REN YI KOW
@sasmec.iium.edu.my
Orthopaedic Surgeon
International Islamic University Malaysia
RESEARCH INTERESTS
Orthopaedic surgery
diabetic foot
musculoskeletal injury
Scopus Publications
Scholar Citations
Scholar h-index
Scholar i10-index
Scopus Publications
R. Y. Kow, C. L. Low, and M. S. Awang
Informa UK Limited
Kow RY, Mohd-Yusof N, Abas MF, and Low CL
Malaysian Orthopaedic Association
The incidence of humeral osteomyelitis is relatively rare as compared to incidence of lower limb osteomyelitis. Despite having no guideline in the management of humeral osteomyelitis, surgeons have utilised their experience in managing lower limb osteomyelitis to treat humeral osteomyelitis. By adhering to principles including thorough debridement of necrotic bone and soft tissue, staged bony and/or soft tissue reconstruction, and targeted antimicrobial therapy, a good outcome can be achieved in the management of humeral osteomyelitis. We report a case of Cierny-Mader type IV proximal humeral osteomyelitis after a severe crush injury of the left shoulder and its subsequent two-stage reconstruction using internal fixation and pedicled Latissimus dorsi musculocutaneous flap.
Kow RY, Low CL, and Yusof MN
Malaysian Orthopaedic Association
Kow RY, Khalid KA, Zakaria Z, and Awang MS
Malaysian Orthopaedic Association
As the number of COVID-19-related infections and deaths increased exponentially in the during 2020, few countries were equipped to manage and curb this novel coronavirus. Initially there was no proven cure or vaccine to this novel virus (SARS-Cov-2), leaving the authorities with no choice but to impose quarantines at the short-term expense of their economies. As we gain more knowledge on this novel virus, the tried-and-tested method of selective testing of the symptomatic patients, used successfully in almost all infectious respiratory diseases, has been replaced with trace-and-test method, as most of the infected patients remained asymptomatic. In early 2021, the availability of vaccines provided a shed of light out from this pandemic. Nevertheless, we faced an enormous task in juggling between vaccination of the population, managing patients with COVID-19 infection as well as non-COVID-19 patients. Here, we share our experience and response in managing this healthcare crisis across a two-year period during the pandemic and we hope other centres can learn from what we went through and help them derive a protocol to navigate through a future pandemic.
Kow RY, Low CL, Ayeop MAS, Che-Ahmad A, and Awang MS
Malaysian Orthopaedic Association
Introduction
The number of people suffering from diabetic foot infection (DFI) has increased precipitously over the years in Malaysia, owing to increased population, urbanisation, the surge of number of people with obesity and physical inactivity. As one of the most dreaded complications of diabetes mellitus, DFI is associated with high morbidity and mortality. We aim to study the microbiological profile of patients with DFI at a university hospital in Kuantan, Pahang.
Materials and methods
This retrospective study was carried out at at Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM) from 1 January 2018 to 30 April 2019. Patients' demographic data, types of infection and surgical intervention, and the microbiological profile were obtained from the medical records.
Results
A total of 142 causative pathogens were cultured from 130 tissue samples, with an average of 1.09 pathogens per lesion. Majority of the pathogens were gram-negative pathogens (52.8%). Staphylococcus sp. was the most common pathogen isolated (22.5%). This was followed by Streptococcus sp. (10.6%), Pseudomonas sp. (9.2%), Morganella sp. (5.6%), Klebsiella sp. (4.9%), Enterobacter sp. (4.9%), and others. Among the 142 pathogens, there were 9 multidrug-resistant strains observed. Most of the antibiotics were effective against the gram-positive pathogens except benzylpenicillin, tetracyclin, fusidic acid and ciprofloxacin. Meanwhile, cefotaxime, amoxicillin and ampicillin-sulbactam were also not suitable against gramnegative pathogens. Oxacillin and sulfamethoxazole/ trimethoprim can be used as empirical antibiotics against gram-positive pathogens, while vancomycin should be reserved for patients with septic shock or suspected multidrug resistant strain infection. Piperacillin/tazobactam and ceftazidime can be used as empirical antibiotics against gram-negative pathogens.
Conclusion
Early initiation of empirical antibiotic(s) is paramount to stymie the infection from getting worse while waiting for the identification of causative pathogens in the management of DFI. This study provides a guide for treating physicians to initiate the most appropriate empirical antibiotic in DFI.
Jun Xiong Lye, Ren Yi Kow, Raffael Ismail, and Kamarul Ariffin Khalid
World Scientific Pub Co Pte Lt
Background: The Michigan Hand Outcomes Questionnaire (MHQ), a self-reported questionnaire for patients with hand disorders, has been widely used globally. It has been cross-culturally adapted into different languages across all continents. Aims of this study were to translate the MHQ into Malay language and to evaluate its reliability and validity compared with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in a Malay-speaking population. Methods: The MHQ was cross-culturally adapted into a Malay version based on the guidelines. A pre-testing involving thirty patients with hand disorders was performed to assess whether it was comprehensible to the target population. One hundred patients with hand disorders were recruited in this study to answer the MHQ and DASH questionnaires. The MHQ was tested twice with an interval of two weeks in between. Statistical analysis was performed to assess the reproducibility and internal consistency via the test-retest method and Cronbach’s alpha calculation, respectively. The association between MHQ and DASH questionnaire was assessed with Spearman’s correlation calculation. Results: In the pre-testing, twenty-six patients (86.7%) understood all the questions in the Malay version of MHQ. The test-retest analysis showed a good reliability across the duration of two weeks with the intraclass correlation coefficient of all subscales ranging from 0.925 to 0.984. Cronbach’s alpha values of the Malay version MHQ ranged from 0.82 to 0.97, indicating a good internal consistency. Spearman’s correlation factor of the MHQ in comparison with DASH showed a fair to moderately strong correlation with the values ranging from 0.513 to 0.757. Conclusions: The Malay version of MHQ was successfully translated and culturally-adapted with excellent reliability (reproducibility and internal consistency) and good construct validity.
Ren Yi Kow, Aminudin Che-Ahmad, Mohd Adham Shah Ayeop, Muhammad Wafiuddin Ahmad, and Shahril Yusof
SAGE Publications
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.
Kow RY and Low CL
Malaysian Orthopaedic Association
Kow RY and Low CL
Malaysian Orthopaedic Association
Kow RY and Goh KL
Malaysian Orthopaedic Association
We read with great interest the case series by Lim et al in the November 2019 issue entitled “Modified Unipolar Hemiarthroplasty for the Treatment of Metastatic Lesions of Proximal Femur with Pathological Fractures: Case Series of Six Patients”. In their paper, they presented their experience in using “modified unipolar hemiarthroplasty for reconstruction after proximal femur resection for pathological fracture of the proximal femur secondary to metastatic lesions. This innovative, cost-effective implant can replace the otherwise expensive endoprosthesis.
Kow RY, Abdul-Aziz A, and Low CL
Malaysian Orthopaedic Association
Ren Yi Kow, Jin Chuan Yuen, Akmal Azim Ahmad Alwi, Muhammad Firdaus Abas, and Chooi Leng Low
Ovid Technologies (Wolters Kluwer Health)
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.
RY Kow, , CL Low, and
Malaysian Orthopaedic Association
modification. (b) The distal end of the left one-third tubular plate has been cut with a plate cutter at 45 degree, creating two hooks. (c) Shows the difference between the two one-third tubular plates after bending. After cutting the plate, the end of the plate can be bent to accommodate a distal screw as well as being fitted to the distal part of the lateral malleolus. Note that the trajectory of the distal screw can now be directed at a more superior-lateral angle compared to the screw trajectory in an uncut plate.
Kow RY, Low CL, Ruben JK, Zaharul-Azri MZ, and Lim BC
Malaysian Orthopaedic Association
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.
Kow RY, Yuen JC, Low CL, and Mohd-Daud KN
Malaysian Orthopaedic Association
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.
Kow RY, Low CL, Ruben JK, Zaharul-Azri MZ, and Ng MS
Malaysian Orthopaedic Association
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.
Kow RY, Zamri AR, Ruben JK, Jamaluddin S, and Mohd-Nazir MT
Malaysian Orthopaedic Association
Introduction: Supracondylar fracture of the humerus is the most common fracture around the elbow in children. Pinning with Kirschner wires (K-wires) after open or closed reduction is generally accepted as the primary treatment modality. However, it comes with the risk of persistent instability and if the K-wire is not inserted properly, it may cause displacement and varus deformity. We present our two-year experience with a new technique of lateral external fixation and K-wiring of the humeral supracondylar fracture. Materials and Methods: A total of seven children with irreducible Gartland Type III supracondylar humeral fracture were treated with closed reduction and lateral external fixation and lateral Kirschner wiring. Patients with ipsilateral radial or ulnar fracture, open fracture and presence of neurovascular impairment pre-operatively were excluded. All the patients were followed up at one, three and six weeks and three and six months. The final outcomes were assessed based on Flynn’s criteria. Results: All the patients achieved satisfactory outcomes in terms of cosmetic and functional aspects. All patients except one (85.5%) regained excellent and good cosmetic and functional status. One patient (14.3%) sustained pin site infection which resolved with oral antibiotic (Checketts- Otterburn grade 2). There was no neurological deficit involving the ulnar nerve and radial nerve. Conclusion: The introduction of lateral external fixation and lateral percutaneous pinning provide a promising alternative method for the treatment of humeral supracondylar fracture. This study demonstrates that it has satisfactory cosmetic and functional outcomes with no increased risk of complications compared to percutaneous pinning.