As the aging of the population, a chronic degenerative joint disease - Osteoarthritis (OA), its incidence and severity are increasing. Compared with cells, the immunogenicity of the exon is low and the immunomodulatory performance is excellent. Various types of mesenchymal stem cell-derived exosomes (MSC-EXOs) are now being used to treat cartilage injury and disease as target drugs or delivery vehicles. A thorough examination of the existing evidence is required in light of the emerging evidence on the effective mechanism and method of MSC-EXOs in OA. This article reviews the specific mechanism and latest research progress of MSCs derived exosomes in OA treatment. It mainly summarizes three mechanisms of action of exosomes: a. Enhancing extracellular matrix (ECM) and preventing cartilage degradation; b. Promoting chondrocyte migration, proliferation, migration, and inhibiting chondrocyte apoptosis, c. Influencing immune protection or immune destruction signals. In addition, the difficulties of exosomes in the clinical treatment of OA are briefly reviewed, with the hope of providing ideas for developing biomaterials scaffolds and clinical treatment of MSC-EXOs.