Publications by authors named "R Justin Mistovich"

41 Publications

Pediatric pelvic fractures: an epidemiological analysis of a population-based database.

J Pediatr Orthop B 2021 Dec 22. Epub 2021 Dec 22.

Case Western Reserve University School of Medicine Case Western Reserve University Center for Clinical Informatics Research and Education, The MetroHealth System Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

Objectives: Despite a high prevalence in the pediatric trauma population, there remains a lack of large population-based epidemiological studies on pediatric pelvic fractures. Using a de-identified national clinical registry, we investigated the epidemiological features of pediatric pelvic fractures.

Methods: We performed a retrospective analysis of data obtained from the IBM Watson Health Explorys Platform (Armonk, NY). From all children ages 0-14, two cohorts were created, children diagnosed with a traumatic injury and children diagnosed with a fracture of the pelvis. We then calculated the overall incidence of pelvic fractures, mortality rate, and identified common associated injuries, fracture locations, and complications.

Results: 2,690 pediatric pelvic fractures were identified yielding an incidence of 9.8/100,000 children per year with a mortality rate of 0.3%. Pelvic fractures were more common among Caucasians than in African Americans and Asians, and more common in males than females. The most common types of pelvic fracture were fractures of the ilium (42%), pubis (18%), sacrum (11%), ischium (10%), and acetabulum (8%). Most common associated injuries included injury of the lower extremity (43%), intracranial injury (16%), chest injury (13%), injury of the abdomen (9%), and urogenital injury (3%). Rates of common complications associated with malunion were low back pain (10%), acquired leg length discrepancy (1%), and acquired scoliosis (0.3%).

Conclusion: The current incidence of pediatric pelvic fracture is 9.8/100,000 children per year with a mortality rate of 0.3%. Further study utilizing large data sets may help to better understand associated injuries, risks of poor outcomes, and optimize treatment strategies.
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http://dx.doi.org/10.1097/BPB.0000000000000945DOI Listing
December 2021

Suture Fixation of a Pediatric Pelvic Ring Injury: A Case Report.

JBJS Case Connect 2021 Oct 27;11(4). Epub 2021 Oct 27.

Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Case: A 2-year-old male child presented as a polytrauma after having been run over by a motor vehicle. His orthopaedic injuries included a pelvic ring injury, a displaced subtrochanteric femur fracture, and a clavicle fracture. His pelvic ring injury ultimately required open reduction with suture fixation after failure of closed management.

Conclusion: Pelvic ring injuries are relatively uncommon in young children, and even more rarely do they require surgical intervention. We detail the case of one such patient who required open management of his anteroposterior compression II pelvic ring injury, and we describe an alternative fixation technique using suture wire.
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http://dx.doi.org/10.2106/JBJS.CC.21.00088DOI Listing
October 2021

Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis.

Spine Deform 2021 Oct 27. Epub 2021 Oct 27.

Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, 11100 Euclıd Avenue, Cleveland, OH, 44106, USA.

Purpose: Proximal junctional kyphosis (PJK) is a commonly encountered clinical and radiographic phenomenon after pediatric and adolescent spinal deformity surgery that may lead to post-operative deformity, pain, and dissatisfaction. Understanding the risk factors of PJK can be useful for pre-operative informed consent as well as to identify any potential preventative strategies.

Methods: We performed a systematic review and critical analysis following the PRISMA statement in July 2019 by searching the PubMed, Scopus, and Embase databases, including all prior published studies. We included articles with data on PJK in patients with operative pediatric and adolescent scoliosis and those that detailed risk factors and/or preventative strategies for PJK. Levels of evidence were determined based on consensus. Findings were summarized and grades of recommendation were assigned by consensus. This study was registered in the PROSPERO database; 202,457.

Results: Six hundred and thirty five studies were identified. Thirty-seven studies met criteria for inclusion into the analysis. No studies including neuromuscular scoliosis met inclusion criteria. No findings had Grade A evidence. There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction. There was no difference in incidence noted between etiology of the curvature. Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs.

Conclusion: Greater sagittal plane correction has Grade B evidence as a risk factor for PJK in both EOS and AIS populations. In EOS patients, an increased number of distractions and posterior element disruption are Grade B risk factors. In AIS patients, longer fusion constructs, higher pre-operative thoracic kyphosis and lumbar lordosis, and posterior (as opposed to anterior) constructs also contributed to PJK with Grade B evidence. These findings can guide informed consent and surgical management, and provide the foundation for future studies.
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http://dx.doi.org/10.1007/s43390-021-00429-wDOI Listing
October 2021

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

Am J Sports Med 2021 Dec 15;49(14):3842-3849. Epub 2021 Oct 15.

Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.

Background: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown.

Purpose: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.

Results: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; ≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; < .001).

Conclusion: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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http://dx.doi.org/10.1177/03635465211046928DOI Listing
December 2021

Surgical site infections in early onset scoliosis: what are long-term outcomes in patients with traditional growing rods?

Spine Deform 2021 Sep 18. Epub 2021 Sep 18.

Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Purpose: Deep surgical site infections (SSIs) are a common and potentially severe complication in early onset scoliosis (EOS) patients. We sought to identify the long-term outcomes following SSI, specific risk factors associated with recurrent infections, and if instrument retention is a prudent SSI management strategy in EOS.

Methods: We performed a retrospective review of all EOS patients who underwent traditional growing rod spine procedures from 2003 to 2017. Infections were categorized as single or multiple SSIs. All infections were treated with operative irrigation and debridement (I&D) as well as antibiotics. Univariate analysis was performed using chi-square and ANOVA tests to assess differing factors between patients with single versus multiple infections.

Results: Eighty-one patients underwent 638 growth-friendly traditional growing rod procedures. There were 21 patients (26%) who developed a total of 27 SSIs (4.2% SSI per procedure). Fifteen patients had a single infection and six patients had multiple infections. Demographics were not significantly different between these two groups. Patients with multiple infections had a significant difference in the number of procedures after initial infection (p value = 0.025) and positive preoperative nasal Staphylococcus aureus screen (p value = 0.0021) when compared to those with a single SSI. Of note, these results were not available at the time of pre-operative antibiotic selection. All 21 patients had resolution of their SSIs. Twenty patients reached final instrumented fusion. Two patients, both of whom had multiple infections, underwent complete removal of instrumentation. Reasons included one each, parental request resulting in termination of treatment and infection > 7 years after final fusion.

Conclusion: Most patients who develop SSIs during growing spine treatment are able to remain instrumented. Risk factors associated with developing multiple SSIs include infection earlier in the course of growing spine surgery, a resultant higher number of procedures following the initial infection and having a positive preoperative nasal Staphylococcus aureus screen.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s43390-021-00412-5DOI Listing
September 2021
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