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Complete Guide for Reduction Forceps (Bone Holding)

Health & Fitness
Posted on | by pritesh

1. Definition

What are Reduction Forceps (Bone Holding)?

Reduction forceps, commonly known as bone-holding forceps or bone clamps, are specialized surgical instruments designed for grasping, manipulating, stabilizing, and compressing bone fragments during orthopedic, trauma, and reconstructive surgeries. Their primary function is to achieve and maintain the anatomical reduction (correct realignment) of fractured bone pieces before permanent fixation with plates, screws, or wires. They act as a “third hand” for the surgeon, providing critical control in a demanding surgical environment.

How it Works

The working principle is based on simple mechanical leverage. The forceps consist of two opposing jaws connected at a pivot point (the joint). When the surgeon applies pressure to the handles, the jaws close with significant force. The jaw tips are designed to grip bone securely without causing excessive damage or splintering. Once clamped, a locking mechanism (often a ratchet or a screw) is engaged to maintain constant pressure and position, freeing the surgeon’s hands to apply fixation hardware. The design ensures a firm, non-slip hold on often slippery and uneven bone surfaces.

Key Components

  1. Handles: The part the surgeon grips. They are typically long to provide good leverage and may have finger rings or textured surfaces for a secure, ergonomic hold.
  2. Shanks/Blades: The elongated body that connects the handles to the jaws. They transmit the force from the handles.
  3. Joint/Pivot Point: The rivet or screw where the two halves of the forceps meet. It allows for smooth opening and closing.
  4. Jaws: The working end of the forceps. This is the most critical component, varying significantly based on the intended use.
    • Teeth/Points: Can be sharp (for penetrating dense cortical bone) or serrated/blunt (for gripping without penetration). Common patterns include:
      • Single Point: A sharp spike on each jaw for deep purchase.
      • Double Point: Two spikes per jaw for more stable grip.
      • Serrated: Multiple small teeth for a broad, non-penetrating hold.
    • Curvature: Jaws can be straight, curved (for accessing awkward angles), or angled.
  5. Locking Mechanism: Usually a series of interlocking teeth (a ratchet) near the handles that allows the forceps to be locked at varying degrees of closure. Some models use a threaded screw or a latch system.

2. Uses

Clinical Applications

  • Fracture Reduction: The core application. Used to grasp and maneuver displaced bone fragments back into their correct anatomical position.
  • Bone Fragment Stabilization: Holding reduced fragments steady while definitive internal fixation (e.g., plate and screw application) is performed.
  • Bone Compression: Certain designs (like Verbrugge or Lane forceps) can apply dynamic compression across a fracture line to promote healing.
  • Temporary Fixation: Can hold a bone plate against the bone before screw placement.
  • Malleable Use: Some forceps can be gently bent by the surgeon to conform to a specific bone anatomy.
  • Specific Procedures: Used in osteotomies (bone cutting), arthrodesis (joint fusion), non-union repairs, and managing complex, comminuted (shattered) fractures.

Who Uses It

  • Orthopedic Surgeons
  • Trauma Surgeons
  • Neurosurgeons (for spinal or cranial procedures)
  • Maxillofacial Surgeons
  • Veterinary Surgeons
  • Surgical Assistants and Scrub Nurses (who prepare and pass the instrument)

Departments/Settings

  • Operating Rooms (ORs) in hospitals, especially in:
    • Orthopedic Surgery Departments
    • Trauma Centers
    • Emergency Surgery
  • Specialty Orthopedic Clinics with surgical facilities
  • Ambulatory Surgical Centers (ASCs)

3. Technical Specs

Typical Specifications

  • Length: Ranges from 15 cm to 25 cm or more, depending on the depth of the surgical site.
  • Jaw Width/Opening: Varies; larger forceps for long bones, smaller for hand/foot bones.
  • Tip Design: Single, double, or multiple points; sharp or blunt.
  • Weight: Typically 150-400 grams, balancing sturdiness and surgeon fatigue.

Variants & Sizes

Reduction forceps are highly specialized. Common types include:

  • Pointed Reduction Forceps (e.g., Lane, Verbrugge): Have sharp, pointed tips for penetrating cortical bone. Excellent for long bones like the femur or tibia.
  • Serrated Jaw Forceps (e.g., Lowman, Kern): Have broad, toothed jaws for a crushing grip without penetration, often used with a bone plate.
  • Cerclage/Wiring Forceps (e.g., Lowman): Have a hole in the jaw to guide cerclage wire around bone.
  • Self-Retaining Forceps (e.g., Ferkel): Have a spring mechanism to maintain grip without manual pressure.
  • Mini Fragment Sets: Smaller, more delicate versions for hand, wrist, foot, ankle, and pediatric surgery.

Materials & Features

  • Materials:
    • Medical-Grade Stainless Steel (AISI 316L): Standard. Offers excellent strength, corrosion resistance, and can withstand repeated sterilization.
    • Titanium: Lighter, non-magnetic, and highly biocompatible. Often used in implants and associated instruments.
    • Surface Treatments: Passivation to enhance corrosion resistance, anodization for color-coding sizes.
  • Features:
    • Ergonomic Handles: Anti-slip patterns, contoured finger rings to reduce hand strain.
    • Ratchet Locks: Multi-tooth ratchets for secure, adjustable locking.
    • Radioucent Options: Some are made from carbon-fiber composites to reduce X-ray interference during intraoperative imaging.

Models

  • Lane Bone Holding Forceps
  • Verbrugge Bone Holding Forceps (with a sliding, compressive design)
  • Lowman Bone Clamp (with plate-holding jaw)
  • Kern Bone Holding Forceps
  • Farabeuf Bone Holding Forceps (with lamb’s ear tips for subperiosteal grip)
  • Lambotte Bone Holding Forceps

4. Benefits & Risks

Advantages

  • Essential for Precise Reduction: Enables accurate anatomical alignment, which is critical for healing and functional recovery.
  • Superior Control and Stability: Provides a firm, locked grip, allowing for precise manipulation.
  • Versatility: Numerous designs for specific bones and surgical situations.
  • Time-Efficient: Speeds up the reduction and stabilization phase of surgery.
  • Durable and Reusable: High-quality instruments last for thousands of cycles.

Limitations

  • Potential for Iatrogenic Damage: Incorrect use can cause bone splintering, necrosis at pressure points, or damage to surrounding soft tissues and periosteum (bone’s blood supply).
  • Learning Curve: Requires skill and experience to apply correct force and placement.
  • Not Definitive Fixation: Only a temporary tool; must be used in conjunction with permanent fixation methods.

Safety Concerns & Warnings

  • Excessive Force: Can crush or fracture bone.
  • Misplacement: Jaws placed too close to a fracture line can cause comminution.
  • Soft Tissue Interposition: Must ensure no muscles, nerves, or vessels are caught in the jaws.
  • Sterility Breach: Any damage to the instrument (nicks, cracks) can harbor pathogens and compromise sterility.

Contraindications

  • Severely Osteoporotic or Brittle Bone: The thin cortex may not withstand the clamping force, leading to collapse.
  • Very Small Bone Fragments: Standard forceps may be too large; micro-instruments are required.
  • Infected Surgical Fields: May require modified technique, though the instrument itself is not contraindicated if properly sterilized.

5. Regulation

  • FDA Class: Generally classified as Class I (exempt from premarket notification [510(k)]). However, forceps with specific technological characteristics (e.g., coated, or used with energy devices) may be Class II.
  • EU MDR Class: Under Regulation (EU) 2017/745, they are typically Class I (sterile or with measuring function) or Class Is (if supplied sterile). Non-sterile, reusable forceps are usually Class I.
  • CDSCO Category: In India, governed by the Medical Devices Rules, 2017. Typically classified as Class A (low risk).
  • PMDA Notes: In Japan, they fall under the Pharmaceutical and Medical Device Act (PMD Act) as Class I medical devices.
  • ISO/IEC Standards:
    • ISO 7151: Surgical instruments – Materials, hardness, and dimensions.
    • ISO 13485: Quality management systems for medical devices.
    • ISO 17664: Processing information for reprocessing.
    • IEC 62366: Usability engineering.

6. Maintenance

Cleaning & Sterilization

  1. Point-of-Use Wipe: Remove gross soil immediately after surgery with a damp cloth.
  2. Ultrasonic Cleaning: Disassemble if possible. Use enzymatic detergent in an ultrasonic cleaner to remove bioburden from hinges and ratchets.
  3. Rinsing & Drying: Rinse thoroughly with distilled water and dry completely to prevent spotting and corrosion.
  4. Inspection: Check for damage, wear, loose joints, and dulled tips under magnification.
  5. Packaging: Wrap in sterilization-grade pouches or container systems.
  6. Sterilization: Autoclaving (Steam Sterilization) is the gold standard (e.g., 134°C for 3-5 minutes). Follow manufacturer’s instructions.

Reprocessing

Reprocessing is the full cycle of cleaning, disinfection/sterilization, and preparation for reuse. It must be done by trained Central Sterile Services Department (CSSD) personnel following strict protocols to prevent healthcare-associated infections (HAIs).

Calibration

These are mechanical instruments and do not require electronic calibration. However, regular functional inspection is crucial: ensuring joints move smoothly, ratchets lock securely at every tooth, and jaws align perfectly.

Storage

  • Store in a clean, dry, temperature-controlled environment.
  • Keep in closed cabinets or drawers to protect from dust and physical damage.
  • Use instrument trays or racks to prevent them from knocking against each other, which can dull points and damage finishes.

7. Procurement Guide

How to Select the Device

Consider:

  1. Surgical Specialty: What types of fractures/bones will it be used for?
  2. Jaw Design: Does the procedure require penetrating or non-penetrating grip?
  3. Size & Length: Appropriate for the surgical site depth and patient anatomy.
  4. Ergonomics: Surgeon preference for handle design and weight balance.
  5. Hospital Workflow: Compatibility with existing sterilization systems.

Quality Factors

  • Finish: Smooth, polished, free of burrs or rough edges.
  • Action: Smooth, friction-free joint movement. Positive, crisp ratchet engagement and disengagement.
  • Alignment: Jaws must meet precisely tip-to-tip when closed.
  • Material Integrity: High-grade stainless steel or titanium with proper hardness (typically Rockwell C 40-45).

Certifications

Look for:

  • CE Mark (for EU market)
  • FDA Registration (for US market)
  • ISO 13485 certification of the manufacturer
  • Country-specific approvals (e.g., JPAL from Japan, CDSCO from India)

Compatibility

Primarily standalone instruments. Ensure compatibility with sterilization trays and potentially with bone reduction systems from the same manufacturer (e.g., dedicated clamps for a specific plating system).

Typical Pricing Range

  • Single Instrument: $80 – $400 USD, depending on design, material (titanium commands a premium), and brand.
  • Basic Set (4-6 key forceps): $800 – $2,500 USD.
  • Comprehensive Orthopedic Set: $3,000 – $10,000+ USD.

8. Top 10 Manufacturers (Worldwide)

  1. DePuy Synthes (Johnson & Johnson) – USA/Switzerland: Industry leader with the broadest portfolio, including the original AO/ASIF instrumentation.
  2. Stryker – USA: Major player with strong trauma and joint portfolios through acquisitions like Osteonics and Howmedica.
  3. Zimmer Biomet – USA: Renowned for orthopedic devices and associated surgical instruments.
  4. Smith & Nephew – UK: Strong in trauma, sports medicine, and advanced wound management.
  5. B. Braun Aesculap – Germany: High-quality surgical instruments and orthopedic systems.
  6. Medtronic – Ireland/USA: Leading in spinal devices and associated reduction instruments.
  7. Arthrex – USA: Dominant in sports medicine and minimally invasive orthopedic surgery with innovative instrument design.
  8. Integra LifeSciences – USA: Known for neurosurgical, extremity, and orthopedic instruments.
  9. Jeil Medical Corporation – South Korea: A major global OEM/ODM manufacturer of surgical instruments.
  10. KLS Martin Group – Germany: A premier manufacturer of high-precision surgical instruments for maxillofacial, neurosurgery, and orthopedics.

9. Top 10 Exporting Countries (Latest Year – Based on HS Code 901890)

Rank based on typical global medical instrument trade data:

  1. Germany: Global hub for precision surgical instruments. Known for top-tier quality.
  2. United States: Home to major OEMs and a large domestic market for re-export.
  3. Pakistan (Sialkot): World-famous for hand-crafted surgical instruments, a major source for economical options.
  4. China: Mass manufacturer, increasingly moving up the value chain into higher-quality products.
  5. Switzerland: Associated with the AO Foundation and high-precision manufacturing.
  6. Japan: Known for exceptional craftsmanship and high-quality steel.
  7. United Kingdom: Historic expertise, home to several specialist manufacturers.
  8. France: Strong medical device industry with notable instrument makers.
  9. Italy: Known for design and specialized orthopedic instruments.
  10. Mexico: Major exporter to the US market under trade agreements.

10. Market Trends

  • Minimally Invasive Surgery (MIS): Driving demand for longer, more slender, and low-profile forceps that can work through small incisions and portals.
  • Material Innovation: Increased use of titanium and composite materials for lighter, stronger, and radiolucent instruments.
  • Integration with Navigation & Robotics: Development of trackable forceps that can be integrated into computer-assisted surgical systems for enhanced precision.
  • Ergonomics & Surgeon Wellness: Focus on designs that reduce hand fatigue and the risk of repetitive strain injuries among surgeons.
  • Rising Trauma Cases & Aging Population: Key demand drivers due to increased incidence of fractures from accidents and osteoporosis.
  • Value-Based Procurement: Hospitals are balancing cost with quality and total lifecycle cost (durability, ease of reprocessing).

11. Training

Required Competency

  • Anatomical Knowledge: Deep understanding of bone anatomy, fracture patterns, and soft tissue structures.
  • Surgical Principles: Knowledge of fracture reduction techniques and biomechanics.
  • Hands-On Skill: Proficiency in applying the correct amount of force, choosing the right instrument, and placing it optimally on the bone.

Common User Errors

  1. Using the Wrong Forceps Type: e.g., using a pointed forcep on a thin, fragile bone.
  2. Poor Placement: Clamping too close to the fracture edge, causing splintering.
  3. Over-tightening the Ratchet: Applying excessive crushing force.
  4. Neglecting Soft Tissues: Failing to protect muscles and periosteum.
  5. Using a Damaged Instrument: Proceeding with a forcep that has loose joints or dull/misaligned tips.

Best-Practice Tips

  • Plan Your Grip: Visualize the vector of force needed for reduction before applying the forceps.
  • Protect the Periosteum: Minimize stripping. Use blunt or serrated tips where possible.
  • Step-Lock the Ratchet: Engage the ratchet one click at a time while assessing force and bone reaction.
  • Double-Check Alignment: Use intraoperative imaging (C-arm) to confirm reduction after clamping.
  • Maintain Your Tools: Immediately report any instrument damage to the CSSD.

12. FAQs

Q1: What’s the difference between reduction forceps and a bone tenaculum?
A: Bone tenacula are smaller, often single-hooked or double-hooked instruments used for finer manipulation and temporary fixation of smaller bones (e.g., in the hand or face), not for major long bone reduction.

Q2: Can reduction forceps be used on soft tissue?
A: No. They are specifically designed and hardened for bone. Using them on soft tissue would cause severe crushing damage.

Q3: How do I choose between sharp and blunt/serrated jaws?
A: Use sharp, pointed jaws for dense cortical bone (femur, tibia) where you need deep, secure purchase. Use blunt or serrated jaws for cancellous bone, fragile bone, or when you need to hold a bone plate against the bone.

Q4: Why do some forceps have a hole in the jaw?
A: These are cerclage forceps (e.g., Lowman). The hole is used to guide and tension cerclage wire around a bone for fixation.

Q5: How often should reduction forceps be replaced?
A: There’s no set timeframe. They should be replaced when inspection reveals irreparable damage: cracks, excessive wear, loose pivots, or misaligned/damaged tips that cannot be re-sharpened.

Q6: Are disposable/reduction forceps available?
A: Yes, primarily in the form of sterile, single-use plastic radiolucent clamps used in specific minimally invasive procedures. Traditional metal forceps are overwhelmingly reusable.

Q7: What does “reduction” mean in this context?
A: In orthopedic surgery, “reduction” refers to the process of restoring a fractured or dislocated bone to its correct anatomical alignment and position.

Q8: Can I sterilize bone-holding forceps with chemicals?
A: Steam autoclaving is the recommended and most reliable method. Chemical sterilization (e.g., glutaraldehyde) may be used for heat-sensitive items but is not typical for robust stainless steel instruments and requires careful rinsing.

13. Conclusion

Reduction forceps are fundamental, mechanical extensions of the orthopedic surgeon’s hands, playing an indispensable role in successful fracture management. Their value lies in their ability to provide controlled, stable, and precise bone manipulation. Selecting the correct type—based on bone, fracture, and surgical approach—is as critical as the surgeon’s skill in using it. While technological advancements in materials and integration with digital surgery continue, the core principles of robust construction, proper maintenance, and skilled application remain timeless. Understanding this instrument in depth is key to ensuring optimal patient outcomes in trauma and reconstructive orthopedic surgery.

14. References

  1. AO Foundation. AO Surgery Reference. https://surgeryreference.aofoundation.org/
  2. Association of periOperative Registered Nurses (AORN). Guidelines for Perioperative Practice.
  3. U.S. Food and Drug Administration (FDA). Device Classification. https://www.fda.gov/medical-devices/overview-device-regulation/classify-your-medical-device
  4. European Commission. Medical Device Regulation (MDR).
  5. ISO 7151:2012. Surgical instruments — Metallic materials — Part 1: Stainless steel.
  6. Orthopedic Surgical Instrument Guides (Various manufacturers: DePuy Synthes, Stryker, Zimmer Biomet).
  7. Hoppenfeld, S., deBoer, P., & Buckley, R. (2012). Surgical Exposures in Orthopaedics: The Anatomic Approach. Lippincott Williams & Wilkins.
  8. UN Comtrade Database. (For HS Code 901890 trade data).