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‘Fix and Replace’ – an emerging paradigm for treating acetabular fractures: A systematic review of literature to evaluate functional outcome of patients.

Abstract

Acetabular fractures in the elderly population, with associated osteoporosis and general debility are a serious public health concern, these are treated by operative and non-operative measures. According to the UK’s Pelvic and Acetabular surgical community, no specific intervention has been found to guarantee positive health outcomes in the form of mobility restoration in elderly and fragile osteoporotic patients. Although interventions such as open reduction and internal fixation (ORIF) and total hip replacement (THR) of acetabular fractures remain technically challenging within the surgical field, there are considerable benefits when compared to traditional treatment options. The following systematic literature review is aimed at identifying how fix and replace treatment approach with acute concurrent arthroplasty or delayed arthroplasty for arthritis following acetabular ORIF is compared with conventional THR or Total Hip Arthroplasty (THA). The results indicate that surgical interventions carry the highest risk procedures where patients can have significant mobility restoration if all goes well or have post-surgical complications such as site infections and other new comorbidities that could result to death. While acetabular fix and replace can be lengthier, complex with significant risks during and after surgery, the results can also be positive and enhance the quality of life of the patient.

Introduction

The hip joint is a multiaxial joint that transmits the load of the upper body to the lower limbs and its normal function is essential for efficient locomotion. Damage to the articular cartilage on either side of the joint when caused by trauma or osteoarthritis can cause pain, stiffness and ultimately limit a patient’s mobility and quality of life [1].

Acetabular fractures vary in their presentation based on where they occur.. The fracture pattern relates to the mechanism of injury and the bone quality [1]. Acetabular fractures due to high energy trauma are common in young fit patients while in the elderly, these are mainly as a result of fragility within the osteoporotic population. When the acetabulum gets fractured, the femoral head may sustain significant damage or the acetabulum itself developing incongruence. Consequently, if the joint remains irregular or unstable, the resulting cartilage damage may lead to arthritis [3]. Similarly, some acetabular fractures that occur in patients with pre-existing osteoarthritis or articular damage are most likely to develop symptomatic post traumatic arthritis. Among the increasingly elderly population, acetabular fragility fractures are very common as a result of falls from a standing height [1].
Some patients with acetabular fractures on a background of pre-existing osteoarthritis or such articular damage that progression to early post traumatic arthritis is expected, may benefit from staged or single stage total hip arthroplasty alongside stabilisation of the acetabular fracture [4]. Iqbal et al. intimate that acute concurrent hip arthroplasty can be recommended where there is a pre-existing osteoarthritis, significant femoral head damage and acetabular impaction [4].
Besides falls, hip injury can be sustained with high energy trauma, for example road traffic accidents. After resuscitation of the high energy trauma patient, in the presence of a displaced acetabular fracture further imaging is obtained where possible in the form of a CT scan to define the fracture pattern and allow for surgical planning of approach and fixation +/- arthroplasty. A displaced fracture with a loss of joint congruence will most likely lead to early post traumatic osteoarthritis with pain and loss of mobility [1]. Surgical intervention is preferred where safe to do so in the appropriately consented patient. This paper will delve deeper into evaluating the

optimum treatment approach and functional outcomes of patients based on a systematic literature review.

Research Question

The outcome of this systematic review is to provide answers to the following research question:
• How does fix and replace treatment approach with acute concurrent arthroplasty or delayed arthroplasty for arthritis following acetabular ORIF compare with conventional Total Hip Replacement (THR) or Total Hip Arthroplasty (THA)?

Aims

• To investigate the optimum clinical management of acetabular fractures

• The role of THR in the management of acetabular fractures

• To evaluate the functional outcomes targeting complications and infections rate of patients with acetabular fractures having undergone hip arthroplasty.

Materials and Methods

Type of Study

Studies that were published in English of participants who had experienced acetabular fractures and undergone acute or delayed THR were reviewed. Results were then compared between each study cohort and deductions inferred. Date limits for the research were set between

2010 and 2020 to ensure coverage of new treatment approaches, experiences, and current additions to the existing body of literature.

Inclusion and Exclusion Criteria

Inclusion Criteria:

The study included patients (aged 55 to 96) with traumatic fractures of the acetabulum who underwent total hip arthroplasty (THA) post acetabular ORIF or THA. The use of THA and ORIF procedures for the treatment of post-traumatic arthritis was also considered. Additionally, information capturing the participant’s demographics and the outcomes of their THA, including acute fix and replace, delayed “fix and replace,” and THR. Other variables of interest included time from Acetabular Fracture to THA, operative characteristics, and the results following conversion arthroplasty. Besides, full-text manuscripts available in the English language published in leading peer-reviewed journals within the last 10 years.

Exclusion Criteria:

Existing systematic reviews and meta-analysis were excluded from this research as they did not provide original information on the use of ORIF, acute THA, delayed THA, and combine hip replacement procedures. Research studies on non-traumatic hip fractures (pathological or metastatic acetabular fractures) that required non-surgical intervention were not deemed appropriate for this study. Moreover, studies published in languages apart from English were also excluded for data homogeneity on acetabular fractures and total hip arthroplasty.

Primary and Secondary Outcomes

Imperatively, this systematic literature review intends to investigate acetabular fractures and the total hip replacement based on the variables of patient demographics. Additionally, the data attributes for consideration will include acetabular fractures to THA, characteristics of post- operation experiences, and the inherent outcomes related to the conversion of arthroplasty. The paper will investigate survival rates, need for revision and re-surgery, the pooled complication rate and functional scores, and other predictors of poor outcomes impact post-operative arthroplasty among patients presenting with acetabular fractures. Results will be compared based on the following categories, which are described below and include delayed THR after failed ORIF, acute THR after ORIF, and a historical cohort of THRs for osteoarthritis.

Delayed THR:

The delayed THR is regarded as a reliable procedure that is often conducted after a patient suffers symptomatic post traumatic arthritis following acetabular fractures. The term delayed implies that the process is performed at a later time when alternative acetabular fractures treatment options do not provide expected outcomes [6]. Delayed THR is therefore conducted at such a time to prevent progressive impairment of hip functionality. In some cases, THR is performed on patients who develop post-traumatic arthritis or necrosis of the femoral head despite operative or non-operative intervention that was chosen for initial treatment.

Acute THR:

The acute THR is described as the immediate total hip replacement in patients manifesting acetabular fractures [4]. Acute THR is proposed as a treatment option for patients with acetabular fractures since it potentially provides an immediate full weight-bearing and minimizes

the occurrence of delayed surgery, especially for the post-traumatic onset of osteoarthritis. Acute THR is the recommended intervention for patients with significant pre-existing osteoarthritis, or with a fracture pattern that is felt to be at high risk of early progression to osteoarthritis.

Cohort THR:

Cohort THR is known as the retrospective evaluation of past THR interventions based on diagnosis, treatment, and outcomes.

Data Source, Searching Strategies, and Keywords

The research incorporated the use of Pubmed/MEDLINE, CINAHL, SCOPUS, Embase, Revman, Cochrane, and Ovid to search for articles. The following lead terms were used; “fix and replace,” “acetabular,” “fracture,” “arthroplasty,” “failed acetabular fixation ORIF,” and “post- traumatic arthritis.” Other keywords included “surgical treatment,” “total hip replacement,” and “total hip arthroplasty.” The use of lead terms prevents one from interacting with numerous unnecessary sources that could be touching on the same topic but not answering the intent of the researcher.

Data Management, Reduction and Selection Process

The researcher intends to use an excel spreadsheet that will be used for data entry with the kind of treatment offered to the patients used as the primary comparator. Additionally, the excel sheet will be used to gather information on the number of patients that participated in the studies, the mean age of participants, classification of their fractures, the type of treatment accorded to them, and the mean operating time. Other parameters for consideration would be repeat surgery, emerging complications, post-operative rehabilitation, and radiographic results.

The entries would then be analyzed statistically and compared with one another to help in drawing the appropriate inferences.

Data Analysis Plan

Data collection was guided by the PRISMA model in Fig. 1 below. A total of 60 records were identified using search engines such as PubMed, MEDLINE, Cochrane, and Ovid. A total of 60 sources that were identified using the database mentioned above, searches were screened for relevance, and 5 duplicates eliminated. The 55 remaining sources were further filtered to identify full-text articles and discard incomplete abstracts. Thus, 45 full-text articles were identified, and a further 35 removed as they did not address the research question, aims, and objectives. A total of 10 identified sources where identified, 5 qualitative and 5 quantitative approaches, as indicated in the literature matrix shown in Appendix 1 of this research.

Sources of Bias and Mitigation

The paper intends to exclude all the studies that shall have been considered as having a higher risk of attrition, which for this research is defined as greater than 30% of the patients being lost to follow up after undergoing total hip replacement or total hip arthroplasty. Similarly, all articles that are deemed to have not met all the necessary criteria for inclusion shall be excluded as well. In furtherance, conference and meeting abstracts will also be excluded. Thus, to fix the risk of bias, systematic sampling from a vast pool of sources using inclusion and exclusion criteria will help in getting a representative sample.

Details of any barriers that may be faced in implementing the study. How will they be

addressed?

Conducting any review comes with its fair share of challenges and limitations, and this one is not exempted from the same. While the systematic literature review focused on relevant data sources, for instance, it became apparent that the identified case series lacked control groups from which comparisons would have been made. Through a systematic literature review where control groups are rarely included as part of the analysis, it becomes more likely to suffer from publication bias, which is mostly manifested in the studies identified. The most glaring limitation is the heterogeneity of data sources, especially when comparing age groups and treatment methods, which presents a bias that cannot be easily overcome due to the high number of studies involved [8].

PICOS

Problem/Patient/Population

When fragility acetabular fractures occur in the elderly population, surgical interventions become complex coupled with adverse consequences hence the need to have a multidisciplinary approach to minimize the inherent peri-operative risks. Although the success of every surgery is dependent on the type of intervention and patient factors such as health status, the current research aims to provide a solution on what best intervention can be adopted for the management and treatment of acetabular fractures in the elderly patients.

Intervention

While there are several traditional surgical and non-surgical interventions towards the management and treatment of acetabular fractures, not all of them have the same success rates. The current paper will compare these interventions and find the most reliable one that can be adopted in the handling of the elderly patients with acetabular fractures. Thus, the paper will compare “fix and replace” approaches such as ORIF, THR, acute THR, and delayed THA.

Comparison

The interventions to be compared with one another are ORIF, THR, and acute THA and delayed THA, where non ORIF groups will be compared with the ORIF group and THA compared with ORIF alone. A combination of THA and ORIF and ORIF alone will also be investigated.

Outcomes

The targeted outcomes will include a reduction of post-operation complications, reinfections, reconstructions, improved survival rates, and positive results on the patients’ general well-being.

Results

Search Results

The database search will yield 60 potential articles where five qualitative and five quantitative studies are to be accessed and reviewed after meeting all the requirements for inclusion. Most importantly, all publications will be from the year 2010-2020, which will provide a comparative cohort analysis, case series (retrospective and prospective) on THR treatment. A review will be conducted on articles with cohort patients treated with acute THR, delayed THR, or ORIF in line with the research questions.

Indications and Clinical Assessment Outcomes

A study by Iqbal et al. revealed that patients achieved radiological union of fractures at an average of 21 weeks when a total hip replacement was used for initial surgical outcomes with reduced post-operative complications. When follow up was conducted, Iqbal et al. found complications in seven patients postoperatively [1]. As such, two patients were observed to have developed epidermal surgical site infections and were treated conservatively; one patient sustained a dislocation while two others underwent total hip replacement revision with two

others having Brooker I heterotopic ossification. Additionally, there were positive outcomes among the group that had a primary total hip replacement with a follow up after two years, indicating that 78% of the patients had achieved improved functionality when the Harris Hip score was used [1]. Borg et al. meanwhile, appraised the efficacy of combined hip procedure (CHP) and if they were performed separately (CHP – THA and ORIF or ORIF or THA) on 27 patients with acetabular fracture and the results compared to determine which of the two methods was more efficient. Lou et al., in agreement with Iqbal et al. contend that no patient within the CHP group required further surgical intervention as confirmed by the 100% survival rate of the THA group compared to the 28.6% among the ORIF group [2]. Borg et al. study, however, contrasts Iqbal’s finding by suggesting that the CHP group had a high mortality rate after three years of following up when it is believed it is the best approach to treating acetabular fractures [2].
The results presented by Wang et al. indicate the impact of clinical variables such as surgery duration, amount of blood loss and transfusion requirements on the surgical method used in the ORIF and the non-ORIF groups [3]. Wang et al. noted improvement in the Harris Hip Scores after surgery in both the ORIF and the Non-ORIF groups. However, of the 21 patients treated with ORIF intervention, 6 of them required reconstruction to rectify bone defects compared to 7 in the non-ORIF category [3]. Meanwhile, Luo et al. appraised the efficacy of THA by conducting a follow-up post-surgery and identified that there was no infection among the group that had THA and which showed a remarkable Harris Hip Score that improved from
48.5 to 90 points. Similarly, in cases where THA was conducted, there were minimal hip dysfunction and osteoarthritis complications post-surgery [4].

Weaver et al. have similar results as Luo et al. on the efficacy of total hip arthroplasty on displaced acetabular fractures as observed on 33 patients who were treated using ORIF with 37 getting THA and the results compared over a 22 month follow up [6]. Radiographic data from the THA and ORIF cohort was then analyzed between the two sets of patients [6]. The results compiled by Weaver et al. revealed that those who had ORIF conducted on them had the highest probability of undergoing reoperation at a 30% chance while those that had THA had only a 14% probability of undergoing reoperation [6]. Meanwhile, it was also revealed that patients who had undergone THA had improved functionality compared to the ORIF group. The treatment of acetabular fractures, according to Boelch et al., depends on the surgical approach used by the surgeon, the condition of the patient, and the underlying diseases [5].
Similarly, Boelch et al. found that THR performed exceptionally well in patients with acetabular fractures compared to those that were treated with ORIF. In furtherance, THR allowed for advanced interventions such as the use of mechanical reconstruction of acetabular fractures [5]. Lastly, Murphy contends with Borg et al. in their shared opinion that acetabular fractures should be treated with ORIF and THR because of the inherent benefits compared to traditional treatment alternatives [7].
Salama et al. tested the efficacy of simultaneous ORIF and THA as a treatment option for osteoporotic acetabular fractures and made a 22 month follow up on the operated patients. The results revealed that all the patients could walk without assistance [10]. Meanwhile, 13 of the 18 patients were found to have a 72.7% Harris Hip Score with all fractures reported to have healed, 5 patients that were reviewed had heterotopic bone formation, which did not hinder the activity of the patient. Among the interventions used, it was noted that the acetabular cups inserted

during surgery were intact except for two patients who experienced a 2mm medial migration from the acetabulum cup. Ultimately, the research revealed that adopting ORIF, together with THR, provided a good chance for the patient to recover from acetabular fractures and regain optimal functionality [10].

Discussion

Iqbal et al., suggest that THR is the most appropriate method for treating acetabular fractures, especially in complex cases where the patient presented with some underlying comorbidities such as osteoarthritis [1]. Nonetheless, Iqbal et al. warn that the procedure for total hip replacement is not a guarantee that the patient will not suffer complications. Mostly, elderly populations are prone to recurrent falls, unable to follow post-operative instructions and are at a higher risk of deterioration due to other comorbidities [1]. Meanwhile, Borg et al. [2] suggest that most acetabular fractures can have better outcomes when ORIF and acute THA are used simultaneously as opposed to using each separately. Thus, Borg et al. indicate that surgeons must choose the best suitable treatment strategy for the older patients based on the risks associated with each procedure [2].
Boelch et al., suggest that the application of the ORIF procedure in treating acetabular fractures in older osteoporotic patients continue to provide inconsistent results [5]. The comparison of acute THR with delayed THR revealed that acute THR was mainly associated with positive health outcomes among patients presenting with acetabular fractures. Additionally, patients with acetabular fractures or other pathological fractures, presenting simultaneously with osteoarthritis of the hip can opt for THR [4]. Similarly, Luo et al. contend that THA can effectively treat patients with hip injuries/dislocations and fractures with reasonably good

functional outcomes without the patients suffering serious complications and risk of infection recurrence [4].
Alternatively, a study by Wang et al. on THA in post-traumatic osteoarthritis confirmed that THA was an equally reliable procedure recommended for pain alleviation and restoration of optimal functionality post hip replacement [3]. Wang et al. further suggest that when delayed THA is used for acetabular fracture treatment, the outcome may sometimes be complicated by the length of the delay, thereby making it a complicated procedure to patients who had had other surgical interventions such as ORIF [3]. According to Luo et al., the use of cementless THA has proven quite effective in the treatment of patients with a history of reinfection [4]. Furthermore, it has been noted that there are higher survival chances that can go beyond 10 years post- operation with little or no complications at all. The risk of infection in such patients undergoing cementless THA is also significantly low [4].
The use of ORIF as a treatment option before proceeding with THA procedures presented a challenge of experiencing similar problems encountered during the initial phase of surgery, as evidenced by the manifestation of proliferative scar tissues and other bone defects [10]. In furtherance, acetabular bone malformations contribute to the inferior outcomes witnessed in THA procedures when reconstructing previous hip dislocations. Delayed THA can have long- term inferior consequences as well when the acetabular fracture had underlying deficiencies such as in the presence of osteoarthritis [5].
Weaver et al. suggest that acute reconstruction of acetabular fractures using THA in elderly patients seems to be performing better when compared to ORIF. However, both have an almost similar rate of complications but with pain improving over time during recuperation [6]. Weaver et al. further agree with Boelch et al. by suggesting that most patients who undergo

ORIF tend to revert to THA within 2 years of operation. Thus, THA also provides better outcomes compared to traditional surgical interventions [6]. Meanwhile, Murphy and Carrothers suggest that the use of ORIF should only apply to younger and middle-aged populations suffering from acetabular fractures with acute THR strongly preferred for elderly patients [7].
Murphy and Carrothers, however, suggest that underlying conditions such as osteoporosis, obesity, and hip infections impact outcomes on acute THR intervention [7].
Guinta et al. also suggest that primary THA is preferable compared to ORIF, which has been shown to present poor results among older patients. Thus, when acute THA is considered, improvements become better post-operation [8]. However, McCormick et al. suggest that ORIF alone should not be discarded but rather normalize the use of ORIF and THA, although patients who are treated with acute THA also tend to survive better with indications of improved functional scores [9]. Similarly, Salama agrees with McCormick that ORIF alone is not as competent and reliable in treating acetabular fractures. Still, when THR is incorporated, the combination can work better in elderly adults compared to traditional surgical alternatives [10].

Limitations

Since limitations are inevitable, the project encountered a few during this research study. One of the limitations is that most of the articles reviewed were retrospectively reviewed, which makes it have current information on advanced clinical practice. Thus, very few reviews and research were done prospectively, thereby increasing the possibility of selection bias that compromises study outcomes. The fact that the number of patients involved may not necessarily represent the actual phenomenon as it is hinting at queries for on the credibility of findings based on small sample sizes. Inherently, the other primary concern for this study, however, is that treatment for

acetabular bone fractures takes different forms, as already highlighted in the research. Hence, it is plausible to deduce that each treatment option has its unique outcomes. Therefore, having a single solution as an option can be difficult because some of the treatment options are combined to get the desired results, which may compromise the study results [5].

Conclusion

Acute THA has been suggested as the most effective approach in treating acetabular fractures in elderly patients with co-morbidities because of its low mortality rates and its ability to necessitate optimal functionality. Meanwhile, underlying comorbidities such as old age, chronic diseases, and re-injury have been shown to lead to poor outcomes when delayed THA is performed on elderly osteoporotic population. Nonetheless, when acute THA was performed among elderly osteoporotic patients, the outcomes report improved post-surgical mobility and a higher survival rate compared to late THA. Acute THA is a challenging procedure with significant risks to the patient, however, this must be considered in context to the risks other treatment modalities entail. ORIF is considered to be the treatment of choice for younger patients with acetabular fractures but necessitates future surgery. Alternatively, when ORIF and THA are used simultaneously, there is a better probability that acetabular fractures among the elderly can be effectively managed with positive health outcomes which include immediate weight bearing and speedy rehabilitation, short hospital stay and reduces early and late complications. However, acetabular fix and replace can be lengthier and complex with a significant risk of perioperative death in the presence of early complications. Although the evidence is limited, ‘fix and replace’ is an emerging treatment of choice for particular group of patients.

References

1. Iqbal F, Ullah A, Younus S, Aliuddin A, Zia OB, Khan N. Functional outcome of acute primary total hip replacement after complex acetabular fractures. European Journal of Orthopaedic Surgery and Traumatology. 2018 Dec 1;28(8):1609-16.
2. Borg T, Hernefalk B, Hailer NP. Acute total hip arthroplasty combined with internal fixation for displaced acetabular fractures in the elderly: a short-term comparison with internal fixation alone after a minimum of two years. The Bone and Joint Journal. 2019 Apr;101(4):478-83.
3. Wang T, Sun JY, Zha JJ, Wang C, Zhao XJ. Delayed total hip arthroplasty after failed treatment of acetabular fractures: an 8-to 17-year follow-up study. Journal of Orthopaedic Surgery and Research. 2018 Dec 1;13(1):208.
4. Luo, Y., Yang, Z., Yeersheng, R., Li, D. and Kang, P., 2019. Clinical outcomes and quality of life after total hip arthroplasty in adult patients with a history of infection of the hip in childhood: a mid-term follow-up study. Journal of Orthopaedic Surgery and Research, 14(1), p.38.
5. Boelch SP, Jordan MC, Meffert RH, Jansen H. Comparison of open reduction and internal fixation and primary total hip replacement for osteoporotic acetabular fractures: a retrospective clinical study. International Orthopaedics. 2017 Sep 1;41(9):1831-7.
6. Weaver, M.J., Smith, R.M., Lhowe, D.W. and Vrahas, M.S., 2018. Does total hip arthroplasty reduce the risk of secondary surgery following the treatment of displaced acetabular fractures in the elderly compared to open reduction internal fixation? A pilot study. Journal of Orthopaedic Trauma, 32, pp. S40-S45.7

7. Murphy CG, Carrothers AD. Fix and replace; an emerging paradigm for treating acetabular fractures. Clinical Cases in Mineral and Bone Metabolism. 2016 Sep;13(3):2
8. Giunta, J. C., Tronc, C., Kerschbaumer, G., Milaire, M., Ruatti, S., Tonetti, J., and Boudissa, M. (2019). Outcomes of acetabular fractures in the elderly: a five year retrospective study of twenty seven patients with primary total hip replacement. International Orthopaedics, 43(10), 2383-2389.
9. MacCormick, L. M., Lin, C. A., Westberg, J. R., Schmidt, A. H., and Templeman, D. C..

Acute total hip arthroplasty versus open reduction internal fixation for posterior wall acetabular fractures in middle-aged patients. Ota International. 2019; 2(1): e014.
10. Salama W, Mousa S, Khalefa A, Sleem A, Kenawey M, Ravera L, Masse A. Simultaneous open reduction and internal fixation and total hip arthroplasty for the treatment of osteoporotic acetabular fractures. International Orthopaedics. 2017 Jan 1;41(1):181-9.

Appendix 1 FIX AND REPLACE 21

Quantitative Literature Review Matrix
Author/
Date Methodology Analysis and
Results Conclusions Comments/Outcomes/Implic
ations

Wang et al. (2018) Cross-sectional Cohort study design involving 33 patients from January 1997-January 2008 Surgery duration, blood loss and transfusion among the ORIF group were higher than in the non-ORIF group (p<0.05). Significant improvement in the Harris Hip Scores in both the ORIF and non-ORIF groups Delayed THA with previous acetabular fractures is a challenging procedure. Initial fracture treatment does not influence the outcome of delayed THA, and modern ceramic bearing has promising results in the long-term follow-up. The initial fracture treatment does not influence the functional results and component survival of subsequent THA at long- term follow-up. FIX AND REPLACE 22 Borg, Hernefalk and Hailer (2019) A cross-sectional study involving 27 patients with similar acetabular fractures with a mean age of 72.2 years (50-89) No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). The CHP confers a considerably reduced need for further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. THA has an excellent survival rate compared to hip joint survival in the ORIF group. Giunta et al. (2018) Retrospective Cohort Analysis reviewed from 2010-2015 involving 27 elderly patients operated for acetabular fractures Twenty patients (74%) were satisfied by the surgical treatment. Twenty post- operative complications (74%) were found. Two patients died during follow-up (7%). Primary THA for acetabular fracture in the elderly population might be a good therapeutic option that allows a return to the previous daily life activity. This surgery is difficult and selection of elderly patients, i.e., with acetabular fractures are expected to get a poor result with ORIF compared to THA FIX AND REPLACE 23 Lau et al. (2019) Retrospective Cohort Analysis reviewed from 2009-2016 The sample included 209,192 patients; most (69%) experienced symptoms for 1–5 years. A few patients (14%) experienced symptoms for <1 year, for longer than five years (6–10 years [11%]), or >10 years (5%). Patients with a symptom duration <1 year had better post-surgical pain and function outcomes Symptom duration before a hip replacement has become more standardized in England over time. However, increasing length of time remains a significant predictor of poorer outcomes after surgery FIX AND REPLACE 24 Mac Cormick et al. (2019) Retrospective case-controlled study Patients aged 45 to 65 years old with acetabular fractures involving the posterior wall treated with acute THA or ORIF at a level 1 trauma centre between 1996 and 2011. Patients were matched by fracture pattern and age at a 2 (ORIF):1 (acute THA) ratio. Functional outcome, complications, and reoperation rates of acute THA and ORIF were compared. Sixteen acute THA patients (average age 56.4 years) and 32 ORIF patients (average age 54.3 years) were evaluated at an average follow-up of 6.2 years (range 1–15.2). The average Oxford Hip Score in the acute THA group was 44 compared to 40 in the ORIF group (P = .075). Complication rates were similar between both the groups. Twelve hips (37%) in the ORIF group had undergone THA or been referred for THA, and two revisions (13%) had occurred in the acute THA group Both ORIF and acute THA for high-energy acetabular fractures involving the posterior wall in middle-aged patients can provide excellent results, with acute THA patients achieving improved survival of the index procedure and improved functional scores. FIX AND REPLACE 25 Qualitative Literature Review Matrix Author/ Date Methodology Analysis and Results Conclusions Comments/Outcomes/Implications FIX AND REPLACE 26 Luo et al. (2019) A retrospective study on Clinical Review of 101 patients (51 men, mean age 52.3 years undergoing cementless THA between 2008- 2015.Assessment of Clinical Outcomes No cases of infection were reported during the follow- up, and patients showed significant improvement in Harris Hip Score, for which the mean score increased from 48.5 to 90 points; the modified Merle d'Aubigne and Postel (MAP) Hip Score; the Hip Dysfunction and Osteoarthritis Outcome Score; the SF-12; and mean limb length discrepancy, which decreased from 3.4 to 1.1 cm Cementless THA can effectively treat patients with a quiescent period of infection of the hip of more than ten years, resulting in good functional outcomes and fewer complications. Risk of infection recurrence after THA in these patients seems extremely low. Results should be interpreted with caution given that this was a retrospective evaluation without a control group. Also, we were unable to compare outcomes between unilateral- and bilateral THA. FIX AND REPLACE 27 A prospective All patients achieved a Primary total hip Iqbal et al. (2018) observational study radiological union of replacement is a valid was conducted in the fractures at an average and reasonable one- orthopedic department duration of 21 weeks. During stage surgical the follow-up, seven treatment of complex complications were acetabular fractures observed. Two patients and in aged developed superficial individuals. However, surgical site infection, which the complications are was treated conservatively. not uncommon. One patient had a dislocation, which was reduced closely, while two patients had acetabular cup loosening, which was revised. FIX AND REPLACE 28 Retrospective Clinical Twenty-three patients were The described ORIF for acetabular fracture in older patients is Boelch et al. (2017) Study on ORIF and treated with ORIF and nine technique achieved unsatisfactory and maybe even worse for THR for osteoporotic with primary THR sufficient acetabular osteoporotic fractures. Immobilization for long- acetabular fractures (performed with an anti- component stability. term restricted weight-bearing after ORIF is protrusion cage). If the Primary THR with an hazardous. Primary THR may enable early post- posterior column was anti-protrusion cage is operative full weight-bearing unstable, THR was an advantageous combined with posterior option to ORIF and column bridge plating. should be strongly Indications for THR were considered for the presence of a osteoporotic acetabular comminuted fracture pattern, fractures approach-related risk factors for ORIF, and mobilization issues. Biomechanical reconstruction was acceptable with THR. Acetabular component loosening was observed only once. Secondary THR was indicated in 45 % of the ORIF cases. FIX AND REPLACE 29 Case series analysis of At the latest follow up, all ORIF and Combining ORIF and THR have consistently Salama et al. (2017) 18 patients (eight patients could walk simultaneous THR is a shown improvements in patient outcomes females), with an independently. Thirteen good option for the compared to acute THR/THA. average age of 66 patients (72.7 %) had treatment of certain years (range 35–81 excellent Harris hip scores types of acetabular years) who had HHS, five, patients (27.7 %) fractures, particularly displaced acetabular had good results. All in the elderly fractures fractures were healed, and population. the acetabular autologous bone grafts were well incorporated. There were no delayed unions or non- unions. Two patients (11 %) had heterotropic bone formation, which did not affect the activity of the patients. There were no signs of loosening of the acetabular cups; however, one patient had 2 mm medial migration of the cup. FIX AND REPLACE 30 Weaver et al. (2018) A retrospective review in two American trauma centres involving 33 patients was treated with ORIF and 37 were treated with THA. The mean follow-up was 22 months (range 6–89 months). Patients were interviewed, and radiographs were examined. Those treated with ORIF had a higher rate of reoperation (10/33, 30%) compared with those treated with THA (5/37, 14%); however, this was not statistically significant (P = 0.12). Patients reported better bodily pain scores as measured by SF-36 (48 vs 39, P = 0.04), and a trend toward improved function as measured by patient-reported Harris Hip Scores (82 vs 63, P = 0.06) in those treated with THA compared with ORIF. Acute reconstruction of acetabular fractures with THA in the geriatric population seems to compare favourably with ORIF, with a similar rate of complications, but with improved pain scores. Besides, there was a high rate of conversion to THA within two years of injury when patients were treated with ORIF. Acute THA as primary treatment in this patient population merits further, more controlled, comparative study. Treatment of acetabular fractures by reconstruction with THA presents several potential challenges, including the risk of loosening of the femoral or acetabular components and the possibility of dislocation of the hip prosthesis. FIX AND REPLACE 31

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attachment 1 : the dissertation proposal – grade earn is 68 – serve as an understanding of the country industry.

attachment 2: dissertation paper is currently working on is a slight diversion from the proposal – have not completed with Question or formulate the hypothesis. The 250 words for writer to provide me with hypothesis or question. Will need that as soon as the writer can provide for me to start on the survey questionnaire.”

Jodie Thang Kelly – ACIER Engineering Services Pte Ltd – Roehampton University purchased an essay from us. Please follow this site for more details.

Supervisor: DR. Christopher Fong, and course moderator, DR. Samuel Lee.

“Title: The issue of skill mismatch affecting the sustainability of offshore oil and gas industry in Singapore.

Order 6250 words:: 4000 words for Literature Review + 2000 words for Design and Methodology, + 250 words for hypothesis or questions.

attachment 1 : the dissertation proposal – grade earn is 68 – serve as an understanding of the country industry.

The decline of the academies is certainly not exaggerated. Today, aside from being saturated with Neo-Marxist diarrhoea and irksome nihilism, the world of academia has seen an ever-widening gulf appear between tutor and student. Since the 1960’s, universities across the Western world have become similar to pre-revolutionary France, with faculty acting like the pampered aristocrats of Versailles and the average student a lowly peasant, with instead of the yoke of eternal serfdom around his neck, the yoke of student debt.

Perhaps a better comparison would be with Communist Russia, the Politburo and the proletariat, let’s face it, most academics are Socialists, Maoists or some other kind of ideology. The way the academy has restructured itself over the past 40 to 50 years, coupled with increased university tuition fees, has created a seismic gap between those who attend a university with the hope of furthering their skills and obtaining a flourishing career at the end of it, and those who see a university as a giant cash cow.

The Not So Honourable System

Whereas the academies were once a place that valued classical education and thus attracted curious and intellectual minds, who understood the great works of the masters, like Plato, Aristotle et al, it now attracts the soulless careerist. Men and women who perpetuate flimsy ideologies, the red flag waving revolutionaries, unless it’s anything to do with their paymasters, then they’re the most well behaved little boys and girls.

As standards surrounding higher education have dropped so dramatically over the decades, we’ve seen the increase in Postmodernism, which is now the cast iron and unquestionable doctrine of every university across the Western world. In the words of Jordan Peterson, professor of psychology at Toronto University, Canada, Postmodernism is so popular because it makes stupid people feel intellectual, without having to do any of the hard work.

A House Built on Sand

One of the most egregious aspects of the modern university and one which is cheating gullible students out of a ton of money and an actual career is the teaching of pointless subjects. Another leftover from the baby boomers temper tantrum against their parents, subjects like gender studies, formerly women’s studies, have gained a prominent place at universities, proving the theory that we are becoming ever more an idiocracy.

Gender studies are Postmodernism in its purest form, a flimsy mish-mash of nonsensical drivel coupled with a victimhood mentality. Often taught by hairy, man-hating “professors” (and I use the word professors in the loosest possible term) who indoctrinate the blank canvas like minds of young girls in misandry and viewing femininity as a weapon conceived by the mythical “patriarchy”.

It is not just the rise of purposeless courses, but traditional subjects, specifically those in the arts and humanities, have become completely dismantled and reshaped to fit with Postmodernist teaching methods. Art history and English Literature, for example, are now so far removed from what they once were in the 1950’s and early 1960’s, they are now mere shells of their former selves.

Great works of literature by Shakespeare and Wordsworth and art by Michelangelo and Bernini are now observed through the prism of identity politics, the male gaze and so-called anti-racism. Everything is dismantled and taught to be patriarchal, sexist, homophobic and racist, so we have graduates being churned out year-by-year who have little understanding of what a novel or a painting actually is. Culture is merely the byproduct of an oppressive system that keeps down the poor little minorities.

End Game

None of this would have happened if the academies stuck to their core principles, those which were laid out by the ancient Greek philosophers. Secondly, the downgrading of admissions for tutors and professors, combined with government interference in tuition fee increases etc, has created a noxious atmosphere, which has given rise to a pampered yet intellectually redundant elite.

The end game of contemporary higher education is clear, to perpetuate a very dangerous deconstructivist ideology, which keeps an elite secure and the rest of the university going population ignorant and deep in debt.

Shakespeare’s gifts to the English language are numerous. From his prose to his plays, the Bard invented a dictionary’s worth of words and phrases, that to this day are still used in common parlance. There is not a day that goes by where we do not use at least one word by the playwright. In essay writing, for example, you would use up to and above 1000, from the simplistic and rudimentary to the specific and technical.

William Shakespeare Portrait

Unlike many other languages, the English language was, during the Elizabethan era, in a continual state of flux. Whereas other major languages like Greek and German were fixed and rooted, English was fluid. Shakespeare was the second man to trigger a state of efflorescence in the language, with the first being the Late Medieval poet Geoffrey Chaucer.

A Love of Words

Shakespeare’s love of languages (he was proficient in seven of the Romance languages, including Italian, French and Latin) is confirmed by the fact his works contain around twenty-seven thousand words, which is more than any other writer. In comparison to other men of letters, such as Homer and Dante, James Davie Butler, author of ‘The Once Used Words in Shakespeare’ explains: “The total vocabulary of Milton’s poetical remains is more nearly seventeen than eighteen thousand (17,377); and that of Homer, including the hymns as well as both Iliad and Odyssey, is scarcely nine thousand. Five thousand eight hundred and sixty words exhaust the vocabulary of Dante’s Divina Comedia.”

Obsequiously: Meaning and Use

Richard III Poster

The word “obsequiously”, meaning to act in an excessively servile manner, appears in Richard III. In Act I Scene III, Lady Anne is mourning over the body of her father-in-law King Henry VI, and the word appears in her impassioned outpouring of grief.

“Set down, set down your honourable load,

If honour may be shrouded in a hearse,

Whilst I awhile obsequiously lament

The untimely fall of virtuous Lancaster.

Poor key-cold figure of a holy king!

Pale ashes of the house of Lancaster!

Thou bloodless remnant of that royal blood!

Be it lawful that I invocate thy ghost,

To hear the lamentations of Poor Anne,

Wife to thy Edward, to thy slaughter’d son,

Stabb’d by the selfsame hand that made these wounds!

Lo, in these windows that let forth thy life,

I pour the helpless balm of my poor eyes.”

Here, we see the word, used in the first person, is not meant in a derogatory way. Its connotations with cringe-worthy sycophancy would not manifest until several centuries later, in the novel David Copperfield by Charles Dickens, published in 1850. The character Uriah Heep, whose personality was so comically cringing, gave English speakers the perfect literary representation for the word, and from then on would be forever synonymous with this type of spineless behaviour.

Hamlet Poster

In Richard III, we see that “obsequiously”, although at its base, meaning to fawn over someone, is used more to articulate an expression of intense grief and emotional devotion to the other person; however, in Hamlet, despite the word “obsequiously” not being used, its contemporary universally understood meaning is played out.

In a scene between Hamlet and Polonius, Hamlet points to the sky and asks Polonius if the cloud above has the shape of a camel and Polonius agrees. Hamlet then changes his mind and says the cloud looks like a weasel and Polonius agrees. Hamlet once again changes his mind and opines that it looks like a whale and Polonius once more affirms it.

When Meanings Solidify

Old Books

As the English language began to form firm foundations, words such as “obsequiously” so too began to solidify. A word, which in Shakespeare’s time, could be used in several ways to explain something, would become defined by only one meaning and one visual representation in the minds of those who use it.

In Richard III it’s clear Shakespeare was using “obsequiously” as a form of literary decoration, to brocade and make richer Lady Anne’s lamentation. His use of artistic license helped to launch the word and its meaning into the widening ocean of the English language.

Essay Writing The Fundamentals : A Cheat Sheet by The Uni Tutor

In this cheat sheet, you will learn everything from starting an essay all the way to the conclusion and then editing.

We’ve carefully written this document so students can make the most out of it.

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How to Write a Biology Essay

Students are usually expected to know how to write a biology essay in biology classes in many universities. Articulate formatting and organisation is required in writing a scientific research paper. For this reason, Academic Sciences, a unique assignment writing service, provides comprehensive “how to guides” to students to help them study about how to write a biology essay.

GETTING STARTED

Once you select an appropriate topic then learning how to write a biology essay becomes very easy and enjoyable. Before you start writing a custom biology essay, you should get ready to research and investigate issues. First and foremost, you should select a topic in which you have genuine interest. Owing to the vastness of the subject, our professional essay writers can help you to come up with a topic based on the subjects you take from Zoology, Genetics and Botany. As get to learn on how to write a biology essay, there are some basic concepts you need to grasp such as formatting, writing the abstract and executing the total structure of the paper accurately.

A formally written biology essay should be in the Times New Roman body, a font size of 11 and a line spacing of 1.5. Many universities require you to use normal page margins in formatting your biology essay. The page number and your surname or university identifier should always be placed on the right upper side of every page. While gaining knowledge on how to write a biology essay, students will note that the title is always in bold and font 14 with the heading at the top of every page. Other details include the student’s full name, school, department and address all written in bold.

Academic Sciences has professionals who are well trained and qualified to coach you on how to write a biology essay. They also teach you how to write the abstract, a section which is largely similar to the summary of the whole essay. It should be clear and concise. The aim of the abstract is to give the reader a general idea of what is discussed in the entire paper. Only a few sentences usually offer some background information on the researched subject. It should briefly describe all the applied experiments, methods and the conclusions drawn from the results.

Writing Your Essay

Academic Sciences provides assistance in essay writing to ensure that as a student, you become highly skilled on how to write a biology essay. The essay should include the introduction, body, conclusion and citations.

INTRODUCTION

The introductory paragraph should set the tempo for the readers. It ensures that readers get to understand what the essay entails. A good introduction paragraph should be developed step by step. It is recommended that students limit their introductory pages to 2 pages at most. When learning how to write a biology essay, this is adequate to provide a detailed overview about the whole subject under study. It should include all necessary information to enable the reader understand results of the whole essay. Of greater significance is to enable the reader the indispensability of the subject. As the learner discovers how to write a biology essay he/she will note the importance of adding results from the previous research and experiments which they have conducted on the topic under study. Final introductory concepts should point out the experimental design, what is being defined with the experiment as well as the original hypothesis.

BODY

In this section of the essay, the student is expected to disclose the essay in details. As the student gains skills on how to write a biology essay they ought to precisely discuss the different forms of plant or animal life. Any experiments and dissections performed need to be discussed explicitly in order to assert the theory of life. Such a writing assignment creates a greater impact when it is written in combination with illustrations and diagrams irrespective of whether the student is taking Zoology, Botany or Genetics. For instance, a botany student ought to discuss cell division and all related cell life forms like mitosis and meiosis. A zoology student, on the other student, needs to discuss hereditary factors as well as asexual and sexual reproduction.

CONCLUSION

A student who has learned how to write a biology essay should be able to sum up all the work done successfully. The Academic Sciences graduate writers will help you to re-emphasise all the important points in order to come up with a powerful conclusion. Like the introduction, the conclusion bit ought to leave a great impact on the audience. In order to produce a near-perfect paper, proofreading and editing are inevitable. A good biology paper should be completely original along with proper referencing and formatting.

A Guide On Harvard Referencing Style

One of the most widely used referencing styles in the world is the Harvard referencing style. Based on an author-date system, Harvard referencing is recommended by many universities throughout the world because it is easy to use, read academic work and also facilitate findings and enlist all bibliographic references.

Harvard referencing can be used in any type of paper including literature reviews term papers, empirical studies, theoretical studies, methodological articles and other forms of academic writing. Harvard referencing style is an easy way of providing evidence and accrediting the sources used in a paper. This avoids suspicions of plagiarism because it gives credibility to the work of the authors involved.

Manner of referencing

There are several sources from which you can cite in an academic paper: journals, books, newspaper articles, internet websites or newspaper articles among others. In order for readers to find out the original material in your paper, Harvard referencing style consists of in-text citations indicating the author and the year of publication, and a detailed bibliography.

In-text citations mention the name of the author and the date of publication in brackets. Rules governing in-text citations include:
• They should exhibit consistency throughout the paper.
• In-text citations are written in round brackets. They are normally found at the end of a sentence, just before the sentence’s concluding punctuation. If there is a citation referring to a particular part of a sentence, it should be inserted at the end of a respective clause. Of importance to note is the fact that if an author’s name is included in a sentence, the citation should appear directly after the respective author’s name.
• When there is more than one author for a specific publication, all their names should appear in brackets in the same order as they appear in their publication and separated by the ampersand “&”. But if their names form part of a sentence, then use “and” to separate the authors’ last two names. For instance: “James and John (2012) indicate that…” or “more research on the same matter (Jacobsen, O’Malley & Kevin, 2008) reveals that…”
• If the author of some work cannot be identified, you should use the terms “Anon.” or “Anonymous” along with the work’s title in italics and the date of publication. However, in such cases, it is better to make efforts to find the name of the author especially when the work is part of the supporting evidence for your study. For instance: “Marketing Strategy (Anon., 2008) provides invaluable evidence for…”

References

The Harvard referencing style requires a list of sources at the very end of an academic paper where full bibliographic details of every book, website, journal or article are listed. Such a list enables all your readers to locate various pieces of information used in your study with ease. All items mentioned the list of references should be arranged in the alphabetical order of the names of authors. Details about items in the list of references should be mentioned including the year of publication, publisher, authors, website URLs, dates when websites were acceded etc. In this section, we shall expound on all these items. The Harvard referencing style does forbid the use of personal communications like informal emails and letters in the list of references. However, they can be cited in the text where need arises.
The manner of referencing ought to be very precise and adherent to the rules. The author’s name is followed by the year of publication; both details in parentheses at the end of the sentence. An alternative is to mention the author’s name and then putt the year in brackets when referring to some work in a direct manner.

Example one: “… the study heretofore has been proven by many researchers as well. (Jacobsen, 1989)”

Example two: “…not more than 40 percent of all incidences, as Jacobsen (1989) proved after several years of research.”

Another focal point in the Harvard referencing style involves direct quotes. When a student is quoting a fragment text comprising of less than 30 words, the student is allowed to incorporate the fragment in the text in single quotation marks. However, the year of publication and page number should be included in parentheses. When The pages being mentioned should be preceded by “p.” The Harvard referencing style requires users to write “pp.” for all page ranges.

Example: “demonstrate to the client that you are on top of their matter” as Sparksman (2008, p. 41) stated.
In the case of quotes with more than 30 words, the student is required to include a double space of 1.3cm of indent containing fragment text without quotation marks. However, you should introduce it with your own words.

Example: Mark L. Kutner adds weight on this physics aspect: When the time concept becomes suspect, it is important to reinvestigate the concept of length. We also need to think about how to measure the length of any given object. The two positions of the ends are measured and the difference taken. Nonetheless, measurements should be taken simultaneously in order for this procedure to become meaningful. (Kutner 2003, p. 129)

In other cases, an author may quote the work of another author. Harvard referencing style requires the author to acknowledge both primary and secondary sources by providing significant details for both sources in the reference list. For instance, if an Godwin cites work from Jackson, the text should appear as follows:
Jackson (cited in Godwin, 2011) offers compelling evidence concerning the facts enlisted below:

or:

We have enough evidence to back up the aforementioned claim (Jackson, cited in Godwin, 2011).

Book Referencing in the List of Sources
The following rules are imposed by the Harvard referencing style when mentioning details of a book in the list of sources:
• Titles should be written in italics.
• Book information should appear in the following order: year of publication, title of the book, series, edition, editor, volume number (if any) or the number of volume(s), the publisher, place of publication, and the pages.
• Harvard referencing style requires minimal capitalisation: the student should limit capitalisation only to proper nouns as well as the first word of a book title. Subtitles should not capitalised. However, they should be separated from the main title of the book with a colon.
• In case we don’t have an author, the source can be listed with the first significant word in the title or with the editor’s name where available.

Bibliographical details are listed as follows in the Harvard Referencing style:

A Chapter in a book:
Author, X., Author, Y., and Author, Z. Year. Title of the Chapter: Subtitle. In: Editor M and Editor N (eds) Title of the Book. Place: Publisher, 11–22.

Journal articles:
General: Author, X., Author, Y., and Author, Z. Year. Title of the Article: Subtitle. Vol. number (issue): 11–22.

Example of Reference in a Book
Julie Dickson, 2001, Evaluation and Legal Theory. Hart Publishing.

Referencing a Book Chapter:
Frances, S., Ellie, W, Sizer. E. 2011. Nutrition Controversies & Controversies. In: The Proteins and Amino Acids: The Structure of Proteins. Oxford: Elsevier, 190-195.

Referencing a Journal Article
Wright, R., and Slatter, D. 2012. The Whole is Always Smaller than Its Parts’ – A Gigital Test of Gabriel Tardes’ Monads. The British Journal of Sociology, 64(3): 590-615

Different works of the same author and same year
When referencing works done by the same author you need to differentiate the year of publication—which is the main criterion for ordering. In case you are referencing two books done by one author and also published in the same year, Harvard referencing style requires that lower-case letters are used e.g. “x”, “y” or “z” after the year of publication. This should be done both in-text and the list of references.
Smith, X. 2010, The Power of Legal Systems, New York.
Smith, X. 2010a, The Law and Business in the 21st, Dallas.
Smith, X. 2010b, The Contemporary Legal-Business Regime, Austin.

Referencing an Unpublished Thesis
Chris M.N. 2001. Problems Suffered when Focusing on Reflective Activities: Potential Measures for Developing Self-assessment Skills in Learning Languages, Oxford University.

Referencing Newspapers
Neil, C. 2013. Bale of the Century. The Sun, 13 June, p. 7

Below are some abbreviations commonly used in reference lists:
Vols. Volumes
vol. Volume
trans. translator(s)
rev. Revised
suppl. Supplement
ser. Series
p. (pp.) page (pages)
n.d. no date
Edn. Edition
ch. Chapter

Website referencing

Harvard Referencing style recommends inclusion of full URLs when citing websites along with dates on which the author accessed them. Examples include:
– Webpages without an author: Neanderthal Man, 2006. [online] It’s available at: < http://www.smithsonianmag.com/science-nature/neanderthal.html/ page=984> [Accessed 6 August 2013].
– Web documents: Department of the Treasury, 2013. Treasury Honors Initiatives That Strengthen Global Communities and Advance American Interests. [online] Available at: < http://www.treasury.gov/press-center/news/Pages/Treasury-Honors-Initiatives-that-Strengthen-Global-Communities-and-Advance-American-Interests.aspx>. [Accessed 6 August 2013].
– Websites: NASDAQ, 2013. Information on Market Prices. [online] Available at: <http://www.nasdaq.com/> [Accessed 6 August 2013].

For more information about the Harvard referencing style, check referencing sections from websites like Monash University or Anglia Ruskin University.

Jodie Thang Kelly – ACIER Engineering Services Pte Ltd – Roehampton University purchased an essay from us. Please follow this site for more details.

Essay Writing The Fundamentals : A Cheat Sheet by The Uni Tutor

In this cheat sheet, you will learn everything from starting an essay all the way to the conclusion and then editing.

A Guide On Harvard Referencing Style

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