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  1. Kow RY, Che-Ahmad A, Ayeop MAS, Ahmad MW, Yusof S
    J Orthop Surg (Hong Kong), 2021 11 11;29(3):23094990211043987.
    PMID: 34753329 DOI: 10.1177/23094990211043987
    BACKGROUND: Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically.

    METHODS: Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques.

    RESULTS: There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829).

    CONCLUSIONS: Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them.

    LEVEL OF EVIDENCE: Level II, randomized controlled trial.

  2. Kow RY, Low CL, Siron Baharom KN, Sheikh Said SNB
    Cureus, 2021 Jun;13(6):e15758.
    PMID: 34290935 DOI: 10.7759/cureus.15758
    Introduction After detailed anatomical delineation of the anterolateral ligament (ALL) of the knee, there is a surge in research on this anatomical structure. Owing to the anatomical variation and lack of experience in the identification of this structure, magnetic resonance (MR) evaluation of the ALL produces mixed results. It was aimed to evaluate the ALL using the routinely performed MR imaging of the knee and to determine any associated factors with ALL injuries. Materials and methods Thirty-six MR images of the knee from 31 patients from January 1, 2017, to June 30, 2017, are evaluated. MR sequences performed include T1-weighted, T2-weighted, proton density (PD), and PD fat saturation (FS). All MR images were double-read by two authors and approved by a consultant radiologist with more than 20 years of radiological experience. The ALL was divided into three portions: femoral, meniscal, and tibial, and the ALL was considered fully visualized when all three portions were seen on MR images. Results At least a portion of the ALL was visualized in 27 scans (75%), and it was fully visualized in 20 scans (55.6%). The femoral portion was the most commonly identified (75%), followed by the meniscal portion (69.4%) and the tibial portion (58.3%). ALLs were best visualized on coronal view in PD FS with the lateral inferior genicular artery as a guide to locate the bifurcation of the meniscal and tibial components. Conclusion The ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via a PD-weighted sequence with fat saturation on the coronal plane. The ALL injury was associated with an anterior cruciate ligament (ACL) injury.
  3. Kow, Ren Yi, Hazwan Ab Wahid, Ed Simor Khan Mor Japar Khan, Colin Komahen, Low, Chooi Leng, Ruben Jaya Kumar
    MyJurnal
    Cervical spine injury is commonly associated with
    road-traffic accidents. The true incidence of cervical
    spine injuries is unknown due to under-reporting of
    such injuries. Cervical spine injury is associated with
    high morbidity and mortality if it is missed. With the
    advancement of imaging modalities, the number of
    missed cervical injuries has reduced. Nevertheless, some
    clinicians are dependent solely on imaging tools to rule
    out cervical spine injury in a trauma victim. We report
    two cases of “near miss” C6 fracture to highlight the
    importance of a detailed clinical history and clinical
    examination with imaging as an adjunct to rule out
    cervical injury.
  4. Zakaria Mohamad Z, A Rahim A, Kow RY, Karupiah RK, Zainal Abidin NA, Mohamad F
    Cureus, 2022 Jan;14(1):e20889.
    PMID: 35145794 DOI: 10.7759/cureus.20889
    Background Transpedicular biopsy of spinal lesions is imperative for the generation of a definite diagnosis. Thus far, literature comparing the accuracy and adequacy between fluoroscopy-guided and computed tomography (CT)-guided transpedicular biopsy of spinal lesions is scarce. We aim to compare the accuracy and adequacy of samples collected with the two techniques at the largest tertiary hospital in Malaysia. Materials and methods A total of 60 patients (37 patients with spinal infection and 23 patients with spinal tumour) underwent percutaneous transpedicular biopsy of spinal lesions from January 2013 to December 2017 at a tertiary centre. Demographic data, biopsy method (fluoroscopy-guided and CT-guided), diagnosis, adequacy, and accuracy of samples obtained were assessed. Results Among the 60 samples obtained, only two samples (3.3%) were deemed inadequate. There were 10 biopsy samples (16.7%) that were inaccurate. There was no statistical difference between fluoroscopy-guided and CT-guided transpedicular biopsy in terms of accuracy (p = 0.731) and adequacy (p = 0.492). Conclusions Fluoroscopy-guided and CT-guided transpedicular biopsy of spinal lesions offer similar accuracy and adequacy. Fluoroscopy-guided biopsy of the spinal lesion will be an option for spine surgeons when CT-guided biopsy is not available.
  5. Anwarali Khan MH, Kow RY, Ramalingam S, Sofian A, Ho JPY, Jaharan Singh KS, et al.
    Cureus, 2023 Jun;15(6):e40479.
    PMID: 37456372 DOI: 10.7759/cureus.40479
    Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remain high among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion  The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.
  6. Low CL, Kow RY, Abd Aziz A, Mohd Yusof M, Lim BC, Kamarudin NA, et al.
    Cureus, 2023 Jun;15(6):e40484.
    PMID: 37461753 DOI: 10.7759/cureus.40484
    Introduction Computed tomography pulmonary angiography (CTPA) is the reference investigation of choice to diagnose pulmonary embolism (PE). Nevertheless, the use of CTPA should be weighed against its risks, such as radiation and contrast-induced nephropathy. We aim to assess the yield of CTPA in diagnosing PE at a tertiary centre in Malaysia. We also identify predictive factors associated with the yield of CTPA in this cohort. Methods This was a cross-sectional study involving all patients who had had CTPA done at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, from January 1, 2021, to November 30, 2021. All patients' records were retrieved and reviewed. CTPA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS). They were double-reviewed by the authors, with the initial reports redacted from reporting radiologists to prevent reporting bias. The predictive factors were determined using simple logistic regression and multiple logistic regression. Results A total of 351 CTPAs were reviewed, of which 93 were found to be positive for PE, giving rise to an overall CTPA yield of 26.5%. Upon simple logistic regression, factors such as gender, discipline, history of trauma, presence of COVID-19 infection, and pneumonia were found to be associated with positive CTPA. Upon multiple logistic regression, male patients were found to have a higher chance of positive CTPA results. On the other hand, patients with COVID-19 infection and pneumonia have a lower chance of positive results in CTPA. Conclusion The yield of CTPA in diagnosing PE at our institution was acceptable at 26.5%. Upon multiple logistic regression, patients with COVID-19 infection and pneumonia were more likely to have a negative CTPA result, highlighting the need for clinicians to be more prudent in requesting CTPAs in these patients.
  7. Kow RY, Razali K, Low CL, Siron KN, Zakaria Mohamad Z, Mohd Yusof M, et al.
    Cureus, 2023 Jul;15(7):e41979.
    PMID: 37593261 DOI: 10.7759/cureus.41979
    CT pulmonary angiography (CTPA) is the investigation of choice for diagnosing pulmonary embolism (PE). Due to the speed and ease of performing the CTPA scans, more clinicians are becoming overly reliant on them, even for patients without strong suspicion of PE. We conducted a bibliometric analysis on the PubMed database from 1990 to 2022 to investigate the literature on the diagnostic yield of CTPA in the diagnosis of PE. A total of 166 articles were published in 98 journals. The number of publications has steadily increased since 2010 and peaked in 2020. Authors from 24 countries contributed to these publications, with the overwhelming majority emanating from United States of America, totaling 66 articles. The authors' contributions were relatively well spread out, with the top four authors publishing the highest number of articles at six each. When we investigated the collaboration between the authors, we found limited multinational and multi-institutional collaborations on this topic. Therefore, more multinational and multi-institutional collaborations will be valuable in future studies. In conclusion, this bibliometric analysis summarizes the literature on diagnostic yield of CTPA in the diagnosis of PE and sheds light on the future pathway that researchers and institutions can focus on.
  8. Ahmad Alwi AA, Low CL, Kow RY, Tajudin FA, Lim BC, Halim Lim AA, et al.
    Cureus, 2023 Oct;15(10):e48067.
    PMID: 38046487 DOI: 10.7759/cureus.48067
    Background A soft tissue defect resulting from a diabetic heel ulcer can be difficult to address due to limited reconstructive options and unique local area demand. The medial plantar artery flap is ideal for heel defect coverage as it provides a thick glabrous skin with good sensory feedback. The prerequisite of medial plantar artery flap surgery is a patent medial plantar artery, which is a branch of the posterior tibial artery (PTA). Nevertheless, no feasibility study of the medial plantar artery flap in diabetic patients with vascular insufficiency has been reported so far. We conducted a pilot study with the aim of investigating the patency of the medial plantar artery in diabetic patients with suspected peripheral artery disease to determine the vascular feasibility of the medial plantar artery flap in these patients. Material and methods A pilot study was performed at Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia (IIUM). A total of 15 diabetic patients with suspected vascular insufficiency who had undergone lower limb computed tomography angiography (CTA) from January 2022 to June 2023 were included in this study. All patients were identified via the electronic record system. Lower limb CTA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS) and were double-reviewed. Both the posterior tibial artery (PTA) and medial plantar artery (MPA) were assessed for their patency, and the diameter of the lumens was measured if they were patent. Bedside clinical assessments such as palpation of pulses and portable Doppler assessment were evaluated to determine whether they could serve as substitutes for computed tomography angiography (CTA) in assessing the feasibility of medial plantar artery flap using the McNemar test. Results In this study cohort, the medial plantar artery was present in 16 legs and absent in another 14 legs. The largest diameter of the medial plantar artery was 2.5mm (range 0-2.5mm). Palpation of the posterior tibial artery was not optimal for predicting the patency of the medial plantar artery, with a false positive of 21.4% and a false negative of 68.7%. Similarly, a hand-held Doppler assessment of the posterior tibial artery was also ineffective, with a false positive of 64.3% and a false negative of 18.8%. While the medial plantar artery is a continuation of the posterior tibial artery (PTA), PTA patency did not necessarily correlate with medial plantar artery patency. This was demonstrated on CTA assessment, where two legs with absent PTA still have reconstitution, resulting in patency of the medial plantar artery. Additionally, one leg with patent PTA did not have a patent medial plantar artery distally due to calcified vessels. Conclusion This is a first-of-its-kind pilot study attempting to determine the feasibility of medial plantar artery in diabetic patients with vascular insufficiency. The medial plantar artery was present in more than 50% of the investigated lower limbs, paving the way for using the medial plantar artery flap in these patients. Nevertheless, a computed tomography angiogram is essential to determine the patency of the medial plantar artery prior to the flap procedure, as palpation and hand-held Doppler were inadequate to predict the patency of the medial plantar artery in these high-risk patients.
  9. Kow, Ren Yi, Dhiauddin Hai Ismail, Jamaluddin Shafie, Ruben Jaya Kumar, Nor Hafliza Md Salleh, Low, Chooi Leng
    MyJurnal
    Marjolin’s ulcer is a malignant cutaneous ulcer
    that undergoes transformation from a previously
    traumatized or chronically inflammed skin.1 Causes
    leading to ulcerations can be burn injury, trauma,
    chronic osteomyelitis and varicose ulcers.2 It is named
    after a French surgeon, Jean Nicolas Marjolin, who
    first described the condition in patients who developed
    malignant ulcers from burn scars.3 We report a case of
    a chronic non-healing foot ulcer that has become a
    Marjolin’s ulcer after 12 years. (Copied from article).
  10. Kow Ren Yi, Ed Simor Khan Mor Japar Khan, Fauziana Abd Jabar, Fauziana Abd Jabar, Low Chooi Leng
    IIUM Medical Journal Malaysia, 2019;18(102):69-0.
    MyJurnal
    Majority of the traumatic spine injuries are located at the thoracolumbar region. They can be compression fractures, burst fractures, flexionextension injuries (Chance fractures), dislocations, or any of the combination. Surgery is indicated for patients with thoracolumbar injury classification scoring (TLICS) of 4 or more. Traditionally, surgical approaches for thoracolumbar spinal injuries involve open surgery, instrumentation with/without decompression. In our previous study, open surgery for traumatic thoracolumbar injuries and history of blood transfusion have been found to be associated with higher risk of deep surgical site infection requiring surgical debridement. With the advent of modern implants and equipments, minimally invasive surgery (MIS) has been made possible for spine surgeries. We report our two-year experience in utilizing MIS to treat traumatic thoracolumbar spinal injuries. Materials and method: Patients who underwent spinal surgeries at Hospital Tengku Ampuan Afzan, Kuantan from July 2017 to July 2019 were screened for suitability to be included in this study. Only patients who underwent spinal minimally invasive surgeries have been included in this study. Patients who underwent open spinal surgeries were excluded. Results: A total of 8 patients were included in this study. There were 3 burst fractures and 5 chance fractures. All patients underwent a minimum of 4-level posterior spinal instrumented fusion with MIS techniques and 2 patients had laminectomy at the injured level for decompression. All but one patient did not require blood transfusion and there was no incidence of surgical site infection among these patients. Conclusion: Minimally invasive surgery (MIS) is a better option compared to open surgery in treating traumatic thoracolumbar spinal injuries. By minimizing the surgical incision, we are able to reduce blood loss and avoid deep surgical site infection.
  11. Kow Ren Yi, Ed Simor Khan Mor Japar Khan, Mohd Jumaidi Md Hashim, Anas Nazhar, Low Chooi Leng
    IIUM Medical Journal Malaysia, 2019;18(102):61-0.
    MyJurnal
    Solat or prayer, as one of the five pillars of Islam, and it is associated with bio-psycho-social benefits in Muslim patients. Â Many Muslim patients neglected solat while being hospitalized as they are unaware of the convenience (rukhsoh) available for them. Ibadah Friendly Hospital Courses have been conducted in different states of Malaysia to impart knowledge to the hospital staff who can in turn educate their patients. This study aims to construct a content-validated assessment tool and to assess the effectiveness of a state-level Hospital Mesra Ibadah course. Materials and methods: A self-administered questionnaire was constructed and content-validated by a panel of three experts (two religious teachers and one consultant spine surgeon). All 15 questions achieved item-level content validity index (I-CVI) of 1.00 after two rounds of validation. The questionnaires were distributed to participants of a state-level Hospital Mesra Ibadah course to compare the participants’ pre-course test score and post-course test score. Results: A total of 88 participants (48.9%) were included in this study. There was a significant difference in the pre-course test mean score and post-course test mean score among the participants. There was also a significant reduction of unsure answer after the course. There was no significant association found between the gender, place of working and occupations with the pre-post test score difference. Conclusion: This study demonstrates that the Hospital Mesra Ibadah course is effective in imparting as well as consolidating the knowledge among participants, hence it should be routinely organized to benefit more participants.
  12. Raj JJ, Kow RY, Ramalingam S, Low CL
    Cureus, 2021 Jul;13(7):e16155.
    PMID: 34367767 DOI: 10.7759/cureus.16155
    Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.
  13. Kow RY, Yuen JC, Ahmad Alwi AA, Abas MF, Low CL
    JBJS Case Connect, 2019 6 25;9(2):e0163.
    PMID: 31233428 DOI: 10.2106/JBJS.CC.18.00163
    CASE: A 17-year-old male sustained an open fracture of the right medial malleolus (MM) with significant bone and soft tissue loss following a motor-vehicle accident. Following serial wound debridement, his ankle was effectively reconstructed with MM antiglide plate stabilization, iliac autogenous bone graft, and a free radial forearm soft tissue flap.

    CONCLUSIONS: Open MM fracture with bone and soft tissue loss is rare. It is feasible to treat this injury with a novel surgical reconstruction technique involving autogenous bicortical iliac bone graft and radial forearm free flap.

  14. Jaya Raj J, Kow RY, Ganthel Annamalai K, Kunasingh DE, Panicker GK, Lim BC, et al.
    Cureus, 2021 Sep;13(9):e18110.
    PMID: 34692321 DOI: 10.7759/cureus.18110
    Background and objective Femoral neck fractures are relatively rare in young adults, but they result in prolonged loss of function in these patients, thereby placing a huge burden on a country's healthcare and economy. Femoral neck fractures in young adults are normally treated with head salvage surgery. However, primary head replacement surgeries have been gaining traction recently to expedite the recovery of these patients. In this study, we aimed to investigate the outcomes in young patients with femoral neck fractures and factors associated with their complications. Patients and methods Patients with femoral neck fractures who underwent surgery in three tertiary hospitals [Hospital Tengku Ampuan Afzan (HTAA), Hospital Sultan Haji Ahmad Shah (HOSHAS), and Hospital Kuala Lipis] in Pahang state in Malaysia were reviewed and included in this study. The demographic profile of the patients, injury patterns, intervention details, functional outcomes, and complications were analyzed. The comparison between the sociodemographics, clinical assessment, and complication outcomes was analyzed using statistical software. Results The complications were associated with the mechanism of injury, capsulotomy, and type of fixation. A total of 46 patients were included in the study. Most of the patients were found to have severe displacement based on Garden and Pauwels classification. The majority of the patients underwent femoral head salvage surgeries. Almost half of the patients sustained complications and were unable to achieve weight-bearing status at six months postoperatively. Conclusion Despite a relatively short follow-up period in our study, femoral neck fractures in young adults were found to be associated with a high rate of complications. Primary head replacement surgeries should be considered in high-risk patients with femoral neck fractures.
  15. Anwarali Khan MH, Kow RY, Ramalingam S, Ho JPY, Jaya Raj J, Ganthel Annamalai K, et al.
    Cureus, 2021 Oct;13(10):e18820.
    PMID: 34804677 DOI: 10.7759/cureus.18820
    Background and objective Periprosthetic joint infection (PJI) is one of the dreaded complications in patients after arthroplasty surgeries, owing to the risk of morbidity and arduous investigations and management associated with it. Nevertheless, as Malaysia is currently battling against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) pandemic head-on, the treatment for other non-life-threatening diseases including PJI has taken a backseat. In this study, we present a case series of 11 patients with PJI who were managed surgically at the largest tertiary hospital in Malaysia and we hope to shed some light on the difficulties we have encountered during this trying period. Patients and methods Patients with PJIs who underwent surgical intervention during the ongoing COVID-19 pandemic (March 1, 2020, to June 30, 2021) were reviewed and included in this study. The demographic profile of the patients, presenting complaints, prosthesis topography, biochemical investigative findings, surgical interventions, and short-term outcomes were summarized. Results A total of 11 patients were treated surgically at Hospital Kuala Lumpur for PJI. Among them, five patients are still awaiting their second-stage surgeries despite the completion of their antibiotic regimes, and they are fit for the procedure. Conclusion The COVID-19 pandemic has wreaked havoc on the treatment of patients with PJI. In a setting with scarce resources, surgeons should strongly consider single-stage revision surgeries for the treatment of patients with PJI.
  16. Yuen JC, Kow RY, Jaya Raj J, Low CL
    Cureus, 2022 Dec;14(12):e32254.
    PMID: 36620812 DOI: 10.7759/cureus.32254
    Joint replacement surgeries have been performed to treat joint arthropathies with excellent outcomes. As the number of joint replacement surgeries surges, the incidence of periprosthetic joint infection (PJI) has also increased. Currently, two-stage revision surgery is the gold standard in the treatment of periprosthetic joint infection. Two-stage revision surgery involves joint washout, the removal of the primary implant, the insertion of a cement spacer, and subsequently the reimplantation of prosthesis after the infection has been eliminated. Custom-made articulating cement spacer has been used with success to improve the patient's ambulatory status and quality of life. Nevertheless, custom-made articulating cement spacer or commercialized cement mold is generally costly. By the modification of previous authors' techniques, we manage to fabricate reusable silicone molds, which can be used to create articulating cement spacers for both hip and knee joints. We share two case reports to illustrate how these fabricated silicone molds can be a cost-effective technique to create articulating cement spacers to manage periprosthetic joint infection in both hip and knee joints. Surgeons in resource-deprived countries can utilize this technique to create articulating cement spacers with minimal cost, but they need to discuss with their patients and check with the local regulatory board on the feasibility of this technique to create cement spacer that will be used in a patient.
  17. Kow RY, Mustapha Zakaria Z, Khan ESKM, Low C
    J Orthop Case Rep, 2019 3 28;8(6):65-67.
    PMID: 30915298 DOI: 10.13107/jocr.2250-0685.1262
    Introduction: Fracture of the ulnar coronoid process is uncommon. It is commonly associated with posterior dislocation of the elbow, but it may also present as an isolated fracture. In general, all ulnar coronoid process fractures with elbow joint instability and large fracture fragments are fixed surgically. We report two cases of the rare isolated Regan-Morrey type III ulnar coronoid process fractures and their outcomes.

    Case Report: Case Report 1: Mrs P, a 27-year-old right-hand dominant female, was involved in a motor vehicle accident (MVA) and sustained an isolated Regan-Morrey type III ulnar coronoid process fracture. In view of the large coronoid process fragment causing elbow joint instability, she underwent an open reduction and internal fixation when the elbow swelling had subsided. An anterior approach was used to identify the fracture fragment and it was fixed with two half-threaded cancellous lag screws with washers to achieve an anatomical reduction. Postoperatively, she recovered with excellent outcome based on the Mayo elbow performance score (MEPS).Case Report 2: Mr M, a 23-year-old right-hand dominant gentleman, was involved in a MVA and sustained an isolated Regan-Morrey type III ulnar coronoid process fracture. During examination under general anesthesia, passive range of the movement of his right elbow was noted to be <90°due to the impaction of the fracture fragment. An open reduction through an anterior approach was performed and Kirschner wires were inserted to fix the coronoid process fracture. Kirschner wires were opted for the ease of post-operative removal as the patient was not keen to have a retained implant after recovery. He recovered with good outcome based on the MEPS.

    Conclusion: Isolated fracture of the ulnar coronoid process is rare. Open reduction and internal fixation is mandatory for patients with coronoid process fracture and unstable elbow joint to achieve good functional outcomes.

  18. Khan ES, Kow RY, Arifin KBBM, Komahen C, Low CL, Lim BC
    Cureus, 2019 Apr 03;11(4):e4377.
    PMID: 31218142 DOI: 10.7759/cureus.4377
    Introduction Surgical site infection (SSI) is the most common healthcare-related infection in surgical patients. Patients who have undergone spinal surgeries and have contracted postoperative SSI face increased morbidity and mortality, which invariably leads to additional burden on the healthcare system and higher costs. The risk factors for the increase in SSI in patients who have undergone spinal surgery have been investigated in numerous studies but no studies have been performed in Malaysia. The aim of this pilot study is to determine the incidence and factors associated with deep SSIs in patients that have undergone spinal surgeries. Methods This retrospective study includes all patients who underwent spinal surgeries at Tengku Ampuan Afzan Hospital, Kuantan, from 1 January 2016 to 31 December 2017. Patients with an active spinal infection, polytrauma, and open fractures were excluded from this study. Patient characteristics and laboratory investigations were extracted to determine the risk factors for deep SSI events. Associations between SSI and risk factors were analyzed with SPSS V21.0 (IBM, Armonk, NY). Results The univariate analysis indicated that fracture dislocation at the thoraco-lumbar junction (p=0.008) and a history of preoperative blood product transfusion (p=0.003) were associated with deep SSI. Other factors such as age (p=0.162), gender (p=0.262), body mass index (p=0.215), smoking status (0.272), number of vertebrae involved in the surgery (p=0.837), spinal cord involvement (p=0.259), postoperative hemoglobin reduction (p=0.816), and preoperative white blood cell count (p=0.278) were not associated with deep SSI. Conclusions This pilot study highlights the factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings.
  19. Nizam Siron K, Mat Lani MT, Low CL, Kow RY
    Cureus, 2021 Nov;13(11):e19254.
    PMID: 34900455 DOI: 10.7759/cureus.19254
    Introduction Shoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia. Materials and methods This was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder. Results A total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients' subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six-month post-operation. Conclusion In this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters.
  20. Yuen JC, Pang HN, Kow RY
    Cureus, 2023 Jun;15(6):e39925.
    PMID: 37409196 DOI: 10.7759/cureus.39925
    Although uncommon, neglected developmental dysplasia of the hip (DDH) poses a technically demanding problem for treating surgeons. Due to the congenital malformation of the native hip joint and distortion of the surrounding soft tissue, addressing limb-length discrepancy is intricate. Despite detailed planning and meticulous soft tissue handling, complications can be difficult to avoid in these patients even under experienced hands. In this case report, we present a 73-year-old lady with neglected DDH who had undergone initial total hip arthroplasty and subsequent revision surgery that failed due to aseptic loosening. Due to limited length in the distal femur, we used a telescoping allograft prosthetic composite (APC) to provide adequate length to the native distal femur during revision with proximal femur fixation. This technique can help avoid the need for total femur replacement (TFR) surgery, which is more invasive and may require tibia replacement.
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