# Bone marrow-derived mesenchymal stem cells combined with intramuscular injection promote the healing of diabetic foot ulcers: a systematic review and meta-analysis

## TL;DR

A review finds that bone marrow-derived stem cells injected into muscles can significantly improve healing of diabetic foot ulcers, especially when used in specific doses and for certain patient groups.

## Contribution

This study identifies optimal cell therapy protocols and patient subgroups for treating diabetic foot ulcers using systematic review and meta-analysis.

## Key findings

- Cell therapy significantly improved ulcer healing rates and reduced amputation rates in diabetic patients.
- Intramuscular injection of autologous bone marrow-derived mesenchymal stem cells showed the best outcomes.
- Patients with large ulcers and shorter diabetes duration benefited most from the therapy.

## Abstract

Diabetic foot ulcers (DFUs) represent a debilitating complication of diabetes characterized by high rates of morbidity and mortality, yet conventional management often yields limited efficacy. Although cell-based therapies offer a promising therapeutic avenue, their clinical efficacy and optimal target populations remain to be definitively established.

We searched databases including PubMed, Embase, the Cochrane Library, Web of Science, and the China National Knowledge Infrastructure from inception to November 2025 for randomized controlled trials (RCTs). Study quality was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Meta-analysis, subgroup analysis, and heterogeneity analysis were performed using R software (version 4.3.3). Sensitivity analysis was conducted via the leave-one-out method.

Thirty-two RCTs involving 2059 patients were included, assessing nine core outcomes including ulcer healing rate and amputation rate. Pooled analysis demonstrated that cell therapy significantly improved the ulcer healing rate (OR = 4.64, 95% CI: 3.11 to 6.90), reduced the amputation rate (OR = 0.29, 95% CI: 0.18 to 0.49), enhanced limb perfusion (ABI MD = 0.14, 95% CI: 0.05 to 0.22; TcPO2 MD = 11.58, 95% CI: 5.36 to 17.80), alleviated pain (resting pain score MD = -1.04, 95% CI: -1.49 to -0.59), reduced ulcer area (MD = -2.15, 95% CI: -3.74 to -0.56), and shortened healing time (MD = -16.83 days, 95% CI: -27.93 to -5.74). Subgroup analyses revealed: 1) Cell Type: Autologous bone marrow-derived mesenchymal stem cells (BMMSCs) yielded the most favorable outcomes (ulcer healing OR = 8.33, P < 0.01). 2) Administration Protocol: A medium-to-high dose range combined with intramuscular injection was identified as optimal. Specifically, high and very-high doses demonstrated the strongest efficacy in critical limb salvage outcomes (amputation and healing rates), while the medium-dose regimen exhibited the most robust statistical consistency across all secondary metrics (e.g., ulcer area reduction). 3) Target Population: Patients with shorter diabetes duration (<10 years), larger ulcer area (≥10 cm²), or prolonged non-healing ulcers (>200 days) derived more significant benefit.

Cell therapy shows significant potential as an adjuvant treatment for DFUs. Current evidence suggests that a protocol utilizing autologous BMMSCs within a medium-to-high dose range (targeting 1×107 to 1.2×109 cells) via intramuscular injection may optimize therapeutic efficacy while ensuring clinical feasibility. Exploratory findings indicate that this strategy might be particularly suitable for patients with large, refractory DFUs and short diabetes duration, though these observations require further validation in large-scale trials.

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251247289.