two separate procedures three to five weeks apart: a needle biopsy of the patellar tendon under local anaesthetic, then an ultrasound-guided injection under local anaesthetic. Serology screening for HIV and hepatitis B and C is required before cell culture. Donor-site morbidity in the elbow series was low — mean knee pain 1.69/10 at four hours and 1.13/10 at four weeks, with no residual symptoms or disability [4].

Aftercare as it was actually delivered in the trials. Two days of rest, light household or office duties for four weeks, forearm extensor stretches four times daily, simple analgesia as required, and no supervised physiotherapy or formal strengthening programme; work and sport restrictions were lifted at four weeks [4]. This is worth stating plainly, because it is a materially lighter rehabilitation burden than after a release, and it is one of the more defensible claims made for the technique.

Where it sits. The 2025 systematic review positions ATI as a second-line option for resistant tendinopathy, notes that its cost is higher than corticosteroid or PRP, and concludes that a control group is essential before efficacy can be claimed [1]. That is a fair summary of the position, provided the reader understands that "second line" here means second line on uncontrolled data.

Counselling a patient who asks for it by name. The defensible position is that ATI is safe on the evidence available; that the uncontrolled results in refractory tennis elbow are consistent and durable to 4.5 years; that no controlled trial supporting it has ever been published; that the trial most often cited in its favour is a sponsor announcement rather than a paper; that the comparator in that trial is an operation which has not beaten placebo; and that natural history alone resolves about 90% of tennis elbow within a year. Patients who understand all of that and still wish to proceed are making a reasonable choice about an unapproved product, and the SAS pathway exists for exactly that decision.

Key Evidence

  • [L1] A systematic review of autologous tenocyte injection identified only five studies totalling 50 patients — three case series and two case reports, all from Australia — and concluded that a control group is essential before efficacy can be assessed. [1] (10.3390/jfmk10010095)
  • [L4] In chronic resistant lateral epicondylitis, ATI improved maximum-pain VAS by 86% and QuickDASH by 91% at 12 months, with MRI tendinopathy scores improving from 4.31 to 2.88. [4] (10.1177/0363546513504285)
  • [L4] Those gains were maintained at a mean 4.51 years, with no infection, rupture, haematoma, nerve injury or ossification. [11] (10.1177/0363546515579185)
  • [L4] Skin-derived tenocyte-like cells reduced median PRTEE from 78 to 12 at six months in 12 patients with refractory disease. [10] (10.1136/bjsm.2008.056457)
  • [L2] Surgical excision of the degenerative ECRB conferred no additional benefit over placebo surgery for chronic tennis elbow — so an operation is not a benchmark that establishes biological activity. [13] (10.1177/0363546517753385)
  • [L1] About 90% of people with untreated tennis elbow achieve symptom resolution at one year, based on the placebo and no-treatment arms of randomised trials. [21] (10.1097/corr.0000000000002058)
  • [L1] Surgery for tennis elbow is no more effective than non-surgical treatment on the available evidence. [20] (10.1177/1758573217745041)
  • [L2] Reversing as few as three patient outcomes would overturn the statistical significance of randomised trials of non-operative management of lateral epicondylitis. [14] (10.1016/j.xrrt.2025.03.008)
  • [L2] Industry affiliation influences the results reported by randomised trials of platelet-rich plasma for lateral epicondylitis. [15] (10.1016/j.jseint.2024.06.010)
  • [L2] Spin was present in most mesenchymal stromal cell trials, and abstracts reported significantly more significant p-values than the main texts of the same papers. [16, 17] (10.1177/03635465241274155, 10.1177/23259671251374306)
  • [L2] Studies of biologics in lateral epicondylitis adhere poorly to MIBO reporting standards, so cell dose and viability are often unrecoverable. [19] (10.5397/cise.2024.01060)
  • [L5] Tenocyte-seeded scaffolds improved rotator cuff healing in juvenile and aged animals but had no effect in adult animals. [7] (10.1002/jor.23381)
  • [L4] ATI for gluteal tendinopathy produced sustained clinical improvement to 24 months, but tendon appearance on MRI did not significantly change. [23] (10.1177/2325967116688866)
  • [L4] Allogeneic adipose-derived MSC injection reduced VAS from 66.8 mm to 14.8 mm over 52 weeks in 12 patients with lateral epicondylosis. [12] (10.1002/stem.2110)
  • [L1] Cell therapy across tendon sites has been safe, with no serious adverse events reported. [22] (10.1186/s40634-022-00520-9)
  • [L5] Apoptosis and autophagic cell death occur in the ECRB in chronic lateral epicondylitis, which is the rationale for repopulating the lesion with healthy tendon cells. [2] (10.1016/j.jse.2009.07.064)
  • [L2] Autologous dermal fibroblast injection reduced the retear rate after arthroscopic repair of full-thickness rotator cuff tears larger than 2 cm — a cheaper cell source with randomised human support. [9] (10.1177/03635465241311605)

References

[1] Demeco A, de Sire A, Salerno A, Marotta N, Comuni B, Gabbi M, Lippi L, Invernizzi M, Ammendolia A, Costantino C. Effects of Autologous Tenocyte Injection for Overuse and Degenerative Tendinopathies: A Systematic Review. J Funct Morphol Kinesiol. 2025;10(1):95. DOI: 10.3390/jfmk10010095

[2] Chen J, Wang A, Xu J, Zheng M. In chronic lateral epicondylitis, apoptosis and autophagic cell death occur in the extensor carpi radialis brevis origin. Journal of Shoulder and Elbow Surgery. 2010;19(3):355-362. DOI: 10.1016/j.jse.2009.07.064

[3] McBeath R, Edwards R, Parks S, O'Hara B, Taormina M, Shapiro I, Osterman AL. Tendinosis Results From Oxygen Tension-Dependent Rac1 Signaling in Aging Tenocytes. The Journal of Hand Surgery. 2018;43(9):S39-S40. DOI: 10.1016/j.jhsa.2018.06.085

[4] Wang A, Breidahl W, Mackie KE, Lin Z, Qin A, Chen J, Zheng MH. Autologous Tenocyte Injection for the Treatment of Severe, Chronic Resistant Lateral Epicondylitis. The American Journal of Sports Medicine. 2013;41(12):2925-2932. DOI: 10.1177/0363546513504285

[5] Wang K, Wang A, Cheng TS, Landao-Bassonga E, Lee C, Tai A, Damiani M, Zheng MH. Impact of age and donor sites on bioactivities of tendon cells in autologous tenocyte implantation (OrthoATI) for treatment of chronic tendinopathy. Journal of ISAKOS. 2024;9(4):603-608. DOI: 10.1016/j.jisako.2024.05.007

[6] Roßbach BP, Gülecyüz MF, Kempfert L, Pietschmann MF, Ullamann T, Ficklscherer A, Niethammer TR, Zhang A, Klar RM, Müller PE. Rotator Cuff Repair With Autologous Tenocytes and Biodegradable Collagen Scaffold: A Histological and Biomechanical Study in Sheep. The American Journal of Sports Medicine. 2019;48(2):450-459. DOI: 10.1177/0363546519892580

[7] Huegel J, Kim DH, Cirone JM, Pardes AM, Morris TR, Nuss CA, Mauck RL, Soslowsky LJ, Kuntz AF. Autologous tendon-derived cell-seeded nanofibrous scaffolds improve rotator cuff repair in an age-dependent fashion. Journal of Orthopaedic Research. 2016;35(6):1250-1257. DOI: 10.1002/jor.23381

[8] Lee J, Kim YH, Rhee S, Han J, Jeong HJ, Park JH, Oh JH, Jeon S. Rotator Cuff Tendon Healing Using Human Dermal Fibroblasts: Histological and Biomechanical Analyses in a Rabbit Model of Chronic Rotator Cuff Tears. The American Journal of Sports Medicine. 2021;49(13):3669-3679. DOI: 10.1177/03635465211041102

[9] Kim YK, Kim YT, Won Y, Jang YH, Hwang ST, Han J, Jeon S, Kim SH, Oh JH. Efficacy of an Autologous Dermal Fibroblast Injection in Reducing the Retear Rate After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2025;53(3):592-599. DOI: 10.1177/03635465241311605

[10] Connell D, Datir A, Alyas F, Curtis M. Treatment of lateral epicondylitis using skin-derived tenocyte-like cells. British Journal of Sports Medicine. 2009;43(4):293-298. DOI: 10.1136/bjsm.2008.056457

[11] Wang A, Mackie K, Breidahl W, Wang T, Zheng MH. Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up. The American Journal of Sports Medicine. 2015;43(7):1775-1783. DOI: 10.1177/0363546515579185

[12] Lee SY, Kim W, Lim C, Chung SG. Treatment of Lateral Epicondylosis by Using Allogeneic Adipose-Derived Mesenchymal Stem Cells: A Pilot Study. Stem Cells. 2015;33(10):2995-3005. DOI: 10.1002/stem.2110

[13] Kroslak M, Murrell GA. Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. The American Journal of Sports Medicine. 2018;46(5):1106-1113. DOI: 10.1177/0363546517753385

[14] Shah R, Yu A, Kelley MG, Yendluri A, Bienstock D, Nietsch K, Megafu MN, Li X, Kelly JD, Parisien RL. Randomized controlled trial outcomes for nonoperative management of lateral epicondylitis of the elbow are statistically fragile. JSES Reviews, Reports, and Techniques. 2025;5(4):798-804. DOI: 10.1016/j.xrrt.2025.03.008

[15] Castonguay JB, Kotlier JL, Fathi A, Petrigliano FA, Liu JN. Industry affiliation influence on randomized controlled trials for platelet-rich plasma in the treatment of lateral epicondylitis. JSES International. 2024;8(6):1284-1289. DOI: 10.1016/j.jseint.2024.06.010

[16] Woolley K, Milan N, Master Z, Feeley BT. Evaluation of Spin in Clinical Trials of Mesenchymal Stromal Cells for the Treatment of Knee Osteoarthritis: A Systematic Review. The American Journal of Sports Medicine. 2025;53(9):2264-2272. DOI: 10.1177/03635465241274155

[17] Milan N, Woolley K, Master Z, Feeley BT. Analysis of P Values in the Abstract Compared With the Main Text of Randomized Controlled Trials and Clinical Trials of Mesenchymal Stromal Cells for the Treatment of Knee Osteoarthritis. Orthopaedic Journal of Sports Medicine. 2025;13(10). DOI: 10.1177/23259671251374306

[18] Robert G, Butler JJ, Tishelman J, Lorentz N, Robertson D, Krebsbach S, Rubin J, Kennedy JG. Poor Adherence to the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) Guidelines. Clinical Orthopaedics & Related Research. 2025;484(3):591-599. DOI: 10.1097/corr.0000000000003711

[19] Hedbany D, Lezak BA, Butler J, Mercer NP, Krebsbach S, Kennedy JG. Adherence rates to the Minimum Information for Studies Evaluating Biologics in Orthopedics guideline. Clinics in Shoulder and Elbow. 2026;29(1):105-114. DOI: 10.5397/cise.2024.01060

[20] Bateman M, Littlewood C, Rawson B, Tambe AA. Surgery for tennis elbow: a systematic review. Shoulder & Elbow. 2017;11(1):35-44. DOI: 10.1177/1758573217745041

[21] Ikonen J, Lähdeoja T, Ardern CL, Buchbinder R, Reito A, Karjalainen T. Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis. Clinical Orthopaedics & Related Research. 2021;480(4):647-660. DOI: 10.1097/corr.0000000000002058

[22] Mirghaderi SP, Valizadeh Z, Shadman K, Lafosse T, Oryadi-Zanjani L, Yekaninejad MS, Nabian MH. Cell therapy efficacy and safety in treating tendon disorders: a systemic review of clinical studies. Journal of Experimental Orthopaedics. 2022;9(1). DOI: 10.1186/s40634-022-00520-9

[23] Bucher TA, Ebert JR, Smith A, Breidahl W, Fallon M, Wang T, Zheng M, Janes GC. Autologous Tenocyte Injection for the Treatment of Chronic Recalcitrant Gluteal Tendinopathy: A Prospective Pilot Study. Orthopaedic Journal of Sports Medicine. 2017;5(2). DOI: 10.1177/2325967116688866

[24] Wang AW, Bauer S, Goonatillake M, Breidahl W, Zheng M. Autologous tenocyte implantation, a novel treatment for partial-thickness rotator cuff tear and tendinopathy in an elite athlete. BMJ Case Reports. 2013;2013:bcr2012007899. DOI: 10.1136/bcr-2012-007899

[25] Wang A, Ebert JR, Fitzpatrick J, Hughes J, Lee CM, Zheng MH. A Randomised Controlled Trial Of Autologous Tenocyte Versus Corticosteroid Injection for Partial Thickness Rotator Cuff Tears and Impingement Syndrome. Journal of ISAKOS. 2023;8:S155-S156. DOI: 10.1016/j.jisako.2023.03.395

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1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.