Quality Enhancement Research Initiative in ischemic heart disease: a quality initiative from the Department of Veterans Affairs. QUERI IHD Executive Committee.

Despite the dramatic fall in ischemic heart disease (IHD) mortality rates over the last 3 decades, it remains the number one cause of death in the United States, and one of the most frequent indications for care by the US Department of Veterans Affairs. National practice guidelines have been developed and disseminated both by societies that specialize in cardiology and within the Veterans Health Administration. Despite these efforts, a substantial minority remains of patients with IHD who are not treated with guideline-recommended therapies. The Quality Enhancement Research Initiative in IHD is a Veterans Health Administration-sponsored initiative to address the gap between guideline-recommended therapies and actual Department of Veterans Affairs practice. Because guideline development for patients with IHD is relatively mature, the Quality Enhancement Research Initiative in IHD will concentrate on measuring existing practices, implementing interventions, and evaluating outcomes in veterans with IHD. Measurement of existing practices will be evaluated through analyses of existing Veterans Affairs databases developed for the Continuous Improvement in Cardiac Surgery Program, as well as data collected at the Center for the Study of Practice Patterns in veterans with acute myocardial infarction. To measure existing practices in outpatients with IHD, we plan to develop a new database that extracts electronic data from patient laboratory and pharmacy records into a relational database. Interventions to address gaps between guideline recommendations and actual practice will be solicited and implemented at individual medical centers. We plan to emphasize point-of-care electronic reminders as well as online decision support as methods for improving guideline compliance.

Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial translation.

This study was undertaken to determine the contribution of various structures in the posterior cruciate ligament-deficient knee in resisting posterior tibial translation. With "isolated" injuries to the posterior cruciate ligament, the amount of posterior translation will decrease with the posterior drawer test as the knee is taken from neutral to internal tibial rotation. The present study was performed to conclusively determine the anatomic structure responsible for this clinical observation. The TestStar device was used to perform single-plane posterior drawer tests in 14 cadaveric knee specimens. The tests were performed with the knee in neutral tibial rotation and in 20 degrees of internal tibial rotation. The intact knee was tested and then the knee was tested after sequential sectioning of the meniscofemoral ligaments, the posterior cruciate ligament, the posteromedial capsule, and the superficial medial collateral ligament. With the knee in neutral rotation, posterior translation continued to increase as each structure was sectioned. With the knee in internal tibial rotation, posterior displacement was significantly less than in neutral rotation for each state until the superficial medial collateral ligament was sectioned; posterior translation was increased after its sectioning. Our data demonstrate that the superficial medial collateral ligament is the structure responsible for a decrease in posterior tibial translation in the posterior cruciate ligament-deficient knee.

Meniscal repair in the goat model. The use of healing adjuncts on central tears and the role of magnetic resonance arthrography in repair evaluation.

We evaluated the effect of adjunctive healing measures on central tears of the adult goat medial meniscus and the role of magnetic resonance arthrography in the assessment of menisci that have undergone a repair. Peripheral tears were made unilaterally in the medial menisci of seven goats in Group I and repaired with nonabsorbable suture. Six Group II goats had central medial meniscal tears repaired as in Group I plus an exogenous fibrin clot. Eight Group III goats had central tears plus abrasion of the parameniscal synovium and tear edges. Six months after surgery, a magnetic resonance imaging scan and a magnetic resonance arthrogram were obtained and the menisci were examined grossly. Group I goats showed healing in all seven knees. Central tears repaired with a fibrin clot (Group II) showed healing in one of six knees (17%). Central tears repaired with abrasion (Group III) showed healing in seven of eight knees (87.5%). Magnetic resonance arthrography was 100% accurate in detecting the presence or absence of complete residual tears. This study supports the current trend of using adjunctive measures for repair of central tears. Furthermore, abrasion of the parameniscal synovium and the tear edges appears to be more effective than the use of an exogenous fibrin clot. Magnetic resonance arthrography is useful in the evaluation of menisci that have undergone repair.

Ideal tibial tunnel length for endoscopic anterior cruciate ligament reconstruction.

A successful single-incision endoscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft requires attention to many technical details. The emphasis of placing the femoral bone plug flush with the opening of the femoral tunnel results in distal shift of the graft. Longer tibial tunnels are required to prevent excessive graft extrusion. The purpose of this study is to compare four direct and indirect measurement methods of tibial tunnel preparation to determine which method can be used to create consistently reproducible tibial tunnels that prevent excessive extrusion or recession of the graft within the tunnel. Tunnels placed at the empiric angles of 40 degrees, 50 degrees, and 60 degrees to the tibial plateau resulted in the incidence of acceptable tibial tunnel lengths of 44%, 83%, and 39%, respectively. Tunnels placed at an angle determined by the formula "N + 7" where 7 degrees is added to the patellar tendon length (N) resulted in acceptable tunnels 89% of the time. Direct measurement methods using the formulas "graft - 50 mm" and "N + 2 mm" resulted in acceptable tibial tunnels of 44% and 100%, respectively. We recommend using the "N + 7" in conjunction with the "N + 2 mm" formula to obtain the advantages of both indirect and direct measurement methods.

Graft selection in anterior cruciate ligament revision surgery.

Revision anterior cruciate ligament surgery can be very demanding. Graft selection for revision surgery is a pivotal part of this procedure. Often, the usual first choice of tissue is not available. Therefore, familiarity with alternative graft sources and understanding their advantages and disadvantages is imperative for the surgeon who does anterior cruciate ligament revision surgery. This study will review the advantages and disadvantages of each graft choice available to the surgeon for this procedure.

Meniscal repair. An experimental study in the goat.

To evaluate the healing potential of the meniscus, we created a longitudinal medial meniscal tear in both knees of 24 adult goats (48 knees). In all goats, the meniscus was repaired in one knee and left unrepaired in the other. The goats were placed into one of three groups based on the location of the tear and the status of the anterior cruciate ligament. At 6 months' followup, an arthrogram was obtained and the menisci were examined. In knees with an intact anterior cruciate ligament, tears in the peripheral 20% to 25% of the meniscus healed in six of seven repaired menisci, but in only one of seven of the unrepaired menisci. Tears in the peripheral 40% to 50% healed in only one of the eight repaired menisci and in none of the unrepaired menisci. When the anterior cruciate ligament was incised, tears in the peripheral 20% to 25% of the meniscus healed in only 1 of 8 repaired menisci and in none of the unrepaired menisci; the rest developed into complex tears. Arthrography was 92% accurate in predicting the status of meniscal repair. This study supports current clinical practices in meniscal repair and emphasizes the importance of tear location and knee stability in successful meniscal repair.