Background The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. MethodsIn this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63•8%) were men, and 14 524 (46•5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71•9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27•5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88•7%] of 195 patients with open fractures; 426 [44•7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47•7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50•5%]), while Second Delays ...

Good tissue union and cosmetically acceptable scar is vital for ideal surgical practice. Since their discovery in 1949, cyanoacrylate compounds have evoked interest as being the ideal "tissue glue". Several different forms of this compound have been developed in order to eliminate tissue toxicity. In this article, we have described a technique of sutureless closure of operative skin wounds and compared it to closure of skin with silk. Inter-group comparison was carried out with respect to the time required for closure, rate of infection, cosmesis and patient acceptance. N-butyl 2-cyanoacrylate was used for sutureless skin closure in 100 patients and compared with skin closure with sutures. The time taken to close the wounds with cyanoacrylate was found to be significantly less, the cosmetic outcome better and patient acceptability higher than when sutures were used.

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Ergonomics is the science of best suiting the worker to his job, or to make the setting and surroundings favorable for the laparoscopic surgeon. The term was formally defi ned in 1949 and has brought benefi t and safety to many areas of human endeavor.1 The importance of ergonomics in the setting of laparoscopy cannot be overemphasized. Studies have shown that correct ergonomics can reduce suturing time.2 Pressurerelated chronic pain has been shown to be relieved by the use of ergonomically designed products.3 This article on ergonomics reviews the basic concepts and techniques, for example, triangulation, optimal coaxial alignment, drawbacks for the surgeon and the patient, and how to overcome these diffi culties by recent advances in technology.

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