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Reproducibility of laser Doppler fluximetry and the process of iontophoresis in assessing microvascular endothelial function using low current strength

Al-Tahami BA, Yvonne-Tee GB, Halim AS, Ismail AA, Rasool AH

Methods Find Exp Clin Pharmacol, 2010 Apr;32(3):181-5.
PMID: 20448860 DOI: 10.1358/mf.2010.32.3.1423887

Iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) combined with laser Doppler fluximetry (LDF) is a tool used to determine microvascular endothelial function. Our aim was to study the reproducibility of different parameters of this technique using iontophoresis with low current strength on the forearm skin of healthy subjects. Baseline skin perfusion was done before application of five current pulses with 1 min of current-free interval. Current strength of 0.007 mA, current density of 0.01 mA/cm(2) and charge density of 6 mC/cm(2) were used, along with 1% ACh and 1% SNP. The absolute maximum change in perfusion (max), percent change in perfusion (% change), peak change in perfusion (peak) and area under the curve during iontophoresis (AUC) at the anodal and cathodal leads were recorded. Measurements were performed in three sessions for 2 days. The coefficient of variation (CV) was calculated for each parameter. Among the parameters studied, maximum change in perfusion and peak flux were the most reproducible parameters.
Fulltext The outcomes of salvage surgery for vascular injury in the extremities: a special consideration for delayed revascularization

Jagdish K, Paiman M, Nawfar A, Yusof M, Zulmi W, Azman W, et al.

Malays Orthop J, 2014 Mar;8(1):14-20.
PMID: 25279079 MyJurnal DOI: 10.5704/MOJ.1403.012

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries. The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients' limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann's ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.
Compatibility of Porous Chitosan Scaffold with the Attachment and Proliferation of human Adipose-Derived Stem Cells In Vitro

Gomathysankar S, Halim AS, Yaacob NS, Noor NM, Mohamed M

J Stem Cells Regen Med, 2016;12(2):79-86.
PMID: 28096632

Adipose-derived stem cells (ASCs) have potential applications in the repair and regeneration of various tissues and organs. The use of various scaffold materials as an excellent template for mimicking the extracellular matrix to induce the attachment and proliferation of different cell types has always been of interest in the field of tissue engineering because ideal biomaterials are in great demand. Chitosan, a marine polysaccharide, have wide clinical applications and it acts as a promising scaffold for cell migration and proliferation. ASCs, with their multi-differentiation potential, and chitosan, with its great biocompatibility with ASCs, were investigated in the present study. ASCs were isolated and were characterized by two different methods: immunocytochemistry and flow cytometry, using the mesenchymal stem cell markers CD90, CD105, CD73 and CD29. The ASCs were then induced to differentiate into adipogenic, osteogenic and chondrogenic lineages. These ASCs were incorporated into a porous chitosan scaffold (PCS), and their structural morphology was studied using a scanning electron microscope and hematoxylin and eosin staining. The proliferation rate of the ASCs on the PCS was assessed using a PrestoBlue viability assay. The results indicated that the PCS provides an excellent template for the adhesion and proliferation of ASCs. Thus, this study revealed that PCS is a promising biomaterial for inducing the proliferation of ASCs, which could lead to successful tissue reconstruction in the field of tissue engineering.
The use of glycerol-preserved skin allograft in conjunction with reconstructive and flap surgery: seven years of experience

Saad AZ, Halim AS, Khoo TL

J Reconstr Microsurg, 2011 Feb;27(2):103-8.
PMID: 20976667 DOI: 10.1055/s-0030-1268208

Major reconstructive surgery may be extensive and prolonged, and it may cause edema and compromise the flap pedicle if closed under tension. Glycerol-preserved skin allograft (GPA) can provide a means for tension-free closure and temporary cover of the wound. Seven years of analysis on GPA used in conjunction with major reconstruction was undertaken to highlight its indications, results, and outcomes. Forty-seven patients were included, aged between 9 and 73 years. Majority of patients had reconstruction following tumor resection and trauma. The main indication for use of GPA was temporary, loose cover of the wound in 44% of cases; flap pedicle protection in 31% of cases; donor site wound cover in 10%; flap monitoring in one case; and management of flap-related complications in 6% of cases. Free flap reconstruction was performed in 72% of cases. In conclusion, GPA is a useful adjunct in reconstructive surgery. It can be used temporarily to allow tension-free wound closure, as well as to protect the flap pedicle until edema subsides and the pedicle becomes stable. This latter approach allows secondary wound closure and good esthetic outcome.
A prospective, randomised, double-blinded trial to study the efficacy of topical tocotrienol in the prevention of hypertrophic scars

Khoo TL, Halim AS, Zakaria Z, Mat Saad AZ, Wu LY, Lau HY

J Plast Reconstr Aesthet Surg, 2011 Jun;64(6):e137-45.
PMID: 20869928 DOI: 10.1016/j.bjps.2010.08.029

Despite widespread beliefs regarding the use of topical tocotrienol in the prevention of hypertrophic scars, there is very little evidence from well controlled and randomised clinical trials to justify its benefits for surgical scars.
Long-term outcome of free fibula osteocutaneous flap and massive allograft in the reconstruction of long bone defect

Halim AS, Chai SC, Wan Ismail WF, Wan Azman WS, Mat Saad AZ, Wan Z

J Plast Reconstr Aesthet Surg, 2015 Dec;68(12):1755-62.
PMID: 26420474 DOI: 10.1016/j.bjps.2015.08.013

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.
Functional outcomes in total talus reconstruction with triangular double-barrel free fibula flap following oncological resection: A retrospective case series review

Rosli MA, Sulaiman WAW, Ismail WFW, Yahaya S, Saad AZM, Wan Z, et al.

J Plast Reconstr Aesthet Surg, 2021 Oct 07.
PMID: 34756555 DOI: 10.1016/j.bjps.2021.09.032

BACKGROUND: With the advent of new techniques, foot salvage is feasible following talus oncological resection. As the reconstruction aims to achieve a pain-free, stable ankle for ambulation, biological limb reconstruction is the best option. This case series will evaluate the primary indications, complications, and functional outcomes of the reconstructed talus and highlighting the technical aspects of the surgery with a novel technique of triangular double-barrel free fibula flap.
METHODS: We performed a retrospective case note review of patients undergoing foot salvage surgeries and primary talus reconstruction with double-barrel free fibula flaps between 2009 and 2019. Patient demographics, aetiologies, operative details, complications, and outcomes were analysed. All patients underwent the same talar reconstruction technique whereby a wide-based triangular framework was created from two bony struts of the osteotomized fibula. The Musculoskeletal Tumour Society (MSTS) scoring system was used to analyse the short- to mid-term functional outcomes.
RESULTS: Four consecutive patients with aggressive benign and malignant tumours were identified. They consist of three males and one female, with a median age of 32 (range 27-39). Patients were followed up for a median duration of 60 months (range 24-132). Two flaps were complicated with venous thromboses; however, all were salvageable following re-explorations. All patients achieved solid bony fusion with good functional and aesthetic outcomes. The median MSTS score was 74.5% (range 66-76). No donor site morbidity and local recurrence were reported.
CONCLUSION: The triangular double-barrel free fibular flap is a good option for limb salvage following total talus resection, with good short- to mid-term functional and aesthetic outcomes.
Reproducibility of different laser Doppler fluximetry parameters of postocclusive reactive hyperemia in human forearm skin

Yvonne-Tee GB, Rasool AH, Halim AS, Rahman AR

J Pharmacol Toxicol Methods, 2005 Sep-Oct;52(2):286-92.
PMID: 16125628

Postocclusive reactive hyperemia in forearm skin is a commonly used model for studying microvascular reactivity function, particularly in the assessment of vascular effect of topically applied pharmacological substances. In this study, we investigated the reproducibility of several different laser-Doppler-derived parameters in the measurement of postocclusive reactive hyperemia at forearm skin in healthy subjects.
Dependence of human forearm skin postocclusive reactive hyperemia on occlusion time

Tee GB, Rasool AH, Halim AS, Rahman AR

J Pharmacol Toxicol Methods, 2004 Jul-Aug;50(1):73-8.
PMID: 15233971 DOI: 10.1016/j.vascn.2004.02.002

Human postocclusive forearm skin reactive hyperemia is not only a potential means of identifying early signs of cardiovascular diseases, it can also be used in the assessment of local microvascular response to topically applied compounds on skin. The method is not fully characterized. In this study, we investigated the influence of occlusion time on postocclusive forearm skin reactive hyperemia using laser Doppler fluximetry (LDF).
Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children

Sulaiman AR, Wan Z, Awang S, Che Ahmad A, Halim AS, Ahmad Mohd Zain R

J Pediatr Orthop B, 2015 Sep;24(5):450-5.
PMID: 26049965 DOI: 10.1097/BPB.0000000000000197

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoot deformity. We concluded that resection of the middle shaft of the fibula for the purpose of a vascularized fibula graft, leaving a 6 cm distal fibular stump in children younger than 6 years old, may give rise to abnormal growth of the distal tibial physis, leading to valgus ankle. The entire proximal fibular resection for the similar purpose in a 6-year-old child may give rise to weakness of tibialis posterior and hindfoot valgus.
Breakage of an intramedullary rod after bone union in congenital pseudoarthrosis of the tibia: a report of two cases

Sulaiman AR, Simbak N, Wan Ismail WF, Wan Z, Halim AS

J Orthop Surg (Hong Kong), 2011 Aug;19(2):250-3.
PMID: 21857057

We report 2 patients with congenital pseudoarthrosis of the tibia who underwent intramedullary Rush rod transfixation through the ankle joint following refracture and nonunion of vascularised fibular grafting 6 and 8 months earlier. After 9 and 5 years, both Rush rods were broken at the level of the ankle joints, while the reconstructed area was solidly united. The growth of the distal tibia increased the distance of the tips of the broken rod and hence the ankle joint motion. The broken tips may damage the articular cartilage and result in valgus deformity of the ankle and limb length discrepancy.
Reconstruction of large sacral defects following tumour resection: a report of two cases

Cheong YW, Sulaiman WA, Halim AS

J Orthop Surg (Hong Kong), 2008 Dec;16(3):351-4.
PMID: 19126905

Sacral tumours often present surgical resection and reconstruction challenges. Wide resections result in large sacral defects and neoadjuvant radiotherapy impairs wound healing. The wounds need to be covered with bulky, well-vascularised, healthy tissues. We present 2 cases where large sacral defects were reconstructed following tumour resection. Both defects were reconstructed with inferiorly based, transpelvic, pedicled vertical rectus abdominis myocutaneous flaps. This is a robust flap and carries a well-vascularised muscle bulk and skin paddle. The donor site is distant from the lesion site and is thus unaffected by both the resection and radiotherapy. This is a useful flap for reconstructing large sacral defects.
Residual nonunion following vascularised fibular graft treatment for congenital pseudarthrosis of the tibia: a report of two cases

Sulaiman AR, Nordin S, Faisham WI, Zulmi W, Halim AS

J Orthop Surg (Hong Kong), 2006 Apr;14(1):64-6.
PMID: 16598090

Resection and reconstruction using a vascularised fibular graft is a viable alternative treatment for congenital pseudarthrosis of the tibia, although distal junctional nonunion and residual deformity are known complications that are difficult to treat. We illustrate 2 cases in which bony union was achieved following a technique using fibular grafting and intramedullary nailing, without additional bone grafting. This technique was feasible because of hypertrophy of the fibular graft.
Reconstructive treatment following resection of high-grade soft-tissue sarcomas of the lower limb

Leow AM, Halim AS, Wan Z

J Orthop Surg (Hong Kong), 2005 Apr;13(1):58-63.
PMID: 15872402

To review the role of free tissue transfer in reconstructive surgery following resection of high-grade soft-tissue sarcomas of the lower limb.
Composite vascularised osteocutaneous fibula and sural nerve graft for severe open tibial fracture--functional outcome at one year: a case report

Halim AS, Yusof I

J Orthop Surg (Hong Kong), 2004 Jun;12(1):110-3.
PMID: 15237132

Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.
Contribution of MSX1 variants to the risk of non-syndromic cleft lip and palate in a Malay population

Salahshourifar I, Halim AS, Wan Sulaiman WA, Zilfalil BA

J Hum Genet, 2011 Nov;56(11):755-8.
PMID: 21866112 DOI: 10.1038/jhg.2011.95

Oral clefts are clinically and genetically heterogeneous disorders that are influenced by both genetic and environmental factors. The present family-based association study investigated the role of the MSX1 and TGFB3 genes in the etiology of non-syndromic oral cleft in a Malay population. No transmission distortion was found in the transmission disequilibrium analysis for either MSX1-CA or TGFB3-CA intragenic markers, whereas TGFB3-CA exhibited a trend to excess maternal transmission. In sequencing the MSX1 coding regions in 124 patients with oral cleft, five variants were found, including three known variants (A34G, G110G and P147Q) and two novel variants (M37L and G267A). The P147Q and M37L variants were not observed in 200 control chromosomes, whereas G267A was found in one control sample, indicating a very rare polymorphic variant. Furthermore, the G110G variant displayed a significant association between patients with non-syndromic cleft lip, with or without cleft palate, and normal controls (P=0.001, odds ratio=2.241, 95% confidence interval, 1.357-3.700). Therefore, these genetic variants may contribute, along with other genetic and environmental factors, to this condition.
The Effects of Passive Cigarette Smoke Exposure on the Survival of the Reverse Sural Fasciocutaneous Flap

Sadagatullah AN, Halim AS, Bathusha MS, Ramachandran AK

J Hand Microsurg, 2017 Dec;9(3):120-125.
PMID: 29302135 DOI: 10.1055/s-0037-1605354

Background The possibility of a person who had undergone surgery to be exposed to the ill effects of cigarette smoke is high, more so if the person lives with a smoker. With increasing popularity of reverse sural fasciocutaneous flaps, a surgeon may have to manage a person who lives with a smoker or is exposed to cigarette smoke. A clear understanding of the effects of exposure to cigarette smoke on reverse sural fasciocutaneous flaps is necessary. This study was performed to establish a clearer understanding of the effects of smoking on reverse sural fasciocutaneous flaps and evidence for preoperative patient counseling about smoking and smoke exposure. Objective The study investigated effects of exposure to cigarette smoke on the survival of the reverse sural fasciocutaneous flap. Methods This was an experimental observational study conducted at the Laboratory for Animal Research Unit in the Health Campus of Universiti Sains Malaysia. Twelve adult White New Zealand rabbits ( Oryctolagus cuniculus ) were divided into two groups of six. All 12 rabbits had a 2.5- × 2.5-cm reverse sural fasciocutaneous flap raised on both its hind limbs. The group exposed to cigarette smoke underwent 4 weeks of smoke exposure for 2 hours daily prior to surgery. This was then continued until analysis of the results. The control group had no intervention. All flaps were analyzed on the seventh postoperative day, after tracing on transparent plastic sheets with the necrotic area marked followed by 2D planimetry done on a grid paper. The flaps were assessed on the total flap area and survival area percentage. It was recorded as mean ± SD. The presence or absence of infection and hematoma was also noted. Results Twelve flaps were analyzed in each group. Total mean flap area and survival area percentage of the control group were 120.33 ± 31.03 mm 2 and 80.12 ± 15.75%, respectively, whereas in the cigarette smoke-exposed group, it was 121.83 ± 17.93 mm 2 and 62.04 ± 34.01%, respectively. The control group had two infections and one hematoma, and the smoking-exposed group had six infections and nine hematomas. The comparison between the groups was made in terms of total flap area, survival percentage, presence of infection, and hematoma for which the p values were 0.886, 0.115, 0.083, and 0.003, respectively. The differences between right and left hind limbs were also analyzed ( p = 0.414). Conclusion There was no statistical difference in the results from the right and left hind limbs. There was no statistical difference in the survival of reverse sural fasciocutaneous flap between the control and smoking-exposed groups.
Fulltext Contribution of 6p24 to non-syndromic cleft lip and palate in a Malay population: association of variants in OFC1

Salahshourifar I, Halim AS, Sulaiman WA, Zilfalil BA

J Dent Res, 2011 Mar;90(3):387-91.
PMID: 21297019 DOI: 10.1177/0022034510391798

Non-syndromic cleft lip, with or without cleft palate, is a heterogeneous, complex disease with a high incidence in the Asian population. Several association studies have been done on cleft candidate genes, but no reports have been published thus far on the Orofacial Cleft 1 (OFC1) genomic region in an Asian population. This study investigated the association between the OFC1 genomic region and non-syndromic cleft lip with or without cleft palate in 90 Malay father-mother-offspring trios. Results showed a preferential over-transmission of a 101-bp allele of marker D6S470 in the allele- and haplotype-based transmission disequilibrium test (TDT), as well as an excess of maternal transmission. However, no significant p-value was found for a maternal genotype effect in a log-linear model, although single and double doses of the 101-bp allele showed a slightly increased cleft risk (RR = 1.37, 95% CI, 0.527-3.4, p-value = 0.516). Carrying two copies of the 101-bp allele was significantly associated with an increased cleft risk (RR = 2.53, 95% CI, 1.06-6.12, p-value = 0.035). In conclusion, we report evidence of the contribution of the OFC1 genomic region to the etiology of clefts in a Malay population.
Combination of vascularized outer-table calvarial bone graft based on the superficial temporal vessels and allomatrix for the repair of an orbito-frontal blow-out fracture in a child

Ali F, Halim AS, Najihah SZ, Ibrahim M, Abdullah J

J Craniomaxillofac Surg, 2005 Oct;33(5):326-30.
PMID: 16125400

A vascularized outer-table calvarial bone graft was used for repairing a Posnick type 2 traumatic orbito-frontal bone defect supported by the use of a calcium-based putty (Allomatrix) in a 7-year-old girl. Gaps between the donor and recipient sites were filled with Allomatrix containing demineralized bone matrix particles. Four years later there was a good cosmetic result using an artificial left eye.
The Practice of First Aid for Burn Injuries Among the Population of East Coast of Peninsular Malaysia for 2012-2016

Seow SN, Halim AS, Wan Sulaiman WA, Mat Saad AZ, Mat Johar SFN

J Burn Care Res, 2020 Jul 03;41(4):905-907.
PMID: 32166315 DOI: 10.1093/jbcr/iraa025

Burns are a devastating public health problem that result in 10 million disability-adjusted life-years lost in low- and middle-income countries. Adequate first aid for burn injuries reduces morbidity and mortality. The rate of proper first aid practices in other countries is 12% to 22%.1,2 A 5-year retrospective audit was performed on the database of the Burn Unit in Hospital Universiti Sains Malaysia for 2012-2016; this involved 485 patients from the east coast of Malaysia. The mean age of the patients is 17.3 years old. The audit on first aid practices for burn injury showed poor practice. Out of 485 burned patients, 261 patients (53.8%) claimed that they practiced first aid. However, only 24 out of 485 patients (5%) practiced the correct first aid technique where they run their burn wound under cool water for more than 20 minutes. Two hundred and twenty-two patients had not received any first aid. Two patients did not respond to the question on the first aid usage after burn injury. The mean age of patients who practiced first aid was 15.6 years old. Out of the 261 patients who practiced first aid, 167 (64%) run their wound under tap water for different durations. Others practiced traditional remedies such as the application of "Minyak Gamat" (6.5%), soy sauce (5.5%), other ointments (3.6%), milk (1.8%), and eggs (0.7%), as well as honey, butter, and cooking oil (0.4% each). First aid practices for burn injuries in the population of east coast Malaysia are still inadequate. The knowledge and awareness of school children and the general Malaysian population must be enhanced.

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