Bubba Tech Inc Essay Example for Free

Bubba Tech Inc Essay After seven years working, Carson became a certified public accountant and Boone successfully complete a masters egree program in Information System at Southern Methodist University. In 2001, Carson and Boone formed a manufacturing company, Bubba Tech Inc. (BTI) in Austin which is privately owned by them and venture capital firm. Boone becomes chief executive officer (CEO) and Carson become chief financial officer (CFO) in BTI. There was no board of director because the firm has completely confidence in the ability of Carson and Boone. Venture capitalists provide a provision into their agreement where Boone and Carson would received 10% return on their investment for five ears and after company went public they would be repaid the amount of their investment. BTI had hired Randy Burnham ; Co. to audit its financial statement on 31 December 2012 due to their plan to go for public within five years. Burnham completed its audit for that five years in BTI and give unqualified opinion on the audited financial statement. In 2007, BTI decided to go as public. In meeting with Burnhams auditor, Boone ask Clint Strait, the partner who in charge of BTI audit to prepare a list of top operational issues to consider as the company went from being privately held to publicly held corporation. Then, Strait set up a team to proceed. The teams consist of Randy Burnham and Clint Strait itself, Shania Hill (the manager in charge of audit), Faith Twain (who had in charge consulting services engagement for BTI), Garth Chesney (tax department) and Kenny Brook (who responsible for information technology work related to audit of BTI). QUESTION 1 Based on the limited facts of this case, prepare a list of the operational issues to present the top management at BTI. Include in your list any corporate governance issues of importance in relation to the management of BTI after it becomes a public ompany and any issues related to the relationship between BTI and Randy Burnham co. ANSWER: Referring to the case of Bubba Tech, Inc. (BTI), there are several operational issues to be presented to the top management at BTI which concerning the corporate governance and issue related to the relationship between BTI and Randy Burnham Co. The operational issues that can be highlighted are the issue of working with potentially biased audit firm, lack of internal control and lack of corporate governance. The chief financial officer (CFO) of BTI, Willie Carson was once an employee of the Randy Burnham Co. , an accounting tlrm that is currently acting as the auditor tor BTI. The relationship between Carson and the auditors from Randy Burnham Co. may cause a conflict of interest. A conflict of interest is a situation in which private interests or personal considerations could affect or to perceived to affect both Carson and the auditors from Randy Burnham Co. Judgements to act in the best interests of BTI. The relationship of Carson and the auditors may influence the Judgement and the decision relevancy that creates many of the conflict of interest problems in the business. For instance, Carson may ask the auditors favour to conceal the material misstatement found in the financial statement from the venture capital firms knowledge. Objectivity and integrity are essential qualities for employees of any organization. The affected result is not only the unqualified opinions rendered for the audited financial statements for previous years are arguable but also the transparency of every future Judgement and decision is doubtful as BTI is working with an audit firm that potentially biased towards BTI. The second issue that can be highlighted is the lacking of internal control in BTI rganization. One of the best defences against business failure, as well as an important driver of business performance, is having an effective internal control system, which manages risk and enables the creation and preservation of value. A system of internal control refers to the process by which organizations maintain environments that encourage incorruptibility and deter fraudulent activities by management and employees. Based on the fact stated in this case, BTI was privately owned by Carson, Boone, and a venture capital firm where Carson has been appointed as CFO, Boone as CEO and there was no board of directors. Obviously all the decision related to operations, management, and financial are decided by either Carson or Boone, or both of them. There is no other party to question, monitor and evaluate their action. This situation is proving the issue of lacking of internal control in BTI organization. If BTI proceeds with the plan to go public, it should establish a well-tailored, govern, and implemented set of internal control in its organization. Corporate governance is the internal structure of a corporation from its lowest level workers all the way up to its executives. Corporate governance has far-reaching ffects not only for the business itself but for the financial market as a whole. In the case of BTI, the CFO management integrity and the external auditor integrity are questionable as the relationship built between them may cause conflict of interests and fraud. Management integrity, or the moral character of persons of authority, sets the overall tone for the organization. However, managements enforcement of policies is the major indicator of an organizations commitment to a successful internal control system. Unfortunately, was not applied by BTI organization. Another issue that can be raised is the segregation of duties. The absent of board of directors fgure in BTI organization causing so many critical issue as there is no stewardship centre that determining the companys approach to corporate governance, including developing a set of corporate governance principles and guidelines that are specifically applicable to the company . Carson and Boone have the freewill to decide on anything related to the company. Segregation of duties is critical to effective internal control because it reduces the risk of mistakes and inappropriate actions.

Treatment of Ankle Syndesmosis Injuries

Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as â€Å"high ankle sprain†with incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore importa nt to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis. 1.1. Anatomy The inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament. At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12). The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula [Fig. 1.1]. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) [Fig. 1.2]. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation [Fig. 1.2]. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9). Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35%; the transverse ligament, 33%; the interosseous ligament, 22%; and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability. 1.2. Biomechanics The primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus ‘‘wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion t o full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20). When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume. 1.3. Mechanism of Injury The 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30). Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in â€Å"Pronation-External Rotation† (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic cha llenge. These injuries are sometime referred as â€Å"high syndesmotic sprain† (4, 27, 34). 1.4. Diagnosis Diagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36). Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"medial clear space† is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship: (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm; (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width; (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42). 1.5. Treatment of Syndesmosis diastasis and review of literature Injuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation. Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant diff erence in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes follow ing syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group. Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation. Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67). The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire ® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the fol low-up reported in the literature is short and the number of cases are limited [Table 1]. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reporte d subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series. Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syn desmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term. 1.6. Aims and Objective The primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome. Population (P) Adult patients with acute fixation of ankle syndesmosis. Intervention (I ) Tightrope fixation of ankle syndesmosis. Comparison (C) Syndesmosis screw fixation. Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan. Chapter No. 2 2. PATIENTS AND METHODS We conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control. The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed. The inclusion criteria were as follows: adults (> 18 years) with acute ankle syndesmosis injury willing to give informed consent to participate in the study , fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria. The exclusion criteria set out for this study included: P patients with open fracture, I i ndividuals with diabet es ic or neuropathic arthropathy, M multi trauma patients and P patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control. Pregnancy was included in exclusion criteria B because of radiation exposure in this study. â€Å"pregnancy† was also mentioned as exclusion criteria. i I ndividuals unwilling to consent to the study Patients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively; and intraoperative confirmation under fluoroscopy using â€Å"external rotation stress test† and â€Å"hook test† in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"Tightrope† depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFA S) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications.   All patients were scanned supine in the axial plane with no gantry tilt.   Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx [Fig. 2.1]. This technique was adopted in order to reduce the radiation exposure to the patient without compromising th e quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond. 2.1. Outcome Variables The â€Å"accuracy of syndesmosis reduction† on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at > 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on A P radiographs and > 6 mm of tibiofibular clear space is considered abnormal, the criterion of > 2 mm would be justified.   Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function. In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses. 2.2. Data Collection and Measurements Demographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes. Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The â€Å"tibiofibular clear space† is defined a Treatment of Ankle Syndesmosis Injuries Treatment of Ankle Syndesmosis Injuries Chapter No. 1 1. INTRODUCTION Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as â€Å"high ankle sprain†with incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore importa nt to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis. 1.1. Anatomy The inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament. At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12). The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula [Fig. 1.1]. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) [Fig. 1.2]. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation [Fig. 1.2]. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9). Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35%; the transverse ligament, 33%; the interosseous ligament, 22%; and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability. 1.2. Biomechanics The primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus ‘‘wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion t o full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20). When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume. 1.3. Mechanism of Injury The 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30). Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in â€Å"Pronation-External Rotation† (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic cha llenge. These injuries are sometime referred as â€Å"high syndesmotic sprain† (4, 27, 34). 1.4. Diagnosis Diagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36). Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The â€Å"tibiofibular clear space† is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The â€Å"tibiofibular overlap† is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the â€Å"medial clear space† is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship: (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm; (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width; (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42). 1.5. Treatment of Syndesmosis diastasis and review of literature Injuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation. Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant diff erence in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes follow ing syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group. Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation. Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67). The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire ® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the fol low-up reported in the literature is short and the number of cases are limited [Table 1]. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reporte d subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series. Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syn desmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term. 1.6. Aims and Objective The primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome. Population (P) Adult patients with acute fixation of ankle syndesmosis. Intervention (I ) Tightrope fixation of ankle syndesmosis. Comparison (C) Syndesmosis screw fixation. Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan. Chapter No. 2 2. PATIENTS AND METHODS We conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control. The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed. The inclusion criteria were as follows: adults (> 18 years) with acute ankle syndesmosis injury willing to give informed consent to participate in the study , fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria. The exclusion criteria set out for this study included: P patients with open fracture, I i ndividuals with diabet es ic or neuropathic arthropathy, M multi trauma patients and P patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control. Pregnancy was included in exclusion criteria B because of radiation exposure in this study. â€Å"pregnancy† was also mentioned as exclusion criteria. i I ndividuals unwilling to consent to the study Patients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively; and intraoperative confirmation under fluoroscopy using â€Å"external rotation stress test† and â€Å"hook test† in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fr actures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either â€Å"Transosseous Screw† or â€Å"Tightrope† depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFA S) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications.   All patients were scanned supine in the axial plane with no gantry tilt.   Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx [Fig. 2.1]. This technique was adopted in order to reduce the radiation exposure to the patient without compromising th e quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond. 2.1. Outcome Variables The â€Å"accuracy of syndesmosis reduction† on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at > 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on A P radiographs and > 6 mm of tibiofibular clear space is considered abnormal, the criterion of > 2 mm would be justified.   Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including â€Å"tibiofibular clear space (TFCS 6 mm)† and â€Å"medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function. In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses. 2.2. Data Collection and Measurements Demographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes. Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The â€Å"tibiofibular clear space† is defined a

Latvian Jews and the Holocaust :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  The Holocaust seemed as if it was one mans (Adolf Hitler) determination to exterminate all Jews in Europe, but in fact this is not completely true. The Holocaust was the determination of many men and woman of different backgrounds and languages. One of which is the people of Latvia. During WWI, the was was no less disruptive to the Jews than to anyone else. They were and used for both Capitalist exploitation and Communist conspiracy. During WWII they were beaten, killed, and/or imprisoned mercilessly in camps throughout Europe, not excluding the two camps in Riga, Latvia.   Ã‚  Ã‚  Ã‚  Ã‚  The Latvian Jews had a long history. In 1897 the census for Latvia, just before WWI, reported a combined number of about 200,000 Jews. At this point, Riga held about 33,000 Jews. Since Kurland became a duchy of Poland in the sixteenth century, Jews of Luthuanian Poland moved north. There, even though, routinely reguarded as outsiders, having to pay taxes and fees and fines, Jews prospered and expanded themselves in number. They engaged in commerce of every variety including leasing, brokering, and peddling. Jew were goldsmiths, brandy distillers, artisans, tradesmen, and even sometimes hired as tax collectors. Jews were the ceter of economic life. They controlled exports of cereal, flax, eggs, and timber. Tanneries, sawmills, and banks were often owned by Jews, even clothing factories and stores were owned and operated by mostly Jews. Most well known doctors and lawyers and entertainers were Jewish, but of the 5,921 civil servants, only 21 were Jews. Around fifty percent were involved in commerce and trade, as opposed to the one percent of Latvians. This was because most Latvians were engaged in agricultural production. Jew also lived mostly in the city and town areas and created strong Jewish communities. After WWI, when the census was done again in 1925, Latvia had only counted for 95,675 Jews, less than half of pre-WWI. Now the aggrivated nationalist mind was getting very dissoriented by what had happened after Soviet annexation, the people were seeing the Jew and Bolshevism as one and the same, and as before, estermination was the only answer.   Ã‚  Ã‚  Ã‚  Ã‚  The massacres of Jews began immediately after the Soviet counterattcks on June 29, 1941, before German police and officials even arrived. In Daugavpils, all Jews between the ages of sixteen to sixty were called to the down town square where they were assembled and incarcerated. At one of the main streets in Riga, Bear Slayer Street (the bear stands for the Russians) were the two Riga ghettos.

How to Solve the Foreclosure Crisis Essay -- Economics

There should be a bifurcated targeting of the housing market. The first and main target of the housing recovery needs to be the cautious restructuring of the government sponsored entities—GSE’s—Fannie Mae (FNM), Freddie Mac (FRE) and to a lesser extent FHA. Recent news headlines put the combined total mortgage market share for the FNM, FRE and FHA at seventy-two percent (72%) [i] of the entire industry. The restructuring of those three entities will be a process of dividing their combined debt into at least ten smaller portfolios which individual investors can either incorporate into the existing businesses or form entirely new businesses made up of all or any part of the portfolio(s) they purchase. Each portfolio ideally will represent no more than a 5% to 7% share of the mortgage market so that we no longer have behemoths that are â€Å"too large to fail†. Further, the government will in all likelihood have to guarantee—for a limited period of time and with expectations of profit sharing similar to that of the banking bailouts and in fact the funds the banks are now paying back could be used for the purpose of guaranteeing so as not to offend the public—part of the initial funding that the private enterprises will need and want in order to get their respective pieces of the mortgage market launched. The breakup of these three GSE’s into numerous pieces will help manage the ability of success as it is not likely that all ten pieces will fail and as smaller players are easier to manage this will help increase the likelihood for success. In order for the government to get both the best price/value for each portfolio created from the breakup each of these portfolios should have different levels of mortgage debt risk. This will incr... ...o handle or avert another crisis should one come our way in the future and to return to the tax payer the monies it has already paid to bailing out these institutions. Works Cited [i] A combined market share of 72% for Fannie Mae, Freddie Mac and FHA as indicated by Mortgage Market Note—CIRE Magazine: http://www.ciremagazine.com/article.php?article_id=307 (04/01/2009; 09/14/2009) also see the NPR report at http://www.npr.org/templates/story/story.php?storyId=98285028 (12/17/2008; 09/14/2009) [ii] BretWhissel Mortgage Calculator http://www.bretwhissel.net/cgi-bin/amortize (09/14/2009) [iii] American Institute for Economic Research report http://www.aier.org/research/commentaries/583-update-on-the-house-price-trends (10/16/2008; 09/14/2009) also see the iTulip report http://www.itulip.com/housingbubblecorrection.htm (01/20/2005; 09/14/2009)

Godiva Hong Marketing Plan

Marketing Plan for GODIVA HONG in the Netherlands GODIVA HONG Chocolate therapy   Introduction This report consists of a situational analysis and a potential market analysis of Godiva Hong. This report is prepared by the RBS Marketing Consulting Firm. RBS is the only authorized marketing strategic partner of GODIVA in Europe.The purpose of this report is to attain insight into the success-increasing factors (strengths) and the value-decreasing (weaknesses) factors of introducing Godiva Hong to the Netherlands, and produce a feasible marketing strategy with which the product can be introduced. The analysis is done with the help of a SWOT-analysis. The market environment consists of both the macro environment and the micro environment. The structure of this marketing plan is based partly on the structure presented in Export business plan The Netherlands (2009). 2] Other academic books referenced for this report’s structure and data will be stated in the reference. 1. Profile 1 . Company Profile The Godiva Company was founded in Belgium in 1926 for the production and retail confectionary products. The company was founded by Joseph Draps and was named after Lady Godiva; â€Å"a woman of great generosity and beauty left an indelible impression upon the people she reigned over in Coventry† (Godiva: 2012). [3] Since its inception the company has kept to its tradition of making chocolates with â€Å"a unique formula of rich chocolate with unparalleled smoothness† (Godiva: 2012). 3] The company has maintained its image of confectionery excellence by paying careful attention to quality, innovation and design, evidence of the latter can be seen through their exquisite European-style gold ballotins and handcrafted seasonal packaging. Till date the company owns and operates over 450 retail shops and boutiques worldwide and issues out six seasonal mail order catalogs yearly (Godiva: 2012). [3] 2. Company Product Godiva offers a wide range of products fr om chocolate assortments and truffles; chocolate bars; chocolate treats; biscuits, coffee, and cocoa; dark, milk, and white chocolate gifts to baked desserts.The company just recently started producing a line of cocktails called Godiva Liqueur (Godiva: 2012). [3] The company Godiva, plan on introducing a new line of chocolates onto the Dutch market in 2012. The new product is called Godiva Hong. The product is a special blend of Chinese red bean paste with a rich dark chocolate coating. The product seeks to blend the traditional exquisite look, smell and delicious taste of Godiva chocolates with an equally tasty red bean paste that has health benefits. The name â€Å"Hong† was given to give the product an oriental feel. Hong means red in Chinese and the color symbolizes luxury and joy. 3.Company Mission â€Å"A passion for innovation and luxury combined with a truly memorable experience contained in each mouthful has made Godiva legendary. † (Godiva 2012) [3] 2. DESTEP analysis 1. Demographic Analysis: According to CBS, the Netherlands is the 27th most densely populated country in the world. The 16 million Dutch men and women are concentrated on an area of 41, 52 km?. This means that the country has a population density of 397 per km?. The emigration rate in the Netherlands is high, for this reason the population growth is expected to decrease while the aging of the population is expected to increase. Education levelAccording to the OECD Health data, the Netherlands has a relatively the high education rate compared to other countries in Europe. 21 % of the educated population has university degrees. Eating and buying habits Dutch consumers have diverging eating and buying habits, consumers are paying more and more attention to having a healthier lifestyle. They are eating healthier, exercising more and as a result of globalization are welcoming healthy foods and trends from other cultures (Terry B. , 2012) 2. Economic Analysis. The economical str ucture of The Netherlands is characterized as open, outward-looking and thinking out of the box.The Dutch economy has a strong international focus, as the Netherlands is one of the European Union's most dynamic centers of trade and industry. Owing largely to its favorable location by the North Sea, it plays a key role as a main port and distribution centre for companies operating worldwide. Amsterdam's Schiphol Airport is one of the largest airports in Europe. For these reasons the Netherlands is often called, the Gateway to Europe. (Diane L. , 2011). [3]On the other hand economic growth declined in by 0. 9% in the 4th quarter of 2008. According to CBS, the economy declined a further 3. 50 % in 2009 and another 0. 5 % in 2010. (Svend H. , 2008) Purchasing power In figure 1 shows a chart of consumer purchasing power in the Netherlands. It can be observed from this chart that before the recession consumers had a high purchasing power. (Terry B. , 2011) Fig. 1 Purchasing power of consu mers in the Netherlands | |Purchasing Power developments | |Periods |% | |2004 ~ 2005 |-0. | |2005 ~ 2006 |3 | |2006 ~ 2007 |3. 1 | |2007 ~ 2008 |0. 3 | |2008 ~ 2009 |1. | |CBS, 7-12-2009 | | 3. Social and environmental Analysis Dutch people are open-minded; they are adaptable and welcome or often embrace new cultures from all over the world. (Diane L. , 2011). [2]Majority of the people in the Netherlands speak English and more often than not other European languages. Dutch people tend to be very private; this however does not mean they are not welcoming simply value their privacy and respecting the privacy of others.The Dutch are also not known for their display of wealth for this reason it is very hard to distinguish between the well to do and poor in the Dutch society. 4. Technological Analysis Modern technology has been a major cause of the change in living standards in most countries. The Netherlands like many other developed countries has taken full advantage of this phenomeno n to create a seemingly comfortable life for its citizens. One of the key tools that have played a monumental part in this transformation has been the internet.Since the creation of the World Wide Web in the early 1990s, the Internet has been transformed from a mere communication tool into an undeniably incredible technology. The internet has since single handedly managed to revolutionize the way communication, business is done in today’s world. Since its inception, many tools have been developed to enable the conduction of business through the internet; one of which is e-commerce. E-commerce is a collective term used to describe the various methods of making online payments. E-commerce makes trading convenient and substantially reduces the costs involved in making trades. . Ecological Analysis The ecological rules for doing business in the Netherlands have been tightened in recent years; environmental health and safety have become very important. Businesses that wish to oper ate in the Netherlands have to adhere to these strict rules (HACCP rules) or face sanctions and fines. The ISO standard was introduced in the Netherlands in 2005. The ISO standards have a lot of requirements for management systems for the food industry in the Netherlands, these help to ensure safety in food chains. Alternative packagingAlternative packaging is a hot topic in the fast consuming goods industry. Paper, tinned paper, paper box and plastic box are still frequently used in chocolate industry. However, in recent years, moves have been made to replace paper with PP material, which is cheap and excellent at protecting chocolate from heat. On the other hand PP material ages easily and has a tendency to break in low temperatures. 6. Political The Dutch government is what one calls a â€Å"monarchical government†, meaning that it is not only comprised of the ministers and the state secretaries, but also the monarch, Queen Beatrix.Another term for describing this is: a co nstitutional monarchy with a parliamentary system, whereby the constitution has determined how the powers are divided between the Queen and the other institutions of the government. (Holland Handbook, 2011) [2] The cabinet’s responsibilities are: preparing and implementing legislation, overseeing the local government, carrying out the day-to-day business of government and maintaining international relationship. There are two houses (the Lower House and the Upper House) in the Parliament.The Lower House is elected directly by people and the Upper House are elected by the members of the provincial councils. The two Houses of Parliament have been given 4 rights: the right to set a budget; the right of interpellation; the right to put questions to ministers and state secretaries; and the right of inquiry. Furthermore, the Lower House has been given two additional rights: the right of amendment and the right to propose legislation. (Holland Handbook, 2011)[2] The Netherlands not o nly has a central government, but also provincial and municipal government and the water boards.The central government is responsible for national interest. The provincial government concerns social work, cultural events, environmental management, energy and sports. The municipal governments occupies traffic, housing, social services, health care, water supply, education and recreation. In order to secure these activities, the provincial government and the municipal government receive fund from the central government and levy tax. The aspect is deserve to be noticed before launching a marketing plan is the Netherlands operates the same taxation system as all European countries.Currently, the standard VAT rate is EU is 19% with a reduced rate of 6% only applying for certain goods and Service. (Government Profile: 2011) Upon business-based aspect of Dutch politics, a change of government does not usually impact domestic and international business dramatically. All in all, the Netherla nds, as a the gateway to Europe, the government protects and supports its development by emphasizing strongly on tax law, health, labor, company , commercial, civil, environment and intellectual property matters. 3. Competitive Analysis-Applying Porter’s five forces . 1 Threat of new entrants The threat of new entrants to Godiva can be analyzed from the following aspects: Supply-side economies of scale; Godiva chocolates are produced in Belgium and the USA to satisfy demand worldwide. However, the company’s products which are specialty goods are not produced on a large scale, this results in the fixed costs per unit being relatively high. A new entrant could use this to their advantage by producing relatively more and competing on price. Capital requirement; a large sum of money is needed to establish a complete producing line.A new entrant will have to fund, fixed costs such as factory and machines, variable costs such as raw material, labor force, and advertisements. In addition, chocolate distribution is not easy. Special considerations like the temperature, and damage during transportation, will need to be taken into consideration. This will demand more requirements from a Third Part Logistics provider which will result in a high distribution fee. When all these factors are considered, the threat of new entrants to Godiva is not high. 3. 2 Bargaining power of suppliers The bargaining power of Godiva’s supplier is high.The reasons are numerous. The key raw material for the production of chocolates is cocoa beans; these are grown in South America, Africa, and Middle East Asia. However, Godiva uses only high quality cocoa beans in the production of its chocolates and these are hard to come by, so once a supplier is selected, a corporative relationship is cultivated in order to maintain a long business relationship. The bargaining power of raw material supplier is therefore high; since the supplier can easily decide to sell his cocoa beans to Godiva’s competitors. 3. 3 Bargaining power of buyersThe diversity and highly differentiated chocolate products of Godiva keep the bargaining power of customer at a low level. As one of the most famous Belgian chocolate producers with loyal customers worldwide, when buyers think of buying chocolate with wonderful flavors and elegant packaging, they think Godiva. Same as Victoria’s secret and Starbucks, Godiva mainly focus on creating surprise, passion, and excitement around its brand (Philip Kotler, 2008). [9] It is also difficult for buyers to integrate forwards into Godiva due to its special handmade product line.The bargaining power of buyers is therefore low. 3. 4 Threat of substitutes Although current market full of hundreds of chocolate producers with very competitive products, Godiva still has a stable market share. Godiva achieved this by positioning its self away from mass markets and associating its brand with other luxury brands like Armani Exchange, Vic toria’s secret, Bose, Tiffany & Co, Coach, and so on. These companies share common characteristics, such as portrayal of desirable luxury in their product design or taste and their high, but not too expensive price range.Godiva does not consider mass market products like Mars and Snickers its substitutes but rather luxury gift items like champagne, expensive jewelry or products from other high-end chocolate brands like Guylian, Neuhaus, and Leonidas, when these other product are considered the potential threat is high. 3. 5 Industry competitors The industry competitors at the same level as Godiva are few. However, Godiva’s product assortments are more deeply differentiated than that of the others. The cost of switching from other brands to Godiva for a customer is relatively low.Godiva spreads its fixed costs per unit by producing large quantities compared to its competitors; because of this Godiva’s prices have remained competitive. In addition, Godiva has over 450 special stores and more than 1000 retail shops, which have already taken up a sizeable market share. All these factors considered makes Godiva’s, exit barrier relatively low. However, rivalry is expected to intensify when competitors launch marketing strategies such as price changing, publishing new products, and improving customer service.Especially during special holidays like Easter, each company will launch new product to attract more market segments. 4. Competitor’s analysis Among the competitor’s list, the strong competitors of Godiva in the Netherlands are: Neuhaus, Leonidas and Guylian 1. Competitor one: Guylian Guylian chocolates are sold in over 100 countries across Europe, Asia, Australia and America. It is one of the top ten best selling boxed chocolate brands, and often seen on  Valentine’s day, Mother's day, Easter, Christmas and other popular holidays. 17] Products: Guylian's chocolates range includes the world famous chocolate Sea S hells, truffles, assorted pralines, bars and many other gourmet creations. All made in  Belgium with the finest Belgian chocolate. Strengths: †¢ Strong brand names; †¢ High quality chocolate made by pure cocoa butter; †¢ Highly distinctive chocolate like Sea shells and sea horse, sugar-free dark chocolate ; †¢ Available in most major high street retailers, including supermarkets, hypermarkets, department stores, specialty food stores, petrol stations, duty free shops. Weaknesses online-shop are not available Marketing strategy: †¢ Constantly launching new accessories to meet customer’s special requirement. Special holidays, for instance, Guylian designed new greeting cards and chocolate boxes to enrich their product display. †¢ Enhance product line by producing luxury sea shells and sea horse chocolate. †¢ Enhance public realization through taking part in different product exhibitions and social activities. 4. 2 Competitor two: Neuhaus The Neuhaus group is an independent manufacturer of pralines and other chocolate delicacies in the luxury chocolate sector.It is established in over 50 countries with 1500 sales outlets. [10] Products: Neuhaus’s chocolate products consist of Pralines, Ice Cream, Confectionery, Boxes, and other chocolate. Strengths: †¢ Very strong brand name which has over 100 years Belgium Royal chocolate; †¢ Deeply differentiated product line; Concentrated on their core products; †¢ Neuhaus products are available in many boutiques, department stores, shopping centers, airports and online-shopping center. †¢ Favorable access to distribution networks; Well organized online customer service Weakness: †¢ Fewer specialty stores in the Netherlands. †¢ Price is comparatively high. †¢ Niche market share Marketing Strategy: †¢ Focus on their core business; †¢ Special customer service: offer corporate discounts starting for order of $1000 or above; Provide fre e customize gift card with logo ; †¢ Use newsletter to receive customer’s feedback and improve their products. Guarantee customer’s buying chocolate will be delivered next morning. 4. 3 Competitor three: LeonidasLeonidas is a world-renowned chocolate maker. It is famous for its freshness, generosity and traditional taste. It’s selling over 100 different kinds of Belgian chocolate through 1,400 outlets around the world. [11] Product: Butter cream chocolates; Special cream chocolates; Ganache chocolates; candied fruit; Marzipan; Liqueur cream chocolates; Cream caramel chocolates; Pralines; Plain chocolate Strengths †¢ Clarify assortment of products according to ingredients, design, occasions and taste. †¢ Good reputation among customers With 250 specialty stores in the Netherlands, customers can buy their products at any city †¢ Price is acceptable even for personal consumption Weaknesses †¢ Online shop is not available; †¢ European m arket too saturated Marketing Strategy †¢ Launched a new premium product line â€Å"L†, smaller and more refined chocolate, similar to Godiva’s ‘G’ collection (Chang Sub Kim, Deyeon Kim, March, 2008) †¢ Clear organization mission: A century of freshness, generosity and tradition †¢ Large number of shops to create a sense of â€Å"A word of chocolate is closer than you think† for customer . SWOT ANALYSIS | |Strengths |Weaknesses | |Environme| | | |ntal | | | | | | | | |.Efficient and effective distribution channels and | ·New taste | | |systems | | | | ·High-quality product | | | | ·Healthy product | | | |. High market share | | | |.Unique taste | | | |. Unique design | | | |. Product specialty | | | |. Existing marketing policy | | | |. High market share | | | |.New Marketing policy | | |Organizat|Opportunities |Threats | |ional | | | | | | | | | | | | | ·Expanding the market |.Substitute product | | |. Product Diversification |. Competitors | | | |. Product extension | 5. 1 Strength: Healthy product: Godiva Hong is has health benefits; according to Chinese medicine the red beans that we will used in the new chocolates have health improving effects. Scientific research has proven that the red beans are a good source of protein, soluble (and insoluble) fiber, folate (vitamin B12), magnesium, potassium and a number of other health promoting nutrients.The researchers concluded that it reduces heart attack by more than 80% [16]. According to USDA researcher Ronald Prior, red beans contain even more proanthocyanidins than blueberries, cranberries, and small beans [16]. So it is one of our most important strong points that we will be providing health with taste. High quality: Godiva is already famous for its high quality products. Godiva Hong, will offer customers the same quality in taste and exquisite design of its packaging. Godiva considers its quality as one of its strengths because it already has a satis fied amount of targeted consumers; its experience in this field becomes its strength.Efficient and effective distribution channels and systems: Godiva has a very efficient and effective distribution system. Godiva Hong can be ordered online from Godiva’s official website or other websites. It can also be ordered via telephone. Existing marketing policy: Godiva has various strategies for marketing its products. The company has its own website that has a web shop, they also have a catalogue system; their catalogs are released usually in the fall, holiday, Valentine's Day, Easter, spring, Mother's Day and summer periods. During the holidays 10 million books are circulated. Godiva's most recent data card lists 35,200 catalog buyers from the last 12 months.They are also well equipped with seasonal promotional offers and strong media coverage policy. [13] This existing marketing policy will be used to help promote Godiva Hong. Unique taste: The new product has a rich chocolate coat ing outside with traditional Godiva flavor and a red bean paste inside. It will have an aroma that evokes interest, curiosity. The product will merge the unique taste of sweetened red bean with the traditional rich taste of Godiva dark chocolates. Unique design: The packaging for Godiva Hong will be an elegantly designed bamboo box covered in red silk. In Chinese tradition the color red symbolizes warmth, passion and luxury.The design and color of our package is to stir up these feelings in our clients. The use of Chinese materials in the packets of Godiva Hong will give it a unique texture [pic] Product specialty: The color and all other materials that will be used for Godiva Hong will represent the brand’s luxury and excellence. Color, design, materials of Godiva Hong will be a perfect representative of Chinese culture also. High market share: According to the annual report of 2006 Godiva’s market share is in good position and its increasing [15]. So it is a strong p oint for the new product. Well organized Godiva boutique established its image as a luxury good; it attracts a huge amount of customer.We will make it stronger using our effective marketing policy. New Marketing policy: Godiva has media plans including image and tactical print in various magazines such as Vogue, In Style, Harper's and Vanity Fair, and also regional newspapers during the holidays. Direct mailing is done to support some product launches [13]. Exhibitions will also be organized in several shopping centers and our boutiques, free samples will be given to current customers when they visit our boutiques to buy our other well-known products. Godiva Hong will also use product placement and sponsorship to meet its objectives. 5. 2 Weakness New taste: Our main weakness is the new unfamiliar taste.This taste is familiar with Chinese people but for European people it will be a totally new taste. It is a weakness that we need to overcome by promoting this new taste in an attract ive manner: Well organized promotion, attractive packaging and designing. We will also maintain and combine the existing taste with the new product and also the same aroma so that the existing customer can identify this new product as a part of Godiva. 5. 3 Opportunities Expanding the market: After Godiva Hong has gained enough recognition with the current customers of Godiva, the target market will be expanded to include young customers (20-30) to expand our customer segment. Product Diversification:We will diversify our product portfolio in future by promoting more new taste inside Godiva chocolate. This will open an opportunity for us to enrich our market share. Product extension: In future we will look forward to extend our product to more diverse product line. We will make Ice-cream Hong, Candy Hong and more. 5. 4 Threats Substitute product: Godiva Hong is a luxury product, the company considers other luxury products like Champaign or flower bucket its substitute. The relative price and performance of these substitute products are a threat. Still we can overcome this threat by maintaining our customer oriented marketing policy. Competitors:In Netherlands competitors like Neuhaus, Leonidas and Guylian are able to cause great threat to Godiva because of their brand positioning and quality production. Still we can overcome this threat by establishing the uniqueness of the new chocolates with the new unique taste and its strong brand positioning policy. 6. Marketing Strategy 6. 1Marketing Objective 6. 1. 1 Awareness Objective In 2012, Godiva will embark on a campaign to introduce its customers in the Netherlands to a new line of oriental themed chocolates called Godiva Hong. 6. 1. 2 Sales Objectives †¢ Increase overall brand sales by 3% with the introduction of Godiva Hong by the second quarter of 2014. Widen target market for Godiva Hong by focusing mainly on young adults (ages 20 – 30) by 2016. 6. 2 Marketing Strategy Since Godiva Hong is a new product, creating awareness for it will take a front seat in the company’s promotional activities. The product will be introduced through Advertisements, Exhibitions and Social Media. The product will primarily be introduced on the company’s website and its customer catalogs. The advertising for Godiva Hong will focus on staying true to Godiva’s position as a high end chocolate brand that is unique and glamorous. The adverts will appeal to the customer’s emotions by branding the product as a luxury treat.The adverts will be telecast on all major Dutch television channels at prime times. There will also be adverts about Godiva Hong placed in luxury magazines the company already advertises in; they include Vogue, Forbes, In Style, Harper's and Vanity Fair. The company will strike a deal with KLM to distribute free samples of Godiva Hong to their first class passengers. A similar deal will be struck with some 5 star hotels in the Netherlands to put free samp les of Godiva Hong in welcome baskets. Exhibitions will also be organized in several shopping centers and our boutiques, free samples will be given to current customers when they visit our boutiques to buy our other well known products.These exhibitions will also be used to attract new customers, and will give the company the opportunity to get feedback from our customers on what they think of the new product. The sales objective will be achieved with the aid of social media. Through data and tests conducted in the past the company has managed to form a very good picture of who its current customers are. Through these tests they know demographic figures such as, 75% of our current customers are over the age of 32, 60% have children; more than 85% have completed college. They also gathered some psychographic information such as these customers love to indulge but are still health conscious.With the aid of this data, the company will communicate individually with these clients through social media (Face book, Twitter and blogs). The new product Godiva Hong will be introduced to them, as a treat with exquisite taste, the health benefits of the new product will also be emphasized while asking them questions and using their responses to improve on the marketing strategy. Godiva will also use product placement and sponsorship to meet its market expansion objectives. The company will hire the services of popular Dutch celebrities like artistes Nick and Simon by placing the new Godiva Hong in some of their videos. This strategy is to help make Godiva Hong attractive to young adults.These are the tools Godiva will use to meet its marketing objectives for Godiva Hong. The company will focus first on its current clients and when enough attention has been created on the product in that domain it will widen its target market to include young adults. 6. 3 Target market and Positioning The people of Netherlands like other European countries will continue to embrace the consu mption chocolates in search of indulgence. In recent years, chocolate consumption is being enhanced by a growing demand for healthier, higher quality products that incorporate new tastes. These circumstances in the Dutch market offer a good opportunity for confectionery products like Godiva Hong.When Godiva Hong is introduced its primary target market will be the current customers of Godiva products in the Netherlands. After the product has gained recognition and acceptance from the current flock of Godiva customers the target market will then be widened to include young adult (people between the ages of 20 and 30 who have just started working careers). Godiva Hong like all other Godiva products is an upscale luxury product, and like the other products will be positioned as such. The aim is to strengthen the products position as a high-end product that customers will be proud to buy. 7. Marketing action plan 7. 1 Description of productGodiva Hong is an oriental themed chocolate with sweetened red bean paste and a rich dark chocolate coating. Instead of traditional nut, alcohol, walnut or jam filling, GOVIDA is going to use sweetened red bean paste. It is a healthy traditional Chinese filling in Baozi, Zongzi, Yuanxiao, moon cakes and other snack. It is sweet, soft and melts smoothly in the mouth. The packaging for Godiva Hong is an elegantly designed bamboo box covered in red silk. 7. 1. 1 Product Classification Godiva already has several different product lines: chocolate assortments and truffles; chocolate bars; chocolate treats; biscuits, coffee, and cocoa; dark, milk, and white chocolate gifts; and baked desserts.Godiva Hong is a new product with a brand extension strategy that appeals to existing market. It is a new product in the chocolate collections& treats product line. In addition to chocolates, Godiva also sells truffles, coffee, cocoa, biscuits, dipped fruits and sweets, chocolate liqueur, shakes, wedding and party favors and other items arranged i n gift baskets. Godiva's signature package is the Gold Ballotin (French for â€Å"small, elegant box of chocolates†). Godiva also produces seasonal and limited-edition chocolates with special packaging for all major holidays. Godiva also has license for the production of ice cream, cheesecake, coffee pods and liqueur that comes in several chocolate-related flavors. (Godiva, 2012) 7. 1. Package Because the target market of Godiva Hong is middle and high class people, the packaging was designed to unique and elegant in order to evoke a sense of luxury. Chinese elements were added to the design in order to give an inclination to the origin of the product: †¢ On the wrapping paper or baskets, the Chinese knotting will be presented. †¢ Also environmentally friendly, materials such as bamboo will be used in the design for the packaging †¢ So our traditional package for present product line is better changed as red for main color. 7. 1. 3 Service Several special servi ces are provided as follows: †¢ Online and telephone order.Customers can order Godiva Hong online or via telephone, due to a standing contract the Godiva company has with UPS they can be assured of a timely delivery. †¢ Gift card. Beautiful gift cards and exquisitely-designed packages can be sent with every order at the customers’ request. †¢ Unique design. Customers can get involved in the production of their chocolate orders by designing the chocolate shapes themselves with the aid of our chocolate design software online. †¢ Name and blessings. Names and blessings can be carved into the chocolates or the packaging upon the customer’s request. 7. 2 Price The main purpose of price strategy is to price Godiva Hong at an acceptable level, while aiding in the promotion of the product 7. 2. 1 Pricing strategy for GodivaGodiva Hong seeks to attract customers who are willing and proud to pay a little more for high quality product. Our target customers are the current Godiva customers; mainly middle and high class people who are looking for high quality chocolates as gifts for birthday, wedding, special events and business purposes. The price of Godiva products has stayed stable over many years. This proves Godiva has a strong brand image that does not compete on price. 7. 2. 2 Pricing for Godiva Hong Godiva Hong is a new product with a brand extension strategy that appeals to existing market. So, the price of our new product will be set to meet the consistency of existing product in the chocolate collections& treats product line.Price for Godiva Hong |Beaded Easter Egg |â‚ ¬25 | |Enchanted Easter Gift Basket |â‚ ¬90 | |Signature Chocolate Truffle Assortment |â‚ ¬40 | |Gift Box |â‚ ¬30~â‚ ¬70 of different sizes | |Delights Gift Basket with Spring |â‚ ¬75 |Price for Godiva Hong and competitors (cooperation as small size gift box) |Godiva Hong |â‚ ¬40 | |Neuhaus |â‚ ¬48 | |Leonidas |â‚ ¬36 | |Guylian |â‚ ¬ 20 | [10][11][17] 7. 3 Place The main purpose of our place strategy is to choose the best distribution channels to sell Godiva Hong. 7. 3. 1 Traditional distribution channel:local malls Thanks to our existing local malls which provide maturity distribution channels, Godiva Hong can be bought wherever and whenever the customers want to purchase it. 7. 3. 2 New distribution channel: online and telephone orderIn recent years, online and telephone orders have attracted a lot of attention. According to Godiva’s last marketing report, the quantity of orders through these two new distribution channels is increasing year by year. So, it is a good choice to sell Godiva Hong also through these two new distribution channels. The customer can just log in our online order website to buy chocolate as the follow: http://www. godiva-online-store. eu/index-en. htm. Due to the contract with UPS a timely delivery is assured. Other services provided on the website are gift cards. The customers c an just buy it on the website. It has â‚ ¬30, â‚ ¬50, â‚ ¬100 different choices. 7. 3. 3 New distribution channel: co-worker websiteThe customers can also buy Godiva Hong on other websites as follows: †¢ Gift for euro †¢ Pick up flowers †¢ Gifts n ideas These website are co-operating with our company. So the customers can buy Godiva Hong from these websites when they buy some other gifts and flowers. 7. 3. 4 New distribution channel: Fashion event& business press release Godiva is co-operating with event organizers for fashion shows and business press releases. Association with these events is to aid in the extension of Godiva Hong’s the popularity as a luxury brand. Also, the patrons of these events make up our core clients so, sales could also be generated by selling Godiva Hong at these events. 7. 4. PromotionThe main purpose of our promotion strategy is to introduce Godiva Hong to existing customers and potential consumers. 7. 4. 1 Marketing channe l: advertisements Advertising is Godiva’s traditional marketing channel. Advertisements have had tremendous impact on sale of Godiva products. So we will still adapt this marketing channel. The commercial advertising will be concentrated in following Medias: †¢ Television. The period of time that we will advertisement will be related to special event such as Easter, Queen's Day. †¢ Magazine. The magazines that we will consider are included Vogue, Forbes, In Style, Harper's and Vanity Fair this kind of high-fashion magazines. †¢ Internet including social media.Social Media channels such as face book or twitter will be used to communicate to our clients individually on the merits of Godiva Hong. 7. 4. 2 Marketing channel: The shopping center exhibition Promotional exhibitions are also an important marketing channel for Godiva. It is soon April. Several holidays, such as Easter, Queen's Day, are in the April. We will have promotional events in shopping centers whe re our shops exist. The customers can have tasting sessions for Godiva Hong in our shop for free. Feedback will be gathered from them on how to further improve the product or its marketing strategy 7. 4. 3 Free sample delivery Several main strategies are implemented to improve the popularity of Godiva Hong for the first three months. Strategy one:Existing customers, who will buy our traditional products, will have a small Godiva Hong sample for free. Strategy two: According to the last six months order records, the Godiva Hong sample will be sent to those customers as a gift, who ordered other products of chocolate gift baskets, seasonal gifts, gifts by occasion and business gifts product lines. Strategy three: In the airport, the Godiva Hong sample will be provided in the first class of KLM. Strategy four: In some international 5-star chain hotels, the Godiva Hong sample will be provided as a gift in the welcoming basket. 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