E-marketing Plan for Lexus Assignment Example | Topics and Well Written Essays - 4000 words

E-marketing Plan for Lexus - Assignment Example With the help of that this paper analyses the situation, factors, opportunities, problems, etc. And then finally need to take decision, which strategy we will follow. I feel there might be some shortcomings of my planning. But it would take consideration that, if it can overcome the inconsistencies properly that found in control stage, and then it won't be difficult for LEXUS to regain the lost position. LEXUS has gained a deserving status for turning out utterly refined luxury vehicles. The hallmarks of this brand are a calm, well-crafted cabin, a plush ride and commendable performance from powerful and nearly silent engines. It was launched by Toyota in the fall of 1989; the Lexus line represents its effort to create a world-class luxury-car brand. Groundwork for the Lexus line was laid in the mid-'80s, when the company began tapping U.S. focus groups in an attempt to define design concepts best suited for American users. By the early 1990s, the Lexus brand was expanded to other markets, including the United Kingdom, Canada and Australia.4 As a Marketing Executive of LEXUS, like to create an outline e-marketing plan for my organization. 1. 1-2: Problem Statement: 1. I would like to make the plan by analyzing situation that we are in now, objectives where we want to get to, strategy how we are going to get there, tactics details of the strategy, actions how to implement the strategy, controls monitoring and reviewing where we are going. 2. Determining whether the plan would be cost-effective, and finish able timely or not. Along with that what is going to happen when and was that intended or not. CHAPTER 2: RESEARCH DESIGN 2-1: Methodology: E-marketing specify sell of any goods or services using digital technologies. These technologies are a valuable

Culture of Armenia - history, people, women, beliefs, food, customs Essay Example for Free

Culture of Armenia history, people, women, beliefs, food, customs Essay (I am trying to make art that relates to the deepest and most mythic concerns of humankind and I believe that, at this moment of history, feminism is humanism. Judy Chicago, 1990) Armenian traditions and culture made an Armenian woman unable to work outside of their homes for several decades. As women were supposed to marry at very young ages there was no need for personal and professional growth except being excellent households. In the first stage (0-19 years) of their lives, they were dependent financially on their families, especially fathers, after that they were depended on their husbands. As lives of many of Armenian girls were already decided before they were born, there was no room for education and career. However, even in that kind of situation, there were several motives for pushing women to education and workforce. Industrialization and technology development were some of those reasons. So, we may think that women were not utilized entirely by the society, that’s way with the development the role of women in the family decreased hence increased in the society. And as women started to enter the workforce and get out of their â€Å"home† comfort zone, the need for secure rights and respect increased by them. So, why it was not important to have rights within the family? Here come tradition and culture. Armenian women were always thought from their young ages, that family is the most valuable thing that can happen in their lives and family wife, the mother must always sacrifice their happiness, dreams and overall lives to build a strong and â€Å"ch ild-friendly† environment within their families. As families were big (6 10 members) there was no time left for the women to think about their long-term goals and dreams. They were entirely taken by day-to-day household activities and child’s upbringing, however, I personally think that if girls were taught about other values from younger ages, the society would change itself even with very little steps. It is a cyclical system and all starts from the childhood. There is another argument, that we may also consider: women were accepted as the â€Å"tool† of continuing the nation with next generation. Women were blamed when they were not married because they will not be able to give a birth to a child, especially a boy. And those women who decided not to marry were forced to wear old, black clothes and they needed to cover their faces. There is another crucial fact, as many towns and villages couldn’t provide a primary education mothers were supposed to teach their children as well. So, the way that child’s brain and imagination will be shaped was in the hand of their mothers. At the first glance, we may think that women in poverty or girls who were married by force were the main engine of driving the society into feminist ideas. Because they were the ones who had no voice in the family and society, most of their husbands migrated to other towns to make money. In villages especially, women were publicly harassed for their speech in front of another man. However, the history showed us that feminists were from the elite class of the society, we can see lots of cases both in Armenia and worldwide. So, why were feminists from the highest social class, if they could have anything that they needed? There are several reasons for that, but in this paper, I will consider just two of them: being able to afford higher education; free time. A good education has always been an expansive experience. Even now, when almost every city has its own school and at least one university, for graduating you need to have money. What about 19th centuries? When people started to value the education and wealthy families were seeking to give their children the best education, both for their status and for their next generation’s welfare. Graduates from all institutions that provided higher education were from wealthy families. And only the most wealthy families will spend money for their daughter’s education. From that institutions, girls got only knowledge but a dream of getting more than just having husbands and children. They wanted to use their talents and knowledge to change something in this world. Education â€Å"educate† people to move forward and always take into account one’s individual ways of thinking, sometimes feelings and even just intuition when making decisions. However, all these cannot be i ntegrated into typical Armenian Family\s daily routine. Most of the decision was made by the man and sometimes never advised with the women. Even if the issue is really crucial and important for family’s future. So, the women are a subordinate, just an active resource that can be used based on man’s decision. Some people argue that while the feminist movement certainly opened up jobs and opportunities available to women, it ultimately harmed women, children, and family because it devalued motherhood. I would agree with some part of this statement, however, I will change a word in it: As the feminist movement certainly opened up jobs and opportunities available to women, it ultimately changed women, children, and family because it devalued patriarchal families. With the increase of women in the workforce the birth rate decreased. And women got less time to provide to their personal lives and more importantly number of children born by a single woman decrease.When women Ð °cquired greÐ °ter clÐ °ss stÐ °tus and power without conducting themselves differently from mÐ °les, feminist politics were undermined. Middle- Ð °nd lower-middle clÐ °ss women who were suddenly compelled by the ethos of feminism to enter the workforce did not feel liberated once they fÐ °ced the hard truth that working outside the home did not mean work in the home would be equally shÐ °red with mÐ °le partners. So, what is the reason? Is there any solution that could combine a working mother and more children in one family? Yes, in my point of view, there is one. If the life of a woman changes during decades, a routine of man was stable. They haven’t met any crucial changes in their daily routines and plans with this development. And here is the problem. If the father took some of the women’s activities and concerns within the family, everything would be balanced. Because the woman changes entirely after having a child, and in the workplaces, it is not always guaranteed that women could get her job back after maternity leave. Some countries found the solution: paternity leave. Fathers have equal rights to get leave for the newborn baby, and the problem is somehow solved. So, how is this connected to social status? Women from higher social classes have the opportunity of choosing. It can be just an ability to choose a dress or choose a life partner. Along with this, they have more time available (they have servants) for their own interests, so instead of doing household activities they are building their personalities and constructing their own lives. There are lots of examples of wealthy feminists from the history both worldwide and in Armenia. One of the most famous Armenian feminists was Serbouhi Dussab. She was a good example of well-educated, self-confident Armenian women. She was well-known in her time because she had a social status, and it made her voice to be heard. In the traditional Armenian society, it was not always easy to express your opinion as an individual, especially in novels. In her second novel (Siranush, published in 1884) she talked about family life, marriage and women’s right in Armenian families. She stepped into the sphere that was never touched deeply by women. Every question, especially regarding genders, have at least two viewpoints, and it is not always to be in the â€Å"middle†. Women should look into the question of gender equality with a cold heart and sharp mind, or else feelings will make a decision instead of them. This is what we can see in writings of Ms. Srbouhie Dussab. However, in Armenian society women were not only making a difference in literature but also found several charitable funds and organizations, which changed the society’s way of thinking step by step. Some of those organizations were: The School-Loving Ladies Society, founded in 1979 by Ms. Nurik Simanian, Ms. Taguhie Paltazarian, and Mrs. Armaveni Minassian. The goal of the society to promote education of Armenian girls and train teacher for provinces, set private free schools for Armenian girls ; â€Å"Education-loving Ladies†, founded in 1880 and society’s goal was to take care of poo rs, orphans, widows ; â€Å"Union of girls and young men† founded in 1919, an example of joint man and woman organization and â€Å"Armenian Women’s Association† founded in 1919, aimed to contribute to Armenian women’s moral intellectual, material and physical development, establish cooperation between all Armenian women, use Armenian potential to promote the Armenian Cause. The Armenian women’s charitable society of Tiflis Was the largest and long-lived women’s organization. On 4th of December, 1879 114 ladies gathered in the conference hall of the Mariamian-Hovnanian girls’ school, organized fundraising, raised 407 rubles for sending to Constantinople. On 31st of December, 1881 Society’s Charter was adopted. According to the Charter, the goal of the Society was to promote the education of women: a. by opening and maintaining a private school for females at its own cost b. by supporting parochial schools for females with its own funds as well as by assisting those women that wish to become teachers in parochial schools\. The society also granted scholarships for unmarried women to study education or medicine. Within first 10 years, Society organized 11 balls, 6 performances, 3 concerts, 2 public lectures, all of which proved quite successful as fund-raisers. One of the most memorable organizations was Armenian Society â€Å"Meghu† in Tiflis â€Å"Meghu† decided to stop poverty by waging war against women\s unemployment. First, there was the issue of cheap labor. The number of job-seekers is constantly on the rise and fear of starvation forces workers to accept lower wages. Second, there was a danger of the flaw of living at the expense of someone else\s labor. The founders of the Society divided those living at someone else\s labor into two groups, evil-doers or robbers, and beggars. \A beggar with his rags and nakedness does the same thing as a robber: beggary, too, is a trade and a mask, which can be used to peacefully rob someone without running any risk.\ A power was needed that would help them at the time of despair and would encourage them. The class came to the conclusion that the existing charities were powerless to fight against a huge force of economic crisis. Those women came up with an idea of establishing a purely democratic association that would be able without hurting people\s self-respect to provide the unfortunate victims of our materialistic age, especially women. Armenian female workers are the most oppressed, ill-used and exploited social class because, on the one hand, of their shyness and, on the other hand, of the overall economic situation. Women earned their living with home-craft (ex. sewing, and they would make kopecks).The Society set a goal of establishing the \House of Work\ (workshops) and of assisting in promoting the cause of eliminating illiteracy of poor women. Workshops, such as dress-making, dry-cleaning, cardboard, artificial flowers, basketry, cooking. For 13-17 years old-sold girls society opened a school. The final decision was that only girls that have a level of knowledge equal to the graduates of the parochial elementary school shall be admitted to the school at the Meghu House of Work. As mentioned before, a good education and self-confidence can have a cyclical effect and attract more women to take their lives in their hands. Maybe the engines of feminism revolution were a wealthy woman, but they helped the society to understand the importance of equality in every sphere of life. They changed the world by writing novels, founding organizations, societies, and schools. Importance of a good education is rising day-by-day and feminists have a huge role in it by their activities. They brought the problems of women from top to the lives of people and made middle- and low- social class women to think about their futures by themselves.

Interview with a Massage Practitioner Essay -- Interview Essay

Many people pass this concrete stucco looking office on the strip mall. Most people who pass by may go to the bar next door to Dr. Mason’s chiropractic office. No one pays much attention to a place where all the windows are low tinted dark with a door that has the word doctor on it. People only look for doctors when they are injured or sick. I’m sure the lighted Budlight sign flashing and smell of food attract more people. It was different than what I expected from a doctor’s office. Surprisingly the roof was flat not pointed like most offices and not a very tall building. I expected lots of rocks, small bushes near the door, smooth concrete building with slight indentions for decoration, metal plaque inside the concrete and the area to be surrounded by other doctor offices. I was nervous as I stepped over the curb and onto the side walk to the entrance. â€Å"What if she is really busy or rude,† I thought, â€Å"But massage therapist are usually nice and calm.† The door was average height and swung open very easily. Inside the clinic it smelled crisp and was cool. The sun shined through the windows where the shade was raised. All the walls were painted in a slight off-white color. Instead of the typical tile or vinyl flooring carpet was used. The freestanding reception desk was in an open area with plants, filing cabinets, and a copy machine next to it. Behind the desk was a full height wall that changed to a chest height wall. In the open office there are two chiropractic tables, which were separated by a wall that is about chest height. On the other side of the room is a traction station, two stretching machines, a massage chair. In the lobby section of the open office there are two flat screen TVs and lots of children movies... ... people to unwind and relax. Mary entered the job knowing her skills and prepared to put them to work. A massage â€Å"is the manipulation of superficial layers of muscle and connective tissue to enhance the function and promote relaxation and well-being.† I asked Mary if she like her job. â€Å"I love my job it is never boring I treat people from ages ten to seventy-five. I love helping people and I find the human body fascinating. Today people are trying to live a long and health by taking care of their body, my job helps.† There are many schools that offer massage therapy. Anyone who would like to pursue it as a major should be comfortable with touching other people. Before leaving I told Mary I appreciated the time she took to allow me to interview her. I was satisfied overall with the interview. The environment made me happy that I chose a relaxing career to explore.

Macbeths Demise :: essays research papers

Macbeth Essay   Ã‚  Ã‚  Ã‚  Ã‚  The tragedy Macbeth by William Shakespeare is based on a thane in whom is corrupted by greed and a negative ambition. The character Macbeth contradicts his moral responsibility in this play a great deal; many moral questions are brought forth to Macbeth. He questions himself and whether or not he should follow through with the evil deeds that he does. Macbeths ambition causes him to compromise his honour, he doesn’t take into consideration that he is being trusted and that every action that he takes will have a reaction. Macbeth attains his position as king unjustly. As is evident by the conclusion, justice prevails as usual and Macbeths demise is a result of his evil deeds. Macbeth negates his moral responsibility as a person as well as a king. He doesn’t take into consideration that he will pay for all the evil deeds that he executes. Killing Duncan is the worst crime that is possible to commit since the kings were the closest in hierarchy next to god. It is evident that Macbeth is aware that this is an evil sin when he states, â€Å" I dare do all that may be come a man, who dares do more is none.† (Act I Scene VII, Line 46-47) The previous statement shows that Macbeth believes that killing Duncan will make him nothing more than a beast. Nevertheless he goes against his morals and kills King Duncan. Sin is a prevalent theme in this play, Macbeth shows that he knows he has lived a sinful life, â€Å"Seyton I am sick at hearth, when I behold Seyton I have live’d long enough.† (Act V Scene III, Lines 20-22) Ambition takes over Macbeth when he decides to hire assassinators to kill Macduffs wife and children, â€Å"The castle o f Macduff I will surprise; seize upon Fife; give to the edge of the sword in this line.† Lanoue 2 (Act IV Scene I Lines 150-153) Macbeth shows the insignificance of his morals and responsibilities by his actions, he shows that becoming king is of much more importance.   Ã‚  Ã‚  Ã‚  Ã‚  The weird sisters (witches) have a great impact on Macbeths state of mind when he decides to follow through with many of his actions. The witches are responsible for putting the idea of Macbeth becoming king in his head. Faith in the witches compromises his honour since they are believed to be evil however Macbeth

Organizational Structure Essay

To be successful in today’s world, organizations must quickly respond to a competitive and continuous changing environment. In most cases that means being innovative, reinventing themselves’ and changing many of the established ground rules of their own industry. Organizational leaders can’t allow their staff to settle and be content with ideas of the past. Organizations must challenge its management staff to embrace change while continuing to look for ways and methods to improve. In many instances, an organization’s structure can impact the degrees of its successes. For instance, an organization with a decentralized structure, which has open communication system, tends to be more innovative. Organizations that are more highly centralized with most of the decisions being made at the upper level, tend to be much slower in their actions because of decisions that are handed down from level to level, where as the decentralized organizations tend to react faster because it empowers its employees and allows them to make decisions at all levels of the organization. An organizational system that is being used world wide by many organizations is that of the cross-functional team. This team concept brings together employees from various functional units within the division and it enables them to implement and integrate new ideas more rapidly, because of the upfront teamwork that limits the amount of trial and error normally associated with change. The cross-functional team approach provides an upfront opportunity to research the impact decisions will have on each functional area and modify them accordingly. The organizing function of management is the deployment of organizational resources to achieve strategic goals. The deployment of resources is reflected in the organization’s division of labor into specific departments and jobs, formal lines of authority, and mechanisms for coordinating diverse organization tasks. Organizing is important because it follows strategy. Strategy defines what to do, and organizing defines how to do it. The organizing process leads to the creation of organization structure. Organization structure is a tool that managers use to harness resources for getting things done. Organization structure is defined as the set of formal tasks assigned to individuals and departments; formal reporting relationships, including lines of authority, decision responsibility, number  of hierarchical levels, and span of managers’ control; and the design of systems to ensure effective coordination of employees across departments. Parker Powertrain primarily utilizes a decentralized organizational structure. Although we are part of a six billion dollar organization, most decisions that impact our division are made within our division. The organization does have many centralized strategic goals that are handed down to all divisions, but each division also has its own internal strategic goals that apply to and impact only that division and its customers and product markets. Parker Powertrain also utilizes the cross-functional team concept within its division for most of its continuous improvement ideas. We have cross functional teams that work on product design, six sigma, scrap reduction, new product launches, cost reduction, and productivity improvements. We even have teams that focus on improving communication, along with recognizing and rewarding employees for outstanding performances and behavior. Depending on the tasks at hand, employees are chosen from all vital departments within the division, and on man y occasions some employees are chosen from non-vital departments, just to offer a little diversity to the team. We have several formal cross-functional teams which are part of the organization’s formal structure. These teams usually consist of the same members all the time, and their primary focus is usually planning the strategic goals within the division. We also have special purpose teams, which have a specific purpose and once that purpose is complete the team disbands. An example of our special purpose teams would be our communication and our rewards and recognition team. They were brought together to help fix or improve a problem, and once they are finished the team will dissolve. Another type of cross-functional team that our division uses is a problem-solving team. This type of team usually consists of hourly associates from within the same department who voluntarily meet to discuss ways of improving quality, scrap, and productivity. These teams continue to focus and work on those types of problems as they arise. Although our organization is already utilizing many of the tools mentioned in this article, I still believe we at Parker Powertrain can benefit more by implementing more of the problem-solving teams. We have several of our  departments that currently don’t utilize this method, and they could improve many of their daily tasks if they would evaluate them and look for improvements. Unfortunately, we still have several managers that seem to be from the dark ages and don’t realize that our employees are our greatest asset, and that usually they can develop ideas and methods that can greatly improve processes because they can bring the knowledge that comes from first hand experience. My challenge to my divisional staff would be for them to either replace those managers that are holding the rest of us back, or convince them to seek the training and the skills necessary to enable them to brace change head on. Buhler, Patrick M.,The Manager’s Role in Building an Innovative Organization, Supervision; Burlington; Aug 2002.

Carbon Budgeting

Carbon Budgeting Carbon Budgeting Carbon budgeting is a project currently carried out by nearly all the countries in the world today. It is closely linked to the carbon trade concept which simply refers to the contributions of all the major industrial powers to the provision of a green economy. In other words, carbon trading is a situation in which all the developed nations contribute a share of their budget to clean the environments. Since it these countries which greatly contributes to the environmental pollution, it is incumbent upon them to allocate resources to ensure that they clean the environment. Typically, the emission of green gasses is mainly done by the developed countries. However, they do not suffer from their effects since the most affected victims are the vulnerable people from the Less Developed Nations (Helm, D., 2005). According to the Kyoto Protocol of 1997, all the 38 industrialized countries are supposed to provide funds to be used in the cleanliness of the environment. However, this does not imply that they should spend the money in their home countries. Instead, these funds should be sent to these developing nations to be used in the process of cleaning their environment. In other words, the money is used in the planting of more trees. It is only through this exercise that more forests can emerge to be used as cleaning agents of these places. Despite the fact that each country has its own internal policies regarding this matter, it is important to note that they are all obliged to adhere to the terms of Kyoto Protocol which are quite categorical and precise in this matter. Since humanity has failed to observe environmental ethics, it is undoubtedly accepted to assert that the biodiversity has suffered a lot because of these perceived anthropogenic destructions done to the ecosystem. Carbon budgeting is necessary because it is the only way through which people can be salvaged from the harmful effects of such irresponsible use of the natural resources. As already highlighted, it is only the poor people who suffer from the effects of green gas emissions done by the rich North. Failure to avert this problem has led to global warming which has resulted into unpredictable weather patterns normally characterized by increased temperatures, droughts and floods. These have, in one way or another, caused a perpetual hunger and diseases such as cancer which have of course led to the loss of many lives. As was explained in the Kyoto conference, it is the third world countries which greatly feel the pains of green gas emissions because of their vulnerability. A part from being extremely poor, they are more vulnerable since they can not adequately protect themselves from the effects of such degradations (Smith, S., 2008). In other terms, it is only those who do not contribute to the pollution who suffer most from the effects of the destructions. This is what compels the major contributors to channel a large portion of their budget to sponsor this exercise. A lot of money should therefore be sent to the developing countries to help the in planting a lot of trees. If this is properly done, there will be a large area under forest coverage. Hence, the environment will be cleaned from the green gas emissions. If this is done, life will be better because these people will be saved from their problems such as wars which are always attributed to pollution. It is generally accepted that these people often fight for the few resources such as food which have become scarce because of climate change (Nordhaus, W., 2007). On the other hand, carbon budgeting may entail carrying out of cleanliness activities within the polluting countries. This means that the governments which are responsible for green gas emissions should launch environmental protection programs aimed at reducing such emissions within their territorial borders. They can carry out initiatives such as stopping certain projects which are believed to be the chief source of pollutions. At the same time, stringent regulations can be enforced to advocate for Environmental Impact Assessments before establishing any project which may be a recipe to environmental pollution. If funds are channeled to the Third World Countries as a carbon trading initiative, deliberate efforts must be taken to ensure that they are used in a right manner. Nobody should be any opportunity to misappropriate them (James R.F., 2010). They should not be spent in a selfish manner. Instead, it should be known that this is a kind of project done for the benefit of the entire world to cater both for the current and future generations. Similarly, carbon budgets can be used for providing environmental education to the people. Even if man is the chief source of pollution in the world today, it must be accepted that most of their activities are conducted because of ignorance. Many people are not aware of the environmental ethics which demand that the environment should be used sparingly in a sustainable manner in order to provide a sustainable economic growth. Life is a cyclic continuous process which involved successive generations. However, none of them should suffer because of the irresponsible consumption of others (Glasson, J. et al., 2007). In this regard, I would like conclude by agreeing with the fact environmental consciousness is the most important tool which everyone should be armed with. No one should be selfish in the use of natural resources since they are essential for the life of the entire biodiversity. Deliberate efforts must be taken to ensure that pollution is eliminated. Otherwise, adequate funds should be provided through the carbon budget initiative to ensure that all the emissions generated so far; are eliminated.

Oral Communication Essays - Communication, Human Communication

Oral Communication Essays - Communication, Human Communication Oral Communication Once viewed as two separate disciplines, business and communication, have now meshed together to produce a hybrid business environment in which the everyday functions of business are intimately tied to communication (Pincus, 1997). Communication in the business world is imperative for success. This holds true for interpersonal communication, communication between management and staff, and for practically every other contact a business has, both within its own establishment and the outside world. Effective communication is critical for the success of any organization. Through the use of proper communication skills, individuals will be better able to function as a group, thus allowing organizations to share information, analyze situations and to set goals (Nelton, 1995). Communicating properly among peers improves an individuals all around skills. The more successfully a business functions the better it enables employees to perform jobs better. Managers pass on information and train subordinates more effectively, and in general a business has a better chance of profiting. In todays turbulent economic environment and rapid technological change, communication is critical in allowing a business to deal with the restructuring of national and international economies, in preventing market saturation, and in allowing a business to deal with their competitors more effectively (Nelton, 1995, PG). Cushman and King (1997) have proposed the high speed management to describe this new busin ess environment. They emphasize the importance of communication in this theory and conclude that: In the final analysis it is the innovative, adaptable, flexible, efficient, and rapid use of information and communication which allows an organization to reorient rapidly and successfully in a volatile business environment. Another very important factor in the changing business environment is that of globalization (Nelton, 1995). It is very evident when we look at the current state of world affairs that our world is becoming a smaller place. We now have overnight delivery of packages, email communication and the ever so popular cellular communication. Globalization and increased international business can be directly attributed to mass media and mass transit. With new technologies such as videophone, Internet chat and Internet meeting rooms the thought of globalization becomes a reality for even the smallest of companies. The concept of globalization sometimes approaches this change as being one which either should or will result in a complete homogenization of culture and the formation of a unified global community. At the very least globalization will result in a number of distinct border cultures, which are hybrids of interacting cultures. What this means is that the savvy business person not only ha s to be prepared to communicate with those of his or her own culture but also with other cultures (Nelton, 1995). Many obvious precipitators of this increased business contact between the worlds cultures can be attributed to this globalization phenomenon. One of the reasons is international agreements such as the North American Free Trade Agreement. The North American Free Trade Agreement was initiated between the United States, Canada, and Mexico on January 1, 1994. This agreement referred to as the trade agreement has had a huge impact on exchange of material and cultural goods between the United States and other nations in North America as well as on the degree of business communication which occurs between these countries. Increased business diversity is not only occurring because of factors such as the North American Free Trade Agreement, it is also occurring because of a greater number of cultures within business itself. Women in the workplace are also making the work force more diversified and increasing the need for more effective communication skills (Nelton, 1995). It is an acknowledged fact that conversational styles and communication skills vary between cultures and genders (Nelton, 1995). It has been noted regarding the increased business contact between cultures as a result of globalization; increased diversity in the workplace itself, whether through the presence of an increased number of cultures or through the presence of a greater number of women; businesses must now devote greater amounts of effort toward communication in recognition of the different communication styles which exist (Nelton, 1995). Deborah Tannen, author of Talking from Nine to Five states: Each individual has a unique style, influenced by a personal history of many influences such as geographic region, ethnicity, class, sexual

Leach and Leech - Commonly Confused Words

Leach and Leech - Commonly Confused Words The words leach and leech are homophones: they sound alike but have different meanings. Definitions The verb leach means to empty, drain, or remove. The noun leech refers to a bloodsucking worm or to a person who preys on or clings to another. As a verb, leech means to bleed with leeches or to act as a parasite. Examples Batteries are difficult to dispose of and contain harmful heavy-metal compounds that may leach into the soil.The river water was more corrosive than the Detroit systems and caused more lead to  leach  from its aging pipes. Lead can be toxic, and children are especially vulnerable.(Reuters, Michigan Attorney General Sues Frances Veolia in Flint Water Crisis. The New York Times, June 22, 2016)Similar to bloodletting, leeches were used to draw out the bad blood that medieval physicians believed caused many of their patients ailments.The sun rose in a cloudless sky, the same as before. We passed a large island without grass or tree or bush.  The sun  was a leech  that sucked the moisture from our flesh.(Scott ODell, The Kings Fifth. Houghton Mifflin, 1966)She  called him a leech, said hes always sponging off the rest of us.(Swati Kaushal, A Girl Like Me. Penguin, 2008) Idiom Alerts The expression leach away (something) or leach (something) away means to gradually erode or wash away.- Normally the excess salt would be  leached away  as rainwater percolates down through the soil. In dry climates, however, where there isnt enough rain or irrigation to drive the water down that far, salts can accumulate in the root zone.(Ann Larkin Hansen,  The Organic Farming Manual. Storey, 2010)- Nathan? Are you awake? The sweetness quickly  leached away  at the touch of Roiphes nasal voice, leaving a sourness tinged with anxiety, which, Nathan understood, was his default reaction to Roiphe.(David Cronenberg, Consumed. Scribner, 2014) Practice: Leaches or Leeches? (a) Its not pollution that makes the water so black; tannic acid naturally _____ into the river from cypress and pine trees growing along the shoreline. (Bruce Hunt)(b) In modern medicine, _____ are used in reconstructive surgery to provide a vacuum effect that helps stimulate blood circulation. Answers to Practice Exercises (a) Its not pollution that makes the water so black; tannic acid naturally leaches into the river from cypress and pine trees growing along the shoreline.(Bruce Hunt)(b) In modern medicine, leeches are used in reconstructive surgery to provide a vacuum effect that helps stimulate blood circulation.

Managing Information Systems within Jobcentre Plus Essay

Managing Information Systems within Jobcentre Plus - Essay Example Britain hypermarket net Tesco is one of such leaders. This company sails one third of all foodstuffs in the country. Tesco can firmly be named as a "national shop". Rich, average and poor customers can find the goods according their wishes and financial abilities. In the beginning of 1990th Tesco took up the small category of retail market for lower-income customers. More expensive line for well-off customers was concerned with J. Sainsbury and Waitrose. Comfortable location, competitive prices, polite staff, great variety of goods and products, mainly, circumspect development strategy helped Tesco to become a really national shop. It has happened neither due to only British goods are sold nor due to the state authorities discrimination of American "Wal Mart" or French "Carrefour. National brand buildup took place thanks to Tesco owners and managers, who understood British customers wishes, whims and the mechanism of decision making. It became possible after using Management Information System (MIS). Tesco set close cooperation with University College London. The scientists offered new methods of gathering, checking, collating, review, storage, access, retrieval and update of statistics information of retail sells. Fed every second by Tesco's 12 million Clubcard holders, the Crucible database could in theory generate about 12 billion pieces of data a year if each cardholder bought just 20 items a week. This information is analyzed very attentively. MIS helps managers to understand what goods are sold better together, to place them accordingly on the counters in supermarkets. Experts, who carry out such analysis for Tesco, insist that the company has one of the biggest customer databases in the world. At first, hypermarket provides constant (season, holiday, single) discounts for that goods and stuffs, which customer buys oftener then others. At the end of a quarter each Clubcard holder gets voucher, equivalent to sum total, he spent in Tesco hypermarkets. Additionally they are rewarded with coupons, which allow discounts to that goods, the customers can enjoy (according to MIS results). Surely, this generated information is based on purchase data analysis. Management Information System (relevant module) defines the consumer goods basket, which can be potentially interested to a customer. During the quarter Tesco sells about 6 million letters with propositions of different discounts to loyal clients. Also Tesco MIS provides detailed sells information, which allows placing the goods on the counters according to consumers' tastes in each particular region or even in dependence of daytime. In the morning customers buy one stuffs, in the evening - another. Tesco shops in the center of London differ greatly from the little out-of-the-way ones. Other MIS module takes into account ethnic and demographic factors, fashion and even the contents of TV programs. Can you imagine customer joy and

Key concepts in science -see tasks attached Essay

Key concepts in science -see tasks attached - Essay Example Therefore, there was a need to have standard units of measurement to be used conventionally, especially that the world is becoming global. In a global village there is need of communication across-cultures for ease of communication in commerce and science, the driving engines of globalization. This means that there was need to harmonize units of measurement to enable coordination between the different disciplines in the world (Barry 797). This metric system is useful in several ways. It gives a standardized way of making measurements (using standardized units of measurement globally). It bring together various organization on the international scene to forge a common definitions for SI and set rules that govern writing and presentation of measurement in a universally accepted standard way. As already mentioned this development eases coordination between the several disciplines especially in commerce and science. Other advantages of the SI units include: global adoption (they have been adopted globally) and provides a universal framework for developments and research in measurements. In this system a power tong assembly in which a safety latch mechanism consists of a power portion equipped with two side connections of outlet, one that is linked to a control portion for controlling the cross section opening of the side connection of the tank. The power portion has a control element within the kind of a piston-shaped body value with equal magnitude surfaces on both subject end faces to the working medium pressure and with an opening running in the valve body movement direction. This opening has a conical expansion of its end of inlet flow. This blocks the direct link of the supply with tank return. Pressure and force interaction can be observed in the description of this system. In one type of control a lever valve within the unit is put

Electro Mcnichael Assignment Example | Topics and Well Written Essays - 1750 words - 4

Electro Mcnichael - Assignment Example The main electrical systems supplied by the emergency power supply include navigation and communication equipment, emergency lighting, the fire and sprinkler pumps, the water tight doors and lifts, the steer gear and bilge pump. The system is automatically connected to the emergency switchboard and is automatically started if the main power source goes off. The system is always located higher up and outside the engine room spaces. This insulates them from any damage and / or fire to the engine room. Batteries in ships are backup source of power as an emergency system or form part of the standby power system installed to protect property and life from the various consequences of loss of primary power supply. They are an excellent source and store for electrical power since they are used as instant supply source of available energy. They are also used to provide low voltage direct current supply on regular basis to various machines on the deck and engine. Generally, there are two types of batteries used onboard a ship; the lead acid batteries and the alkaline batteries. The Lead – Acid batteries also known accumulators consist of six separate cells in a series and each cell contains a lead peroxide plate as the positive terminal and a lead plate as the negative terminal which are both immersed in dilute sulphuric acid, the two plates are known as electrodes and the sulphuric acid is known as the electrolyte. This whole arrangement is kept in a leak proof casing. The two plates are joined by a wire and this develops a potential across this wire which eventually ensures current starts flowing through it. These batteries develop a total output of 12 volts since each cell in the series has a potential of producing 2 volts. The Lead Acid accumulators used currently has many plates which are interleaved in one cell. For proper insulation the whole arrangement

Management Finance Essay Example | Topics and Well Written Essays - 2250 words

Management Finance - Essay Example In the following parts of this paper, first features of ABC have been provided in which entire ABC process has been included. Subsequently, comparison relating to selling price and selling volume with absorption costing has been included. After this step, budgeting and planning, budgeting and control, budgeting and performance evaluation and budgeting and motivation parts have been given before the conclusion. Activity-Based Costing (ABC) refers to as â€Å"It is a technique which involves identification of cost with each cost-driving activity and making it the basis for apportionment/assignment of costs over different cost objects/jobs/products/customers/services† (Pandikumar, 2009, p. 414). The analysis of this definition further highlights that ABC is mainly based on three fundamental activities: cost identification, activities and apportionment basis. Fundamentally, ABC is based on a sequence of activities in which costing process is carried out. In the first step, the process of identifying the activities is carried out in which organizational activities are properly pointed out; in the second step, computation of the cost of each activity is conducted; in the last step, the process of identifying the activity cost driver takes place which concludes the entire sequence of ABC (Ryan, 2014). And the typical examples of cost activities are schedule production jobs, machine set up costs, number of orders and number of batches (Ryan, 2014). In addition, cost pool and cost activities are two different activities. In the cost pool, total attached costs are combined and the combined costs are further allocated to cost activities. However, before allocating costs to cost activities, identification of drivers is of paramount importance. In the Berry Ltd, the company has budgeted machine set up costs $280,000, material ordering costs ($316,000), machine running

Literature review Research Paper Example | Topics and Well Written Essays - 3000 words

Literature review - Research Paper Example Studies where there was no MRSA screening were also excluded because these studies did not offer the information needed to address the major goal of this review. In addition, studies where MRSA infection was not confirmed by microbiologic techniques were excluded because this review was designed to study only patients that were confirmed to carry the infection after both screening and microbiologic techniques. Based on the findings from the cases in the literature, the broad problem was that too many patients are transmitting Methicillin resistant Staph aureus in ICU. Specifically, the literature aimed to provide evidence for the question, â€Å"Would the high transmission rate decrease if screening in adult patients was conducted upon admittance to the ICU unit as opposed to not screening?† This problem is important to pursue because it affected patient outcomes including the length of stay and complications from other illnesses. This problem also had a potential impact on th e quality of treatment due to overcrowding and understaffing. The costs were also affected since the hospital was forced to use more money for testing, medicine, and housing patients. Finally, the access to needed medications was limited, and ordering caused further delays. For the purposes of this study, the patients in each case study were limited to adults who were admitted to the ICU section. Children were not included in any of the studies regarding MRSA, and patients in other sections of the facility were also excluded. The following review placed eleven case studies into discussion, focusing on the interventions, comparisons, and outcomes of the studies. Each study included a report on the interventions used for that study, with interesting results from each case study. Clancy, Grepler, Wilson, Douglas, Johnson, and Price (2006), used swab samples which were obtained upon admission to ICUs and weekly thereafter patients who tested positive from nasal or clinical specimens wer e placed in contact isolation, even after readmission DNA fragments were analyzed for similarity of banding PFGE patterns. Dalla Valle, Pasca, De Vitis, Marzani, Emmi, and Marone (2009), also gathered swab samples, although they obtained the samples upon admission and twice-weekly thereafter. Patients who screened positive received isolation and/or antibiotic or colonization therapy. Honda, Krauss, Coopersmith, Kollef, Richmond, Fraser, and Warren (2010), conducted nasal screening, and had the patients who screened positive had contact precautions implemented with no antibiotic or colonization therapy. Clancy and Dalla Valle would have probably described Honda’s practice as irresponsible since antibiotics were not administered and patients were not relocated to a secluded area. This made the study ineffective, because there was no way to prevent the spread of MRSA between patients in the ICU. Other case studies that used the swab method included Lucet, Paoletti, Lolom, Paugam -Burtz, Trouillet, Timsit, Deblangy, Andremont, and Regnier (2005) used nasal swabs to obtain within 24 hours at admission and weekly thereafter. Although once a week was a consistent testing window, the case study probably would have generated far stronger results if testing had been conducted at lease twice a week. Contact precautions were implemented in MRSA positive patients. Another method used to determine MRSA was the standard culture method. Cunningham, Jenks, Northwood,

Management Finance Essay Example | Topics and Well Written Essays - 2250 words

Management Finance - Essay Example In the following parts of this paper, first features of ABC have been provided in which entire ABC process has been included. Subsequently, comparison relating to selling price and selling volume with absorption costing has been included. After this step, budgeting and planning, budgeting and control, budgeting and performance evaluation and budgeting and motivation parts have been given before the conclusion. Activity-Based Costing (ABC) refers to as â€Å"It is a technique which involves identification of cost with each cost-driving activity and making it the basis for apportionment/assignment of costs over different cost objects/jobs/products/customers/services† (Pandikumar, 2009, p. 414). The analysis of this definition further highlights that ABC is mainly based on three fundamental activities: cost identification, activities and apportionment basis. Fundamentally, ABC is based on a sequence of activities in which costing process is carried out. In the first step, the process of identifying the activities is carried out in which organizational activities are properly pointed out; in the second step, computation of the cost of each activity is conducted; in the last step, the process of identifying the activity cost driver takes place which concludes the entire sequence of ABC (Ryan, 2014). And the typical examples of cost activities are schedule production jobs, machine set up costs, number of orders and number of batches (Ryan, 2014). In addition, cost pool and cost activities are two different activities. In the cost pool, total attached costs are combined and the combined costs are further allocated to cost activities. However, before allocating costs to cost activities, identification of drivers is of paramount importance. In the Berry Ltd, the company has budgeted machine set up costs $280,000, material ordering costs ($316,000), machine running

LOVE Probation or Parole Policy Evaluation Research Paper

LOVE Probation or Parole Policy Evaluation - Research Paper Example The paper outlines the reason why a person should fund this review and its importance for policy makers. There is also a budget for the review and conclutory statements. In criminal justice, parole is the supervision that occurs when the government authorizes release of criminals to the community after serving a certain period of prison term (Eseinberg, 1999). Their release has certain conditions. In immigration law, parole refers to granting of visa to a person who does not meet the requirements to enter United States of America. The government gives the visa basing on humanitarian grounds (Purves, 1992). The policy for review is the humanitarian parole policy. This policy allows entry into the United States of America to a person who is ineligible to get US visa. The purpose behind humanitarian parole policy is to provide humanitarian services to an individual on a temporary basis and once the US government confirms the safety of the individual, they can leave the country at the expiry of their visas. The review of humanitarian parole policy is important because it is an extraordinary measure that brings an inadmissible alien into the United States of America for a period of time due to a compelling emergency condition (Wasem, 2010). For instance, On January 18th 2010, the Secretary of homeland security, Janet Napolitano, allowed orphaned children from Haiti passage into United States of America on a temporary and individual basis in order for these vulnerable children to receive the attention and care they could not get in Haiti. This was part of the humanitarian programme and policies of the American government in aiding Haiti. The issues that emerge from this policy include laws governing the humanitarian parole policy, conditions of an alien for obtaining parole under this policy and personal information of the parolee. Additional issues that emerge from this policy are information of the person

Analysing an Inspector Calls by J.B. Priestly Essay Example for Free

Analysing an Inspector Calls by J.B. Priestly Essay In the closing scene of the play the main focus is on Eddie and how badly he wants his name back and he is willing to do anything to get it, even kill if he has to. When Rodolpho comes and kisses Eddies hand, it is showing that Rodolpho is willing to settle for half, which links back to Alfieris prologue, this demonstrates the fact that Rodolpho knows he has been caught and that Marco will have to go back to Italy but he doesnt mind as long as he can be friends with the uncle of his bride. Rodolpho, by coming to apologise s really trying to protect Marco because he knows what he is going to do, as later on he says Eddie, please, he has children! You will kill a family! we know then that this is leading up to the climax of the play and then the resolution. First of all Eddie only wants is him to come here and apologise to him but later on when Rodolpho does come to apologise his demands change and he now wants his name back because Marco publicly shamed him when he shouted I accuse that one he also said he killed my children! That one stole the food from my children! because Marco will now no longer be able to work in America, he will not be able to earn money to send back to Italy to feed his children. After he shouted this out in the neighbourhood and everyone knows that Eddie Carbone snitched he only wants his name and reputation back. When Marco appears (his eyes are murderous and he cracks his knuckles)we are given an indication here that Eddie is going to do something to Marco, although he tries to stay positive by saying maybe he come to apologise to me. After this we are brought to the climax of the play Eddie (lunges for Marco) and Marco instantaneously strikes Eddie in return. As the inevitable happens and the knife is plunged into Eddie by Marco and the crowd rush in to separate them Marco has delivered his own justice upon Eddie but with a knife and not using the law like Alfieri suggested he do. This is the climax of the play and has terrible consequences for both of the characters as there search for justice ends simultaneously, because Eddie is dead so can no longer have justice and Marco has killed Eddie so has carried out his own justice. In Alfieris epilogue he again raises the fact that most of the time now we settle for half but this is not something which Marco was willing to do, he wanted justice and there was nothing that was going to stop him. Conclusively, miller communicates strong themes of law and justice in the play. Each character has their own views on what is right and what is wrong. The differences between the Sicilian society and the American society also play a large part. This is shown when Marco says that Eddie would be dead by now if he was in Italy because he had snitched on the two brothers. This is probably why Marco wanted to deliver his own justice because thats what he would do in his own country. Also Eddie hadnt actually done anything wrong in the eyes of the law, in fact it was commendable by the law because he reported illegal immigrants, and it was the fact that he betrayed relatives that needed justifying.

Treatment of Ankle Syndesmosis Injuries

Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. 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 â€Å"high ankle sprain†with 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 importa nt 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 t o full dorsiflexion. 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 â€Å"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 cha llenge. These injuries are sometime referred as â€Å"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 â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"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 mortise 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 than 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, the fol low-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 reporte d 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. 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 syn desmosis 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. 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. â€Å"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 â€Å"external rotation stress test† and â€Å"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 fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"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 (AOFA S) scoring system (78) and a patient reported Foot and Ankle 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 th e quality of the scans and the axial images thus 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 â€Å"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 A P radiographs and > 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 â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS 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 â€Å"tibiofibular clear space† is defined a Treatment of Ankle Syndesmosis Injuries Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. 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 â€Å"high ankle sprain†with 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 importa nt 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 t o full dorsiflexion. 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 â€Å"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 cha llenge. These injuries are sometime referred as â€Å"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 â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"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 mortise 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 than 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, the fol low-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 reporte d 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. 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 syn desmosis 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. 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. â€Å"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 â€Å"external rotation stress test† and â€Å"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 fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"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 (AOFA S) scoring system (78) and a patient reported Foot and Ankle 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 th e quality of the scans and the axial images thus 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 â€Å"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 A P radiographs and > 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 â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS 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 â€Å"tibiofibular clear space† is defined a