Adolescent Femoral Nail (AFN)

The Door to Malaysia Healthcare.

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INDEX Warning
This publication describes the recommended procedures for using AFN devices and instruments. It offers

Indications guidance that you should pay attention to. But as with any such technical guide, the guide alone does not
provide sufficient background for direct use of the instrument set, each surgeon should also consider the
particular needs of each patient and make appropriate adjustments when required. Instruction by experienced
Surgical Technique surgeon is still highly recommended.

All non-sterile devices must be cleaned and sterilized before use. Multi-component instruments must be
Instrument Set disassembled for cleaning. Please follow the instructions provided in our Reprocessing, Care and Maintenance
Guide (RCMG-2012).

Please refer to Package Insert for a complete list of potential adverse effects, contraindications, warnings and
precautions. The surgeon must discuss all relevant risks, including the finite lifetime of the device, with the
patient, when necessary.

Indications
The Adolescent Femoral Nail is indicated for use in adolescent and small-stature adult patients to stabilize.
• Fractures of the femoral shaft
• Subtrochanteric fractures
• Ipsilateral neck/shaft fractures
• Impending pathologic fractures
• Nonunions and malunions
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Surgical Technique

STEP 1 STEP 1 STEP 3 STEP 4

PATIENT POSITION AND SURGICAL APPROACH PATIENT POSITION AND SURGICAL APPROACH INSERT GUIDE WIRE OPEN PROXIMAL FEMUR TO MEDULLARY CANAL
Position the patient in the lateral prone or supine position on a Place the Protection Sleeve and Drill Sleeve on the bone surface and Remove the Drill Sleeve, drill the Cannulated Drill Bit along the Guide
fracture table or radiolucent operating table. Abduct the body by insert the Guide Wire. The Guide Wire must be inserted laterally at Wire to a depth of approximately 75mm; Or place the Cannulated
10-15° to the unaffected side ( or adduct the affected leg by 10-15° ). an angle of 12° to the center of the medullary canal. The tip of the Reverse Awl over the Guide Wire and open the medullary canal. Use
For obese patients, increase the adduction angle properly. Palpate Guide Wire should be centered in the medullary canal 20 mm distal a twisting motion to advance the awl to a depth of approximately 75
the posterior edge of the greater trochanter. Make a 3cm incision in to the lesser trochanter. mm. Use the Soft Tissue Protector to protect soft tissue.
line with the central axis of the intramedullary canal in the lateral
view, and depending on the anatomy of the patient, 2–5cm proximal
to the tip of the greater trochanter. Dissect lengthwise the skin, the
subcutaneous tissue and the gluteus medius muscles to expose the
tip of the greater trochanter.

12°

20mm

STEP 2 STEP 2 STEP 4 STEP 5

DETERMINE ENTRY POINT DETERMINE ENTRY POINT OPEN PROXIMAL FEMUR TO MEDULLARY CANAL INSERT GUIDE WIRE AND PERFORM REDUCTION
The insertion point is 12° lateral to the greater trochanter, as After realizing closed or open reduction, insert the Reduction Rod
measured from a point 20mm distal to the lesser trochanter. The into the medullary canal. Then introduce the Guide Wire with Olive
entry point can also be described as lateral to the greater trochanter Head along with the Reduction Rod until the distal medullary canal of
at the same level as the superior aspect of the base of the femoral femur.
neck (just above the piriformis fossa). In ML view, the entry point is in
the central axis of medullary nail.
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STEP 6 STEP 7 STEP 8 STEP 8

CALIBRATE THE NAIL INSERT THE NAIL INSERT PROXIMAL LOCKING SCREWS (RECON LOCKING) INSERT PROXIMAL LOCKING SCREWS (RECON LOCKING)
Select a nail with appropriate length and diameter. Connect the nail After performing reduction, remove the Guide Wire with Olive Head. There are two forms of proximal locking: in case of femoral shaft B.Insert another Guide Wire according to step A. In AP view, the
to the insertion handle. Wholly assembled to calibrate the nail. Insert a Guide Wire along the Reduction Rod and remove the rod. fractures, perform standard locking. In case of subtrochanteric Guide Wire should be located in the higher 1/3 part of the femoral
Insert the calibrated nail along the Guide Wire. While advancing the fractures, femoral neck fractures combined with ipsilateral shaft neck and approximately 5 mm from the subchondral bone of the
Note: The nail needs to be calibrated preoperatively. superior 1/3 of the nail, rotate it approximately 90°during insertion. fractures, perform recon locking. While using recon locking, it is femoral head. ( If the physis in the femoral head is not fully arrested,
After the insertion of the nail, remove the Guide Wire. ( If necessary, necessary to insert the femoral neck screws before inserting distal stop the wire short of the physis.) In ML view, the Guide Wire should
the Connector can be fixed onto the Insertion Handle and use the locking screws. be located in the center of the femoral head.
Slide Hammer to assist in insertion. In case of encountering big
A.Connect the Insertion Handle with the nail and the Proximal Aiming
resistance, it is recommended to use another nail with smaller
Arm. Introduce the Protection Sleeve, Drill Sleeve and Trocar through
diameter or the Reamer to further open the medullary canal to ensure Note: Check the position of the two Guide Wires: in AP view, the two
the oblique holes on the Proximal Aiming Arm. Make a small skin
that the diameter of the canal is at least 1 mm greater than the nail Guide Wires divide the femoral head into three equal parts. In ML
incision and with blunt dissect advance the Trocar until it reaches the
diameter. In need of adjusting the nail position, fix the Extraction view, both of the two Guide Wires are located in the center of the
cortical bones. Remove the Trocar and insert the 3.3mm Guide Wire.
Screw for Nail to the Connector and attach the Slide Hammer directly femoral head. It is also necessary to verify if the Guide Wires are still
Check the position under image intensifier. In AP view, the Guide
to the Extraction Screw to adjust the position with light hammer straight.
Wire should be located in the lower 1/3 part of the femoral neck and
blows.)
approximately 5 mm from the subchondral bone of the femoral head.
( If the physis in the femoral head is not fully arrested, stop the wire
short of the physis.) In ML view, the Guide Wire should be located in
the center of the femoral head.

STEP 7 STEP 7 STEP 8 STEP 8

INSERT THE NAIL INSERT THE NAIL INSERT PROXIMAL LOCKING SCREWS (RECON LOCKING) INSERT PROXIMAL LOCKING SCREWS (RECON LOCKING)
C.Remove the Drill Sleeve and insert the Depth Gauge along the D.On the basis of the measured length, adjust the Fixation Sleeve to
Guide Wire and read off the required length of the femoral neck the correct place on the Φ5.0mm Drill Bit. Drill it through the Guide
screw from the Depth Gauge. Wire until its stop and to check the drilling under image intensifier.
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Surgical Technique
Static locking

Dynamic locking

STEP 8 STEP 9 STEP 11 STEP 11

INSERT PROXIMAL LOCKING SCREWS (RECON LOCKING) INSTALL THE FIXATION PIN INSERT PROXIMAL LOCKING SCREWS (STANDARD LOCKING) INSERT PROXIMAL LOCKING SCREWS (STANDARD LOCKING)
E.Use the T25 Screwdriver to thread the femoral neck screw into the A.Connect the Distal Aiming Shaft and Distal Location Arm to the Note: While performing standard locking, firstly insert distal locking A.Adjust the hole on the Aiming Arm to dynamic status. Introduce the
bone. While the zero scale line is at the same level of the Protection Insertion Handle. Introduce the Protection Sleeve and Trocar through screw and then insert the proximal locking screw. Protection Sleeve, Drill Sleeve and Trocar through the hole on the
Sleeve edge, the screw is in right place. the hole on the Location Arm. After determining the position on skin, Aiming Arm. Make a small skin incision and with blunt dissect
make a small incision and with blunt dissect advance the Trocar until For standard locking, three targeted proximal locking options are advance the Trocar until it reaches the cortical bones.
it reaches the cortical bones. possible:
B.Remove the Trocar and use the Φ3.3mm Drill Bit to drill through
F.Repeat step C, D and E to insert another femoral neck screw. B.Remove the Trocar and insert the Drill Sleeve. Through the Drill 1. 120° antegrade locking the bilateral cortical bones. Remove the Drill Bit.
Sleeve, insert the Φ5.0mm Drill Bit for Fixation Pin. Turn it clockwise 2. Dynamic locking
to clear away the bone debris on the platform. C.Use the Depth Gauge to measure the required length of the locking
3. Static locking screw. While measuring the depth it is necessary to make sure that
C.Remove the Drill Bit. Insert the Flat Head Drill Bit to the platform. the Protection Sleeve has good contact with the cortical bone.
Turn it clockwise to clear away the bone debris. a) For sufficient proximal static locking, always use the 120°
antegrade locking option in combination with the transverse static D.Remove the Depth Gauge. Select the locking screw of measured
D.Remove the Flat Head Drill Bit and the Drill Sleeve. Insert the screw. length and insert the screw with Torxdrive Screwdriver through the
Fixation Pin into the Protection Sleeve. Ensure that the Fixation Pin Protection Sleeve. When the zero scale line is at the same level of
has contacted with the platform surface and use the U-Clip to fix the b) For immediate primary dynamization, insert only one proximal the Protection Sleeve edge, the screw is inserted in the right place.
Fixation Pin to the Location Arm. locking screw through the dynamic locking option.
E.Insert the Compression Screw through the hole of Connecting
c) For secondary dynamization, insert the locking screws through the Screw until it reaches the dynamic locking screw. Use the T-Wrench
dynamic locking option and 120° antegrade locking option. to rotate clockwise the Compression Screw until the compressed
reduction of the fragments is accomplished. Verify the reduction
effect under image intensifier.

Note:
Do not overtighten the Compression Screw, otherwise, the locking
screw may be distorted.

STEP 10 STEP 10
INSERT DISTAL LOCKING SCREWS INSERT DISTAL LOCKING SCREWS
A.Introduce the Protection Sleeve, Drill Sleeve and Trocar through D.Remove one Drill Bit and the Drill Sleeve. Use the Depth Gauge to
the distal hole on the Aiming Arm. Make a small skin incision and with measure the required length of the locking screw. While measuring
blunt dissect advance the Trocar until it reaches the cortical bones. the depth it is necessary to make sure that the Protection Sleeve has
good contact with the cortical bone.
B.Remove the Trocar and use the Φ3.3mm Drill Bit to drill through the
bilateral cortical bones. Remain the Drill Bit in the hole. E.Remove the Depth Gauge. Select the locking screw of measured
length and insert the screw with Torxdrive Screwdriver through the
Introduce the Protection Sleeve, Drill Sleeve and Trocar through Protection Sleeve. After the zero scale line is at the same level of the
another distal hole on the Aiming Arm. Make a small skin incision and Protection Sleeve edge, the screw is inserted in the right place.
with blunt dissect advance the Trocar until it reaches the cortical
bones. Remove the Trocar and use the Φ3.3 mm Drill Bit to drill F.Remove the Drill Bit and Drill Sleeve in another hole. Then repeat
through the bilateral cortical bones. step D to measure the depth and repeat step E to insert the locking
screw.
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Instruments 115450000

112680400 AFN Radiographic Ruler

120°

111220700 Reverse Awl

STEP 12 STEP 13
INSERT 120° ANTEGRADE LOCKING SCREW INSERT END CAP
112680700 AFN Guide Wire Sleeve, Φ12.9
In need of performing 120°antegrade locking, insert the screw After accomplishing proximal and distal locking, remove Distal
through the oblique holes on the handle. Refer to step A, B, C, D, E Location Arm, Distal Aiming Arm, Connecting Screw and Insertion
for the detailed methods to drill, measure and insert locking screw. Handle. Use the T25 Screwdriver to insert the End Cap.

Note: To minimize the chance of cross threading, turn the end cap
counter-clockwise until the thread of the end cap aligns with that of
the nail. Then turn the end cap clockwise to thread it into the nail.
112680800 AFN Drill Sleeve, Φ15.5/Φ13.0

111190200 Guide Wire, Φ3.2×400

112840600 Holder for Guide Wire, Φ4.2×107

STEP 14
REMOVE THE IMPLANTS
A.Make a incision on the previous surgical position and use the T25
Screwdriver to remove the End Cap.
112680300 AFN Drill Bit, Φ13.0×288, cannulated
B.Connect the Connection Shaft and Extraction Screw to the nail.
C.Make a incision on the previous surgical position and use the
Screwdriver to remove the locking screw.
D. Use Slide Hammer blows to remove the nail. Finally, suture all the
incisions.
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111190600 T-Handle, quick coupling 112681000 AFN Compression Screw

110350700 Soft Tissue Protector 110351000 Wrench, hexagonal, with T-Handle,

for Connecting Screw

112844900 Guide Wire, Φ2.5, length 1000mm, 110353700 T-wrench for Connecting Screw,
with olive head variable angle

111190900 Reduction Rod, 90×470 112680200 AFN Connector

112680500 AFN Insertion Handle 113412300 Extraction Screw for the Nail

112680600 AFN Proximal Aiming Arm 113412400 Connection Shaft for Extraction Screw

112680900 AFN Connecting Screw 110351200 Ratchet Wrench, SW11

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112841400 Slide Hammer 111196700 Fixation Sleeve

112681100 AFN Trocar, Φ3.3 112681700 AFN Depth Gauge

112681200 AFN Drill Sleeve, Φ8.0/Φ3.3 112681800 AFN Measuring Device

112681300 AFN Protection Sleeve, Φ8.0/Φ5.0 112681900 AFN Screwdriver Shaft, T25

112681400 AFN Drill Bit, Φ3.3×360 112843200 PFCN Screwdriver, torxdrive, T25

112681500 AFN Fixation Sleeve, Φ18.0×12 112682000 AFN Locking Screw for Aiming Arm

112681600 AFN Drill Bit, Φ5.0×475 110355500 Fixation Sleeve for Fixation Pin
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110355600 Drill Sleeve for Fixation Pin, Φ5.0 112685700 AFN Distal Aiming Arm Shaft, long

110355700 Trocar for Fixation Pin 112685800 AFN Distal Aiming Arm Shaft, short

110355400 Drill Bit for Fixation Pin, Φ5.0 112682700 AFN Screwdriver T25, for End Cap

110355300 Drill Bit, with flat head, Φ5.0 112685900 AFN U-Clip

112682600 AFN Fixation Pin 112686300 Guide Wire, Φ2.5, length 1000mm,
without olive head

112682500 AFN U-Clip

112682100 AFN Distal Location Arm

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115140100 Adolescent Femoral Nail Instrument Case