Integrative Approaches to Psychology and Christianity Essay

Just as the title describes, Entwistle explains within the book the attempts and varied approaches of integrating both psychology and Christianity, two entities which seem to have been at odds with each other since the time of Galileo. By explaining key historical conflicts, such as instances of friction between religion and science, readers are able to understand how psychology and Christianity are intertwined, and how the same principles that hold them together also seek to push them apart. As said best by Entwistle, â€Å"The interaction of psychology and theology is virtually inevitable due to their mutual interest in understanding the ambiguities and mysteries of human behavior, and healing human brokenness.† (Entwistle, 2010, p.51) According to Entwistle each person has their own worldview, a unique way in which one sees the world around them shaped by their own experiences, knowledge, and culture. The family we were born into, the town we grew up, the continent our town is located all help shape our worldview. Our worldview allows us to question if what we believe is true and if our beliefs have a place within our religion. In taking a Christian worldview believing and understanding in the creation, Fall, redemption, and consummation provides a starting point for integration by allowing Christians to understand how the world around them began and their place in that world. (Entwistle, 2010, p.67) Five paradigms are described as ways of relating psychology to Christianity and they are as follows: enemies, spies, colonialists, neutral parties, and allies as subjects of one sovereign. As enemies, there is no possible way that psychology and Christianity can be integrated. As spies, allegiance is held to one while borrowing principles from the other. As colonialists, there is a recognition of the importance of psychology, but does not attempt to use any of its principles. As neutral parties, both psychology and Christianity recognize findings that are paramount between the two, however both are separated from one another. And lastly, as allies the integration of both psychology and Christianity embrace the word and works of God and his ability to rule over both disciplines. (Entwistle, 2010, p.154) In conclusion, the road to integrating psychology and Christianity continues to be a long one. As Christians, we know that God is the creator of man and that we are born in His image but have sinfully fallen short, and that Jesus died for our sins so we are able to seek forgiveness. The Bible remains our guide for daily living. Psychology is the scientific study of the mind and our behaviors attempting to explain why we think and behave the ways we do. â€Å"Rather, the task at hand is the difficult work of reading the psychological and biblical sources, checking the research and the interpretations, and then asking how together they can help us attain a more complete picture of the human condition.† (Entiwistle, 2010, p.267) Concrete Response In reading this book it triggered a memory from over ten years ago. In 2001, I lost my great-grandmother to heart related issues. For me her death went farther than just losing a relative. As far back as I can remember my great-grandmother was a part of my daily life. My mother had me when she was still in high school so naturally she still lived at home. My father was nonexistent in my life so my world revolved around a house full of women: my mother, grandmother, and great-grandmother. I had just graduated high school and was anxiously approaching the start of my first semester in college the following August. Everyone else in the household was at work, while I was enjoying my summer vacation. It was still early in the morning and my great-grandmother had decided to lay down for an early nap. At this point in her life she needed help remembering when to take her medications so I went to her bedroom to wake her up. Upon entering her bedroom I did not notice anything out of the ordinary, but as I nudged her and called her name I became more frantic as the realization of my worst fears came to fruition, that no matter what I did she would never wake up again. One of the first questions that came to mind was, â€Å"Why God?† Then, â€Å"Why me?† soon followed. But as a Christian, I understood that God has a plan for all of us. When I was able to see through my grief I knew that her suffering on Earth was over and she was in her heavenly home. However, this event solidified in my mind the concept that we are mortals and our days on Earth are numbered. In some way I feel this event helped shape my decision to help others. Reflection In reading this book, some questions come to mind. While discussing the history and innate differences between psychology and Christianity why did Entwistle not find it relevant to discuss the ways the two had been integrated in the past? Relevant to the history of both are the few people through history that have used both psychology and theology in healing the minds and bodies of followers. Even Native American shamans used both the healing properties of plants and medicines and their belief and worship of spiritual beings to restore health to believers. I think it is important that in moving forward for one to understand the past in preventing history from repeating itself and by learning from others mistakes. Another point I feel that Entwistle failed to make is the possibility of our worldview changing. I feel that although our worldview is shaped over the course of our life that there are reasons that would cause a person’s worldview to change dramatically. For instance, let’s consider a child that has known nothing but abuse and neglect since being brought into the world. Everything they know about the world is skewed by the will to merely survive from day to day. Consider how that child’s worldview would change once that child has been removed and placed with either a foster-family or relative that can begin to teach them that love, trust, and stability do exist in the world. Would that child now hold a different worldview? Action I believe that I have learned many things concerning the integration of psychology and Christianity. The community mental health facility in which I work does not endorse the use of religion in counseling sessions due to their ethics and boundaries policy. However, I feel by allowing the client the opportunity to discuss their own feelings and stance on religion opens the door for me as a therapist to utilize that information in integrating religion into their counseling sessions. By allowing them to include such an integral part of their life I feel they are going to be more successful in overcoming illness and life problems that are their undoing. In conclusion, knowing that I have such limited expertise and experience in combining both religion and psychology, I think it is important as a therapist to know if you are practicing outside your realm of knowledge, therefore I am interested in learning what facilities exist that provide Christian counseling in proximity to my hometown. Clients should feel empowered and have options with which services they receive. It is through my years of working as a therapist that I have also learned clients’ want to feel like they are choosing what is best for themselves rather than being forced. I know I share the same views in my own life and hope I can help others heal within theirs. References Entwistle, D.N. (2010). Integrative Approaches to Psychology and Christianity. (Second Edition e.d.). Eugene, OR: Cascade Books.

Impact of mobile and internet banking Essay

Abstract Financial institutions have been in the process of significant transformation. The force behind the transformation of these institutions is innovation in information technology. Information and communication technology is at the Centre of this global change curve of mobile and internet banking in Kenya. Rapid development of information technology has made banking tasks more efficient and cheaper. This study sought to  determine the impact of mobile and internet-banking on performance of financial institutions in Kenya where the survey was conducted on financial institutions in Nairobi. The study also sought to identify the extent of use of mobile and internet banking in financial institutions. The study investigated 30 financial institutions. The study found that the most prevalent internet banking service is balance inquiry while the least is online bill payment. Cash withdrawal was the most commonly used mobile banking service whereas purchasing commodities was the least commonly used. CHAPTER ONE. INTRODUCTION. Background of the study Mobile banking is an innovation that has progressively rendered itself in pervasive ways cutting across several financial institutions and other sectors of the economy. During the 21st century mobile banking advanced from providing mere text messaging services to that of pseudo internet banking where customers could not only view their balances and set up multiple types of alerts but also transact activities such as fund transfers, redeem loyalty coupons, deposit cheques via the mobile phone and instruct payroll based transactions (Vaidya 2011). The world has also become increasingly addicted to doing business in the cyber space, across the internet and World Wide Web. Internet commerce in its own respect has expanded in various innovative forms of money, and based on digital data issued by private market actors, has in one way or another substituted for state sanctioned bank notes and checking accounts as customary means of payments (Cohen 2001). Technology has greatly advanced playing a major role in improving the standards of service delivery in the financial institution sector. Days are long gone when customers would queue in the banking halls waiting to pay their utility bills, school fees or any other financial transactions. They can now do this at their convenience by using their ATM cards or over the internet from the comfort of their homes. Additionally due to the tremendous growth of the mobile phone industry most financial institutions have ventured into the untapped opportunity and have partnered with mobile phone network providers to offer banking services to their clients. ATM  banking is one of the earliest and widely adopted retail e-banking services in Kenya (Nyangosi et al. 2009). However according to an annual report by Central Bank of Kenya its adoption and usage has been surpassed by mobile banking in the last few years (CBK 2008). The suggested reason for this is that many low income earners now have access to mobile phones. A positive aspect of mobile phones is that mobile networks are available in remote areas at a low cost. The poor often have greater familiarity and trust in mobile phone companies than with normal financial institutions. Banking In general terms, banking is the business activity of accepting and safeguarding money owned by other individuals and entities and then lending out this money in order to earn a profit. The Banking Act of Kenya defines banking to mean the accepting from members of the public of money on deposit repayable on demand or at the expiry of a fixed period or after notice, the accepting from members of the public of money on current account and payment and acceptance of checks and the employing of money held on deposit or on current account or any part of it by lending, investment or in any other manner for the account and the risk of the person so employing the money. Currently Kenya has 43 licensed commercial banks of these, 31 are locally owned and 12 are foreign owned. Citibank, Habib Bank, standard chartered and Barclays Bank are among the foreign-owned financial institutions in Kenya. The government of Kenya has a substantial stake in three of Kenya’s commercial banks. The remaining local commercial banks are largely family owned. Commercial banks in Kenya accept deposits from individuals and make a profit by using the deposits to offer loans to businesses at high interest rates. These banks are regulated by the Central Bank Act and the Companies’ Act, which stipulates the activities they should be engaged in, the rules on publishing of financial statements, minimum capital requirements as well as reserve requirements. Examples of new innovations in the Kenyan banks include adoption of ATMs, smart cards, internet and mobile banking as discussed below. Mobile banking Mobile banking (m-banking) refers to provision and availment of banking and  financial services through the help of mobile telecommunication devices. The scope of offered services may include facilities to conduct bank and stock market transactions, administer accounts and to access customized information. Mobile networks in Kenya offer m-money services in the name of M-pesa by Safaricom, Orange money by Orange, Yu-cash by Essar, and Airtel money by Airtel. Currently the mobile money market size is about 15 million users transferring Kshs. 2 billion daily, of these over 14 million are Mpesa customers. M-money providers have partnered with commercial banks such as Equity Bank, I&M Bank, and Kenya Commercial Bank, Barclays and Co-operative to offer mobile based financial products that aim to reach the unbanked. Internet banking Internet banking (e-banking) is the use of internet and telecommunication networks to deliver a wide range of value added products and services to bank customers (Steven, 2002) through the use of a system that allows individuals to perform banking activities at home or from their offices or over the internet. Some online banks are traditional banks which also offer online banking, while others are online only and have no physical presence. Online banking through traditional banks enables customers to perform all routine transactions, such as account transfers, balance inquiries, bill payments, and stop-payment requests, and some even offer online loan applications. Customers can access account information at any time, day or night, and this can be done from anywhere. Internet banking has improved banking efficiency in rendering services to customers. Financial institutions in Kenya cannot ignore information systems since they play an important role in their operations because custome rs are conscious of technological advancements and demand higher quality services. Problem Statement A fundamental assumption of most recent research in operations improvement and operations learning has been that technological innovation has a direct bearing on performance improvement (Upton and Kim, 1999). Strategic management in financial institutions demand that they should have effective systems in place to counter unpredictable events that can sustain their operations while minimizing the risks involved through  technological innovations. Only financial institutions that are able to adapt to their changing environment and adopt new ideas and business methods have guaranteed survival. Some of the forces of change which have impacted the performance of financial institutions mainly include technological advancements such as use of mobile phones and the internet. Since the beginning of e-banking Kenyan financial institutions have witnessed many changes. Customers now have access to fast, efficient and convenient banking services. Most financial institutions in Kenya are investing large sums on money in information and communication technology (ICT). However while the rapid development of ICT has made some banking tasks more efficient and cheaper, technological advancements have their fair share of problems; for example they take a large share of bank resources, plastic card fraud particularly on lost and stolen cards and counterfeit card fraud. Thus there is a need to manage costs and risks associated with internet banking. It is crucial that internet banking innovations be made through sound analysis of risks and costs associated to avoid harm on banks performance. Bank performance is directly dependent on efficiency and effectiveness of internet banking and on the other hand tight controls in standards to prevent losses associated with internet banking. In order not to impair on their prosperity, financial institutions need to strike a balance between tight controls and standards in efficiency of internet banking. This is only possible if the effects of internet banking on financial institutions and its customers are well analyzed and understood. Mobile money has emerged as a strong competition to financial institutions in Kenya. Initially cellular phones were developed to improve communication from the earlier primitive forms of communications such as smoke and drums. Financial institutions introduced ICT as an improvement to the banking channels. This has thus enabled bank customers’ access information relating to their accounts, (Tiwari, Buse and Herstatt, 2007.). In this regard mobile phone service providers have taken mobile money services deeper into the financial sector by offering a range of financial services through their networks. The CBK and the Communication Commission of Kenya (CCK) have allowed service providers to offer mobile money services as there appears to be no reprieve as competition in the mobile money business is still heating up with entry of new money transfer systems which now allow transactions across all mobile  telephone service providers like M-pesa. Objectives of the study. The study objectives are: To establish the impact of mobile and internet banking on the performance of financial institutions in Kenya. To establish the extent of use of mobile and internet banking in financial institutions in Kenya. Significance of the study The study will be crucial to emerging financial institutions as it will provide answers to the factors against the implementation of internet banking in Kenya, prove of the success and growth associated with the implementation of internet banking and highlight the areas of banking operations that can be enhanced via internet banking. It is equally significant for bank executives and indeed the policy makers of the banks and financial institutions to be aware of internet banking as a product of internet commerce with a view to making strategic decisions. The study is also expected to give an insight on the state of mobile money services as a competition to the commercial banks in Kenya and the factors that have greatly influenced its growth. Players in the financial institution sector and telecommunications industry will find the study useful as they can use the findings to strategize on how they can mutually benefit from this development. Finally, our study adds to the existing literature, and is a valuable tool for students, academicians, institutions, corporate managers and individuals who want to learn more about mobile and internet banking. Limitations of the study In undertaking this study a number of challenges were faced. There was bureaucracy in getting approval to respond to questionnaires with most institutions insisting that permission be sought from the Chief Executive Officer or Human Resource Manager. This led to delays in obtaining the required responses for data analysis in time. Some customers were unwilling to divulge information and seemed to not have time to fill in the questionnaires. CHAPTER TWO. Literature Review. This chapter seeks to explore in depth the concept of internet and mobile banking through a review of the various theories as well as empirical studies. Theoretical framework Theory of information production and contemporary banking theory Diamond (1984) suggested that economic agents may find it worthwhile to produce information about possible investment opportunities if this information is not free; for instance surplus units could incur substantial search costs if they were to seek out borrowers directly. There would be duplication of information production costs if there were no banks as surplus units would incur considerable expenses in seeking out the relevant information before they commit funds to a borrower. Banks enjoy economies of scale and have expertise in processing information related to deficit units (borrowers). They may obtain information upon first contact with borrowers but in real sense it’s more likely to be learned over time through repeated dealings with the borrower. As they develop this information they develop a credit rating and become experts in processing information. As a result they have an information advantage and depositors are willing to place funds with a bank knowing that this will be directed to the appropriate borrowers without the former having to incur information costs. Bhattacharya and Thakor (1993) contemporary banking theory suggests that banks, together with other financial intermediaries are essential in the allocation of capital in the economy. This theory is centered on information asymmetry, an assumption that â€Å"different economic agents possess different pieces of information on relevant economic variables, in that agents will use this information for their own profit† (Freixas and Rochet 1988). Asymmetric information leads to adverse selection and moral hazard problems. Asymmetric information problem that occurs before the transaction occurs and is related to the lack of information about the lenders charact eristics, is known as adverse selection. Moral hazard takes place after the transaction occurs and is related with incentives by the lenders to behave opportunistically. Innovation diffusion theory Mahajan and Peterson (1985) defined an innovation as any idea, object or practice that is perceived as new by members of the social system and defined the diffusion of innovation as the process by which the innovation is communicated through certain channels over time among members of social systems. Diffusion of innovation theory attempts to explain and describe the mechanisms of how new inventions in this case internet and mobile banking is adopted and becomes successful Clarke (1995). Sevcik (2004) stated that not all innovations are adopted even if they are good it may take a long time for an innovation to be adopted. He further stated that resistance to change may be a hindrance to diffusion of innovation although it might not stop the innovation it will slow it down. Rogers (1995) identified five critical attributes that greatly influence the rate of adoption. These include relative advantage,compatibility,complexity,triability and observability.According to Rogers, the rate of adoption of new innovations will depend on how an organization perceives its relative advantage, compatibility, triability,observability and complexity.If an organization in Kenya observes the benefits of mobile and internet banking they will adopt these innovations given other factors such as the availability of the required tools. Adoption of such innovations will be faster in organizations that have internet access and information technology departments than in organizations without. Empirical studies Internet banking Recent literature has a narrow focus and ignores internet banking almost entirely; it equates internet money with the substitution of currency with internet gadget. For instance Freedman (2000) suggests that internet banking and internet money consists of three devices; access devices, stored value cards, and network money. Internet banking is simply the access to new devices and is therefore ignored. Internet money is the sum of stored value (smart cards) and network money (value stored on computer hard drives). Santomero and Seater (1996), Prinz (1999) and Shy and Tarkka (2002) present models that identify conditions under which alternative payments substitute for currency. Most of these models indicate that there is at least a  possibility for internet substitutes for currency to emerge and flourish on a wide scale depending on the characteristics of the various technology and those of the potential users. Friedman (1999), intimated that internet banking presents the possibility that an entire alternative payment system not under the control of the Central Bank may arise. Today computers make it at least possible to bypass the payment system altogether, instead using direct bilateral clearing and settlement (Friedman, 1999). Trends in mobile and internet banking in Kenya With the emerging wave of information driven economy, the banking industry in Kenya has inevitably found itself unable to resist technological indulgence. This has led to a boom in development of mobile banking laying down a strong base for low cost banking, and growth of mobile phone use in rural Kenya. Standard Chartered in 2009 launched its mobile banking in seven markets in Africa. In the Kenyan market it offers a number of services on a unique, user-friendly platform called Unstructured Supplementary Services Data (USSD) and is only available on GSM carrier networks which enable customers to access banking in real time, anywhere in the world, through their mobile phones. The platform is a convenient menu-driven application that is not dependent on specific customer handsets and does not need to be downloaded. Barclays bank’s m-banking platform is known as ‘hello money’. It allows customers to carry their bank in their mobile and access banking services anytime/anywhere on the move. Unlike other players in the sector this is all for free. Co-operative bank pioneered mobile banking way back in 2004 by enabling customers to access their accounts and transact using their mobile phones. It offers services such as balance enquiries, mini-statements, SMS alerts on credit and debit transactions to an account, pay utility bills and funds transfer. Equity bank on the other hand has its own m-banking platform known as Eazzy 24/7 offering services similar to those of co-operative bank. Telephone and PC banking is a facility that enables customers, via telephone calls, find out about their position with their bankers by merely dialing the telephone numbers given to them by the banks. In addition, the computers on the phone would require special codes given to the customers as a mea ns of identification of authentic users before they can receive any information they requested for. Telephone and PC banking brings the bank to the doorstep  of the customer, it does not require the customer to leave his premises. The card system is a unique internet payment type. Smart cards are plastic devices with embedded integrated circuit being used for settlement of financial obligations. Depending on the sophistication, it can be used as a Credit Card, Debit Card and ATM cards. The cards are internetally loaded with cash value and can be carried around like cash and store information on a microchip. The microchip contains a â€Å"purse† in which value is held internetally. In addition, it also contains security programs which protect transactions between one card user and the other. It can also be transferred directly to a retailer, merchant or any other outlet to pay for goods and services, and like cash, transactions between individuals without the need for banks or any other third parties. Also, the system does not require central clearing, it is valued immediat ely. CHAPTER THREE. Research Methodology A research methodology guides the researcher in collecting, analyzing and interpreting observed facts (Bless and Achola, 1988). This chapter introduces the logical framework to be followed in the process of conducting the study. It is divided into: research design, population and sample, data collection and data analysis. Research Design According to McMillan and Schumacher (2001) a research design is a plan for selecting subjects, research sites and data collection procedures to answer the research questions. It is the conceptual framework within which research is conducted and constitutes the blueprint for the collection of data and the analysis thereof of the collected data Based on the purpose of the study and the type of data involved, descriptive and qualitative research designs were used. The goal was to provide a clear understanding of mobile and internet banking and its usage in financial institutions and therefore conclude on the impact it has had on their performance. Qualitative data was collected from the managers, subordinate staff as well as from customers of the financial institutions. Population and Sample. Cooper and Emory (1995) define population as the total collection of elements about which the researcher wishes to make some inferences. An element is the subject on which the measurement is being taken and is the unit of the study. The population of interest in this study consisted of 61 financial institutions operating in Kenya of which only 30 responded. The managers, employees and customers were targeted as the key respondents. There was a need to sample the population because not all the population elements use mobile and internet banking. The study therefore used stratified sampling. This is the process of dividing members of the population into homogeneous subgroups before sampling. The strata should be mutually exclusive: every element in the population must be assigned to only one stratum. Financial institutions were classified according to microfinance institutions, SACCOS and commercial banks where 2 microfinance institutions, 11 SACCOS and 17 commercial banks were sampled . Data Collection. Primary sources were used in data collection. Open and close-ended questionnaires were administered to target respondents. In total two questionnaires were delivered: one to managers and employees and another to customers. They purposed to find out information regarding the level of usage of mobile and internet banking, demographics of the customers, services offered and used, level of satisfaction, impact on performance, opportunities for growth and challenges faced through the use of mobile and internet banking. This instrument allowed for cost and time savings for the respondents as well as the researchers. Data Analysis According to Bryman and Bell (2003) data analysis refers to a technique used to make inferences from data collected by means of a systematic and objective identification of specific characteristics. Once data is collected it has to be edited to verify to the completeness of data, coded in order to assign numbers or symbols to the various answers for effective categorization/classification, entered in order to convert the information gathered to a medium for viewing and manipulation (e.g. excel or statistical  package for social sciences SSPS) and finally displayed through the use of frequency tables and charts. Collected data was analyzed using both quantitative and qualitative measures. Qualitative data regarding customer level satisfaction, challenges faced demographics and services provided and used were analyzed using content analysis to measure the semantic contents of the message. Qualitative data was analyzed using statistical data analysis. The data was tabulated in pie-cha rts, tables and graphs for easier understanding and presentation. Data Analysis and Interpretation This section presents the data analysis, findings and discussion of the study in line with the research objectives of the study, the study’s research objective was to establish the impact of mobile and internet banking on financial performance of financial institutions in Kenya. To achieve the objective the research raised a number specific objective; to establish the extent of use of mobile banking and the extent of use of internet banking in financial institutions in Kenya. Data analysis The response rate of the questionnaires from the three types of institutions under study was fairly high, out of the 98 questionnaires sent to the respondents, 64 questionnaires both from customers and managers/employees were returned for analysis. To enhance the quality of the data obtained structured questions were used whereby the respondents were asked to give various indicators on mobile and internet banking. Various data were collected to satisfy this study in accordance with the methodology. The software that was used for the following analysis was Microsoft excel and Statistical Package for Social Sciences (SPSS). Summary The study revealed that among the financial institutions surveyed, commercial banks had the highest usage of internet banking at 43.3%, SACCOs had the second highest usage of internet banking whereas none of the microfinance institutions used internet banking.Amongst all the financial institutions surveyed commercial banks had the highest usage of mobile banking, SACCOs the second highest whereas MFIs had the least usage of mobile banking even though all of them used mobile banking. Of the services provided by financial institutions via internet banking the service that customers used most was online balance inquiry (40%) whereas the least used service was online bill payment (3.3%). According to the financial institutions the customer turn out level was high (63.3%) as a result of the use of internet banking. 66.7% of the respondents indicated that internet banking had a positive impact on performance whereas only 6.7% indicated that it had not impacted on performance of the financi al institutions Conclusion The study was able to achieve the set objectives; to explore the impact of mobile and internet banking on performance of financial institutions, as well as the extent of use of mobile and internet banking, by surveying a representative sample of financial institutions within Nairobi. The study found that commercial banks had the highest rate of usage of internet  banking among the financial institutions sampled. SACCOS are slowly adopting internet banking, while micro finance institutions have not yet adopted internet banking. The study revealed that the most prevalent internet banking services were seeking product rate information and the use of online credit cards. Since its introduction in mid-2005, the adoption of internet banking has been slow due to impaired unavailability of infrastructure and lack of supportive legislation for internet banking (Nyangosi et al 2009). However the adoption of internet banking has enhanced performance of the banking industry due to increased efficiency, effectiveness and productivity. The study found that mobile banking faces various challenges among them being, system delays by the mobile money transfer service providers, slow processing of transactions especially during the weekends, high transactions costs, limit on the amount of money that can be withdrawn in a day and fraud. These challenges can be solved through regular maintenance of mobile money transfer systems which will help in managing the systems’ capacity and in turn address the problem of transaction delays and improve customer service through speedy support and lower user charges. Suggestions for further study The study focused on the impact of internet and mobile banking on financial performance of financial institutions in Kenya while its evident its rampant growth impacts on the overall economy as well. Therefore, a study should be conducted to investigate the impact of mobile and internet banking on the economy.The study found that mobile banking has been adopted at a faster rate than internet banking therefore a study needs to be conducted to investigate why this is the case. References: Berestien, A. (1998), Monetary Policy Implications of Digital Money, Kyklos, Vol. 51. Bhattacharya, S. and A. Thakor (1993), ‘’Contemporary Banking Theory,’’ Journal of Financial Intermediation 3, 2-50. Bilderbeek, R (Dir.) (1994): ‘’Case studies in innovative and knowledge- intensive business services.’’ TNO Report. STB/94/041. Research project for the EC DG XIII, print EIMS Programme. Bryman and Bell (2003), is the resource-based ‘view’ a useful perspective for strategic management research?, The Academy of Management Review, 26(1), 22-40 Central Bank of Kenya. (2008) Bank Supervision Report. Nairobi: Central Bank of Kenya Central Bank of Kenya. (2009) Bank Supervision Report. Nairobi: Central Bank of Kenya Central Bank of Kenya. (2010) Annual Report. Nairobi: Central Bank of Kenya Cooper, D and Emory, C. (1995) Business Research Methods. Chicago. Irwin Diamond, D. and P. Dybvig (1983) ‘’ Bank runs, deposit insurance and liquidity,’’ Journal of Political Economics 91,pp.401-419 ECB (1999) ‘’ Payments Systems in the European Union’’: Addendum incorporating 1997figures (Blue Book), January. Freedman, C. (2000), Monetary Policy Implementation: Past, Present and Future-‘’Will Electronic Money Lead to the Eventual Demise of Central Banking?’’ International Finance, Vol.3, No.2, pp. 211-227 Freixas, X. and J.C. Rochet (1998), Microeconomics of banking, MIT Press. Friedman, B, (1999), the Future of Monetary Policy: The Central Bank as an Army with Only a Signal Corps?InternationalFinance, Vol.2, No.3, pp.321-338. Goodhart, E. (2000). Can Central Banking Survive the IT Revolution? InternationalFinance, Vol. 3, No.2.pp.189-209. Juniper Research, (2009). Mobile Banking Strategies: Applications, Opportunities and Markets 2010-2015. Kariuki, N. (2005), Six Puzzles in Electronic Money and Banking IMF Working Paper, IMF Institute. Vol. 19. February. Mcmillan & Schumaker (2001); Non-enforceable implementation of enterprise mobilization: and exploratory study of the critical success factors, Industrial Management & Data Systems, 105 (6), 786-814. Prinz, A. (1999), Money in, the Real and the Virtual World; E-Money, C-Money, and the Demand for CB-Money, Netnomics, Vol.1, pp.11-35. Santomero, A.M, and Seater J.J, (1986). Alternative Monies and the demand for Media of Exchange, Journal of Money, Credit and Banking, Vol.28, pp. 942-960. Steven A. (2002), Information Systems: The Information of E-Business, New Jersey: Natalie Anderson, pp.11-36 Tarkka, J.(2002), The Market for Electronic Cash Cards, Journal of Money, Credit and Banking, Vol.34, pp.299-314.

Market Structure Research Paper Example | Topics and Well Written Essays - 1500 words

Market Structure - Research Paper Example (Eaton, Diane and Douglas, 2002 pp.93) The firm is in equilibrium if it maximizes profit defined as the difference between revenues and costs (** = R-C). The equilibrium point is where the firm produces the output that maximizes the difference between TR & TC curves as shown below. In the short term the firm will either be making excess profits or losses depending on the position of an AC curves i.e. if the AVC curve lays below the price the firm is making excess profit as shown below. It is only possible for the firm to be equilibrium. The short run without necessarily breaking even point. However, in the long run the firm will either make neither losses nor excess profit i.e. the break even point will be the equilibrium point for the firm as shown below. The supply of such a firm may be derived by the points of intersection of MC curve with the successive demand curve. Assuming that the market prices increase gradually the demand curve will tend to shift upwards. Given the slope of the MC curve is positive each higher demand curve cuts the given MC curve on a point which lies to the right of the previous intersection. This implies that the quantity supplied by firm increases as the price increases. (Eaton, Diane and Douglas, 2002 pp.85) Changing from perfect competition to a monopoly that changes a single price will have associated implications to the firm. This is because as a monopoly market the market structure will consist of one single firm that will deal with products that have no close substitute, there will be no free entry of into the market and the firm will be a price maker meaning that the amount sold in the market will depend on the price Q = F (P) The monopolist will have a normal demand curve Q = a - b P with an option of making either of the following two decisions: (1) the price - in this case the quantity will be determined by the customer (2) the quantity- in this case the price will be determined by the future of demand and supply in the market The demand is equal to the average revenue (P = AR) for the monopolist since: Q = a - b P b p = a - q P = a - Q or a - 1____ ____ ____ Q b b b TR = P Q but P = a - 1____ ____ Q b b AR = TR = (a/b) Q - (1/b) Q2 = (a/b) - (1-b) Q thus P = AR ________________ Q They all have a common intercept (a/b) with the MR curve being twice as steep as the AR or the Demand

Strategy Formulation Essay Example | Topics and Well Written Essays - 500 words

Strategy Formulation - Essay Example In this respect effective use of communication techniques within and without the organization is emphasized by strategic management experts in order to achieve these long term objectives. Communication within the organization is necessarily influenced by its leadership style and organizational culture and structure. A vertical top-down structure with an autocratic leadership style is less likely to facilitate efficient communication between different layers of the hierarchy while conversely a horizontal structure with a democratic leadership style would more likely facilitate good communication flow between departments. Strategic long term goals such as market share, profitability, an increase in the share price, quality improvements, customer satisfaction and brand loyalty have to be achieved by adopting such strategies as good internal and external communication practices, employee relations, good motivation strategies and HRM practices, sound financial management including positive cash flows and better overall performance metrics. For example there are good and bad business practices being adopted by companies in the process of planning and design of management and business strategy. Many organizations depend on the available information to make such decisions. This is strategically a bad business practice because information asymmetry often misleads managers and their subsequent decisions based on such imbalanced information could be wrong. Nowadays organizations have better approaches to such intricate problems. In the planning and design process of VRIO (value, rarity, inimitability and organization) framework businesses have adopted such revolutionary approaches. For instance Accenture, the largest strategic management consultancy in the world, places emphasis on VRIO framework in such a manner that it’s very difficult for its competitors to duplicate its VRIO environment in any meaningful manner. This example illustrates

Discussion Essay Example | Topics and Well Written Essays - 250 words - 83

Discussion - Essay Example While my preference to be a quiet person during teamwork has hindered my role as a team member, it has also helped strengthen the team in many ways. For instance, I have not been able to communicate effectively during teamwork and this has adversely affected the perception of my team members towards me. Additionally, I have not been able to work to my full potential during teamwork because some of my team members see me as hands off person when it comes to critical matters that are supposed to be handled by all the team members. When it comes to the benefit of my preference as a suite person to my behavior, I have to note that I have developed a listening attitude over the years and this has helped progress my team in various ways. This means that I have helped my team by analyzing each of the perception of my team members before coming up with a conclusive blend of ideas. This has greatly benefited my role as a team member by working behind the scenes. Owing to the fact that my preferences may portray me as a resigned person, I have developed various strategies for managing my preferences so that I behave in a way that is most effective for a team member. Some of them include being proactive when performing various tasks as a team and communicating to team members where necessary as a way of opening

Business decision making Essay Example | Topics and Well Written Essays - 2000 words - 5

Business decision making - Essay Example The essential focus of this feasibility study is to help in decision-making in relation to opening Chatime at UK Coventry. The feasibility study is a great measure that is used in assessing the appropriateness of any given venture. It involves gathering data, storing it in addition to processing it to provide the information required for decision-making As such, this feasibility report will seek to present the computation behind the preliminary capital expenditure, the estimated sales, and the accepted payback period. Data collection process requires intensive planning in order to yield optimal results. Planning enables the data collection crew to set in place the various tools required for the entire process. For instance, the preparation for collection of primary data must acknowledge the contribution of this source of data collection to the entire research design. Quite often, primary data represents fresh evidence of data that other researchers have not delved into before. In real sense, a lot goes into the preparation process required prior to data collection process. For instance, the supervisor must ensure logistical plans are addressed appropriately. Considering the fact that data collection process may take place in varied places, it is important that transport means are made available prior to data collection. All the staff involved in data collection must be transported to their various sites that have been identified within reasonable time. This will also entail setting up central poi nt where all the data that has been collected is presented. This is to ensure that proper storage is guaranteed for all the data that is collected. At the same time, it is very significant to contact the local authorities within the area affected by data collection. This is meant to limit any possible suspicion on the part of local leaders or authorities.

Design study on, HER2 overexpression and HER2 glycobiology changes Essay

Design study on, HER2 overexpression and HER2 glycobiology changes - Essay Example In the last years, multiple attempts have been conducted to develop strategies that could actually determine the over-expression of HER 2 positive breast cancer indicators in secondary breast cancer cell line compared to the primary cell line expression and the glycosylation process changes connected. In this regard, breast cancer lines have significantly been used to investigate the cancer pathobiology for new emerging therapies thereby identifying the cancer oncogenesis as a molecular heterogeneous disease (Schwab & Thomson Gale 2008). HER2 over-expression in metastatic breast cancer and O-Glycan changes exhibition has been used in invasive breast cancer in conjunction with the therapy involved for the illness. Therefore, HER-2 issues in metastatic versus primary breast cancer overexpression are associated with the HER-2-positive discovered disorder (Tavani, 2006). The increased prominence of HER-2 overexpression accompanied by glycosylation changes has increased interest in Breast cancer pathobiology researchers and academic learners to focus mainly on the basic theories and explanations for the origin and therapies for this particular condition. Many authors claim that the HER-2 oncogenes have been found to encode a transmembrane tyrosine kinase receptor that is responsible as the central classifier for the targeted therapy and invasive breast cancer disease (Jo & Zeon, 2015). On a broad analysis, the immunohistochemistry, fluorescence and chromogenic in-situ hybridization and the major marketed slide-based HER-2 methods are presented and contrasted broadly against the fundamental background of the HER-2 testing guideline testing (American Society of Clinical Oncology–College of American Pathologists guidelines). The over-expression of the HER2 receptor and glycosylation changes associated with breast cancer

Microbiology- SLP Essay Example | Topics and Well Written Essays - 500 words

Microbiology- SLP - Essay Example Both Escherichia coli and Lactobacillus bulgaricus are bacteria; however, Escherichia coli are gram-negative bacteria and Lactobacillus bulgaricus are gram-positive bacteria. Escherichia coli are gram-negative bacteria, which inhabit the intestines of healthy animals and humans (Canadian Medical Association Journal, 2000). Majority of the Escherichia coli serotypes are not pathogenic; however, those that lead to diseases are grouped and classified based on their pathogenic mechanisms. Presently, there are six Escherichia coli pathotypes known to cause diarrhea in human beings, and they include enteroinvasive E. coli, enteropathogenic E. coli, enterohaemorrhagic E. coli (EHEC) (shiga toxin-producing E. coli [STEC]), enterotoxigenic E.coli (ETEC), diffusing adhering E. coli, and enteroaggregative E. coli (Naicker, Olaniran, and Pillay, 2011). However, pathotypes of E. coli such as ETEC and STEC are potent pathogens linked with mortality and waterborne disease outbreaks in humans (Naicker, Olaniran, and Pillay, 2011). On the other hand, Lactobacillus delbrueckii subspecies bulgaricus is a gram-positive bacterium, and it is closely associated to L. acidophilus, L. acetotolerans, L. amylophilus, L. gasseri, L. helveticus, and L. amylovorus. The ratio of GC content in L. delbrueckii subsp. bulgaricus is higher (49-51 percent) than the other species (34 – 46 percent) in this phylogenetic tree (The Regents of the University of California, 2012). The structure of both Escherichia coli and Lactobacillus bulgaricus are the same. Both bacteria are rod shaped, and they are non-spore forming. However, there are differences that distinguish Escherichia coli from Lactobacillus bulgaricus. Escherichia coli are non-spore forming rod bacteria. Most of the strains possess peritrichous flagella, fimbriate and motile. A capsule in the form of mucoid is usually

Theories of Globalization in Communication Essay

Theories of Globalization in Communication - Essay Example Subsequently, the impact of the mass media and communication on the culture of people is also presented. The impact is surmised and given in the conclusion of the paper. A number of theories have come about linking the communication, specifically media, the culture and the society at large. While the media was thought to have cast an alter personality who would be forced to behave in a specific way. The altercast theory do have supporters and some of the behavioural traits generated go in line with this. A development of the altercast theory is the cultivation theory which says that the thought processes in the people who are watching the media can be cultivated over a period of time. Like a plant or stalagmites on the roofs of the cave, they are slowly and steadily built over a period of time. This also meant that the presence in the media is needed and continuously too. The domestication theory, on the other hand, looks at the entire society to be a network of households; a network that runs on cultural, social and technological creations. Miller (1988) defined the concept of domestication theory into four phases; from appropriation, objectificati on, incorporation and conversion starting from the creating a product to objections to its usage and then on to incorporating into the daily lives. Incorporation would also involve converting the technologies and products to suit the cultural style of the locale. This also includes the environment. The final stage is when the household converts itself in line with the trends that is happening in the society and tries to be in line with the outside world. While the gatekeeper theory, pushes forward the much observed, head of the family concept, where one of the members of the family, the mother or the wife wields more strength in deciding on what gets bought (Golding & Harris 1997). What kind of food and clothing is worn by the people is decided more by them rather than by the other members of the family. A person who wants to push need to ensure that the deciding person is the one addressed in their media ads. Gatekeeping concepts have been developed subsequently, so that many organisations even use gatekeeping in their organisational setup (Mattelart A 1998). Even these decisions by the gatekeepers are decided based on the mental models that they have in their mind. Most of the decisions made by the people depend on the mental pictures that they have of the product in their mind, according to Thussu (2000). He also stressed that reasoners build models of truth rather than models of false. Therefore, it is easier for people to make m istakes during such model building exercises. Modernisation theory came up in three waves. Modernisation invariably brings in the western culture under focus and its spread in the world. The first wave of the theory accepted the influence of modernisation with the western culture and technologies at its core. It dominated the entire world and was part of the globalisation agenda. During the second wave that happened in the 1970s and 1980s, the cultural impacts were more widespread. But at the same time, there were very few supporters of the western influence in the cultures of the world. Modernisation was noticed and continued to happen but there was opposition even among the western society, specifically the

The Invasions of Europe Essay Example for Free

The Invasions of Europe Essay On the later stage of the dark ages or the Middle Ages, Europe experienced loses from barbaric attacks by Vikings, Magyars and Moslem invaders which ranged from early 9th century up to 11th century. These invasions had made Roman Empire lost most of its land area as well as the trust of people to the Christian leaders. Vikings started their attack because of overpopulation in their homeland. They came first to England then to Iona, Ireland and the rest of the north and western part, destroying the most civilized part of the region and plundering the rich trading centers and monasteries. As each attack became successful, they would return in more numbers. Their invasions had become easier on them because they had their sail ships compared to their earlier invasions which was by foot. People started fearing to live in the coastal region. While some of the Vikings battle in the western half of Mediterranean, some began settling in the northwest of France and the others came to Moslem Spain and Great Britain. Chieftains would bribe them in order for Vikings not to attack their villages. Some groups such as Danes began the resistance and successfully defended England. As Normans settled down, they began to decrease in number. They became civilized and were converted to Christianity. They had lost their lust in plundering. During that period, in the other part of Europe, the Moslems had gone invading Spain, threatening Italy, droving out Byzantines in Sicily and southern Italy. They almost got into Rome. While Moslems continued their attack in the Mediterranean, Magyars began invading the east. These groups of invaders which simultaneously attacked from all sides had surrounded the European continent. Magyars invaded Germany each year. They had passed through Germany, France, Burgundy, all the way to Italy. While some of them continued to pursue their attacks at France, others left for Spain. Until the Magyar armies were annihilated by a German king Otto I, Europe became safe from invasions.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   All of these invasions had contributed to the downfall of the rich Holy Roman Empire. But they experienced the worst attack from the Magyars mainly because during that time that they attacked, Europe was already suffering from attacks of Vikings and Moslems. There were almost no civilized regions left during that time and areas became less populated. They invasion became so damaging as they suffered simultaneous attacks from all sides.   As the Roman Empire tends to collapse, they failed to resist these attacks earlier because they had fewer warriors.   Some locals burn their fields not letting the barbarians have it. Most of the richest parts were prone to attack while monasteries were heavily subjected to being destroyed. People suffered heavily. They lost their lands, livelihood and their wealth. As they mourn, they ran to the church for comfort but they were disappointed as there were anomalies in the leader of the churches.   Some of them became robbers, adulterers, and murderers and converged into realms of politics. There were numerous replacements of popes. At a time there were â€Å"illegal doings† in the papal palaces. Some must have lost their trust in their belief. Yet, Christianity did not end there. It was reformed by Benedictine monks in France. As the Magyars were defeated during that time, they became converts to Christianity and settled at Hungary. Vikings were also converted to Christianity but one of the main reasons is that Christians didn’t want to trade with and marry non-Christians. During the latter course of Dark Ages, Europe gradually recovered from the invasion. Leaders were crowned but had conflicts with Christian leaders. There were tensions between them about who had the greatest power. And so the Dark Ages ended. References Kimball, C. (2001). Chapter 7: The Viking Era. A History of Europe. Retrieved December 7,   Ã‚  Ã‚   2007, from http://xenohistorian.faithweb.com/europe/eu07.html. Knight, J. (2001). The Carolingan Age. Middle Ages: Almanac, 39-45. Retrieved December 7,    2007, from http://www.4shared.com/file/28008239/b4f1dc89/Gale_- _Middle_Ages_Reference_Library_Vols1-5.html [database].

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