Shakespeare’s Richard II Essay: Search for Identity in Richard II

Search for Identity in Richard II Â   Shakespeare's Richard II tells the story of Richard's fall from power. Being dethroned by Bolingbroke forces Richard to confront the limitations and nature of his power as king. As audience members, we follow Richard on his journey of self-discovery, which enlightens him even as his life is shattered by Bolingbroke's revolt. Paradoxically, it is in utter defeat that Richard comes closest to understanding what it is to be human. Unfortunately he is unable to accept life as an ordinary subject after having tasted what it means to rule. For God's sake, let us sit upon the ground, And tell sad stories of the death of kings- How some have been deposed, some slain in war, Some haunted by the ghosts they have deposed, Some poisoned by their wives, some sleeping killed, All murdered. For within the hollow crown That rounds the mortal temples of a king Keeps Death his court; and there the antic sits, Scoffing his state and grinning at his pomp, Allowing him a little breath, a little scene, To monarchize, be feared, and kill with looks, Infusing him with self and vain conceit, As if this flesh which walls about our life Were brass impregnable; and humored thus, Comes at the last, and with a little pin Bores through his castle wall; and farewell, king. Cover your heads, and mock not flesh and blood With solemn reverence. Through away respect, Tradition, form, and ceremonious duty, For you have but mistook me all this while. I live with bread, like you; feel want, Taste grief, need friends. Subjected thus, How can you say to me I am a king? (III.ii. 151-1173) Â   The above speech expresses nicely Rich... ...n is, With nothing shall be pleased till he be eased With being nothing. (V.v.38-41) Richard can never bring himself to be "eased" with being ordinary, with being what he sees as "nothing" and so he can never live as a subject instead of a ruler. It is perhaps significant that when he dies he seeks to return to the only identity he really knew, that of a ruler, and warns that "Exeter, thy fierce hand / Hath with the King's blood stained the King's own land" (V.v. 109-10). He has accepted intellectually the transient nature of kings' power and understands he can no longer possess even that, yet in death he reaches for the only identity he ever really held, that of absolute monarch. Works Cited: Shakespeare, William. The Tragedy of King Richard The Second. William Shakespeare: The Complete Works. Ed. Alfred Harbage. Baltimore: Penguin Books, 1969.

K-19 Disaster

Leadership is the process in which an individual influences the group of individuals to attain a common goal. Good leadership ensures that the goal is attained by mutual cooperation and cohesive behavior. An effective leader infuses a sense of positivist and efficiently directs others to reach the specified goal.The captain in the movie placed too much emphasis on power. A captain who attempts to control circumstances with power most often becomes authoritarian in his expression which can lead to dissent among subordinates. On the other hand, a captain who communicates effectively and collaborates with all team members is often respected and becomes more successful. In K- 10, the co-captain was an antithesis to the actual captain. The stark contrast between the two men's leadership styles conveyed a message about the relative effectiveness of each one.The crew embers were more loyal to the co-captain because he worked as a team to reach a goal Instead of ordering his subordinates ar ound. When disaster struck the crew was more apt to follow orders from the authority figure who worked with them as a team because they trusted him to care for their well-being. The only way to efficiently govern a large number of people is to instill a sense of trust. Those who abuse their power will not be trusted and thus will not become effective leaders. During war time people tend to experience and strong sense of nationalism.A citizen of Russia n the movie would feel patriotism for his own country starting at a very early age. It's a socio-cultural phenomenon that has been examined for ages. Many social psychologists believe that the patriotism is derived from the innate human desire to belong. Therefore, when Russian begins to experience military tensions during the onset of WWW, many citizens felt the need to defend and protect not only the country's honor, but their own as well. This explains why it was so hard for the captain to abandon the mission that his government had assigned him to.He felt that it was only right to risk his life defending his country and his own reputation, When technology advances rapidly, there is often a discrepancy between the capabilities of technology and the capabilities of the people in charge of said technology. Examples of such discrepancies can be found throughout all time periods. During the industrial revolution, for example, the technology allowed for mass production of goods, but the society of the time did not have regulations in place to successfully prepare workers for the hazardous conditions. As a result many lives were tragically lost.During WWW, Germany was beginning to use planes In the war. However, the first airplane had been flown Just over a decade earlier and the technology was still in its Infancy. Consequently, the average life span of a fighter pilot In WWW was only two weeks. When watching K-19 it is quite easy to understand why such a disaster could occur. The government at the time was despera te to have the cutting-edge technology, but did not have time to properly train those who would be working with the equipment. In today's society our technology Is once again advancing at a 1 OFF startling rate.As social medial becomes more prominent, minors are more expos to the adult world and the dangers that accompany it. We must be careful, as a society, to guard against technology being controlled by those who don't know how to properly utilize it. The movie was a powerful, reality based drama that causes viewers to consider the effects of nuclear power and the dangers of radiation. However, it also has underlying tones that speak to the very nature of humans. Leadership skills, nationalism, and technological innovation continue to be pressing issues in society throughout the ages.

Treatment of ankle syndesmosis injuries - Free Essay Example

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

Multiculturalism of the American Society In The Chinese in All of Us by Richard Rodriguez Free Essay Example, 1750 words

In The Chinese in All of Us , Richard Rodriguez explores Multiculturalism. Rodriguez talks about the effects that multiculturalism of the American society had on his life. Being the son of Spanish speaking Mexican immigrant parents, he narrates the constant encounters he experienced while growing up in America. In defense of all the labeling and accusations he faced as a reaction to his book, which highlighted issues such as bilingual education and affirmative action, he wrote his understanding of the issue of Multiculturalism while maintaining one s own ethnic identity. He further elaborates, that though America is a blend of various cultures and it takes pride in it, it still has its own identity. America has its own individuality, its own culture. Multiculturalism in America and its impact on the American identity is constantly debated, where one side calls it the essence of American society whereas the other side considers it a threat to the American identity. (Rodriguez n. p)A merica is a multicultural society, where different cultures coexist alongside each other. Multiculturalism started as a movement at the end of the 19th century in the United States and Europe. We will write a custom essay sample on Multiculturalism of the American Society In The Chinese in All of Us by Richard Rodriguez or any topic specifically for you Only $17.96 $11.86/pageorder now The mass immigration of southern and eastern Europeans and Latin Americans were the driving forces behind it. The genesis of multiculturalism was the concept of cultural pluralism. The different features of different cultures often combine and incorporate. In this way, a cultural blend is formed which creates an environment of tolerance and respect for each other. In a multicultural society, individuals have the freedom to practice their own religion, follow their own dressing code, to eat what they want and participate in cultural practices despite its variance from the mainstream cultural norms. Since the first half of the 19th century, the United States has witnessed a constant mass immigration. These immigrants have played a pivotal role in shaping the cultural landscape of America. The immigrants having their own values, beliefs and attitudes, created their own perception of the adopted home.

Social Exposure And Through Important Life Events

Question 1: Faith inculcation can work in many different ways, but the main two are by social exposure and through important life events. If asked, anyone will say their faith was influenced by either important figures in their life or an event that caused them to look at the world differently. My belief is that there is no one way that someone gains his or her view of faith. It can be influenced by countless conditions in which a single person experiences. Furthermore, when it comes to religion, there are two kinds of people, those who have an overtime transformation of their current faith or a sudden conversion of faith. To begin with, the first type is those who have been accustomed to his or her faith their whole life. For example,†¦show more content†¦Is there a god that will take me in after I die? Does he judge me everyday based on the things I do? This made me rethink my life and why I believe what I do. For others, it may be an event that causes them to become clos er to the god they already believe in. An example is getting married or having a child. These events allow people to praise the god they worship and give thanks for doing something amazing in your life. Augustine (1997) states that, â€Å"My faith, Lord, shall call on Thee, which Thou hast given me, wherewith Thou hast inspired me, through the Incarnation of Thy Son, through the ministry of the Preacher.† This quote shows that the faith in which Augustine has is based solely on God having given it to him. Also, in book one, Augustine states, â€Å"but how shall they call on Him in whom they have not believed? Or how shall they believe without a preacher?† Augustine brings up an interesting point about how can a person call upon God when that person has never believed in him or does not have someone to guide them to God. This reinforces the idea that when faced with a life altering experiences, we as humans search for something bigger to believe in. We all want to belie ve there is something after life. Which has caused many people to turn toward having faith when there is nothing else to turn to. Question 2: As Augustine reflects on his childhood in book one, he explains how he believes in original sin because of how he has seen children envy Social Exposure And Through Important Life Events Question 1: Faith inculcation can work in a variety of different ways, but the main two are by social exposure and through important life events. If asked, anyone will say their faith was influenced by either major figures in their life or an event that caused them to look at the world differently. My belief is that there is no one way that someone gains his or her view of faith. It can be influenced by countless conditions in which a single person experiences. Furthermore, when it comes to religion, there are two kinds of people, those who have an overtime transformation of their current faith or a sudden conversion of faith. To begin with, the first type is those who have been accustomed to his or her faith their whole life. For†¦show more content†¦Is there a god that will take me in after I die? Does he judge me everyday based on my actions? This event forced me to think more critically about the faith that I wanted to be associated with. For others, it may be an event that causes them to become closer to the god they already believe in. An example is getting married or having a child. These events allow people to praise the god they worship and give thanks for doing something amazing in their life. Augustine (1997) states that, â€Å"My faith, Lord, shall call on Thee, which Thou hast given me, wherewith Thou hast inspired me, through the Incarnation of Thy Son, through the ministry of the Preacher.† This quote shows that the faith in which Augustine has is based solely on God having given it to him. Also, in book one, Augustine states, â€Å"but how shall they call on Him in whom they have not believed? Or how shall they believe without a preacher?† Augustine brings up an interesting point about how can a person call upon God when that person has never believed in him or does not have someone to guide them to God. This reinforces the idea that when faced with a life altering experiences, we as humans search for something bigger to believe in. We all want to believe there is something after life. Which has caused people to turn toward having faith when there is nothing else to turn to. Question 2: As Augustine reflects on his childhood in book one, he explains how he believes in original sin because of how

The Open Boat by Stephen Crane free essay sample

The Open Boat by Stephen Crane Stephen Crane’s Open Boat is based on his own experience when he was shipwrecked off the coast of Florida. The story is famous for its philosophical theme of existentialism, powerfully evoked in the line† If I am going to drowned (repeated thrice), why in the name of the seven mad gods, who rule the sea, was I allowed to come thus far and contemplate sand and trees? † (Crane). This opens up an existential view of man’s place in the universe. Man is utterly insignificant and nature, with all its power, has no care for its individual existence. The line was therefore fitting for Billie, the oiler, who did not make it shore. From an existential point of view, one could argue that Billie was not claimed by death; rather he was not worthy to live. Seeing the fine line between death and existence, the survivors had gained an extraordinary experience that could only be brought out by such tragedy—where their life could hang in the balance. Thus, they could be interpreters of existence and it’s opposite. They have conquered death and they have proved to that all powerful nature that they deserve life, which Billie wasn’t able to. As it happens, the existentialist view comes from the survivors’ examination of their condition while lost at sea. The correspondent—the fictional equivalent of Crane—tries desperately to justify their survive and understand the wrath of nature against them. But his ability to comprehend it all was utterly inadequate. It only seems to him that nature does not care. Nature, or the seven mad gods, as he called it, is indifferent to all the courage, brotherhood and valor that the survivors have shown. They receive no complement or reward to such defiance to survive. Their prayers fall into dead ears and God, it seemed, does not care. It was at this point that Crane found it appropriate to use the word absurd to summarize their misfortune. The sinking of their boat, their life clinging to a small dingy boat, this quest to find shore are all affairs that are absurd. Immediately, Crane echoes the existentialist anthem. There is no meaning to the story. No heroes, just survivors played around by nature and have become the victims of the sea. But at that desperation, man can draw his own analogy—and yes, his own reality—which is again another existentialist theme. Shut away from an uncaring cosmos, the men of the sea form a brotherhood and the correspondent—the narrator of the story—constructs his own meaning to it. Thus, when constructing meaning within a universe that regards them as insignificant, the correspondent tries to attach human qualities to things. For instance, the narrator refers to nature as a woman calling it â€Å"she†. To him, nature is an old mistress, often inscrutable, who operates beyond anyone’s understanding. By the end of the story, the cook, the captain and the correspondent have given up understanding and conversing with nature. The irony here is delivered in the final sentence wherein the narrator believes that the three men can be the interpreter’s of the ocean’s voice. Yet their understanding of the sea simply refers to its voice as an endless incoherent rumbling voice that portrays the universe in a cosmic void. At the end of it, there is nothing to interpret. It is up to man himself to interpret his own things. What is notable in this story is how the survivors reached that conclusion, as they go through the proper human response to the acts of nature. They go through as series of progression that lead them to believe that nature is all powerful and all disenchanted. At first, the men are angry to the fact that they could not do anything to sway nature. Moreover, they are disturbed by the fact that nature could kill them if she wishes. At this venture, they realize that nature does not regard them with value. The universe will not be maimed by their death and could dispose of their lives in the course of the movements of the sea. They could not even throw bricks at a temple to vent their rage toward God. But soon the men realize they could not do anything to change nature, so they decided to follow a different route of thinking. Their progress then pins their hopes to worshipping nature. The men decided that they should find something that represents nature and bow down to it as a sign of respect. They start to plead to nature that they be spared from death. Regardless, the men realized that neither anger or their grovelling could sway nature into leading them to their deaths. This is where they realized that nature is indifferent to their pleas and prayers. They became existentialist who start to think that existence is ultimately freedom. You are thrown into existence and be left on your own. They cannot influence the strength of nature. The only hope they have, within their rationalizations, is to respond to the wrath of nature and endure its power. Consequently, the survivors decided to form a brotherhood as a way to compensate their growing fear of death. The brotherhood gives them strength and comfort and it helps them tolerate the might of nature. The four men turn out to become friends, â€Å"friends in a more curiously iron-bound degree than may be common† (Crane). It is through their friendship that had prevented them from falling into complete despair. For example, when the correspondent serves as a watchman at night, he sees a shark and wishes that one of his companions would wake up and keep him in company. Of course, two persons awake would not have driven off the shark, but their togetherness kept them strong and their hopelessness would be kept at bay—thus keeping things less ominous. The shark sighting is a representation of nature itself who threatens the existence man. The correspondent’s fear of the shark’s presence is the same throughout the story; that nature is constantly threatening them to cease from existence. But the brotherhood provided comfort and prevented the feeling of helplessness. The most vicious of the survivors’ despair is their fear of drowning. They recite this fear at three different times â€Å"If I am going to be drowned,† they all remark (Crane). They recite this before and during the long uncertain nights. At this point, the men know that they are under the mercy of nature and its all consuming power. However, with this desperation comes the understanding that it is them versus nature; them versus all the elements that is pitted against them. This unique situation and the strength that they have gathered from their brotherhood made them numb at the concept of death. Later on, the men overcome their fear of drowning and hence, death itself. When the men jumped out of the boat, the correspondent knew that he and the others were no longer afraid. They have completely submitted to their fate, wherever it takes them. In the face of mortal peril swam toward the shore and unafraid of anything else, regardless of the fact that they could die easily. It is just the plain fact that the situation was out of their control. It is for this reason why it did not surprise the correspondent, the captain and the cook that the oiler, Billie, had died. The oiler was commended in the story as the strongest among the four, yet this further proves their realization that they have no power over nature, despite their strengths, courage, prayers—you name it. But it is this understanding that the men become existentialists-in-action that they throw themselves toward existence without trepidation. The lesson here, if there be a lesson, was that those that do not throw themselves into existence, those that continue to believe that nature cares for your life, would faced a more dangerous peril because of the blind faith they have on it. The oiler swam fast and strong ahead of the others, while the three maintained their comradeship. The captain helped the cook and the correspondent reach shore; while the oiler does not continue the brotherhood and depends on his strength to challenge nature. In the end, with the oiler’s death, the men showed no sadness over his loss. They have, at this point, no longer the slaves of death’s threats. Their existence was all up to them. Not by God or anyone. This is why they were allowed to come thus far and contemplate sand and trees. Work Cited Crane, Stephen. â€Å"The Open Boat: A Tale intended to be after the Fact. † Edgar Roberts. â€Å"Literature-an introduction to reading and writing. † 9ed

The United States Housing Bubble

The housing bubble of 2000s remains one of the greatest economic challenges ever faced by the US. The housing bubble defines an economic bubble in which there was a remarked increase in housing prices in the United States.Advertising We will write a custom essay sample on The United States’ Housing Bubble specifically for you for only $16.05 $11/page Learn More The price escalation was fueled by increased demand and speculation. Increase in demand for houses against the limited supply in the housing market marked an onset of the housing bubble. With such a situation, speculators got into the housing market with a view to making profits through buying and selling of houses in the short-term. The entry of such speculators increased the demand further. With time, the demand decreased while the supply increased. This led to a significant drop in housing prices leading to the bursting of the bubble. The bursting of the housing bubble led to serious eco nomic repercussions on the economic front (Roberts, 57). The housing bubble can largely be attributed to financial activities and monetary policies. The housing prices in the United States escalated due to increased demand and reached an all time high in early 2006. From 2007, the prices started to decline tremendously. In particular, the Case Shriller Home Price Index, in 2008, recorded the biggest price drop in its history. The bursting of the bubble had much effect on the home valuations, mortgage markets and real property markets. While a lot of factors contributed to the housing bubble, financial activities and monetary policies played crucial roles in causing the bubble (Trass, 42). Traditionally, the Glass-Steagall Act played an imperative role in regulation of the financial sector. This act strictly regulated the lending activities of the commercial banks. It limited the banks’ lending activities and interest loans. However, from 1980s, significant changes occurred in the banking sector that set the stage for housing bubble. The banks were deregulated through several Acts. Most notable Acts are the Gramm-Leach-Bliley Act of 1999 and the Garn-ST. Germain Depository Institutions Act of 1982, which permitted banks to set any interest rate on their loans. These Acts also allowed for adjustable rate mortgages in the economy. In addition, these Acts allowed developers easy access to credit. The availability of credit increased people’s demand for houses. Similarly, the power of the developers to erect more houses to meet the heightened demand increased. This contributed to the housing bubble crisis. The deregulation brought about by the financial Acts enabled the banks to present risky products to the people. By enabling the banks to adjust their lending rates and interest rates, it was easy for the house bubble to set in. the security markets were equally to blame for the housing bubble.Advertising Looking for essay on business economics ? Let's see if we can help you! Get your first paper with 15% OFF Learn More The Federal Reserve rapidly lowered the loan interest rates in response to the precedent dotcom bubble. The historically low interest rates made credit access much easier than before. The lowering of interest rates increased supply that served to cause a further drop in prices of houses in most states. The intense competition between the mortgage lenders pushed them to loosen their lending conditions. Subprime lending intensified due to the easy credit access conditions. Prior to 2003, subprime mortgage lending remained below 10%. However, this doubled to 20% by 2006 during the peak of the bubble. This led to an increase in demand for houses causing an increase in prices of houses, hence the onset of the bubble. The effects of the United States housing bubble on various aspects of the economy cannot be understated. The sharp drop in housing prices increased the rate of loan defaulting significantly . This was down to the increased subprime lending. The fall in housing prices made it difficult for subprime lenders to refinance their loans. Prior to the bubble, there was a massive inflow of foreign capital into the US economy from other world economies. This foreign money inflow plus the low interest conditions, increased credit availability and access in the United States. The decline in housing prices plunged global financial institutions into crises as they witnessed heavy losses. This affected virtually all aspects of global trade for established economies (Trass, 71). The lending potential of financial institutions declined and the governments engaged in extra financial commitments in their bid to bail out the fundamental institutions. This has limited the money available for investment in opportunities globally. In addition, the volume of global trade will decline tremendously since the industrialized countries will tend to reduce their demand for imports from other econom ies. The business cycle has not been spared either of the eminent effects of the housing bubble. The housing bubble led to a slowdown in the economy. With the United States constituting nearly one third of the world’s GDP, the world’s business cycle will undoubtedly be affected. The housing bubble has profoundly affected the country’s demand for exports from other countries thereby affecting the world business cycle (Cline, 112). The economic slowdown due to the housing bubble, also impacts on the workers’ wages. Workers’ wages are much likely to stagnate for long periods especially during this recovery period.Advertising We will write a custom essay sample on The United States’ Housing Bubble specifically for you for only $16.05 $11/page Learn More The housing bubble did not only affect the US economy but it had unpleasant effects on economies afar, as well. The distant places such as California, Wall Street an d Europe were all connected through the cash inflows. With the increasing prices, investors from varied ends were investing in the US housing markets from Europe and even the fast growing Asian economies. Works Cited Cline, William. Financial Globalization, Economic Growth, and the Crisis of 2007. New York: Peterson Institute, 2010. Print. Roberts, Lawrence. The Great Housing Bubble. California: Monterey Cypress LLC, 2008. Print. Trass, Kieran. The Housing Bubble: The Real Estate Cycle- Why You Can Grow Rich in Slumps as Well as Booms. Auckland: Penguin Group, 2009. Print. This essay on The United States’ Housing Bubble was written and submitted by user Jair H. to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.