Mesenchymal Stem Cell-Derived Exosomes Combined With 3-Dimensional Hyaluronan-Based Scaffold Promote Tendon-to-Bone Tunnel Healing.

Sergen Karatas; Gokce Yildiran; Gulsemin Cicek; Hande Akdeniz; Fatma Oz Bagci; Zekeriya Tosun

doi:10.1016/j.jhsa.2026.05.009

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Mesenchymal Stem Cell-Derived Exosomes Combined With 3-Dimensional Hyaluronan-Based Scaffold Promote Tendon-to-Bone Tunnel Healing.

Sergen Karatas·Gokce Yildiran·Gulsemin Cicek·Hande Akdeniz·Fatma Oz Bagci·Zekeriya Tosun

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Abstract

PURPOSE: Tendon-to-bone healing remains a major clinical challenge due to poor regenerative capacity at the enthesis. This study aimed to evaluate the effects of mesenchymal stem cell-derived exosomes combined with a 3-dimensional hyaluronan-based scaffold on graft healing within bone tunnels. This study was conducted in accordance with the ARRIVE (Animal Research: Reporting of In Vivo Experiments) guidelines. METHODS: A total of 128 tendon-bone models were created in 64 Sprague-Dawley rats, randomized into four groups: control, exosome-only, scaffold-only, and exosome-loaded scaffold. At weeks 4 and 8 postoperatively, samples were analyzed histologically (hematoxylin-eosin, Masson Trichrome), immunohistochemically (fibroblast growth factor 2, bone morphogenetic protein 2), and biomechanically (maximum failure load). RESULTS: At both time points, the exosome-loaded scaffold group demonstrated significantly enhanced vascularization, cellular activity, and collagen fiber continuity and parallelism compared to all other groups (P < .05). Fibroblast growth factor 2 and bone morphogenetic protein 2 expression levels were highest in the exosome-loaded scaffold group, indicating early activation of proregenerative pathways. Biomechanically, this group also exhibited the greatest maximum failure load (15.64 ± 0.86 N at week 4; 22.97 ± 2.86 N at week 8), suggesting superior tendon-to-bone integration. The exosome-only group showed delayed but comparable improvements by week 8. CONCLUSIONS: Combining mesenchymal stem cell-derived exosomes with a 3-dimensional hyaluronan-based polycaprolactone/tricalcium phosphate scaffold enhances early and sustained healing at the tendon-bone interface. This cell-free, biocompatible strategy significantly improves vascularization, growth factor expression, collagen organization, and mechanical strength. These findings support its potential as a clinically translatable approach for improving tendon-to-bone healing outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

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Animals Hyaluronic Acid Rats, Sprague-Dawley Tissue Scaffolds Rats Wound Healing Exosomes Mesenchymal Stem Cells Bone Morphogenetic Protein 2 Tendons Fibroblast Growth Factor 2 Male Biomechanical Phenomena Random Allocation 3-dimensional hyaluronan scaffold enthesis regeneration mesenchymal stem cell−derived exosomes tendon-to-bone healing Journal Article

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Sergen Karatas, Gokce Yildiran, Gulsemin Cicek, Hande Akdeniz, Fatma Oz Bagci, Zekeriya Tosun. 2026-07-02. Mesenchymal Stem Cell-Derived Exosomes Combined With 3-Dimensional Hyaluronan-Based Scaffold Promote Tendon-to-Bone Tunnel Healing.. https://doi.org/10.1016/j.jhsa.2026.05.009

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