Objectives : Deferred urethroplasty for pelvic fracture-related urethral injuries remains a clinical challenge, and we describe our experience of such procedures. Methods : A retrospective analysis of 58 patients who had undergone deferred urethroplasty for pelvic fracture-related urethral injuries. The patients were subjected to serial postoperative monitoring involving a questionnaire about their symptoms, uroflowmetry, and cystoscopy. Success was defined as no worsening of urinary flow and the absence of strictures on cystoscopy. Results : The patients' median age was 35 years (range : 11 to 74). The median urethral gap, which was estimated from urethrograms, was 20 mm (range : 5 to 50). The median duration of the follow-up period was 22 months (range : 7 to 89). All of the urethroplasties were performed via stricture excision and primary anastomosis, and no substitution procedures were required. Repair was performed via a perineal procedure in 54 cases (93.1%) and via a perineo-abdominal procedure in 4 cases (6.9%). Urethroplasty was successful in 52 of the patients (89.6%). Two of the 6 failed urethroplasties were salvaged with a perineo-abdominal procedure, resulting in a final success rate of 93.1%. The surgical complications included lower extremity compartment syndrome in 2 patients, scrotal hematoma in 3 patients, and a surgical site infection in 1 patient, and all of them were managed conservatively. Conclusions : Deferred posterior urethroplasty for pelvic fracture-related urethral injuries has a high success rate and causes few morbidities.

　　Purpose : The purpose of this study was to evaluate the efficacy of inducing mild hypothermia (HT) and administering barbiturate therapy (BT) immediately after a computed tomography (CT) scan as a treatment for severe traumatic brain injuries (TBI). Methods : This study was a historical control study. The inclusion criteria were severe TBI patients (Glasgow Coma Scale score : ≤8) whose bilateral pupillary light reflexes were absent or who exhibited extensive subarachnoid hemorrhaging or absent cisterns on CT. The 11 patients that were transferred to our facilities between 2012 and 2014 and in whom HT was induced and BT was administered immediately after a CT scan comprised the early HT group. The 36 patients who met the inclusion criteria and were treated with HT between 1997 and 2012 made up the control group. Results : There was no significant difference in the patient characteristics of the two groups. The prognosis of the early HT group was significantly better than that of the control group. Conclusion : Inducing HT and administering BT immediately after a CT scan might improve the prognosis of severe TBI.

　　 [Introduction] The use of non-operative management (NOM) to treat splenic injuries has been expanding in recent years. We investigated the validity and limits of NOM as a treatment for such injuries in patients with unstable hemodynamics. [Materials and Methods] We registered 18 cases of splenic injury and categorized the cases into two groups : the shock and non-shock groups. The frequencies of massive transfusions (MT), aortic blockage, and interventional radiology (IVR) were compared between the two groups. [Results] There were 10 and 8 patients in the shock and non-shock groups, respectively. We observed that MT (p<0.01) and IVR (p=0.04) were significantly more common in the shock group than in the non-shock group. The frequency of aortic blockage was 30% (3/10) in the shock group. In the shock group, the selection rate and success rate of NOM were 80% (8/10) and 88% (7/8), respectively. The hemodynamics of the patients in whom NOM was successful were improved by damage control resuscitation (DCR) ; however, in the cases in which NOM was unsuccessful, DCR did not improve the patients' hemodynamics due to the presence of abdominal compartment syndrome. [Conclusion] The NOM of splenic injuries was successful in a high percentage of patients with unstable hemodynamics. In cases of splenic injury, if the patient's hemodynamics are not improved by DCR surgery should be performed immediately.

　　In trauma cases, hemorrhaging is the factor associated with the greatest risk of death. In particular, hemorrhaging of the extremities is a preventable cause of death. At our hospital, we have equipped our helicopter ambulance with the Combat Application Tourniquet^® (CAT^®) since 2014, based on the concept of tactical combat casualty care (TC3). The CAT^® is a tourniquet that is used to treat injuries that occur during combat. It is small, easy to affix, and is used to treat injuries of the extremities, where astriction can be difficult to achieve. In this study, 10 cases in which the CAT^® was used were investigated to examine the efficacy of this approach. Hemostasis was achieved using the CAT^®. The patients were transported to the emergency center with no subsequent re-bleeding or complications, and all cases had favorable outcomes. A comparison of the patients' on-site and emergency center revised trauma scores (RTS) indicated that their emergency center RTS were significantly better than their on-site RTS (7.6±0.2 vs. 7.0±0.3 ; p=0.021). This improvement in the patients' RTS could have been caused by the strong hemostatic effects of the CAT^®. In future, we need to increase awareness of the CAT^® and become proficient at using it. The CAT^®, which has strong hemostatic effects, is useful for prehospital treatment.

　　Severe injuries to the extremities require combined specialized orthopedic and plastic surgery at an early stage. The management of such injuries is difficult because of the lack of specialized trauma centers and so they often lead to poor outcomes. A 32-year-old patient with a Gustilo 3B open tibia fracture initially presented to a local hospital. After the initial skeletal fixation procedure, in which an implant was inserted, he underwent soft tissue reconstruction. However, a pedicled muscle flap partially failed, and the implant was exposed. Two weeks later, he was referred to our facility for soft tissue reconstruction and definitive skeletal fixation. As our facility was located around 900 km away, the patient was transported by jet plane. A year later, he returned to work without any major complications. Severe injuries of the extremities require simultaneous treatment by dedicated surgical teams. It is necessary to establish trauma networks for patients with such injuries to ensure that they receive appropriate treatment. The use of jet planes to transport patients to specialized trauma centers could aid the development of such networks.

　　We report a case of severe multiple blunt trauma in a 51-year-old male who had fallen from a height. After the arrival of the air ambulance, he was diagnosed with a massive left hemothorax and an unstable pelvic fracture. At the scene, he underwent tracheal intubation and left thoracostomy. Upon arrival at hospital, he was in a state of cardiopulmonary arrest caused by hemorrhagic shock due to the massive left hemothorax. Therefore, resuscitative thoracotomy was performed for the massive left hemothorax, and immediate pulmonary hilum clamping was conducted as a damage control measure against active bleeding from a deep pulmonary laceration. After aortic occlusion had been performed to achieve primary hemostasis, the patient was transported to a hybrid operating room, and left lower lobectomy was performed along with gauze packing. After the lobectomy, transcatheter arterial embolization and external fixation were carried out for the unstable pelvic fracture. Thus, this case shows that resuscitative thoracotomy and pulmonary hilum clamping are radical and applicable to a limited subset of cases of severe hemorrhagic shock caused by blunt trauma-induced deep pulmonary lacerations.

Summary

　The panel discussion focused on the roles of trauma centers, including treatment for orthopedic trauma.

　From the viewpoint of acute care surgeons, "the staff of critical care centers should include orthopedic surgeons or emergency physicians whose subspecialty is orthopedics from the stage of life-saving treatment. On the other hand, orthopedic trauma surgeons consider that "critical care should be provided by emergency physicians, and the role that should be fulfilled by orthopedic surgeons is to enhance functional recovery" .

　Since the ultimate goal is to establish a medical system that covers both "critical care" and "functional outcome" , this point should be reconfirmed. "Critical care" and "functional outcome" must be recognized as "two resources" , rather than "conflicting axes" . Trauma patients should be treated by teams of "surgeons specializing in trauma" responsible for "critical care" and orthopedic trauma surgeons in charge of "functional recovery" , instead of simple collaboration among different clinical departments.

　Now that helicoptors and ambulances on-boarding physicians are available across Japan, trauma patients can be centralized to specific facilities. This suggests that the case volume makes no difference. Only facilities with superior treatment outcomes qualify as trauma centers. From the viewpoint of orthopedic surgery as well, it is significant to assemble fracture patients to specific facilities for treatment provided by orthopedic trauma surgeons.

　Physicians can be clearly divided into those who are "interested in trauma and diseases" , and physicians "interested in diseases" will never become interested in trauma. The idea that these two types of physician can cooperate with each other is overly optimistic. It is necessary to establish optimal trauma centers that recruit a number of physicians "interested in trauma" to provide high-level treatment to increase life and functional recovery.