Tibialis Anterior Tendon Reconstructed With Plate and Screw

Tibialis Anterior Tendon Reconstructed With Plate and Screw Traumatic Ruptures On The Insertion Of The Tibialis Anterior Tendon Reconstructed With Plate And Screw Fixation Technique And Anterolateral Thigh Flap Running title: tibialis anterior tendon reconstructed with plate and screw fixation technique Haijun Mao M.D., Guangyue Xu M.D. Institution:Orthopedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China Abstract Objective: Traumatic ruptures of the tibialis anterior tendon are rare but can cause substantial functional deficiencies. This study aimed to evaluate the effectiveness of the reconstruction of traumatic ruptures on the insertion of the tibialis anterior tendon using plate and screw fixation technique and anterolateral thigh (ANTEROLATERAL THIGH) flaps. Methods: Eight consecutive patients with a traumatic rupture of anterior tibialis tendon on the insertion were managed from February 2008 to February 2012. The insertion was reconstructed with plate and screw fixation technique, and the tissue defects were repaired with ANTEROLATERAL THIGH free flaps. Results: All flaps survived without any complications. The average preoperative and postoperative American Orthopedic Foot and Ankle Society ankle-hind foot scores of the patients were 51 and 94.7.Good ankle dorsiflexion strength against strong resistance was observed in eight ankles postoperatively, and a substantial improvement in strength was noted compared with the preoperative examination. Conclusion: Repairing a ruptured insertion of the tibialis anterior tendon using plate and screw fixation technique and ANTEROLATERAL THIGH flaps was a reliable technique and yielded satisfactory results. Level of Evidence: Level V, retrospective case series. Key words: tibialis anterior tendon; plate and screw fixation technique;rupture Introduction Ruptures of the tibialis anterior tendon, either traumatic or atraumatic, are uncommon. Traumatic ruptures are caused by an acute trauma accompanied with osseous or soft-tissue injuries in addition to pain and weakness in dorsiflexion of the ankle[1,2]. Tibialis anterior tendon is important in ankle dorsiflexion3. Ruptures of this tendon can cause functional deficiencies. A localized pseudotumor is usually present at the anteromedial aspect of the ankle, corresponding to the retracted, ruptured tendon end. Physical examination may include loss of the contour of the tibialis anterior tendon over the ankle and the use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the ankle[2]. Traumatic ruptures are usually accompanied with associated injuries. Traumatic ruptures of the tibialis anterior tendon that occur in the avascular lesion within 2cm to 3cm of the insertion make an end-to-end suture impossible because bone reattachment is necessary[1,3–6]. These ruptures are caused by accidents and result in tissue defects. Consequently, island or free flaps may be required during the repair of the tibialis anterior tendon. Clear guidelines about the treatment of these injuries are currently unavailable. Reconstruction of this tendon to restore ankle dorsiflexion and inversion includes end-to-end repair, tendon transfer, or allograft augmentation[4,7–10]. The present study describes a surgical technique using plate and screw fixation with anterolateral thigh (ANTEROLATERAL THIGH) flaps to reconstruct traumatic ruptures of the tibialis anterior tendon. Patients and Methods Eightconsecutive patients with a traumatic rupture of anterior tibialis tendon on the insertion were managed from February 2008 to February 2012. These patients comprised six males and two females with an average age of 32(range,24-46) years. Five and three ruptures involved the right and left legs, respectively. This study defines traumatic rupture as a rupture that occurred because of direct blunt trauma (e.g., accident) to the tendon accompanied by osseous or soft-tissue injuries. These blunt traumatic cases were accompanied by tissue defects, which were reconstructed with ANTEROLATERAL THIGH free flaps. Early repair (3weeks after the rupture or less) was performed for all the traumatic cases, and the average time from rupture to surgery was 1.8(range: 3days to 3weeks) weeks. Rupture of tibialis anterior tendon was diagnosed based on history and physical examination. All patients had functional complaints, includingweakness in dorsiflexion or unsteady gait, limping, and increased fatigue with walking. Physical examination included a pseudotumor at the anterior part of the ankle, loss of the normal contour of the tendon, and weak dorsiflexion of the ankle accompanied by hyperextension of all toes. Magnetic resonance imaging was performed to assess the retraction of the tendon and confirm the diagnosis. All patients were available for follow-up. A retrospective review was conducted on medical records, final patient interviews, and physical examinations at an average of 2years and 3months (range: 1year and 3months to 4years) postoperatively of all cases. Postoperative manual strength testing was performed using a 0 to 5 scale (0, no evidence of contractibility; 1 (trace), evidence of muscle contraction with no joint motion; 2 (poor), range of motion with gravity eliminated; 3 (fair), range of motion against gravity; 4 (good), range of motion against some resistance; and 5 (normal), range of motion against strong resistance. 11 The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used for preoperative and postoperative evaluation. This 100-point standard rating system is designed to compare the results of different treatment methods in patients with the same disorder. The anti-hindfoot AOFAS scores evaluate pain (50 points), function (including gait, range o f motion, and strength) (40 points), and alignment (10 points). 12 Surgical Technique All surgical cases were performed under general anesthesia in the affiliated drum tower hospital of nanjing university medical school.A small longitudinal incision was made above the superior extensor retinaculum. The extensor retinaculum was left intact if possible to avoid adhesions of the tendon.The proximal ruptured tendon end typically retracted to the inferior edge of the retinaculum or just beneath it. Debridement was performed for the proximal and distal parts of the tendon.If the tendon could be brought to its insertion, a direct tendon repair was carried out. If the tendon ends could not be approximated or if the tendon could not be apposed onto its insertion site, an interpositional tendon graft, which included plantaris tendon (two cases), extensor digitorum longus tendon (one case), and peroneus tertius tendon (one case), was used to bridge the gap and reinforce repair . An anchor is usually used in most reported literature. However, this study employed plate and screw fixation technique to repair the tibialis anterior tendon to its anatomical insertion. Direct tendon repairs were performed in four cases. The end of the tibialis anterior tendon was placed on its anatomical insertion, and then a mini-plate was pressed on it and screwed. The harvested grafts had smaller diameter than the tibialis anterior. In most patients, this tendon could be doubled, which usually resulted in a graft with a diameter of 5mm to 6mm. The ankle and foot were held in maximal dorsiflexion and maximal supination, respectively, to determine the final length of the tendon graft. One end of the grafted tendon was fixed using plate and screw fixation technique. The tendon should surround one screw to ensure a firm insertion. When the bony attachment was performed, the tendons were sutured to each other with Vicryl using the side-to-side technique. Finally, the tissue defect was repaired with free flaps. In this study, the ANTEROLATERAL THIGH was performed in all cases. Short-leg cast immobilization was used for the first 2weeks to maintain the ankle in 0Â ° of dorsiflexion. Weight bearing in the cast was allowed in the succeeding 2weeks. The duration of cast immobilization was determined in part by the surgeon’s perception of repair quality during surgery. At 6weeks postoperatively, weight bearing and full dorsiflexion were allowed. Plantar flexion was gradually increased. Results All ANTEROLATERAL THIGH flaps survived without any complications, such as necrosis and infection, except for bloated appearance. The average preoperative and postoperative AOFAS Ankle-Hind foot scores of the patients were 51 and 94.7, respectively. Active dorsiflexion was possible after 2weeks to 3weeks. Good ankle dorsiflexion strength against strong resistance was observed in eight ankles postoperatively, and a substantial improvement in strength was noted compared with the preoperative examination. All patients were able to walk without a visible limp. However, one patient had a little residual weakness in dorsiflexion in comparison to the uninjured side. On physical examination they still had5/5 strength. This caused some symptoms of fatigue or pain after prolonged walking. One patient had 4/5 strength result in a little claudication and continued hyperextension of the toes when walking. Because of the small sample size, there was no valid statistical means to compare the results. Complications arose in one patient. She developed a regional pain syndrome. At the final assessment, we considered that the adhesion of the intermediate branch of the superficial peroneal nerve may be the cause of complication. After the operation of releasing nerve, the patient reported no residual pain and walked with a normal gait. All patients were satisfied with the final result and would undergo the procedure again. Case report A 46year-old man suffered from a tissue defect and rupture on the insertion of the tibialis anterior tendon from a motor vehicle accident (Figure 1). His preoperative AOFAS Ankle-Hind foot score and ankle dorsiflexion strength were 53 and 3/5, respectively. One week later, a complete debridement was performed. We used the plate and screw technique to reconstruct the tendon insertion without tendon grafting (Figure 2). The defect was reconstructed with ANTEROLATERAL THIGH free flap. After the operation, a short-leg cast was performed. At 2weeks after the operation, the flap was stable and the wound healed well. At a 14month follow-up, the postoperative result was 95.3 and the ankle dorsiflexion strength was 5/5 (Figures 3 and 4). He was able to walk without a visible limp. Discussion Ruptures of the tibialis anterior tendon are rare but can lead to considerable functional deficiencies. Ouzounian and Anderson[10]reviewed their clinical experience with 12 patients who had tibialis anterior tendon ruptures. Two types of ruptures were identified based on clinical presentation: (1) atraumatic ruptures, which occurred in low-demand older patients who presented late with minimal dysfunction and (2) traumatic ruptures, which occurred in high-demand younger patients who presented earlier with more disabilities. The authors concluded that patients with traumatic ruptures, regardless of the time of presentation, demonstrated better function after operative intervention.13 In our studies, the average age of the patients was 32(range,24-46) years. Therefore, correct diagnosis should be performed as early as possible. Delayed diagnosis is common because of intact ankle dorsiflexion that occurs as a result of secondary function of the extensor hallucis longus and extensor digitorum communis muscles[14-17]. The diagnosis is significantly based on physical examination, accompanying by weakness of ankle dorsiflexion and a palpable defect of the subcutaneous portion of the tendon and a peseudotumor at the anterior part of the ankle. A pseudotumor usually corresponds with the retracted ruptured tendon end, which becomes entrapped at the distal extent of the superior extensor retinaculum. Ankle dorsiflexion is weaker than that in the contralateral extremity. A steppage gait is a characteristic but is not universally present. Conservative treatment with ankle-foot orthoses, bracing, and activity modification is a viable option in inactive patients. However, we speculated that even in cases with a considerable delay, a reconstruction should still be considered regardless of the age of the patients[8]. Several operative techniques have been published. Many reports recommend an end-to-end suture, but most publications report the use of other techniques because of the difficulties of obtaining an adequate suture repair[2,3,18]. In cases where tendon stumps are often retracted and undergo degenerative changes, an end-to-end suture does not provide adequate tensile strength to transmit the forces required for function. For such cases, tendon graft is needed. In recent literature, the interpositional autografts used include plantaris tendon, extensor digitorum longus, extensor hallucis brevis, and Achilles tendon[2,13,19]. We used ANTEROLATERAL THIGH flaps for the soft tissue reconstruction in these patients. The advantages of ANTEROLATERAL THIGH flaps include consistent and reliable anatomy, long pedicle, being far from the ablative site, allowing two-team approach, the feasibility to create multiple skin paddle by recruiting additional perforators, the flexibility to reconstruct composite defect with chimeric flap by recruiting different tissue types based on a single pedicle, and low donor-site morbidity. When a muscle component is required, we preferred to elevate the flap in a chimeric fashion anterolateral thigh hough elevating the flap as a musculocutaneous flap is also a viable option and may decrease the operative time[20]. A suture anchor or a bio-tenodesis screw is often used for the reconstruction of the insertion of the tibialis anterior tendon. However, this study employed the plate and screw fixation technique to reconstruct the insertion because of its several advantages. The screw can fix the tendon to the bone as point, and the plate can fix the tendon as flat. According to the physics formula of pressure(p)=force(f)/square(s), large square results in small pressure when muscle tension is constant. The plate and screw fixation technique may increase the square and decrease the pressure, thereby improving the firmness between the bone and the tendon. Two patients removed the cast a week after the operation. At the last interview, the patients had a manual strength of 5/5 and walked without a visible limp. These results indicate that the technique decreased the duration of cast immobilization compared with previously published reports. However, no valid statistical approach could be performed bec ause of the small sample size. In our future research, we will use a large sample size to validate the results statistically. The applied technique was simple and easy to follow. During our operation, we tested different directions (perpendicular, parallel, or other angles) of the plate to the tendon and the direction of the muscular contraction. We considered that placing the plate perpendicular to the tendon is relatively easy. We speculated that a share force exists between the plate and tendon if the plate is parallel to the tendon. In addition, a cutting action may be produced on the tendon after a long time. Thus, we situated the plate perpendicular to the direction of muscular contraction. This study has few limitations. First, it is retrospective and lacks a control group of nonoperatively managed patients. The results are not representative of all patients with tibialis anterior rupture; this study only included younger patients who were symptomatic. Second, the AOFAS Ankle-Hindfoot score was used as the clinical outcome measurement, which is not a validated instrument. Nevertheless, this study allows comparison of results because AOFAS Ankle-Hindfoot score is also used in other published studies. Conclusion We recommend surgical reconstruction of the traumatic ruptured tibialis anterior tendon using plate and screw fixation technique and ANTEROLATERAL THIGH flaps. This technique allows early mobilization and yields satisfactory results.

The Three Main Theories of Deviance and Their Strengths and Weaknesses

The Three Main Theories of Deviance and Their Strengths and Weaknesses A functionalist analysis of deviance looks for the source of deviance in the nature of society rather than in the biological or psychological nature of the individual. Although functionalists agree that social control mechanisms such as the police and the courts are necessary to keep deviance in check, many argue that a certain amount of deviance can contribute to the well-being of society. Durkhiem (1895) believed that: * Crime is an 'integral part of all healthy societies'. This is because individuals are exposed to different influences and will not be committed to the shared values and beliefs of society. * Crime can be functional. All societies need to progress and all social change begins with some form of deviance. In order for change to occur, yesterday's deviance must become tomorrow's normality. Nelson Mandela, once imprisoned as a 'terrorist', eventually became president of South Africa. * Societies need both crime and punishment. Without punishment the crime rate would reach a point where it became dysfunctional. Durkheim's views have been developed by A. Cohen (1966) who discussed two possible functions of deviance: 1. Deviance can be a 'safety valve', providing a relatively harmless expression of discontent. For example, prostitution enables men to escape from family life without undermining family stability. 2. Deviant acts can warn society that an aspect is not working properly, for example widespread truanting from school. Merton (1938) explains how deviance can result from the culture and ... ... (taking advantage of 'insider' knowledge to make huge profits on the stock exchange). This is illegal, which suggests that capitalists do not always get the laws they want. 5. 'Left Realists' believe that Marxists put too much emphasis on corporate crime. Other crimes such as burglary cause greater harm than Marxists imply. Their victims are usually working-class and the consequences can be devastating for them. 6. Post-modern Criminology rejects Marxist criminology as being neither believable nor defensible. Despite these criticisms, Marxism has been an influence on a number of critical perspectives on deviance. Some have drawn their inspiration from Marxism and can be referred to as neo-Marxist approaches. Others owe less to Marxism and are better defined as radical approaches.

Youth Unemployment and Attitude towards Employment: Comparative Study between Migrants and Non-Migrants

Introduction and Background to the Research Area The United Kingdom’s youth unemployment refers to the rate of unemployment among those individuals who are aged between 18 and 25. These figures are often used as part of political discussions to measure the general position of the economy, however it is contended in this research paper that there is a lack of understanding in terms of the factors that lead to youth unemployment in the first place. By targeting the background reasons, greater improvements can be achieved. The latest statistics or the rate of unemployment among youths in London shows that there are several individuals under 25 years of age who are not employed, which currently stands at 20% (Glaser and Rice, 2008). In this research paper it is suggested that there are substantial difference between migrants and non migrants within an area and that this could in fact offer a strong explanation as to why youth unemployment is so prevalent in modern society. Migration refers to the movement of people from one place to another specifically in search of some economic or social benefit. Migrants refer to the people who move from one place to another in search of better opportunities, while non-migrants are the local people. Politically there have been several heated debates on the topic of employment among migrant youths and non-migrant youths, which has necessitated this study to establish the attitude of both sets of groups towards employment. For example in Hackney, London, the number of employed migrant youths is higher, compared to that of non-migrants. However, the percentage of the migrant youths who are employed is higher than that of non-migrants. This suggests that non-migrants have a higher positive attitude towards employment than non-migrants The high rate of unemployment among young people in the country and London, in particular, has forced some media personalities and politicians to term it the â€Å"lost generation† (Hackney, 2013) This paper aims to look at the attitude of youths towards employment by comparing the migrants and non-migrants in Hackney, London. It is believed that the attitudes of these young individuals might be the major reason why there are high levels of unemployment among young people in this region and more generally elsewhere. Aims & Objectives of the Research The rate of unemployment among the youth population has been a problem that has raised several debates among politicians and media commentators. However, it has been argued that the attitudes of the youth in Hackney, London, have been the major reason behind the increasing rate. The main objective of this paper is to examine the reasoning or the suggestion that it is the attitudes of these young people towards employment that makes them miss the opportunities to land some. The research aims to achieve its overall objective by seeking the views of the youths in Hackney, London, towards employment. Purpose of the Research The outcome of the research will be based on the findings from the data collected through interviews, which will later be analysed. The outcome will depend on the method of data collection, which will involve interviews conducted with the youth in the area, in order to test the hypothesis. It is anticipated that the results of this study will help the community in understanding what its young people want, in terms of employment, in order to support them in their growth and career development. In addition, the result will also offer guidance to employers when allocating the available opportunities to either migrants or non-migrants. Importance of the Research This research is important in the field of both academic studies and career development, as its results will enable the students, their parents and teachers to understand how best to equip these youngsters by focusing the latter’s attention on their future employment opportunities. It will also help potential employers in selecting the right people for various positions in their companies or organisations. Research Approach It is suggested that the best method for collecting data in this qualitative study is through the use of interviews. The aim of the interview will be to have the respondents reflect on their feelings towards employment and past experiences, while also attempting to communicate freely with the interviewers in such a manner that both interviewer and interviewee come to a mutual agreement concerning the experiences’ meanings. The format of the interview could involve informal chats or discussions between the researcher and the respondents regarding their responses (Salter, 2010). If the respondents want to give further information or expand upon anything they have said, the interviewer will then ask additional questions and encourage the respondents to give further information or explanations. The interviewer will have to clarify that it will be an open process and that the interviewee is free to question or ask for more detailed explanations, talk in a manner with which they are comfortable, or even pause, if they wish to do so. The responses should not be evaluated as being right or wrong by the researcher. The researcher should make it clear to the respondents that they are free to make any comments or give any information that they wish. The focus of the interview will be on the participants and attempting to ascertain their attitudes, values, opinions, experiences and beliefs. Methodology This research will take the form of structured interviews, which will be used as the method of data collection. The standardised interview or structured interview is typically used in quantitative research. The sample of the study will include 300 migrant youths into the country and 300 non-migrant youths. The migrant and non-migrant youths will be interviewed in order to establish their attitudes towards employment, in an attempt to confirm or disapprove the hypothesis that non-migrants have a negative attitude towards employment. The reason for interviewing the two sets of individuals is to find out whether the problem is confined to the migrant youth population, or both migrant and non-migrants. The structured interviews will take the form of questionnaires, which will be given to the interviewee by the interviewer who, in this case, is the researcher. The questions that will be used in the study will be literature informed. This means that the results will have been compiled and the questions will have a range of options. The formulation of the questions in the survey will be done by considering the existing literature. In addition, interviews will be used as the survey questions will actually be literature informed. The reliability and validity of the research will be measured by using the semi-structured interviews. Another significance or importance of the use of interviews is that they should help in obtaining additional information that may have been ignored by the current literature review. Ethical Considerations The safety and confidentiality of the respondents will be the major priority of this research. This will be undertaken by considering the benefit/analysis ration, and also through the use of information that is available to conduct the assessment and supervision of the study as it continues. The participants will be handled with the utmost care and they will be assured of the highest levels of confidentiality. Before any participant is involved in the research, their formal consent will be sought, in writing. The researchers will need to take care not to divulge any sensitive information that might have been provided by the respondents for their own safety. If there are any unpredicted findings in the study, as it progresses, the participants will be informed accordingly. The participants will be reassured that, in giving information, they will not be obliged to reveal any information which they chose not to do so. Suggested Existing Literature Several existing texts will be used as part of a detailed literature review to gain a background understanding of the issues facing the region and the general trends associated with unemployment. The following indicative initial bibliography is suggested as a starting point for the research project. Blaikie, N. (2003). Analyzing quantitative data: From description to explanation. London: Sage. Ford, M R 2009, The Lights in the Tunnel: Automation, Accelerating Technology and the Economy of the Future, Acculant Publishing. Glaser, D, and Rice, K 2008, â€Å"Crime, Age and Employment.† American Sociological Review 24, no. 5: 679–686. Greenberg, DF 2009, â€Å"The Dynamics of Oscillatory Punishment Processes.† Journal of Criminal Law and Criminology 68, no. 4: 643–651. Hackney 2013 â€Å"Hackney Facts and Figures Leaflet† Available at: http://www.hackney.gov.uk/Assets/Documents/facts-and-figures.pdf Hochstetler, A, and Shover, N 2010, â€Å"Street Crime, Labor Surplus, and Criminal Punishment,† 1980–1990.† Social Problems 44, no. 3: 358–367. International Labour Office. 2009, Bibliography of unemployment : covering the period 1920-1929, Geneve. Isabel, T 2008, Bibliography of Unemployment and the Unemployed, Burt Franklin Publisher. Moss, P, and Tilly, C 2009, Hiring in Urban Labor Markets: Shifting Labor Demands, Persistent Racial Differences. New York: Plenum. Rifkin, Jeremy 2008, The End of Work: The Decline of the Global Labor Force and the Dawn of the Post-Market Era, New York: Tarcher–G.P. Putnam’s Sons. Rusche, G, and Kirchheimer, O 2007, Punishment and Social Structure. New York: Columbia University Press. Reprint, New York: Russell and Russell. Salter, H. 2010. Interview secrets. London: Collins.

Robert Frosts The Road Not Taken - The Significance of...

The Significance of The Road Not Taken My father introduced me to The Road Not Taken when I was a young teenager because he figured that I was beginning a period of my life where I would be forced to make many important decisions, and he saw this poem as a source of guidance through those decisions. This poem carries truth and edification in its words. It forms a beautiful analogy of life and all its complications. After my father finished reciting the poem, I never gave a second thought that day to Robert Frost or his poetry. It was weeks, possibly months, before I resumed thought on The Road Not Taken. It was not until one year ago that I actually read it. Nevertheless, I did remember that poem, and no†¦show more content†¦This was achieved by looking at each path and deciding on the one that was grassy and wanted wear (8). In other words, the narrator didnt want to follow in anybody elses footsteps. He wanted to be independent, to be free from the influence or control of others. The author knew that the only w ay that he could do this was to break away from the mold that society had already made take the path that had not been worn, that was not subject to the grooves of the previous drifter. This decision is not to be taken lightly. For once it is set in motion; it cannot be disengaged, even though the intention may be to return someday and explore the option you first resisted. The author is aware of this but feels strongly that he is making the right decision. I shall be telling this with a sigh Somewhere ages and ages hence: Two roads diverged in a wood and I I took the one less traveled by, And that has made all the difference. (16-20) In this stanza, a feeling of nostalgia is created or at least a foreshadowing of nostalgia, yet it is a sigh that he begins with. A sigh of relief or of regret, or is it simply a sigh of wonder? The title of this poem is The Road Not Taken. 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