ࡱ> uwt/ yIbjbj 4Lbhbh r..8$6T *"L X $s h29`^*``2..Bk`R.l ` ,0qXp0   (```````22``````` `````````X :  OPERATION: Femur - Intramedullary Nailing PROCEDURE: The femur is the long thigh bone. It is a weight bearing bone and will need to be fixed for you to walk on it. Your surgeons feel that the best way to hold the bone together is to insert a nail through the bone hence hold the two ends together and allow proper bone healing. The femur is essentially a long hollow tube with marrow in the middle. A nail (or metal rod) can pass through the hollow and bridge the two broken pieces. Your surgeon will see you before the operation. The surgeon will mark your broken leg with a felt pen to make sure the correct leg is operated on. If you have any questions, now might be a good time to ask them. You will have an anaesthetic given in theatre. This may be a general (when you are asleep) and/ or a regional (when an area is numbed but you are awake). When in theatre, you will lay on your back. The legs will usually be placed in a stirrup. The surgeon will clean the leg with antiseptic solution and place clean towels (drapes) around the site. A small cut will be made just at the side hip above the thigh bone. This allows the surgeon to feel the top of the bone. A surgical drill (reamer) can then remove the bone marrow from the middle of the tibia. This will allow a nail to pass down across the break to the other side of the bone. The surgeon will take X-rays at regular intervals to make sure that the position of the nail is correct. When satisfied, the surgeon may then pass screws into the nail from the side to hold it in position. These are called inter-locking screws. When the surgeon is happy with the X-ray position of the fracture and the nail, the wounds can be closed. Some surgeons prefer stitches while others use clips (skin staples). Both are equally successful and come down to your surgeons experience. When you wake up, you leg will sore, this is normal. You will have a bandage across the lower leg. If the pain is excruciating, you must tell some one. You will have repeat X-rays and a blood test the day after and will be shown how to walk with crutches without putting weight through the affected leg. ***Please be aware that a surgeon other than a consultant, but with adequate training or supervision may perform the operation*** ALTERNATIVE PROCEDURE: When your femur has been broken it is very advisable to have it fixed. Not fixing may result in non-healing, delayed union or mal-union. All these can cause quite significant disability and long term problems. There may be other options available to treat this fracture; these including external fixation or plating. However, it is the suggestion of the consultant surgeon looking after you that nailing is the best option. You are of course entitled to a second opinion. There MAY also be a non-operative option. This would be to place the fractured leg in traction and regularly x-ray to watch the bone healing. You will have to be non-weight bearing and there is a high risk of non-union (when the bone ends do not fix properly of do not meet at all) in these fractures which may eventually require an operation such as the one above. RISKS As with all procedures, this carries some risks and complications. COMMON (2-5%) Pain: There will inevitably be some pain after the operation. This may be around the wound site, the fracture site or at the hip or knee. If you are in pain it is important that you ask for pain killers. Pain will decrease over the next few days to weeks as the bone heals and the swelling decreases. Very rarely, pain may continue. This may be due to failed fixation in which case another operation may have to be performed. Pain at the knee is common after the operation. Bleeding: There will be some bleeding. This is usually minimal and can be stopped at the time of operation. Very occasionally a blood transfusion or iron tablets may be necessary Infection: the wound site may become red, swollen and painful. There may also be discharge. If this occurs, antibiotics may need to be given. If the metalwork becomes involved, it may be removed. There may be spread of the infection to bone or blood (sepsis). Again antibiotics may be necessary. Extremely rarely, very severe local infections my require the leg to amputated. Numbness: the skin around the wound sites may be temporarily or more permanently numb. LESS COMMON (1-2%) Stiffness of the joints around the fracture: may occur and may require vigorous physiotherapy Stiffness: and osteoarthritis may continue. This may require vigorous physiotherapy and or repeat surgery. Fat embolus: the fat in the middle of the bone (marrow) may be spread to the blood and eventually the lungs during manipulation or during the original break. This can cause severe breathing problems. Very rarely, this can be fatal. Blood clots: a DVT (deep vein thrombosis) is a blood clot in a vein. These may present as red, painful and swollen legs (usually). The risks of developing a DVT are greater after any surgery (and especially bone surgery). Although not a problem themselves, a DVT can pass in the blood stream and be deposited in the lungs (a pulmonary embolism PE). This is a very serious condition which affects your breathing. Your surgeon may give you medication through a needle to try and limit this risk of DVTs from forming. Some centres will also ask you to wears stockings on your legs, while others may use foot pumps to keep blood circulating around the leg. Start to walk and getting moving is one of the best ways to prevent blood clots from forming. Catheterisation: The team may pass a tube into the bladder. This is usually temporary but will collect your urine. RARE (<1%) Compartment syndrome: this is a build up pressure within the thigh and can cause pain, nerve damage, blood vessel damage and muscle damage. If this occurs, an emergency operation will have to be performed to prevent death of tissue of the lower leg/ foot. Damage to the skin under the tourniquet: this may require dressing, surgery or skin graft. There may also be numbness of the skin under the tourniquet, this is usually temporary. Failed reduction: this is difficulty in aligning the two ends of broken bone. In this case, the operation may need to be repeated or an alternative operation may be done at a later date. Removal of metalwork: this may be necessary if it becomes infected or painful or damages the skin. Sometimes, the nail can be removed to allow greater movement once the bone has healed. Abnormal wound healing: the scar may become thick, red and painful (keloid scar). This is more common in Afro-Caribbeans. Deformity of the leg: the bone may not heal in its intended alignment. This may require physiotherapy or further operation (including removal of nail). Delayed or non-union of fracture: this is when the bone ends do not join adequately. At this point, a bone graft & further surgery may be necessary. I have read/ understand the procedure, risks and complications. I have asked any questions and raised any immediate concerns I might have. I understand another surgeon other than my consultant may perform the operation.(although they will have adequate training/ supervision). I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health Signature. Print name.... Date.//20 2nd Confirmation............... .Date./..20.   I also give consent for my notes and any data recorded curing this operation to be used in any current or future projects/ research m Signature& & & & & & & & & & & & & & & & & Date& & & & & & & ..      AFFIX PATIENT DETAIL STICKER NHS Organisation& & & & & & & . HERE Responsible surgeon. Forename.. Job Title Surname Hospital Number... D.O.B.././ No special requirements ( NAME of SURGEON (Capital letters).. SIGNATURE of SURGEON. POSITION..     9:;<EG - . OPGHz{^`agcG% hs%>* hhs%hs%CJaJ hs%5hs%CJ aJ hs%5CJ aJ hs%jhs%UmHnHuM    :;< )$$d %d&d 'dN OP Qa$gds%`gds%* $d%d&d'dNOPQgds%gds% - . OPGHz{)$$d%d&d'dNOPQa$gds% $ a$gds%)$$d %d&d 'dN OP Qa$gds%`agcG%sQ)$$d%d&d'dNOPQa$gds%gds%)$$d%d&d'dNOPQa$gds%%sQ2KLPX&(09wF<iD-NOPU[o B o ! !*!:!!!!""B""""##7#K#hs%5CJ aJ hs%5 hs%>* hhs%hs%Y2L(wF<&$d%d&d'dNOPQgds%)$$d%d&d'dNOPQa$gds%iD-NOP[B o !*!!!!B""")$$d%d&d'dNOPQa$gds%"#7###)$o$%&&&&&&''C' $If`gds% $Ifgds% ($1$7$8$H$Ifgds% $$Ifa$gds%)$$d%d&d'dNOPQa$gds%K####$)$o$%%%&&&&&&&&&'''' ' 'B'C'D'E'F'G'H'I'J'K'L'M'N'O'P'Q'R'S'T'U'V'W'X'Y'Z'['\']'k'((D)F)H)Ļİjhw3Ujhs%Uhs%CJaJhfhs%CJaJhs%CJH*aJhs%CJaJhs%CJ aJ h?hhs%OJQJ_HmH sH #h?hhs%5OJQJ_HmH sH  hs%>*hs%:C'D'E'G'H'I'J'K'L'M'N'O'P'Q'R'T'U'gds%hkd$$Ifl ! !0 !644 lalp U'V'W'X'Y'Z'['\']'((F)J)L)P)R)V)X)\)^)`)b)f)h)j)l)$a$gd6hm $ 9r a$gd6hmgds%H)J)L)N)P)R)T)V)X)Z)\)^)`)b)d)f)h)j)l)n)p)r)t)v)x)z))** *O*d*******+5+6+7+8+9+:+B+j+k+l++++++HHHHIuIvIwIxIyIU johs% jhe0+h6hmUmHnHuhs%h6hmjhw3Uhw3?l)n)p)r)t)v)x)z)* *O*d******7+8+9+:+j+k+l++++++gds%If you have any complaints about your treatment or your care, you are always encouraged to discuss them with your surgical team. However, if you wish to complain to the trust, each hospital will have a PALS or Patient Advise and Liaison Service. The head nurse on the ward or out patients clinic can direct you to them. The PALS team will treat all complaints seriously. +HHuIvIwIxIyI$a$gds%21h:pMo. A!"#$% $$Ifl!vh#v !:V l0 !65 !/ alp FVDd bp  s >A?Picture 4"RU{Gd? 顁^UFVU{Gd? 顁JFIFddDuckydAdobed^~     !X1"# AaQ2$wx9Br38qRC5u&v:   !1AQ"aq2ғUVB#R3u78Cst6vbrc4& %e ?)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LRn~5LVŁYi&DH>偠l N*i%YO0>bPRZMC$f=8 q*@1O}fjF)JR,F`=vԥ^ي#X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6!ߘ翖8>l参\OoO{cc>X)u$6ծNњ˵.{v충h#7$J'"%Lܠ~ΣMVڻSFv59Ʈ X=OMNV7AC;nB`Ix|qLr>i^bz20rpqR0w#cE,_$LKڰs%6h6:;*2#zShqv'x+el9#2<0Nٚol`hg@ \݁[ }Э>T;?׷۔ƴ}f1Jb)S)LR1JeYq/S,vdEQ)jp&XN}hFTP>L@LU7oo=?DQ4á Uywk\op.3VN$uV*s3iP_m KRB+brM7evO),(>hU/Tې݅M~csnOsݙ%ħA3ab} ll}<[i$Jޞr=B8,vF*qLR1JbP{yLXƋ2+dGktUF7:%%MM Q pD`3Lc Ϧܷ8;RRS1N]S\p=Bh^=c=P~Fђ:8h5b&H7Q33DzuT0Ϳu5h7=~zŷm#t[U LA?0Adޯx4)S)LRVtQ~ie0dYkǨ&AP&"H@`.H}w8 $\}YJcGu}ݵt :ci1xl=yY²}g^cPm]ubx_\?^ީ"n«aL5m]ekwVs7'{:E}NЙ;[GC*Jvr+Xmb_e^jG MIInjYSG{}v"I$Q⯇P"j[Z5r֝s/6y[^roB,W{b-4Qsj|jD8wQ؛H7[(ļҪL"ZvZm6Gq9>'RS"+t;Rv .PY 3UFOx OCN~w1va\{ra5W-zcgw3a͟xufrz^dͷM/lGL~AR.xYv !̘=@G::NZ4\pȘT#Սsm崴ŮZ]Ig7ו6i6ˮkVU-2gxd}B6vK;UJ#>:MYjMmx1ʍ}\?ڭ<76m$N!Ik-ϊ-ۦ5ԛhM5e&fq+R&&嘺\{H=߳:^!7e C$0Ģ?7-;Kye8vVi- "^)%pJ-w[:v(w>Q\M 3$p*AJ)fae =`A{ej- RhܚV@xfQ;'dخ1R);z>[V~7f%(\M_rmK0飏x;EzZ<{˹iw/Y&e0*E%]|,ǭ0}s]ӯlc3C$jO3ׯG[gp1M Pu{#EnW~Sqj;ԅn2Kf5ݛ;^B*Mh|P&RS aέwAjy"$FW.\u-g@K$r *H # VSԋ*)8Xsokӛz.wg1u:Eس;P:>5KiH ƸdifX!s > p/?j R:jMo#e^h{t5Vj0}yVFt82*G A I{wY qA1{FۖZ67KmmZ6)_wO\bzއtSݔRvL27>=/_ nZisXҶ4ل[nUɥ&`i +5nTDFHNdr4sHHV.TeN'j\,7^&XX4pH `:jօ%?P4 m^D!O9.CVk.l+-J])rNaV>^8z<+RWS- [≬+'JAuLz:"zg5b)S)LR1JIժVq2h l*95 lbiU5յt.UR~0 ÷Udukڄ(RIE/SP=hF(ΙDx I |s?zUpU(d(8W7YT$6@1z*3P8UJBu05j" ,:iy~7nNO!#ZfSijb_V #VHB۷jWRq;-1%G[⤫2OJG,1ǎI%E*NFU{O ߉Xvj™JOz P~ Yp`Y;}H{o0[ Rn14TH/|["H%?UO&T'ĮM1\:D{^ao9 obms=z `^nޙ2?jǎiYZw4/a6꜄,Ŷ$'$=ز]'3C5\PP~:fm_Vд}"m"%%{j% 3`u=qGָ͞˖7Fw67{ۀWNF"@Ysѻ}s\)b _A N)aN"<HbR#UIܗp`[.Mѿb9nnHk% XʷpNI$!٭65y7Lk ;0@psy2hLv(դN/zM&Zg~?[9Z>KZ$dk-nbQ UAfqU]z1 z"r,4{yE[B۞Ɔ\=$"z,rC쫤ayN۳d`M,8<4 gH@$+&O;c4z5E찤T㌻IxWC&|UXID뙵^;f=ƷbTĬdI2%eBKaih\*Mص˴!),,!I LٗJ3wjvÖUZsV;5EIayI5JAbJ&GEEsF9FaiąMLARf0U}y_#6-D_ޢ xن*UgXApѻo7㣔-:0J--+3QU/@dEscǯCv= x/z:1A`#UK8g2^CV $W)7jeIΫ&ټznnX[: ّ'V~Lv.߶bqe3GA0C"J_\*G#wsP #6)X$Muh]ft#+@QT`U޻+ C}rOh\d1gIJV8x,hV؜n|p\ s*,1EcQZKܚ}1~H&PQ/RYW9~`c: s%si*k YI@Ssp˶5V:BNQϫ:b$x䓐z[)x*ֵd\WkW7{~M]PnseܑӀt*:k4Um⭳ms\x!DQKS2ࠀ們o-{Be3;PK;1㓠3 Bcaܶ޼AI6o޸q_o'c%i U > 2SLB1B Sm:r:դpU2Cw,9{,1 5S򖥯OE֍qÐfl>1 p5rTZTXnaO3:֛&a}uKc[3{*edj^ՍRkctxW1Qd5 A.pSsJqٛݫoikTfsH (˿|whJ5۾Foނ5Qf5,' 718f='!l2L֓Z2$`U]AˆNnt H Bf&@Fb3#睛N:Y3*CuOSnmJF3֣ħ3U݂Q"eMhۢ,RI$ГTFظ`OBkNso#9Z2a> #'>*[0")6Õ{S)Yl *qٿN/`H&dԼJT 'G1?`hE7G;hż("EXuT@ k:j.5sݼ@VF* X1v#H n={<Щ.@qg)GiJA-L@&*ѭ!AzL\Ŝ5#Ѿ[Ca_l+{.<ڼ9{6Ԓ{2l 2")Eq=b癯&8਺Z܎ $V^A$_];Ż{ / !(YYREV%NF$ukX$=Vè\ԥ}T`\2zN'y(S#<#ٻ ,Fk̛(/jآRmN=ӡ66^KJFFU͎6w0zw[4)ĻeQd=׍Ыo >ɱkXUN=t68@ r1F[HTH5wToo>[[*≏B gõ:fX4w.8,&v!j%F&aK#R.tG-h;FyyŠ"ګ"KI't)T2-EAi/"ܻl/d*cE R(&~CvH[BeFF!- Y1L׸,KU叒 eMHDBo_{H~oOwsL^,2~?=p{KyC&ɿosvuH}}efMnIyE.01h]_wShMdZ]8\-ޘm) ,1Pa}ɭ Il~! zWq1Jb)S)LR1JܜtMDDV5C D@}'1Wg2 Mx5yثx J? 9gG_ƧA"(E7™_[ v2˘Gs7t>$}nQ\{oa~@ɨ 7W ռ#[)e9PВ TVA|iz0Yxmq:w2ֹ/#Z4/X;'omm*H&&?h#zљOCSHPڻOk-{UA *T4+xACثGgQ}*,>cxkwۏuj:ůn%b(*ǛkLH2l"L?[4Hkidn5O~P#'P5HT(z7sYFs Dċ9h${JYMTysU7ɼlƁ=SRhA"1bC ] vq%isnk@ѥ'#(1<>ޔuZ !TuY.I""ܤ1DKz}Xڶ%.z6I.G^>&,1/0$uM[eUO[l6j$ _岬+7T[͒ :Fj{sȪSuw$N;q Bvu)9؊ MĚV3d" գV[ @ݺDI)@ R&敥O$Inxb-PƁT{ +ƿn2^pUAGlWAu8"*(D=|q9V}5]WV(m-C)>"J9It a")YiIDHB}"9XmKg7a/cmc#;RCŃzNzfV5j *P5V!`&TZE5I&P"GQORou}B}WR.ei$v8wbh>m G-8cAqDP=A@kg]*w3O\ǖ᫜.W ;7Wiay~w@Ӵ3WpĭںϦZY-9Tz.-o釃z`1.F"=nRm:/Fݦëc+Ux؝,.ClEy-OejfRcƵC*7 =v,/XDLdu'+{qƙ ϚYZj3 MR+s)\LjЍ_^0yZY (!ABt6'8 m[[l>=y/h~m%^kq;?2B 2ƺlŵ:3IkeaTJU#&͘wv >pҳPz3>{7ϨN7呔'_z@VؖV:vҭ4Тt ٣V/Ļ1v>b}5&2'R BAQb\Ȉ,Y?uf T~Cfqq񞫥Eu2 nXAˉGB}5 {YKͤhvv1P} 4NHU'#j|#yč)fβ~AW.0c]D{&ᓴ]EP!r-{|i޿i n1M%{<pʮ15,\6y!upۑ#(#*̤z j9=IVGZrjIӗŢ,ؗoFk$TUPUa'iSt^Ub52G*䋋r$ cTM6d34"T3X>\X"pcҤwCXn-_P՛.«lM]Ctջ 5֙&X9:%[vsf+S rR-P䟗϶i)&2hO7.6m-QҔثқ_w7m,YࠕY%7H=@n[vA͹akmnu ӱXa;1 o̖P졹hQ,rTŽ[B+vx `דUpk֤sS)dLjFIES0HaG#d8FX{\ׅcH|ru `Hh+vW?)FL&Z 2Yt!TDGu %")sve%$?{5hn=ӝ4EZG(X{nNdi*Yy*o谸@9Jf'2,ɀu:^qV柺-k fQH r`]u\zW;x>]WcB$s%,%FuGQj #X3r5g$V+aҼqsO΋7*" T2MU{is__ZRrCl Yr[l)2o0er|FmXoDn#HWP阴Ş7%,vQY.vRq5aI&eLqz "3ޛjM7p;A>>kmgp;wOm[_K4ʑF/_n/sKYKk沄_EHŸkk7m^0mW{@A5+*fvcJj6Fy;t[pZѕz4R'j\&lÅvEйk/c у4qVM+iC4gsC՟umU:lmYklU=le1ʰ[oRRjSi /׽c7}`\ ?N5ZU' in=e?YL[c_TGrk濪[F޵(ʲp.cX3$ s}Ro.K߶uZ\Ԕ.dHW:_>^cmw{27LXHYsƙqkK7\BAN)5;o֚4U"ddrʆ!%Tmɮksood(\HI"Cf̫yEkoYJ=X[4XRXE#)# ZvεKl9Qm$:+zY582dQ*n!LakF5zniqw|HNp(`u$ {vm>o,4бyR5N\lEPǢHO:~ZWȧ7c_jYvXO`2@ؑ⠘5,&Vi㗑##"F /+ceE-v5O0om,xM(ޖ8Ŷ- b;LT|$tu((ԈoLPI>ZH6#Tы貅 cvCxi1]:M:Hі1BZJEpkܔ2M*-iFlns(ݵc۴{A&Sl 80&%,Q#L ">&2$7Ⱦeb; )( Ho@{clyɍ,+]TdUZƄEb!wf9g*2slĂ2|3x3.$ݥ6 E/է"X6!")*=-۶72 7ݱ7 @\c),Hec O榵.!sr:VծUi{N^lڪhAE6r +U!Q"9vߏ IΪ 2x(,s9ͮdMvxSdfdP@vpyɬ*.{ Uk*ċDl읂* vE!!4n۔{mub,m $aTcԅFwsUǍ]N0{q-) v^e|V$^֖Вe|j{(0޵5O찹^UNgNUv`EW>ߺ+A>ỆDR}zU;IQƳ:k#`l δ+Fk}ܪ8bJeɔ&x@SJNԼr񶴶̀9T#Ne8xke吹(&'V`p ,=d 淟O1@Y2.YINTDyf-[GڗsR1rzDe H*18MwxnWXKj倊E8 ì2=LsUPhrĶKSwoYso]f\mh5O ? þi|u+#Ps;p/աff`PreO?ϚWGҗiZy*)ЎRxs5^5s,Z KlW\Ȧ~AzbM5 L׷Wm: ^Vmgy/m]O˵Zߓj.?{_23P3"w $Ƽ j]x׼CJ⍋7wFSc9MHwuFW"q C>r!s?:ťLJ?R"kUV | f`g턖FGhBX;Opk8vsʖg|Z5FJe%<ám-Zޥve17u#5ŀ8Y_8A@?|:W]9AfuIDTTCv{?H7H#WXX'x h;q[{_5bSJKo#4ޘ*&S'O=G&[~ ù 'Q$?A䌱_d86mr.n^|&OcȾq.5( rD/V.&I=&}"̧i6Vt"7wRvdaO!_S8iM$J{Qz&'q5/-GCvuҠ}rٌ$ M ~86jʦǪU_EsB`:h޻]xD#)=)e;7ƛ4IeU U.GA/Vuu^])A E6ӪGFt;UkTEJX@2J: xȘ(2b4A01L=DDG;jZ_˪jKqF.ij1$kFv[Cg[F(aE8x*I$I5%b'#$a&LCKw-*ͼdkj:Ej֪5QTMD%0|5qn쓣VRU2 Q_tq["YXVR0*#`GCTx8zKx3O\&:6xktD9 ؔzm/O@B)-{kQkH$o7叻TVÌ˓u21ċi>Hq \d.X#u^c!5nYH@foU8_r?nN4rP]-mtR+U+І|ZVt*dG: {gh:VK Tzժ9VW,[N,Tb9I* UMvn });@f_߻!iHDN'*'bI']!,OxnSf#|AWT.T Y7Nhr.Jc6FDITz2Y"=;gCt0u/4lmͅù JqXO̡:uَ'zUo@t=y j8pqm̡Tb(W:( *,̡cTu-nMOW[BS#v>I@<M4=7J+{ jWpN$I$j)' ,3KǢΧb!spĒ(cCx: =^> mse>>98xt/V;,x{2c|\+*2"2;GM*Շi8.Nlw7_fN6/ .;&]Ois+*:+{:|ZfYZ`6RIV`O5OfǺӣZI*[ ;i*3T1BpNL 2^r7fw;\4HIq%2T{t8ZmmnEC`$ 00=F[?^5mj(o=ND#& >Ȑ+ڋf|61X}$]Ӌ/в Q)z^qSޡǝ3WʱF:n@};vd\K\Nln JJ^-$V\ČY#!=1X*Lsa6ɌڱF\'W89g#seǮ+%0P`2S^Cx8kq=RΜVl;]W.$I5w$h#E_\Y[m/_v,5 ȥvkLmPE5Xfba"]9e[Bۺ[6Dt$m؜FV8Ioiv}â-n#x<+;`2p$>̬ʪ1sB{ѥŋ[+Z=JȌ$DYk{{>Y{woi:fkaku&wD$8В0z*޼W7Yży&Ab}z \::Z6s+P6uU!&&r.J$hpDL Q'q~Ȟܺ׭&c3&uθ2W>=޵*ܻwMݚ{Vt뀡6Vd zF#Z{c‚KӉy.'G=UթݽL`dZ1hWCܔ gCzs#]#~C"#Ŏ& M@3Kct8Mi~Fxw+tӛ«xҭT[65?4 c#,f;l̰DߝU![$RMz4^,NS]n}WdkrᕁVdU2jVJYuL=tza*)S)LR +/`=(Au2H[.ژ%iL%01GkWgNzOGB nm"MY=tdqYq#ARA1}3djD#x[dQIyJIXI\vL,Ȁ2&c$/9[TI?F772X,W1e謾9ؗ Hz74Hx+w( 朖 @#ӳݥ}ސ_ߐMOd%Ⱥhq1}ʵ4NMaut+v\{dˏKv7dP1lcᛄ] ' 9ATt: ?ntdMmZȒE GPHk=u)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb0 LS LQ q5v.=CkO{p"e28* u~"?O\ۧ nA{a{8`k]}Z0}duiEV5+5JGæ6Uۧ+z UeL;N:uGvQWz(tPHv4}3)fi-Չ>>zVcS)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)S)LR1Jb)Sx666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ rNormalCJ_HaJmH sH tH DA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List 4@4 rHeader  9r 4 @4 rFooter  9r PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y |q#|qt#&L %K#H)yI! "C'U'l)+yI "%@ @ >(  V  # "? P   "? P   "? B S  ?H0(  ER#L! tr t t _Hlk102824516 # #         ' ( ## ! + }@K.5          ' ( m!p!!!" "7#D###333333333333333336hms%Mow3  @4kk ""#`@`(`T@`@UnknownG.[x Times New Roman5Symbol3. .[x ArialC ArialMTArialSMonotype SortsSymbolC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"hæwҥF:F:A203Q@P)?(2!xxJ  The Femur AMIT_ATR michael kurer Oh+'0|  8 D P\dlt The Femur  AMIT_ATRNormalmichael kurer4Microsoft Office Word@G@pI@JGpF ՜.+,0 hp   East Sussex Hospitals NHS Trust:  The Femur Title  !"#$%&()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRTUVWXYZ[\]^_`abcefghijkmnopqrsvRoot Entry Fp XpxData 'V1TableS WordDocument4LSummaryInformation(dDocumentSummaryInformation8lCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q