BACKGROUND: Subarachnoid hemorrhage (SAH) is a severe neurological emergency with high morbidity and mortality, primarily due to vasospasm and delayed ischemia. Hesperidin (HSP), a natural flavonoid, possesses strong antioxidant and vasoprotective properties. This experimental animal study examined HSP’s neuroprotective role in oxidative stress and vascular remodeling after SAH, focusing on the extracellular regulated kinase 5–Kruppel-like factor 2–endothelial nitric oxide synthase (Erk5-KLF2-eNOS) pathway.
METHODS: The study was conducted from 2021 to 2022. Forty female Wistar albino rats were divided into five groups: control (G1, n=8), sham (G2, n=8), SAH + Vehicle (G3, n=8), SAH with low-dose HSP (G4, n=8), and SAH with high-dose HSP (G5, n=8). SAH was induced using a double injection of homologous blood into the cisterna magna. Biochemical markers (superoxide dismutase [SOD], catalase [CAT], glutathione peroxidase [GPx], nitric oxide [NOS]), basilar artery morphometry, and molecular expressions (Erk5, p-Erk5, KLF2, eNOS) were evaluated 48 hours post-SAH.
RESULTS: SAH significantly increased oxidative stress and reduced vascular lumen diameter in untreated rats (G3). Both HSP-treated groups (G4 and G5) showed improved antioxidant enzyme levels (SOD, CAT, GPx) and near-normal NOS levels. Morphometric analysis demonstrated significant preservation of basilar artery lumen diameter in treated groups, with no significant changes in wall thickness. Molecular analysis revealed upregulation of the Erk5-KLF2-eNOS pathway, suggesting a role in vasodilation and mitigation of oxidative stress.
CONCLUSION: HSP protects against SAH-induced vasospasm and oxidative damage by enhancing antioxidant capacity and modu-lating the Erk5-KLF2-eNOS pathway, suggesting its therapeutic potential.

BACKGROUND: Mediastinitis is a rare but life-threatening complication after upper gastrointestinal (GI) surgery. Although advances in perioperative care have improved outcomes, the prognostic impact of the timing of onset remains unclear. Clarifying whether early-onset versus late-onset mediastinitis influences clinical, microbiological, and surgical outcomes is essential to guide management.
METHODS: We retrospectively analyzed 27 patients with mediastinitis after upper gastrointestinal surgery treated at our center between 2015 and 2025. Our institution is a tertiary-level, high-volume center performing complex upper GI procedures. During this period, 728 patients underwent upper GI surgery, among whom anastomotic leakage occurred in 44 (6.1%), and mediastinitis developed in 27 (3.7%). Patients were classified into early-onset (≤14 days) and late-onset (>14 days) mediastinitis groups based on the postoperative interval. Demographic and clinical variables, comorbidities, smoking history, malignancy status, microbiological culture results, surgical interventions, intensive care unit (ICU) admission and duration, hospital stay, duration of antibiotic treatment, complications, and mortality were recorded and compared.
RESULTS: During the 10-year study period, 728 patients underwent upper gastrointestinal surgery at our institution, and mediastinitis developed in 27 patients (3.7%) following esophageal or gastric procedures. The median age was 64 years [interquartile range: 54–74.5], and 55.6% were male. Malignancy was present in 70.4%, most frequently gastric adenocarcinoma (n=6). Overall, ICU admission was 81.5%, with a median ICU stay of two days, and mortality occurred in eight patients (29.6%). Culture positivity was observed in 16 patients (59.3%), most commonly with Klebsiella pneumoniae, Proteus mirabilis, and Enterobacter spp. Compared with late-onset mediastinitis, early-onset mediastinitis was associated with significantly shorter ICU stay (median 1 vs. 6.5 days, p=0.020), hospital stay (16 vs. 41 days, p=0.003), and antibiotic duration (14 vs. 35 days, p=0.002). The early-onset group demonstrated a lower mortality rate than the late-onset group (17.6% vs. 50.0%, p=0.102). Late-onset mediastinitis correlated with higher culture positivity and a greater need for complex surgical procedures, including video-assisted thoracic surgery (VATS), thoracotomy, and endoscopic stenting. Reoperations were required in 13 patients (48.1%). When stratified into abdominal and thoracic procedures, abdominal re-operations were more frequently observed in the late-onset group (5/8, 62.5%), whereas thoracic reoperations predominated in the early-onset group (4/5, 80%). Patients without reoperation constituted 51.9% of the cohort (14/27).
CONCLUSION: Early-onset mediastinitis after upper GI surgery is associated with improved outcomes. It correlates with better survival, shorter ICU and hospital stay, reduced antibiotic treatment, and a lower need for complex surgical procedures, whereas late-onset mediastinitis is linked to higher microbial burden, more frequent reoperations, and poorer outcomes.

BACKGROUND: This multicenter retrospective cohort study aimed to develop a novel five-parameter scoring model to predict incidental appendiceal neoplasia in patients aged ≥40 years diagnosed with acute appendicitis. Previous literature has reported a significant increase in the risk of neoplasia, particularly after age 40, and this cut-off value was used as the basis for our study design.
METHODS: A multicenter retrospective cohort analysis was conducted across six tertiary hospitals between January 2019 and December 2024. Adult patients aged ≥40 years who underwent appendectomy with preoperative contrast-enhanced computed tomography (CT) and had available laboratory data were included. Predictive variables were identified using multivariate logistic regression. The scoring system incorporated age, female sex, appendix diameter, absence of CT wall enhancement, and low neutrophil count. Diagnostic performance was assessed via receiver operating characteristic (ROC) analysis.
RESULTS: Of 2,143 patients analyzed, 122 (5.7%) had incidental neoplasia. The scoring system yielded an area under the ROC curve of 0.641 (95% confidence interval: 0.594–0.690). Using a cutoff score ≥3, sensitivity was 56.6%, specificity 65.4%, positive predictive value 9%, and negative predictive value 96.1%. Patients with a maximum score of 5 had a 33.3% incidence of neoplasia.
CONCLUSION: This five-parameter scoring system demonstrates a high negative predictive value and may help identify low-risk patients in whom standard appendectomy can be safely performed. This model, which allows low-risk patients to be safely excluded thanks to its high negative predictive value, provides an innovative contribution to clinical decision-support systems.

BACKGROUND: Traumatic brain injury (TBI) is one of the common reasons for decompressive craniectomy (DC). The management of DC must include cranioplasty procedures. Although both procedures may cause several complications, postoperative outcomes are of greater concern for patients. The timing of cranioplasty (CP) and the type of CP material are the main parameters evaluated retrospectively in this report in terms of their impact on postoperative complications and cosmetic results.
METHODS: A total of 47 patients who underwent autologous cranioplasty (n=22) or custom-made titanium cranioplasty (n=25) due to TBI between January 2017 and January 2024 in our department were retrospectively analyzed. The groups were compared in terms of demographic characteristics, complication rates, and operative parameters. Cosmetic results and one-year mortality rates were also reported. The Odom criteria were used for the assessment of cosmetic results.
RESULTS: Baseline characteristics and overall complication rates did not differ significantly between the groups. Blood loss was significantly lower in titanium cranioplasty compared to autologous cranioplasty (126.2±47.9 ml vs. 215.5±35.6 ml, p<0.001). The highest complication rate was observed in cranioplasties performed 3–6 months after DC. In the early period (<3 months), autologous grafts were associated with significantly more complications than titanium (5/7 vs. 0/7, p=0.021). Cosmetic outcomes were significantly better with titanium, while timing had no effect on cosmetic results. One-year mortality rates were similar between the groups.
CONCLUSION: The timing of cranioplasty and the type of cranioplasty material may influence postoperative outcomes in patients with TBI. Titanium plates could be a preferable option for early cranioplasty if autologous bone cannot be used for reconstruction, whereas late cranioplasty appears to be associated with fewer complications overall. Further studies are needed to support these findings.

BACKGROUND: The 2023 Türkiye earthquake resulted in a large number of pediatric victims with musculoskeletal trauma, many of whom developed compartment syndrome (CS) and crush-related complications. This study aimed to identify clinical and biochemical parameters associated with disease severity, renal failure, and limb loss in children affected by the disaster.
METHODS: A retrospective analysis was conducted on 103 pediatric patients (0–18 years) admitted after the earthquake. Demographic data, duration of entrapment, laboratory values (creatine kinase [CK], myoglobin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], urea, potassium), and therapeutic interventions (fasciotomy, negative-pressure wound therapy [NPWT], hyperbaric oxygen therapy [HBOT], hemodialysis, and amputation) were evaluated. Receiver operating characteristic (ROC) analyses were used to determine cut-off values predicting adverse outcomes.
RESULTS: Forty-seven patients (45.6%) developed compartment syndrome involving 68 limbs and underwent fasciotomy. Thirteen patients (12.6%) required limb amputation, and 19 (18.4%) underwent hemodialysis due to acute kidney injury. An entrapment duration exceeding 8 hours (area under the curve [AUC]=0.84, p<0.001), CK>10,000 U/L, and myoglobin >4,000 ng/mL were independent predictors of renal failure, fasciotomy, and amputation. NPWT was applied in 66% and HBOT in 85% of patients with necrosis, contributing to an 82% limb salvage rate. No amputations occurred in patients without persistent necrosis. Three patients (2.9%) died from severe crush-related injuries and multi-organ failure.
CONCLUSION: Prolonged entrapment and markedly elevated CK and myoglobin levels are reliable indicators of adverse outcomes in pediatric earthquake victims with compartment syndrome. Early recognition, timely decompression, and structured wound management (NPWT and HBOT) are essential for improving survival and limb salvage when early surgical intervention is not feasible in large-scale disasters.

BACKGROUND: This study aimed to investigate changes in vibration sensation in patients with anterior talofibular ligament (ATFL) rupture following acute ankle sprain and to assess its potential use as a proprioceptive assessment tool.
METHODS: A 128 Hz tuning fork was applied to the ATFL region—identified as ruptured via ultrasound—while the ankle was positioned in inversion and plantar flexion. Vibration duration was measured using a stopwatch. Data were compared with those from a healthy population and from patients with lateral ankle edema following acute sprain without rupture. The study was prospectively designed.
RESULTS: A total of 81 patients (48 male, 33 female) were included, with a mean age of 29.19 years. Among the 27 patients with ATFL rupture, nine had an additional calcaneofibular ligament (CFL) injury and five had an additional posterior talofibular ligament (PTFL) injury (Grade 2–3). The mean vibration duration in ATFL rupture patients was 5.72 seconds on the injured side and 7.87 seconds on the uninjured side, showing a statistically significant difference (p=0.001). At the 12-week follow-up, the mean vibration time improved to 7.65 seconds, which was also statistically significant (p=0.001).
CONCLUSION: Proprioceptive impairment due to acute ATFL rupture was associated with reduced vibration sensation at the rupture site. As proprioception improved, vibration sensation also recovered. Therefore, vibration measurement using a tuning fork may serve as a practical proprioceptive assessment tool and an adjunctive diagnostic method.

BACKGROUND: Vertebral compression fractures of varying severity and morphology may result from trauma and often require the preparation of a forensic medical report. Given the legal implications, accurate measurement of the compression ratio is critical. This study aims to evaluate whether four literature-defined methods for determining compression ratios are consistent with one another and with radiology reports, and to examine whether the choice of method alters the conclusions of forensic medical reports.
METHODS: A retrospective review was conducted of forensic reports issued by our Department of Forensic Medicine between June 1, 2014 and June 1, 2024. Forty-two cases met the predefined inclusion criteria. For each vertebral fracture, the compression ratio was calculated using four established methods. Consistency was assessed both among these methods and between each method and the compression ratio documented in the corresponding radiology report. Finally, it was evaluated whether measurement discrepancies would alter the forensic conclusions regarding (1) the effect of the fracture on life functions, (2) permanent weakness or loss of function of one of the senses or organs, and (3) degree of disability.
RESULTS: Agreement among the four measurement methods was weak to moderate, with inconsistency rates of 14.8% to 66.7% compared to radiology reports. Forensic report conclusions varied according to the measurement method.
CONCLUSION: Method selection significantly influences both calculated compression ratios and the resulting conclusions of forensic reports in vertebral compression fractures. A standardized, universally accepted measurement protocol is therefore required in forensic practice to support fair and consistent legal decisions.

BACKGROUND: We evaluated the long-term outcomes of bone autograft versus tibial medullary cancellous bone graft combined with allograft as therapeutic interventions for medial compartment osteoarthritis associated with genu varum deformity.
METHODS: This retrospective cohort study included patients with knee osteoarthritis who underwent medial open-wedge high tibial osteotomy (MOWHTO), receiving either an autogenous bone graft or a tibial medullary cancellous bone graft combined with an allograft. Clinical status was assessed using the Visual Analog Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiological parameters, including the hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), and femorotibial angle (FTA), were measured preoperatively and at the 6-month follow-up.
RESULTS: In total, 157 patients were included: 81 in Group A (autograft) and 76 in Group B (tibial medullary cancellous bone graft combined with allograft). No significant differences were observed between the groups in postoperative HKA, MPTA, and FTA values. However, VAS and WOMAC scores were significantly lower in the combined graft group.
CONCLUSION: The use of a combined tibial medullary cancellous bone graft with allograft in MOWHTO is associated with improved functional outcomes at the 6-month follow-up, as evidenced by statistically significantly reduced VAS and WOMAC scores.

BACKGROUND: The purpose of this study was to present a new method for managing displaced metaphyseal fractures of the distal radius in pediatric patients that could not be reduced by closed reduction, and to evaluate the clinical and radiological outcomes of reduction after the stepwise injection of physiological saline.
METHODS: A total of 24 pediatric patients who underwent closed reduction of displaced metaphyseal distal radius fractures using the stepwise injection of physiological saline in our clinic between May 2018 and May 2020 were retrospectively examined. Follow-up visits were scheduled for all patients at three, six, and 12 months. Radiological and functional outcomes were evaluated. The Mayo Wrist Score was used in the clinical assessments, and union and deformity were assessed radiologically.
RESULTS: Sixteen patients were boys and eight were girls, with a mean age of 9.38±2.123 years. Among the etiologies of injury, falling off a bike accounted for six cases, skating injuries for five, scooter-related falls for four, falls at school for four, falls at home for three, and falls from stairs for two cases. Fourteen patients had right-sided fractures and ten had left-sided fractures. The mean number of pins used during surgery was 2.79±0.588. The mean amount of physiological saline used during surgery was 16.25±4.72 mL. The patients stayed in the hospital for a mean duration of 2±0.590 days after surgery, and their mean follow-up duration was 80.54±24.775 days. The mean time for pin removal was 4.46±0.658 weeks. Four patients had good Mayo Wrist Scores, and 20 patients had excellent scores. During follow-up, only two patients developed pin site infections.
CONCLUSION: Closed reduction and percutaneous pinning using the stepwise injection of physiological saline appears to be an effective and safe treatment technique for displaced distal radius fractures that cannot be reduced by closed reduction in pediatric patients.

BACKGROUND: This study aims to evaluate the mental health outcomes of orthopedists after the 2023 Kahramanmaraş earthquakes through a comprehensive analysis based on orthopedic care and amputations.
METHODS: This cross-sectional, questionnaire-based study, conducted six months after the 2023 Kahramanmaraş earthquakes, included a total of 95 orthopedists. The online questionnaire assessed demographic characteristics, professional experience, and mental health outcomes using the Impact of Event Scale-Revised (IES-R) and the Depression Anxiety Stress Scale-21 (DASS-21). Scale scores were analyzed according to earthquake zone challenges, orthopedic care provision, and amputation-related stress factors.
RESULTS: Care for earthquake victims was provided by 61.5% of orthopedists in the earthquake area, including local (16.8%) and supporting orthopedists (42.1%), while 36.8% treated victims at referral hospitals outside the area. Overall, 76.8% of participants reported performing amputation surgery on earthquake victims. Performing amputations in the pediatric age group (82.2%), witnessing patients’ losses or other earthquake-related difficulties (64.4%), and amputations involving multiple extremities (56.2%) were reported as the three most common stress factors related to amputations. Orthopedists at referral hospitals and local orthopedists reported higher total IES-R scores (11.0 [0-58] and 11.5 [0-46] vs. 1.0 [0-39]), as well as higher avoidance (3.0 [0-20] and 3.0 [0-17] vs. 0.0 [0-13]) and intrusion (4.0 [0-20] and 5.0 [0-20] vs. 0.0 [0-14]) subscale scores. Referral hospital orthopedists showed higher anxiety (2.0 [0-13] vs. 0.0 [0-7]), stress (5.0 [0-16] vs. 2.0 [0-12]), and total DASS-21 scores (11.0 [0-44] vs. 6.0 [0-29]) than supporting ortho-pedists in the disaster zone. Those performing amputations in patients with earthquake-related difficulties reported higher DASS-21 depression scores (4 [0-18] vs. 1 [0-15], p=0.013). IES-R scores were negatively correlated with age (r=-0.203, p=0.049), while other factors showed no correlation with IES-R or DASS-21 scores.
CONCLUSION: Our study shows that treating earthquake victims has a significant impact on orthopedists' emotional states and traumatic stress, especially for local and referral hospital orthopedists. The key stress factors included pediatric amputations, multiple extremity amputations, and patient-related difficulties. While tragic events involving relatives did not show a significant association with the scores, performing amputations on patients with earthquake-related difficulties increased depression scores, and younger orthopedists reported higher IES-R scores than older orthopedists. Our findings highlight the need for regular mental health screening, risk group identification, structured psychological support, and resilience training among orthopedic surgeons following large-scale disasters, as well as enhanced preparedness for future emergencies.

BACKGROUND: This research aimed to compare the surgical data and the clinical and radiological results of patients who under-went open posterior versus percutaneous posterior instrumentation for burst-type spinal fractures in the thoracolumbar junction.
METHODS: This study included 73 patients; 43 underwent open posterior instrumentation, and 30 underwent percutaneous posterior instrumentation. Perioperative parameters included the time between fracture and surgery, duration of surgery, perioperative blood loss, fluoroscopy duration, and total length of hospital stay. Clinical evaluation was performed using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI). Preoperative, postoperative, 7th-day, and last follow-up values were analyzed. Radiological evaluation included the anterior vertebral body height ratio (AVBHR) and Cobb angle.
RESULTS: Fluoroscopy time was significantly longer in the percutaneous surgery group than in the open surgery group (12.77±1.89 minutes vs. 4.33±1.24 minutes; p<0.001). Hospitalization time was significantly longer in the open surgery group (3.79±1.53 days vs. 2.13±0.76 days; p<0.001). VAS scores differed significantly between the open and percutaneous surgery groups on the 7th postoperative day (p=0.02) and at the last follow-up (p=0.02). Similarly, lower ODI scores were observed in the percutaneous group compared to the open surgery group on the 7th postoperative day and at the last follow-up (p<0.001). Regarding radiological outcomes, significant postoperative improvements were achieved in both groups in terms of AVBHR, but differences in the Cobb angle in the sagittal plane were not statistically significant (p=0.07).
CONCLUSION: According to the results of this study, the percutaneous surgery group showed significantly better improvement in VAS and ODI scores on postoperative day 7 and at the final follow-up. Similar postoperative improvements were achieved in both groups in terms of AVBHR and sagittal Cobb angle.

BACKGROUND: This study aimed to compare the medium- to long-term results of elbow collateral ligament repairs performed with suture anchors.
METHODS: Patients undergoing surgery for elbow collateral ligament repairs between 2011 and 2023 were retrospectively analyzed. We included patients who had undergone surgery for complex elbow dislocations. Patients were excluded from the study if they had a previous infection, a fracture, an operation on the same elbow, a stiff elbow, or a follow-up period of less than 1 year. For the functional evaluation, the range of motion (ROM) and the Mayo Elbow Performance Score (MEPS) were used for the postoperative functional assessments. The radiological evaluation used varus and valgus stress radiographs of healthy and operated extremities taken while applying an 80 N force with a digital dynamometer.
RESULTS: Thirty-five patients (24 male and 11 female) were included in the study. Eighteen patients had isolated lateral collateral ligament (LCL) injuries, nine patients had isolated medial collateral ligament (MCL) injuries, and eight patients had LCL and MCL injuries. The mean age was 32 (18–68) years, and the follow-up period was 104.8 (32–147) months. The mean value of the MEPS was 92.1±10.3; 22 patients had excellent, 11 patients had good, and only two patients had fair results. Patients with isolated LCL and MCL repairs achieved better flexion motion than patients with combined ligament repairs (142.5° and 141.7° vs. 138.6°). When comparing operated and healthy extremities, radiocapitellar joint distance (RCJD) was found to increase by 0.8±0.5 mm, and ulnotrochlear joint distance (UTJD) was found to increase by 1.18±0.5 mm, but these changes were not statistically significant.
CONCLUSION: The results of this study suggest that the use of suture anchors in elbow collateral ligament injuries is a valid solution for treatment and prevention of instability in patients with isolated or combined repairs.

Mechanical bowel obstruction due to a giant colonic calculus is an exceedingly rare clinical entity, typically associated with gallstone ileus or migration through a cholecystocolonic fistula. This case report describes the clinical presentation, diagnostic process, and treatment of an 81-year-old male with a history of cholelithiasis who developed acute mechanical large bowel obstruction due to a 5 cm sigmoid colon calculus. The patient, with comorbidities including diabetes mellitus, hypertension, chronic renal failure, prior prostatectomy, and appendectomy, presented with abdominal pain, nausea, and vomiting. Physical examination revealed tenderness in the left lower quadrant without rebound or guarding, indicating no evidence of perforation. Laboratory findings showed leukocytosis (white blood cell count [WBC]: 12,000/μL, neutrophil percentage: 85.2%) and elevated C-reactive protein [CRP] (33 mg/L). Non-contrast abdominal computed tomography (CT) revealed a 5 cm calculus in the sigmoid colon, with proximal dilatation, air-fluid levels, and pneumobilia. A prior hepatobiliary ultrasound had documented a 49 mm gallstone, suggesting migration via a cholecystocolonic fistula. Sigmoidoscopy, performed using an Olympus CF-HQ190 colonoscope with tripod grasping forceps, successfully extracted the calculus. Due to the patient’s advanced age and significant comorbidities, surgical repair of the cholecystocolonic fistula was not pursued. A follow-up hepatobiliary ultrasound one month post-procedure revealed no residual gallstones. The patient achieved rapid recovery and was discharged the following day. This case is notable for the exceptionally large 5 cm calculus, which is rare compared to the 2–3 cm stones typically reported, and highlights the efficacy of sigmoidoscopy in managing such cases in elderly patients with significant comorbidities.

Meckel’s diverticulum (MD) is a frequently silent congenital anomaly of the gastrointestinal tract. While complications such as bleeding and obstruction are more common, traumatic perforation remains extremely rare, particularly from penetrating injuries. To date, isolated perforation of MD following self-inflicted abdominal stab wounds has been reported only sporadically. We present the case of a 39-year-old male with a long-standing history of schizophrenia and epilepsy who arrived at the emergency department following his fifth self-inflicted abdominal stab injury over the past decade. On physical examination, a segment of small bowel was found protruding from a 4 cm periumbilical wound. Emergency exploratory laparotomy revealed extensive intra-abdominal adhesions and an isolated perforation of a Meckel’s diverticulum located 60 cm proximal to the ileocecal valve. No other visceral injuries or hemorrhage were detected. The diverticulum was resected using a linear stapler, and serosal defects were repaired. The postoperative course was uneventful, and the patient was discharged on postoperative day five. Isolated MD perforation caused by penetrating abdominal trauma is exceedingly rare and diagnostically challenging. When occurring in psychiatric patients with repetitive self-harm behavior, it presents an even more complex scenario. This case underscores the importance of meticulous intra-abdominal exploration in stab wound patients and contributes novel insight to the limited literature on traumatic MD injuries.