Christianity and Islam: Beyond the Looking Glass Essay

Christianity and Islam are two of the world’s major religions that are often perceived as largely distinct in doctrines and practices. These two, are being regarded to have contradictory principles. But is the disparity of their beliefs truly that big? To have a deeper understanding of both religions, it would be best to consider their followers in the picture. Sad to say, some people equate the Muslims with terrorists. I have personally talked to friends who are afraid to ride a plane with Muslim co-passengers in it. Are these purely misconceptions because we have already established certain schema against the Muslims? Or are there truths in it on which such beliefs originated? If we are to read Suras 2:190-193, 2:216, 4:76, 5:32-36, 7:96-99, 8:12-14, 8:59, 8:65, 9:5, 9:14, 9:23-29, 9:38-41, 9:123, 47:4, 47:35, 61:4 and 66:9, many passages in the Quran exhort Muslims to kill infidels (non-Muslims), wherever they find them (Faithfacts, 2004). Some Arabic terms are only even softened sometimes by English translators who use â€Å"fight† instead of â€Å"kill†. In fact, Osama bin Laden was quoted as saying â€Å"I was ordered to fight the people until they say there is no god but Allah, and his prophet is Muhammad† in the famous videotape discovered in Afghanistan in the late 2001 (cited in â€Å"Fundamentalism, 2004). These words echo the language in the Quran itself and such calls to violence are not merely distortions of the Quran by extreme radicals who try to twist it for their violent ends because violence is an integral part of Islam. Even Muhammad himself laid the foundation for violence as seen in his deeds and commands, which are traceable in the hadiths. Furthermore, 11 percent of the pages of the Bukhari Hadiths mention the Holy War (jihad), which is a means to use violence in order to spread faith. However, it must be realized as well that violence is not unique to Islam for even the Bible has its share of violence, particularly in the Old Testament. In fact God instructs the Israelites coming out of Egypt to take over the land Christianity and Islam 2 of Canaan and kill all the inhabitants. There is a difference though between this and the Quranic violence because the Bible makes it clear that the Canaanite society deserved it as it was completely polluted by their wretchedly evil practices, including the horrible practice of child sacrifice as found in Deuteronomy 9:1-6, 12:29-31, 18:9-14, 1 Kings 14:24, Chronicles 33: 1-9, Ezra 9:11 (Faithfacts, 2004). Cases like these are particularly limited for a particular purpose established by God unlike the Quran, where we encounter general commands to kill and destroy the enemies of Islam that are applicable for all times, places and groups. Even then the fact remains that none of these religions are spared from committing violence, which proves that their disparity is not that big at all (cited in â€Å"Fundamentalism†, 2004). Another thing to consider is the difference in the practices and teachings of the subject religions’ prophets – Jesus of Christianity and Muhammad of Islam. If the latter has led at least 27 bloody invasions, assassinated many of his opponents during his lifetime and executed hundreds of captured men in his battle against the Quraiza Jews, Jesus’ teachings have remained consistent in maintaining its tone of peace, service, love and humility as found in the biblical passages that could be cited in Mathew 5:1-12, 5:43-44, 9:36, 19:30, 26:50-52, Mark 9:35, Luke 6:27-36, 9:54-55, 10:30-37, 22: 49-51, 23:32-34, John 10:7-18, 13:1-17, Galatians 5:22-23, Philippians 2:6-8, 1 Thessalonian 5:15, and 1 Peter 3:8-9 (The New Testament, 2008). There is nothing like the Christian concept of â€Å"love your enemies† or â€Å"turn your other cheek† (Luke 6:27-37) that can be found in Islam. While Christianity teaches its believers to love their neighbors as themselves (Matthew 19:19), the Quran instructs its followers not to even take Christians or Jews as friends (Suras 3:118, 5:51, 60:1-3). Jesus was even aware of this when he warned, â€Å"the time is coming when anyone who kills you will think he is offering a service to God† as cited in John 16:2-4 (The New Testament, 2008). Another notable point is the difference in both religions’ concept of charity. their followers to give alms to the poor but unlike the biblical concept where charity is not limited to any group (cited in â€Å"Luke† 10:30-37), the Muslims are taught to give alms to the Muslim poor only (cited in â€Å"Islam†, 2008). The two religions also have differences in their concept of justice and forgiveness. In the teachings of the New Testament as cited in Matthew 6:12, 14-15, the act of forgiveness is being given exceptional emphasis, â€Å"For if ye forgive men their trespasses, your heavenly father will also forgive you, but if ye forgive not men their trespasses, neither will your Father forgive your trespasses†. In the teachings of Islam as cited in Sura 5:38 â€Å"As for the man who steals and the woman who steals, cut of their hands as a punishment for what they have earned, an exemplary punishment from Allah; and Allah is Mighty, Wise†. Muslims do this even to their children if they steal out of hunger. They would not show compassion and feed the child but would instead sever their hands and wrists to drive home the lessons of Allah. Likewise, in the Old Testament as cited in Leviticus 19:11, â€Å"Ye shall not steal, neither deal falsely, neither lie to one another. If we analyze the above teachings, it is evident that both religions consider stealing as evil however, the Christians are more compassionate and subtle in dealing with it since the teachings of Jesus’ wants his followers to be forgiving. Another interesting difference is on how the two religions treat women and marriage. In Islam, a man can have up to four wives at the same time (Sura 4:3) and has the right to beat his disobedient wife until she obeys (Sura 4:34, Bukhari 8:68). Even Muhammad himself had thirteen wives, two concubines, and four women of uncertain relationships. (cited in â€Å"Fundamentalism†, 2004). In the teachings of Christianity, Jesus insisted on the sanctity of marriage (Mark 10:5-12), thus, in the Christian’s current practice, a couple has to undergo the process of divorce before they are allowed to remarry legally. Christianity also condones the abuse of women. The Christian teachings consider the fairness of men and women Christianity and Islam 4 (Matthew 5:32, 1 Corinthians 11:11-12, Galatians 3:28, Ephesians 5:25-33) unlike that of Islam, which does not give the wife the right to divorce her husband (Sura 2: 228). Islam even teaches that majority of the people in hell are women (Bukhari 1:28, 1:301, and 2:161). Christianity and Islam also differ in the way they consider the nature of God. While the former teaches that God is a Trinity – one God revealed in three persons or manifestations, Islam denies vehemently the doctrine and even considers it as blasphemy (Suras 4:171, 5:17, 5:72-75). However, it is interesting to note that Islam has a high regard of Jesus. What it denies is his divinity, and that he is the Son of God (Suras 9:30, 10:68, 19:35, 43:81-83). Another difference is that the God of the Bible is holy – perfect in all respects: moral, just, faithful, loving, all-knowing etc. (Hebrews 7:26), while the God of Quran does not always come as holy. He changes his mind, promises and does not offer assurance of salvation (Suras 4:116, 5:18, 9:15). In other words, he is arbitrary (cited in â€Å"Faitfacts†, 2004). Both religions also vary in their concept of salvation and heaven. Christianity teaches us that man cannot earn salvation. We need a savior to save us from sin thus, he sent Jesus, his only begotten son. As it says in the Bible â€Å"All of us have become like one who is unclean, and all our righteous acts are like filthy rags. † (Isaiah 64: 5-7) â€Å"But God demonstrated his love for us in this: while we were still sinners,Christ died for us. † (Romans 5:8). This belief is totally denied by Islam, even Jesus’ crucifixion (Sura 4:157). On the concept of heaven, the Muslim considers the paradise as a carnal and sensual place, where gorgeous palaces are found and wine are abundant. Christians, on the other hand see it as a place of bliss, where pain, and tears will be gone and men, women, and children will be treated equally. In the previous discussions, we have already noted several differences on the two religions, which in some instances also meet each other. However, we must also note that they are not just different. If we are to take a look at the beliefs of Christians and Muslims, we can see Christianity and Islam 5 that they have some commonalities. Both religions agree in some aspects: that there is one God who created the universe and is sovereign in the lives of men; God is the source of justice and morality; that his ultimate justice is dispensed via life after death in heaven and hell, and that things like pornography and unchaste living are pollutants to the society (cited in â€Å"faithfacts†, 2008). In other words, both religions believed in a supreme being, whether God or Allah. There is also an agreement that he is the creator of all things. Their teachings both acknowledge that there is good and evil, where the former is rewarded and the latter is punished. The forms of reward though, and punishment vary in both religions. Both also emphasizes that following the teachings would let the person experience heaven when he dies. It is clear that Christianity and Islam are not that different at all, neither is Islam an evil belief. The latter may have emphasized the role of violence in its teachings, but it still depends on how such is being interpreted and carried out. They might differ in many ways: nature of God; concept of justice; forgiveness and more, but we still could not discount the fact that both are religions with followers that are humans, Christians and Muslims, no matter what doctrines they follow, also need respect. They may not necessarily agree with each other but there is still a point of agreement as exemplified by their similarities. The issue is therefore, not a question of which belief is right a wrong, nor is it about superiority or inferiority. What matters most is that we are guided by our beliefs and in doing this, we do not do actions that would harm the other. References Daniel, Abu Yusuf. , Isma’il Kaka, Abu Maryam. , & Squires Robert, Abu Iman. (n. d). Misconceptions about Islam. Retrieved February 17, 2008, from http://www.geocities.com/window2islam/miscon.html

Pocket Should Be Given to the Teenagers or Not

Yes, they definitely should. Nowadays teenagers are moving to independence and it will help them if they have some practice in managing money. Giving pocket money teaches teenagers to manage money while they are still young and parents can still guide them. Also, it help teenagers to make choices and to see that sometimes people have to wait and save up some money to get what they really want. While searching for the story idea today, I came across an interesting survey on pocket money been given to the teenagers and young adults. For once, it struck me that this unique yet interesting subject has never been covered on this site before. So, let me take a dig at it. The important predicament of pocket money must have certainly flashed your mind either during your childhood or as a parent now. Of course, the dilemma is always much more grave if you are a parent. Parents extensively differ in their perspectives of upbringing children in a system of granting pocket money to take care of their petty expenses. At first, the definite expenses that should be termed as ‘petty’ is pretty much subjective in nature and needs to be well-defined to start with. The second question you need to ask is – what is the extent to which a child be given freedom to spend money which is deemed as pocket money? While lot of parent’s concerns revolves around promoting unhealthy competition amongst children on the amount of money they get and loss of control on a child’s spending habits, there are also some positive lessons for teenagers such as inculcating money management skills and making tough decision regarding spending desires that offer less value to their lifestyle. The â€Å"Current Pocket Money Trends in Urban India† survey by ASSOCHAM has cited that metropolitan children in the 12-20 age group get as much as Rs. 3600 to over Rs. 12000 a month of pocket money to spend on apparels, physical appearance, cell phone and other lifestyle products. Further, the monthly pocket money of teenagers and young adults, in cities like Delhi and Kolkata, have surged whopping 10-fold since 2005. In Ludhiana, 45% of surveyed teenagers get an allowance of Rs. 2000 on weekly basis. While the urban teens spend about 55% of their pocket money on electronic gadgets, almost a quarter of it goes towards watching movies and spending in malls. The remaining 20% of allowance goes towards eating out and food. The surprising factor over here being that with rising cost of living and soaring inflation, the pocket of teenagers has also grown deeper. Rather than controlling the overall family budget, parents have shown generosity in ensuring that their children maintain their prevailing lifestyle and spending habits. While giving pocket money to teens is not so bad a concept, you must also ensure that you allocate the right amount of money towards it which is more suitable to your family budget. At the same time, see to it that the sum granted by you is comparable and realistic to meet the day-to-day requirements of your child’s life. POCKET MONEY Pocket money as the name suggests is money given to children to take care of petty expenses. This amount of money can be given by parents' everyday, every week or every month or even on adhoc basis, as and when the child requires it. As long as the child has the freedom to spend the money, it will be deemed as pocket money. Parents extensively differ in their perspectives of whether or not to give pocket money to children. Some parents believe that pocket money should not be given since * That will make the child feel that ‘parents money is not his/her money', * ‘It could lead to fights between children', * ‘Unhealthy competition amongst children on the amount of pocket money they get' * ‘Loss of control on where children spend the money' However, giving pocket money to children has several advantages: * Children feel a sense of independence and responsibility towards spending the money the right way. They learn & understand the value of money. They also learn to understand that amount of money is limited and they need to always choose between their various desires to ensure correct use of their pocket money. * Children get into the habit of planned income and expenditure. They also learn about saving & budgeting. For eg: if they want to buy a present for their mother's birthday, they will need to put aside some amount of money every month to collect the commensurate amount and buy the gift. Giving pocket money to children also makes them feel an important part of the family since they know that they get a part of the family's monthly income. Some parents even believe in their children earning pocket money. What does that mean? It means that parents can often inculcate values/ beliefs/ actions in their children by rewarding them for it in the form of pocket money. In such cases, pa rents divide the pocket money amount in two parts: * One that is given on a timely basis. * Second that is earned against some house jobs. For eg: every Sunday, you could start giving a fixed sum of money to your son if he helps his father in cleaning the car. Or if your daughter helps around in dusting the house. This will in a way also inculcate the habit of weekly cleanliness in them since childhood. Similarly, if you strongly wish to inculcate the value of ‘ helping others' in your children, you could promise them an extra sum of money during summer vacations if they help your maid's child learn the basics of math. Once parents are clear that they want to give pocket money to their children, they also need to decide when is the good time to start giving the same to their children. Once children start spending sometime away from their parents in going to school, sports classes, tuitions, etc, they need to carry some amount of money on them. This could be a good time to start giving them pocket money. Obviously, in the beginning, the amount of money should be small and should be periodically reviewed as the child grows. For eg: you could decide that every birthday, you will give an increment to your child’s pocket money. Additionally, if your child excels in academics/sports, they could get higher pocket money increments! When parents start giving pocket money to children, they need to explain to them where the money is to be used. For eg: when you first give Rs. 50 to your daughter, you need to explain that this money is to cover her school special lunch, candies/soft drinks requirements for a week. If the child is given money without any direction, you could run the risk of the child using the money is a way that does not agree with you. In such cases, parents need to be very careful in not micro- managing where the child spends the pocket money, else the child will get irritated and will not get the ‘sense of independence’ that parents want to instill in the child. Parents must explain to children that pocket money is to be used over the week/ month and hence children should plan their expenses over the time frame. It must be made clear that in case children use-up their money earlier, they will not be given extra money. Pocket money will be given only on the fixed day as decided. This will help children learn the concept of planned expenditure and savings. Parents must always ensure that they give comparable pocket money to their children. It should neither be too much or too little compared to friends. Giving more pocket money than friends will make your child spend more and consider money as frivolous and easily available. If your child gets less pocket money than his/her friends, it will lead to an inferiority complex and the child might start resenting you. Last, but not the least, parents must be careful not to use pocket money as a way of punishment to their children. Often, parents use ‘suspension of pocket money’ as an easy way of punishing their children. This format of punishment is not wrong to use but must be applied carefully. I. e if the child has a broken a beautiful vase and you want him/ her to understand the value of the same, you can penalize the child by deducting/ taking away the month’s pocket money. But you cannot start using pocket money as a weapon to get the child to abide by all your wishes. For eg; you might want your child to have two glasses of milk everyday which he may not want to; in such cases by incentivizing the child for more pocket money will be wrong to do since such a format of giving money is not pocket money but ‘bribe’. Similarly, pocket money penalty cannot be used as a blanket punishment to all wrong – doings. If the child starts feeling that he/she will never really get pocket money due to some punishment, he/she might be tempted to steal money from parents.

A Persona Of Renaissance Poet Thomas Wyatt

A Persona Of Renaissance Poet Thomas Wyatt Sir Thomas Wyatt, born in 1503 in at Allington Castle, was fated to become one of English literature’s most important Renaissance period poets. Wyatt’s father, Henry Wyatt, was a Lancastrian who followed a similar life as his son in that he was arrested under the reign of Richard III and was released by Henry VII and rewarded with multiple grants and titles. Wyatt’s father was an executor of Henry VII’s will and a Privy councilor in 1509 and continued to server under King Henry VIII and was eventually knighted. During Watt’s childhood, it is said that he was raising a lion cub when one day the cub turned on Wyatt to which Wyatt stabbed his rapier through the lion’s heart. King Henry VII caught wind of this story and commented â€Å"Oh, he will tame lions†. Thomas Wyatt attended St. John’s College in Cambridge which was well known for its humanism. In 1520 Wyatt married the daughter of Lord Cobham, Elizabeth Brooke, and they had a son for whom had the Duke of Norfolk as his standing godfather. These early life experiences, along with those to come in Wyatt’s future, played a key role in the development of the influences on his works as his relationships with others, his, so called, relationships with Anne Boleyn, and his legal difficulties with arrests and imprisonments (Anne Boleyn Files, â€Å"Sir Thomas Wyatt the Elder†). Through Wyatt’s father, his friend Cromwell, and many other famous poets before him Wyatt was influenced and shaped by these relationships. Sir Henry Wyatt, Thomas Wyatt’s father was not a direct influence on the works of his son but was indeed a direct influence on the life of his son which in turn was a key reason for which Wyatt’s life and works went down the path which they did. The most evident of these influences was Henry Wyatt’s influence on his son to pursue a diplomatic career, leading to Thomas Wyatt’s many important position under King Henry VIII much like his father’s. Along with Thomas Wyatt’s similarities to his father in the diplomatic career, the both of them had arrests and imprisonments. These, along with the happenings in the diplomatic environment led to several of Thomas Wyatt’s most famous works as a poet. Cromwell, Wyatt’s most notable friend, performed the apprehension of Thomas Wyatt. Once arrest ed Cromwell helped Wyatt out by talking to the tower guard and making sure that Wyatt was as comfortable as possible during his imprisonment, promising that Wyatt would be out soon. Thomas Wyatt is believed to have mourned the loss of his dear friend in â€Å"The Pillar Perished† which was written following Cromwell’s execution. However, this was not Thomas Wyatt’s only friend. He wrote about several other deaths of close friends such as â€Å"Weston, that pleasant was and young† for whom â€Å"all we should weep that thou [Weston] are dead and gone† (Lean, â€Å"Sir Thomas Wyatt :†). Elizabeth Brooke, Thomas Wyatt’s wife, cause him much grief and pain throughout their marriage and is believed to have been the reason for which Thomas Wyatt translated Petrarch’s sonnets with an angered and frustrated lover as the narrator of the works (Lean, â€Å"Sir Thomas Wyatt :†). Wyatt was not only influenced by friends and family, but also other writers of his time and times before him. Francesco Petrarch, a 14th century esteemed Italian Poet, was translated by Wyatt. These translations were not mere practice performed by Wyatt to improve his skills, but these translations maintained their same style and form under Wyatt’s pen but they also acquired new concepts and ideas which came together to form a uniquely English style of poetry. These translations; however, seemed to have diverted original questions on severely controversial and significant themes like those of political intrigue and courtly betrayal. Even preceding these translations of Petrarch were Wyatt’s translations of Plutarch. Plutarch wrote chronicles based on the lives of Roman and Greek leaders which used extremely engaging details to communicate the deeds of Plutarch’s characters. Wyatt was also an admirer of the works of Chaucer, with whom he had many similarities, but Wyatt wanted the English Literature to be developed into a more respected and elevated form of literature. Lastly is the famous Plato, who which was mentions in Wyatt’s poem â€Å"Farewell Love† as a source of contemplation and solace (Lean, â€Å"Sir Thomas Wyatt :†). Wyatt is acclaimed to have had fallen in love with Anne Boleyn following her arrival to the English courts in 1522. In fact, George Wyatt, who was Thomas Wyatt’s grandson wrote that his grandfather was â€Å"surprised by the sight there of â€Å"(Anne Boleyn Files, â€Å"Sir Thomas Wyatt the Elder†) when Anne Boleyn was first sighted by Wyatt. Three years after Anne Boleyn’s arrival to the courts in 1522 Thomas Wyatt parted from his wife and his unhappy marriage which is believed to have been partly due to his acquaintance with Anne Boleyn. Even though the love match between Anne Boleyn and Wyatt would nearly have been impossible due to the admiration which the King had for Boleyn, she is still indirectly mentioned numerous times in the works of Wyatt. For this reason the love between Boleyn and Wyatt is considered to have been purely ‘one-way’. However, a story in The Chronicle of King Henry VIII depicts Wyatt visiting the home of Anne Boleyn wher e he found her in bed and they had physical relations until interrupted by the sound of the footsteps of her lover. Yet another story told by Wyatt’s grandson, George Wyatt, tells of Wyatt entertaining Boleyn with his poetry while she performed some needle work. Wyatt had seen a hanging jewel around Boleyn’s neck and snatched it as a trophy. Later on when Wyatt was playing bowls with the King the two were arguing over a shot to which Wyatt took out the jewel he had swiped from Boleyn and used it to measure the shot. The King recognized the jewel and stormed off to question Anne Boleyn about it. Multiple works of Wyatt’s were indirectly attributed to Anne Boleyn including â€Å"What Wourde is that that Changeth not†, â€Å"The Lover Confesses Him in Love with Phyllis†, and â€Å"Whoso list to hunt†, which was developed off the story of Caesar’s deer who bore the collar of Caesar (Anne Boleyn Files, â€Å"Sir Thomas Wyatt the Elderâ₠¬ ). Wyatt compares Boleyn to Caesar’s deer with its â€Å"graven with diamonds in letters plain/there is written her fair neck round about:/Noli me tangere, for Caesar’s I am† (Wyatt, â€Å"Thomas Wyatt Poetry†) in which Caesar represent the King with his jewels being worn around the neck of Anne Boleyn. Thomas Cromwell, one of Wyatt’s dear friends, apprehended Wyatt in 1536 by order of the King. This first arrest is believed to have been in conjunction with Anne Boleyn. Cromwell assured Wyatt that he would watch out for him but that he would have to be imprisoned in the tower for the time being. Wyatt said that he was stainless and had no reason to fear. Thomas Wyatt watched from his window in the bell tower the executions of Weston, Bereton, Norris, Smeato, and George Boleyn. These sights from the tower led to one of Wyatt’s most famous poems, â€Å"Innocentia Veritas† (Anne Boleyn Files, â€Å"Sir Thomas Wyatt the Elder†). These sights, as described in Innocentia Veritas, were said that â€Å"The Bell Tower showed me [Wyatt] such sights that in my head stick day and night†. Thomas Wyatt was promptly released from the tower as he had already regained the favor of King Henry VIII (Academy of American Poets, â€Å"Thomas Wyatt). In conclusion, following Thomas Wyatt’s rather eventful childhood with his ‘taming’ of the lion, he attended the humanism esteemed St. John’s College in Cambridge, went on to lead a diplomatic career much like his father, and married having one son. Through Wyatt’s father, Petrarch, Plato, Chaucer, Cromwell, Anne Boleyn, and the multiple arrests of Thomas Wyatt, his woks developed into some of the first reputable English poetry written and showcased his relationships with others including Anne Boleyn and his arrests and visits to the bell tower which showed him inspiration for one of his most dramatic poems.

Evaluate the extend to which Altman's Z Score and Argenti's A Score Essay

Evaluate the extend to which Altman's Z Score and Argenti's A Score become useful to different groups in the society and also comment on the extend to which the - Essay Example Ratio between 1.8 and 3.0 are considered in the gray area of the scale, the closer it gets to the 1.8 barrier the greater the risk of the company going bankrupt. The Z Score model which was created by Edward Altman in the 1960s is pretty accurate in real world application the model was able to successfully predict 72% of corporate bankruptcies two years prior to the companies filing for chapter 7 (Investopedia, 2008). The Altman Z Score tool integrates know financial ratios into the equation whose utilization in the equation give the predictor credibility among the financial industry users. Professor Altman used the Z-score tool he created to develop a model differentiating companies with high probabilities of bankruptcy from companies that are not prone to this type of hazard. Altman’s Z Score determines the likelihood of bankruptcy by utilizing five metrics commonly used by financial analyst to determine five particular financial ratios. The data to the financial ratios is directly extracted from the financial statements of a company. The five variables composed of financial ratios that make up the formula are illustrated below: The metrics involved in the formula are derived from the Income Statement and Balance Sheet financial statements of a company. The tool is both applicable to financial statements of manufacturing and non-manufacturing corporations. The Z-score model substitutes the book value of equity (owner equity) for market value in X and thus it can be used to evaluate privately and publicly held firms on an equal basis (EPA, 2000) The Altman’s Z score is a useful tool for the banking industry. Banks have to make decision on the credit worthiness of corporation in order to determine if a company is eligible for bank loans, credit lines or vehicle financing among others. By utilizing the Z Score tool the bank would know that if a company scores in the low 2 the enterprise is high risk type endeavor.

Ford Focus Term Paper Example | Topics and Well Written Essays - 1500 words

Ford Focus - Term Paper Example Further, different marketing strategies have been adopted by the company in order to meet the Ford’s objectives in promoting this new brand of car in the market. The company had used several promotional campaigns in order to create brand awareness to its target market around the world, such as print and digital ad campaigns. Moreover, it continues to evolve itself in order to meet the high demands of customers and keep track of technological advancements in the business world. In order to achieve excellence, Ford has laid out its set of objectives to lead their workforce in realizing the company’s goal. II. Company Description and Input from Corporate Strategies â€Å"Ford Motor Company was founded by Henry Ford in 1903† and become one of the top carmakers across the globe (â€Å"Heritage†). Ford had partnered with various businessmen to form the company. The first three cars, namely, the Models A, C, K, and T were done by three workers, and in order to in crease their production of cars, Ford introduced the assembly line in 1913. Since then, the company had a high demand for its Model T cars because it was sold at a cheaper price. In 1920, the company became the top carmaker in the world. After the company had befallen during the World War I and II, the company picked up its pace and became successful in the production of cars like the Thunderbird and Mustang. In 2006, the company had undergone reconstruction with the hope of producing more cars that attract consumers (Wilson). During the economic downturn in 2008 and 2009, Ford had maintained its composure, and it never asked for government financial assistance to continue its operations in comparison with its other competitors, such as Chrysler and GM. Also, the company relied its financial capability by focusing its strategy on the Ford car brand. The market share of the brand had increased as a result from the implementation of the strategy (Ferrel and Hartline 3l). Lately, the c ompany had created cars that answered to the needs of people, as well as integrated the latest technologies on their designs. In 2013, Several Ford car models are made available, including the Hybrid, Edge, and Escape, which feature the latest technology and consume less fuel as compared with other cars in the market (â€Å"Product Information: Ford 2013 Product Guide†). The company’s mission and vision statement emphasizes the importance of a unified team, plan, and goal to position itself as a leading company in the automotive industry. In order to achieve a unified team, Ford urges its workforce to uphold cooperation and create a team with a common objective so that it will remain or maintain as the best automotive company in the world. The company’s cooperation and teamwork can be accessed through bringing out the satisfaction of customers, employees, and business partners. It has also laid out its unified plan for the future, which includes: (1) a constant evolution of its operations that conform to the present demand and demographic behavior of the market; (2) speed up the creation of new products that conform with the preferences and desired needs of customers; (3) improve the financial environment of the company and; (4) work like a team in an effective manner. The main goal of Ford is â€Å"delivering profitable growth for all† (â€Å"Our Company: One Ford Mission and Vision†). Jackson, Sawyers, and Jenkins also cited one of the

Coaching Principles and Practice Essay Example | Topics and Well Written Essays - 2750 words

Coaching Principles and Practice - Essay Example Many coaches never make a conscious decision regarding the coaching method(s) they adopt or could adopt. Often coaches adopt methods they experienced as athletes, or as a consequence of watching other coaches, maybe as a spectator, or as an assistant coach. This approach to learning how to coach is often called the apprentice model because the learning occurs 'on the job' and at the side of a more experienced coach. This model may work well if the exemplary coach is a quality coach and has the time to spend with the apprentice coach, but many times this is not the case and the result is that undesirable coaching practices continue to be reproduced. The work of Tinning et al. (1993) reminds against slipping into the belief that methods exist separately from the coach, and that they can be simply implemented unproblematically by the coach. Coaching is a social practice, and this implies the involvement of the whole person, in relation to specific activities as well as social communities. Thus, methods can be viewed not as a â€Å"set of strategies which can be successfully or unsuccessfully implemented by a teacher [read coach], they are more like a set of beliefs about the way certain types of learning can best be achieved. They are as many statements about valued forms of knowledge as they are about procedures for action†. The direct method of coaching involves the coach to do the following: †¢ Providing the information and direction to the group/individual †¢ Controlling the flow of information... Often coaches adopt methods they experienced as athletes, or as a consequence of watching other coaches, maybe as a spectator, or as an assistant coach. This approach to learning how to coach is often called the apprentice model because the learning occurs 'on the job' and at the side of a more experienced coach. This model may work well if the exemplar coach is a quality coach and has the time to spend with the apprentice coach, but many times this is not the case and the result is that undesirable coaching practices continue to be reproduced. The work of Tinning et al. (1993) reminds against slipping into the belief that methods exist separately from the coach, and that they can be simply implemented unproblematically by the coach. Coaching is a social practice, and this implies the involvement of the whole person, in relation to specific activities as well as social communities. Thus, methods can be viewed not as a "set of strategies which can be successfully or unsuccessfully implemented by a teacher [read coach], they are more like a set of beliefs about the way certain types of learning can best be achieved. They are as much statements about valued forms of knowledge as they are about procedures for action" (Tinning et al. 1993, p. 123). Characteristics of Coaching Methods Direct Method The direct method of coaching involves the coach to do the following: Providing the information and direction to the group/individual Controlling the flow of information Privileging the demonstration, (it can be given by the coach or the athlete, or be on video) (Kirk et al. 1996) Giving little recognition to the diverse needs of the athletes Behaving in ways that can be categorised as managerial and organisational Setting goals that are specific

Challenges of Advance Planning in Care-Giving Assignment

Challenges of Advance Planning in Care-Giving - Assignment Example This assignment explores one of the most basic challenges in advanced planning as the misconception that it requires a complex legal documentation process. These make patients reluctant in engaging in the process. In such a situation, a patient may require some time to go and rethink the issue over and prepare for a discussion over the matter. It is necessary at this point to demonstrate the benefits of the plan to their lives and to family members (Laverty, Laverty, & Cindy, 2010). Initiating this program only requires patients to be thoughtful and engage the family in their discussions. Lack of awareness, State laws support advance directives in care giving for all individuals. Nevertheless, there is still no clear process and procedures to allow individual wishes to be known and be fulfilled at the appropriate time. Support studies sponsored by various organizations such as Robert Johnson Foundation in America reported that almost 75% of terminally ill patients do not like cardiop ulmonary resuscitation but less than 50% of their care givers know about this. Even if the patient had documented his preference, less than 42% of the cases are discussed by the actual care giver (Bumagin & Hirn, 2006). These bring lack of awareness as a strong challenge to the process of advanced planning. Denial is also a key problem in advance care planning. The society’s denial of death and dying puts patients in a situation where they cannot make decisions for themselves. These make them unable to heed waning of life just as we acknowledge the waning of birth. Denial about death makes people not to review life. Live in fear and uncertainty when these happens, the patient is unable to make clear directives of his health care preference. Confusion this is also a big challenge that affects advance plans in health care giving. Despite a strong desire for quality life and â€Å"good death†, many people worry about conflicting feelings within them. These conflicts arise from palliative care and doing whatever it takes to extent patient’s life. Research carried out by Regence Foundation shows that almost 50% of the respondent ascertained that emphasizing on palliative and end of life care options can interfere with the processes put in place to extent the patient’s life as long as possible (Bumagin & Hirn, 2006). This creates a misunderstanding of what to take as the best alternative. Majority of patients, who benefit from Medicare of all racial and ethnic groups, argue that in the event of a terminal illness with less than months to live, they would rather stay at home and die. They would not like to use life-prolonging drugs that have uncomfortable side effects to prolong their lives for a week or month hindering advance planning. However, various researchers like Amber Barnato, MD and colleges have discovered different distribution of end life preferences in different races ethnic groups. For example a research done between the whi tes and the blacks shows that more blacks are likely to die in the hospital compared to white.  

HCM337-0704B-01 Current Legal, Ethical, and Regulatory Issues in H - Essay - 3

HCM337-0704B-01 Current Legal, Ethical, and Regulatory Issues in H - Phase 2 Discussion Board - Essay Example NAP’s Ethical Guidelines for Professional Care Services in a Managed Health Care Environment (1999) put patients at the top of their priorities. Their commitment for a patient-focused care means that they would rigidly observe the rights of their patients such as the right to have access to appropriate professional services, the healthcare’s obligation to meet with patient’s satisfaction, and the healthcare provider’s duty to provide delivery by uniquely trained personnel when complexity of the patient’s condition requires the knowledge and expertise beyond those of the primary care provider. Failure of compliance to these ethical guidelines can result to major penalties. A case documented by Klein and Campbell (2006) wherein members of the groups clinical and anatomic pathology laboratory, and 2 Michigan-based consulting and management services companies were sued by the government because or their alleged submission of â€Å"$1.3 million in false claims to Medicare and Medicaid†. The government also argued that the defendants â€Å"engaged in fraudulent conspiracy by offering referring physicians a discounted price for a routine, automated chemistry panel.† After the accused were proven guilty, they were, under the False Claims Act, potentially liable for 3 times $1.3 million, or $3.9 million, penalties of up to $10,000 for each of the 134,655 claims, and $116,000 for the cost of the investigation by the OIG. The physicians, who sold the laboratory to Corning in 1995 for $6.6 million, denied breaking any laws, but in 1998 settled with the government for $ 875,000. The consulting companies and their owner, whom the pathologists argued put into place the challenged billing practice, settled for $35,000. With the information supplied by other postings about my current and future health work, I can see outright the repercussions that might

Administrative Law Essay Example | Topics and Well Written Essays - 2250 words

Administrative Law - Essay Example ts. Consequently, there has been an urgent need to tackle and overcome such activities of prostitution which are in most communities considered as unacceptable. However, many countries in the light of the stated problem have legalized prostitution through brothels with the imposition of certain restriction so as to minimize criminal offences, simultaneously preserving social interests. For instance, even though an increasing percentage of population worldwide deciphers a strong believe that legalization of prostitution or brothels can de-motivate the performing of such offences, communities still perceive that such acts are immoral and should never be legalised as it might harm the social environment and the following generations by a large extent. Based on this understanding, in the light of Brothel Licensing Act 2011 (Cth), the case scenario of Alice will be assessed. Alice is an adult citizen of Sydney and runs a number of art galleries. Deciding that she would become a brothel â €˜madam’, Alice renovates a dilapidated youth hostel into a high class brothel. Correspondingly, she applies for a brothel license pursuant to the Brothel Licensing Act 2011 (Cth). Although she is granted with a brothel license, two conditions were mentioned rigidly in the agreement which she feels to be inhibiting her business growth prospects. Accordingly, many issues are observed to emerge opposing the license granted to the brothel. Concentrating on these issues, the report will intend to evaluate the specifications of such acts and its justness to be enacted. Decision or Decisions That Alice Can Seek Judicial Review Of The Minister decides to grant Alice a brothel license based on two rigid conditions. The first condition restricts that there be a maximum of four people on the premises at any one time. Correspondingly, the second condition deliberates that the brothel shall provide prostitution services only within the hours of 9am to 5pm and from Monday to Friday onl y. It is worth mentioning in this regard that prostitution has been found as one of the oldest professional practices performed by people even after being strongly opposed in the orthodox period of human civilisation. In the current day perspective, many countries including United Kingdom, Canada, France, and Germany among others have made prostitution and brothel legal with the intention to reduce the rate of sex crimes bringing-in various legal restrictions. Laws that prohibit prostitution and brothels have often been opposed by feminists accusing it to act as sex discrimination. Therefore, in a free and independent society, such laws are regarded as inappropriate as these legal implications tend to violate the basic rights and individual liberties unnecessarily. Prostitution services do not harm any of the party engaged in the prostitution due to mutual agreements; rather it does de-motivate people to forcefully indulge in such activities. People who agree to pay value for the pr ostitution services rendered to them at their own will and interest are the likely clients of the brothels. It has often been mentioned that it is appropriate to enact strict laws against trafficking defining it to be a category of sex crime, rather than on brothels which focuses on agreed sexual activities1. Thus, with reference to Alice’

Impacts of Cyber Vandalism on the Internet Essay

Impacts of Cyber Vandalism on the Internet - Essay Example With intent to discuss the issue, this paper will cover the associated terms like administrative discretion, cybersecurity threats, and statutory protections for public employees.   In the legal context, the term discretion indicates the power to decide or act according to one’s own judgment. Some legal systems like the US allow certain discretionary powers to administrative authorities. To illustrate, US law system has framed some broad limits within which an administrative authority can operate. For instance, a statute confers discretion if it is reasonable and is in public interest. To define, the administrative discretion is the expertise of professional expertise and judgment as opposed to strict adherence to regulations or statutes, in making a decision or performing official acts or duties (The Free Dictionary). In other words, when a legal system permits an administrative authority to practice discretion, it is called administrative discretion. The discretionary powers are given to an administrative authority by statute or delegation. It has observed that, generally, broad discretionary powers are given to administrative agencies in order to e ffectively exercise their administrative authority. However, it is held that the discretionary power must not be vague or arbitrary, but it has to be in accordance with legal requirements. US Supreme Court stated that â€Å"an administrative agency enjoys wide discretion in ascertaining the best way to handle related, yet discrete issues in terms of procedures and priorities† (USLegal). Although the law imposes certain regulations on the administrative authorities in exercising their discretionary powers, it is often seen that their functions are not in line with law requirements.

Accounting Theory and Development Essay Example for Free

Accounting Theory and Development Essay The methodology is often be â€Å"going from the general to the specific† as the research must develop a logical structure for accomplishing the objective then, which based on the definition and assumptions. The validity of any theory developed through this process is highly dependent upon the ability of the researcher to correctly identify and relate the various components of the accounting process in a logical manner. Induction is a method of reasoning by which a general law or principle is inferred from observed particular instances. Inductive approach emphasis making observations and drawing conclusions from it and is often be â€Å" going from specific to general, because the research generalizes about the universe on the basis of limited observations of specific situations. The inductivist is to draw theoretical and abstract conclusion from rationalizations of accounting practice. Applied to the accounting, the inductive approach begins with observations about the financial information of business enterprises and proceeds to construct generalizations and principles of accounting from those observations on the basis of recurring relationship. Reading 1. 2 Accounting theory and development Accounting Theory Construction with Inductive and deductive approach Normative theory vs. Positive theory Normative theory attempts to justify what ought to be, rather than what is. The major criticism of normative theories is that they are based on value judgments. Positive (Descriptive) theories attempt to find relationships that actually exist. Deductive systems are normative and inductive systems attempt to be descriptive. The deductive method is basically a closed, non-empirical system. Theory verification Theory verification or validation is an integral part of theory construction. According to Popper, the testing of deductive theories could be carried out along four lines. There is the testing of the theory by way of empirical applications of conclusion, which can be derived from. This step is necessary to determine how the theory stands up to the demand of practice. If its predictions are acceptable, the theory is said to be verified otherwise, the theory is said to be falsified. Aspects of theories, their construction and verification Figure 2 Distinguishing features

Educational stages Essay Example for Free

Educational stages Essay Education in its general sense is a form of learning in which knowledge, skills, and habits of a group of people are transferred from one generation to the next through teaching, training, research, or simply through autodidacticism. [1] Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts. Systems of schooling involve institutionalized teaching and learning in relation to a curriculum, which itself is established according to a predetermined purpose of the schools in the system. Schools systems were also based on peoples religion giving them different curricula. [edit] Curriculum Main articles: Curriculum, Curriculum theory, and List of academic disciplines School children in Durban, South Africa. In formal education, a curriculum is the set of courses and their content offered at a school or university. As an idea, curriculum stems from the Latin word for race course, referring to the course of deeds and experiences through which children grow to become mature adults. A curriculum is prescriptive, and is based on a more general syllabus which merely specifies what topics must be understood and to what level to achieve a particular grade or standard. An academic discipline is a branch of knowledge which is formally taught, either at the university–or via some other such method. Each discipline usually has several sub-disciplines or branches, and distinguishing lines are often both arbitrary and ambiguous. Examples of broad areas of academic disciplines include the natural sciences, mathematics, computer science, social sciences, humanities and applied sciences. [5] Educational institutions may incorporate fine arts as part of K-12 grade curriculums or within majors at colleges and universities as electives. The various types of fine arts are music, dance, and theater. [6] [edit] Preschools Main article: Preschool education The term preschool refers to a school for children who are not old enough to attend kindergarten. It is a nursery school. Preschool education is important because it can give a child the edge in a competitive world and education climate. [citation needed] While children who do not receive the fundamentals during their preschool years will be taught the alphabet, counting, shapes and colors and designs when they begin their formal education they will be behind the children who already possess that knowledge. The true purpose behind kindergarten is â€Å"to provide a child-centered, preschool curriculum for three to seven year old children that aimed at unfolding the child’s physical, intellectual, and moral nature with balanced emphasis on each of them. †[7] [edit] Primary schools Main article: Primary education Primary school in open air. Teacher (priest) with class from the outskirts of Bucharest, around 1842. Primary (or elementary) education consists of the first 5–7 years of formal, structured education. In general, primary education consists of six or eight years of schooling starting at the age of five or six, although this varies between, and sometimes within, countries. Globally, around 89% of primary-age children are enrolled in primary education, and this proportion is rising. [8] Under the Education For All programs driven by UNESCO, most countries have committed to achieving universal enrollment in primary education by 2015, and in many countries, it is compulsory for children to receive primary education. The division between primary and secondary education is somewhat arbitrary, but it generally occurs at about eleven or twelve years of age. Some education systems have separate middle schools, with the transition to the final stage of secondary education taking place at around the age of fourteen. Schools that provide primary education, are mostly referred to as primary schools. Primary schools in these countries are often subdivided into infant schools and junior school. In India, compulsory education spans over twelve years, out of which children receive elementary education for 8 years. Elementary schooling consists of five years of primary schooling and 3 years of upper primary schooling. Various states in the republic of India provide 12 years of compulsory school education based on national curriculum framework designed by the National Council of Educational Research and Training. Students working with a teacher at Albany Senior High School, New Zealand Students in a classroom at Samdach Euv High School, Cambodia In most contemporary educational systems of the world, secondary education comprises the formal education that occurs during adolescence. It is characterized by transition from the typically compulsory, comprehensive primary education for minors, to the optional, selective tertiary, post-secondary, or higher education (e. g. university, vocational school) for adults. Depending on the system, schools for this period, or a part of it, may be called secondary or high schools, gymnasiums, lyceums, middle schools, colleges, or vocational schools. The exact meaning of any of these terms varies from one system to another. The exact boundary between primary and secondary education also varies from country to country and even within them, but is generally around the seventh to the tenth year of schooling. Secondary education occurs mainly during the teenage years. In the United States, Canada and Australia primary and secondary education together are sometimes referred to as K-12 education, and in New Zealand Year 1–13 is used. The purpose of secondary education can be to give common knowledge, to prepare for higher education or to train directly in a profession. The emergence of secondary education in the United States did not happen until 1910, caused by the rise in big businesses and technological advances in factories (for instance, the emergence of electrification), that required skilled workers. In order to meet this new job demand, high schools were created, with a curriculum focused on practical job skills that would better  prepare students for white collar or skilled blue collar work. This proved to be beneficial for both employers and employees, for the improvement in human capital caused employees to become more efficient, which lowered costs for the employer, and skilled employees received a higher wage than employees with just primary educational attainment. In Europe, grammar schools or academies date from as early as the 16th century, in the form of public schools, fee-paying schools, or charitable educational foundations, which themselves have an even longer history.

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