Corrigendum: Dual-mTOR Inhibitor Rapalink-1 Reduces Prostate Cancer Patient-Derived Xenograft Growth and Alters Tumor Heterogeneity.

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Dual-mTOR Inhibitor Rapalink-1 Reduces Prostate Cancer Patient-Derived Xenograft Growth and Alters Tumor Heterogeneity.

Bone metastasis is the leading cause of prostate cancer (PCa) mortality, frequently marking the progression to castration-resistant PCa. Dysregulation of the androgen receptor pathway is a common feature of castration-resistant PCa, frequently appearing in association with mTOR pathway deregulations. Advanced PCa is also characterized by increased tumor heterogeneity and cancer stem cell (CSC) frequency. CSC-targeted therapy is currently being explored in advanced PCa, with the aim of reducing cancer clonal divergence and preventing disease progression. In this study, we compared the molecular pathways enriched in a set of bone metastasis from breast and prostate cancer from snap-frozen tissue. To further model PCa drug resistance mechanisms, we used two patient-derived xenografts (PDX) models of bone-metastatic PCa, BM18, and LAPC9. We developed in vitro organoids assay and ex vivo tumor slice drug assays to investigate the effects of mTOR- and CSC-targeting compounds. We found that both PDXs could be effectively targeted by treatment with the bivalent mTORC1/2 inhibitor Rapalink-1. Exposure of LAPC9 to Rapalink-1 but not to the CSC-targeting drug disulfiram blocked mTORC1/2 signaling, diminished expression of metabolic enzymes involved in glutamine and lipid metabolism and reduced the fraction of CD44+ and ALDEFluorhigh cells, in vitro. Mice treated with Rapalink-1 showed a significantly delayed tumor growth compared to control and cells recovered from the tumors of treated animals showed a marked decrease of CD44 expression. Taken together these results highlight the increased dependence of advanced PCa on the mTOR pathway, supporting the development of a targeted approach for advanced, bone metastatic PCa.

Manipulation under anaesthesia for frozen shoulders: outdated technique or well-established quick fix?

Manipulation under anaesthesia (MUA) for frozen shoulder (FS) leads to a considerable increase in range of motion and Oxford shoulder score, a significant reduction in pain and around 85% satisfaction.A clearly defined indication for MUA in FS patients cannot be extracted from this review or the available literature. The associating criteria before proceeding to MUA vary widely.All but one study in this review lacked a control group without intervention. Therefore, firm conclusions about the role of MUA in the treatment of FS cannot be drawn from the current literature.An overall complication rate of 0.4% was found and a re-intervention rate of 14%, although most of the included papers were not designed to monitor complications.The following criteria before proceeding to MUA are proposed: a patient unable to cope with a stiff and painful shoulder; clinical signs of a stage 2 idiopathic FS; lessening pain in relation to stage 1; external rotation < 50% compared to contralateral shoulder joint; a minimal duration of symptoms of three months; and failure to respond to an intra-articular corticosteroid infiltration. Cite this article: EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044.

An ex vivo Tissue Culture Model for the Assessment of Individualized Drug Responses in Prostate and Bladder Cancer.

Urological malignancies, including prostate and bladder carcinoma, represent a major clinical problem due to the frequent occurrence of therapy resistance and the formation of incurable distant metastases. As a result, there is an urgent need for versatile and predictive disease models for the assessment of the individualized drug response in urological malignancies. Compound testing on ex vivo cultured patient-derived tumor tissues could represent a promising approach. In this study, we have optimized an ex vivo culture system of explanted human prostate and bladder tumors derived from clinical specimens and human cancer cell lines xenografted in mice. The explanted and cultured tumor slices remained viable and tissue architecture could be maintained for up to 10 days of culture. Treatment of ex vivo cultured human prostate and bladder cancer tissues with docetaxel and gemcitabine, respectively, resulted in a dose-dependent anti-tumor response. The dose-dependent decrease in tumor cells upon administration of the chemotherapeutic agents was preceded by an induction of apoptosis. The implementation and optimization of the tissue slice technology may facilitate the assessment of anti-tumor efficacies of existing and candidate pharmacological agents in the complex multicellular neoplastic tissues from prostate and bladder cancer patients. Our model represents a versatile "near-patient" tool to determine tumor-targeted and/or stroma-mediated anti-neoplastic responses, thus contributing to the field of personalized therapeutics.

Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders.

AIM: To investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs). METHODS: A two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk. RESULTS: Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups. CONCLUSION: Additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

Does hydroxyapatite coating enhance ingrowth and improve longevity of a Zweymuller type stem? A double-blinded randomised RSA trial.

INTRODUCTION: An ongoing discussion is whether using a hydroxyapatite coating enhances the ingrowth and longevity of a femoral stem in total hip arthroplasty. The best way to predict speed of ingrowth and long-term outcome is by evaluating micromotion by radiostereometric analysis. To study the effect of hydroxyapatite (HA) coating on the migration of the SL-PLUS hip stem, we performed a prospective double blind randomised controlled trial comparing the early migration of the hydroxyapatite (HA)-coated SL-PLUS stem compared to the Standard (non-coated) SL-PLUS stem. PATIENTS AND METHODS: 51 patients were randomly assigned to receive either an uncoated or a HA-coated femoral component during total hip replacement. RSA images were obtained direct postoperatively and at 6 weeks, 12 weeks, 6 months, 12 months and 24 months. HOOS scores were obtained preoperative and at final follow-up. RESULTS: RSA evaluation demonstrated significant migration up to 3 months postoperatively in both groups. After initial setting no significant migration was observed. There was no significant difference in migration between the HA-coated group and the uncoated group. Both Harris Hip Score (HHS) and HOOS domain scores (pain and ADL) significantly improved compared to baseline at 24 months after surgery in both treatment groups (p<0.001 for all comparisons). Improvement did not differ significantly between the 2 groups. CONCLUSIONS: At 2 years follow-up, the HA-coated and uncoated Zweymuller type, distal fitting stem do not show different migration patterns.

How to treat a frozen shoulder? A survey among shoulder specialists in the Netherlands and Belgium.

A frozen shoulder is a common cause of a painful and stiff shoulder. A web-based survey was conducted to obtain insight in the current preferences about the diagnosis and treatment of a frozen shoulder. A response rate of 54% was reached among shoulder specialized orthopaedic surgeons from the Netherlands and Belgium. Non-steroidal anti-inflammatory drugs and intra-articular corticosteroid injections are used frequently in the first phase of the condition. Physiotherapy is assumed to be more important in the final phase. The results of the survey indicate a wide variety of treatment strategies in the different phases of a frozen shoulder. Three out of four respondents considered that the management of a frozen shoulder could benefit from a written guideline. The development of a written guideline should lead to an improved level of consensus and a more standardized approach in the treatment of a frozen shoulder among shoulder specialists in the Netherlands and Belgium.

The biomechanical effects of polytetrafluoroethylene suture augmentations in lateral-row rotator cuff repairs in an ovine model.

BACKGROUND: This study investigated the biomechanical effects of expanded polytetrafluoroethylene (ePTFE) suture augmentation patches in rotator cuff repair constructs. METHODS: The infraspinatus tendon in 24 cadaveric ovine shoulders was repaired using an inverted horizontal mattress suture with 2 knotless bone anchors (ArthroCare, Austin, TX, USA) in a lateral-row configuration. Four different repair groups (6 per group) were created: (1) standard repair using inverted horizontal mattress sutures, (2) repair with ePTFE suture augmentations on the bursal side of the tendon, (3) repair with ePTFE suture augmentations on the articular side, and, (4) repair with ePTFE suture augmentations on both sides of the tendon. Footprint contact pressure, stiffness, and the load to failure of the repair constructs were measured. RESULTS: Repairs with ePTFE suture augmentations on the bursal side exerted significantly more footprint contact pressure (0.40 ± 0.01 MPa) than those on the articular side (0.34 ± 0.02 MPa, P = .04) and those on both sides (0.33 ± 0.02 MPa, P = .01). At 15 degrees of abduction, ePTFE-augmented repairs on the bursal side had higher footprint contact pressure (0.26 ± 0.03 MPa) compared with standard repairs (0.15 ± 0.02 MPa, P = .01) and with ePTFE-augmented repairs on the articular side (0.18 ± 0.02 MPa, P = .03). The ePTFE-augmented repairs on the bursal side demonstrated significantly higher failure loads (178 ± 18 N) than standard repairs (120 ± 17 N, P = .04). CONCLUSIONS: Inverted horizontal mattress sutures augmented with ePTFE patches on the bursal side of the tendon enhanced footprint contact pressures and the ultimate load to failure of lateral-row rotator cuff repairs in an ovine model.

Arthroscopic Capsular Release for Idiopathic Adhesive Capsulitis.

INTRODUCTION: Our technique of arthroscopic capsular release involving two posterior portals and one anterior portal, to accomplish a complete 360° release, improves motion and reduces pain in patients with idiopathic adhesive capsulitis. STEP 1 POSITION THE PATIENT: Place the patient in a beach-chair position for shoulder joint arthroscopy. STEP 2 ESTABLISH A ROUTINE POSTERIOR GLENOHUMERAL JOINT ARTHROSCOPY PORTAL: Use a routine posterior glenohumeral arthroscopy portal to introduce the arthroscope. STEP 3 ESTABLISH AN ANTERIOR PORTAL: Establish the anterior portal under direct vision using a spinal needle. STEP 4 RELEASE THE ROTATOR CUFF INTERVAL AND SUBSCAPULARIS TENDON: Release the rotator cuff interval, dividing no more than the upper half of the intra-articular subscapularis tendon. STEP 5 RELEASE THE ANTERIOR-INFERIOR ASPECT OF THE CAPSULE: Cut the anterior-inferior aspect of the capsule completely. STEP 6 ESTABLISH A POSTERIOR-INFERIOR PORTAL: Determine the location of the posterior-inferior portal with a spinal needle. STEP 7 RELEASE THE POSTERIOR-INFERIOR ASPECT OF THE CAPSULE: Release or perforate the posterior-inferior capsule of the joint with the arthroscopic wand. STEP 8 GENTLY MANIPULATE THE ARM: Manipulate the arm in abduction, then forward and backward flexion, and then external and internal rotation. RESULTS: An arthroscopic capsular release with use of the technique described here was performed in forty-nine shoulders in forty-three patients with idiopathic adhesive capsulitis4. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

CT measurement of range of motion of ankle and subtalar joints following two lateral column lengthening procedures.

BACKGROUND: Lateral column lengthening (LCL) has become an accepted procedure for the operative treatment of the flexible flatfoot deformity. Hindfoot arthrodesis via a calcaneocuboid distraction arthrodesis (CCDA) has been considered a less favourable surgical option than the anterior open wedge calcaneal distraction osteotomy (ACDO), as CCDA has been associated with reduced hindfoot joint motion postoperatively. The ankle and subtalar joint ranges of motion were measured in patients who underwent an ACDO or CCDA procedure for flatfoot deformity. METHODS: CT scanning was performed with the foot in extreme positions in five ACDO and five CCDA patients. A bone segmentation and registration technique for the tibia, talus and calcaneus was applied to the CT images. Finite helical axis (FHA) rotations representing the range of motion of the joints were calculated for the motion between opposite extreme foot positions of the tibia and the calcaneus relative to the talus. RESULTS: The maximum mean FHA rotation of the ankle joint (for extreme dorsiflexion to extreme plantarflexion) after ACDO was 52.2 degrees ± 12.4 degrees and after CCDA 49.0 degrees ± 12.0 degrees. Subtalar joint maximum mean FHA rotation (for extreme eversion to extreme inversion) following ACDO was 22.8 degrees ± 8.6 degrees, and following CCDA 24.4 degrees ± 7.6 degrees. CONCLUSION: An accurate CT-based technique was used to assess the range of motion of the ankle and subtalar joints following two lateral column lengthening procedures for flatfoot deformity. Comparable results with a considerable amount of variance were found for the range of motion following the ACDO and CCDA procedures.

Overview of subtalar arthrodesis techniques: options, pitfalls and solutions.

BACKGROUND: Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified. MATERIALS AND METHODS: A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation. RESULTS: The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68-100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36-96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications. PITFALLS: The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion. SOLUTIONS: The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment. CONCLUSION: The review provides practical suggestions to optimize SA-techniques.

Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view.

BACKGROUND: Hindfoot malalignment is a recognized cause of foot and ankle disability. For preoperative planning and clinical follow-up, reliable radiographic assessment of hindfoot alignment is important. The long axial radiographic view and the hindfoot alignment view are commonly used for this purpose. However, their comparative reliabilities are unknown. As hindfoot varus or valgus malalignment is most pronounced during mid-stance of gait, a unilateral weight-bearing stance, in comparison with a bilateral stance, could increase measurement reliability. The purpose of this study was to compare the intra- and interobserver reliability of hindfoot alignment measurements of both radiographic views in bilateral and unilateral stance. MATERIALS AND METHODS: A hindfoot alignment view and a long axial view were acquired from 18 healthy volunteers in bilateral and unilateral weight-bearing stances. Hindfoot alignment was defined as the angular deviation between the tibial anatomical axis and the calcaneus longitudinal axis from the radiographs. Repeat measurements of hindfoot alignment were performed by nine orthopaedic examiners. RESULTS: Measurements from the hindfoot alignment view gave intra- and interclass correlation coefficients (CCs) of 0.72 and 0.58, respectively, for bilateral stance and 0.91 and 0.49, respectively, for unilateral stance. The long axial view showed, respectively, intra- and interclass CCs of 0.93 and 0.79 for bilateral stance and 0.91 and 0.58 for unilateral stance. CONCLUSION: The long axial view is more reliable than the hindfoot alignment view or the angular measurement of hindfoot alignment. Although intra-observer reliability is good/excellent for both methods, only the long axial view leads to good interobserver reliability. A unilateral weight-bearing stance does not lead to greater reliability of measurement.

A 3-portal approach for arthroscopic subtalar arthrodesis.

We present a 3-portal approach for arthroscopic subtalar arthrodesis with the patient in the prone position. The prone position allows the use of the two standard posterior portals and it allows for accurate control of hindfoot alignment during surgery. Furthermore, the introduction of talocalcaneal lag screws is easy with the patient in this position. In addition to the standard posterior portals, an accessory third portal is created at the level of the sinus tarsi for introduction of a large diameter blunt trocar to open up the subtalar joint. Due to the curved geometry of the posterior subtalar joint, removal of the anterior articular cartilage is impossible by means of the posterior portals only. An advantage of the 3-portal approach is that ring curettes can be introduced through the accessory sinus tarsi portal to remove the articular cartilage of the anterior part of the posterior talocalcaneal joint. Arthroscopic subtalar arthrodesis in patients with a talocalcaneal coalition presents a technical challenge as the subtalar joint space is limited. The 3-portal technique was successfully used in three subsequent patients with a talocalcaneal coalition; bony union of the subtalar arthrodesis occurred at 6 weeks following surgery. With the 3-portal technique, a safe and time-efficient arthroscopic subtalar arthrodesis can be performed even in cases with limited subtalar joint space such as in symptomatic talocalcaneal coalition.

Determination of consistent patterns of range of motion in the ankle joint with a computed tomography stress-test.

BACKGROUND: Measuring the range of motion of the ankle joint can assist in accurate diagnosis of ankle laxity. A computed tomography-based stress-test (3D CT stress-test) was used that determines the three-dimensional position and orientation of tibial, calcaneal and talar bones. The goal was to establish a quantitative database of the normal ranges of motion of the talocrural and subtalar joints. A clinical case on suspected subtalar instability demonstrated the relevance the proposed method. METHODS: The range of motion was measured for the ankle joints in vivo for 20 subjects using the 3D CT stress-test. Motion of the tibia and calcaneus relative to the talus for eight extreme foot positions were described by helical parameters. FINDINGS: High consistency for finite helical axis orientation (n) and rotation (theta) was shown for: talocrural extreme dorsiflexion to extreme plantarflexion (root mean square direction deviation (eta) 5.3 degrees and theta: SD 11.0 degrees), talorucral and subtalar extreme combined eversion-dorsiflexion to combined inversion-plantarflexion (eta: 6.7 degrees , theta: SD 9.0 degrees and eta:6.3 degrees , theta: SD 5.1 degrees), and subtalar extreme inversion to extreme eversion (eta: 6.4 degrees, theta: SD 5.9 degrees). Nearly all dorsi--and plantarflexion occurs in the talocrural joint (theta: mean 63.3 degrees (SD 11 degrees)). The inversion and internal rotation components for extreme eversion to inversion were approximately three times larger for the subtalar joint (theta: mean 22.9 degrees and 29.1 degrees) than for the talocrural joint (theta: mean 8.8 degrees and 10.7 degrees). Comparison of the ranges of motion of the pathologic ankle joint with the healthy subjects showed an increased inversion and axial rotation in the talocrural joint instead of in the suspected subtalar joint. INTERPRETATION: The proposed diagnostic technique and the acquired database of helical parameters of ankle joint ranges of motion are suitable to apply in clinical cases.

In-vivo range of motion of the subtalar joint using computed tomography.

Understanding in vivo subtalar joint kinematics is important for evaluation of subtalar joint instability, the design of a subtalar prosthesis and for analysing surgical procedures of the ankle and hindfoot. No accurate data are available on the normal range of subtalar joint motion. The purpose of this study was to introduce a method that enables the quantification of the extremes of the range of motion of the subtalar joint in a loaded state using multidetector computed tomography (CT) imaging. In 20 subjects, an external load was applied to a footplate and forced the otherwise unconstrained foot in eight extreme positions. These extreme positions were foot dorsiflexion, plantarflexion, eversion, inversion and four extreme positions in between the before mentioned positions. CT images were acquired in a neutral foot position and each extreme position separately. After bone segmentation and contour matching of the CT data sets, the helical axes were determined for the motion of the calcaneus relative to the talus between four pairs of opposite extreme foot positions. The helical axis was represented in a coordinate system based on the geometric principal axes of the subjects' talus. The greatest relative motion between the calcaneus and the talus was calculated for foot motion from extreme eversion to extreme inversion (mean rotation about the helical axis of 37.3+/-5.9 degrees, mean translation of 2.3+/-1.1 mm). A consistent pattern of range of subtalar joint motion was found for motion of the foot with a considerable eversion and inversion component.

Open-wedge osteotomy of the lateral femoral condyle for extensor mechanism instability.

OBJECTIVE: To achieve extensor mechanism stability in postpatellectomy patients by elevating the lateral femoral condyle, thus creating a deeper trochlear groove. INDICATIONS: Instability of the quadriceps tendon after patellectomy and other realignment interventions, including but not limited to the release of the lateral patellofemoral ligaments, advancement of the vastus medialis obliquus muscle and, in some cases, transfer of the tibial tubercle. Stabilization of a normal dislocating patella in presence of a hypoplastic lateral femoral condyle. CONTRAINDICATIONS: Medical conditions precluding surgery. SURGICAL TECHNIQUE: An open-wedge osteotomy of the lateral femoral condyle is performed. Predrilling at the osteotomy level is followed by a multiple-step curved-type osteotomy starting laterally, directed upward to the trochlea. Bone wedges are inserted under the levered bony fragment and the intrinsically stable osteotomy is secured with one or more countersunk screws. POSTOPERATIVE MANAGEMENT: A removable splint is applied in 30 degrees of knee flexion. With patellectomy, the splint is applied in 90 degrees of knee flexion for the first 3 days. Continuous passive motion and partial weight bearing are started 4 days after surgery in all patients. Use of the splint is advocated for 6 weeks in total. RESULTS: Eight knees (six patients) with extensor mechanism instability underwent this procedure. In five knees patellectomy had been performed earlier, one patient underwent an osteotomy combined with patellectomy bilaterally, in one patient a normal patella was left in situ. No instability was reported after surgery (average follow-up 8 years, range 2-17 years). Modified Lysholm Knee Scores showed two excellent, two good, and four fair results. Follow-up radiographs showed a healed osteotomy and an increase in trochlear depth.

Arthroscopy of the posterior subtalar joint.

The subtalar joint is a complex and functionally important joint of the lower extremity. It plays a major role in the movement of inversion and eversion of the foot. With the development of small-joint arthroscopes and instrumentation, surgeons became interested in posterior subtalar joint arthroscopy. Diagnostic and therapeutic indications for this technique have increased; however, arthroscopic subtalar surgery is technically difficult and should be performed by an experienced arthroscopist. The number of reports dealing with posterior subtalar arthroscopy remains relatively small.

Subcapital hip fractures: the Garden classification should be replaced, not collapsed.

OBJECTIVES: To evaluate rater agreement for a simple 2-category classification of subcapital hip fractures versus the 4-category Garden classification and to determine the effect of clinician experience on the level of agreement. SETTING: Sunnybrook and Women's Health Sciences Centre, Toronto, a level 1 trauma centre. METHOD: Eleven raters, with varying levels of clinical experience (3 fellowship-trained orthopedic surgeons, 4 clinical fellows and 4 residents), classified 34 pairs of anteroposterior and lateral radiographs of patients with subcapital hip fractures according to whether the fracture was stable (the fragments move as a unit) or unstable (the fragments move independently), and according to Garden's original 4-category classification. The exercise was repeated 1 month later. The radiographs were obtained from a fracture database to represent a wide spectrum of injury severity. OUTCOME MEASURES: The level of agreement beyond chance, quantified by use of the SAV statistic of O'Connell and Dobson. RESULTS: The most experienced raters demonstrated almost perfect inter- and intrarater agreement with respect to stable and unstable fractures (SAV > 0.80). The raters demonstrated only fair agreement for the Garden classification (mean SAV 0.64). Even junior clinicians demonstrated substantial agreement regarding fracture stability, with much lower scores for the Garden classification. Collapsing the Garden classification responses into 2 categories (stages I and II v. III and IV) was not synonymous with rater categorization of stable versus unstable. CONCLUSION: The Garden classification for subcapital hip fractures is unreliable and should be abandoned in favour of categorizing fractures as stable versus unstable.