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Fulltext Giant epidermoid cyst of the thigh

Mohamed Haflah N, Mohd Kassim A, Hassan Shukur M

Malays Orthop J, 2011 Nov;5(3):17-9.
PMID: 25279030 MyJurnal DOI: 10.5704/MOJ.1111.001

Epidermoid cyst is a common benign cutaneous swelling frequently encountered in surgical practice. It usually presents as a painless lump frequently occurring in hairbearing areas of the body particularly the scalp, scrotum, neck, shoulder and back. Giant epidermoid cysts commonly occur in hairy areas such as the scalp. We present here the case of a rare occurrence of a giant epidermoid cyst in the less hairy area of the right upper thigh mimicking a soft tissue sarcoma. Steps are highlighted for the management of this unusual cyst.
Fulltext Coordinating a Postgraduate Orthopaedic Exam During the COVID-19 Pandemic

Mohamed-Haflah NH, Abdullah S, Abdul-Rani R

Malays Orthop J, 2021 Mar;15(1):16-20.
PMID: 33880143 DOI: 10.5704/MOJ.2103.003

The Coronavirus (COVID-19) pandemic and institution of the Movement Control Order (MCO) had resulted in the cancellation of a major orthopaedic exam in April 2020. The exam is known as the Malaysian Orthopaedic Specialist Committee (OSC) Part I Examinations. It is similar to the British Royal Colleges of Surgeons Membership (MRCS) exams and held twice annually in April and October. There are up to 200 candidates involved. With implementation of new guidelines and standard operating procedures (SOP), the OSC Part I exam was successfully held by Universiti Kebangsaan Malaysia (UKM) from 5th-9th October 2020. Here we highlight the challenges we faced whilst coordinating a major exam at a national level during the COVID-19 pandemic with recommendations for future exams.
Fulltext Outcome of Skeletal Reconstructive Surgery for Metastatic Bone Tumours in the Femur

Mohamed-Haflah NH, Kassim Y, Zuchri I, Zulmi W

Malays Orthop J, 2017 Mar;11(1):28-34.
PMID: 28435571 MyJurnal DOI: 10.5704/MOJ.1703.013

INTRODUCTION: The role of surgery in skeletal metastasis is to reduce morbidity and improve the quality of life in terminally ill patients. We report our experience with patients who underwent skeletal reconstructive surgery for metastatic bone tumour of the femur.
MATERIALS AND METHODS: Twenty nine operations for skeletal metastasis of the femur performed in our centre between 2009 and 2015 were included in this study. We evaluated the choice of implant, complications, survival rate and functional outcome. Fourteen patients were still alive at the time of this report for assessment of functional outcome using Musculoskeletal Tumour Society (MSTS) form.
RESULTS: Plating osteosynthesis with augmented-bone cement was the most common surgical procedure (17 patients) performed followed by arthroplasty (10 patients) and intramedullary nailing (2 patients) There were a total of five complications which were implant failures (2 patients), surgical site infection (2 patients), and site infection mortality (1 patient). The median survival rate was eight months. For the functional outcome, the mean MSTS score was 66%.
CONCLUSION: Patients with skeletal metastasis may have prolonged survival and should undergo skeletal reconstruction to reduce morbidity and improve quality of life. The surgical construct should be stable and outlast the patient to avoid further surgery.
Fulltext Multiple Scattered and Small Lesions of Lower Limbs: Idiopathic Calcinosis Cutis: A Case Report

Ferdaus-Kamudin NA, Mohamed-Haflah NH

Malays Orthop J, 2018 Mar;12(1):66-68.
PMID: 29725520 MyJurnal DOI: 10.5704/MOJ.1803.008

Calcinosis cutis is a rare presentation and not many cases have been reported especially of idiopathic type. We are reporting a case of idiopathic calcinosis cutis of lower limbs in a 33-year old female who presented to our clinic for multiple painless swellings over her lower limbs for the past six months, without any history of trauma or infection. We have decided to observe her condition on regular follow-up and conservative management.
Fulltext Melorheostosis of the ulna

Abdullah S, Pang GM, Mohamed-Haflah NH, Sapuan J

J Chin Med Assoc, 2011 Oct;74(10):469-72.
PMID: 22036140 DOI: 10.1016/j.jcma.2011.08.019

Melorheostosis is a rare osteosclerotic bone dysplasia. It is usually characterized by dull and aching pain, reduced joint motion and contractures. Classic radiograph findings are of undulating cortical hyperostosis along the length of the bone, simulating a "dripping candlewax appearance". We report two cases of melorheostosis of the ulna bone, diagnosed 6 years apart in two different females in their early 20s. Both the patients presented with the characteristic features of dull and aching pain in the forearm and were treated conservatively. However, we misdiagnosed the first case as bone malignancy and subjected the patient to a biopsy. For the second case, with hindsight we made the correct diagnosis based only on the classic clinical history and radiographs. We believe that the discussion of a misdiagnosed case of melorheostosis with salient findings may be important for clinicians and orthopedicians in day-to-day clinical practice.
Fulltext Unusual Presentation of Giant Upper Limb Malignant Melanoma

Khim OG, Leong JF, Sani MH, Mohamed Haflah NH

Cureus, 2021 Aug;13(8):e16996.
PMID: 34540398 DOI: 10.7759/cureus.16996

Melanoma is rare among the Asian population. In Malaysia, there is little public awareness of melanoma compared to other types of cancer. Giant melanomas measuring more than 10 cm are rarely encountered and there are limited data available regarding this disease. We would like to report an unusual presentation of giant malignant melanoma of upper limb in a 62-year-old patient who presented with a five-month history of a progressively enlarging, painless mass on his left arm. This mass which measures 10 x 15 cm turned out to be a giant malignant melanoma of the left arm. To our knowledge, this is the largest melanoma of arm reported in Malaysia. Radiological findings were suggestive of soft tissue sarcoma with lung metastasis. Patient underwent wide local excision of left-arm mass and upper limb reconstruction. The diagnosis of malignant melanoma was made based on the final histopathology report. Despite aggressive treatment involving multidisciplinary units, it did not prevent the disease progression and patient succumbed five months after his presentation. Here, we present our experience in the management of this large malignant melanoma of the arm and to stress the sinister nature of melanoma.
Fulltext Melorheostosis of the hand affecting the c6 sclerotome and presenting with carpal tunnel syndrome

Abdullah S, Mat Nor NF, Mohamed Haflah NH

Singapore Med J, 2014 Apr;55(4):e54-6.
PMID: 24763843

Melorheostosis is a rare, progressive bone disease accompanied by hyperostosis and soft tissue fibrosis. While affected adults present with contracture and pain, children present with limb length discrepancy and deformity. We report the case of a 20-year-old woman with melorheostosis since childhood who presented with right hand deformity and numbness. Radiographs showed not only a combination of dense sclerosis and opacities, but also the classic 'flowing candle wax' appearance. Radiography can be used to identify melorheostosis, thus preventing unnecessary bone biopsies. Carpal tunnel release revealed the presence of a thickened flexor retinaculum and a degenerated median nerve distal to the retinaculum, but did not show hyperostosis. This case highlights the role of nerve decompression in melorheostosis and the importance of early identification of the disease to prevent unnecessary bone biopsies.
Fulltext Bilateral scaphoid stress fracture in a platform diver presenting with unilateral symptoms

Mohamed Haflah NH, Mat Nor NF, Abdullah S, Sapuan J

Singapore Med J, 2014 Oct;55(10):e159-61.
PMID: 25631904

Scaphoid stress fracture is rare and occurs mainly in gymnasts. The current literature has only two reported cases: unilateral scaphoid stress fracture in a platform diver and bilateral scaphoid stress fracture in a gymnast. We herein report bilateral stress fracture of the scaphoid in a platform diver who presented with only one symptomatic side. Our patient was a 16-year-old competitive platform diver with an 18-month history of pain in the right wrist. Radiography revealed fracture of the right scaphoid at the waist. As part of our preoperative plan of measuring the scaphoid length to determine the appropriate screw, radiography of the contralateral side was performed, revealing an unexpected fracture of the left scaphoid. Due to the frequency of stress fractures in competitive sports, especially gymnastics, we recommend that bilateral scaphoid radiography be performed for athletes presenting with a unilateral scaphoid fracture, to avoid missing a fracture in the contralateral side.
Dendritic fibromyxolipoma: a variant of spindle cell lipoma with extensive myxoid change, with cytogenetic evidence

Wong YP, Chia WK, Low SF, Mohamed-Haflah NH, Sharifah NA

Pathol. Int., 2014 Jul;64(7):346-51.
PMID: 25047505 DOI: 10.1111/pin.12176

Dendritic fibromyxolipoma (DFML), a rare, recently described distinct benign soft tissue tumor, has many clinicopathological features reminiscent of spindle cell lipoma and solitary fibrous tumor with myxoid change. It is distinguished histologically from both entities by the presence of spindle and stellate cells with dendritic cytoplasmic prolongations, prominent myxoid stroma with abundant keloidal collagen and occasional small plexiform vascular proliferation. We describe a case of histologically confirmed DFML of the left shoulder in a 67-year-old male, in which subsequent cytogenetic analysis revealed deletion involving 13q14.3 region in all the tumor cells, typically detected in spindle cell lipoma. In the presence of many clinicopathological similarities between DFML and spindle cell lipoma including chromosomal abnormalities, we postulate that DFML is merely a rare variant of spindle cell lipoma with extensive myxoid degeneration, and may not be considered as a separate entity. The possible differential diagnosis and their distinguishing features are briefly discussed.
Fulltext Rheumatoid arthritis serotype and synthetic disease-modifying anti-rheumatic drugs in patients with periodontitis: A case-control study

Nik-Azis NM, Mohd N, Mohd Fadzilah F, Mohamed Haflah NH, Mohamed Said MS, Baharin B

PLoS One, 2021;16(6):e0252859.
PMID: 34153036 DOI: 10.1371/journal.pone.0252859

Patients with rheumatoid arthritis (RA) experience a higher prevalence of periodontitis. This study aimed to examine the variation of periodontitis experienced with different serotypes suffered by RA patients and to examine the relationship between the different medications taken for RA that may influence this relationship. Two hundred and sixty RA and control participants underwent standardized periodontal examinations. Medical, serological and radiological (Sharp/van der Heijde) records were assessed. Functional status was assessed using the administered Health Assessment Questionnaire. Moreover, disease parameters, including disease activity (DAS28-ESR) and anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF) seropositivity were evaluated. Periodontitis was higher in RA (71.54%) compared with controls (54.62%). The stage of periodontitis experienced by ACPA-positive participants were higher than APCA-negative participants. The probing pocket depth and recession experienced by RF-positive participants were higher than those who were RF-negative. RA participants on methotrexate had lower clinical attachment loss and lower periodontal probing depth compared with participants on a combination methotrexate and other disease-modifying antirheumatic drugs. Participants taking corticosteroids had lower gingival index scores. The association between seropositivity and the type of medications taken with periodontal health parameters in this group of patients suggests that both seropositivity and medications taken are important modifiers in the relationship between periodontitis and RA.
Advancement of Electrospun Nerve Conduit for Peripheral Nerve Regeneration: A Systematic Review (2016-2021)

Lee SY, Thow SY, Abdullah S, Ng MH, Mohamed Haflah NH

Int J Nanomedicine, 2022;17:6723-6758.
PMID: 36600878 DOI: 10.2147/IJN.S362144

Peripheral nerve injury (PNI) is a worldwide problem which hugely affects the quality of patients' life. Nerve conduits are now the alternative for treatment of PNI to mimic the gold standard, autologous nerve graft. In that case, with the advantages of electrospun micro- or nano-fibers nerve conduit, the peripheral nerve growth can be escalated, in a better way. In this systematic review, we focused on 39 preclinical studies of electrospun nerve conduit, which include the in vitro and in vivo evaluation from animal peripheral nerve defect models, to provide an update on the progress of the development of electrospun nerve conduit over the last 5 years (2016-2021). The physical characteristics, biocompatibility, functional and morphological outcomes of nerve conduits from different studies would be compared, to give a better strategy for treatment of PNI.
Fulltext Functional Disability and Symptomatic Slow-Acting Drugs for Osteoarthritis in Adults with Periodontitis

Nik-Azis NM, Mohd N, Baharin B, Mohd Fadzilah F, Mohamed Haflah NH, Mohamed Said MS

Healthcare (Basel), 2023 Mar 06;11(5).
PMID: 36900775 DOI: 10.3390/healthcare11050770

Osteoarthritis (OA) patients have decreased functional ability and restricted access to healthcare facilities and are on a spectrum of medications. These can impact their oral health. This study aims to investigate the association between periodontal disease and OA disease parameters, specifically the functional disability and the medications taken. This was a cross-sectional study on OA participants recruited from the Hospital Canselor Tuanku Mukhriz. Periodontal health parameters were obtained from an oral examination of the participants. A Health Assessment Questionnaire (HAQ) was administered to ascertain the functional status of the participants. Out of the 130 participants recruited, 71 (54.6%) had periodontitis. There was a correlation between the teeth count with OA severity, where participants with a greater Kellgren-Lawrence score had less teeth (rs = 0.204, p = 0.025). Participants with a greater degree of functional limitation also had less teeth (rs = -0.181, p = 0.039) and a higher clinical attachment loss (rs = 0.239, p = 0.006). There were no associations found between the symptomatic slow-acting drugs in OA and periodontal health parameters. In conclusion, there was a high proportion of periodontitis in patients with OA. Functional disability was associated with measures of periodontal health. It is suggested that clinicians treating OA patients consider the need for a referral for dental care when managing this group of patients.
Fulltext Synchronous Primary Parosteal Osteosarcoma and Primary Mediastinal Germ Cell Tumour with Atypical Mycobacterial Infection - A Rare Phenomenon: A Case Report

Lim CH, Mohamed-Haflah NH, Abdullah-Sani MH, Loh CK, Abdul-Rahman MR

Malays Orthop J, 2023 Mar;17(1):188-192.
PMID: 37064628 DOI: 10.5704/MOJ.2303.023

Mediastinal germ cell tumours are a rare group of extragonadal germ cell tumours with less than 5% prevalence of all germ cell tumours. Primary mediastinal germ cell tumours themselves account for 16-36% of the extragonadal germ cell tumours. Along the spectrum of osteosarcoma, parosteal osteosarcoma is a well-differentiated surface osteosarcoma with a prevalence of 4% of all osteosarcoma. As such synchronous primary parosteal osteosarcoma and primary mediastinal germ cell tumour are exceedingly rare. This leads to complexity in determining the most appropriate chemotherapy for two different types of tumours and its potential side effects of reduced immunity leading to potential secondary infection. Here we report a case of a 16-year-old boy who presented with synchronous primary osteosarcoma and primary mediastinal germ cell tumour, complicated with atypical mycobacterial infection post-operatively. Additionally, we discuss our choice of chemotherapy and the management of the atypical mycobacterial infection.
Fulltext Distal Tibiofibular Joint Reconstruction Using Autograft in a Rare Case of Lower Limb Sclerosing/Spindle Cell Rhabdomyosarcoma: A Two-Year Follow-Up

Othman H, Mohamed Haflah NH, Sani MH, Wan Ismail WF, Kesu Belani L

Cureus, 2023 Aug;15(8):e42869.
PMID: 37664329 DOI: 10.7759/cureus.42869

Sclerosing/spindle cell rhabdomyosarcoma (s-scRMS) is a rare variant of striated muscle tumours. It has been recognised as an individual entity, the fourth subtype of rhabdomyosarcoma in the latest WHO classification. In the paediatric population, it occurs more commonly in the paratesticular area, whereas in adults, it occurs more commonly in the head and neck region. It has distinctive characteristics in terms of its histopathological and immunochemistry findings, which help in accurate diagnosis. The mainstay of treatment is a multimodal approach, i.e., surgery, chemotherapy, and radiation therapy. However, no standard care is still being established internationally for adult cases. In adults, this tumour has a poorer prognosis as compared to children. We describe a patient with s-scRMS of the lower limb who has undergone wide local resection of the tumour with surgical reconstruction of the distal tibiofibular joint with autograft and its two-year outcome.
Massive Traumatic Skin Defect Successfully Treated with Autologous, Bilayered, Tissue-Engineered MyDerm Skin Substitute: A Case Report

Mohamed Haflah NH, Ng MH, Mohd Yunus MH, Naicker AS, Htwe O, Abdul Razak KA, et al.

JBJS Case Connect, 2018 6 15;8(2):e38.
PMID: 29901479 DOI: 10.2106/JBJS.CC.17.00250

CASE: A 22-year-old man sustained a laceration that measured 180 cm, after debridement, over the anterolateral aspect of the right leg following a road traffic accident. The wound was treated with MyDerm (Universiti Kebangsaan Malaysia), a cell-based, bilayered, bioengineered dermal substitute that contains no animal-derived components and is fully autologous. For its construction, only a small area of skin was harvested from the left groin, which was closed primarily with absorbable sutures.
CONCLUSION: MyDerm is an alternative option for the treatment of a massive skin defect in patients who desire removal of only a negligible amount of skin from the donor site and when use of an autograft is insufficient.
The Use of Engineered Bilayered Skin (MyDermTM) in the Management of Massive Skin Defect in Grade III Gustilo-Anderson Open Fracture

Mohamed Haflah NH, Ng MH, Mohd Yunus MH, Naicker AS, Htwe O, Fahmi M, et al.

Int J Low Extrem Wounds, 2017 Sep;16(3):212-216.
PMID: 28862056 DOI: 10.1177/1534734617724974

Open fracture Gustilo-Anderson grade IIIC is associated with higher risk of infection and problems with soft tissue coverage. Various methods have been used for soft tissue coverage in open fractures with large skin defect. We report a case of a patient who had grade IIIC open fracture of the tibia with posterior tibial artery injury. The patient underwent external fixation and reduction. Because of potential compartment syndrome after vascular repair, fasciotomy of the posterior compartment was performed. This wound, however, became infected and because of further debridement, gave rise to a large skin defect. A tissue engineered skin construct, MyDermTM was employed to cover this large defect. Complete wound closure was achieved 35 days postimplantation. The patient then underwent plating of the tibia for nonunion with no adverse effect to the grafted site. The tibia eventually healed 5 months postplating, and the cosmetic appearance of the newly formed skin was satisfactory.
Efficacy of Human Cell-Seeded Muscle-Stuffed Vein Conduit in Rat Sciatic Nerve Repair

Ramli K, Gasim AI, Ahmad AA, Htwe O, Mohamed Haflah NH, Law ZK, et al.

Tissue Eng Part A, 2019 10;25(19-20):1438-1455.
PMID: 30848172 DOI: 10.1089/ten.TEA.2018.0279

We investigated the efficacy of a muscle-stuffed vein (MSV) seeded with neural-transdifferentiated human mesenchymal stem cells as an alternative nerve conduit to repair a 15-mm sciatic nerve defect in athymic rats. Other rats received MSV conduit alone, commercial polyglycolic acid conduit (Neurotube®), reverse autograft, or were left untreated. Motor and sensory functions as well as nerve conductivity were evaluated for 12 weeks, after which the grafts were harvested for histological analyses. All rats in the treatment groups demonstrated a progressive increase in the mean Sciatic Functional Index (motor function) and nerve conduction amplitude (electrophysiological function) and showed positive withdrawal reflex (sensory function) by the 10th week of postimplantation. Autotomy, which is associated with neuropathic pain, was severe in rats treated with conduit without cells; there was mild or no autotomy in the rats of other groups. Histologically, harvested grafts from all except the untreated groups exhibited axonal regeneration with the presence of mature myelinated axons. In conclusion, treatment with MSV conduit is comparable to that of other treatment groups in supporting functional recovery following sciatic nerve injury; and the addition of cells in the conduit alleviates neuropathic pain. Impact Statement It is shown that pretreated muscle-stuffed vein conduit is comparable to that of commercial nerve conduit and autograft in supporting functional recovery following peripheral nerve injury. The addition of neural-differentiated mesenchymal stem cells in the conduit is shown to alleviate neuropathic pain.

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