Original Article| Volume 36, ISSUE 8, P2215-2228.e2, August 2020

Intra-Articular Injections of Mesenchymal Stem Cell Exosomes and Hyaluronic Acid Improve Structural and Mechanical Properties of Repaired Cartilage in a Rabbit Model


      To compare the efficacy of mesenchymal stem cell (MSC) exosomes with hyaluronic acid (HA) against HA alone for functional cartilage regeneration in a rabbit osteochondral defect model.


      Critical-size osteochondral defects (4.5-mm diameter and 1.5-mm depth) were created on the trochlear grooves in the knees of 18 rabbits and were randomly allocated to 2 treatment groups: (1) exosomes and HA combination and (2) HA alone. Three 1-mL injections of either exosomes and HA or HA alone were administered intra-articularly immediately after surgery and thereafter at 7 and 14 days after surgery. At 6 and 12 weeks, gross evaluation, histologic and immunohistochemical analysis, and scoring were performed. The functional biomechanical competence of the repaired cartilage also was evaluated.


      Compared with defects treated with HA, defects treated with exosomes and HA showed significant improvements in macroscopic scores (P = .032; P = .001) and histologic scores (P = .005; P < .001) at 6 and 12 weeks, respectively. Defects treated with exosomes and HA also demonstrated improvements in mechanical properties compared with HA-treated defects, with significantly greater Young’s moduli (P < .05) and stiffness (P < .05) at 6 and 12 weeks. By 12 weeks, the newly-repaired tissues in defects treated with exosomes and HA composed mainly of hyaline cartilage that are mechanically and structurally superior to that of HA-treated defects and demonstrated mechanical properties that approximated that of adjacent native cartilage (P > .05). In contrast, HA-treated defects showed some repair at 6 weeks, but this was not sustained, as evidenced by significant deterioration of histologic scores (P = .002) and a plateau in mechanical properties from 6 to 12 weeks.


      This study shows that the combination of MSC exosomes and HA administered at a clinically acceptable frequency of 3 intra-articular injections can promote sustained and functional cartilage repair in a rabbit post-traumatic cartilage defect model, when compared with HA alone.

      Clinical Relevance

      Human MSC exosomes and HA administered in combination promote functional cartilage repair and may represent a promising cell-free therapy for cartilage repair in patients.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benedek T.G.
        A history of the understanding of cartilage.
        Osteoarthritis Cartilage. 2006; 14: 203-209
        • Martel-Pelletier J.
        • Barr A.J.
        • Cicuttini F.M.
        • et al.
        Nat Rev Dis Primers. 2016; 2: 16072
        • Makris E.A.
        • Gomoll A.H.
        • Malizos K.N.
        • Hu J.C.
        • Athanasiou K.A.
        Repair and tissue engineering techniques for articular cartilage.
        Nat Rev Rheumatol. 2014; 11: 21
        • Jiang Y.Z.
        • Zhang S.F.
        • Qi Y.Y.
        • Wang L.L.
        • Ouyang H.W.
        Cell transplantation for articular cartilage defects: Principles of past, present, and future practice.
        Cell Transplantation. 2011; 20: 593-607
        • Wakitani S.
        • Nawata M.
        • Tensho K.
        • Okabe T.
        • Machida H.
        • Ohgushi H.
        Repair of articular cartilage defects in the patello-femoral joint with autologous bone marrow mesenchymal cell transplantation: Three case reports involving nine defects in five knees.
        J Tissue Eng Regen Med. 2007; 1: 74-79
        • Nejadnik H.
        • Hui J.H.
        • Feng Choong E.P.
        • Tai B.-C.
        • Lee E.H.
        Autologous bone marrow–derived mesenchymal stem cells versus autologous chondrocyte implantation:An observational cohort study.
        Am J Sports Med. 2010; 38: 1110-1116
        • Wong K.L.
        • Lee K.B.
        • Tai B.C.
        • Law P.
        • Lee E.H.
        • Hui J.H.
        Injectable cultured bone marrow-derived mesenchymal stem cells in varus knees with cartilage defects undergoing high tibial osteotomy: A prospective, randomized controlled clinical trial with 2 years' follow-up.
        Arthroscopy. 2013; 29: 2020-2028
        • Toh W.S.
        • Foldager C.B.
        • Pei M.
        • Hui J.H.P.
        Advances in mesenchymal stem cell-based strategies for cartilage repair and regeneration.
        Stem Cell Rev Rep. 2014; 10: 686-696
        • Caplan A.I.
        • Dennis J.E.
        Mesenchymal stem cells as trophic mediators.
        J Cell Biochem. 2006; 98: 1076-1084
        • Lai R.C.
        • Tan S.S.
        • Teh B.J.
        • et al.
        Proteolytic potential of the MSC exosome proteome: Implications for an exosome-mediated delivery of therapeutic proteasome.
        Int J Proteomics. 2012; 2012: 14
        • Chen T.S.
        • Lai R.C.
        • Lee M.M.
        • Choo A.B.
        • Lee C.N.
        • Lim S.K.
        Mesenchymal stem cell secretes microparticles enriched in pre-microRNAs.
        Nucleic Acids Res. 2010; 38: 215-224
        • Lai R.C.
        • Yeo R.W.Y.
        • Lim S.K.
        Mesenchymal stem cell exosomes.
        Semin Cell Dev Biol. 2015; 40: 82-88
        • Toh W.S.
        • Lai R.C.
        • Hui J.H.P.
        • Lim S.K.
        MSC exosome as a cell-free MSC therapy for cartilage regeneration: Implications for osteoarthritis treatment.
        Semin Cell Dev Biol. 2017; 67: 56-64
        • Zhang S.
        • Teo K.Y.W.
        • Chuah S.J.
        • Lai R.C.
        • Lim S.K.
        • Toh W.S.
        MSC exosomes alleviate temporomandibular joint osteoarthritis by attenuating inflammation and restoring matrix homeostasis.
        Biomaterials. 2019; 200: 35-47
        • Zhang S.
        • Chuah S.J.
        • Lai R.C.
        • Hui J.H.P.
        • Lim S.K.
        • Toh W.S.
        MSC exosomes mediate cartilage repair by enhancing proliferation, attenuating apoptosis and modulating immune reactivity.
        Biomaterials. 2018; 156: 16-27
        • Zhang S.
        • Chu W.C.
        • Lai R.C.
        • Lim S.K.
        • Hui J.H.P.
        • Toh W.S.
        Exosomes derived from human embryonic mesenchymal stem cells promote osteochondral regeneration.
        Osteoarthritis Cartilage. 2016; 24: 2135-2140
        • Cosenza S.
        • Ruiz M.
        • Toupet K.
        • Jorgensen C.
        • Noel D.
        Mesenchymal stem cells derived exosomes and microparticles protect cartilage and bone from degradation in osteoarthritis.
        Sci Rep. 2017; 7: 16214
        • Wang Y.
        • Yu D.
        • Liu Z.
        • et al.
        Exosomes from embryonic mesenchymal stem cells alleviate osteoarthritis through balancing synthesis and degradation of cartilage extracellular matrix.
        Stem Cell Res Ther. 2017; 8: 189
        • Tao S.C.
        • Yuan T.
        • Zhang Y.L.
        • Yin W.J.
        • Guo S.C.
        • Zhang C.Q.
        Exosomes derived from miR-140-5p-overexpressing human synovial mesenchymal stem cells enhance cartilage tissue regeneration and prevent osteoarthritis of the knee in a rat model.
        Theranostics. 2017; 7: 180-195
        • Lee Y.-K.
        • Kim K.-C.
        • Ha Y.-C.
        • Koo K.-H.
        Utilization of hyaluronate and incidence of septic knee arthritis in adults: Results from the Korean National Claim Registry.
        Clin Orthop Surg. 2015; 7: 318-322
        • Chen W.-H.
        • Lo W.-C.
        • Hsu W.-C.
        • et al.
        Synergistic anabolic actions of hyaluronic acid and platelet-rich plasma on cartilage regeneration in osteoarthritis therapy.
        Biomaterials. 2014; 35: 9599-9607
        • Yatabe T.
        • Mochizuki S.
        • Takizawa M.
        • et al.
        Hyaluronan inhibits expression of ADAMTS4 (aggrecanase-1) in human osteoarthritic chondrocytes.
        Ann Rheum Dis. 2009; 68: 1051
        • Bellamy N.
        • Campbell J.
        • Welch V.
        • Gee T.L.
        • Bourne R.
        • Wells G.A.
        Viscosupplementation for the treatment of osteoarthritis of the knee.
        Cochrane Database Syst Rev. 2006; Cd005321
        • Rutjes A.W.S.
        • Jüni P.
        • da Costa B.R.
        • Trelle S.
        • Nüesch E.
        • Reichenbach S.
        Viscosupplementation for osteoarthritis of the knee: A systematic review and meta-analysis.
        Ann Intern Med. 2012; 157: 180-191
        • Sherman B.J.
        • Chahla J.
        • Glowney J.
        • Frank R.M.
        The role of orthobiologics in the management of osteoarthritis and focal cartilage defects.
        Orthopedics. 2019; 42: 66-73
        • Chen T.S.
        • Arslan F.
        • Yin Y.
        • et al.
        Enabling a robust scalable manufacturing process for therapeutic exosomes through oncogenic immortalization of human ESC-derived MSCs.
        J Transl Med. 2011; 9: 47
        • Lai R.C.
        • Arslan F.
        • Lee M.M.
        • et al.
        Exosome secreted by MSC reduces myocardial ischemia/reperfusion injury.
        Stem Cell Res. 2010; 4: 214-222
        • Lee J.H.
        • Luo X.
        • Ren X.
        • et al.
        A heparan sulfate device for the regeneration of osteochondral defects.
        Tissue Engineering Part A. 2019; 25: 352-363
        • Pocock S.J.
        Clinical trials: a practical approach.
        Wiley, Chichester [West Sussex], NY1983
        • Smith G.D.
        • Taylor J.
        • Almqvist K.F.
        • et al.
        Arthroscopic assessment of cartilage repair: A validation study of 2 scoring systems.
        Arthroscopy. 2005; 21: 1462-1467
        • Toh W.S.
        • Foldager C.B.
        • Olsen B.R.
        • Spector M.
        Basement membrane molecule expression attendant to chondrogenesis by nucleus pulposus cells and mesenchymal stem cells.
        J Orthop Res. 2013; 31: 1136-1143
        • Frenkel S.R.
        • Bradica G.
        • Brekke J.H.
        • et al.
        Regeneration of articular cartilage×Evaluation of osteochondral defect repair in the rabbit using multiphasic implants.
        Osteoarthritis Cartilage. 2005; 13: 798-807
        • Griffin M.
        • Premakumar Y.
        • Seifalian A.
        • Butler P.E.
        • Szarko M.
        Biomechanical characterization of human soft tissues using indentation and tensile testing.
        J Vis Exp. 2016; : 54872
        • Miller K.
        Method of testing very soft biological tissues in compression.
        J Biomech. 2005; 38: 153-158
        • Miller K.
        How to test very soft biological tissues in extension?.
        J Biomech. 2001; 34: 651-657
        • Chew J.R.J.
        • Chuah S.J.
        • Teo K.Y.W.
        • et al.
        Mesenchymal stem cell exosomes enhance periodontal ligament cell functions and promote periodontal regeneration.
        Acta Biomater. 2019; 89: 252-264
        • Lai R.C.
        • Chen T.S.
        • Lim S.K.
        Mesenchymal stem cell exosome: A novel stem cell-based therapy for cardiovascular disease.
        Regen Med. 2011; 6: 481-492
        • Neuenschwander H.M.
        • Moreira J.J.
        • Vendruscolo C.P.
        • et al.
        Hyaluronic acid has chondroprotective and joint-preserving effects on LPS-induced synovitis in horses.
        J Vet Sci. 2019; 20: e67
        • Ishida O.
        • Tanaka Y.
        • Morimoto I.
        • Takigawa M.
        • Eto S.
        Chondrocytes are regulated by cellular adhesion through CD44 and hyaluronic acid pathway.
        J Bone Miner Res. 1997; 12: 1657-1663
        • Bonnevie E.D.
        • Galesso D.
        • Secchieri C.
        • Bonassar L.J.
        Degradation alters the lubrication of articular cartilage by high viscosity, hyaluronic acid-based lubricants.
        J Orthop Res. 2018; 36: 1456-1464
        • Altman R.D.
        • Dasa V.
        • Takeuchi J.
        Review of the mechanism of action for supartz FX in knee osteoarthritis.
        Cartilage. 2018; 9: 11-20
        • Astur D.C.
        • Angelini F.B.
        • Santos M.A.
        • Arliani G.G.
        • Belangero P.S.
        • Cohen M.
        Use of exogenous hyaluronic acid for the treatment of patellar chondropathy—a six-month randomized controlled trial.
        Rev Bras Ortop (Sao Paulo). 2019; 54: 549-555
        • Buendía-López D.
        • Medina-Quirós M.
        • Fernández-Villacañas Marín M.Á.
        Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: A randomized controlled trial.
        J Orthop Traumatol. 2018; 19: 1-9
        • Wakitani S.
        • Goto T.
        • Pineda S.J.
        • et al.
        Mesenchymal cell-based repair of large, full-thickness defects of articular cartilage.
        J Bone Joint Surg Am. 1994; 76: 579-592
        • Maehara H.
        • Sotome S.
        • Yoshii T.
        • et al.
        Repair of large osteochondral defects in rabbits using porous hydroxyapatite/collagen (HAp/Col) and fibroblast growth factor-2 (FGF-2).
        J Orthop Res. 2010; 28: 677-686