Background: As the coronavirus disease (COVID-19) pandemic is expected to stay for a longer time, educational activities including residency training have gradually resumed with the aid of virtual tools. In addition to continuing the residency education during COVID-19, it is also important to conduct their examination so that the graduations of final year residents are not delayed. The conventional exam pattern involved clinical case presentations and required resident interaction with a number of patients. However, in view of the COVID-19 pandemic we conducted a "zero-patient contact virtual practical exit examination" for orthopaedic residents. Methods: In order to replicate the conventional exam case-scenarios, clinical cases were prepared in a digital presentation format. The candidate used N-95 facemasks and gloves, and adequate social distancing was maintained in the examination area. We also designed a 10-item questionnaire aimed at assessing the quality and satisfaction with the exam pattern. Results: The mean score for overall satisfaction with the virtual pattern was 4.5 (out of 5) in examiner group while it was 4.1 in examinee group. Higher scores were also reported for questions related to safety of the exam, relevance and quality of the virtual cases, etc. The mean total feedback score for the examiner and examinee group was 48 and 43.4 respectively (out of 50). Conclusion: Orthopaedic residency end-of-training examinations can be successfully conducted during the COVID pandemic, and we hope our experience will be helpful to other residency programs.

Aims The aim of this study was to explore the utility of 18F-FDG PET/CT in the assessment of response to antitubercular treatment (ATT) and identification of treatment endpoint. Patients and Methods Forty patients (mean age, 35.3 years; 27 men) with clinically, radiologically, and histopathologically proven joint tuberculosis prospectively underwent clinical, biochemical, and PET/CT evaluation at baseline and after ~6, 12, and 18 months of ATT. Two patients were lost to follow-up, and 1 defaulted treatment. The remaining 37 were followed up until complete response (CR) was achieved. Images were visually and quantitatively (SUVmax ratio and metabolically active disease volume [MV]) evaluated by 2 experienced nuclear medicine physicians. Results Knee (n = 18) and ankle (n = 7) were the most frequently involved sites. The median MV and SUVmax ratio at baseline were 85.10 mL and 7.21, respectively. Five patients had noncontiguous vertebral involvement, 12 had pulmonary lesions, 2 had abscesses, 6 had mediastinal, and 30 had local lymph nodal involvement. Complete response was seen in 1/39, 11/37, and 30/37 patients after 6, 12, and 18 months of ATT. Significant reductions in visual analog scale score, tenderness, joint swelling, SUVmax ratios, and MVs (Friedman test, P < 0.001) were seen after each follow-up. The median time-to-CR in skeletal lesions was significantly longer than extraskeletal lesions (591 vs 409 days; Wilcoxon signed-rank test, P < 0.001). Time-to-CR in joint lesions positively correlated with MV at first follow-up (Pearson = 0.452, P = 0.005) and negatively correlated with percentage change in MV (first follow-up from baseline) (Pearson = −0.620, P < 0.001). ROC analysis yielded a cutoff of ≤71% reduction in MV at first follow-up (80.8% sensitivity, 81.8% specificity) to predict extension of ATT beyond 12 months. Using ROC analysis at second follow-up, a cutoff of ≤12.67 mL (for CR) was derived and was validated in patients at the third follow-up, with an accuracy of 84.4%. Patients with CR in PET/CT maintained disease-free state during a mean follow-up of 271 days. Conclusions 18F-FDG PET/CT is an excellent tool in estimating total disease burden, assessing response to ATT and identification of treatment endpoint in joint tuberculosis.

Introduction: The WHO defines giant cell tumor as a benign locally aggressive neoplasm with metastasizing capacity and aggressive behavior. Very rarely, these tumors are seen fungating, mostly when neglected. But when they do, the treatment option commonly conferred is amputation of the limb which is disabling and traumatizing. Case Report: We report three cases of fungating limb masses (proximal tibia, distal fibula, and distal radius) diagnosed with giant cell tumor histologically, undergoing limb saving surgeries with various reconstruction techniques to endorse a good quality of life and functioning limb. Conclusion: Our study is one of the earliest to report medium-term follow-up after such limb salvage procedure. We recommend that salvage procedures should be considered in giant cell tumors even in the presence of fungation if there is no neurovascular encasement. Keywords: Giant cell tumor, fungation, limb salvage surgery, endoprosthesis, mesh reconstruction.

Introduction: Fragility hip fractures in nonagenarian patients pose a great challenge in management. To the best of our knowledge, no study has previously evaluated the outcomes and risk factors for mortality after hip fractures in this subgroup of population from the Indian subcontinent. Materials and Methods: A retrospective observational study was performed on nonagenarian patients (aged ≥90) who underwent surgery for hip fractures between March 2016 and March 2019. The patients were divided into two groups: “survivor group” (Group A) and “mortality group” (Group B). The demographic data, type of fracture, side of fractured limb, preinjury ambulatory status, American Society of Anesthesiologists (ASA) status, comorbidities, time interval from injury to surgery, operative time, length of hospital stay, and postoperative ambulatory status were recorded from hospital medical records and were studied between the two groups. The follow-up duration of the study was 1 year. Results: Thirty-four patients were included in the study. Both the groups had 17 patients each. Cardiac dysfunction was the most common cause of mortality. The time interval from injury to surgery (odds ratio [OR] = 11.2), gender (OR = 0.23) and postoperative mobility status (OR = 0.07) were found to be significantly different between the two groups. No significant difference in ASA grade, comorbidities, fracture type, preinjury ambulatory status, operative time, and length of hospital stay was seen between the two groups. Conclusions: Risk factors for mortality after hip fracture surgery in the nonagenarian population are male gender, delay in surgery (>3 days) and poor ambulatory status in the postoperative period. Hence, the aim for such patients with hip fractures should be to perform an early surgery and encourage an early ambulation.

Malakoplakia is a rare chronic granulomatous inflammatory disease, related to immune deficiency and impaired bactericidal macrophage activity. Common sites of involvement include urinary bladder and kidney followed by gastrointestinal tract. We present an unusual case of abdominal malakoplakia diagnosed preoperatively on ultrasound-guided fine-needle aspiration cytology (FNAC). It presented as a large locally aggressive mass with extensive involvement of multiple bowel loops in an 18-year-old boy following blunt trauma to the abdomen. The demonstration of calcified laminated intracytoplasmic Michaelis-Gutman bodies in histiocytes is a reliable diagnostic feature of malakoplakia on FNAC smears, which can guide an appropriate medical management.