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Finding Your First APA Paper Examples

Finding Your First APA Paper ExamplesWhen you first start looking for your first APA paper examples it is very easy to get lost and frustrated because you just don't know where to begin. You know that you want to do a good job, but where do you start? This article will help you narrow down the best choices of papers, as well as give you tips on how to make them look their best.The first thing that you need to do is to begin looking for your first examples. You want to start by searching the library for your library books. These can be used in class, but not often because of formatting problems. Even though they are rather old, they can still be helpful because they usually have references that can help you with what is acceptable and what is not.After you have done this a few times, you may want to try looking online for your manuals. Online manual formats have been greatly improved over the years and usually look much better than the manual you will find in your library. There are p lenty of places online that you can find manuals and APA paper examples. Some of these places are going to be free and some will cost you a small fee. If you plan on buying your own manual for your study, you should look into a place that offers the best deals.Once you start looking for your first paper examples you will want to spend some time thinking about what you are going to write. This doesn't mean that you have to find the perfect paper, but that you should have an idea in your head about what you are going to talk about. Don't get caught up in the perfect paper, but do look at other examples to see what types of examples you should be using.Once you have the ideas in your head, then you can start looking for your APA paper examples. Again, you want to start by looking for your first manual and just start reading. You don't need to read every single example in the manual that you find, but you should read through it a few times to see what is acceptable and what is not.After you have found some paper examples that you like, you will need to go to the library and look for your manual. This can be difficult if you only have one or two available, but once you have found one you can usually borrow it for a few days. This will give you a better chance of the manual being error free.When you have done this you will want to read through the manual and then begin writing your paper. Since you will be doing your work online, it is a good idea to use the same type of formatting that you will use in class. For example, if you are writing an essay, you may want to use some of the formatting found in the book or handout for your examples.After you have written all of your paper examples, you will want to sit down and start working. Before you start, it is important to make sure that you understand everything and have all of the information that you need. Then you can start to put all of your knowledge together in order to write the best paper possible.

Treatment of ankle syndesmosis injuries - Free Essay Example

Sample details Pages: 27 Words: 8122 Downloads: 3 Date added: 2017/06/26 Category Statistics Essay Did you like this example? Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. Don’t waste time! Our writers will create an original "Treatment of ankle syndesmosis injuries" essay for you Create order In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as high ankle sprainwith incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore important to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis. 1.1. Anatomy The inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament. At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12). The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula [Fig. 1.1]. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) [Fig. 1.2]. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation [Fig. 1.2]. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9). Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35%; the transverse ligament, 33%; the interosseous ligament, 22%; and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability. 1.2. Biomechanics The primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion to full dorsifl exion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20). When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume. 1.3. Mechanism of Injury The 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30). Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in Pronation-External Rotation (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic challenge. These injuries are sometime referred as high syndesmotic sprain (4, 27, 34). 1.4. Diagnosis Diagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36). Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The tibiofibular clear space is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The tibiofibular overlap is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial clear space is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship: (1) a tibiofibular clear space on the anterior-posterior and morti se views of less than approximately 6 mm; (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width; (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive tha n radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42). 1.5. Treatment of Syndesmosis diastasis and review of literature Injuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation. Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant diff erence in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes follow ing syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group. Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation. Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67). The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire ® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, th e follow-up reported in the literature is short and the number of cases are limited [Table 1]. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also re ported subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series. Table 1 : Studies reporting o n clinical outcomes and complications of Tightrope fixation . Authors Year Number Followup (months) Time to FWB (Weeks) AOFAS score No. of complication Seitz et al (69) 1991 12 38 0 Thornes et al (71) 2005 16 12 93 0 Mcmurray et al (74) 2008 16 5 6 87 2 Cottom et al (72) 2008 25 10.8 5.5 50.6* 0 Willmott et al (75) 2009 6 5.3 6 2 Coetzee et al (76) 2009 12 27 94 1 DeGroot et al (77) 2011 24 20 5.7 94 6 AOFAS; American Orth opaedic Foot and Ankle Society Score. *   Cottom et al used a modified AOFAS score with maximum score of 63. Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with sy ndesmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term. Table 1.1 : Studies reporting o n clinical outcomes and complications of Tightrope fixation . Authors Year Number Followup (months) Time to FWB (Weeks) AOFAS score No. of complication Seitz et al (69) 1991 12 38 0 Thornes et al (71) 2005 16 12 93 0 Mcmurray et al (74) 2008 16 5 6 87 2 Cottom et al (72) 2008 25 10.8 5.5 50.6* 0 Willmott et al (75) 2009 6 5.3 6 2 Coetzee et al (76) 2009 12 27 94 1 DeGroot et al (77) 2011 24 20 5.7 94 6 AOFAS; American Orth opaedic Foot and Ankle Society Score. *   Cottom et al used a modified AOFAS score with maximum score of 63. 1.6. Aims and Objective The primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome. Population (P) Adult patients with acute fixation of ankle syndesmosis. Intervention (I ) Tightrope fixation of ankle syndesmosis. Comparison (C) Syndesmosis screw fixation. Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan. Chapter No. 2 2. PATIENTS AND METHODS We conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control. The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed. The inclusion criteria were as follows: adults ( 18 years) with acute ankle syndesmosis injury willing to give informed consent to participate in the study , fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria. The exclusion criteria set out for this study included: P patients with open fracture, I i ndividuals with diabet es ic or neuropathic arthropathy, M multi trauma patients and P patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control. Pregnancy was included in exclusion criteria B because of radiation exposure in this study. pregnancy was also mentioned as exclusion criteria. i I ndividuals unwilling to consent to the study Patients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively; and intraoperative confirmation under fluoroscopy using external rotation stress test and hook test in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fractures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either Transosseous Screw or Tightrope depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFAS) scoring system (78) and a patient reported Foot and A nkle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications.   All patients were scanned supine in the axial plane with no gantry tilt.   Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx [Fig. 2.1]. This technique was adopted in order to reduce the radiation exposure to the patient without compromising the quality of the scans and the axial images th us obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond. 2.1. Outcome Variables The accuracy of syndesmosis reduction on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on AP radiographs a nd 6 mm of tibiofibular clear space is considered abnormal, the criterion of 2 mm would be justified.   Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including tibiofibular clear space (TFCS 6 mm), tibiofibular overlap (TFOL 6 mm) and medial clear space (MCS 5 mm). Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function. In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses. 2.2. Data Collection and Measurements Demographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes. Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The tibiofibular clear space is defined as the distance between the lateral border of the posterior tibial tubercle and the medial border of the fibula. The tibiofibular overlap is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial clear space is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). The width of syndesmosis was measured on axial CT scan for both operated and normal ankles simultaneously. Measurements were performed on axial scan 1 cm proximal to the tibial plafond as described earlier to provide measurements that are comparable to those obtained on standard radiographs. The distal fibula shows considerable variation with regard to the prominence of the borders. Four borders of fibula have been mentioned in anatomy textbooks including anterior, posterior, medial and interosseous border [Fig 2.2]. As the cross-sectional anatomy of distal tibia is more constant than fibula we used anterior and posterior tibial tubercle as our reference points for the measurements of anterior and posterior syndesmosis width. Although anterior width of syndesmosis was not used for comparison of malreduction, it was measured to evaluate normal anatomic variations in uninjured ankle syndesmosis. Two measurements were performed. Anterior width was measured from anterior tibial tubercle to the nearest point on the fibula. Similarly, the posterior width was measured from posterior tibial tubercle to the nearest point on the medial boarder of fibula [Fig. 2.3]. Measurements were performed by an independent musculoskeletal rRadiologist on using digital software on CT work station. CT measurements were performed twice at an interval of 2 weeks without the knowledge of previous readings, to assess the intra-observer agreement. Clinical assessment was performed by an independent clinician who was blinded for the type of syndesmosis fixation. AOFAS and FADI scores were completed at this review. As this was a non-randomised study there were possibilities of bias and every effort was made to reduce the bias. All consecutive patients who fulfilled the eligibility criteria were invited for participation in the study to reduce the selection bias. It was confirmed retrospectively that different methods of syndesmosis fixation were assigned to patients only on the basis of surgeons preferred choice, irrespective of age, sex or type of associated fracture. This means thatIn essence, patients admitted on certain days of the week were fixed with syndesmosis screw and patients attending on the remaining days were treated with tTightrope fixation technique. Measurements on the CT scan and radiographs were performed by an independent radiologist. As blinding was not possible, measurements were performed twice at an interval of 2 weeks to assess intra-observer reliability of measurements. Finally, the clinical assessment was performed by an independent clinician not directly involved in the study and was blinded to the type of fixation. This was important to reduce assessors or interviewers bias. 2.3. Sample Size Sample size was calculated on stata 11.1 for comparison of two means, using measurements of normal syndesmosis on CT scan as reported by Elgafy et al (12) . Using mean of 4 mm and standard deviation of 1.19 and considering 2mm as clinically significant difference gives minimum of 10 cases in each group for 90% power. Although 2 mm difference is used for detection of malreduction in individual patient, there might not be a mean difference of 2 mm. Therefore we calculated the sample size for one standard deviation difference from the normal mean value which requires 22 cases in each group. A sample size calculation was performed based on the primary outcome measure i.e. measurements of normal syndesmosis on CT scan as reported by Elgafy et al (12) Elgafy et al . The formula used to determine the number of participants required in the study involved the prediction of the standard deviation ( à Ã†â€™ ) for normal CT measurements and an anticipated significant clinical change or deviation from normal CT measurements of the ankle (Ά) [Fig. 2.4] . The value for the à Ã†â€™ was obtained from the paper by Elgafy et al (12) Elgafy et al . Although 2 mm difference is widely used for detection of malreduction in individual patient s , the difference is often not 2 mm in individuals presenting with problems. Therefore we considered 1 millimetre as a clinically significant difference (Ά) so that the final power of the study is not undermined . The value of the constant K, 7.8, was dictated by the significance level chosen for the study, in this case a two- sided significance level of 5% with an 80% chance of detecting a treatment effe ct. Based on a two group comparison, power calculations indicated that a minimum of 46 participants were required to detect a change of 1mm on the CT measurements at a two-sided significance level of 5% and a power of 80%, assuming a à Ã†â€™ of 1.19 points. This analysis was confirmed using Stata 11.1  ® statistical software. Number of participants required in each of the comparison groups must be greater than the value calculated using the following formula 2 (Constant K) ( à Ã†â€™ of the normal CT measurements) 2 (What is considered to be a clinically significant change in CT measures) 2 2 (7.8 for two sided test with significance level of 0.05) (1.19) 2 (1) 2 2 (7.8) (1.42) 1 23 participants per group Therefore in order to detect a clinically significant change of 1 mm deviation on the CT measurement, a minimum of 46 participants were required in total 2.4. Statistical Analysis Statistical analysis was performed on Stata 11.1 ®. Demographics were compared for the two groups using mean values and proportions. Mean, standard deviation, ranges and confidence interval (CI) were calculated for the continuous variables including age, follow-up, time to full weight bearing, radiographic and CT parameters and functional outcome scores. Mean values were calculated for the radiographic and CT parameters for both operated and normal ankle in two groups separately and compared using t-test within each group for measurement of statistical significance. Difference in the width of syndesmosis between normal and operated side were calculated and compared using unpaired t-test with p-value 0.05 to be considered statistically significant. 22 table was formulated for categorical variables including malreduction of syndesmosis and complications and were analysed to calculate relative risk and statistical significance using fishers exact test. Potential confounders incl uding age and duration since surgery were accounted for using regression analysis when analysing the correlation of syndesmosis malreduction with functional outcome scores.   As our primary outcome variable was accuracy of syndesmosis reduction based on syndesmotic width measured on axial CT scans, we also assessed intra-observer agreement for CT measurements using intra-class correlation coefficient (ICC) (80). The values for ICC range from 0.0 to 1.0 and can be interpreted as follows: 0-0.20 indicates poor agreement: 0.21-0.40 indicates fair agreement; 0.41-0.60 indicates moderate agreement; 0.61-0.80 indicates strong agreement; and 0.80 indicates almost perfect agreement. 2.5. Data protection The study was approved by the institutional review board and due consideration was given to data protection rules (appendix ivii). Patients were fully informed about the purpose of the study and outcome measures using an information leaflet (appendix iv). All patients included in the study voluntarily signed an informed consent (appendix vi). Patients data was stored on electronic database using unique identification code making it completely anonymous for analysis and storage purpose. Research data will be retained for a minimum of 5 years after the publication of the research.   Chapter No. 3 R ESULTS 3. 1. Participants Of the 228 consecutive patients operated for ankle fractures during the study period of 2 years, 167 patients did not have any syndesmosis injury.   Sixty one patients had associated syndesmosis injuries and were potentially eligible for study inclusion. Six of those 61 patients were excluded on the basis of study exclusion criteria. One patient died before recruitment, 2 were visitors from abroad and were   uncontactable, 2 had compound injury and 1 had bilateral injuries to his ankles. Fifty five patients were finally eligible for the study and invited for participation. Forty nine consented for the study, 5 refused to participate in the study as they did not have any problem and thought a review is unnecessary. One more patient moved abroad by that time. Out of 49 patients who consented for the study, 3 more were not able make it to the appointment because of work commitments leaving 46 patients for final analysis who attended for final follow up and CT scan. 3.2. Patients demographics and injury classification Forty-six patients finally attended for the review, 23 in tightrope group and 23 in screw group. Mean age was 41.65 years (range 24 69 years) and 39.82 years (range 18 65 Table 3.1: Comparison of patients demographics and injury pattern between two groups Tightrope Group Syndesmosis Screw Group Total number 23 23 Gender Male 17 (74%) 16 (70%) Female 06 (26%) 07 (30%) Age(years) 41.65 (24 69) 39.82 (18 65) Side Right 08 (35%) 10 (43%) Left 15 (65%) 13 (57%) Mechanism of injury Sports 5 (21.7%) 6 (26.1%) Fall from height 6 (26.1%) 3 (13.1%) Trip and fall 9 (39.1%) 7 (30.4%) Slipped on ice 3 (13.1%) 5 (21.7%) Dancing 0 2 (08.7%) Classification Weber B (SER) 02 (08.7%) 02 (08.7%) Weber C (PER) 13 (56.5%) 15 (65.2%) Maisennouve 08 (34.8%) 06 (26.1%) Number of fixations Single 16 20 Double 7 3 years) respectively in each groups. There were 17 (74%) male and 6 (26%) female in tightrope group while screw group had 16 (70%) male and 7 (30%) female. Right ankle was operated in 8 (35%) in tightrope group and 10 (43%) in screw group while left ankle was operated in 15 (65%) and 13 (57%) patients respectively.   There were 2 weber B fractures, 13 weber C and 8 Maisennouve fractures in tightrope group while 2 weber B, 15 weber C and 6 Maisennouve fractures in screw group. In tightrope group single tightrope was used in 16 patients while two tightropes were used in 7 patients. In screw group 20 patients had single syndesmosis screw while 3 patients required double screw fixation. Mean follow up was 30.2 months (range 18 41 months) in tightrope group and 29 months (range 18 41 months) in syndesmosis screw group. 3.3. Computed Tomographic measurements Measurements for the normal tibiofibular syndesmosis are summarized in [Table 3.2]. Mean tibiofibular width in normal ankles were 2.85 mm (range 1.9 4.4mm), anteriorly and 4.03 mm (2.2 6.3mm), posteriorly. In men the mean anterior width was 2.7 mm and posterior width was 4.12 while in women mean width was 3.23 mm anteriorly and 3.81 mm posteriorly. The measurements were performed twice in random order at least two weeks apart and analysed for intra-observer agreement. The intra-class correlation coefficient value was 0.91 for the two measurements. Comparison of syndesmosis width between normal and operated ankle showed mean values of 4.04 + 0.95 mm for normal side and 4.37 + 1.12 mm for operated side in tightrope group ( p = 0.30, t-test). In syndesmosis screw group the mean width of syndesmosis was measured as 4.02 +0.87 mm on the normal side and 5.16 + 1.92 mm on the operated side ( p = 0.01, t-test) [Table 3.3] [Fig. 3.2]. Table 3.2: Mean values of the width of normal syndesmosis Mean, standard deviation and range Anterior width (mm) Posterior width (mm) Total Mean 2.85 4.03 n = 46 Standard deviation 0.75 0.9 Range 1.9 4.4 2.2 6.3 Male Mean 2.7 4.12 n = 33 Standard deviation 0.68 0.91 Range 1.9 4.4 2.2 6.3 Female Mean 3.23 3.81 n = 13 Standard deviation 0.8 0.87 Range 2.1 4.4 2.7 5.6 Table 3.3: Comparison of syndesmosis width between normal and operated ankle in two groups Normal ankle Operated ankle p value (t-test) Tightrope group 4.04 + 0.95 mm 4.37 + 1.12 mm P = 0.30 n = 23 (2.2 6.0)   (2.5 6.4) Screw group 4.02 + 0.87 mm 5.16 + 1.92 mm p = 0.01 n = 23 (2.7 5.6)   (2.1 10.3)   All values are mean values in mm + standard deviation (SD) and (ranges). P value 0.05 is considered statistically significant.   Table 3.4: Malreduction of syndesmosis between tightrope and screw group Malreduction No Yes Total Tightrope group (n = 23) 23 0 23 Screw group (n = 23) 18 5 (21.73%) 23 Total 41 5 46 Malreduction was diagnosed on the bases of pre defined criteria of 2 mm difference from the normal side. p 0.05 Fishers exact test. The primary outcome measure, malreduction of syndesmosis was diagnosed on the basis of pre-defined criteria of 2 mm difference from the normal side [Table 3.4]. There was no case of malreduction in tightrope group as compared to 5 (21.7%) cases of malreduction out of 23 cases of syndesmosis screw fixation (p 0.05, Fishers exact test) [Fig. 3.3]. Risk of malreduction was 21.7% higher in screw group than tightrope group. 3.4. Radiographic measurements Radiographic parameters of syndesmosis integrity were measured on standard AP radiograph of ankle 1 cm above the tibial plafond. Mean pre operative and post operative values are compared in [Table 3.5] [Fig. 3.4]. Mean post operative medial clear space (MCS) was 3.36 + 0.5 mm in tightrope group and 3.23 + 0.6 mm in syndesmosis screw group (p = 0.48). In tightrope group the mean post operative tibiofibular clear space (TFCS) was 4.04 + 0.8 mm as compared to 5.0 + 1.8 mm in screw group (p 0.05) while mean tibiofibular overlap (TFOL) was 8.21 + 2.0 mm and 7.47 + 2.0 mm respectively (p = 0.22). Table 3.5: Pre and post operative radiographic parameters of syndesmosis integrity Tightrope group Syndesmosis screw group p value Medial clear space Pre-Op 5.86 + 2.3 mm (3 15) 6.67 + 1.7 mm (4 10) Post-Op 3.36 + 0.5 mm (2 4 ) 3.23 + 0.6 mm (2 5) p = 0.48 Tib-Fib Clear space Pre-Op 7.04 + 2.1 mm (4 12) 7.82 + 1.6 mm (4 10) Post-Op 4.04 + 0.8 mm (2 6 ) 5.0 + 1.8 mm (3 8) p 0.05 Tib-Fib Overlap Pre-Op 3.95 + 2.0 mm (0 8) 3.78 + 2.3 mm (0 8) Post-Op 8.21 + 2.0 mm (4 11) 7.47 + 2.0 mm (4 10) p = 0.22 Based on radiographic criteria of syndesmosis integrity, 9 patients had syndesmotic malreduction. Only 3 patients with true malreduction on CT scan were correctly diagnosed using radiographic parameters while 6 had a false positive result [Table 3.6]. Table 3.6: Comparison of CT scan and radiographs for diagnosis of syndesmosis malreduction Malreduction on CT scan Malreduction on radiographs Total No Yes No 35 6 41 Yes 2 3 5 Total 37 9 46 The radiographic criteria for syndesmosis malreduction included TFCS 6 mm or TFOL 6 mm on standard AP ankle radiographs. On CT scans malreduction was diagnosed if there was 2 mm difference in the width of syndesmosis as compared with normal side. 3.5. Clinical outcomes Mean time to full weight bearing was 8 + 1.2 (range 6 10) weeks in tightrope group as compared to 9.1 + 1.8 (range 6 13) weeks in screw group (p = 0.11) [Fig. 3.5]. Mean American orthopaedic foot and ankle society (AOFAS) hind foot score was 89.56 + 8.6 (95% CI 85.83 93.29) in tightrope group and 86.52 + 9.6 (95% CI 82.34 90.70) in screw group (p = 0.26). Similarly foot and ankle disability index (FADI) score was 82.42 + 11.2 (95% CI 77.56 87.27) in tightrope group and 81.22 + 15.6 (95%CI 74.46 87.97) in screw group (p = 0.76) [Table 3.6]. Both functional scores were measured on a scale of 0 100 with higher scores associated with better functional outcomes. None of the clinical outcome measures differ significantly between the two groups ( t -test) [Fig. 3.6]. Table 3.6: Clinical outcomes Tightrope group Syndesmosis screw group p value Time to full weight bearing 8.0 + 1.2 weeks (6 10) 9.1 + 1.8 weeks (6 13) p = 0.11 AOFAS Score 89.56 + 8.6 (69 100) 86.52 + 9.6 (65 100) p =0.26 (95%CI 85.83 93.29) (95%CI 82.34 90.70) FADI Score 82.42 + 11.2 (58.7 97.1) 81.22 + 15.6 (47.1 98.1) p =0.76 (95%CI 77.56 87.27) (95%CI 74.46 87.97) Regression analysis was performed to find any significant correlation between the two groups and the clinical outcome score (AOFAS) while adjusting for potential confounders [Table 3.7]. Type of fixation was not significantly associated with the clinical outcome score. Malreduction of syndesmosis on CT scan was the only variable that reached statistical significance when keeping other variables constant with regression coefficient -12.39; t = 2.43 and p 0.05 [Table 3.7]. Table 3.7: Regression analysis to determine the predictors of functional outcome. AOFAS Coef. Std. Err. t p I t I 95% Conf. Interval Syndesmosis Malreduction   Ãƒâ€šÃ‚  Ãƒâ€šÃ‚   -12.39   Ãƒâ€šÃ‚   5.102 -2.43   Ãƒâ€šÃ‚   0.02 -22.7 -2.09 Fixation techniques   Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚   0.29   Ãƒâ€šÃ‚   2.855   Ãƒâ€šÃ‚   0.1   Ãƒâ€šÃ‚   0.91 -5.47   Ãƒâ€šÃ‚   6.05 Duration since surgery   Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚   -0.05   Ãƒâ€šÃ‚   0.176 -0.34   Ãƒâ€šÃ‚   0.73 -0.41   Ãƒâ€šÃ‚   0.29 Age 0.008   Ãƒâ€šÃ‚   0.105 0.08   Ãƒâ€šÃ‚   0.93 -0.2   Ãƒâ€šÃ‚   0.22 Constant 90.68   Ãƒâ€šÃ‚   7.025 12.91   Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚  Ãƒâ€šÃ‚   0 76.49 104.87 AOFAS score is used in this regression analysis as the measure of functional outcome. Syndesmosis malreduction is the only independent predictor of worse functional outcome score. Regression coefficient of -12.39 indicates that the presence of malreduction in this study resulted in reduction of 12.39 points on the outcome score. Coef: regression coefficient; Std Err: standard error; Conf. Interval: confidence interval. Chapter No. 4 D ISCUSSION In this study we compared the accuracy and maintenance of syndesmosis reduction, based on computed tomographic scans and its correlation with the clinical outcomes. This study showed that there was significant difference in the mean width of syndesmosis between operated and normal ankles in screw group as compared with tightrope group. Students t-test was used to compare the means between operated and normal ankles. The p value for screw group was 0.01 as compared to 0.30 in tightrope group confirming that the results were statistically significant. According to our criteria of malreduction there were 5 cases of malreduction in screw group while none of the tightrope group showed malreduction. There was 21.7% increased risk of syndesmosis being malreduced when treated with screw fixation rather than tightrope technique (p 0.05, Fishers exact test). This is in accordance with previous literature regarding syndesmosis screw fixation. The incidence of malreduction of syndesmosis has b een reported between 16% and 52% (44, 50, 60, 81) . Weening et al (44) reported 16% of malreduction of syndesmosis in patients treated with syndesmosis screw. The diagnosis of malreduction in that study was based on standard radiographic parameters of syndesmosis integrity and demonstrated a direct relation of malreduction with poor functional outcome scores. As the literature has suggested that the standard radiographic measurements are not accurate (7, 39, 82, 83) and sufficient to diagnose syndesmotic malreduction, several authors has used CT scans for this purpose. Gardner et al (60) has reported 52% of syndesmosis malreduction in there series of 25 patients treated with syndesmosis screw based on CT scans as compared to only 24% using   standard radiographic criteria. This is the highest incidence of malreduction, reported so far in the literature but the validity of the results is limited by the lack of comparison with the uninjured ankle and the lack of clinical correl ation. Furthermore they considered the difference of more than 2 mm between anterior and posterior measurement of syndesmosis as significant for the diagnosis of malreduction. This criterion is questionable as Elgafy et al (12) has demonstrated in their study of CT measurements of normal ankle syndesmosis that the mean difference in the anterior and posterior width of syndesmosis was 2 mm. When comparing male and female separately the mean difference was 3 mm for male and 2 mm for female (12) . Our study also showed similar variations in anterior and posterior width of syndesmosis. The mean difference was 1.2 mm (range 0 3.3 mm) with wider difference in males than females on normal uninjured side [Table 3.2]. Considering the magnitude of normal variations, Gardner et al probably over estimated the incidence of malreduction in their study. Wikeroy et al (50) reviewed 48 patients treated with syndesmosis screw from an earlier randomised controlled study after 8.4 years and also repor ted 20.8% incidence of malreduction based on axial CT scan when comparing with normal side. Similar to Wikeroy et al our study showed 21.7% incidence of malreduction in screw group. Radiographic criteria of syndesmosis integrity as described by Harper et al (38) is routinely used in practice to diagnose syndesmosis diastasis despite several reports questioning the accuracy of those parameters . Our study showed no significant difference between the two groups regarding medial clear space (MCS) (p = 0.48) and tibiofibular overlap (TFOL) (p = 0.22) using t-test . Tibiofibular clear space was although significantly wider in screw group than tightrope group (p 0.05, t-test ). When radiographic parameters were used to diagnose diastasis there were nine cases of malreduction but did not correlate well with the CT diagnosis. Three out of five of the true malreductions were correctly diagnosed by radiographs while there were six false positive. This also confirms the findings of previous studies (7, 39, 82, 83) . Although, there was a trend towards better clinical outcomes in tightrope group but when adjusted for potential confounders such as age and duration since surgery there was no statistically significant difference in time to full weight bearing and functional outcome scores (AOFAS, FADI). Malreduction of the syndesmosis was the only independent variable which significantly affected the functional outcome scores. Similar findings were also reported by weening et al (44) and Wikeroy et al (50) . Accurate reduction of syndesmosis is essential to restore normal biomechanics of ankle joint. Malreduction leads to mismatch in tibial and talar articular surfaces and significantly reduce the contact area and increase the joint reaction forces which can results in early arthrosis and long term morbidity. Tightrope fixation for syndesmosis injury is a relatively new technique which provides dynamic fixation and obviates the need for routine removal of implant. So far the literature is limited regarding Tightrope and mainly comprises of few case series and nonrandomised comparative studies with limited number of patients and shorter follow up. Thornes et al (71) and Cottom et al (73) compared Tightrope and syndesmosis screw fixation in non randomized comparative study and reported a trend towards better functional outcomes. Thornes et al also performed CT scan in 11 out of 16 patients in Tightrope group after three months and did not find any loss of reduction. None of the syndesmosis screw group had a CT scan limiting the significance of that part of the study. Coetzee et al (76) reported similar trend of better clinical outcomes in there preliminary results of a randomized controlled trail. Earlier studies did not report any complication with this technique but later it has become e vident that like any novel technique there is a learning curve and cases of hardware removal has been reported in few studies due to soft tissue irritation over the lateral knot (75-77) . We did not have any complication in Tightrope group requiring hardware removal. In all our cases of tightrope fixation great care was taken to bury the knot deep. We created a periosteal recess at the posterior aspect of fibula before inserting the Tightrope and the knot was buried sub-periosteally. Theoretically, this technique might have helped in reducing the soft tissue irritation over the lateral knot but the association could be just incidental and no hard evidence can be provided on the basis of this study. So far this is on the only study that compared the accuracy and maintenance of syndesmosis reduction between Tightrope and syndesmosis screw group and showed that Tightrope fixation was significantly better in maintaining the reduction even after a mean duration of 30 months post surgery. The reason for high incidence of malreduction in syndesmosis screw group is hard to determine from this study as CT scans were not performed immediately post operatively which make it hard to discern at which time the diastasis occurred. Whether the syndesmoses were malreduced at the time of surgery or evolved over time. The possibility of increased gap after removal of syndesmosis screw cannot be ruled out. On the other hand Tightrope doesnt require routine removal and thus continue to maintain reduction. As Tightrope is a flexible device one possible explanation of accurate reduction is that fibula is pulled into the concave incisura of distal tibia as it is tightened. There are several limitations in this study. Firstly, this is a non randomized study and the treatment choice was based on the consultants preference. As no other variable influenced the choice of fixation, the demographics and the injury pattern in the two groups were comparable. Secondly, it is not possible to identify exactly the reason for higher incidence of malreduction in screw group. It was also not possible to blind the assessor for radiographic and CT measurements as it was obvious which group they belong. To reduce the measurement bias all the measurements were performed by an independent Musculoskeletal Radiologist. CT measurements were repeated at an interval of two weeks in random order, without the knowledge of previous measurements. Intra-class correlation coefficient of 0.91 showed high level of intra observer concordance. Clinical assessment and interviews were performed by an independent assessor who was blinded to the group of patients and two functional outcome scores one clinician reported (AOFAS) and other patient reported (FADI) were used to increase the validity. Despite these limitations, considering the appropriate sample size and follow up duration the results of the study are valid and show that Tightrope fixation is at least equivalent to the conventional screw fixation for the treatment of syndesmosis injuries with potential advantages of providing and maintaining accurate reduction and avoiding need for routine removal. The technique is simple and can be used both in isolation and with plate fixation. It minimise the risk of hardware complication associated with screw fixation and the need for second operation. Like any novel technique, there is a learning curve and care must be taken to avoid soft tissue complications that may require implant removal. Further long term randomized controlled trials would be helpful in clarifying the issue.  Ãƒâ€šÃ‚   Chapter No. 5 C ONCLUSION Ankle syndesmosis injuries are complex and require accurate reduction and fixation to restore normal biomechanics of ankle joint and avoid long term complications. Syndesmosis screw and Tightrope fixation are both valid options for the treatment of syndesmosis injuries. Although, short to medium term clinical results were comparable for both the groups, Tightrope provides and maintains more accurate reduction of syndesmosis as compared to screw fixation and obviates the need for routine removal of implant. The radiographic parameters of syndesmosis integrity routinely used are inaccurate and care must be taken to appropriately reduce the syndesmosis before fixation as malreduction of syndesmosis is the most important independent predictor of long term functional outcome.

Culture, And, By Luigi Pirandello - 1789 Words

Culture, and subculture, posses a certain intrinsic value which is often learned through immersion –imperative in understanding one’s psychological foundation. Society possesses a preconceived idea of what is normal due to years of experience and reform. This process has led to conflict between cultures in regards to the definite definition of â€Å"normal.† However, can one derive a definite definition of culture? Although, culture is something that we are born into, we have the power to decide to leave the culture for another – accepting the risk of not ever finding our cultural identity. The argument of whether culture is inherited or learned, the theory of cultural determinism, and the ways in which these concepts conflict with culture in short stories, such as â€Å"Blue Winds Dancing† by Thomas Whitecloud, and â€Å"War,† by Luigi Pirandello, are discussed in the following essay. Culture When considering the connotative meaning of culture, often known as an identifying factor in a family, organization, or society, it can be rather simple to experience disconnect with rationalism. The concept of culture – complex and subjective – has been a paramount topic throughout history due to the curiosity, growth, and sprawl of populations. In modern era, an important idea to note resides in the fact that culture is not a term which is locked-in by political borders. Rather, culture exists as the embodiment of a group’s beliefs, experiences, and behavior; as well as the contrast apparent inShow MoreRelatedAnalysis Of Heidi s The Great Gatsby 2003 Words   |  9 Pagesto finally see both sides of herself allows for the climax to occur. Heidi s situation is also ironic since she is able to laugh at herself despite her insecurities. To create irony, the self can choose not to take its own creation seriously (Pirandello, On Humor 6-7). This approach to life keeps Heidi from giving up on herself and assists in making her a dark comedy protagonist instead of a tragic figure. Skepticism is also a factor in The Heidi Chronicles since the spectator is set upRead MoreAnalysis Of Harold Pinter s The Lover2155 Words   |  9 Pagesmeaning is carried by a system as a whole. In this sense, each play, relates to other plays as a system and this system , in turn, intersects with other systems of literature , nonliterary performance , other art forms (both high and low), and culture generally(17). Richard Hornby gave five distinct techniques that may be found in metatheatre. These include, ceremony within a play, role-playing within a role, reference to reality, self-reference of the drama, and play within a play. In MetatheatreRead MorePostmodernism in Literature5514 Words   |  23 Pagestotalizing mechanisms extends even to the author; thus postmodern writers often celebrate chance over craft and employ metafiction to undermine the authors univocal control (the control of only one voice). The distinction between high and low culture is also attacked w ith the employment of pastiche, the combination of multiple cultural elements including subjects and genres not previously deemed fit for literature. A list of postmodern authors often varies; the following are some names of authors

An Analysis of Culture and Organisation

Question: Discuss about the An Analysis of Culture and Organisation. Answer: Introduction to ZTE and its environment The report will discuss in detail about the company ZTE Corporation which is one of the largest and infect international leader in the field of telecommunication and IT. The company focuses on providing a system which is integrated by nature and also provide an end-to-end innovation to the customer (Zhu Liu, 2010). The company serves many customers from different businesses to public sector customers from all across the world and also make sure that there is constant connectivity and also productivity in order to unlock the strength of the technology in the society (Zhu Liu, 2010). The company got established in the year 1985 and the company is also listed at Hong Kong and Shenzhen Stock exchange. Not only this, the company is the largest listed telecommunication company in China (Fan, 2011). The company is providing variety of product which is extremely comprehensive by nature and provide end-to-end solutions. ZTE offers number of option from many value services, high quality wireless which is cutting edge, bearer and access, terminal and managed services to number of telecommunications carriers (Fan, 2011). Also the company is into providing structured ICT solutions for companies and number of government agencies. The company has a team of highly qualified people who have capacity to take the company on number one position in the field of telecommunication and also the company got listed in Fortune 500 enterprises among almost hundred and sixty countries to achieve business aim and also attain competitiveness constantly (Rogers Ruppersberger, 2012). The company has also indulged in providing smartphones like AXON, SPRO and Blade. These mobile devices are highly demanded since the company come up with a lot of trust by the consumers all around the world. ZTE is also an active part of UN global compact and the company is devoted to create a vision which is balanced in nature and provide sustainable development solutions for the environment and also economic fields (Rogers Ruppersberger, 2012). The company also believes in providing freedom of speech all across the world and with the company being indulged in the innovation through technology and along with the concept of going green into effective product life cycle (Rogers Ruppersberger, 2012). This includes research and development, logistics, production and customer service. The company is also devoted to provide high energy efficient solutions and at the same time also minimise carbon emission from the area. The Hofstede theoretical framework Hofstedes cultural dimensions theory is actually a framework for those companies or people in general who migrate to different parts of the country and indulge in cross culture communication (Taras et al, 2010). The concept was developed by Geert Hofstede. It defines an effect on the culture of the society and the value system of the member of the society. This also discusses the value which is closely connected with the behaviour by using a proper structure and which also comes from many elements and its analysis (Taras et al, 2010). The theory is entirely based on the basic idea that different values are places on 6 dimensions. These dimensions are power which throws light on equality and inequality in the society, individualism versus collectivism, avoidance of any kind of uncertainty which can also be compared uncertain level of tolerance, masculinity and femininity, indulgence and restraint and temporal orientation (Taras et al, 2010). Following is the detailed discussion of all six dimensions: 1. Power-distance index: Hofstede has emphasized that power distance can be defined as an extent where in an organisation; people who are little less powerful can accept or even expect that power can be distributed unequally (Hofstede, 2010). Here, the level of distribution of power is not calculated rather the focus is more on the way people actually feel about the whole situation. In fact, the low power-distance score actually means that cultures has the power to expect or accept different power relations and is more democratic by nature and where members are actually viewed as equals (Hofstede, 2010). High power-distance scores emphasize on the less powerful people in the society who can easily accept the place and can also realise the level of existence in a more formal and hierarchical positions (Hofstede, 2010). 2. Individualism and collectivism: this element discusses the degree to which an individual can be integrated in a group and the main dimension does not have any political connotation and it is also related to the group instead of any individual (Hofstede, 2011). Culture that promotes individualistic approach gives importance on attaining personal goals. In collective societies, these goals or objective are the group of people and its wellbeing which are valued over those of many individuals (Hofstede, 2011). 3. Uncertainty versus avoidance: tolerance level in a society can be uncertain and also create an ambiguous situation. This is actually a dimension that can measure the way any society can deal with many unknown situations and can also face many unexpected events and the level of stress also changes (Yoo et al, 2011). When culture score high on this index are very less tolerant of any kind of change and also tend to minimise the level of anxiety or worry in the unknown place by implementing various rigid rules, laws and regulations(Yoo et al, 2011). Societies that actually score comparatively low on any index are more open to different kind of change and also have less rules and laws and more free or flexible guidelines. 4. Masculinity versus Femininity: - this element focuses on the distribution of many emotional roles which exist between the genders. This dimension calculate the level of importance in a culture that places on many stereotypical value which are masculine by nature like assertiveness or power or materialism and also typical feminine values like value to human relationships (Yoo et al, 2011). Cultures that are high in masculinity scale are generally based on having more distinct differences in the genders and also tend to be very competitive and ambitious by nature. When these score is low on many dimensions have less differences between the gender and overall place gives higher values on building the relationship (Yoo et al, 2011). 5. Long term orientation versus short term orientation: there are number dimension that can explain a societys time and its horizon. Short-term oriented culture focuses on traditional or more conventional values or methods that give a lot of time to build relationships and in common have a view as circular (Taras et al, 2012). In other words, the past or the present are more interconnected by nature and also it cannot be executed today or many can be done in the future. The complete opposite of this is long term orientation which has the capability to see the time as a more linear and it also look for the future rather than the present or even the past. It is more goal oriented and value rewarding by nature (Taras et al, 2012). 6. Indulgence versus restraint: this element calculates an ability of the culture that has the capacity to satisfy the constant needs and also the personal ambitions for its members (Taras et al, 2012). Those values can also restraint and have a very strict or rigid society rules and conditions which can satisfy or even drives in a more regulated or discouraged manner. Importance of Hofstede theoretical framework There are number of issues that are measured based on Hofstede dimensions which are discussed in detail as follows: 1. The society is from a time or a culture that shows high power distance dimension and at the same time, subordinates or employees are used to abide by what the managers tells them to do instead of focussing more open or democratic methods (Hofstede et al, 2010). On the other hand, the engineer or other technical people come from a culture where the dimension is low and it will also flatter many kind of power structure and it also includes the authority and accountability of employees so that they can work on more equal terms (Hofstede et al, 2010). 2. The overall community is actually collective driven on the other hand, the engineers belongs to a more individualistic culture (Woodside et al, 2011). This is why; the community actually gave importance to a group that have opinions despite the fact that these are more personal opinions. This is why, when an individual is walking through number of problems was asked to voice his or her opinion and when the person takes a step back when it comes to expressing the opinion, since many members of the community or society have nothing to do with that individual problem (Woodside et al, 2011). 3. The levels of low uncertainty actually avoids and also have a high power distance focuses on many community rules, the members are focused on organising as a part of the family where the chief or head take responsibility (Engelen Brettel, 2011). The primary focus is with the head of the family or organisation who must take decision on the right action plan. 4. Whereas, when a technical sound person comes under a situation where power distance as well as uncertainty avoidance is comparatively low, the project is actually drawn till the end and the engineer is more focused to collect in many members of the society though the head or the chief has less or not interested (Pauwels, 2012). Schein theoretical framework and why it is not selected? This framework is proposed by Edger Schein and he stated that it takes time to adopt a culture and it cannot be done in a single day, rather it is formed in due course of time as employees have to face many changes and also adapt to the external environment and solve issues (Rai, 2011). People gain from their past experiences and also practice it daily. This leads to forming a culture in a workplace. New employees look hard to adjust in the new place and lead a stress-free time (Rai, 2011). Following are the three level of organisation culture according to this framework: 1. Artefacts: this level is the characteristic of any organisation that can be easily viewed or heard or even felt by number of people in a collective manner and known as artefacts (Hogan Coote, 2014). In this level everything from dress code of employees to office furniture to overall code of conduct of the employees and mission, vision come under Artefacts (Hogan Coote, 2014). 2. Values: in this level Schein focused on organisation culture and its value to the workforce. The values of a single individual working in the organisation actually play an important role in deciding the organisational culture (Baskerville Wood-Harper, 2016). The overall mind-set of any person who is connected with a particular firm impacted the culture of that workplace (Baskerville Wood-Harper, 2016). 3. Assumed Values: the last level focus on many values of the employees which cannot be measured but does have the power to make the difference in the culture of the organisation (Baskerville Wood-Harper, 2016). There are many types of theories in cultural and organisational models; however Hofstede framework for culture is an effective one because it is one of the most referred and used theories all across the world. The major difference between Hofstede and Schein cultural framework is that Hofstede look for major differences on international platforms all across the employees in a multinational companies and this is an effort to deicide the features for attainting the international culture in the working environment. Globalisation is an important element of todays time and this is why this theory has become even more crucial for organisational culture. Application of Hofstede theoretical framework on ZTE Managers all across the world are constantly facing number of difficulties and challenges which are thrown in a way that global interdependence of the market and HR department cannot be exempted (De Mooij Hofstede, 2011). When in a company like ZTE has common culture, personnel management is challenging because everyone faces some or other common conception of right or wrong or accepted attitude or behaviour. At the same time, when various team members come from a different kind of cultural background or have background where manager or a team have different outlook, there can be a situation that lead to many misunderstanding which is not good for the organisation (De Mooij Hofstede, 2011). Following is the importance of culture and its connection with Hofstede framework of culture is discussed in detail: 1. Recruitment: the complete definition of an effective candidate is completely different from the culture that prevails. Those candidates who have a strong outlook on thing and are outspoken are actually considered potential candidates for the company. These individuals are part of masculine societies (De Mooij Hofstede, 2010). 2. Now a day, where collectivist feminine is given importance, there people who are fumble and perfectly connected participants or candidates and are good ones (De Mooij Hofstede, 2010). Positioning as a manager in the country like USA which is masculinity rate is high, is actually very different from doing so in more countries near Scandinavian where masculinity is quite low. 3. Appraisal: many processes in appraisal or promotion are actually based in countries like USA or other developing countries like UK and these countries are high rate of individualism as well as also have power distance which is low (Migliore, 2011). Therefore, according to many countries, the right way of performing is enhancing the direct and more frank feedback. At the same time, this does not focus on considerations like those countries with high power distance or have collective culture. This comes from a culture where feedback is not appreciated (Migliore, 2011). According to Hofstede framework for culture, it can be concluded the cultural differences are seen very important towards the way any consumer can classify and test the product or services (Migliore, 2011). ZTE is a telecommunication company therefore according to the framework more importance is given to the power distance and individualism dimension which are crucial to be considered. As per the Hofstede, these cultures can be recognised as the interesting variables (Migliore, 2011). Many studies have proved that there is string negative connection between the power distance and individualism. However, both the dimensions are adopted by many researchers. Conclusion According to individualisms and collectivism, one can understand the high degree of individualism with a belief that values are independent and also achieve self-actualisation stage (Alkailani et al, 2012). In addition, the research also focuses on the customer adaptation and its acceptance of different forms of advertising like SMS through mobile phone and it has been found that consumer in an individualistic culture are based on individual considerations. At the same time, the overall intention of the collectivist consumer is directly impacted by social norms and many attitudinal factors (Alkailani et al, 2012). According to this framework, a model can actually by hypothesized in connection to the effect on consumer and his or her behaviour. This is why; it is possible that ZTE apply this model to investigate the purchasing behaviour of the mobile phone and other services (Alkailani et al, 2012). Telecommunication services can be looked as the most influential decision in terms of purchasing attitude. This is why, Hofstede dimension must be considered very useful and also valuable tool for evaluating the purchasing pattern in the present market (Alkailani et al, 2012). Reference Alkailani, M., Azzam, I. A., Athamneh, A. B. (2012). Replicating Hofstede in Jordan: ungeneralized, reevaluating the Jordanian culture.International Business Research,5(4), 71. Baskerville, R. L., Wood-Harper, A. T. (2016). 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Pete Rose And The Hall Of Fame Essays - Pete Rose, WWE Hall Of Fame

Pete Rose and the Hall of Fame To some, including myself, baseball is the greatest sport that has ever been played. It is a game played by two opposing teams made of multiple players, but only nine players per team play at the same time. To be part of one of the thirty teams that get to play professional baseball, a player has to play the game extremely well (www.baseballhalloffame.com). When a player plays the game better than most have played he gets rewarded, usually with lots of money in a big contract. Then there are those rare players, the 244 elite players of the game that have already been inducted into the Hall of Fame. Being inducted in the Hall of Fame is the utmost of baseball fame. The players listed are remembered forever. This brings me to my argument. Pete Rose should be allowed induction into the Hall of Fame. Now, most of the baseball critics and brass do not want Pete Rose inducted. They claim that his illegal betting on baseball games should keep him out of the Hall of Fame. Almost all of the "highly questionable" evidence that Commissioner Bart Giamatti held was derived from former friends and associates of Rose. "Up to $30,000 per day", so some of Roses' "close" friends say. These former friends of Rose are Tommy Gioiosa, Donald Stenger, Mike Fry, and Paul Janszen. This evidence is what prompted the banishment from baseball of Pete Rose, which he signed. The evidence was enough for the Commissioner. In 1989, baseball's Commissioner Bart Giammati suspended Pete Rose from association with professional baseball for life for gambling (Reston 1997). Rose also spent five months in a minimum-security prison for tax evasion in 1990. He did not report cash money he accepted for signing baseballs and photographs at baseball card shows (Reston 1997). It is still to this day not proven that Rose 'did' bet on the baseball team that he was managing. Rose himself still holds true to his statement that he never bet on the game of baseball. Evidence is minimal and it has been over ten years, yet he is still ineligible to be voted into the Hall of Fame. If it was left up to his statistics, he should have been inducted years ago. There are a handful of the 244 elites that are in the Hall of Fame that did far worse things than gamble on the game of baseball or evade paying their taxes. For instance, the beloved Ty Cobb was a horrible racist and once admitted killing a man. One day while walking in Detroit, he stepped in freshly poured asphalt. Then a construction worker, named Fred Collins, who just happened to be black, yelled at him. Cobb responded by slapping Collins to the ground. Cobb was found guilty by the courts, and received a suspended sentence. Collins filed a civil suit, but settled out of court for $75. Ty Cobb had to deal with the law in one form or another many diff erent times for striking black men (www.totalbaseball.com). The powers that run the baseball organization seem to turn their eyes, quite conveniently, away from any number of wife-beaters, and drug addict's everyday. They let known, proven criminals continue to play the game, but not Rose. There is no 'absolute proof' that Pete Rose did bet on baseball. So, why is it that a baseball player with so many of the greatest statistics is left out of the Hall of Fame? Pete Rose should be allowed induction into the Hall of Fame. Many of the players that have made it to the highest level of the game, being inducted into the Hall of Fame, do not have even one tenth of the statistics that Pete Rose has (Gilbert 1994). Rose has more career hits than anyone who has ever played the game, 4,256 to be exact. Rose also played in 3,562 games (a major league record), was the 1963 Rookie of the Year, and in 1973 was the National Leagues Most Valuable Player. He holds the all-time league record for most at bats (14,053), the record for the most singles (3,315), and the record for most doubles (746). He also