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Fulltext Reminder: Interpret the "Science" with Caution

Kow RY, Low CL

Malays Orthop J, 2020 Jul;14(2):157.
PMID: 32983397 DOI: 10.5704/MOJ.2007.027
Fulltext Arthrofibrosis after Anterior Cruciate Ligament Reconstruction: The Devil is in the Detail

Kow RY, Low CL

Malays Orthop J, 2020 Nov;14(3):204-205.
PMID: 33403089 DOI: 10.5704/MOJ.2011.036
Fulltext Modified One-third Tubular Plate with Hook for Distal Lateral Malleolus Fracture Fixation

Kow RY, Low CL

Malays Orthop J, 2019 Mar;13(1):60-61.
PMID: 31001388 DOI: 10.5704/MOJ.1903.013
Miss-A-Nail Technique for Neck of Femur Screw Fixation: It Is Easier Said Than Done

Kow RY, Abdul-Aziz A, Low CL

Malays Orthop J, 2020 Mar;14(1):96-97.
PMID: 32296491 DOI: 10.5704/MOJ.2003.017
Supracondylar Humerus Fractures in Infants and Toddlers: An Unexplored Area

Kow RY, Low CL, Awang MS

J Invest Surg, 2023 12;36(1):1-2.
PMID: 36345727 DOI: 10.1080/08941939.2022.2136803
Fulltext Comment to: The Incidence of Fracture-Related Infection in Open Tibia Fracture with Different Time Interval of Initial Debridement

Esmat SM, Kow RY, Low CL

Malays Orthop J, 2024 Mar;18(1):153-154.
PMID: 38638670 DOI: 10.5704/MOJ.2403.020
Fulltext Neck of Femur Fracture in Young Patients With End-Stage Renal Disease and Hyperparathyroidism: A Report of Three Cases and Proposed Treatment Algorithm

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.
Reuse of dialysis reverse osmosis reject water for aquaponics and horticulture

Chang E, Lim JA, Low CL, Kassim A

J Nephrol, 2021 02;34(1):97-104.
PMID: 33394342 DOI: 10.1007/s40620-020-00903-0

BACKGROUND: Water crisis is becoming a threat to the well-being of the human population worldwide and use of water for healthcare contributes substantially to this resource depletion. Hemodialysis consumes large quantities of water. A huge volume of high purity dialysis water is required to safely perform dialysis treatment. In this process, up to 60-70% of source water is discarded. Many strategies have been suggested to promote green dialysis, and these include reuse of water, however, very few dialysis facilities have taken the preliminary steps to employ it.
METHODS: We share our experience in a developing country on an innovative reject-water reuse program combining aquaculture, hydroponic and horticulture activities. This is by far the first report on a "green dialysis" project involving aquaponics that reuse dialysis reverse osmosis (RO) reject water.
RESULTS: Our expereince suggests that reject water can be reused to promote water conservation with encouraging results. It provides a good and biosecure environment for fish breeding and vegetable farming . This project promotes a reduction in carbon footprint, a reduction in water waste, a sustainable organic food source, may lead to income generation, and provides a shared purpose and sense of pride among staff and dialysis patients.
CONCLUSIONS: Encompassing "environmental protection" practices into a hemodialysis unit can be done with relatively simple and practical steps.
Fulltext Late Presentation of Paediatric Pink Pulseless Supracondylar Fracture of Humerus: A Case Report

Kow RY, Yuen JC, Low CL, Mohd-Daud KN

Malays Orthop J, 2019 Nov;13(3):77-79.
PMID: 31890116 DOI: 10.5704/MOJ.1911.014

Supracondylar humeral fracture is the most common elbow injury in children. It may be associated with a vascular injury in nearly 20% of the cases with a pink pulseless limb. We present a unique case of a paediatric pink pulseless supracondylar humeral fracture, seen late, on the 16th-day post-trauma. Open reduction, cross Kirschner wiring, and brachial artery exploration and repair were performed, and the patient recovered well. Early open reduction and exploration of the brachial artery with or without prior CT angiography was a safe approach in treating patients who presented at 16 days.
Fulltext Arthroscopic Subacromial Decompression in the Treatment of Shoulder Impingement Syndrome: A Prospective Study in Malaysia

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.
Fulltext The Creation of Articulating Cement Spacer Using Custom-Fabricated Silicone Mold for the Treatment of Periprosthetic Joint Infection: Two Case Reports

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.
Fulltext Factors Associated with Deep Surgical Site Infection Following Spinal Surgery: A Pilot Study

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.
Fulltext Scurvy: A Neglected Cause of Muscle Pain and Weakness in a Child With Picky Eating Behavior

Kow RY, Nik Abdul Adel NA, Abdul Razak AH, Low CL, Awang MS

Cureus, 2021 Jul;13(7):e16289.
PMID: 34405060 DOI: 10.7759/cureus.16289

Ascorbic acid (vitamin C) is an essential micronutrient that the human's body cannot synthesize endogenously. Scurvy, a disease of ascorbic acid deficiency, can manifest in a myriad of presentations. Due to its rarity in the modern world, scurvy is considered as a disease of the past. We present a paediatric case of scurvy with musculoskeletal manifestations as a result of picky eating behavior. We report a previously healthy nine-year-old boy who presented with unexplained progressive bilateral lower limb generalized weakness and pain for two months. All initial biochemical and radiological investigations were unremarkable. Upon further history taking, he had severe picky eating behavior which raised the suspicion of scurvy. The diagnosis was confirmed with a serum ascorbic acid test. After ascorbic acid supplementation, his symptoms resolved immediately. Further food behavioral modification counselling to his family members helped to change his diet in a lasting way. As a result, he had no recurrence of symptoms. This case highlights the importance of having a high index of suspicion for an uncommon disease and emphasizes the need for a detailed dietary history upon patient's presentation.
Surgical Reconstruction of an Open Medial Malleolus Fracture Using a Novel Technique: A Case Report

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.
Fulltext MRI Evaluation of Anterolateral Ligament of the Knee: A Cross-Sectional Study in Malaysia

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.
Fulltext Microbiology of diabetic foot infections in three district hospital in Malaysia and comparison with South East Asian Countries

Kow RY, Low CL, Ruben JK, Zaharul Azri WMZ, Mor Japar Khan ESK

Med J Malaysia, 2019 Oct;74(5):394-399.
PMID: 31649215

INTRODUCTION: Diabetic foot infection, a complication that is associated with lower-limb amputation, incurs a huge economic burden to the hospital and health care system of Malaysia. The bacteriological profile of pathogens in diabetic foot infections in Malaysia has been sparsely studied. We investigated the microbiology of diabetic foot infections in patients admitted to the district hospitals on the east coast of Malaysia.

METHODS: A retrospective analysis was conducted in three district hospitals (Hospital Kuala Lipis, Hospital Bentong and Hospital Raub) in Malaysia from 1st of January 2016 to 31st December 2016. The clinical specimens were cultured using Clinical and Laboratory Standards Institute (CLSI) guidelines. Antibiotic sensitivity testing to different antibiotics was carried out using the disc diffusion method.

RESULT: A total of 188 pathogens were isolated from 173 patients, with an average of 1.09 pathogens per lesion. Majority of the pathogens isolated were gram negative pathogens (73.4%). The most commonly isolated pathogens were Staphylococcus aureus (17.5%). This was followed by Klebsiella spp. (17%), Pseudomonas spp. (15.4%) and Proteus spp. (13.8%). Gram positive pathogens were sensitive to most of the antibiotics tested except penicillin and fusidic acid. Gram negative pathogens were sensitive to all antibiotics tested except ampicillin and amoxicillin/clavulanic acid. Amikacin provide coverage for all gram negative pathogens in DFI.

CONCLUSION: For the management of patient with infection in diabetic foot, the choice of antibiotic therapy depends on the sensitivity of the pathogens, the severity of the infection, the patient's allergies history, toxicity and excretion of the antibiotics.
Fulltext Predictive Factors of Major Lower Extremity Amputations in Diabetic Foot Infections: A Cross-sectional Study at District Hospital in Malaysia

Kow RY, Low CL, Ruben JK, Zaharul-Azri MZ, Lim BC

Malays Orthop J, 2019 Nov;13(3):45-52.
PMID: 31890110 DOI: 10.5704/MOJ.1911.008

Introduction: Diabetic foot infection, a complication which can lead to lower limb amputation, is a major source of morbidity and mortality in Malaysia. The objective of this study was to determine the predictive factors of major lower limb amputation among patients with diabetes mellitus in a cluster of three district hospitals in Pahang, Malaysia. Materials and Methods: This cross-sectional study involved 170 patients who had undergone surgical interventions for diabetic foot infections at three district hospitals from 1st of September 2014 to 31st December 2015. The predictors for major amputation of lower limb were determined using simple logistic regression (LR) and forward LR multiple logistic regression. Results: A total of 21 patients had undergone major amputations of lower limb (15 transtibial and 6 transfemoral). The following factors were associated with major amputation of lower limb; longer duration of disease, age ≥ 60 years, patients from Bentong Hospital, presence of hypertension, presence of fever, history of multiple limb-salvaging surgeries, monomicrobial culture, necrotising fasciitis, anemia and leukocytosis. Upon forward LR multiple logistic regression, only duration of disease, history of more than three previous limb-salvaging surgeries and total white blood cell count ≥15X109/L were found to be significant as predictive factors of major amputation of lower limb. Conclusion: Among the factors analysed in this study, a longer duration of disease, raised total white blood cell count and history of more than three limb-salvaging surgeries were identified as predictors for major amputation of lower limb in diabetic foot infections using stepwise logistic regression analysis.
Fulltext Life-threatening Chlorhexidine Anaphylaxis: A Case Report

Kow RY, Low CL, Ruben JK, Zaharul-Azri MZ, Ng MS

Malays Orthop J, 2017 Jul;11(2):72-74.
PMID: 29021884 MyJurnal DOI: 10.5704/MOJ.1707.008

Chlorhexidine is a common antiseptic and disinfectant used in the medical field. Allergy to chlorhexidine has been reported in the literature but life-threatening anaphylactic shock is rare. We present a case of severe anaphylactic shock due to chlorhexidine occurring during surgery. Literatures suggest that profound anaphylactic shock to chlorhexidine is commonly preceded by milder, non-specific reactions. These mild symptoms are often dismissed by both the patient and physicians alike. Direct questioning of these symptoms is necessary as a part of the pre-operative assessment and the patient should be referred for further immunology testing if indicated.
Fulltext The Role of Medial Plantar Artery Flap in Heel Pad Reconstruction: A Report of Two Cases

Oon ZS, Kow RY, Ahmad Alwi AA, Ayeop MAS, Low CL, Che Ahmad A

Cureus, 2023 Jul;15(7):e41844.
PMID: 37575710 DOI: 10.7759/cureus.41844

The heel and sole possess unique anatomical characteristics that serve a weight-bearing and shock-absorbing function. The heel is particularly vital, as any defects in this area can lead to gait instability. Reconstructing a heel defect presents challenges, as the donor flap must be durable enough to withstand high force loads while also providing protective sensation. Recently, the medial plantar artery flap has been successfully employed for the reconstruction of defective heel pads. This flap offers glabrous skin capable of weight transmission and intact protective sensation. In this report, we present two cases of heel pad loss secondary to chronic diabetic complications and trauma, respectively, which were treated with medial plantar artery flap reconstruction. Both cases were successfully treated, and they showed a good functional outcome.
Fulltext Primary B-cell Lymphoma of the Thoracic Spine: A Rare Cause of Spinal Cord Compression

Zakaria Mohamad Z, Kow RY, Low CL, Hamdan AH, Awang MS

Cureus, 2021 Jul;13(7):e16608.
PMID: 34447645 DOI: 10.7759/cureus.16608

Primary non-Hodgkin lymphoma arising from the spine is exceedingly rare. Spinal cord compression can be the first presentation of a patient with primary spinal non-Hodgkin lymphoma. Due to its rarity and vague clinical presentation, the diagnosis can be confused with tuberculosis of the spine, a more common disease in this country. We present a case of primary thoracic spine B-cell lymphoma in a 45-year-old lady who presented with spinal cord compression. This case highlights the importance of obtaining histopathological samples for examination and the treating physician should be vigilant on this rare cause of spinal cord compression. Treatment can be initiated promptly once the diagnosis is established as primary spinal non-Hodgkin lymphoma carries a dire prognosis.

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