Supracondylar Fractures In Children Research Articles

Minimally invasive surgical technique for unstable supracondylar humerus fractures in children (Gartland type III or IV).

Achieving and maintaining anatomical reduction during the treatment of pediatric humerus fractures, classified as Gartland type III or IV, presents a clinical challenge. Herein, we present a minimally invasive surgical approach using a novel and simple K-wire push technique that aids in achieving and maintaining anatomical reduction. We reviewed data of children receiving treatment for supracondylar fractures of the humerus at our hospital between January 2016 and December 2020. Patients were divided into two groups based on the method of treatment: Group 1 was treated with the K-wire push technique, and Group 2 was treated with the standard technique as described by Rockwood and Wilkins. The medical records and radiographic images were reviewed. In total, 91 patients with Gartland types III and IV fractures were included, with 37 and 54 patients in Groups 1 and 2, respectively. The postoperative reduction radiographic parameters and Flynn scores at final follow-up were not significantly different between the two groups. The minimally invasive K-wire push technique for unstable supracondylar fractures in children is a safe and effective alternative for improving reduction. Using this technique, complications can be minimized, and the requirement for open reduction can be reduced.

The fate of the malrotated elbow supracondylar fractures in children: is varus really a problem?

To evaluate the functional and cosmetic effects of elbow supracondylar fractures (SCF) in children with residual rotational deformity. Retrospective review cohort of patients with evidence of malrotation after treatment for SCF. An analysis of the postoperative X-ray of 305 consecutive SCF type 3 treated surgically during fiveyears identified 46 elbows with rotational deformity that fulfilled the selection criteria and were recalled for review; only 27 patients agreed to participate. Patients were evaluated clinically and radiographically. Clinically, the elbow and shoulder ROM were assessed. The postoperative fracture rotation (PFR) was radiologically measured using the Berdis method. Results were categorized according to Flynn criteria, and functional outcomes were evaluated with the QuickDASH questionnaire. On final assessment, a radiograph of both elbows was obtained, and measures were compared. Descriptive analysis was made calculating median, range, proportions, and confidence intervals. Non-parametric tests were used to test the association between variables. The group had a median age of fouryears and a median follow-up of 52months. Shoulder rotation was asymmetrical in 13 patients; six patients presented a change on carrying angle > 5° (4 varus/2 valgus). The higher the residual rotation, the higher the chances of an altered shoulder rotation (for each degree of PFR, the shoulder rotation was changed to 0.4°). However, there was a low correlation between the amount of rotation and the final carrying angle (r = 0.37). According to Flynn's criteria, over 95% had excellent or good results. There was a weak correlation between varus and rotational malalignment. Patients with moderate residual malrotation could be expected to have a good outcome even if some shoulder rotation changes persist.

Reconstruction of medial and lateral column periosteal hinge using Kirschner wire to assist in closed reduction of multi-directional unstable humeral supracondylar fractures in children

To investigate the effectiveness of medial and lateral column periosteal hinge reconstruction using Kirschner wire in the closed reduction of multi-directional unstable humeral supracondylar fractures in children. A clinical data of 43 children with multi-direction unstable humeral supracondylar fractures, who met the selection criteria and were admitted between August 2020 and August 2022, was retrospectively analyzed. Twenty-one cases of fractures were treated wuth closed reduction after medial and lateral column periosteal hinge reconstruction using Kirschner wire and percutaneous Kirschner wires fixation (study group), while 22 cases of fractures were treated by traditional closed reduction technique and percutaneous Kirschner wire fixation (control group). There was no significant difference in gender, age, cause of injury, fracture side, and interval from injury to operation between the two groups ( P>0.05). The operation time, intraoperative fluoroscopy times, the number of children who were changed to open reduction after closed reduction failure, fracture healing time, complications within 2 months after operation, and the Flynn score of elbow joint function at last follow-up were compared between the two groups. All the fractures in the study group were successfully closed reduction, and 4 cases in the control group were changed to open reduction and completed the operation, the difference between the two groups was significant ( P=0.040). The operation time and intraoperative fluoroscopy times of the study group were significantly less than those of the control group ( P<0.05). All children in both groups were followed up 6-18 months with an average of 9.0 months in the study group and 9.8 months in the control group. Imaging review showed that the fractures of both groups healed, and the difference in the healing time between the two groups was not significant ( P=0.373). According to Flynn score at last follow-up, the excellent and good rate of elbow joint function was 95.2% (20/21) in the study group and 86.4% (19/22) in the control group, with no significant difference ( P=0.317). There was no complication such as infection or irritation at the end of Kirchner wire within 2 months after operation. For children with multi-directional unstable humeral supracondylar fractures, the use of Kirschner wires to reconstruct the medial and lateral column periosteal hinge to assist in closed reduction has the advantages of shortening operation time, reducing intraoperative fluoroscopy times, and effectively reducing the incidence of open reduction, and can achieve similar postoperative elbow joint function when compared with traditional closed reduction technique.

Management of displaced supracondylar fractures in children and adherence to the BOAST guideline- experience in a District General Hospital, UK

BackgroundSupracondylar fracture is the most common elbow fracture in children. These fractures can be associated with significant complications, including nerve injury, vascular compromise, compartment syndrome and clinical deformity. The British Orthopaedic Association Standards for Trauma (BOAST) provide clear and comprehensive guidance for managing the supracondylar fracture. AimsWe reviewed the management of displaced (Gartland type 2 and 3) supracondylar fractures and adherence to BOAST guidelines between 1st audit and re-audit following the introduction of supracondylar assessment proforma. MethodsWe retrospectively analysed the adherence to BOAST guidelines for 103 patients operated between 2014 and 2020. Documentation of vascular status and individual nerve functions were assessed during presentation to the emergency department, immediately before surgery, and postoperatively before discharge from the hospital. We also reviewed the documentation of the K-wire's size utilised for fixation, the medial wire fixation technique, and post-fixation stability during the operation. A new supracondylar fracture assessment proforma was designed and implemented after the 1st audit as part of the quality improvement measure. During the second stage of the audit cycle, we reviewed 22 patients and used the same methodology as the first audit to analyse the data. ResultsResults: We found significant improvements in the documentation of capillary refill time from 65 % to 95.5 % (p = 0.0038), radial pulse from 59.2 % to 95.5 % (p = 0.0009), and documentation of individual nerve function from 37.9 % to 72.7 % (p = 0.0040) in the emergency department during 2nd stage of the audit cycle. Individual nerve function documentation by the operating team immediately before surgery changed from 42.7 % to 50 %. The use of 2 mm K-wires improved from 53.3 % to 89.5 % (p = 0.0037) Documentation of medial wire fixation technique and post-fixation stability increased to 100 % from 82.9 % to 89.5 % from 42.7 % (p = 0.0002), respectively. Postoperatively, we noted improvement in both radial pulse and capillary refill time documentation from 27.2 % to 54.2 % (p = 0.0216) and the individual nerve function from 9.7 % to 50 % (p = 0.00005). ConclusionPoor adherence in stage 1 of the audit cycle to BOAST standards was significantly improved in stage 2 (Re-audit) after introducing a simple supracondylar fracture assessment proforma and focussed educational sessions.

Retracted: Clinical Application of Remifentanil Combined with Sevoflurane in Manual Reduction of Humeral Supracondylar Fracture in Children.

[This retracts the article DOI: 10.1155/2022/2410433.].

Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases.

We evaluated the management of supracondylar paediatric fractures at our institution over a 10-year period in this retrospective cohort study. In total, 762 children with a supracondylar fracture were treated. The mean age of injury was 5.2 years. The incidence of documented nerve and/or vascular injury was 8.3%. A total of 26 patients had early plastic surgeon involvement; of these, 25 had an open exploration. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis. There were 17 late referrals to the plastic surgery service, of which three were explored (two neurolysis, one neuroma resection and sural nerve grafting). In all cases of nerve injury, the deficit took 7.9 months to recover, indicating a more significant injury than neurapraxia. Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention.Level of evidence: IV.

Preoperative simulated surgery on 3D model assists osteotomy feasibility verification and surgical guidance for patients with cubitus valgus/varus deformity: a retrospective observational study

BackgroundAs the common delayed complication of supracondylar fractures in children, cubitus valgus/varus deformity might lead to pain and loss of motion of the elbow. The current corrective treatment might not be accurate enough and even contribute to postoperative deformity. This study retrospectively analyzed the clinical value of preoperative simulated surgery on 3D model-assisted osteotomy feasibility verification and surgical guidance for cubitus valgus/varus deformity.MethodsSeventeen patients were selected from January 2017 and November 2019. Deformities were analyzed from imaging data and 3D models and corrected after the simulated operations. The radiographic evaluation comprised osseous union, carrying angle, and anteversion angle of the distal humerus. The clinical evaluation was performed according to the Hospital for Special Surgery (HSS) scoring system.ResultsAll patients underwent the operation successfully and had no postoperative deformity. The carrying angle was significantly improved postoperatively (P < 0.001). The anteversion angle of the distal humerus did not change significantly (P > 0.05). The HSS score rose after surgery (P < 0.001). The function of the elbow joint was excellent in seven cases and good in ten cases.ConclusionSimulated surgery on 3D model plays an important role in osteotomy plan and surgical guidance, contributing to good surgical efficacy.

Douyin as a source of information and education on humeral supracondylar fracture of children during the COVID-19 pandemic in Chinese Mainland: An observational study.

We aimed to investigate whether Douyin videos on pediatric humeral supracondylar fractures could be a useful source during the COVID-19 pandemic. A search was conducted using the term "humeral supracondylar fracture of children" on Douyin. The top 100 videos were selected based on view count. 74 was the final analysis, after excluding 26 videos for various reasons. First, the videos were classified into medical and the non-medical groups based on authorship. The medical team videos were about explanations or detailed surgical procedures directly related to child's fracture. There were also non-medical videos, mostly about personal experiences and other things. The videos were then also divided into 2 groups abased on the year of COVID-19 pandemic. The number of views, content type, video duration and number of likes about the video were analyzed. Among the 74 videos included in this study, had a total of 19,647,988 views (median 205,129, range 7874-1,495,004). Compared to the medical group, the non-medical group had more views (P = .004), likes (P = .000), view ratio (P = .019), and video power index (P = .024). During the COVID-19 pandemic, views (P = .033), view ratio (P = .006), and video power index (P = .043) also increased. Douyin has been a valuable source of health information for patients during COVID-19 pandemic regarding the occurrence of humeral supracondylar fracture in children. Medical professionals and institutions should upload credible, informative videos and clear, high-quality, scientifically reviewed surgical footage of children with humeral supracondylar fracture. And the videos uploaded by medical professionals and filtered by Douyin's staff appear to be necessary.

Clinical Application of Remifentanil Combined with Sevoflurane in Manual Reduction of Humeral Supracondylar Fracture in Children.

Objective To explore the effect of the combination of remifentanil and sevoflurane on children with humeral supracondylar fractures undergoing manual reduction. Methods A total of 60 children undergoing manual reduction external fixation due to humeral supracondylar fractures were enrolled between September 2020 and September 2021. According to the random number table method, they were divided into the control group (inhalation of 7% sevoflurane) and the observation group (inhalation of 7% sevoflurane and intravenous infusion of remifentanil). The heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) in both groups were investigated. The sedation and analgesic effects, fracture reduction, and complications were compared between the two groups. Results There was no significant difference found in HR, MAP, or SpO2 between the two groups at 3 minutes prior to anesthesia, 2 minutes post anesthesia, and post manual reduction (P > 0.05). The difference in HR, MAP, and SpO2 between the two groups was not statistically significant at any time point (P > 0.05). The good rate of sedation and analgesia in the observation group was 93.33%, which is significantly higher than that in the control group (P < 0.05). The reduction time and success rate of one-time manual reduction in the observation group were higher than those in the control group (P < 0.05). There was no significant difference in fracture healing time between the two groups (P > 0.05). Both groups had airway complications (nausea and vomiting, neurovascular damage and asphyxia, and laryngospasm). Conclusion The combination of remifentanil and sevoflurane showed good sedative and analgesic effects on children with humeral supracondylar fractures undergoing manual reduction with relatively higher safety.

Technical Report: Percutaneous Reductions on Gartland Type III Supracondylar Fractures.

Various surgical treatments for supracondylar fracture in children remain the motive of research and study. A common factor in each technique is anatomic reduction, which is critical for the excellent recovery of the fracture. Anatomic reduction is preferably realized through closed and percutaneous approaches. This study aimed to present a closed percutaneous technique to treat Gartland III supracondylar fractures to aggregate a facilitating factor in the surgical approach to this condition. Our technique was applied to surgical patients in orthopedic and traumatology emergency care and illustrated by a synthetic elbow model, including soft tissue and intraoperative images.

Does compliance with British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines matter for displaced supracondylar fractures in children?: the experience of a tertiary referral major trauma centre over a 3.5-year period.

Departments ofaPaediatric Orthopaedics bTrauma and Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, UK Received 2 December 2021 Accepted 26 December 2021 Correspondence to Andreas Rehm, MD, Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 0QQ, UK, Tel: +44 1223 216101; fax: +44 1223 596367; e-mail: [email protected]

A PROFILE OF PATIENTS WITH CUBITUS VARUS DEFORMITY IN FOLLOW-UP CASES OF SUPRACONDYLAR FRACTURES

Background/Aim: Cubitus varus is a frequent deformity following healing of supracondylar fractures, particularly in children. However, there are limited studies describing its epidemiology. Methodology: This study was carried out over a period of one year at a tertiary care facility in Central India and included a total of 19 patients who developed cubitus varus following supracondylar fracture healing during the follow-up. Demographic data such as age, sex, place of residence, side of involvement and time since supracondylar fracture were noted. Carrying angle of normal side and affected side was noted. Mean lateral condylar prominence index (LCPI) was calculated. Data has been presented as number and percentages and mean±standard deviation. Results: All had unilateral involvement. Mean age of patients was 9.95±4.43 years. Majority were aged 5-9 years and were males from rural areas (63.2%). Left side (68.4%) was more commonly involved than the right side (31.6%). Mean time since primary injury was 16.63±4.39 months. Mean carrying angle of normal and affected side were 10.32±1.67 and -18.05±2.97o respectively. Mean LCPI was -0.11±4.55o. Conclusion: Cubitus varus is a common deformity seen in healing supracondylar fractures in children. The deformity is generally reported within one-year of primary fracture. Corrective and preventive strategies should be adopted to provide relief to the affected patients.

Humerus Supracondylar Fracture in Children Treated with Closed Redution Percutaneous Cross Pinning vs Two Lateral Pinning

Objective: With this research, we hope that we can compare the effectiveness of percutaneous cross pins in treating paediatric supracondylar humerus fractures to that of two-lateral pins. Study Design: Prospective study Place and Duration: Children Hospital Faisalabad/ Bahawal Victoria Hospital Bahawalpur.April 2018-Oct 2018. Methods: This research included 104 patients of both sexes. After permission, the patient's age, sex, and BMI were recorded. The patients ranged in age from 3 to 10. Children with supracondylar humerus fractures were split into two groups. Percutaneous cross pinning was performed on group C patients, whereas two lateral pinning was done on group D patients. We examined the radiological and functional results and the occurrence of problems between the two groups. SPSS 21.0 was used to analyze the data. Results: In current study surgical time in group C was lower as compared to group D and had higher radiation time with p value &lt;0.003. Post operatively frequency of excellent results in group C was higher among 35 (67.3%) cases as compared to group D in 27 (51.9%) patients. Frequency of poor results in group D was higher in 5 (9.6%) patients as compared to group C in 1 (1.9%) cases. Complication rate was also higher in group D 12 (23.1%) patients as compared to group C in only 6 (11.5%) cases. Conclusion: We observed that percutaneous pinning was more advantageous than two lateral pinnings in treating children with closed reduction supracondylar humerus fractures. Keywords: Children Percutaneous cross pinning, supracondylar humerus fracture,Two lateral pinning

- Characteristics of Patients With Humeral Supracondylar Fracture in Children at Sanglah General Hospital 2019-2020

Humeral supracondylar fracture is a fracture that occurs at the elbow, precisely at the distal part of humeral bone as high as the humeral epicondyle which passes through the olecranial fossa. Humeral supracondylar fracture is a common fracture occur in the pediatric, 18% of all fractures experienced by children. The aims to determine the characteristics of supracondylar humeral fractures in children Sanglah Hospital Denpasar in 2019-2020. Research use descriptive method with cross-sectional study. Determination of samples based on inclusion and exclusion criteria. Data analyzed using SPSS 26 software to obtain characteristics of patient humeral supracondylar fractures based on age, sex, fracture classification, location of the incident, onset, management, and complications. The results showed that cases of humeral supracondylar fractures in children at Sanglah Hospital Denpasar in 2019-2020 there are 16 cases. Humeral supracondylar fractures mostly occurred in 5-9 year age group (62.5%), dominated by male sex (62.5%). The most common classification of fractures is Gartland type III with percentage of 56.3%. Most of samples had fractures when they fell at home (62.5%) with acute onset of 93.8%. Most of samples received operative management of 68.8% and 93.8% did not experience complications. This research useful because can provide perception about characteristics of patients with supracondylar humeral fractures in children at Sanglah Hospital Denpasar 2019-2020. Analytical research needed to understand the relationship between characteristic variables of supracondylar fractures.&#x0D; Keywords : Humeral Supracondylar Fracture, Characteristic, Children.

Shortening dome osteotomy for correction of severe cubitus varus secondary to malunited supracondylar fractures in children.

We present retrospective review of prospectively collected data of 18 patients (11 boys and 7 girls) who underwent shortening dome osteotomy between January 2011 and December 2019 for severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture. The procedure involved the removal of convexo-concave bone (5-8mm wide) between the two domes. Humero-ulnar angles, lateral condylar prominence index (LCPI), and elbow range of movements were recorded preoperatively and postoperatively. Mean age was 7.5years (range 5years-11years). Indication for surgery was poor cosmesis in all the patients and tardy ulnar nerve symptoms in three patients. Mean preoperative humero-ulnar angle was 26.1° varus (range 22°-34°), while it was 7.1° valgus (range 0°-12°) for contralateral normal elbow. They were followed for a mean duration of 2.2years (range 12months-5.8years). The mean postoperative valgus angle achieved was 7.3° (range 2°-12°) as total angular correction achieved was 34.4° (range 30°-44°) (p < 0.001). Radiological healing was observed in all the patients at mean duration of 7.1weeks (range 5weeks-9weeks). Mean preoperative and postoperative LCPI were - 2.4 (range +4.7 to - 10.5) and - 1.7 (range +4.5 to - 5.1), respectively (p = 0.595). Three patients had pin tract infections and two of them responded to aseptic dressings and oral antibiotics, while another required early pin removal and additional protection in splint. All patients regained preoperative arc of motion within 6months after the procedure. Shortening dome osteotomy is a safe and effective method for correcting severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture in children.

Spontaneous humeral torsion deformity correction after displaced supracondylar fractures in children

BackgroundAfter displaced supracondylar humerus fractures (SCHF) in children, residual deformities are common with cubitus varus (CV) being the clinically most visible. Distal fragment malrotation may lead to instability, fragment tilt and subsequent CV. Detection and assessment of malrotation is difficult and the fate of post-traumatic humeral torsion deformity is unknown. The aim of this study was to evaluate the incidence of humeral torsion differences in children with surgically treated SCHF and to observe spontaneous changes over time.MethodsA cohort of 27 children with displaced and surgically treated SCHF were followed prospectively from the diagnosis until twelve months after trauma. Clinical, photographic, sonographic and radiological data were obtained regularly. Differences in shoulder and elbow motion, elbow axis, sonographic humeral torsion measurement and radiological evaluation focusing on rotational spur were administered.ResultsSix weeks after trauma, 67% of SCHF children had a sonographically detected humeral torsion difference of > 5° (average 14.0 ± 7.6°). Of those, 44% showed a rotational spur, slight valgus or varus on radiographs. During follow-up, an average decrease of the difference from 14° (six weeks) to 7.8° (four months) to 6.5° (six months) and to 4.9° (twelve months) was observed. The most significant correction of posttraumatic humeral torsion occurred in children < 5 years and with internal malrotation > 20°.ConclusionAfter displaced and surgically treated SCHF, most children had humeral torsion differences of both arms. This difference decreased within one year after trauma due to changes on the healthy side or correction in younger children with severe deformity.Level of Evidence/Clinical relevanceTherapeutic Level IV

THE APPROACH OF SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN

Surgical techniques of supracondylar fractures in children are repeatedly the subject of discussion. This study compared the experience with the technique of crossed Kirschner wires at our hospital with current literature. METHODS:- This study was performed from April 2020 to May 2021, a total of 80 children aged 2 to 12 years were treated using crossed K-wire osteosynthesis. This study was performed in the Department of Orthopaedics, MGMMCH, Jamshedpur, Jharkhand. Follow-up was conducted at an average of 32 months. Results were evaluated based on von Laer's criteria. RESULTS:- The complications were migration of the K-wires in seven percent of cases and secondary dislocation and re-operation in 4% of cases. Lesion of the radial nerve was diagnosed postoperatively in two cases. On average, the hospital stay was two days postoperative immobilization in an upper arm splint and implant removal after six weeks. More than half of children received physiotherapy during treatment. Satisfactory results were recorded for 83% of patients. CONCLUSION:- K-wire osteosynthesis is connected with a low difculty rate and is a safe procedure for stabilizing supracondylar humerus fractures.

Evaluation of Gartland Type-III Closed Supracondylar Fracture of Humerus in Children Treated by Lateral Percutaneous K-Wires under C-Arm Guidance

Introduction: This study has been designed to evaluate the success rate of closed reduction and stabilization by two lateral parallel percutaneous K-wires with the help of C-arm in the management of Gartland type-III closed supracondylar fracture of humerus in children. Materials and Methods: A prospective quasi experimental study was conducted from January 2015 to December 2016 in NITOR. A total of 30 patients of Gartland type-III closed supracondylar fracture of humerus in children presenting between ages 3-12 years. Informed written consent was taken from patient’s guardian. Regular follow up was targeted for at least 6 month’s. Result was evaluated according to Flynn’s grading. Results: Mean age was 6.85± 2.37 years, number of patients ware 30, Male patients were more affected 22 (73.33%) than female 8(26.67%), left side patients were more affected. Mean loss of elbow flexion was 9.53 degrees, mean loss of carrying angle was 8.5 degrees. Complications included four (13.33%) cases of pin tract infection, four (13.33%) cases of fracture blister, one (3.33%) case of median nerve palsy, two (6.66%) cases of inadequate pin fixation at first attempt. There were six excellent (20%), eighteen good (60%), three (10%) fair and three (10%) poor results according to Flynn’s grading. The overall 90% satisfactory result and rest 10% unsatisfactory result. Conclusion: Closed reduction and stabilization by two lateral parallel percutaneous K-wires is a better method for treatment of Gartland type-III closed supracondylar fracture in children. Medicine Today 2021 Vol.33(2): 138-142

Commentary on “Tips and pitfalls of reduction and fixation in displaced supracondylar fractures in children”

Commentary on “Tips and pitfalls of reduction and fixation in displaced supracondylar fractures in children”

Tips and pitfalls of reduction and fixation in displaced supracondylar fractures in children

Supracondylar humeral fractures are the most common injury of the elbow in children. Compared to flexion type fractures, extension type fractures are more common, up to 98%. Gartland classification has been used to guide the management of this injury, which is based on the extent of the displacement. If not adequately managed, completely displaced (type III) fractures may have a higher incidence of concomitant injury or complications, including neurovascular injury, compartment syndrome, or cubitus varus. Closed reduction followed by percutaneous pinning has been suggested as the standard operative method for the displaced supracondylar humeral fractures. However, these fractures can be challenging to reduce, with the traditional technique of closed reduction. Lateral-entry pinning is known as a sufficient method of fixation for this injury. However, the lateral pin only fixation technique may also result in loss of reduction in some particular patterns of fractures, such as fractures with medial column comminution. We discuss and describe the reduction techniques of completely displaced supracondylar humeral fractures, including technical tips and pitfalls for closed reduction and open reduction. We also discuss indications of medial pinning, and its safe method, when the lateral-entry pins may not achieve adequate stability.