Minimally Invasive Metatarsal Realignment

Abstract

Systems, techniques, and devices are described that can be used in minimally invasive bone realignment procedures. In some examples, a method for performing a minimally invasive metatarsal correction procedure includes using a bone preparation guide having a guide surface with a length that is shorter than the diameter of the bone to be cut using the guide surface. A clinician can guide a bone preparation instrument along the guide surface and angle the bone preparation instrument beyond one or both ends of the guide surface to cut the end of the underlying bone beyond one or both ends.

Description

[Technical Field]

[0001] cross reference This application claims the benefit of U.S. Provisional Patent Application No. 63 / 406,486, filed September 14, 2023, the entire contents of which are incorporated herein by reference.

[0002] The present disclosure relates generally to devices and techniques for repositioning bones, and more particularly to devices and techniques for repositioning bones of the foot. [Background technology]

[0003] Bones in the human body, such as those of the foot, can be anatomically misaligned. For example, one common type of bone deformity is hallux valgus, a progressive foot deformity that affects the first metatarsophalangeal joint and often results in severe functional disability and foot pain. The metatarsophalangeal joint is laterally displaced, resulting in the first metatarsal bone abducting while the phalanges adduct. This often leads to a soft tissue outgrowth and bony prominence on the medial side of the foot, known as a bunion.

[0004] Surgical intervention may be performed to correct a bunion deformity. There are a variety of surgical procedures to correct a bunion deformity, which may involve removing abnormal bony enlargement of the first metatarsal and / or attempting to realign the first metatarsal relative to the adjacent metatarsals. Surgical instruments that provide efficient, accurate, and reproducible clinical results are useful for physicians in performing bone realignment techniques.

[0005] In patients, surgical intervention requires making one or more incisions in the patient's skin to access the underlying bone in order to perform the corrective procedure. The longer the incision, the more access the surgeon has to perform the procedure. However, a longer incision also leaves the patient with a longer scar after healing, which may be cosmetically undesirable. For this reason, patients may request shorter incisions. This can be difficult for the surgeon because it limits access to perform the corrective procedure. Summary of the Invention

[0006] In general, the present disclosure is directed to devices, systems, and techniques for performing minimally invasive metatarsal realignment surgery that minimize the length of one or more incisions utilized to access the bone to perform the surgery. As a result, patients undergoing this surgery may experience shorter, less noticeable incisions and resulting scar lines compared to surgeries using longer incisions, providing healing and / or cosmetic benefits.

[0007] In some embodiments, a clinician surgically accesses the tarsometatarsal ("TMT") joint, which is defined between the metatarsal and the opposing cuneiform. The TMT joint can be the first TMT joint, between the first metatarsal and the medial cuneiform, or the second, third TMT joint, between the second, third metatarsal and the opposing cuneiform. The clinician may use an incision guide placed on the patient's skin to identify the correct location to incise the skin to surgically access the TMT joint. The incision guide can be used to mark the incision location and / or to guide a cutting instrument to incise the patient's skin.

[0008] In some applications, the clinician inserts the wire percutaneously (through the patient's skin) into the TMT joint and then aligns the incision guide with the portion of the wire protruding from the joint. The use of the incision guide can help ensure that the incision is small and accurately positioned relative to the TMT joint, because a misplaced incision can limit the clinician's surgical access through a small incision.

[0009] Regardless of whether the clinician uses an incision guide, the clinician can surgically access the TMT joint and prepare the end surfaces of the metatarsal and opposing cuneiform bones. In some instances, the clinician inserts the guide into an incision made in the patient's skin. The guide can have one or more side walls defining an opening. The guide can be used to move soft tissue at the incision site, for example, by moving the soft tissue against the outer surfaces of the side walls, thereby providing surgical access through the opening in the guide while minimizing interference with the soft tissue. Additionally or alternatively, the clinician may utilize one or more retractors to retract skin and / or other soft tissue from the incision site to help provide access to the underlying joint space.

[0010] Before and / or after preparing one or both end faces, the clinician may dissociate soft tissue and / or bony processes to assist in moving one or both bones of the TMT joint for realignment. For example, the clinician may insert a cutting instrument (e.g., an osteotome, a saw blade) into the dorsal side of the TMT joint to dissociate soft tissue within the joint and / or cut one or more bony processes. Additionally or alternatively, the clinician may insert a cutting insert into the proximal lateral corner of the metatarsal to assist in moving the metatarsal for repositioning. In some such embodiments, the clinician may insert, for example, a biplanar tissue dissociation instrument including two connected cutting bodies that define an angled angle (e.g., a 90-degree angle) between each other. The biplanar tissue dissociation instrument can be inserted into the proximal lateral corner of the metatarsal, with one cutting body inserted into the TMT joint space and the other cutting body inserted into the joint space between the metatarsal and the adjacent metatarsal. The biplanar tissue dissection instrument is capable of efficiently and effectively cutting soft tissue through small incisions made in the patient's skin.

[0011] An example of a surgical technique according to the present invention involves preparing the end surfaces of a metatarsal bone and an opposing cuneiform bone. Example preparation steps may include reaming, cutting, rongeuring, curettage, burring, fenstrating, and / or other similar techniques to expose subchondral bone and / or establish bleeding bone surfaces to promote fusion after reunification of the metatarsal and cuneiform bones. In some embodiments, the clinician positions a bone preparation guide over the end of the metatarsal and / or cuneiform bone to be prepared. The bone preparation guide may have one or more guide surfaces, such as one or more slots, configured to guide bone preparation instruments to prepare the end of the underlying bone.

[0012] In some examples, a bone preparation guide for minimally invasive metatarsal surgery includes one or more guide surfaces that are smaller in size than the size of one or more underlying bones to be prepared using the guide. For example, the bone preparation guide may include a slot into which a bone preparation instrument can be inserted to prepare the underlying bone (e.g., metatarsal, cuneiform). The length of the slot may be shorter than the diameter of the underlying bone. Thus, when the bone preparation guide is positioned over a bone, the slot may cover a portion of the bone to be prepared, but not the entire bone. This may facilitate the use of a relatively small bone preparation guide, allowing a clinician to make a smaller incision appropriate for the relatively small bone preparation guide, rather than the longer incision that may be required when using a larger bone preparation guide.

[0013] To prepare the entire end face of the bone that is partially but not completely covered by the guide surface (e.g., slot) of the bone preparation guide, the clinician can manipulate the bone preparation instrument in multiple directions relative to the guide surface. For example, the clinician can translate the bone preparation instrument along the length of the guide surface to prepare the portion of the end face of the bone covered by the guide surface. In doing so, the bone preparation instrument can extend generally perpendicularly from the bone preparation guide and advance linearly along the guide surface. Additionally, or alternatively, the clinician can tilt the bone preparation instrument relative to the length of the guide surface so that the axis of the bone preparation instrument is at an angle less than or greater than 90 degrees relative to the length of the guide surface. When the bone preparation instrument is tilted relative to the guide surface, the clinician can extend the distal portion of the bone preparation instrument below and / or above the side wall of the bone preparation guide to cut one or more portions of the bone beyond the end(s) of the guide surface (e.g., slot) of the bone preparation guide.

[0014] In some embodiments, the bone preparation guide includes one or more side walls that include one or more side wall notches. The side wall notches may extend partially, but not completely, along the height of the side wall. In use, a clinician can angle the bone preparation insert along the side wall and lower it into the side wall notch. The side wall notch allows bone preparation instruments to be aimed at a more acute angle than would be possible without the side wall notch, for example, to better access the bone to be prepared beyond the side wall.

[0015] Before and / or after preparing one or both end faces, the metatarsal can be realigned relative to the opposing cuneiform in one or more planes in three-dimensional space. The clinician can manipulate the position of the metatarsal by hand (e.g., optionally using a wire inserted into the bone) and / or with a bone positioner (also called a bone positioning device). In some instances, the clinician engages the bone positioner with the metatarsal and a bone other than the metatarsal, such as the cuneiform and / or an adjacent metatarsal. The clinician can then use the bone positioner to apply a force to the metatarsal, thereby moving the metatarsal in one or more planes.

[0016] After moving the metatarsal relative to the opposing cuneiform and / or adjacent metatarsal, the clinician can perform various steps to complete the surgical procedure. In some instances, the clinician installs a compressor and uses the compressor to compress the end surface of the prepared metatarsal and the end surface of the prepared cuneiform together. Additionally or alternatively, the clinician may temporarily fixate the moved position of the metatarsal relative to the cuneiform. For example, the clinician can insert one or more fixation wires from the metatarsal to one or more adjacent bones (e.g., from the adjacent metatarsal across the TMT joint to the opposing cuneiform).

[0017] In either case, the clinician may fuse the metatarsal to the cuneiform. For example, the clinician may install one or more fixation devices across the TMT joint to fix the position of the metatarsal relative to the cuneiform for subsequent healing and fusion. In some embodiments, the clinician installs one or more staples across the TMT joint. The one or more staples can apply a compressive force across the TMT joint after installation and can be sized to be effectively installed through a relatively small incision to access the TMT joint. The clinician may additionally or alternatively install other fixation devices, such as plates, screws, rods, and / or the like.

[0018] In one example, a method for performing minimally invasive metatarsal correction surgery is described. The method includes positioning at least one guide surface of a bone preparation guide over a patient's metatarsal and / or cuneiform bone to be prepared. The guide surface has a length extending from a first end to a second end, the length of the guide surface being shorter than the diameter of the metatarsal and / or cuneiform bone to be prepared. The method also includes guiding a bone preparation instrument along the guide surface to prepare the end of the metatarsal and / or cuneiform bone. According to this example, the technique may include translating the bone preparation instrument along the length of the guide surface and tilting the bone preparation instrument beyond one or both of the first and second ends of the at least one guide surface to prepare the end of the metatarsal and / or cuneiform bone beyond one or both of the first and second ends of the at least one guide surface. Exemplary techniques may also include moving the metatarsal relative to the cuneiform bone and fixing the position of the moved metatarsal.

[0019] The details of one or more examples are set forth in the accompanying drawings and the description below. Other features, objects, and advantages will be apparent from the description and drawings, and from the claims. [Brief explanation of the drawings]

[0020] [Figure 1A-1B] 1A and 1B are front views of the foot showing a normal first metatarsal position and an exemplary coronal plane rotational deviation position, respectively.

[0021] [Figure 2A-2B] 2A and 2B are top views of the foot showing a normal first metatarsal position and an exemplary transverse plane deviation position, respectively.

[0022] [Figure 3A-3B] 3A and 3B are side views of the foot showing a normal first metatarsal position and an exemplary sagittal plane deviation position, respectively.

[0023] [Figure 4] FIG. 1 is a flow diagram illustrating an exemplary technique for performing a minimally invasive metatarsal realignment procedure.

[0024] [Figure 5A-5B] 5A and 5B are top and side views, respectively, of an example of an incision guide that may be used to assist in sizing and / or positioning an incision prior to making the incision.

[0025] [Figure 6] 1 is an exemplary foot in a dorsal view showing a pin inserted percutaneously through the patient's skin into the underlying TMT joint.

[0026] [Figure 7] 10 is a radiographic image of an example incision guide configuration viewed from the dorsal side, illustrating an example of the positioning of the incision guide relative to the TMT joint.

[0027] [Figure 8] Also shown is a dorsal view of the foot showing an example of positioning the incision guide relative to the TMT joint.

[0028] [Figure 9A-9B] 9A and 9B show exemplary configurations of pins and dissection guides, respectively, that can be used during bone preparation and realignment procedures.

[0029] [Figures 10A-10B] 10A and 10B are top and perspective views, respectively, of an exemplary retraction guide that may be inserted into an incision to retract interfering soft tissue.

[0030] [Figures 11A-11B] 11A and 11B are top and perspective views, respectively, of another exemplary retraction guide that can be inserted into an incision to retract interfering soft tissue.

[0031] [Figure 12] 1 illustrates an exemplary configuration of a retraction guide that is inserted into an incision in a patient's skin to help the clinician separate the surrounding soft tissue underlying the anatomy to be accessed.

[0032] [Figure 13] 1 shows an example of a cutting instrument that may be used during a surgical procedure.

[0033] [Figure 14] 1 illustrates one configuration of a retractor that may be used during a surgical procedure.

[0034] [Figures 15A-15B] 15A and 15B are perspective and top views, respectively, of an exemplary retractor that can be used during a surgical procedure in accordance with the present disclosure.

[0035] [Figures 16A-16B] 16A and 16B are front and back perspective views, respectively, of an exemplary biplanar tissue dissection instrument that can be used during a surgical procedure, such as the minimally invasive surgical procedures described herein.

[0036] [Figure 17] FIG. 1 is a perspective view of a foot showing an example configuration of a biplanar tissue dissociation instrument inserted into the proximal lateral corner of the metatarsal.

[0037] [Figures 18A-18B] 18A and 18B show an example of a bone preparation guide that can be used as part of a minimally invasive surgical procedure.

[0038] [Figure 19] 18C is an exemplary foot viewed from the dorsal side, illustrating an exemplary configuration and positioning of the bone preparation guide of FIGS. 18A and 18B relative to one or more bones to be prepared using the guide.

[0039] [Figure 20] 18C is a radiographic image of an exemplary foot from a dorsal view illustrating an exemplary configuration and positioning of the bone preparation guide of FIGS. 18A and 18B relative to one or more bones to be prepared using the guide.

[0040] [Figure 21]18C is a side view of an exemplary configuration of the bone preparation guide of FIGS. 18A and 18B, showing an exemplary bone preparation instrument guided at an angle relative to the guide surface and extending beyond the end of the bone preparation guide.

[0041] [Figure 22A] 18C are different views of the exemplary configuration of the bone preparation guide of FIGS. 18A and 18B, illustrating exemplary side wall cutouts that may be utilized. [Figure 22B] 18C are different views of the exemplary configuration of the bone preparation guide of FIGS. 18A and 18B, illustrating exemplary side wall cutouts that may be utilized. [Figure 22C] 18C are different views of the exemplary configuration of the bone preparation guide of FIGS. 18A and 18B, illustrating exemplary side wall cutouts that may be utilized. [Figure 22D] 18C are different views of the exemplary configuration of the bone preparation guide of FIGS. 18A and 18B, illustrating exemplary side wall cutouts that may be utilized.

[0042] [Figures 23A-23B] 23A and 23B are cross-sectional views of bone preparation guides illustrating examples of sidewall cutout configurations that may be used in the bone preparation guides.

[0043] [Figure 24] FIG. 10 is a perspective view of an example foot showing a first fixation pin percutaneously inserted through a first fixation hole into the lower metatarsal bone and a second fixation pin percutaneously inserted through a second fixation hole into the lower cuneiform bone.

[0044] [Figures 25A-25B] 25A and 25B are perspective views showing different configurations of an example bone preparation guide with raised fixation holes.

[0045] [Figures 26A-26B] 26A and 26B are back and side views, respectively, of an exemplary bone preparation guide illustrating exemplary tissue deflection features.

[0046] [Figures 27A-27C]27A-27C show different views of an example of a hooked osteotome that can be inserted into a TMT joint and used to extract severed bone fragments from the joint.

[0047] [Figures 28A-28C] 28A-28C show different views of an example of a bone fragment grasping instrument that can be inserted into a TMT joint and used to extract a severed bone fragment from the joint.

[0048] [Figure 29] FIG. 10 shows a side perspective view of one example of a bone positioner that can be used to move a metatarsal bone relative to an adjacent bone.

[0049] [Figure 30] FIG. 1 is a perspective view of an exemplary foot illustrating an exemplary compression tool that can be used to compress the prepared ends of the bone together. DETAILED DESCRIPTION OF THE INVENTION

[0050] The present disclosure generally relates to devices, systems, and techniques for performing minimally invasive bone realignment procedures. In exemplary applications, the devices and techniques can be used during surgical procedures performed on one or more bones, such as bone alignment, osteotomy, fusion procedures, fracture repair, and / or other procedures requiring the placement of one or more bones in a desired position. Such procedures can be performed, for example, on bones of the foot or hand, which are relatively small compared to bones in other parts of the human anatomy (e.g., adjacent bones separated by a joint, or different portions of a single bone). In one example, a procedure utilizing embodiments of the present disclosure can be performed to correct the alignment between a metatarsal bone (e.g., the first metatarsal) and a cuneiform bone (e.g., the medial cuneiform), such as for bunion correction. An example of such a procedure is a Lapidus procedure. In another example, a procedure can be performed by correcting the alignment of a metatarsal bone (e.g., the first metatarsal). An example of such a procedure is a base metatarsal osteotomy.

[0051] Preparation and fusion of two opposing bone segments, such as the metatarsal and cuneiform, may be performed in accordance with the present disclosure for a variety of clinical reasons and indications. Preparation and fusion of the metatarsal and cuneiform bones at the TMT joint may be performed to treat hallux valgus and / or other bone and / or joint conditions.

[0052] Hallux valgus, also known as hallux abducto valgus, is a complex, progressive condition characterized by lateral deviation (alversion, eversion) of the great toe and medial deviation of the first metatarsophalangeal joint. Hallux valgus typically causes a progressive increase in the hallux abductus angle, which is the angle between the long axes of the first metatarsal and proximal phalanges in the transverse plane. As the hallux abductus angle increases, the plantar aponeurosis and tendons of the intrinsic and extrinsic muscles that pass from the metatarsus to the hallux and through the first metatarsophalangeal joint tend to shift outward. As a result, the sesamoid bones may also shift outward relative to the first metatarsophalangeal joint, potentially causing subluxation of the joint between the sesamoid bone and the first metatarsal head. This can increase pressure between the medial sesamoid bone and the crest of the first metatarsal head.

[0053] Although techniques and devices are generally described herein with respect to the first metatarsal and medial cuneiform bones of the foot, these techniques and devices may also be used with other adjacent bones (e.g., bones separated from one another by a joint) and / or adjacent bone portions (e.g., portions of the same bone separated from one another by a fracture or osteotomy). In various examples, the disclosed devices, systems, and / or techniques may be utilized with smaller bones of the foot, such as metatarsals (e.g., the first, second, third, fourth, or fifth metatarsals), cuneiform bones (e.g., medial, middle, lateral), cuboid, phalanges (e.g., proximal, middle, distal), and / or combinations thereof. Bones may be separated from one another by tarsometatarsal ("TMT") joints, metatarsophalangeal ("MTP") joints, or other joints. Accordingly, references herein to the first metatarsal and medial cuneiform bones may be substituted for other bone pairs described herein.

[0054] To further understand the exemplary techniques of the present disclosure, the anatomy of the foot and exemplary misalignments that may occur and be corrected in accordance with the present disclosure will first be described with reference to Figures 1-3. The bony misalignments may be caused by bunions, natural growth deformities, and / or other conditions.

[0055] FIGS. 1A and 1B are front views of a foot 200 showing a normal first metatarsal position and an exemplary position of rotational misalignment in the frontal plane, respectively. FIGS. 2A and 2B are top views of a foot 200 showing a normal first metatarsal position and an exemplary position of transverse plane misalignment, respectively. FIGS. 3A and 3B are side views of a foot 200 showing a normal first metatarsal position and an exemplary position of sagittal plane misalignment, respectively. While FIGS. 1B, 2B, and 3B illustrate each plane of misalignment in isolation, in reality, the metatarsals may be misaligned in any two of three planes, or even in all three planes. Thus, it should be understood that the depiction of a single plane of misalignment in each of FIGS. 1B, 2B, and 3B is for illustrative purposes only, and that the metatarsals may be misaligned in multiple planes, which it is desirable to correct. Furthermore, it should be understood that bone conditions treated in accordance with the present disclosure may not exhibit any of the exemplary misalignments described with respect to FIGS. 1B, 2B, and 3B, and the disclosure is not limited in this respect.

[0056] 1A and 2A, a foot 200 is comprised of multiple bones, including a first metatarsal 210, a second metatarsal 212, a third metatarsal 214, a fourth metatarsal 216, and a fifth metatarsal 218. The metatarsals are distally connected to phalanges 220, and more specifically, each is connected to a respective proximal phalange. The first metatarsal 210 is proximally connected to a medial cuneiform 222, the second metatarsal 212 is proximally connected to a middle cuneiform 224, and the third metatarsal is proximally connected to a lateral cuneiform 226. The fourth and fifth metatarsals 216, 218 are proximally connected to a cuboid 228. The joints 230 between the metatarsals and their respective cuneiform bones (e.g., the first metatarsal 210 and the medial cuneiform 222) are referred to as tarsometatarsal ("TMT") joints. The joints 232 between the metatarsals and the respective proximal phalanges are called metatarsophalangeal ("MTP") joints. The angle 234 between adjacent metatarsals (e.g., between the first metatarsal 210 and the second metatarsal 212) is called the intermetatarsal angle (IMA).

[0057] As previously mentioned, FIG. 1A is a front view of a foot 200 illustrating a typical position of the first metatarsal 210. The frontal plane, also known as the coronal plane, is commonly considered the vertical plane that divides the body into anterior and posterior sections. In the foot 200, the frontal plane is a vertically extending plane, perpendicular to an axis extending from proximal to distal along the length of the foot. FIG. 1A illustrates the first metatarsal 210 in a typical rotational position in the frontal plane. FIG. 1B illustrates the first metatarsal 210 with a frontal plane rotational deformation characterized by a rotation angle 236 relative to the ground indicated by line 238.

[0058] FIG. 2A is a top view of a foot 200 showing a typical position of the first metatarsal 210 in a transverse plane. The transverse plane, also called the horizontal, axial, or transaxial plane, is considered any plane that divides the body into upper and lower parts. In the foot 200, the transverse plane extends horizontally and is perpendicular to an axis that traverses the foot from dorsal to plantar (top to bottom). FIG. 2A shows the first metatarsal 210 with a typical IMA 234 in the transverse plane. FIG. 2B shows the first metatarsal 210 with a transverse plane rotational deformity characterized by a larger IMA caused by the distal end of the first metatarsal 210 pivoting medially relative to the second metatarsal 212.

[0059] FIG. 3A is a lateral view of a foot 200 showing a typical position of the first metatarsal 210 in the sagittal plane. The sagittal plane is a plane parallel to the sagittal suture that divides the body into right and left halves. In the foot 200, the sagittal plane is a vertically extending plane, perpendicular to an axis extending from proximal to distal along the length of the foot. FIG. 3A shows the first metatarsal 210 with a typical rotational position in the sagittal plane. FIG. 3B shows the first metatarsal 210 with a sagittal plane rotational deformation characterized by a rotation angle 240 relative to the ground indicated by line 238.

[0060] Surgical techniques and instruments according to the present disclosure may be useful for correcting misalignment of one or more bones, such as the metatarsal and opposing cuneiform, and / or promoting fusion of opposing metatarsals and cuneiform bones across the TMT joint. In some applications, the techniques involve surgically accessing the TMT joint through a minimally sized incision. Before incising the patient's skin to surgically access one or both of the metatarsal and opposing cuneiform bones, a clinician can use an incision guide to identify the location and size of the incision relative to the TMT joint. After incising the patient's skin, the clinician can release soft tissue to move the metatarsal for realignment and / or prepare the ends of the metatarsal and cuneiform for fusion after realignment. Using one or more instruments configured for minimally invasive surgery, the clinician can retract skin and / or other soft tissue around the small incision and move the metatarsal through the small incision.

[0061] A clinician can prepare the end surface of the metatarsal bone and the opposing end surface of the cuneiform bone with or without a bone preparation guide. In some embodiments, a clinician uses a bone preparation guide with one or more guide surfaces configured to guide a bone preparation instrument relative to the underlying bone(s) to be prepared. Utilizing a bone preparation guide can provide more consistent and reproducible results between surgeons and patients, resulting in consistent and effective clinical outcomes. In some configurations, the bone preparation guide placed on the metatarsal and / or cuneiform bone has one or more guide surfaces that are smaller in size than the bone to be prepared. In other words, the length of the guide surface may extend across only a portion of the width (e.g., diameter) of the metatarsal and / or cuneiform bone, rather than across the entire width. Using a relatively small bone preparation guide allows a clinician to keep the size of the skin incision relatively small compared to using a larger bone preparation guide, which may require a larger incision.

[0062] When using a bone preparation guide having a guide surface size smaller than the width of the underlying bone to be prepared, a clinician can manipulate a bone preparation instrument guided by the bone preparation guide to prepare the underlying bone beyond one or more boundaries defined by the guide surface. For example, a clinician can manipulate a bone preparation instrument to extend a distal portion of the instrument below a side wall of the bone preparation guide. In use, a clinician can guide a bone preparation instrument along the guide surface to prepare a portion of the bone underlying the guide surface (e.g., by linearly translating the bone preparation instrument along the guide surface) and tilt the bone preparation instrument to extend a distal portion of the instrument beyond the edge of the guide surface. In this manner, a clinician can prepare both the portion of the bone covered by the guide surface and the portion of the bone beyond the edge of the guide surface. In some configurations, the bone preparation guide includes one or more notches that allow a bone preparation instrument to be tilted and / or manipulated beyond the edge of the guide surface more efficiently than would be possible without the notches.

[0063] Before and / or after preparing and / or positioning one or both ends of a metatarsal bone on the ends of the opposing cuneiform bone, a clinician can move the metatarsal bone relative to the cuneiform bone to realign the metatarsal bone in one or more planes. For example, a clinician may move a metatarsal bone relative to an adjacent metatarsal bone to narrow the intermetatarsal angle, rotate a metatarsal bone in the frontal plane to reposition the sesamoid bones below the metatarsal bone, and / or anteflex or dorsiflex a metatarsal bone in the sagittal plane. A clinician can move a metatarsal bone in one or more planes directly by hand (e.g., optionally using pins, tenacula, or other instruments) and / or use a bone positioner operably connected to the metatarsal bone to move the metatarsal bone in one or more planes. For example, a clinician can engage a bone positioner with a metatarsal bone and / or with a bone other than the metatarsal bone, and then use the bone positioner to apply a force that moves the metatarsal bone in one or more planes.

[0064] Once the metatarsal is properly repositioned, the clinician can temporarily and / or permanently fix the relocated position of the metatarsal relative to the cuneiform. For example, the clinician may insert fixation pins from the metatarsal (e.g., across the TMT joint) into the cuneiform to maintain the position of the metatarsal for subsequent placement of one or more permanent fixation devices. In some embodiments, the clinician compresses the end surfaces of the prepared metatarsal with the end surfaces of the prepared cuneiform prior to placement of one or more temporary and / or permanent fixation devices. For example, the clinician can place one or more staples, plates, screws, and / or pins to maintain the relocated position of the metatarsal relative to the cuneiform, thereby maintaining the relocated position of the bones, and then allowing the end surfaces of the prepared bones to fuse together.

[0065] 4 illustrates this exemplary technique with respect to the first metatarsal 210 and medial cuneiform 222, but as explained above, it can also be performed with respect to other bones. For ease of explanation, the technique of FIG. 4 will be described with reference to various example images shown in FIGS. 5-30.

[0066] The exemplary technique of FIG. 4 involves surgically accessing the TMT joint 230, which separates the first metatarsal 210 from the opposing medial cuneiform 222 (step 12 of FIG. 4). To surgically access the joint, the patient may lie supine on an operating room table and receive general anesthesia or monitored anesthesia care. Hemostasis may be achieved by applying a thigh tourniquet or a mid-calf tourniquet. An incision 100 (FIG. 12) may be made in the skin 102, such as on the dorsal side of the foot, the medial side of the foot, or the dorsal-medial side of the foot. The incision may be relatively small to perform a minimally invasive procedure, thereby reducing the size of any scars remaining after surgery.

[0067] To size and / or position the incision relative to the TMT joint 230, a clinician can use an incision guide. FIGS. 5A and 5B (collectively referred to as FIG. 5) are top and side views, respectively, of an example incision guide 50 that can be used to assist in sizing and / or positioning the incision prior to making the incision 100. The incision guide 50 can define one or more incision guide surfaces 52 for guiding the incision through the patient's skin. In the illustrated example, the incision guide 50 includes an incision guide surface 52 and an opposing incision guide surface 54, with an incision guide slot defined between the two surfaces. The incision guide surface 52 (and corresponding incision guide slot) has a length extending from a first end 56 to a second end 58. The length of the incision guide surface can be used to set the length of the incision 100 made in the patient's skin.

[0068] For example, during use, a clinician can place the incision guide 50 on the patient's skin at the location where the incision 100 will be made. The clinician can then make the incision 100 by guiding a cutting instrument (e.g., a scalpel) along the length of the incision guide surface 52 and / or along the length of the incision guide slot between the first end 56 and the second end 58. Additionally or alternatively, the clinician can use the incision guide 50 as a template to guide a marking source (e.g., a surgical marker pen) to indicate on the patient's skin surface where the incision 100 should be made. In these examples, the clinician can optionally remove the incision guide 50 from the patient's skin surface and cut the skin along the marked incision line. The incision guide 50 can help set the desired length of the incision 100 to be made in the patient's skin 102, achieving a minimally invasive procedure and helping, for example, to prevent the clinician from making an overly long incision.

[0069] When performing surgery through relatively small incisions, the incision location can be precisely controlled to ensure adequate surgical access at the incision location. This is because a clinician may not have the same flexibility to access one or more target anatomical regions through a relatively small incision if the incision is improperly positioned relative to the underlying anatomical structures. In some embodiments, with the incision guide 50 positioned on the patient's skin, the clinician can take a fluoroscopic (e.g., X-ray) image of at least a portion of the foot 200 surrounding the TMT joint 230 and use the fluoroscopic image to manipulate the position of the incision guide surface 52 relative to the TMT joint. This may allow the clinician to position the incision guide surface 52 at a target location relative to the TMT joint 230 and the first metatarsal 210 and medial cuneiform 222 that define the TMT joint. Once properly positioned, the clinician can use the incision guide to make the incision 100.

[0070] Additionally or alternatively, the incision guide 50 may include or be configured to interface with a feature insertable into the TMT joint 230. This may allow the insertable feature to identify the location of the TMT joint 230 and position the incision guide 50 accordingly. In some examples, the incision guide 50 is utilized as part of a system that includes a pin insertable into the TMT joint 230. In use, a clinician can percutaneously insert the pin into the joint through the patient's skin 102 and position the incision guide 50 relative to the pin.

[0071] FIG. 6 illustrates an exemplary foot 200 from a dorsal view showing a pin 60 percutaneously inserted through the patient's skin 102 into the underlying TMT joint 230. In some instances, a clinician may palpate the patient's foot 200 to identify the TMT joint 230 and then percutaneously insert the pin 60 into the joint. Additionally or alternatively, the clinician may view the foot 200 via fluoroscopy and insert the pin 60 into the TMT joint 230 using fluoroscopy. In either case, the pin 60 may be long enough so that a proximal portion of the pin protrudes from the skin while a distal portion of the pin can be positioned at least partially, and in some instances completely, within the TMT joint 230. A dissection guide 50 may be operatively connected to the pin 60, thereby aligning the dissection guide surface 52 with the TMT joint 230 and / or the metatarsal bones 210 and / or cuneiform bones 222 that define the joint. When used, the pins 60 can have any cross-sectional shape (e.g., circular, square, triangular) and size. In some examples, the pins 60 can be relatively small, having a cross-sectional width (e.g., diameter) of less than 2 mm, e.g., less than 1 mm.

[0072] With further reference to FIG. 5 , the dissection guide 50 may be provided with a pin-receiving hole 62 configured to receive the pin 60. For example, after inserting the pin 60 into the TMT joint 230, a clinician can use the pin-receiving hole 62 to connect the dissection guide 50 to the pin 60. In some instances, the clinician aligns the pin-receiving hole 62 of the dissection guide 50 with the proximal end of the pin 60 and advances the dissection guide downwardly over the pin. In some embodiments, the pin-receiving hole 62 has substantially the same size and shape as the pin 60. In other embodiments, the pin-receiving hole 62 is sized larger than the pin 60 in at least one dimension to allow for relative movement between the dissection guide and the pin after the dissection guide is attached to the pin. For example, the pin-receiving hole 62 may be implemented as a slot that allows the dissection guide to move while the pin 60 is received in the slot.

[0073] In use, a clinician can connect the dissection guide 50 to the pin 60 by positioning the pin in a slot defined by the dissection guide. The slot may be defined by side walls that bound the distal-to-proximal movement of the dissection guide. For example, the slot defined by the dissection guide into which the pin 60 is inserted can extend generally in a medial-to-lateral direction across the TMT joint 230, e.g., generally parallel to the joint line. When configured in this manner, the relative position of the dissection guide 50 in a distal-to-proximal direction along the length of the metatarsal 210 and / or cuneiform 222 can be substantially set by the position of the pin 60 in the side walls surrounding the slot. However, the clinician may be able to move the position of the dissection guide, and in particular the dissection guide surface 52, in a medial-to-lateral direction, for example, within the transverse plane with the pin 60 received in the slot. This allows the clinician to set a specific location for making an incision along the width of the TMT joint 230 after positioning the dissection guide in a desired distal-to-proximal location.

[0074] In some examples, the pin-receiving hole 62 (e.g., the slot defined by the pin-receiving hole) is substantially centered along the length of the incision guide surface 52 between the first end 56 and the second end 58. When configured in this manner, the incision guided by the incision guide surface 52 can be substantially centered over the TMT joint 230 (e.g., approximately half of the incision is over the first metatarsal 210 and approximately half of the incision is over the medial cuneiform 222). In other examples, the pin-receiving hole 62 may be offset relative to the center of the length of the incision guide surface 52. The incision guide 50 may include a handle 66 that a clinician can grasp to position and hold the incision guide during use and / or to manipulate the position of the incision guide relative to the patient's anatomy.

[0075] The dissection guide 50 may include one or more additional pin-receiving holes 64 for receiving one or more additional pins, e.g., inserted percutaneously into the underlying bone through the one or more additional pin-receiving holes. For example, the dissection guide 50 may include pin-receiving holes 62 and / or pin-receiving holes 64 on opposite sides of the dissection guide surface 52 adjacent the first end 56 and / or second end 58 of the dissection guide. Inserting additional pins into the dissection guide 50 may help stabilize the dissection guide relative to the underlying skin and bone, e.g., when the dissection guide is used to guide a cutting instrument along the dissection guide surface 52.

[0076] When an incision guide 50 is used, the incision guide can be placed at any suitable location around the TMT joint 230, such as on the dorsal side of the joint, the medial side of the joint, or the dorsal-medial side of the joint. In some embodiments, the incision guide surface 52 (and / or the widthwise center of the slot defined by the guide surface) of the incision guide 50 is placed on the patient's skin 102 on the dorsal side of the TMT joint 230. The incision guide surface 52 (and / or the slot defined by the guide surface) may be aligned with the longitudinal centerline of the metatarsal 210 and / or cuneiform 222 across the dorsal TMT joint 230, or the incision guide surface (and / or the slot defined by the guide surface) may be offset medially or laterally relative to the longitudinal centerline. Positioning the incision guide surface 52 (and / or the slot defined by the guide surface) offset from the longitudinal centerline of the joint may be useful for preferentially accessing the medial or lateral side of the TMT joint in subsequent steps of the procedure.

[0077] FIG. 7 is a dorsal radiographic image of an example configuration of the incision guide 50 illustrating example positioning of the incision guide relative to the TMT joint 230. FIG. 8 is a dorsal view of the foot 200, also illustrating example positioning of the incision guide 50 relative to the TMT joint 230. In the examples of FIGS. 7 and 8 , the incision slot defined by the incision guide 50 is shown positioned lateral to a longitudinal axis 68 that traverses the TMT joint 230 from proximal to distal and bisects the metatarsal 210 and the cuneiform 222. The longitudinal axis 68 can divide the TMT joint 230 into a medial half and a lateral half in a transverse plane. In some examples, the widthwise center of the incision guide surface 52 and / or the incision slot defined by the guide surface may be positioned in the lateral half of the TMT joint 230 (e.g., substantially centered from distal to proximal) such as the lateral third or lateral quarter of the joint. For example, the widthwise center of the incision slot defined by the incision guide surface 52 and / or guide surface can be positioned at least 1 cm outboard from the longitudinal axis 68, e.g., at least 2 cm, at least 3 cm, or 1 cm to 3 cm. In other configurations, the widthwise center of the incision slot defined by the incision guide surface 52 and / or guide surface can be positioned inboard of the longitudinal axis 68, at any of the locations and dimensions described as outboard. In still other configurations, the widthwise center of the incision slot defined by the incision guide surface 52 and / or guide surface can be positioned substantially on the longitudinal axis 68.

[0078] As mentioned above, the incision guide 50 and the pin 60 can have a variety of different configurations. Figures 9A and 9B illustrate exemplary configurations of the pin 60 and the incision guide 50, respectively, that can be used during bone preparation and realignment procedures. As shown in Figure 9A, the pin 60 can have a relatively small distal portion 70 that can be percutaneously inserted into the TMT joint 230 and a relatively large proximal portion 72. The larger proximal portion 72 can have a cross-sectional width (e.g., diameter) that is at least 50% larger than the distal portion 70, such as at least 100% larger. The larger proximal portion 72 can provide an enlarged area for the clinician to grasp when inserting the distal portion 70 through the patient's skin 102 and into the TMT joint 230. The incision guide 50 can be placed over the portion of the distal portion 70 and / or the portion of the larger proximal portion 72 that protrudes from the patient's skin.

[0079] FIG. 9B illustrates an example configuration of the dissection guide 50 including a channel 74 extending through the insertion guide surface 52 and facing the insertion guide surface 54. The channel 74 is connected to the pin-receiving bore 62 and is shown as a slot extending parallel to the handle 66 of the dissection guide. Configuring the dissection guide 50 with the channel 74 may be convenient for connecting the dissection guide to the pin 60, for example, when the dissection guide is configured with a large portion that can be grasped by the clinician. The dissection guide 50 can be aligned with the portion of the pin 60 that protrudes from the TMT joint 230 (e.g., a portion of the smaller distal portion 70) by advancing the channel 74 over the pin until the pin is positioned within the pin-receiving bore 62. Other dissection guide configurations may be used without departing from the scope of this disclosure. For example, although the incision guide 50 and pin 60 are described as separate components that can be aligned with one another, in other examples, the incision guide 50 may include an integrally formed pin or other alignment feature (e.g., extending from the bottom surface of the incision guide) that is inseparable from the incision guide.

[0080] Regardless of whether a clinician uses an incision guide or a particular configuration of an incision guide, the clinician can dissect the patient's skin and make a cut to access the underlying anatomical structure. The specific length of the incision 100 (distal to proximal, parallel to the long axis of the first metatarsal 210) can vary, but in some instances, the incision length can be less than 6 cm, e.g., less than 5 cm, less than 4 cm, less than 3 cm, 2 cm or less, 1.5 cm or less, or 1 cm or less. In some cases, the length of the incision 100 is in a range of 1 cm to 4 cm, e.g., 1.5 cm to 3 cm, 1.5 cm to 2.5 cm, 1.8 cm to 2.2 cm, or approximately 2 cm (e.g., ±5%). The length of the incision guide surface and / or incision guide slot defined by the incision guide for cutting such an incision can fall within any of the aforementioned ranges.

[0081] With the TMT joint 230 exposed through the incision 100 in the patient's skin 102, the exemplary technique of FIG. 4 may include mobilizing the TMT joint to facilitate subsequent repositioning of the metatarsal 210 (step 14 of FIG. 4 ). For example, after creating surgical access to the joint and before moving the metatarsal into a realigned position, the clinician may cut soft tissue and / or obstructing bone to allow the metatarsal to move relatively freely for realignment. For example, the clinician may insert a cutting instrument (e.g., a saw blade, osteotome) into the TMT joint 230 between the metatarsal 210 and the cuneiform bone 222 and / or into the intermetatarsal joint space between the metatarsal 210 and the adjacent metatarsal 212. The clinician may insert the cutting instrument into the target joint space(s) to cut soft tissue (muscle, tendon, ligament, fascia, etc.) within the joint space. Such soft tissue may be connected and attached to the bone (e.g., metatarsal) intended for realignment. Cutting the soft tissue can move the bone for subsequent realignment. Additionally or alternatively, the clinician can resect (cut) obstructing bone, such as the dorsolateral flare of the metatarsal base, the plantar flare of the metatarsal base (sometimes called the plantar condyle), a portion of the end of the metatarsal facing the cuneiform bone, and / or osteophytes, to create a relatively flat surface relative to the frontal plane and promote free rotation of the metatarsal.

[0082] When surgically accessing one or more joint cavities through a relatively small incision, soft tissue (e.g., skin, tendons such as the extensor hallucis longus (EHL) tendon, etc.) may tend to cover the incision cavity and impede surgical access to the underlying tissue and / or bone. Therefore, in some instances, a clinician may insert a retraction guide into the incision to help separate the soft tissue from the underlying anatomical structures. The retraction guide can shift potentially interfering soft tissue to expose the underlying anatomical structures for surgical access by the clinician. Various retraction guide designs can be used.

[0083] 10A and 10B are top and perspective views, respectively, of an exemplary retraction guide 80 that can be inserted into an incision 100 to retract interfering soft tissue. The retraction guide 80 can include at least one side wall 82 that defines a partially or fully enclosed opening 84 through which a clinician can surgically access the underlying anatomical structure. The retraction guide 80 can be implemented in a variety of sizes and shapes, and the opening 84 can be any desired polygonal (e.g., square, rectangular, triangular) and / or arcuate (e.g., circular, oval) shape. In use, a clinician can insert the retraction guide 80 into the incision 100 using the retraction guide's side wall 82 and move the interfering soft tissue while providing surgical access through the retraction guide's opening 84.

[0084] In the illustrated example, the retraction guide 80 is shown to include a handle 86 that a clinician can grasp to position and / or hold the retraction guide within the incision 100 during use. In the illustrated example, the retraction guide 80 is also shown having at least one outwardly extending foot 88, with the retraction guide 80 shown as being implemented with a pair of feet 88 extending in opposite directions from at least one side wall 82. When the retraction guide 80 is placed in the incision 100, the one or more feet 88 are positioned under the patient's skin 102 to help hold and maintain the retraction guide in the incision during subsequent use.

[0085] 11A and 11B are top and perspective views, respectively, of another exemplary retraction guide 80 that can be inserted into the incision 100 to retract interfering soft tissue. In FIGS. 11A and 11B, features similar to those described above with respect to FIGS. 10A and 10B are designated with like reference numerals. The example retraction guide 80 in FIGS. 11A and 11B is shown as defining a rectangular opening 84 sized to allow a planar cutting instrument (e.g., osteotome, saw blade) to be inserted into the opening to cut underlying tissue and / or bone.

[0086] FIG. 12 illustrates an exemplary configuration of a retraction guide 80 inserted into an incision 100 in a patient's skin 102 to aid the clinician in separating surrounding soft tissue underlying the anatomical structure to be accessed. In particular, in the illustrated example, a retraction guide 80 configuration having a rectangular opening (as shown in FIGS. 11A and 11B ) is shown inserted into the incision 100 with the retraction guide's opening 84 positioned over the TMT joint 230. The foot portion 88 of the retraction guide 80 is positioned under the patient's skin 102 to help maintain the retraction guide under the skin, and the handle 86 is shown extending along the longitudinal axis of the metatarsal. In the illustrated example, a saw blade 90 is inserted through the slot-shaped opening 84 of the retraction guide 80 into the TMT joint 230 to cut tissue and / or bone to move the metatarsal for subsequent repositioning.

[0087] A variety of retraction guide designs (or no retraction guide) may be utilized by the clinician. When a retraction guide is utilized, the retraction guide opening 84 may be positioned at any suitable location on any target anatomical structure the clinician wishes to surgically access. Additionally, when releasing soft tissue and / or bone to realign the metatarsal, the clinician may use any desired cutting instrument. The cutting instrument may be a reciprocating or oscillating instrument connected to a powered hand unit, or may be directly grasped by the clinician with the cutting force applied by the movement of the clinician's hand.

[0088] FIG. 13 shows an example of a cutting instrument 92 that may be used during a surgical procedure. For example, the cutting instrument 92 may release the TMT joint 230 by cutting soft tissue and / or one or more bony processes into the joint space to assist in moving the metatarsals for realignment. The cutting instrument 92 is shown as having a length extending from a first end 94 to a second end 96. The first end 94 of the cutting instrument 92 may be tapered in one or both planes across the thickness of the cutting instrument to provide a sharp tip. In the illustrated arrangement, the cutting instrument 92 includes a depth stop 98 located proximal to the distal end of the cutting instrument.

[0089] In some examples, the length of the cutting instrument 92 may be sized depending on the expected anatomy of the patient undergoing the procedure and / or the retraction guide 80 used in the procedure. For example, the cutting instrument 92 may have a length from the first end 94 to a depth stop 98 such that the cutting instrument can be advanced through the retraction guide 80 and into the underlying anatomy (e.g., the TMT joint 230) to a desired depth. The cutting instrument 92 may have a substantially constant thickness along this length of the instrument. The depth stop 98 may be an outwardly extending feature and / or an area of ​​enlarged cross-sectional thickness configured to contact the upper surface of the side wall 82 of the retraction guide 80. For example, a clinician may thrust the cutting instrument 92 through the opening 84 of the retraction guide 80 and into the underlying anatomy until the depth stop 98 contacts the side wall 82 of the depth stop.

[0090] In practice, in addition to or instead of using the retraction guide 80, a clinician may use one or more retractors to pull the cut skin 102 away from the incision line to assist in widening the surgical access area. FIG. 14 illustrates one configuration of a retractor 104 that may be used during a surgical procedure. The retractor 104 includes a body defining a length terminating in a distal end 106. The distal end 106 of the retractor body may be bent backward along the length of the body to define a curved (e.g., U-shaped) recess 108. In use, the distal end 106 of the retractor body may be inserted under the patient's skin at the incision line, the skin may be captured in the recess 108, and the retractor may be pulled away from the incision line. To facilitate a clinician's grip on the retractor 104 during use, the retractor may include one or more grips 110, such as areas of increased cross-sectional thickness.

[0091] 15A and 15B (collectively referred to as "FIG. 15") are perspective and top views, respectively, of an exemplary retractor 120 that can be used during a surgical procedure in accordance with aspects of the present disclosure. Retractor 120 is shown as a locking retractor including a first arm 122 and a second arm 124 that are movable away from one another. First arm 122 is operatively connected to a first handle 126. Second arm 124 is operatively connected to a second handle 128. In particular, in the illustrated configuration, first arm 122 is shown extending from a first end 122A to a second end 122B, and second arm 124 is shown extending from a first end 124A to a second end 124B. The second end 122B of the first arm 122 is on the widthwise side of the retractor 120 opposite the first handle 126, and the second end 124B of the second arm 124 is on the widthwise side of the retractor 120 opposite the second handle 128.

[0092] The retractor 120 is illustrated as having a first cross arm 130 and a second cross arm 132 for connecting the first arm 122 and the second arm 124 to the corresponding first handle 126 and second handle 128. The first cross arm 130 extends from the second end 122B of the first arm 122 to the first handle 126. The second cross arm 132 extends from the second end 124B of the second arm 124 to the second handle 128. The first and second cross arms 130, 132 extend across the width of the retractor 120. Thus, when the first arm 122 and the second arm 124 of the retractor 120 are not displaced relative to one another (e.g., when the inner surfaces of the arms are adjacent and / or touching one another), the first handle 126 and the second handle 128 are positioned completely apart from one another. A clinician can move the first arm 122 and the second arm 124 apart by grasping the first handle 126 and the second handle 128 and squeezing the handles together, thereby allowing the retractor 120 to be efficiently operated with one hand.

[0093] As briefly mentioned, the clinician may cut soft tissue and / or resect bone at various locations relative to the metatarsal being realigned to mobilize the metatarsal for subsequent movement. In some instances, the clinician cuts soft tissue and / or resects bone at the TMT joint between the metatarsal being realigned and the opposing cuneiform bone, such as TMT joint 230. Additionally or alternatively, the clinician may cut soft tissue within the joint space between the metatarsal being realigned and an adjacent metatarsal, such as the intermetatarsal space between the first metatarsal 210 and the second metatarsal 212. The clinician may use any cutting instrument (saw, osteotome, reamer, etc.) with or without a resection guide to dissect the soft tissue within the intermetatarsal space.

[0094] In some embodiments, a clinician can utilize a biplanar tissue dissociation instrument that can be simultaneously positioned in the TMT joint space and the adjacent intermetatarsal space. For example, a clinician may utilize a cutting instrument that defines an angle or corner between two adjacently connected cutting bodies. The clinician can insert the corner of the cutting instrument into the corner of a metatarsal bone, such as the proximal lateral corner of the metatarsal bone. The clinician can position one cutting body of the biplanar tissue dissociation instrument at least partially within the TMT joint space and the other cutting body of the biplanar tissue dissociation instrument at least partially within the adjacent intermetatarsal space. The clinician can then advance the cutting instrument, for example, by advancing the cutting instrument in a dorsal-to-plantar direction, to cut and / or dissociate soft tissue to realign the metatarsal corners. The use of a biplanar tissue dissociation instrument allows a clinician to achieve efficient and effective tissue dissociation, including when working through relatively small incisions that make it more difficult to visualize and access two different adjacent joint spaces.

[0095] 16A and 16B (collectively referred to as "FIG. 16") are front and back perspective views, respectively, of an exemplary biplanar tissue dissection instrument 150 that can be used during a surgical procedure, such as the minimally invasive surgical procedures described herein. The instrument 150 is shown as having a first cutting body 152 and a second cutting body 154. The first cutting body 152 is coupled to the second cutting body 154, defining an angle 156 between the two cutting bodies. In the illustrated example of FIG. 16, the angle 156 between the first cutting body 152 and the second cutting body 154 is shown as approximately 90°, although different angles may be used in different configurations. In some examples, the angle 156 can be in the range of 45° to 135°, such as in the range of 75° to 105°.

[0096] The first cutting body 152 can have a length extending from a distal end 152A to a proximal end 152B. Similarly, the second cutting body 154 can have a length extending from a distal end 154A to a proximal end 154B. The first cutting body 152 can be connected to the second cutting body 154 along the entire length of the two cutting bodies or along only a portion of the length of the two cutting bodies.

[0097] In use, the distal ends 152A and 154A of the first and second cutting bodies 152, 154 can be advanced into the adjacent joint cavity, with the proximal portions of the cutting bodies following the distal ends advanced into the joint cavity. The distal end of the biplanar tissue dissection instrument 150 (defined by the combination of the distal ends 152A and 154A of the first and second cutting bodies 152, 154) can have a variety of different profiles. In some instances, the distal end of the instrument 150 is planar, such that the distal end 152A is in the same plane as the distal end 154A across the entire width of the instrument. In other instances, the distal end of the instrument 150 is non-planar, e.g., the distal ends 152A and 154A are angled inward or outward relative to each other to define grooves / recesses or protrusions. In the illustrated example of FIG. 16, the instrument 150 is shown as defining a groove 158 between the inwardly beveled distal end 152A of the first cutting body 152 and the inwardly beveled distal end 154A of the second cutting body 154.

[0098] For example, the first cutting body 152 can define a width extending from an outer edge 152C to an intersection location on the inner side 152D where the first cutting body intersects with the second cutting body 154. The second cutting body 154 can also define a width extending from an outer edge 154C to an intersection location on the inner side 154D where the second cutting body intersects with the first cutting body 152. The distal end 152A of the first cutting body 152 can be tapered inward along the width of the first cutting body, e.g., such that the length of the first cutting body is longer at the outer edge 152C of the cutting body than at the inner side 152D of the cutting body. The distal end 154A of the first cutting body 154 can be tapered inward along the width of the second cutting body, e.g., such that the length of the second cutting body is longer at the outer edge 154C of the cutting body than at the inner side 154D of the cutting body.

[0099] The distal ends 152A, 154A of the first and second cutting bodies 152, 154 can be angled inward to define a groove 158 at the distal end of the instrument 150. The groove 158 can be a space free of the material defining the cutting instrument that extends at least partially along the length of the cutting instrument from the distal end of the cutting instrument toward the proximal end of the instrument. The groove 158 can define a proximal-most apex where the distal ends 152A, 154A of the first and second cutting bodies 152, 154 converge at the intersection between the two cutting bodies. The groove 158 can increase in size from the proximal-most apex of the groove to the distal-most end of the biplanar tissue dissociation instrument 150. In various implementations, the groove 158 can generally define the illustrated V-shape, U-shape, C-shape, or any other suitable shape. Configuring the biplanar tissue dissection instrument 150 with grooves 158 allows the clinician to more precisely target the soft tissue to be cut. The clinician can advance the instrument 150 into the adjacent joint space and capture the soft tissue to be cut within the grooves 158 (e.g., using the downwardly extending apexes of the angled distal ends 152A, 152B of the first and second cutting bodies to funnel and / or otherwise guide the soft tissue into the grooves).

[0100] The biplanar tissue dissociation instrument 150 can be configured with one or more sharp surfaces. The instrument surfaces can be polished by tapering the surface across the thickness of the material defining the surface, for example, by cutting, grinding, and / or other abrasive procedures, to form a surface that is sufficiently sharp to cut soft tissue during use. The biplanar tissue dissociation instrument 150 can also be configured with one or more surfaces that are not sharp and are not designed or intended to cut soft tissue during use of the instrument.

[0101] In some implants, the outer edge 152C of the first cutting body 152 and the outer edge 154C of the second cutting body 154 each have an obtuse angle. One or both of the distal end 152A of the first cutting body 152 and the distal end 154A of the second cutting body 154 may be sharpened along at least a portion of their lengths, from their respective outer edges to the medial side where the two cutting bodies join. This configuration allows a clinician to insert the instrument 150 into the adjacent joint space, capture soft tissue within the groove 158, and cut the tissue captured within the groove without cutting tissue contacted by the outer edges 152C of the first cutting body 152 and the outer edges 154C of the second cutting body 154.

[0102] The biplanar tissue dissociation instrument 150 can be configured (e.g., sized and shaped) to be placed in the adjacent joint space. For example, during use, a clinician can position the first cutting body 152 at the TMT joint 230 and the second cutting body 154 in the joint space between the first metatarsal 210 and the second metatarsal 212. FIG. 17 is a perspective view of a foot 200 showing an exemplary configuration of the biplanar tissue dissociation instrument 150 inserted at the proximal lateral corner of the first metatarsal 210, e.g., the proximal lateral corner of the metatarsal is within the angular space defined between the intersection of the first cutting body 152 and the second cutting body 154. The instrument 150 can be inserted through a relatively small incision in the patient's skin, as described above, to aid in mobilizing the first metatarsal 210 for subsequent repositioning. The clinician can advance the biplanar tissue dissociation instrument 150 in a plantar direction through a dorsal incision. As the clinician advances the instrument simultaneously into two adjacent joint spaces, the clinician can capture target soft tissue in the groove 158 between the first cutting body 152 and the second cutting body 154. The one or more sharp surfaces defining the groove 158 can cut soft tissue directed by the clinician into the groove while the outer edges of the cutting bodies are inserted into the adjacent joint spaces without significantly cutting the soft tissue along the outer edges.

[0103] While the specific dimensions of the biplanar tissue dissociation instrument 150 can vary, in some embodiments, the first cutting body 152 and the second cutting body 154 each have a length ranging from 20 mm to 60 mm, e.g., 25 mm to 55 mm, 30 mm to 50 mm, 35 mm to 45 mm, or approximately 40 mm (e.g., plus or minus 10%). Additionally, the width of the first cutting body 152 and the second cutting body 154 may range from 4 mm to 10 mm, e.g., 5 mm to 9 mm, 6 mm to 8 mm, or approximately 7 mm (e.g., plus or minus 10%). In some examples, one or both of the first cutting body 152 and the second cutting body 154 may include a depth indicator that indicates how deeply the distal end of the cutting body has been inserted into a space. For example, as shown, the first cutting body 152 and the second cutting body 154 each include an opening through the plane of the cutting body. The openings may be at defined locations along the length of the cutting body (e.g., 20 mm, 25 mm, 30 mm, 35 mm, 40 mm) that correspond to specific distances between the distal end of the cutting body and the depth indicator. In some examples, the depth indicator includes a protrusion (e.g., a depth step) configured to contact the back surface of the bone and / or skin to limit the depth to which the cutting body is inserted into the joint space. For example, if the depth indicator is an opening, a wire can be inserted through the opening to provide a physical stop when the cutting body is advanced to a position where the wire inserted through the opening contacts the skin and / or bone.

[0104] The first cutting body 152 and the second cutting body 154 can be integrally and permanently joined to form a monolithic cutting body pair. For example, the first cutting body 152 and the second cutting body 154 may be formed as a unitary structure (e.g., by casting or milling). In other examples, the first cutting body 152 and the second cutting body 154 are formed as separate structures and then permanently joined (e.g., by welding) or joined but separable from one another (e.g., by mechanical locks and / or other temporary fastening structures).

[0105] With further reference to FIG. 16 , the biplanar cutting instrument 150 is shown as including a handle 160. In the illustrated configuration, a clinician can manually grasp the handle 160 to control the instrument 150 and guide it into the adjacent joint space of a subject. In some examples, the handle 160 is not configured to be detached during use but is operably connected to the first cutting body 152 and the second cutting body 154. In other examples, the handle 160 is operably connected to the first cutting body 152 and the second cutting body 154 and can be detached by a physician during a surgical procedure. For example, a clinician can insert the biplanar cutting instrument 150 into an adjacent joint space and detach the handle 160 from the cutting body, leaving the cutting body within the joint space. This allows the clinician to better visualize the cutting body within the joint space, for example, when the clinician views it directly with the naked eye and / or with fluoroscopic imaging. The biplanar tissue dissociation instrument 150 may additionally or alternatively be connectable to the handle of a powered drive unit, such as a reciprocating hand unit, that is controllable by the clinician. For example, the biplanar tissue dissociation instrument 150 may include a stem with an AO connection that can engage with an electric or pneumatically driven drive unit.

[0106] In the configuration shown in FIG. 16 , the biplanar tissue dissociation instrument 150 defines an opening 162 between the first cutting body 152 and the second cutting body 154 at the proximal end of the cutting bodies. The opening 162 can be located proximal to the intersection of the first cutting body 152 and the second cutting body 154. When configured in this manner, the biplanar tissue dissociation instrument 150 may not have a plane that intersects with an axis defined by the longitudinal extent of the intersection between the first cutting body 152 and the second cutting body 154. Configuring the biplanar tissue dissociation instrument 150 with a proximal opening aligned with the intersection of the first cutting body 152 and the second cutting body 154 can be useful for a variety of reasons. The opening 162 can prevent accumulation of bodily matter in corner pockets of the instrument and aid in cleaning and sterilization of the instrument 150 between uses. Additionally or alternatively, opening 162 may provide a visualization opening for the clinician to verify the position of the instrument during and / or after insertion. For example, the clinician can view the position of the instrument visually and / or under fluoroscopy (optionally removing handle 160 during viewing) to confirm that the instrument is properly inserted in the desired location (e.g., the proximal lateral corner of the metatarsal) and reposition it if not.

[0107] In the illustrated example, the instrument 150 is implemented with a first arm 164 extending from the first cutting body 152 to the handle 160 and a second arm 166 extending from the second cutting body 154 to the handle. The first arm 164 can extend from a proximal end 152B of the first cutting body 152 to a stem 168 to which the handle 160 is attached. The second arm 166 can extend from a proximal end 154B of the second arm 154 to the stem 168 to which the handle 160 is attached. The opening 162 can be defined as the gap between the first arm 164 and the second arm 166. In some examples, the opening 162 can be 50 mm 2 ~150mm 2 etc., 20mm 2 ~250mm 2 Define an area in the range of

[0108] Regardless of whether the clinician performs any steps to move the metatarsals for repositioning or the particular type of instrument(s) the clinician uses to move the bones, the clinician can prepare the opposing bone ends (e.g., the first metatarsal 210 and the medial cuneiform 222) for fusion. Generally, the clinician can prepare each of the bone ends that form the TMT joint to promote fusion of the opposing bone ends across the TMT joint after realignment. Bone preparation may include applying force to the bone end faces using a tissue removal instrument to create a bleeding bone surface and promote subsequent fusion. Examples of bone preparation instruments (also referred to as tissue removal instruments) that can be used include, but are not limited to, saws, rotary burrs, rongeurs, reamers, osteotomies, curettes, etc. Bone preparation instruments can be applied to the end faces of the bones to be prepared to remove cartilage and / or bone. For example, a bone preparation instrument can be applied to the end faces to remove cartilage (e.g., all of the cartilage) down to the subchondral bone. Additionally or alternatively, bone preparation instruments may be applied to cut, fenestrate, fragment, and / or otherwise reshape bone end surfaces and / or to create bleeding bone surfaces to promote fusion. When performing a cutting operation to remove bone ends, the cut can be performed freehand or using a cutting guide with guide surfaces that can be positioned over the portion of the bone to be cut. When a bone preparation guide is used, the cutting instrument can be inserted into the guide surfaces (e.g., between slots defined between two guide surfaces) to guide the cutting instrument for bone removal.

[0109] In some examples, the clinician cuts at least one bone defining the TMT joint 230 (e.g., one or both of the first metatarsal 210 and the medial cuneiform 222). The clinician can cut both bones defining the TMT joint, or can cut only one bone defining the joint and perform a different preparation technique on the other bone. The clinician may realign the metatarsals in one or more planes before preparing both end faces, after preparing one bone end face but not the other, and / or after preparing both bone end faces. Therefore, unless otherwise specified, the order of bone preparation and / or movement is not limited.

[0110] Referring to FIG. 4 , an exemplary technique includes positioning at least one guide surface of a bone preparation guide over the bone to be cut (step 16 in FIG. 4 ) and using the bone preparation guide to guide a bone preparation instrument to prepare the end of the bone (step 18 in FIG. 4 ). Various bone preparation guides can be used to guide the bone preparation instrument. FIGS. 18A and 18B (collectively referred to as “FIG. 18 ”) show an example of a bone preparation guide 250 that can be used as part of a minimally invasive surgical procedure. FIG. 18A is a perspective view of bone preparation guide 250. FIG. 18B is a top view of bone preparation guide 250. In some configurations, as described in more detail below, bone preparation guide 250 may include one or more guide surfaces that are smaller in size than the bone to be prepared using the guide surfaces. The relatively smaller guide surfaces can facilitate insertion of bone preparation guide 250 into relatively small incisions 100 without requiring a larger incision to accommodate a full-sized bone preparation guide that includes guide surfaces that cover the entire bone to be prepared.

[0111] In the illustrated example of FIG. 18 , bone preparation guide 250 includes a body 252 defining at least one guide surface 254 positionable on a lateral side of the bone to be prepared, such as the dorsal or medial side of the bone to be prepared. A clinician can position a bone preparation instrument adjacent to, and optionally in contact with, the guide surface and move the bone preparation instrument relative to the guide surface to make cuts in a plane parallel to the guide surface. For example, a clinician can position a bone preparation instrument in contact with the guide surface and then translate the cutting instrument relative to the guide surface, e.g., toward the bottom side of the bone and / or in a medial or lateral direction. The guide surface can limit movement of the bone preparation instrument to a desired preparation plane.

[0112] In some configurations, bone preparation guide 250 defines a single guide surface. The single guide surface can be positioned on a bone to be prepared, such as metatarsal 210 and / or cuneiform 222. For example, the single guide surface can be positioned on the end of a first bone to be prepared, and after using the guide surface to prepare the end of the first bone, repositioned on the end of a second bone to be prepared. The single guide surface can then be used again to guide a bone preparation instrument to prepare the end of the second bone.

[0113] In other examples, bone preparation guide 250 can include multiple guide surfaces spaced apart from one another. For example, bone preparation guide 250 can include at least one guide surface positionable on a first bone to be prepared and at least one other guide surface positionable on a second bone to be prepared, where the two bones are spaced apart from one another (e.g., by a joint separating the two bones). For example, in the illustrated example of FIG. 18 , bone preparation guide 250 includes first guide surface 254A positionable on the end of a first bone to be prepared (e.g., metatarsal 210) and second guide surface 256A positionable on the end of a second bone to be prepared (e.g., cuneiform 222). Bone preparation guide 250 can include multiple guide surfaces (e.g., multiple slots) positionable on the first bone and / or second bone, where the different guide surfaces are spaced apart from one another along the length of the bones. This gives the clinician the option of choosing how far along the length of the bone to cut or prepare the bone end.

[0114] In some configurations, one or more of the guide surfaces defined by body 252 of bone preparation guide 250 are open on the opposite side (e.g., to prevent a bone preparation instrument from being constrained between two opposing surfaces). In other configurations, as shown in FIG. 18 , bone preparation guide 250 includes opposing guide surfaces spaced apart from a corresponding guide surface to define a slot between the two guide surfaces. In particular, in the illustrated example, bone preparation guide 250 includes first opposing guide surface 254B within second opposing guide surface 256B. First opposing guide surface 254B is disposed adjacent to first guide surface 254A, defining a slot between the two guide surfaces. Similarly, second opposing guide surface 256B is disposed adjacent to second guide surface 256A, defining a slot between the two guide surfaces. Each slot may be sized to allow a bone preparation instrument to be inserted therein and guided to prepare the underlying bone.

[0115] When bone preparation guide 250 includes at least two guide surfaces (e.g., slots) positionable on different bones spaced apart from one another (e.g., metatarsal 210 and cuneiform 222), the guide surfaces may be parallel to one another or angled relative to one another in the transverse plane and / or relative to the end surfaces of the corresponding bones being prepared. Furthermore, each guide surface may extend straight (e.g., parallel) or at an angle from dorsal to plantar (i.e., in the sagittal plane) to guide bone preparation instruments in the direction defined by the guide surface.

[0116] In some configurations of the bone preparation guide 250, one or more guide surfaces 254, 256 of the bone preparation guide are sized according to the expected size of one or more bones to be prepared using the guide surfaces. For example, the bone preparation guide 250 may include one or more guide surfaces that are sized smaller than the size of the bone to be prepared using the guide surfaces. One or more guide surfaces may have a length that covers only a portion of the width of the bone to be prepared using the guide surfaces, rather than spanning the entire width of the bone to be prepared using the guide surfaces.

[0117] For example, body 252 of bone preparation guide 250 can have a length extending from first end 258 to second end 260. The length of body 252 of bone preparation guide 250 can be aligned (e.g., substantially parallel) with the longitudinal extent of one or more guide surfaces defined by the bone preparation guide. In use, the longitudinal extent of bone preparation guide 250 can be positioned over the widthwise extent (e.g., diameter) of one or more bones to be prepared.

[0118] FIG. 19 is a dorsal view of foot 200 illustrating an exemplary configuration and positioning of bone preparation guide 250 relative to one or more bones to be prepared using the guide. FIG. 20 is a radiographic image of exemplary foot 200 illustrating an exemplary configuration and positioning of bone preparation guide 250 relative to one or more bones to be prepared using the guide. As shown in the examples of FIGS. 19 and 20 , each of guide surfaces 254A, 256A defined by the bone preparation guide is sized smaller than the width (e.g., diameter) of the bone to be prepared using the guide surface. In particular, first guide surface 254A is shown as having a length between first end 258 and second end 260 of the bone preparation guide that is shorter than the diameter of first metatarsal bone 210. Second guide surface 256A is shown as having a length between first end 258 and second end 260 of the bone preparation guide that is shorter than the diameter of medial cuneiform bone 222. Where corresponding opposing guide surfaces are configured, each opposing guide surface may have substantially the same length as the guide surface it faces.

[0119] Configuring bone preparation guide 250 with one or more guide surfaces that are shorter in size than the corresponding extent of one or more bones to be prepared using the guide surfaces can minimize the size of incision 100 made through patient's skin 102 to surgically access the bones. In some instances, incision 100 is small enough that the patient's skin 102 cannot be retracted to expose the full width (e.g., diameter) of one or more bones to be prepared through the incision, and / or the skin cannot be retracted sufficiently to insert a bone preparation guide with one or more guide surfaces that span the full width of the one or more bones to be prepared. In these and other instances, using bone preparation guide 250 with one or more guide surfaces that are shorter than the corresponding extent of one or more bones to be prepared using the guide surfaces can be useful in performing a surgical procedure with a reduced incision length.

[0120] The first guide surface 254A (and / or the slot defined by the guide surface) can define a first length 262 ( FIG. 20 ) from the first end 258 to the second end 260. The second guide surface 256A (and / or the slot defined by the guide surface) can define a second length 264 ( FIG. 20 ) from the first end 258 to the second end 260. The first length 262 of the first guide surface 254A (and / or the slot defined by the guide surface) can be sized smaller than the diameter of the first bone (e.g., the first metatarsal 210 and / or the middle cuneiform 222) to be prepared using the guide surface. The second length 264 of the second guide surface 256A (and / or the slot defined by the guide surface) can be sized smaller than the diameter of the second bone (e.g., the medial cuneiform 222 and / or the first metatarsal 210) to be prepared using the guide surface. In some configurations, the length of each of the one or more guide surfaces defined by bone preparation guide 250 will be less than the diameter of the respective bone being prepared using the bone preparation guide.

[0121] In practice, the diameter of the bones of patients undergoing procedures using bone preparation guide 250 may vary from patient to patient. Therefore, when sizing one or more guide surfaces relative to the diameter of one or more bones of a patient, an average bone size determined from a representative population set can be used to establish an average size of one or more bones. The size of one or more guide surfaces can then be determined relative to this average bone size determined from a representative data set.

[0122] In other examples, bone preparation guide 250 (and other instruments and / or implants used during the procedure) can be designed and constructed with patient-specific sizes and / or characteristics (e.g., one or more characteristics configured to interface with patient-specific anatomical attributes). In these examples, the anatomical characteristics (e.g., size and / or shape) of at least some of the surgical patient's foot can be determined before the surgical procedure is performed. The patient's foot can be imaged to provide data indicative of the size and structure of the patient's foot. A computational model representing the patient's foot can then be generated, and bone preparation guide 250 and / or other instruments and / or implants used during the procedure can be sized and / or otherwise configured to fit the particular anatomical characteristics of the surgical patient's foot. The instruments and / or implants can then be manufactured to provide one or more patient-specific components for use during the subsequent surgical procedure.

[0123] In either case, in some embodiments, bone preparation guide 250 includes at least one guide surface sized according to the diameter of the bone to be prepared using the guide surface. For example, bone preparation guide 250 may include first guide surface 254A (and corresponding slot defined thereby) having a length 262 that is shorter than the diameter of first metatarsal bone 210 (the diameter is measured where the guide surface and / or slot is located). Bone preparation guide 250 may additionally or alternatively include second guide surface 256A (and corresponding slot defined thereby) having a length 264 that is shorter than the diameter of medial cuneiform bone 222 (the diameter is measured where the guide surface and / or slot is located). In various examples, guide surface lengths 262, 264 (and corresponding slots defined thereby) may be less than 80% of the diameter of the underlying bone to be prepared using the guide surface, e.g., less than 70% of the diameter, less than 60% of the diameter, or less than 50% of the diameter. For example, the length 262, 264 of the guide surfaces may be in the range of 25% to 75% of the diameter of the underlying bone to be prepared using the guide surfaces, such as in the range of 40% to 60% of the diameter.

[0124] The length 262, 264 of one or more (e.g., each) of the guide surfaces defined by the bone preparation guide 250 (and the corresponding slots defined thereby) may be less than 30 cm, e.g., less than 25 cm, or less than 20 cm. In some examples, the length 262, 264 of one or more (e.g., each) of the guide surfaces defined by the bone preparation guide 250 (and the corresponding slots defined thereby) may be in a range of 8 cm to 25 cm, e.g., 10 cm to 20 cm, 12 cm to 18 cm, or 13 cm to 16 cm. For example, the length 262, 264 of one or more (e.g., each) of the guide surfaces defined by the bone preparation guide 250 (and the corresponding slots defined thereby) may be approximately 15 cm (±10%). When multiple guide surfaces are configured as in the illustrated example, each guide surface (and / or the corresponding slots defined thereby) may be the same length, or one guide surface (and the corresponding slots defined thereby) may be longer in length than another guide surface (and the corresponding slots defined thereby).

[0125] As initially introduced in connection with FIG. 4 , in this exemplary surgical technique, bone preparation guide 250 can be used to guide bone preparation instruments to prepare the ends of a bone (step 18 in FIG. 4 ). When bone preparation guide 250 is configured with one or more guide surfaces that are smaller in size than the size of the bone to be prepared (e.g., smaller than the widthwise extent of the bone in a cross-section), a clinician can manipulate the bone preparation instruments to prepare the bone beyond one or more boundaries defined by the bone preparation guide. For example, a clinician can manipulate the bone preparation instruments to prepare the ends of the bone immediately below the guide surfaces and / or slots defined thereby. A clinician can also manipulate the bone preparation instruments to prepare the ends of the bone outside (e.g., medial and / or lateral) of the guide surfaces and / or slots defined by the guide surfaces.

[0126] In some examples, the clinician may move a bone preparation instrument along the length of the guide surface and / or slot defined thereby to prepare a portion of the bone immediately underlying the guide surface and / or slot defined thereby. The clinician may further tilt the bone preparation instrument to extend the instrument beyond the first end 258 and / or second end 260 of the bone preparation guide 250. Before, during, and / or after advancing the bone preparation instrument along a path (e.g., a linear path) defined by the length of the guide surface and / or the slot defined thereby, the clinician may tilt the bone preparation instrument to guide the instrument to extend beyond one or more lateral boundaries of the bone preparation guide 250. For example, with the bone preparation instrument aligned with the guide surface of the bone preparation guide 250 (e.g., in contact with and within the slot defined by the guide surface), the clinician may change the bone preparation instrument from being approximately perpendicular to the length of the guide surface to an angle that is non-perpendicular to the length of the guide surface. This can cause the proximal end of the bone preparation instrument to shift laterally within the distal end of the bone preparation instrument and medially relative to the vertical position, or vice versa.

[0127] FIG. 21 is a side view of an exemplary configuration of bone preparation guide 250, showing an exemplary bone preparation tool 266 guided at an angle relative to the guide surface and extending beyond the end of the bone preparation guide. In particular, FIG. 21 shows an example of a bone preparation tool 266 in the form of a saw blade. Saw blade 266 has a length extending from a distal end 268 to a proximal end 270. Proximal end 270 can be attached to a handle that can be grasped by a clinician or to a powered hand unit (e.g., an oscillating or reciprocating hand unit operated by air pressure or electricity) that can be operated by the clinician. FIG. 21 shows an example of an oscillating motion pattern 272 that saw blade 266 can travel during operation of the bone preparation tool.

[0128] As shown in the example of FIG. 21 , bone preparation instrument 266 can extend beyond one or both ends 258, 260 of the body defining bone preparation guide 250. For example, bone preparation instrument 266 can include a distal portion 274 that can be angled to extend beyond one or both ends 258, 260 of bone preparation guide 250, and in the illustrated arrangement is shown extending beyond first end 258 of the bone preparation guide. Bone preparation instrument 266 can be guided at an angle relative to a vertical axis extending along the height of the bone preparation instrument (e.g., in the sagittal plane). As a result, distal portion 274 of bone preparation instrument 266 can extend below the end of bone preparation guide 250 to prepare portions of the bone located outside of the bone preparation guide (e.g., portions of the bone located outside the area directly below the guide surface of the bone preparation guide).

[0129] The extent of bone preparation that can be achieved by angledly directing a bone preparation instrument beyond one end 258, 260, or both ends of bone preparation guide 250 can vary based on, for example, the length of the bone preparation instrument, the depth to which the bone preparation instrument is inserted into the bone preparation guide (e.g., along a guide surface and / or through a slot), and / or the angle at which the bone preparation instrument is directed. Bone preparation instrument 266 can be angled at an angle 276 defined between an axis 278 that bisects the length of the bone preparation instrument and an axis 280 that is perpendicular to the length of one or more guide surfaces and / or parallel to the height of the bone preparation instrument. In some examples, angle 276 can be in the range of 10° to 80°, such as 15° to 75°, 20° to 70°, or 30° to 60°. Angle 276 can be measured in either a positive or negative direction relative to axis 280, depending on which direction the clinician is angled the bone preparation instrument.

[0130] In practice, rather than advancing bone preparation instrument 266 at a single angle beyond the end of bone preparation guide 250, the clinician can instead move the bone preparation instrument back and forth through a range of angles that may include or encompass any of the angles described above. In different embodiments, the clinician can advance distal portion 274 of bone preparation instrument 266 beyond one end of bone preparation guide 250 (e.g., the medial end, where the bone preparation instrument prepares a portion of the bone located medially beyond the end of the bone preparation guide, or the lateral end, where the bone preparation instrument prepares a portion of the bone located laterally beyond the end of the bone preparation guide) or beyond both ends of the bone preparation guide.

[0131] During a surgical procedure, a clinician can move bone preparation instrument 266 along the length of the guide surface defined by the bone preparation instrument to prepare a portion of the bone underlying the guide surface. For example, a clinician can cut a portion of the bone underlying the guide surface by guiding a cutting instrument along the length of the guide surface. A clinician can move bone preparation instrument 266 linearly in one direction or in an anterior-posterior direction along the length of the guide surface (e.g., a slot defined by the guide surface). When moving bone preparation instrument 266 along the guide surface, longitudinal axis 278 of the bone preparation instrument can be parallel to axis 280 or angled relative to the axis (e.g., at any of the angles described above).

[0132] Before, during, and / or after moving the bone preparation instrument along the guide surface to prepare the portion of the bone directly below the guide surface (e.g., the cutting slot defined by the guide surface), the clinician can advance the distal portion 274 of the bone preparation instrument beyond one or both ends of the bone preparation guide 250 to the portion of the bone beyond one or both ends. Thus, the clinician can translate the bone preparation instrument 266 and then change the angle of the bone preparation instrument to advance the instrument beyond one or both ends of the bone preparation guide 250, or the clinician can translate the bone preparation instrument at an angle to advance the angled instrument beyond one or both ends of the bone preparation guide.

[0133] 18A and 18B, bone preparation guide 250, which defines a body, includes a first sidewall that defines a first end 258 of the body and a second sidewall that defines a second end 260 of the body. When bone preparation guide 250 is placed through an incision on the dorsal side of one or more bones to be prepared using the guide, first sidewall 258 that defines the first end of the body may be positioned medially and second sidewall 260 that defines the second end of the body may be positioned laterally.

[0134] When bone preparation guide 266 is advanced beyond the first and / or second ends of the body of bone preparation guide 250, a distal portion of the bone preparation guide may protrude below the bottom of first side wall 258 and / or the bottom of second side wall 260. To increase the angle at which bone preparation instrument 266 can be tilted relative to bone preparation guide 250 and / or the area of ​​bone that can be prepared beyond the bone preparation guide, one or both side walls 258, 260 may include one or more notches into which a bone preparation instrument can be inserted at an angle. The one or more notches may be recesses, grooves, and / or other areas where the side walls of the bone preparation guide are absent (e.g., bounded by adjacent areas of the side walls). The bone preparation instrument may be advanced at least partially into one or more notches, e.g., such that at least a portion of the bone preparation guide extends into an area of ​​the bone of the bone preparation guide bounded by the one or more side walls. Providing one or more wall notches in bone preparation guide 250 may allow bone preparation instrument 266 to be guided at a greater angle 276 than would be possible if the bone preparation guide were to contact the upper and / or lower edges of the wall without the one or more notches. As a result, the distal portion of bone preparation instrument 266 may be advanced further medially and / or laterally relative to the medial and / or lateral sides of bone preparation guide 250, allowing for preparation of a greater area of ​​bone beyond the medial and / or lateral sides of the guide than would be possible without the notches.

[0135] 22A-22D (collectively "FIG. 22") are different views of an exemplary configuration of bone preparation guide 250, illustrating exemplary sidewall cutouts that may be utilized. FIG. 22A is an inner side view of bone preparation guide 250. FIG. 22B is a bottom perspective view of bone preparation guide 250. FIG. 22C is a side view of bone preparation guide 250. FIG. 22D is a top perspective view of bone preparation guide 250.

[0136] 22A and 22B, the first side wall 258 can extend from an upper end 282 to a lower end 284. As shown in FIGS. 22C and 22D, the second side wall 260 can extend from an upper end 286 to a lower end 288. The first and / or second side walls 258, 260 can include one or more notches relative to the upper and / or lower ends of the side walls.

[0137] For example, first sidewall 258 can include a first sidewall notch 290 extending from sidewall lower end 284 toward upper end 282. First sidewall notch 290 can align with a guide surface (e.g., a slot) defined by bone preparation guide 250. If multiple guide surfaces are configured, bone preparation guide 250 can include multiple sidewall notches (e.g., each configured as described above with respect to first sidewall notch 290), each notch aligned with a respective guide surface and / or slot.

[0138] Second side wall 260 may additionally or alternatively include second side wall notches 292, shown as a pair of second side wall notches 292A, 292B. Each second side wall notch 292 may extend from the upper end 286 toward the lower end 288 of the side wall. Second side wall notch 292 may align with a guide surface (e.g., a slot) defined by bone preparation guide 250. If multiple guide surfaces are configured, bone preparation guide 250 may include multiple side wall notches (e.g., each configured as described above with respect to second side wall notch 292), each notch aligned with a respective guide surface and / or slot.

[0139] 23A and 23B are cross-sectional views of bone preparation guide 250 illustrating example side wall cutout configurations that can be used with bone preparation guide 250. Figure 23A shows bone preparation instrument 266 aligned in a first angular orientation with the guide surface of bone preparation guide 250 (e.g., inserted into a slot in the bone preparation guide). Figure 23B shows bone preparation instrument 266 aligned in a second angular orientation with the guide surface of bone preparation guide 250, with a distal portion of the bone preparation instrument extending beyond the end (e.g., side wall) of the bone preparation guide.

[0140] As shown, the first sidewall 258 can define a height 294 measured from the top to the bottom of the sidewall. The first sidewall cutout 290 can also define a height 296. In some embodiments, the height 296 of the first sidewall cutout 290 is less than 50%, e.g., less than 40%, less than 30%, less than 25%, or less than 20%, of the overall height 294 of the first sidewall 258. For example, the height 296 of the first sidewall cutout 290 can be in the range of 10% to 50%, e.g., in the range of 20% to 40%, of the overall height 294 of the first sidewall 258. The height 296 of the first sidewall cutout 290 can be large enough to allow the bone preparation instrument 266 to be advanced to a desired position below the sidewall. However, the height 296 of the first side wall notch 290 may be small enough to limit the angle at which the bone preparation instrument 266 can advance under the side wall (e.g., to prevent unintentional cutting in a medial direction).

[0141] 23A and 23B also illustrate that the second sidewall 260 can define a height 298 measured from the top to the bottom of the sidewall. The second sidewall cutout 292 can also define a height 300. In some embodiments, the height 300 of the second sidewall cutout 292 is greater than 25% of the overall height 298 of the second sidewall 260, e.g., greater than 30%, greater than 40%, greater than 50%, greater than 60%, or greater than 75%. For example, the height 300 of the second sidewall cutout 292 can be in the range of 25% to 75%, e.g., 40% to 60%, of the overall height 298 of the second sidewall 260. The height 300 of the second sidewall cutout 300 can be sufficiently large to allow the bone preparation instrument 266 to be advanced to a desired position below the opposing first sidewall 258. However, the height 300 of the second side wall notch 292 may be small enough to limit the angle at which the bone preparation instrument 266 can advance under the opposing side wall (e.g., to prevent unintentional cutting in a medial direction).

[0142] In some examples, the terminal edges of first sidewall 258 and / or second sidewall 260 are angled where the sidewalls meet the corresponding sidewall cutouts. The angling of the terminal edges can aid in angular alignment of the bone preparation instrument 266 relative to the sidewalls in the corresponding cutouts. For example, as shown in FIGS. 23A and 23B , first sidewall 258 can define a lower edge 302 that surrounds first sidewall cutout 290, and the lower edge can be outwardly angled. Similarly, second sidewall 260 can define an upper edge 304 that surrounds second sidewall cutout 292, and the upper edge can be outwardly angled.

[0143] 19 and 20 , bone preparation guide 250 can be positioned on one or more bones to be prepared using the bone preparation guide. When bone preparation guide 250 includes one or more guide surfaces (e.g., slots) that are smaller in size than the corresponding bone to be prepared, the guide surfaces can be positioned at various locations along the bone. In the illustrated configuration, bone preparation guide 250 is positioned such that each guide surface 254A, 256D extends across the lateral-most aspect of the corresponding bone to be prepared (e.g., the lateral-most aspects of first metatarsal 210 and medial cuneiform 222 when viewed from the dorsal to the plantar side). When positioned in this manner, a clinician can guide bone preparation instrument 266 along each guide surface to cut the lateral portion of the bone directly below each guide surface. A clinician can also advance a portion of bone preparation instrument 266 beyond the medial end of bone preparation guide 250 to prepare the medial portion of the bone beyond the medial end of the bone preparation guide.

[0144] In another example, bone preparation guide 250 can be positioned so that each guide surface 254A, 256D extends across the medial-most aspect of the corresponding bone to be prepared (e.g., the medial-most aspect of first metatarsal 210 and medial cuneiform 222 when viewed from the dorsal to the plantar side). When positioned in this manner, the clinician can guide bone preparation instrument 266 along each guide surface to cut the medial portion of the bone directly below each guide surface. The clinician can also advance a portion of bone preparation instrument 266 beyond the lateral end of bone preparation guide 250 to prepare the lateral portion of the bone beyond the medial end of the bone preparation guide.

[0145] In yet another example, bone preparation guide 250 is positioned such that each guide surface 254A, 256D is located between the outermost and innermost portions of the corresponding bone to be prepared. Positioned in this manner, a clinician can guide bone preparation instrument 266 along each guide surface to cut the portion of the bone directly beneath each guide surface. The clinician can also advance portions of bone preparation instrument 266 beyond the outer and inner ends of bone preparation guide 250 to prepare the outer and inner portions of the bone beyond the outer and inner ends, respectively.

[0146] During a surgical procedure, a clinician can insert bone preparation guide 250 through incision 100 in a patient's skin 102 and use the bone preparation guide to prepare the end of an underlying bone, for example, by using the bone preparation guide to cut the end of the bone. In some applications, a clinician can secure bone preparation guide 250 to one or more bones to enable stable placement of the bone preparation guide during subsequent use. Accordingly, bone preparation guide 250 can include one or more fixation holes into which one or more corresponding pins can be inserted to secure the bone preparation guide to the underlying bone.

[0147] 22A and 22C, bone preparation guide 250 is shown to include a first arm 310 extending outward from a body 252 of the bone preparation guide and a second arm 312 extending outward from the body of the bone preparation guide. First arm 310 can define a first fixation hole 314. Second arm 312 can define a second fixation hole 316. A clinician can insert a first pin into first fixation hole 314 to secure the bone preparation guide to a first bone (e.g., first metatarsal 210) and a second pin into second fixation hole 316 to secure the bone preparation guide to a second bone (e.g., medial cuneiform 222).

[0148] To minimize the length of the incision 100 made in the patient's skin 102, the pins inserted into the first and second fixation holes 314, 316 may be inserted percutaneously. In other words, the incision 100 may not extend far enough along the length of the first metatarsal 210 and / or second metatarsal 222 to expose the underlying bone above the first fixation hole 314 and second fixation hole 316. Rather, the first fixation hole 314 and second fixation hole 316 may be positioned above the corresponding bone at a location outside the incision (e.g., such that the patient's skin is positioned between the bottom of each fixation hole and the underlying bone). A clinician can advance a fixation pin through the respective fixation hole, penetrating the patient's skin 102, and down to the underlying bone. FIG. 24 is a perspective view of an example foot showing a first fixation pin 318 percutaneously inserted through first fixation hole 314 into the lower metatarsal bone and a second fixation pin 320 percutaneously inserted through second fixation hole 316 into the lower cuneiform bone.

[0149] 22A and 22C , first arm 310 of bone preparation guide 250 may include a first pin tower 322 defining a first fixation hole 314. Additionally or alternatively, bone preparation guide 250 may include a second pin tower 324 defining a second fixation hole 316. Each pin tower may include a bottom surface 326, 328 that is positioned above the underlying skin and / or bone during use. In embodiments, when bone preparation guide 250 is pinned to the underlying bone, bottom surface 326, 328 of each pin tower may contact the underlying skin. In other embodiments, when bone preparation guide 250 is pinned to the underlying bone, bottom surface 326, 328 of each pin tower is elevated above the patient's skin. Elevating the pin towers of bone preparation guide 250 above the skin during use can prevent pressure damage to the skin and / or soft tissue (e.g., tendons).

[0150] For example, bone preparation guide 250 can define a bone contacting surface 288, which may be the bottom surface of the guide that is positioned to contact one or more bones through incision 100 during use. Bottom surface 326, 328 of each pin tower may be elevated above bone contacting surface 288 by a distance 332. Distance 332 may be large enough to allow bottom surface 326, 328 of each pin tower to be positioned above the patient's skin when bone preparation guide 250 is inserted through the incision and bone contacting surface 288 is in contact with one or more bones. In some examples, distance 332 is at least 5 cm, e.g., at least 10 mm, at least 15 mm, at least 20 mm, at least 25 mm, at least 35 mm, or at least 45 mm. For example, distance 332 may be within a range of 15 mm to 75 mm, such as 20 mm to 60 mm.

[0151] In addition to, or instead of, offsetting the pin towers from the surface of the skin, the arms of the bone preparation guide 250 may be long enough to position pins inserted through the arms of the bone preparation guide offset from the incision 100 on the patient's skin. If each pin tower 322, 324 is positioned too close to the edge of the incision 100, the pins inserted through the pin towers may cause additional tissue damage, potentially impeding the patient's healing and recovery. Therefore, the pin towers 322, 324 may be long enough to position the corresponding pins inserted through the pin towers away from the edge of the incision.

[0152] For example, the first arm 310 and / or the second arm 312 of the bone preparation guide 250 are sized to position the first fixation pin 318 and the second fixation pin 320, respectively, at least 15 mm away from the outer sidewall surface of the body 252 of the bone preparation guide 250, e.g., at least 25 mm, at least 30 mm, at least 35 mm, at least 40 mm, at least 45 mm, or at least 50 mm away.

[0153] While the bone preparation guide 250 in the illustrated example of Figure 22 is shown as defining a single fixation hole (314, 316) associated with each arm on either side of the guide, in other configurations, the bone preparation guide can include multiple fixation holes defined by each arm and / or additional arms each defining one or more fixation holes. Figures 25A and 25B are perspective views showing different configurations of bone preparation guide 250 with raised fixation holes.

[0154] 25A shows an exemplary configuration of bone preparation guide 250, in which first arm 310 and second arm 312 each include a distal-proximal array of fixation holes, one or more of which can be used by a clinician to insert a fixation pin. The distal-proximal arrangement of fixation holes is useful to allow a clinician to insert a fixation pin at a desired location, which may be as far from the edge of the incision as possible, yet still intersect the desired underlying bone.

[0155] 25B illustrates an exemplary configuration of bone preparation guide 250, in which first arm 310 and second arm 312 each include a medial-lateral array of multiple fixation holes, one or more of which can be used by a clinician to insert a fixation pin. The medial and lateral arrangement of fixation holes may be useful for allowing a clinician to insert a fixation pin at a desired location while avoiding certain soft tissues, such as inserting a pin into the target underlying bone while avoiding the EHL tendon. Although illustrated separately, bone preparation guide 250 may include combined distal-proximal and medial-lateral spaced fixation hole arrangements.

[0156] In some examples, one or more fixation holes defined by bone preparation guide 250 are parallel to one another, allowing fixation pins to be inserted parallel to the fixation holes. Bone preparation guide 250 may additionally or alternatively include one or more angled fixation openings. For example, with reference to FIG. 18B , bone preparation guide 250 may include one or more angled fixation holes 330. As shown, angled fixation holes 330 extend through body 252 of bone preparation guide 250. Thus, when bone preparation guide 250 is inserted into an incision in the patient's skin, fixation pins inserted through angled fixation holes 330 may also be inserted through the incision rather than percutaneously. In other configurations, angled fixation holes 330 may extend from body 252 of bone preparation guide 250 and be inserted percutaneously.

[0157] In use, a clinician inserts two parallel pins into the fixation holes 314, 316 and, if desired, can insert one or more angled pins into one or more of the angled fixation holes 330. This combination of parallel pins and angled pins prevents the bone preparation guide 250 from dislodging from the underlying bone being worked on. When the clinician is finished using the bone preparation guide, the angled pins are removed, leaving the two parallel pins inserted into the underlying bone. The bone preparation guide 250 can be removed by sliding or moving it upward off the parallel pins, and in some instances, a compressor (e.g., a compressor-distractor) is then inserted over the pins. The compressor is then used to apply force to the pins, compressing the prepared ends of the two opposing bones together.

[0158] With further reference to FIG. 18 , bone preparation guide 250 may include or be used with a spacer 340 extending downwardly from body 252. Spacer 340 can be configured to be placed in a joint (e.g., within a TMT joint). In some configurations, spacer 340 is selectively engageable with and removable from the body of the bone preparation guide. The spacer can have a first portion configured to extend into the joint cavity and a second portion engageable with bone preparation guide body 252. For example, in the illustrated configuration, spacer 340 can be received within openings 342 between the set of guide surfaces. Spacer 340 is useful for positioning body 252 in a desired position relative to the joint (e.g., TMT joint 230) and for properly positioning the guide relative to the bone to be cut. The distance between spacer 340 and each guide surface can define the length of tissue removal (e.g., bone or cartilage to be cut) from the edge of the underlying bone.

[0159] If spacer 340 is configured, after making incision 100, the spacer can be inserted into TMT joint 230. After inserting spacer 340 into the TMT joint, opening 342 in bone preparation guide 250 can be aligned with the spacer, and the bone preparation guide can be placed on the spacer, thereby positioning one or more guide surfaces defined by the bone preparation guide over the ends of one or more bones to be prepared. In other examples, spacer 340 can be engaged with bone preparation guide 250 before attachment to TMT joint 230, and then the spacer can be inserted into the joint as an assembly connected to the bone preparation guide. In yet other examples, spacer 340 can be integrally and permanently attached to bone preparation guide 250.

[0160] In addition to or instead of using a spacer, systems and techniques according to the present disclosure can utilize a second spacer 344, which may or may not function as a fulcrum. The spacer 344 may be positionable between the proximal base of the metatarsal being moved (e.g., the first metatarsal 210) and the adjacent metatarsal (e.g., the second metatarsal 212). The spacer 344 can establish and / or maintain space between the adjacent bones being moved and prevent and / or correct lateral movement or base shifting of the bones caused by rotation and / or pivoting.

[0161] In use, spacer 344 may be a stand-alone device, may be coupled to spacer 340 to define a biplanar device, and / or may be coupled to bone preparation guide body 252 to define a composite device. When spacer 344 is coupled to spacer 340 and / or bone preparation guide body 252, the combination may serve to provide a unitary structure (e.g., before or after assembly) that can be positioned between two adjacent intersecting joint spaces (the first joint space between the opposing ends of the metatarsal and cuneiform bones, and the intermetatarsal space between adjacent metatarsals).

[0162] In use, the spacer 340 can be positioned at any suitable location (e.g., anteriorly) across the joint cavity. In some examples, the spacer 340 spans the entire width of the joint cavity between the first metatarsal 210 and the medial cuneiform 222, for example, from the medial-most edge of the joint cavity to the lateral-most edge of the joint cavity. In other configurations, the spacer 340 spans less than the entire width of the joint cavity, for example, no more than the lateral-most half of the joint cavity or no more than the lateral-most quarter of the joint cavity.

[0163] In some configurations, the spacer 340 has a sufficient length (dorsal to plantar) such that the spacer body protrudes dorsally above the joint cavity when inserted into the joint cavity. In other configurations, the spacer 340 can be relatively small such that the top end of the spacer body is flush with or recessed against the dorsal-most surface of the first metatarsal 210 and / or medial cuneiform 222 of the joint when inserted into the joint cavity. This latter configuration can help prevent the spacer 340 from visually obstructing the joint cavity.

[0164] Bone preparation guide body 252 can be secured to spacer 340 to define an integrated instrument. The placement of spacer 340 in the joint space can determine the placement of bone preparation guide body 252 coupled thereto, and correspondingly, the guidance of the bone preparation instrument facilitated by the bone preparation guide.

[0165] The spacer body 344 can be inserted between the first metatarsal 210 and the second metatarsal 212 (or other adjacent bones if metatarsal realignment is not being performed) simultaneously with inserting the spacer 340 into the TMT joint space between the first metatarsal 210 and the medial cuneiform 222. For example, a clinician can insert the spacer 340 into the joint space between the first metatarsal 210 and the medial cuneiform 222 and simultaneously insert the spacer 344 into the joint space between the first metatarsal 210 and the second metatarsal 212. The bone preparation guide body 252 secured to the spacer 340 and / or spacer 344 can be positioned dorsally of the first metatarsal 210 and / or medial cuneiform 222 simultaneously with inserting the spacer 340 and / or spacer 344 into their respective joint spaces.

[0166] The spacer 344 can define a length configured to be inserted into the intermetatarsal space, a thickness configured to extend between the first metatarsal 210 and the second metatarsal 212, and a width configured to extend proximally to distally across the foot. The thickness of the spacer 344 can be substantially constant along its entire length or can taper toward its tip to facilitate insertion of the spacer 344 into the space between adjacent metatarsals. Generally, the spacer 344 can have a width that extends partially into the intermetatarsal space between the first metatarsal 210 and the second metatarsal 212. When inserted into the intermetatarsal space, the spacer 344 can extend from the base (e.g., proximal-most end) of the first metatarsal 210 toward the distal-most end of the first metatarsal by less than half the metatarsal length, e.g., less than one-quarter the metatarsal length, less than 10% of the metatarsal length, or less than 5% of the metatarsal length.

[0167] In some examples, bone preparation guide 250 includes a handle 350. Handle 350 is operatively connected to and can extend from bone preparation guide body 252. By directly connecting the handle to bone preparation guide body 252, a clinician can easily manipulate the position of one or more guide surfaces defined by bone preparation guide body 252.

[0168] Spacer 344 can be operably coupled to spacer 340. In some configurations, spacer 344 is fixedly coupled to spacer 340, forming a permanent, immovable connection between the two spacers. However, in other examples, spacer 344 may be movably coupled to spacer 340 such that spacer 344 is rotatable relative to spacer 340. Configuring spacer 344 to be rotatable relative to spacer 340 can be useful to allow a clinician to change or manipulate the angle between spacer 344 and spacer 340 to accommodate various patient anatomies and conditions that may be encountered during a particular surgical procedure.

[0169] In some embodiments, the spacer 344 is rotatably coupled to the spacer 340 within a limited range of rotation. That is, the spacer 344 is mechanically coupled to the spacer 340 to provide a unitary instrument, but is rotatable relative to the spacer body within a constrained or limited range of rotation. Limiting the range of rotation between the spacer 344 and the spacer 340 can be beneficial to allow some relative movement between the spacer 344 and the spacer 340, while preventing too much relative rotation from causing the spacer 344 to become overly flexible or difficult for the clinician to manipulate during the surgical procedure.

[0170] In use, when the bone preparation guide body is inserted into the incision, soft tissue may tend to impinge on and / or contact the side walls of the bone preparation guide body 252. This may be particularly true when using smaller incisions 100 that limit the extent to which the patient's skin can be pulled back from where the bone preparation guide body 252 is inserted. In some configurations, the bone preparation guide may include one or more tissue deflection features to assist in positioning the soft tissue (e.g., moving the soft tissue to prevent it from being cut by the bone preparation instrument 266).

[0171] 26A and 26B are back and side views, respectively, of a bone preparation guide 250 illustrating an exemplary tissue deflection feature. As shown in this example, the spacer 340 can extend from a proximal end 352 to a distal end 354, for example, the proximal portion of the spacer includes an outwardly extending protrusion 356. The protrusion 356 can define a tissue retraction space 358 into which soft tissue can be positioned. For example, during use, the bone preparation guide body 252 can be inserted through the patient's skin into the incision 100, and the soft tissue is forced dorsally along the inner edge of the spacer 340 and up into the tissue retraction space 358. Soft tissue that may be positioned within the tissue retraction space 358 includes skin and tendons, such as the EHL tendon. Configuring the bone preparation guide 250 with such a tissue retraction space can help separate soft tissue, such as the EHL tendon, from a cutting path passed by a cutting instrument guided by one or more guide surfaces of the bone preparation guide. In other configurations, the bone preparation guide 250 may not include a protrusion 356 extending beyond an adjacent upwardly extending sidewall (e.g., the proximal sidewall). In some applications, such as when using a configuration of the bone preparation guide 250 without an outwardly projecting protrusion 356, the clinician may position the EHL tendon outside of the bone preparation guide 250 (e.g., pressing against the sidewall of the guide) to offset the EHL tendon from a cutting instrument guided through the guide.

[0172] In some configurations, spacer 340 includes a ramp 360 that tapers the width of the spacer over at least a portion of its length. Ramp 360 can aid in inserting spacer 340 into the TMT joint space and / or help guide displacing soft tissue during insertion of the spacer into tissue retraction space 358. While protrusion 356 and ramp 360 are shown as being located on the inside of bone preparation guide 250 (e.g., when the guide is in use), they can additionally or alternatively be located on the outside or another side of the guide.

[0173] In some configurations, bone preparation guide body 252 defines a bottom surface 288, a sidewall 362 (e.g., a distal sidewall), and an angled surface 364 connecting bottom surface 288 and sidewall 362. So configured, angled surface 364 can deflect soft tissue during insertion of bone preparation guide body 252 into incision 100 and / or during use of the bone preparation guide body. Angled surface 364 is shown as extending at an angle of approximately 45 degrees between bottom surface 288 and sidewall 362, but may extend at other angles.

[0174] If one or more bone ends are severed, the physician may then remove the severed bone portions from the joint cavity. Figures 27A-27C show different views of an example of a hooked osteotome that can be inserted into a TMT joint and used to extract severed bone fragments from the joint. As shown, the example osteotome 370 includes a distal end 372, which can be sharpened and define a tip that can be inserted into the TMT joint cavity. The osteotome may include a protrusion 374 extending outward and / or upward (e.g., bottomward) from the plane of the osteotome. In use, the protrusion 374 can define a shelf 376 that can be inserted under a bone slice in the TMT joint cavity and can help lift the bone slide out of the joint as the osteotome 370 is withdrawn from the joint cavity.

[0175] 28A-28C show different views of an example bone fragment grasping instrument 380 that can be inserted into a TMT joint and used to extract a severed bone fragment from the joint. As shown, the example instrument includes a pair of opposing tines 382 that can articulate apart from one another and close to grasp a bone slide between the tines. A spring or other biasing member can bias the opposing tines 382 apart, with the biasing force being overcome by manual pressure by the clinician.

[0176] With further reference to FIG. 4 , before or after preparing one or both ends of the first metatarsal 210 and the medial cuneiform 222, the clinician can move the metatarsal in at least one plane (step 20 in FIG. 4 ). For example, the clinician can move the metatarsal 210 at least in the transverse plane to close the intermetatarsal angle between the metatarsal and an adjacent bone (e.g., the second metatarsal) and / or in the frontal plane (e.g., positioning the sesamoid bone approximately in the center of the metatarsal). In some instances, the clinician moves bone segments in multiple planes, such as the transverse plane, the frontal plane, and / or the sagittal plane. The clinician may or may not use a bone positioning device to facilitate the movement of the bone segments.

[0177] FIG. 29 shows a side perspective view of an example of a bone positioner 400 (also referred to as a bone positioning device) that can be used to move a metatarsal relative to an adjacent bone. In some embodiments, the bone positioning device includes a metatarsal engagement member, a tip, and a mechanism for moving the metatarsal engagement member and tip relative to one another in one or more planes. For example, the mechanism can move the metatarsal engagement member and tip toward one another (e.g., move the metatarsal engagement member toward the tip, move the tip toward the metatarsal engagement member, or move both simultaneously). The bone positioning device may also include an actuator for actuating the mechanism. When the mechanism is engaged, the metatarsal engaged with the metatarsal engagement member can move to modify the alignment in at least one plane relative to a second bone in contact with the tip.

[0178] In the embodiment of FIG. 29 , bone positioning device 400 includes a body member 402, a shaft 404, a metatarsal engagement member 406 connected to the shaft, and a tip 408 connected to the body member. Generally, body member 402 can be sized and shaped to allow passage of an anatomical structure or other instrument (such as a pin or guide) while worn on a patient. In the embodiment of FIG. 29 , body member 402 includes a generally C-shape. In some embodiments, the body is sized and configured to engage a bone in a human foot. Additionally, while bone positioning device 400 is shown as being comprised of two components, body member 402 and shaft 404, the guide can also be manufactured from more components (e.g., three, four, or more) that are coupled together to form the guide.

[0179] The shaft 404 can be movably connected to the body member 402. In some embodiments, the shaft 404 includes threads 410 that engage the body member 402, such that rotation of the shaft moves the shaft relative to the body member. In other embodiments, the shaft can slide within the body member and can be secured in a desired position with a set screw. In still other embodiments, the shaft can be moved relative to the body by a ratchet mechanism or other mechanism that rotates and / or linearly moves the metatarsal engagement member 406 relative to the tip 408. In the illustrated embodiment, the shaft moves along an axis that intersects the tip 508. In other embodiments, the shaft 404 and / or metatarsal engagement member 406 are offset from the tip 408.

[0180] In some examples, the metatarsal engagement member 406 can be configured (e.g., sized and / or shaped) to be placed in contact with the outer surface of the patient's metatarsal 210 and / or skin 102. For example, force applied to and / or through the metatarsal engagement member 406 can be directed through the skin to the underlying metatarsal 210 rather than being applied directly to the metatarsal. As a result, the metatarsal engagement member 406 can be positioned against the patient's skin without an incision, facilitating direct contact between the metatarsal engagement member 406 and the metatarsal 210.

[0181] The tip 408 may be useful when contacting a bone, such as a bone different from the bone being moved by the bone positioning device 400. For example, if the metatarsal engagement member 406 is contacting the skin over the first metatarsal 210, the tip may be contacting the lateral side of another metatarsal (e.g., the second, third, fourth, or fifth metatarsal) and / or the lateral side of the skin over such metatarsal. In some instances, a small stab incision may be made between another metatarsal and the lateral adjacent metatarsal. For example, a stab incision may be made in the intermetatarsal space between the second metatarsal 212 and the third metatarsal 214. The tip 408 of the bone positioning device 400 may be inserted through the incision and positioned with the tip in contact with the lateral side of the second metatarsal.

[0182] In different configurations, tip 408 may be straight or tapered to facilitate percutaneous insertion and contact with bone. The tip may also include a textured surface, such as serrated, roughened, cross-hatched, knurled, etc., to reduce slippage between the tip and bone. In the illustrated embodiment, tip 408 further includes a stop 412. Depth stop 412 may limit insertion depth into the intermetatarsal space (e.g., by contacting the dorsal surface of the metatarsal bone where tip 408 is intended to be placed).

[0183] As shown in FIG. 29 , the bone positioning device 400 may also include an actuator (e.g., a knob or handle) 400 for actuating a mechanism associated with the shaft, in this embodiment. In the illustrated embodiment, the actuator may be useful for allowing a user to rotate the shaft relative to the body member 402. The actuator 414, shaft 404, and / or metatarsal engagement member 406 may include a cannula 416 extending therethrough, allowing a fixation wire (such as a K-wire) to be passed through these components and placed in contact with or through the bone engaged by the metatarsal engagement member. For example, a fixation wire may be placed in the bone engaging the metatarsal engagement member 406 to fix the position of the metatarsal engagement member relative to the bone. In another example, a fixation wire may be placed through the bone in contact with the metatarsal engagement member and into the adjacent bone to maintain the bone position of the bone in contact with the metatarsal engagement member and the adjacent bone.

[0184] Embodiments of the bone positioner may include any suitable material. In certain embodiments, the bone positioner is fabricated at least in part from a radiolucent material, such as a thermoplastic or carbon fiber material, that is relatively transparent to x-rays and other forms of radiation. Such materials are useful for ensuring that the bone positioner, when positioned over the bone, does not interfere with visualization of the bone using an imaging device.

[0185] Regardless of whether the clinician utilizes a bone positioning device or such a guide configuration, the clinician can move the metatarsal 210 in one or more planes. The clinician may move the metatarsal to correct an anatomical misalignment of the metatarsal. For example, the clinician may move the metatarsal so that the metatarsal is anatomically aligned in one or more planes (e.g., two planes, three planes).

[0186] In some instances, the clinician manually moves the first metatarsal 210 in addition to moving the metatarsal with the force applied by the bone positioner 400. For example, the clinician may grasp a pin inserted into the first metatarsal and / or grasp the metatarsal with a tool (e.g., forceps) to manipulate the position of the metatarsal to a desired position. In some applications, the bone positioner 40 may move the first metatarsal 210 in the transverse plane to apply a force to close the IMA with an adjacent metatarsal. However, the amount of frontal plane rotation and / or sagittal plane movement achieved by the bone positioner 400 through the patient's skin may be limited. Therefore, the clinician can manually move the first metatarsal 210 (e.g., by grasping a pin inserted into the metatarsal and at least partially protruding from the metatarsal) to rotate the metatarsal in the frontal plane and / or move the metatarsal in the sagittal plane.

[0187] Generally, anatomically aligned means that the relative angle between the long axis of the first metatarsal and the long axis of the second metatarsal is about 10 degrees or less in the transverse or sagittal plane. In certain embodiments, anatomical malalignment may be corrected in both the transverse and frontal planes. In the transverse plane, the normal intermetatarsal angle (IMA) between the first and second metatarsals is less than about 9 degrees. An IMA of about 9 degrees to about 13 degrees is considered mild misalignment between the first and second metatarsals. An IMA of more than about 16 degrees is considered severe misalignment between the first and second metatarsals. In some embodiments, by placing the first metatarsal at a different angle relative to the second metatarsal, the first metatarsal is moved to reduce the IMA from greater than 10 degrees to about 10 degrees or less (e.g., about 1-5 degrees IMA), down to a negative angle (about -5 degrees) or until it interferes with the second metatarsal.

[0188] In the frontal plane, a normal first metatarsal is positioned so that its crest prominence is approximately perpendicular to the ground and / or the sesamoid bone is approximately parallel to the ground and positioned below the metatarsal. This position can be defined as a 0-degree metatarsal rotation. When the first metatarsal is misaligned, the metatarsal rotates axially from about 4 degrees to about 30 degrees or more. In some embodiments, methods according to the present invention can anatomically align the metatarsal by rotating the metatarsal relative to the medial cuneiform, thereby reducing the metatarsal rotation from about 4 degrees or more to less than 4 degrees (e.g., from about 0 degrees to 2 degrees).

[0189] In some applications, regardless of whether the clinician performs the particular bone realignment technique described above, the clinician may compress the prepared bone end surfaces (e.g., first metatarsal 210, medial cuneiform 222) together. For example, the technique of FIG. 4 optionally includes compressing the prepared end surfaces of the bone portions together before fixation (step 22 of FIG. 4). The clinician may compress the end surfaces together using manual pressure and / or a compression device physically attached to both the first and second bone portions. For example, the clinician may attach a compression device to the metatarsal 210 using one or more fixation pins and a compression device to the medial cuneiform 222 using one or more fixation pins. In some examples, the clinician may raise the bone preparation guide 250 from two or more pins extending parallel to one another, at least one of which is inserted into the metatarsal 210 and at least one of which is inserted into the medial cuneiform 222. The physician can then reattach the compressor onto the parallel pin.

[0190] 30 is a perspective view of foot 200 illustrating an exemplary compression tool 450 that can be used to compress together the prepared end surfaces of first metatarsal 210 and medial cuneiform 222. Compression tool 450 may be attached using at least one fixation pin inserted into first metatarsal 210 through an arm of the compression tool and at least one fixation pin inserted into medial cuneiform 222 through an arm of the compression tool.

[0191] In the technique of FIG. 4 , in addition to or instead of compressing the prepared bone ends together, it may be necessary to temporarily or provisionally fix the displaced position of the first metatarsal 210 relative to the medial cuneiform 220 before attaching a permanent fixation device (step 24 of FIG. 4 ). In some embodiments, in addition to or instead of compressing the ends with a compression tool, the clinician inserts one or more fixation pins through the first metatarsal 210 and into adjacent bones (e.g., the second metatarsal 212, the medial cuneiform 222), such as through the ends of the first metatarsal 210 and the medial cuneiform 220. The fixation pins can be K-wires, olive wires (e.g., pins with enlarged cross-sections), or other fixation pin configurations. A fixation pin cross joint 230 between the first metatarsal 210 and the medial cuneiform 220 can serve to provisionally fixate and / or compress the ends of the two bone portions prior to placement of a permanent fixation device (and subsequent fusion of the bone surfaces). In use, after the permanent fixation device has been attached, one or more fixation pins can be removed from the end faces of the two bone portions and across the junction between the bone portions.

[0192] Regardless of whether the clinician provisionally fixates the translated position of the first metatarsal 210 relative to the medial cuneiform 220, the technique of FIG. 4 may include attaching one or more permanent fixation devices to the first metatarsal 210 and the medial cuneiform 220 across the joint 230 (step 26 of FIG. 4). The one or more permanent fixation devices may maintain the translated position of the first metatarsal 210 relative to the medial cuneiform 220 and allow the end faces of the bone portions to fuse together through the subsequent healing process.

[0193] Any one or more bone fixation devices can be used, including, but not limited to, bone screws (e.g., compression bone screws), bone plates, bone staples, external fixation devices, pins (e.g., intramedullary implants), and / or combinations thereof. The bone fixation device can be secured to the metatarsal 210 on one side, spanning the TMT joint 230, and secured to the proximal medial cuneiform 222 on the other side. Examples of implants that can be used are described in U.S. Provisional Patent Application No. 63 / 406,422, filed September 14, 2022, U.S. Provisional Patent Application No. 63 / 444,225, filed February 8, 2023, and U.S. Provisional Patent Application No. 63 / 519,039, filed August 11, 2023, the entire contents of each of which are incorporated herein by reference.

[0194] In one example, two bone implants can be placed across the TMT joint to achieve biplanar fixation. For example, a first implant (e.g., a staple) can be placed dorsally of the metatarsal and medial cuneiform. A second implant may be placed medially / dorsomedially of the metatarsal and medial cuneiform.

[0195] Various examples have been described. These and other examples are within the scope of the following claims.

Claims

1. 1. A bone preparation guide for minimally invasive metatarsal orthopedic surgery, comprising: a body including a first sidewall, a second sidewall, and at least one guide surface having a length extending from the first sidewall to the second sidewall, the at least one guide surface configured to guide a bone preparation instrument; The bone preparation guide, wherein one or both of the first side wall and the second side wall have a cutout configured to receive the bone preparation instrument extending angularly through the cutout.

2. The bone preparation guide of claim 1 , wherein the at least one guide surface has a length that is shorter than a length of a metatarsal and / or cuneiform bone to be cut using the at least one guide surface.

3. A bone preparation guide according to claim 1 or 2, wherein the length of the at least one guide surface is less than 25 cm, such as between 10 cm and 20 cm, or between 12 cm and 18 cm.

4. the first sidewall extends from an upper end to a lower end; the second sidewall extends from the upper end to the lower end; the first side wall includes a first side wall cutout portion extending from the lower end toward the upper end; the second side wall includes a second side wall cutout extending from the upper end toward the lower end; 4. The bone preparation guide of claim 1, wherein the first sidewall cutout is configured to accommodate a distal portion of the bone preparation tool therein and the second sidewall cutout is configured to accommodate a proximal portion of the preparation tool.

5. the first sidewall defines a height from the top end to the bottom end, and the first sidewall cutout is less than 25% of the height of the first sidewall; The bone preparation guide of claim 4 , wherein the second side wall defines a height from the upper end to the lower end, and the second side wall cutout is greater than 50% of the height of the second side wall.

6. the first sidewall defines a lower edge surrounding the first sidewall cutout, the lower edge being outwardly slanted; The bone preparation guide of claim 4 or 5, wherein the second side wall defines an upper end that surrounds the second side wall cutout, the upper end being outwardly sloped.

7. a first arm extending outwardly from the body, the first arm defining a first fastening hole; a second arm extending outwardly from the body, the second arm defining a second fastening hole; The bone preparation guide of any one of claims 1 to 6, further comprising:

8. the first arm positions the first fixing hole at least 10 mm from the body; The bone preparation guide of claim 7 , wherein the second arm positions the second fixation hole at least 10 mm from the body.

9. the body of the bone preparation guide defines a bone contacting surface; the first arm has a first pin tower defining the first fixation hole; the second arm has a second pin tower defining the second fixation hole; 9. The bone preparation guide of claim 7, wherein the bottom surface of the first pin tower and the bottom surface of the second pin tower are each at least 25 mm higher than the bone contact surface of the body.

10. the first and second fixing holes are configured to receive first and second fixing pins extending parallel to each other; The bone preparation guide of claim 9 , wherein the body defines a third fixation hole configured to receive a third fixation pin extending at an angle relative to the first and second fixation pins.

11. The bone preparation guide of any one of claims 1 to 10, wherein the at least one guide surface comprises a first guide surface and a second guide surface separated from the first guide surface.

12. The body includes: a first opposing guide surface spaced apart from the first guide surface to define a first slot therebetween; a second opposing guide surface spaced apart from the second guide surface and defining a second slot therebetween; The bone preparation guide of claim 11 , further comprising:

13. A preparation guide according to any one of claims 1 to 12; an incision guide defining an incision guide surface for guiding an incision in the patient's skin; Including, the system.

14. 14. The system of claim 13, wherein the incision guide defines a pin-receiving slot configured to receive a pin percutaneously inserted into the tarsometatarsal joint such that the pin extends through the pin-receiving slot.

15. The system of claim 13 , wherein the length of the incision guide surface is less than 3 mm.

16. 1. A biplanar tissue dissection instrument comprising: a first cutting body coupled at an angle to a second cutting body, the first cutting body and the second cutting body configured to be inserted into a proximal-lateral corner of a metatarsal bone to dissect soft tissue at the proximal-lateral corner of the metatarsal bone.

17. the first cutting body has a length extending from a proximal end to a distal end; the second cutting body has a length extending from a proximal end to a distal end; 17. The biplanar tissue dissection instrument of claim 16, wherein the distal end of the first cutting body and the distal end of the second cutting body are each inwardly angled to define a groove therebetween.

18. the first cut body has a width extending from an outer edge to an intersection with the second cut body, and the outer edge of the first cut body has an obtuse angle; the second cut body has a width extending from an outer edge to an intersection with the first cut body, and the outer edge of the second cut body has an obtuse angle; the distal end of the first cutting body is sharpened along at least a portion of the length of the distal end of the first cutting body; 18. The biplanar tissue dissection instrument of claim 17, wherein the distal end of the second cutting body is sharpened along at least a portion of the length of the distal end of the second cutting body.

19. the first cutting body has a length extending from a proximal end to a distal end; the second cutting body has a length extending from a proximal end to a distal end; the biplanar tissue dissection instrument further comprises a handle connected to the proximal end of the first cutting body and the proximal end of the second cutting body; 19. The biplanar tissue dissection instrument of any one of claims 16-18, wherein the biplanar tissue dissection instrument defines openings at the proximal end of the first cutting body and the proximal end of the second cutting body, where the first cutting body joins to the second cutting body to define the angle.

20. 20. The biplanar tissue dissection instrument of claim 19, wherein the biplanar tissue dissection instrument comprises a first arm extending from the first cutting body to the handle and a second arm extending from the second cutting body to the handle, the opening being defined between the first arm and the second arm.

21. positioning at least one guide surface of a bone preparation guide on a metatarsal and / or cuneiform bone of a patient to be prepared, wherein the at least one guide surface has a length extending from a first end to a second end, the length of the at least one guide surface being shorter than a diameter of the metatarsal and / or cuneiform bone to be prepared; guiding a bone preparation instrument along the at least one guide surface to prepare the end of the metatarsal and / or the end of the cuneiform bone, wherein guiding the bone preparation instrument along the at least one guide surface comprises translating the bone preparation instrument along the length of the at least one guide surface and tilting the bone preparation instrument beyond one or both of the first end and the second end of the at least one guide surface to prepare the end of the metatarsal and / or the end of the cuneiform bone beyond one or both of the first end and the second end of the at least one guide surface; moving the metatarsal bone relative to the cuneiform bone; Fixing the displaced position of the metatarsal; A method for performing minimally invasive metatarsal correction surgery, comprising:

22. 22. The method of claim 21, wherein the length of the at least one guide surface is less than 80% of the diameter of the metatarsal and / or cuneiform bone to be prepared, such as less than 70% of the diameter, less than 60% of the diameter, or less than 50% of the diameter.

23. The method according to any of claims 21 or 22, wherein the length of the at least 21 guide surfaces is less than 25 cm, such as between 10 cm and 20 cm, or between 12 cm and 18 cm.

24. 24. The method of claim 21, wherein the bone preparation guide has a first sidewall defining the first end of the at least one guide surface and a second sidewall defining the second end of the at least one guide surface.

25. the first sidewall extends from an upper end to a lower end; the second sidewall extends from the upper end to the lower end; the first side wall includes a first side wall cutout portion extending from the lower end toward the upper end; the second side wall includes a second side wall cutout extending from the upper end toward the lower end; 25. The method of claim 24, wherein tilting the bone preparation instrument beyond one or both of the first and second ends of the at least one guide surface comprises positioning the bone preparation instrument through the first and second sidewall notches with a distal portion of the bone preparation instrument extending beyond the first sidewall.

26. the first sidewall defines a height from the top end to the bottom end, and the first sidewall cutout is less than 25% of the height of the first sidewall; 26. The method of claim 25, wherein the second sidewall defines a height from the top end to the bottom end, and the second sidewall cutout is greater than 50% of the height of the second sidewall.

27. the first sidewall defines a lower edge surrounding the first sidewall cutout, the lower edge being outwardly slanted; The method of any one of claims 24 to 26, wherein the second side wall defines an upper edge surrounding the second side wall cutout, the upper edge sloping outwardly.

28. positioning the at least one guide surface of the bone preparation guide on the metatarsal and / or cuneiform bone to be prepared includes positioning the second side wall on a lateral side of the metatarsal and / or cuneiform bone to be prepared; 28. The method of any one of claims 25-27, wherein tilting the bone preparation instrument beyond one or both of the first and second ends of the at least one guide surface comprises tilting a distal portion of the bone preparation instrument inwardly beyond the lower end of the first side wall and tilting a proximal portion of the bone preparation instrument outwardly beyond the upper end of the first side wall.

29. The bone preparation guide comprises a body defining the at least one guide surface, a first arm extending outwardly from the body, and a second arm extending outwardly from the body, the first arm defining a first fixation hole and the second arm defining a second fixation hole; and positioning the first fixation hole over the metatarsal bone and percutaneously inserting a first fixation pin through the first fixation hole and into the metatarsal bone; positioning the second fixation hole over the cuneiform bone and percutaneously inserting the second fixation pin through the second fixation hole into the cuneiform bone; The method of any one of claims 21 to 28, comprising:

30. 30. The method of claim 29, wherein positioning the first fixation hole on the metatarsal bone and the second fixation hole on the cuneiform bone comprises positioning the first fixation hole and the second fixation hole offset from the patient's skin.

31. the first arm is sized to position the first fixation pin at least 10 mm from the body; 30. The method of claim 29, wherein the second arm is sized to position the second fixation pin at least 10 mm from the body.

32. the body of the bone preparation guide defines a bone contacting surface; the first arm has a first pin tower defining the first fixation hole; the second arm has a second pin tower defining the second fixation hole; 32. The method of claim 29, wherein the bottom surface of the first pin tower and the bottom surface of the second pin tower are each at least 25 mm higher than the bone-contacting surface of the body.

33. 33. The method of any one of claims 29 to 32, further comprising making an incision in the patient's skin and inserting the body of the bone preparation guide into the incision, the body defining a third fixation hole, and further comprising inserting a third fixation pin into the underlying bone through the third fixation hole of the body inserted into the incision.

34. 34. The method of claim 33, wherein the first fixation pin is parallel to the second fixation pin and the third fixation pin is angled relative to the first fixation pin and the second fixation pin.

35. the at least one guide surface includes a first guide surface and a second guide surface separated from the first guide surface; Positioning at least one guide surface of the bone preparation guide on the metatarsal and / or cuneiform bone of the patient to be prepared includes positioning the first guide surface on the metatarsal and the second guide surface on the cuneiform bone; 35. The method of any one of claims 21-34, wherein guiding the bone preparation instrument along the at least one guide surface comprises: translating the bone preparation instrument along a length of a first guide surface and tilting the bone preparation instrument past one or both of the first and second ends of the first guide surface to prepare the end of the metatarsal bone; and translating the bone preparation instrument along a length of a second guide surface and tilting the bone preparation instrument past one or both of the first and second ends of the second guide surface to prepare the end of the cuneiform bone.

36. The bone preparation guide comprises: a first opposing guide surface spaced apart from the first guide surface to define a first slot therebetween; a second opposing guide surface spaced apart from the second guide surface and defining a second slot therebetween; 36. The method of claim 35, further comprising:

37. prior to positioning the at least one guide surface of the bone preparation guide on the metatarsal and / or the cuneiform bone; inserting a pin percutaneously into the tarsometatarsal joint between the metatarsal and the cuneiform bones; positioning an incision guide over the pin percutaneously inserted into the tarsometatarsal joint, the incision guide defining an incision guide surface for guiding an incision through the patient's skin; The method of any one of claims 21 to 36, further comprising:

38. 38. The method of claim 37, wherein the incision guide defines a pin receiving slot, and further comprising aligning the incision guide in a medial-to-lateral direction while the pin inserted percutaneously into the tarsometatarsal joint extends through the pin receiving slot.

39. 38. The method of claim 37, wherein the length of the incision guide surface is less than 3 mm.

40. 40. The method of any one of claims 37-39, further comprising guiding a cutting instrument along the incision guide surface to cut the skin of the patient to access the metatarsal and cuneiform bones.

41. 41. The method of any one of claims 21 to 40, further comprising inserting a retraction guide into an incision in the patient's skin and inserting a cutting instrument through the retraction guide into the tarsometatarsal joint between the metatarsal and the cuneiform before positioning at least one guide surface of the bone preparation guide over the metatarsal and / or the cuneiform.

42. 42. The method of claim 41, wherein the retraction guide includes at least one side wall defining a closed opening, and inserting the retraction guide through the patient's skin and into the incision includes positioning the patient's skin outside the at least one side wall and surgically accessing the tarsometatarsal joint through the closed opening.

43. 43. The method of claim 41 or 42, wherein the cutting instrument includes an osteotome defining a depth stop sized relative to the retraction guide.

44. 44. The method of any one of claims 21 to 43, further comprising inserting a biplanar tissue dissociation instrument into the proximal-lateral corner of the metatarsal to dissociate soft tissue at the proximal-lateral corner of the metatarsal prior to positioning the at least one guide surface of the bone preparation guide on the metatarsal and / or the cuneiform bone.

45. 45. The method of claim 44, wherein the biplanar tissue dissection instrument comprises a first cutting body angledly coupled to a second cutting body, and wherein inserting the biplanar tissue dissection instrument into the proximal-lateral corner of the metatarsal bone comprises inserting the first cutting body into the tarsometatarsal joint between the metatarsal and the cuneiform bone and inserting the second cutting body between the metatarsal and an adjacent metatarsal bone.

46. the first cutting body has a length extending from a proximal end to a distal end; the second cutting body has a length extending from a proximal end to a distal end; 46. ​​The method of claim 45, wherein the distal end of the first cutting body and the distal end of the second cutting body are each inwardly angled to define a groove therebetween.

47. the first cut body has a width extending from an outer edge to an intersection with the second cut body, and the outer edge of the first cut body has an obtuse angle; the second cut body has a width extending from an outer edge to an intersection with the first cut body, and the outer edge of the second cut body has an obtuse angle; the distal end of the first cutting body is sharpened along at least a portion of the length of the distal end of the first cutting body; 47. The method of claim 46, wherein the distal end of the second cutting body is sharpened along at least a portion of the length of the distal end of the second cutting body.

48. the first cutting body has a length extending from a proximal end to a distal end; the second cutting body has a length extending from a proximal end to a distal end; the biplanar tissue dissection instrument further comprises a handle connected to the proximal end of the first cutting body and the proximal end of the second cutting body; 48. The method of any one of claims 45-47, wherein the biplanar tissue dissection instrument defines openings at the proximal end of the first cutting body and the proximal end of the second cutting body, where the first cutting body is joined to the second cutting body to define the angle.

49. 49. The method of claim 48, wherein the biplanar tissue dissection instrument comprises a first arm extending from the first cutting body to the handle and a second arm extending from the second cutting body to the handle, the opening being defined between the first arm and the second arm.

50. 50. The method of any one of claims 21 to 49, wherein positioning the at least one guide surface of the bone preparation guide on the metatarsal and / or cuneiform bone further comprises inserting a spacer into the tarsometatarsal joint between the metatarsal and the cuneiform bone.

51. the spacer extends from a proximal end to a distal end, the proximal portion of the spacer having an outwardly extending projection defining a tissue retraction space; 51. The method of claim 50, wherein inserting the spacer into the tarsometatarsal joint between the metatarsal and cuneiform bones comprises positioning tissue of the patient in the tissue retraction space.

52. 52. The method of claim 51, wherein the protrusion defines a sloped surface that tapers the width of the spacer over at least a portion of the length of the spacer.

53. 53. The method of claim 51 or 52, wherein the outwardly extending projection on the proximal portion of the spacer is on the interior side of the spacer.

54. 54. The method of any one of claims 50 to 53, wherein the spacer is a first spacer, and further comprising inserting a second spacer into the joint space between the metatarsal bone and an adjacent metatarsal bone.

55. 55. The method of claim 54, wherein the bone preparation guide comprises a body defining the at least one guide surface, and the first spacer and the second spacer are each connected to the body of the bone preparation guide.

56. 56. The method of any one of claims 21 to 55, wherein the bone preparation guide comprises a body defining the at least one guide surface, the body defining a bottom surface, a side wall, and an angled surface connecting the bottom surface and the side wall, the angled surface deflecting the patient's tissue.

57. 57. The method of any one of claims 21 to 56, wherein the bone preparation tool is a saw, and guiding the bone preparation tool along the guide surface to prepare the end of the metatarsal bone and / or the end of the cuneiform bone comprises guiding the saw along the guide surface to cut the end of the metatarsal bone and / or the end of the cuneiform bone.

58. 58. The method of claim 57, further comprising, after cutting the end of the metatarsal and / or the end of the cuneiform bone, removing the cut end of the metatarsal and / or the cut end of the cuneiform bone from the tarsometatarsal joint between the metatarsal and the cuneiform bone.

59. 59. The method of claim 58, wherein removing the cut end of the metatarsal bone and / or the cut end of the cuneiform bone from the tarsometatarsal joint comprises inserting an osteotome having a hook between the cut end of the metatarsal bone and / or the cut end of the cuneiform bone and an opposing cut end of the bone, capturing the cut end of the metatarsal bone and / or the cut end of the cuneiform bone in the hook, and removing the osteotome from the tarsometatarsal joint.

60. 60. The method of any one of claims 21 to 59, wherein moving the metatarsal relative to the cuneiform comprises preparing one or both of the ends of the metatarsal and the cuneiform before moving the metatarsal.

61. 61. The method of claim 60, wherein moving the metatarsal relative to the cuneiform bone comprises moving the metatarsal in at least the transverse plane to close an intermetatarsal angle with an adjacent metatarsal and a frontal plane.

62. 61. The method of claim 60, further comprising attaching bone positioners to the metatarsals and bones other than the metatarsals, and wherein moving the metatarsals relative to the cuneiform bones comprises moving the metatarsals using the bone positioners.

63. 63. The method of claim 62, wherein the bone other than the metatarsal is the cuneiform bone and / or an adjacent metatarsal bone.

64. 64. The method of any one of claims 21 to 63, further comprising compressing the prepared ends of the metatarsal and cuneiform together after moving the metatarsal relative to the cuneiform.

65. 65. The method of any one of claims 21 to 64, wherein fixing the displaced position of the metatarsal comprises applying one or more of a bone plate, staples, screws, and pins to a tarsometatarsal joint between the metatarsal and the cuneiform bone.

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