Treatment of ankle syndesmosis injuries - Free Essay Example

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

Roles of Characters in Henrik Ibsen´s A Doll´s House Essay

Reading Henrik Ibsen’s â€Å" A doll’s house† it proves that the writer puts importance on the characters and the roles they play in the stories. The main characters in this story pretend more to be someone else than who reader would prefer them instead of being their true selves. The one person whose character highly stood out throughout the whole story and who’s role couldn’t do more justice than said in the story to point where to seems like she leads two different lives is none other than Nora. According to her husband Torvald, Nora is childish even though she is his wife but however she is loving but little that he is aware that she’s unpredictably a strong and an independent woman. As the plays moves forward readers will highly realize†¦show more content†¦His life was the reason why she was forced to take a loan from a rich man named as Mr. Krosgstad. Nora not only got this loan hiding and behind Torvald’s back but also she broke the legal process a women is allowed to obtain it. Nora’s friend, Mrs. Linden, remarks â€Å"a wife can’t borrow [money] without her husband’s consent† (Ibsen 848). This while act proves that Nora is not solely a money loving person, or the person who just follows her husband’s instructions given out to her but she is a determined individual who does what is needed for the best and safe side of her loved ones. Finally after ample of acts in the play when Torvald finds out of the debt and Nora’s forgery he becomes angry at Nora for what she have done. It was in that moment when Nora finally understood that she was not completely herself through out her marriage with Torvald as she is found defending her position on her actions and in her dialogues she states that â€Å"When I look back on it now†¦ I lived by performing tricks for you, Torvald. But you would have it so† (Ibsen 885). 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Olbers Paradox - Why the Night Sky Is Dark

Student Loan Debt Forgiveness Stimulus For The Economy

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Robert Applebaum, the Author behind the Student Loan Forgiveness Act, believes that student loan should be forgiven to highlight anRead MoreIs Forgiving Student Loan Debt A Good Idea?1227 Words   |  5 PagesForgiving Student Loan Debt a Good Idea?† states Robert Applebaum’s solution for student loan debt is a â€Å"radical and wildly unfeasible solution both economically and politically. Applebaum’s proposal is to â€Å"provide a one-time bailout of student debt†¦as a way to stimulate the still-limping economy.† However, Webley counters that the solution has to have â€Å"the purporte d benefited and fairness of a one-time student loan bailout.† In Webley’s essay, in the sixth paragraph she mentions the average debt totalRead MoreGraduation Speech : College Is Not A Opportunity1817 Words   |  8 PagesWithout a doubt, today’s purpose of college is to foster student development. However, it’s become unclear with the rising costs of tuition as well as the growing importance of preparation for a job upon graduation. In fact, universities are no longer seen as simply a place of higher education. They are rather professional junctions from which students can become secure jobs and steady income afterward. This is partially due to the fact that graduating high school is no longer seen as an accomplishmentRead MoreStudent Loan Debt And Why It Is A Problem Essay1507 Words   |  7 Pages Student Loan Debt and why it is a Problem Student loan debt affects college students all over the United States. Today students are having to take out loans in order to pay for all of their college expenses. It can be a pain to deal with the hassle of paying back the loans. The problems with student loans include causing students to go into debt that they are not able to pay them off in the given time which makes them put major life decisions on hold, and the debt stay with the student evenRead MoreStudent Loan Crisis Research Paper1332 Words   |  6 PagesMany of the protesters occupying Wall Street and other places say they are upset about the rising price of going to college. There is little dispute today that the number of students who have debt has increased, and that the amount of money they have borrowed has gone up (Billitteri). Many students incur large amounts of debt that will never pay dividends in higher wages or greater job satisfaction, and they graduate into a world with weak employment prospects. Its a b etrayal of the American socialRead MoreThe Obama Administration : The Bush Administration Essay1760 Words   |  8 PagesObama has favored internal stimulus packages. So is deficit spending is as necessary as the freedom with our budgets over the last several decades indicates? As millennials, most feel the last 30 years indicate that it is an integral part of our economy: there has never been a moment where the national checkbook has been completely ignored. Joseph Stiglitz, a nobel prize winner, argues that deficit spending increases economic growth and decreases long term government debt (governmentisgood.com). Deficit

The Achaemenid Era Of The Persian Empire - 1652 Words

The Achaemenid Era of The Persian Empire was founded in 550 BCE. At its height of power it the empire â€Å"encompassed approximately 3 million square miles, spanning three continents: Asia, Africa and Europe.† (Persian) The true rise to power of the Persian Empire can be attributed back to one man, Cyrus the Great. Cyrus was born to Camyses I, the King Ansan, and his wife, Mandane. (Religion p. 3) When Cyrus became King his Kingdom was still forced to recognize the Median Lordship of Astyages, a dynasty that had ruled the area for the previous 150 years. In 559 BCE Cyrus formed a rebellion against the Astyages and upon his victory married his daughter Amytis cementing the Medes and Persians together to begin the forming of the Persian Empire. (Briant p. 33) It is believed, although some scholars dispute, that in 547 BCE Cyrus conquered the Lydian Empire and Asia Minor. It must be noted that Cyrus did not attack the Lydian Empire outright, but only responded after Lyd ia attacked the Persian city of Pteria. In response to the attack Cyrus started his campaign against the Lydian empire and did not stop until he had united all of Asia Minor. In 540 BCE Cyrus invaded and conquered the Neo-Babylonian Empire. Again it should be noted that the Neo-Babylonian Empire has conquered many Kingdoms and Cyrus used this as the justification of his invasion. After taking Babylon, Cyrus declared himself â€Å"King of Babylon and King of the four corners of the world.† (Cyrus)Show MoreRelatedThe Empire Of The Persian Empire1051 Words   |  5 Pagesup resulting in a huge change. The leader of the Persian realm named Cyrus was able to gain much territory after a ruler from Lydia named Croesus attempted to provoke Cyrus. Winter was approaching and Croesus was expecting Cyrus to retreat while he retreating back to his capital at Sardis. After, Cyrus was able to invade and take Sardis successfully. This victory over Lydia was significant in aiding the dev elopment and expansion of the Persian empire. There were important social, economic, and culturalRead MoreThe Greek And Persian Empires1156 Words   |  5 PagesThroughout the years, many historians have acknowledged that the classical era was a time when Greek and Persian Empires flourished. With that being said, from approximately 323-800 B.C.E., both the Greek and Persian Empire were experiencing periods of economic, political, and artistic growth. The Persians, like the Greeks, were Indo Europeans, and were located by the Mediterranean Sea, which consequently allowed Greeks and Persians to develop similarities. 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Significance- The biggest city to exist at the time wit the most complex governing, city structure, and buildings of the era, a massive monument to Darius empire. 3. Satrapies pg. 163 A form of government that allowed people, called satraps, selected by the ruler to govern smaller areas, similar to states and governors. Significance- This system allowed a massive empire to be governedRead MoreThe Rise Of The Century King Cyrus And Emperor Constantine1305 Words   |  6 Pagescentral figures in Judaism and Christianity, two of the world’s major organized religions. Cyrus and Constantine took over many lands and built their huge empires on a religious foundation through their autonomous military, economic policies and religious fanaticisms. 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Cyrus and Constantine took over many lands and built their huge empires on a religious foundation through their autonomous military, economic policies and religious fanaticisms. King Cyrus of the Persian Empire and Emperor Constantine of the Roman Empire seized control over neighboring cities with their military strength and later introduce their new religious policies onto the inhabitants living in the landRead MoreDay of Empire Essay2004 Words   |  9 PagesDay Of Empire Summer Reading Essay Empires have dominated our globe for centuries on, yet no one has linked the connection between how these empires rise, and what causes their reign to end. Through collective studies, Day Of Empire author  Amy Chua  presents a persuasive theory which argues that hyper powers achieved their world dominance through tolerance of culture and religion, as well as the individuals residing in the conquered society, amassing their talents for the benefit of theRead MoreThe War Of The Persian War854 Words   |  4 PagesGreece there were many famous wars and conquerors, in every era. These wars were all recorded in early history and lasted a couple of years. The only one that was not, or is thought to be made up, is the Trojan War. The only things they can go off of are the stories and the ruins of the city of Troy. Another famous war was the Persian wars. This war was the first big war between the persian empire and Spartans/Athens. After the Persian war, the Peloponnesian war too k place, which was led by spartaRead MoreThe Conquests and Legacy of Alexander the Great Essay860 Words   |  4 Pagesendeavors echoed far and wide, bringing about new eras and ideas to the world. Alexander earned his place in the world’s history and is worthy of the title ‘The Great’ because of his military prowess, his idealism and his legacy. During the course of his life and reign, Alexander had fought and won many battles and wars, defeating many kings and warlords throughout the ancient world. Perhaps his most recognized conquest was of the Achaemenid Empire of Persia and its ‘King of Kings’ Darius III during

The United States Illegal Immigration Dilemma Free Essays

The United States throughout its history has been built by the hard work and contributions of immigrants. Immigration has always been a vital part of the development of this nation from Colonial days until now; however, Illegal Immigrations has become an issue that is not just discussed by the politicians in Washington, DC and those Border States that are been affected most by it. The issue of Illegal Immigration over the last decade or so is now an issue that seems to be affecting more aspects of the Nation than most seem to be aware of. We will write a custom essay sample on The United States Illegal Immigration Dilemma or any similar topic only for you Order Now Illegal immigration has the United facing a situation that it has not had to deal with in over two centuries. The issue of illegal immigration is poses several questions that need to be addressed; how did we get ourselves in the predicament that we are in? Was it the Government Policies and Laws that were or are not being enforced? Maybe, the lack of border security or could those employers who hire known illegal immigrants be the cause. Another, topic that needs to be address when considering the dilemma facing the US is; What impact does Illegal Immigration have on the countries overall Economic System? How does this problem affect our Health Care System, our Educational Systems and Employment opportunities for legal Tax-paying citizens? The most important topic of all is; what is a viable solution to the problem of Illegal Immigration? What type of Immigration Reform will work for all parties involved? Will allowing States to come up with their own laws, instead of relying on the Federal Laws be the right answer, or will revising the 14th Amendment, or Amnesty is the solution? Congress’ major intent when creating Immigration Laws and Policies both early in US history and recently was to accomplish the several goals; â€Å"First, to reunite families by admitting immigrants who already have family members living in the United States. Second, seeks to admit workers with specific skills and to fill positions in occupations deemed to be experiencing labor shortages. Third, it attempts to provide a refuge for people who face the risk of political, racial, or religious persecution in their country of origin. Finally, it seeks to ensure diversity by providing admission to people from countries with historically low rates of immigration to the United States† (Congressional Budget Office, 2006 p. 8); however, there are others actions, or lack of action by government agencies that seem to counteract the very intent of the laws and policies created. One example is the lack of funding and enforcement of our countries border security system. Another example is the non-enforcement of laws and policies governing employers who knowing hire illegal immigrants. Statements like the following by then President Bush, sums up the US governments state of mind and the country’s National Interest concerning the Illegal Immigration issue; â€Å"the U. S needs more cheap labor from south of the border to do the jobs Americans aren’t willing to do, there are uncalculated cost involved in the importation of such labor – public support and uninsured medical costs† (Costs of Immigration, 2007, para. 1). Illegal Immigration’s impact on the US economy can be seen in the following areas: Our Health Care System, our Education System and in Employment Opportunities for legal citizens. The net fiscal cost of immigration ranges from $11 billion to $22 billion per year, with most government expenditures on immigrants coming from state and local coffers, while most taxes paid by immigrants go to the federal treasury. The net deficit is caused by a low level of tax payments by immigrants, because they are disproportionately low-skilled and thus earn low wages, and a higher rate of consumption of government services, both because of their relative poverty and their higher fertility. This is especially true of illegal immigration. Even though illegal aliens make little use of welfare, from which they are generally barred, the costs of illegal immigration in terms of government expenditures for education, criminal justice, and emergency medical care are significant. California has estimated that the net cost to the state of providing government services to illegal immigrants approached $3 billion during a single fiscal year. The fact that states must bear the cost of federal failure turns illegal immigration, in effect, into one of the largest unfunded federal mandates. Yet we still have those who believe that illegal immigrants do not have an adverse effect on the economy (â€Å"Center for Immigration Studies†, 2006, para. 1). The Health Care system here in the US has probably seen the biggest impact of illegal immigration when looking at the overall picture and considering the dilemma as a whole. An example of these effects in Texas is the statement made by â€Å"Rick Alleyer, director of research for the Health and Human Services Commission, said illegal immigrant health care – mostly emergency hospital care – cost the state over $100 million last year† (Illegal Immigrant Care, 2010, para. 5). Throughout the country in states like Texas, New Mexico, Arizona and California hospitals have had to either closing their doors completely or file bankruptcy because of federally mandated programs requiring free emergency room services to all illegal immigrants. The effects of illegal immigration on the US educational systems may not be as profound as they are for the health care system, the impact is noticeable enough for educators, politicians and state governments to consider when they receive yearly reports of how poorly their schools are performing, the increase in student population, and how the cost of education continues to increase. According to Edwin Rubenstein, â€Å"Immigrant children are poorer than native-born children, and their numbers have increased far faster. At least 19 percent of all K-12 enrollments are the result of immigration. In excess of 9. 2 million are immigrants or the children of immigrants. Because of their lack of language abilities, they take 25 percent of funding. Out of $499. 1 billion in the 2008 school year, $125 billion was spent on foreign born children† (Illegal Alien Education Impact, 2008, par. 7). Notice this was just considering secondary schools in the state of California. There are numerous states and schools that are rewarding illegal immigrants for enrolling in the schools, yet they are denying the same subsidies to lawful students or legal immigrants. The ever increasing number of illegal immigrants flowing into the US every month plays a dramatic role in displacing American workers, over the past five years it is estimated that 1 million legal citizens have been replaced by immigrants allow to come this country on work visas. Another area for concern pertaining to illegal immigration and its effect on employment opportunities is, the trend among illegal immigrants changing from the traditional few industrial area and parts of the country, integrating themselves into all sectors of the economy throughout the nation. The concern here is the increasing widespread demand for their labor. Having discussed some of the areas that our country are faced with, and most do something about, we now will look at some possible solutions on how to deal with this dilemma. Realizing that Immigration Reform is must do, what areas need to be addressed, and what adjustments need to be made is the question at hand. One of the many Immigration Laws and Policies that has been created over the years is the 14th Amendment and the â€Å"anchor baby† concept. This amendment has been in the news and on the mouths of politicians almost as much as Immigration Reform itself. The question that needs to be addressed is will amending this amendment provide enough assistance to drastically decrease the flow of illegal immigrants into the country? If we look at the direct effects that the 14th amendment has on the country some feel very strong about amending this amendment. For example some believe that rescinding the citizenship of anchor babies; â€Å"American hospitals welcome anchor babies†¦Anchor babies are citizens, and instantly qualify for public welfare aid: Between 300,000 and 350,000 anchor babies annually become citizens because of the Fourteenth Amendment to the U. S. Constitution: ‘All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and the State wherein they reside. ’† (Illegal aliens threaten U.  S. economic system, 2008, para. 12). The concept of individual states enacting their own laws and initiatives could be the short term solution. Arizona’s AZ SB 1070 law, even though not fully implemented, is one such example of states taking matters into their own hands not waiting on the Federal government to enforce the laws they created. Arizona Senator Russell Pearce (2010) â€Å"characterizes the illegal immigration problem as one of invasion and quotes the Constitution: â€Å"The United States shall guarantee that every State of this Union a Republican Form of Government, and shall protect each of them against Invasion† (p. ). Arizona is not the only state that has come up with laws to help deal with the illegal immigration population in their states; you have states like Colorado, Georgia, Idaho, and Oklahoma. The state of California has a bill that has begun the signature process, the California Taxpayer Protection Act of 2010, Initiative 09-0010. This bill is for â€Å"real world citizens, â€Å"The people of California have an opportunity to curb the illegal immigration. Many in California may not have seen the grass lately, but we’ve been seeding our roots† (Dvorak, 2009, p. ) The Illegal Immigration Amnesty bill was signed into law by President Reagan in 1986 in an effort to provide amnesty to illegal immigrants that entered the country before 1982. The intent was to be tighter security on the borders and stricter penalties for employers hiring undocumented workers. Needles to say, this law seem to accomplish the exact opposite. There are some who believe that with the proper oversight and funding this could prove to be a viable solution to the illegal immigration problem that the U. S. aces today. There are also those who believe that the Amnesty Law is a major cause of illegal immigration, many immigrants believe that once they get here to the U. S. they will qualify for amnesty in a matter of time. â€Å"Many in California believe the federal government has dropped the immigration ball over the last 40 years. â€Å"In Washington D. C. they have a few nicknames; reform is code word for amnesty† (Dvorak, 2009, p. 2) It is without a doubt that the US was founded on immigration and its many contributions over the years. The dilemma that we face today brings into question if the laws and policies of the past are serving their intended purposes, if they are still beneficial to the country, and if there are new laws that need to be created to address some of the issues that have been created because illegal immigration. Even though actual numbers of illegal immigrants were not discussed because of inaccurate data; the issues concerning how did we get to this point; what are the impacts of illegal immigration on the countries social and economic systems, and probably the ost the most import issue is what are we going to do about it. The solution to this dilemma should include, not just the enforcement, of the policies and laws established but, it should also make sure they are properly funded as well. The solution should contain initiatives that address those topics that negative effect the country as well as initiative that reward positive effects of illegal immigration; keeping in mind the countries national security and national interests in mind. References http://www.redstate.com/renny/2010/08/17/az-sen-russell-pearce-on-his-states-immigration-law-and-the-rest-of-us/ http://www.theamericanresistance.com/articles/art2005mar13.html http://www.rense.com/general81/illega.htm How to cite The United States Illegal Immigration Dilemma, Essay examples

Healthcare Performance Analysis

Question: Research and analyze healthcare performance data in two countries. The two countries which are selected for the comparison are Australia and Canada. Answer: This study aims to research and analyze healthcare performance data in two countries. The two countries which are selected for the comparison are Australia and Canada. A comprehensive comparison will be made in the areas such as funding system (including health insurance systems), governance system, selected population health indicators, health system performance and % GDP spent on Health. This study will also define each of the measures and will provide the results and commentary for the comparison has been utilized to demonstrate healthcare. In Australia, Healthcare is provided by the private as well as the government institutions. The Australian healthcare system offers worldwide access to an inclusive range of services that are mostly funded through universal taxation. In the year 1984, Medicare was introduced which covers worldwide access to the treatment which is free in public hospitals and financial assistances for medical services (Oderkirk et al., 2013). This country possesses a federal system of government, through a Commonwealth (national government) along with two territories and six states. Health remained the liability of the states, at Federation. Though, the Commonwealth Government holds the maximum authority to raise revenue, so the states rely on fiscal transfers so that their systems of health can be supported by the Commonwealth (Morgan et al., 2013). This makes the system of Australian health care a versatile division of roles and responsibilities of the different states of Australia. It is also notic eable by a complex interaction of the public as well as the private sectors. It is also essential to note the number of insured individuals aged over 65 is 1.86 million which represents that around 53% of the populations of Australia are aged over 65 (Eijkenaar et al., 2013). Rising levels of insurance across the elderly Australians is a necessary factor in making sure that this country possesses the ability to deliver outstanding healthcare as its populations get older (Janssen, 2013). On the other hand, in Canada, Healthcare is publicly funded which is mostly cost-free, and most of its services are provided by the private entities. Through federal standards, the government of this country endeavors to guarantee the quality of care (Oderkirk et al., 2013). There is no participation by the government in everyday care or collection of information regarding the health of individuals. The provincially based Medicare systems are partly cost-effective because of the simplicity in administration. In the provinces, the doctors handle the claim of insurance against the provincial insurer (Mossialos et al., 2015). The expenditure of private health accounts for around 30% of finances associated with healthcare. In this country, Single-payer healthcare system is followed in which the costs of healthcare are paid by the private insurers and not by the state itself. The actual financial support of the single-payer system comes from all or a part of a population (Foroughi et al., 2016). The governance system of Canada is based on a federal democratic system which denotes that there is an existence of two systems in this country. One is a provincial government which is involved in the setting of laws along with regulations intended for the region they represent, and other is a federal system which is involved in the governance of the entire country (Walls et al., 2012). On the other hand, Australia is no different than Canada regarding the governance system. It is compulsory for the individuals residing in the country of Australia to cast their vote in the elections and if in case, if they do not cast their vote they possess a risk of getting behind the bars (Schfer et al., 2015). The governance of these two countries closely resembles each other, and both of them follow the British parliamentary system. Their resemblance can be characterized principally by the fact that both of these countries are the members of the British Commonwealth (Schoen et al., 2012). Considering the selected population health indicators such as maternal and mortality rate, infant mortality rate, life expectancy at birth, Health status, low birth weight, diabetes, asthma, hypertension and cancer, the comparison of these two countries can illustrate a clear picture with respect to all these parameters. The first population health indicators which will be compared involves maternal mortality, the ratio of maternal mortality is the number of women who die from the causes that are associated with pregnancy while undergoing through the period of pregnancy or within the termination of pregnancy within 42 days per 1000,000 live births (Bourke et al., 2012). This data is estimated with a model of regression utilizing information on the ratio of maternal deaths (Papanicolas et al., 2013). Maternal mortality rate in Australia is a rare incident in the context of global maternal deaths. From 2008-2012, there had been 106 maternal deaths that took place within 42 days of the end of the pregnancy and represented a ratio of maternal mortality of 7.2 deaths per 1000,000 women who delivered babies (Oderkirk et al., 2013). These deaths ought to be observed as distressing the family and community of the womans. On the other hand, in Canada from 2009-2010, the rate of maternal deaths was 6.1 per 100,000 deliveries. In the year 2010-2011, the most widespread diagnoses that were associated with these deaths was due to the diseases involved with the circulatory, digestive and nervous systems along with some mental disorders (Eijkenaar et al., 2013). Another health indicator which can be compared with respect to both of the countries involves infant mortality rate, which is the number of deaths of infants before reaching one year of age, per 1,000 live births in a year. In the year 2012, there were about 1,032 deaths registered in Australia of the infants who died before reaching the age of one. This ratio was a 9.7% decrease compared with the number registered in the year 2011. Over the last decade, there has been a reduction in the number of deaths of the infants, with a few fluctuations, from 1,265 deaths in the year 2002 to 1, 032 in the year 2012. On the other hand in Canada, in the year 2007, the number of deaths of an infant less than one year of age per 1,000 lives was 5.2. It is the second country with the highest rate of infant mortality (Walls et al., 2012). Life Expectancy at Birth, this is the most frequently, utilized measure to describe the health of the population and it reveals the overall level of mortality of a population. It measures on an average how long individuals are expected to survive based on their present age and sex-specific rate of deaths (Kassebaum et al., 2014). In Australia, life expectancy has improved noticeably for the male and the females in the most recent century. In this country, a male who took birth in the 2011-2013 is expected to live to the age of 80 years and a female is expected to survive to 84 years compared to 46.2 and 51.1 years, respectively, in 1882-1890. On the other hand in Canada, the average life expectancy for males who took birth in the year 2013 is 81 and for the females 84. For both the sexes, life expectancy at birth augmented on an average from 76 in 1990 to 82 in 2012 (Janssen, 2013). Health Status is a comprehensive concept that is established the presence or absence of any type of disease. It mainly comprises of functioning, mental well-being, and physical illness. Australians possess a good health, and this country is one of the healthiest countries in the world. The individuals residing in this country have a relatively high expectancy of life, and it could easily remove its burden of diseases from its communities (Mossialos et al., 2015). The rate of mortality is also comparatively low as compared to Canada. In Australia, a decrease in the rates of mortality has resulted in augmented rates of morbidity for several conditions. On the other hand, the health status of Canada achieves a B' with respect to the overall performance of health (Marchildon, 2013). It has third highest rates of mortality because of diabetes, and this disease is continuing to increase. It is raising concerns, not only for the policy-makers of Canada but also to the public. This country a chieves A' regarding the three indicators: premature mortality, mortality as a result of circulatory diseases and self-reported health (Lecours Bland, 2013). It scores a B for life expectancy, mortality as a result of respiratory diseases, mortality as a result of mental disorders and mortality as a reason of medical accidents (Turner et al., 2013). In Australia, around 6% births result in the infants having low weight when they are born. There were 17,565 babies having low weighed during birth which represented 6.10% of all births. From 2001-2003, there were 3,404 lively births of babies having low weight at birth to the Australian Indigenous mothers (Eijkenaar et al., 2013). On the other hand, in Canada, in the year the percentage of babies having low weight at birth was 6.3%. The low weight birth rate remained comparatively steady between 1979 and 2011, ranging from 5.6% to 6.3% (Deber, 2014). In the year 2010, the percentage of low birth weight was lesser than as compared to girls. In the year, 2010, the percentage of rates of low birth weight was above the national average for mothers between 35 to 49 years (Osborn Squires, 2012). In Australia, the occurrence of obesity and overweight has been progressively rising for the past thirty years. Around 65% of Australians adults, in the year 2011-2012, were categorized as obese or overweight and more than 30% of them fell into the category of obese (ABS 2013). In the year 2007, approximately 26% of children aged 3-16 were obese or overweight, with 7% (Mossialos et al., 2015). A report by the Organization for Economic Co-operation and Development (OECD) 2009, predicted that there will be a constant augmentation in the rate of obesity and overweight across all the groups of age in the next decade, to approximately 68% of the population. On the other hand, in Canada, one in four adults and one in 10 children possess obesity, which means that 6 million Canadians suffering from obesity may require instant support in controlling as well as managing their weight. According to Forbes, it ranks 33 on a 2007 list of fattest countries, having 61.2% of its citizens possessing a body mass index of at least 25 (Eijkenaar et al., 2013) It has considerably increased in the case of children between the years 1989 and 2005, with rates in males increasing from 3% to 14% and rates among females increasing from 3% to 13% (Foroughi et al., 2016). Talking about diabetes, in 2011-12, an estimated 921,000 Australian adults aged 20 years and above had diabetes, based onmeasured and self-reported data, from theABS 201112 Australian Health Survey. It included individuals withtype 1 diabetes and type 2diabetes. Around 2% of the adult population did not report that they suffered from diabetes, which indicated that they were ignorant that they had this condition, contrasted with 5% who were aware of it and reported their condition of diabetes. On the other hand, Fifty-eight percent of Canadians suffering from diabetes reported they cannot stick to prescribed treatment due to the high cost of required medications, supplies, and devices. Because of fear of stigma, 38% of Canadian individuals with type 2 diabetes surveyed by the Canadian Diabetes Association reported they do not feel comfortable revealing their diabetes (Lecours Bland, 2013). In Australia, 1 in 10 individuals has asthma. This disease is more widespread in males aged 114, but among those aged 15 and above, it is more widespread in females (Marchildon, 2013). The rate of asthma among the Indigenous Australians, the rate of asthma is almost two times as high as compared to the non-Indigenous Australians. It is even more noticeable in the elderly age group. It is more prevalent in the individuals residing in the areas that are socioeconomically deprived. The occurrence of this disease is considerably higher in the individuals dwelling in inner remote areas compared with the individuals residing in main cities or outer regional areas (Kassebaum et al., 2014). In Canada, rates of asthma have augmented four-fold over the most recent 20 years. Though asthma-related deaths have reduced to some extent, it still causes around seven deaths every week, in spite of advances in what we know regarding the condition and the accessibility of effectual medications. More than 2 million people of this country suffer from asthma and every year it adds to around 360 deaths (Mossialos et al., 2015). In 2012-13, approximately one-third of all adult Australians suffered from hypertension, comprising 22.5% of the individuals having high blood pressure and 10.2% having normal blood (Papanicolas et al., 2013). Males were more probable to have hypertension in comparison to females. Hypertension was extensively more common at older ages, with approximately 9 in 10 individuals aged 80 years and above having hypertension. On the other hand, in Canada, in 2007/08, almost 6.5 million Canadians aged 25 years or more had diagnosed hypertension (around 6.10 million adults; 4.2 million females and 3.8 million males, crude frequency) (Fineberg, 2012). The rate of occurrence of hypertension among the individuals aged 21 years and above was 23.8% in 2007/08 (25.0% for females and 22.4% for males, crude frequency) (Sussman et al., 2012). This frequency is constant but fairly elevated as compared to the self-reported value reported as of the 2008/09 survey of Canadian Community Health (Turner et al., 2013). The values of Self-reported hypertension might be lesser because around 6% of individuals who report treatment meant for hypertension do not report having hypertension in Canadian self-report surveys, probably for the reason that they believe that they do not suffer from hypertension or else their hypertension has been cured when their blood pressure is controlled by means of medication or alteration in lifestyle (Tchouaket et al., 2012). Talking about the prevalence of cancer in Australia, in the year 2013, there were 123,934 new cancer cases were diagnosed (68,289 males and 54,806 females). In the year 2013, the age-standardized occurrence rate was 486 cases for every 100,000 individuals (573 for males and 413 for females).In the future years, it is expected the incidence of cancer will generally increase with age (Nicholson et al., 2012). The proportions of widespread cases of cancer in the population of Canada increased considerably more than the time periods considered. The three-year occurrence ratio for all types of cancers combined at a yearly rate of 3.0% from 1998 to 2009, following steady from 1995 to 1998. Likewise, the five-year occurrence ratio rose by 3.1% per year from 1998 to 2009, and the ten-year ratio, by 3.4% per year from 2003 to 2009 (Brown et al., 2014). Performance measurement and reporting of health in Australia, utilizing performance indicators, is undertaken by the Australian Government and the state and territory governments, as well as a number of private health-care providers (Lecours Bland, 2013). The measurement of Health system Performance is essential to improve the services that provided by governments as well as other contributors. What is precise reveals the significance to governments, to service providers, to the services (counting taxpayers), in addition to customers along with additional stakeholders. In Australia, national public reporting of measured performance of diverse components of the system of health is carried out by several organizations under nationally approved measures (Marchildon, 2013). Canada achieves a B' with respect to the overall performance of health. It has third highest rates of mortality because of diabetes, and this disease is continuing to increase (Deber, 2014). It is raising concerns, not only for the policy-makers of Canada but also to the public. This country achieves A' regarding the three indicators: premature mortality, mortality as a result of circulatory diseases and self-reported health. It scores a B' for life expectancy, mortality as a result of respiratory diseases, mortality as a result of mental disorders and mortality as a reason of medical accidents (Sussman et al., 2012). Diabetes remains a rising concern. This country has the third highest rate of mortality due to the prevalence of diabetes among the peer countries, and its prevalence goes on to augment (Nicholson et al., 2012). It is raising concerns, not only for the policy-makers of Canada but also to the public. This country achieves A' regarding the three indicators: premature mortality, mortality as a result of circulatory diseases and self-reported health. It scores a B for life expectancy, mortality as a result of respiratory diseases, mortality as a result of mental disorders and mortality as a reason of medical accidents (Smith et al., 2012). As a percentage of GDP, Australias expenditure on health in the year 2009 was much less in comparison to Canada (11.4%) (Tchouaket et al., 2012). In 201011, hospitals were undoubtedly the leading area of health expenditure. They consumed 50% of usual health expenditure (which consecutively made up almost 98% of total health expenditure, the rest being for major equipment and new buildings). The next largest constituent was medical services (19%), including primary services provided by specialists and GPs as private practitioners. Drugs made up another 15%, followed by dental services (8%). On the other hand in Canada, Health expenditure accounted for 11.9% of GDP in Canada in 2013, 1.5 % higher than the OECD average of 9.4%. Though, health expenditure as a share of GDP is much lesser in Canada. The public sector is the major source of funding for health in all OECD countries, except Chile and the United States. In Canada, 75% of health expenditure was financed by public sources in 20 13, somewhat less than the OECD average of 73% (Deber, 2014). Percentage of GDP on Health Source: ((Tchouaket et al., 2012). To conclude, the healthcare performance data in these two countries has provided a clear picture regarding the funding system, governance system, different indicators of population health such as maternal and infant mortality rate, life expectancy at birth, and health status along with the prevalence of diseases like obesity, diabetes, asthma, hypertension and cancer. The obtained data have also revealed the health system performance and percentage of GDP spent on health. The results of the obtained data are more or less similar, and these two still lacks behind in comparison to the other countries regarding healthcare. Though, the healthcare of both the countries is almost acceptable, appropriate, effective, efficient and safe. However, both the countries need to improve their healthcare performance because a good performance in healthcare will lead to the successful existence of the individuals in and efficient manner. References Bourke, L., Humphreys, J. 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