Modified Delphi consensus recommendations for the use of negative-pressure wound therapy in orthopedic trauma and complex wounds in low- and middle-income countries: anAn African consensus study.

BACKGROUND: Open fractures and complex traumatic wounds remain a major cause of morbidity in low- and middle-income countries, where delayed presentation, limited reconstructive capacity, and restricted access to specialized wound care complicate management. Although negative-pressure wound therapy is increasingly used as an adjunct in complex wound management, evidence specific to low- and middle-income countries remains limited and practical consensus recommendations are lacking. PURPOSE: To develop evidence-informed consensus recommendations for negative-pressure wound therapy use in orthopedic trauma and complex wounds in low- and middle-income countries and validate them through a multinational African modified Delphi process. METHODS: A narrative literature review identified evidence regarding negative-pressure wound therapy in orthopedic trauma and complex wounds, with particular emphasis on low- and middle-income countries settings. Draft recommendations were developed by the writing committee and externally validated through a modified Delphi process involving orthopedic-trauma and plastic surgeons from across Africa. Recommendations were initially classified as strong, moderate, or conditional and evaluated by the expert panel. Consensus was predefined as ≥ 80% agreement with the proposed recommendation category, while ≥ 90% agreement was considered very strong consensus. RESULTS: Forty-five experts were invited to participate, and forty completed the survey (response rate 88.9%). Fourteen draft recommendations were evaluated. Two achieved very strong consensus (≥90% agreement), eight achieved strong consensus (80-89%), and four did not reach the predefined threshold and were revised according to the predominant opinion of the panel. Agreement was highest for recommendations emphasizing negative-pressure wound therapy as an adjunct to standard open fracture management, adequate surgical debridement before negative-pressure wound therapy application, and timely definitive soft-tissue reconstruction. Lower agreement concerned technical parameters and organizational aspects, reflecting limited evidence and variability in local resources. CONCLUSION: These recommendations represent a multinational African modified Delphi consensus on negative-pressure wound therapy use in orthopedic trauma and complex wounds in low- and middle-income countries. By integrating the best available evidence with broad expert experience, they provide a pragmatic framework to support safe, context-adapted negative-pressure wound therapy implementation in resource-constrained settings while identifying areas requiring further clinical research.