Devices and techniques for treating metatarsal inversion

Abstract

To provide a method and a bone cutting guide for treating metatarsal adduction.SOLUTION: A technique for metatarsal inversion may include cutting an end of one or both of the second metatarsal and the intermediate cuneiform to create a wedge-shaped opening between the end of the second metatarsal and the intermediate cuneiform. The method may further include cutting an end of one or both of the third metatarsal and the lateral cuneiform to create a wedge-shaped opening between the end of the third metatarsal and the lateral cuneiform. The second and third metatarsals can then be moved in the transverse plane to close the metatarsal adduction angle. The movement of the second and third metatarsals may close the wedge-shaped opening formed between the bone cuts. Once the second and third metatarsals are properly realigned, the clinician can fix the translated positions of the second and third metatarsals.SELECTED DRAWING: Figure 5C

Description

[Technical Field]

[0001] cross reference This application claims the benefit of U.S. Provisional Patent Application No. 63 / 027,340, filed May 19, 2020, and U.S. Provisional Patent Application No. 63 / 126,207, filed December 16, 2020, the entire contents of each of which are hereby incorporated by reference herein.

[0002] The present disclosure relates to devices and techniques for treating metatarsal adduction. [Background technology]

[0003] Metatarsal adduction (MTA) is a foot deformity in which the metatarsals are angled inward. MTA is typically characterized by medial deviation of the metatarsals in the transverse plane. For example, MTA is often described as a structural deformity occurring at the Lisfranc joint (tarsometatarsal joint), in which the metatarsals are medially deviated relative to the lesser tarsus.

[0004] In some patients, MTA presents as hallux valgus, also known as hallux abductor valgus. Hallux valgus is a complex, progressive condition characterized by lateral deviation (valgus, abduction) of the first toe and medial deviation of the first metatarsophalangeal joint. Hallux valgus typically results in an increase in the hallux adduction angle, which is the angle between the long axes of the first metatarsal and the proximal phalange in the transverse plane.

[0005] In some cases, surgical intervention is required to address the MTA and / or hallux valgus deformity, which may involve realigning one or more bones of the foot to improve patient comfort and increase patient mobility. Summary of the Invention

[0006] In general, the present disclosure is directed to devices and techniques for treating metatarsal adduction (MTA), either alone or in combination with treatment for hallux valgus. In some implementations, a clinician surgically accesses the second and third tarsometatarsal joints of the foot to realign and prepare the joints for fusion. The clinician can make incisions at the second and third tarsometatarsal joints, providing, for example, dorsolateral and dorsomedial access. With the joints exposed, the clinician can prepare the end faces of the second and third metatarsals and the opposing middle and lateral cuneiform bones, respectively. With or without a cutting guide, the clinician can cut at least one end of the bones forming the second tarsometatarsal joint and at least one end of the bones forming the third tarsometatarsal joint. The cuts may be angled relative to the end faces of the bones being cut to define an opening between the two bones, like a wedge extending from a narrow end (e.g., apex) to a wide end (e.g., base). When a segment of bone (e.g., a wedge) is removed from the joint space, a gap (e.g., a wedge-shaped gap) may exist between the end of the metatarsal and the opposing cuneiform bone. For example, the narrow portion of the wedge may be on the medial side of the joint, while the wide portion of the wedge may be on the lateral side of the joint. The metatarsal may be rotated in at least the transverse plane, with or without the use of a bone positioning guide, to close the wedge-shaped gap created by cutting and removing the bone wedge. For example, the metatarsal may be translated in the transverse plane, rotated in the frontal plane, and / or translated in the sagittal plane to realign the metatarsal. This may help realign the bone to correct a metatarsal adduction deformity (or other bone condition being treated).

[0007] In some implementations, the second and third tarsometatarsal joints are prepared, and the second and third metatarsals are moved independently of each other in one or more planes, such as the transverse plane. In other implementations, the second and third tarsometatarsal joints are prepared, and the second and third metatarsals can be moved together to address metatarsal angular misalignment. For example, when accessing and preparing the second and third tarsometatarsal joints, the plantar tarsal ligament and the ligaments between the second and third metatarsals can be preserved (e.g., left uncut or unruptured). This can maintain the connective tissue between the second and third metatarsals, allowing the second and third metatarsals to be manipulated as an interconnected block or group during angular readjustment.

[0008] For example, in one implementation, a clinician can access the second and third tarsometatarsal joints and then prepare the ends of the second and third metatarsals and the ends of the intermediate and lateral cuneiform bones. The clinician can cut the ends of at least one of the second metatarsal and intermediate cuneiform bones to, for example, define a wedge-shaped opening between the two bone faces. The clinician can also cut the ends of at least one of the third metatarsal and lateral cuneiform bones to, for example, define a wedge-shaped opening between the two bone faces. The clinician can then move the second and third metatarsals together, for example, by applying force to only the second metatarsal, by applying force to only the third metatarsal, or by applying force to both the second and third metatarsals. In either case, the distal ends of the second and third metatarsals can move laterally, at least in the transverse plane, while the proximal ends of the second and third metatarsals pivot to close the opening (e.g., a wedge-shaped gap) created during bone preparation. The Lisfranc ligament at the base of the second metatarsal can serve as an anchoring point around which rotation of the second and third metatarsals can occur. In some implementations, a soft tissue release is performed between the third and fourth metatarsals to help mobilize and reorient the third metatarsal.

[0009] In addition to realigning the second and third metatarsals, the fourth and fifth metatarsals may also be realigned to help correct metatarsal adduction. The distal ends of the fourth and fifth metatarsals may naturally pivot laterally in the transverse plane as the second and / or third metatarsals are forced to move. For example, when the second and third metatarsals are moved individually or as an interconnected block, the rotation of the metatarsals may cause natural realignment (e.g., lateral pivoting of the distal ends) of the fourth and fifth metatarsals at least in the transverse plane. Forces applied to the second and third metatarsals may be transmitted through tissues (e.g., one or more ligaments) that interconnect the second and third metatarsals with the fourth and fifth metatarsals. In different implementations, the fourth and / or fifth tarsometatarsal joints may or may not be surgically accessed and prepared for fusion (e.g., by preparing the ends of the fourth and / or fifth metatarsals for fusion and / or by preparing the ends of the cuboid bones opposite the metatarsals). Realignment of one or more lesser metatarsals also results in realignment of the remainder of the digit, e.g., the proximal phalanges and other interconnected bones.

[0010] With one or more lesser metatarsals realigned in one or more planes (e.g., at least the transverse plane), the clinician can fix the displaced position of one or more metatarsals. In some instances, the clinician may provisionally fixate one or more displaced metatarsals before permanently fixing their displaced positions. For example, the clinician may insert a fixation pin through the second metatarsal to another bone, such as the lateral cuneiform, and / or insert a fixation pin through the third metatarsal to another bone, such as the intermediate cuneiform. With or without provisional fixation, the clinician may permanently fix the position of the displaced bones by, for example, applying a fixation device across the second and / or third tarsometatarsal joints.

[0011] While surgical techniques according to the present disclosure may involve surgically accessing and preparing multiple lesser tarsometatarsal joints of the foot, such as the second and third tarsometatarsal joints, as discussed above, in alternative implementations, techniques may be performed on a single lesser tarsometatarsal joint (e.g., the second, third, fourth, and / or fifth tarsometatarsal joints). This procedure on a single lesser tarsometatarsal joint may be performed alone or in combination with treating hallux valgus on the first metatarsal. For example, an MTA deformity or other bony deformity may be corrected by operating on a single lesser tarsometatarsal joint (e.g., the second or third tarsometatarsal joint) without operating on the other lesser tarsometatarsal joints, again optionally with correcting the alignment of the first metatarsal through a procedure performed on the first tarsometatarsal joint.

[0012] For example, the surgeon can access the second tarsometatarsal joint, the third tarsometatarsal joint, or even other lesser tarsometatarsal joints. The surgeon can prepare the ends of the metatarsals (e.g., the second metatarsal, the third metatarsal) and / or the ends of the bones on the other side of the joint (e.g., the middle cuneiform, the lateral cuneiform). In some instances, the clinician cuts the ends of each of the bones separated by the tarsometatarsal joint. The clinician can then apply force to one or more of the lesser metatarsals (e.g., the metatarsal with the prepared end and the adjacent metatarsal with the unprepared end). This force can move the metatarsals in one or more planes, such as the transverse plane and / or the frontal plane, to realign the metatarsals. In some implementations, the force substantially moves only the lesser metatarsal that is surgically accessed and operated on, to realign the lesser metatarsals. In other instances, the force displaces the lesser metatarsal being surgically accessed and operated on, as well as one or more (e.g., all) other adjacent metatarsals and / or lesser metatarsals, realigning multiple bones in the foot.

[0013] In situations where the patient also exhibits an angular deformity of the first metatarsal, such as hallux valgus, the clinician may also perform a realignment of the first metatarsal. The realignment of the first metatarsal may be performed before or after the realignment of the lesser metatarsals (the second, third, fourth, and / or fifth metatarsals), or may be performed at least partially simultaneously with the step of realigning the lesser metatarsals. For example, the clinician may realign the first metatarsal in one or more planes before or after realigning the lesser metatarsal and fixing the displaced position of the realigned lesser metatarsal.

[0014] To realign the first metatarsal, the clinician may perform an incision over the first tarsometatarsal joint to access the joint. With the joint exposed, the clinician may prepare the end of the first metatarsal and the opposing end of the medial cuneiform bone. Before or after preparing one or both ends of the bone, the clinician may translate the first metatarsal in one or more planes. For example, the clinician may pivot the distal end of the first metatarsal in the transverse plane to close the intermetatarsal angle between the first and second metatarsals. Additionally or alternatively, the clinician may rotate the first metatarsal in the frontal plane and / or adjust the angular alignment of the first metatarsal in the sagittal plane. Once the first metatarsal is suitably realigned, the clinician may fix the translated position of the first metatarsal.

[0015] Independent of the specific surgical technique performed during a treatment procedure, a variety of different instruments may be provided to help facilitate bone preparation and / or realignment techniques. These instruments may be utilized as part of a metatarsal adduction treatment procedure or even other treatment procedures (e.g., fusion of arthritic joints, realignment of bones other than the metatarsals). For example, a bone cutting guide may be used to assist in cutting the end faces of the metatarsals and / or cuneiform bones to facilitate realignment and / or fusion between the bones. Generally, the bone cutting guide may be sized and shaped to be positioned over one or more bones to be cut. The bone cutting guide may define at least one guide surface along which a cutting instrument may be guided to cut the bone in a plane parallel to the guide surface. For example, the bone cutting guide may define a pair of guide surfaces defining a cutting slot therebetween through which a cutting instrument may be inserted.

[0016] In some examples, the bone cutting guide defines a guide surface configured to be positioned on the dorsal side of the metatarsal and / or cuneiform (or cuboid) bone to be cut. The bone cutting guide may include a positioning feature (e.g., a spacer or pin) that can be inserted into the joint space between adjacent bones and / or into the bone, respectively, to assist in positioning the guide surface over the bone to be cut. The spacer or pin may be fixedly (e.g., non-movably) connected to the guide surface or may be movable relative to the guide surface. For example, if the spacer or pin is movable relative to the guide surface, the spacer or pin may be inserted into the joint space or into the bone, and a structure defining the guide surface may then be inserted over or otherwise attached to the spacer or pin (e.g., via a clamp, pin, screw, or other attachment mechanism). In some configurations, the guide surface may rotate about the spacer or pin, e.g., within a limited angular range of movement, allowing a clinician to adjust the positioning of the guide surface over the bone to be cut by rotating the guide surface about the pin or spacer. Once suitably positioned, one or more other fixation pins may optionally be used to lock the position of the cutting guide relative to the bone to be cut.

[0017] A bone cutting guide configured for a surgical procedure (e.g., a metatarsal adduction procedure) may have a guide surface for guiding the cutting of a single bone or may be configured to guide a cutting instrument to cut multiple different bones. For example, the bone cutting guide may include at least one guide surface (e.g., at least one cutting slot) for guiding a cutting instrument to cut the end of a metatarsal bone and at least one additional guide surface (e.g., at least one additional cutting slot) for guiding a cutting instrument to cut the end of an opposing cuneiform bone. The guide surfaces may be angled relative to each other when the cutting guide is placed on the foot, for example, at an angle that opens toward the outside of the foot. The angle between the guide surfaces may be fixed or adjustable. When configured with an adjustable angle, a clinician can adjust the angle between one guide surface positionable over the metatarsal bone to be cut and another guide surface positionable over the opposing bone (e.g., cuneiform bone) to be cut.

[0018] When the intermediate and lateral cuneiform bones, which face the second and third metatarsals, respectively, are prepared through cutting, the cuneiform bones may be cut individually or together. In one implementation, for example, a cutting guide having an elongated guide surface configured to extend over both the intermediate and lateral cuneiform bones may be used. The guide surface may be parallel to adjacent guide surfaces to define a cutting slot. The cutting slot may be positionable on the dorsal side of the intermediate and lateral cuneiform bones and may extend from at least the medial side of the intermediate and lateral cuneiform bones to the lateral side of the lateral cuneiform bone. When configured in this manner, a clinician can guide a cutting instrument along the guide surface (e.g., through the cutting slot) to cut both the intermediate and lateral cuneiform bones. This may result in the intermediate and lateral cuneiform bones having parallel cutting end surfaces, which may assist in readjustment to close the metatarsal adduction angle.

[0019] In addition to or instead of using a bone cutting guide, a bone preparation template may be provided that the surgeon can overlay on one or more bones to be prepared to mark locations for preforming subsequent bone preparation steps. The bone preparation template may include one or more orientation features relative to one or more underlying bones (e.g., metatarsals, cuneiform bones, and / or joint lines) that indicate one or more locations where the bone should be cut or otherwise prepared. The surgeon may use the bone preparation template to mark one or more underlying bones where preparation is to occur. The surgeon may then perform guided and / or freehand bone preparation (optionally removing the bone preparation template beforehand) to prepare the one or more bones at the locations marked using the bone preparation template. The surgeon may move and / or fixate the one or more bones as discussed in connection with the use of the bone cutting guide.

[0020] In one example, a method for treating metatarsal adduction is described. The method includes resecting an end of at least one of a second metatarsal and a middle cuneiform bone to create a wedge-shaped opening between the end of the second metatarsal and the middle cuneiform bone. The method also includes preparing the other end of the second metatarsal and the middle cuneiform bone. The method further includes resecting an end of at least one of a third metatarsal and a lateral cuneiform bone to create a wedge-shaped opening between the end of the third metatarsal and the lateral cuneiform bone. The method also includes displacing the second metatarsal and the third metatarsal bone in a transverse plane to close the metatarsal adduction angle. The method also provides for fixating the displaced positions of the second metatarsal and the third metatarsal bone.

[0021] In another embodiment, a method for treating metatarsal adduction is described, comprising positioning cuneiform guide surfaces of a cutting guide on the dorsal side of the middle cuneiform and the dorsal side of the lateral cuneiform, and positioning metatarsal guide surfaces of a cutting guide on the dorsal side of the second metatarsal facing the middle cuneiform and the dorsal side of the third metatarsal facing the lateral cuneiform, using the cuneiform guide surfaces to advance a cutting tool in a plane parallel to the cuneiform guide surfaces to remove a portion of the middle cuneiform and a portion of the lateral cuneiform, and using the metatarsal guide surfaces to advance a cutting tool in a plane parallel to the metatarsal guide surfaces to remove a portion of the second metatarsal and a portion of the third metatarsal. The method includes moving the second and third metatarsals in a transverse plane to close the metatarsal adduction angle, and fixing the moved positions of the second and third metatarsals.

[0022] The details of one or more examples are set forth in the accompanying drawings and the description below. Other features, objects, and advantages will become apparent from the description and drawings, and from the claims. [Brief explanation of the drawings]

[0023] [Figure 1A] FIG. 1 is a top view of the foot showing normal metatarsal alignment. [Figure 1B] FIG. 1 is a front view of the foot showing normal metatarsal alignment.

[0024] [Figure 2A] FIG. 1 is a top view of a foot showing an exemplary metatarsal adduction bony misalignment. [Figure 2B] FIG. 1 is a front view of a foot showing an exemplary metatarsal adduction bony deviation.

[0025] [Figure 3A] 1 illustrates the various anatomical planes of the foot.

[0026] [Figure 3B] Metatarsal adduction of the feet in Figures 2A and 2B is shown, characterized by the metatarsal adduction angle.

[0027] [Figure 4] FIG. 1 is a flow diagram illustrating an exemplary technique for preparing the TMT joint for fusion and realigning multiple metatarsals to treat metatarsal adduction deformity.

[0028] [Figure 5A] FIG. 10 is a top view of the foot showing exemplary cutting guides positioned on the second and third TMT joints to illustrate exemplary bone wedges that can be cut during joint preparation.

[0029] [Figure 5B] 10 illustrates exemplary bone preparation steps that may be performed on a foot using an exemplary cutting guide. [Figure 5C] 10 illustrates exemplary bone preparation steps that may be performed on a foot using an exemplary cutting guide. [Figure 5D] 10 illustrates exemplary bone preparation steps that may be performed on a foot using an exemplary cutting guide. [Figure 5E] 10 illustrates exemplary bone preparation steps that may be performed on a foot using an exemplary cutting guide.

[0030] [Figure 6] FIG. 1 is a diagram showing a schematic diagram of the ligament structure of the foot.

[0031] [Figure 7A] FIG. 10 is a side perspective view of an exemplary bone positioner that may be used to move a metatarsal bone relative to an adjacent bone.

[0032] [Figure 7B] FIG. 10 illustrates an exemplary compressor engaged with a foot to facilitate movement of the second and third metatarsals.

[0033] [Figure 8A] FIG. 10 is a dorsal view of an exemplary X-ray image showing an exemplary temporary fixation pin configuration.

[0034] [Figure 8B] FIG. 10 is a dorsal view of an exemplary X-ray image showing another exemplary temporary fixation pin configuration.

[0035] [Figure 9A] 5 is a dorsal x-ray image of an exemplary foot prior to a therapeutic procedure performed in accordance with the surgical technique discussed in connection with FIG. 4. [Figure 9B] 5 is a dorsal x-ray image of an exemplary foot following a therapeutic procedure performed in accordance with the surgical technique discussed in connection with FIG. 4.

[0036] [Figure 10] FIG. 5B is a top view of the foot showing the exemplary cutting guide introduced in relation to FIG. 5A.

[0037] [Figure 11] FIG. 10 is a top view of a foot showing another exemplary configuration of a cutting guide.

[0038] [Figure 12A] FIG. 10 is a top view of a foot showing another exemplary configuration of a cutting guide. [Figure 12B] FIG. 10 is a top view of a foot showing another exemplary configuration of a cutting guide.

[0039] [Figure 13] 10A-10C are top views of an exemplary configuration of a cutting guide in which the angle between the distal-most and proximal-most guide surfaces of the guide is constant.

[0040] [Figure 14A] FIG. 10 is a top view of another exemplary configuration of a cutting guide, in which the angle between the distal-most guide surface of the cutting guide and the proximal-most guide surface of the guide is variable.

[0041] [Figure 14B] 1 shows an example of a cutting guide with separate guide surfaces for cutting two metatarsals, where the angular positions of the guide surfaces are both adjustable.

[0042] [Figure 15] FIG. 10 is a perspective view of a foot showing exemplary positioning features that may be used with the cutting guide.

[0043] [Figure 16] 10 shows an exemplary cutting guide engaged with and advanced in a plantar direction along a positioning feature to assist in orienting the bone guide over one or more bones to be cut.

[0044] [Figure 17] 10A-10C show two different configurations of cutting guides in which the cutting guide is restricted to a limited range of rotational movement relative to a spacer or pin that is insertable into the underlying bone structure. [Figure 18] 10A-10C show two different configurations of cutting guides in which the cutting guide is restricted to a limited range of rotational movement relative to a spacer or pin that is insertable into the underlying bone structure.

[0045] [Figure 19] 1 is a perspective view of an exemplary cutting guide with associated alignment features.

[0046] [Figure 20] FIG. 20 is a front perspective view of the foot showing the cutting guide of FIG. 19 positioned on the dorsal side of one or more bones to be cut.

[0047] [Figure 21] FIG. 21 is a top view of a foot with the cutting guide of FIG. 20 engaged.

[0048] [Figure 22] FIG. 1 is a perspective view of an exemplary cutting guide having two associated alignment features.

[0049] [Figure 23A] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23B]10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23C] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23D] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23E] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23F] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23G] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23H] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide. [Figure 23I] 10 illustrates exemplary target locations on the foot for inserting one or more placement features associated with the cutting guide.

[0050] [Figure 24] 1A-1C are perspective views of exemplary configurations of cutting guides having at least one adjustable fixation hole.

[0051] [Figure 25] 25 is a top view of the exemplary cutting guide of FIG. 24 showing exemplary positions to which the adjustable fixation holes can be moved.

[0052] [Figure 26A] 26 is a top view image of an exemplary foot showing the cutting guide of FIGS. 24 and 25 positioned on the foot. [Figure 26B] 26 is a top view image of an exemplary foot showing the cutting guide of FIGS. 24 and 25 positioned on the foot.

[0053] [Figure 27A]10A-10C are top views of an exemplary configuration of a cutting guide showing an exemplary connection between two adjustable fixation holes. [Figure 27B] 10A-10C are top views of an exemplary configuration of a cutting guide showing an exemplary connection between two adjustable fixation holes.

[0054] [Figure 28A] 10A-10C are top views of an exemplary configuration of a cutting guide showing exemplary rotational realignment positions for adjustable fixation holes. [Figure 28B] 10A-10C are top views of an exemplary configuration of a cutting guide showing exemplary rotational realignment positions for adjustable fixation holes.

[0055] [Figure 29] 1 is an image of an exemplary patient's foot showing distal offset between the second and third TMT joints.

[0056] [Figure 30] FIG. 10 is a perspective view of an exemplary cutting guide that can be used to remove protruding bone portions.

[0057] [Figure 31] FIG. 31 is a top view of the foot showing an exemplary positioning of the cutting guide of FIG. 30.

[0058] [Figure 32] FIG. 1 is a perspective view of a foot showing an exemplary cutting guide and blocking element, where the blocking element is positioned to limit movement of a cutting instrument to help prevent inadvertent cutting of adjacent metatarsals.

[0059] [Figure 33] 1 is a perspective view of an exemplary bone preparation template defining one or more guide surfaces that can be used to guide a marking instrument. DETAILED DESCRIPTION OF THE INVENTION

[0060] Generally, the present disclosure is directed to devices and techniques for preparing one or more tarsometatarsal joints ("TMT joints") for fusion and realigning one or more metatarsals separated from opposing bones by a tarsometatarsal joint. While the disclosed techniques can be performed on any TMT joint, in some implementations, surgical techniques are performed on at least the second and third TMT joints. During the procedure, a clinician may cut one or both ends of the second metatarsal and the opposing medial cuneiform. Additionally or alternatively, a clinician may cut one or both ends of the third metatarsal and the opposing lateral cuneiform. In some examples, a clinician advances a cutting instrument along a path (e.g., a linear path and / or a curved path) to cut one metatarsal end followed by another metatarsal end and / or one cuneiform end followed by another cuneiform end. In either case, bone portions may be removed from the TMT joint spaces, such as between both the second and third TMT joint spaces, and the bone portions and / or the space from which they were removed may be shaped to facilitate subsequent repositioning of the metatarsal relative to the opposing cuneiform bone, for example, by shifting the metatarsal to partially or completely close the space created during removal of the bone portions.

[0061] Regardless of how one or more TMT joints are prepared, a clinician can apply force to one or more metatarsals, such as the second and / or third metatarsals, to rotate one or more metatarsals in at least one plane (e.g., one or more of the transverse, frontal, and / or sagittal planes). When repositioning both the second and third metatarsals, the second and third metatarsals may or may not remain interconnected through ligamentous attachments, such as the plantar ligament and / or the second-third intermetatarsal ligaments. If they remain interconnected, the second and third metatarsals may be pivoted together as a block (e.g., in at least one plane, such as the transverse plane). For example, the second and third metatarsals may pivot generally about the medial aspect (e.g., lateral aspect) of the second TMT joint in the transverse plane, closing a larger opening on the lateral side of the joint. In some implementations, the second and / or third metatarsals may be pivoted at least in the transverse plane, with the base of the second metatarsal attached to the Lisfranc ligament and acting as a pivot point about which the bone block can rotate. A clinician can pivot the second and third metatarsals by hand and / or with the aid of a bone positioner engaging at least one of the second and third metatarsals and a bone other than the one to which the bone positioner is engaged.

[0062] The fourth and fifth metatarsals may also be pivoted in one or more planes (e.g., at least the transverse plane), for example, simultaneously with the second and / or third metatarsals being pivoted in one or more planes. The fourth and fifth metatarsals may be realigned without accessing or preparing the fourth or fifth TMT joint. However, in some instances, the fourth and / or fifth metatarsals may be surgically accessed and prepared by preparing the end of the fourth metatarsal and / or the end of the opposing cuboid and / or fifth metatarsal. After suitably realigning one or more of the second, third, fourth, and / or fifth metatarsals, the relocated position of the one or more metatarsals may be fixed. In some instances, a temporary fixation step is performed in which one or more temporary fixation pins are placed to maintain the relocated position of the one or more metatarsals (e.g., by inserting fixation pins through one or more relocated metatarsals and into one or more adjacent bones). Permanent fixation devices may be used to hold the displaced bones in place for subsequent fusion. Exemplary permanent fixation devices include, but are not limited to, pins (e.g., intramedullary nails, K-wires, Steinmann pins), plates, screws, staples, and combinations thereof.

[0063] The clinician may prepare and move the first metatarsal before, after, or simultaneously with preparing and moving one or more lesser metatarsals (e.g., one or more of the second, third, fourth, and / or fifth metatarsals). The clinician may prepare the end of the first metatarsal and also prepare the opposing end of the medial cuneiform bone. Before or after preparing one or both epiphysis, the clinician may move the first metatarsal in one or more planes. For example, the clinician may pivot the distal end of the first metatarsal in the transverse plane to close the intermetatarsal angle between the first and second metatarsals. Additionally or alternatively, the clinician may rotate the first metatarsal in the frontal plane and / or adjust the angular alignment of the first metatarsal in the sagittal plane. Once the first metatarsal has been suitably realigned, the clinician may fix the moved position of the first metatarsal. Further details regarding exemplary first metatarsal realignment instruments and techniques that may be used in connection with the present disclosure can be found in U.S. Pat. No. 9,622,805, issued April 18, 2017, entitled "BONE POSITIONING AND PREPARING GUIDE SYSTEMS AND METHODS," U.S. Pat. No. 10,245,088, issued April 2, 2019, entitled "BONE PLATING SYSTEM AND METHOD," U.S. Patent Application Publication No. 2020 / 0015856, issued January 16, 2020, entitled "COMPRESSOR-DISTRACTOR FOR ANGULARLY REALIGNING BONE PORTIONS," and U.S. Patent Application Publication No. 2020 / 0015856, issued January 16, 2020, entitled "MULTI-DIAMETER BONE PIN FOR INSTALLING AND ALIGNING BONE FIXATION PLATE WHILE MINIMIZING BONE PORTIONS." No. 2020 / 0015870, entitled "Blocking Insulation Damage," the entire contents of each of which are incorporated herein by reference.

[0064] Preparation and fusion of one or more TMT joints may be performed in accordance with the present disclosure for a variety of clinical reasons and indications. TMT joint preparation and fusion may be performed to treat metatarsal adduction, hallux valgus, and / or other bone and / or joint conditions.

[0065] Metatarsal adduction is a foot deformity characterized by a transverse plane deformity in which the metatarsals are adducted at the Lisfranc joint. The degree of metatarsal adduction deformity can be characterized by the metatarsal adduction angle. The metatarsal adduction angle can be defined as the angle between the long axis of the second metatarsal (representing the long axis of the metatarsal) and the long axis of the lesser tarsus. The measurement of the long axis of the lesser tarsus can be characterized by a line perpendicular to the transverse axis of the lesser tarsus, using the lateral articulation of the fourth metatarsal with the cuboid as a reference.

[0066] Hallux valgus, also known as hallux abductus valgus, is a complex, progressive condition characterized by lateral deviation (eversion, eversion) of the great toe and medial deviation of the first metatarsophalangeal joint. Hallux valgus typically results in a gradual increase in the hallux adduction angle, i.e., the angle between the long axes of the first metatarsal and the proximal phalanges in the transverse plane. An increase in the hallux adduction angle can tend to laterally displace the plantar aponeurosis and intrinsic and extrinsic muscle tendons that cross the first metatarsophalangeal joint from the metatarsal to the hallux. As a result, the sesamoid bones, for example, can also be laterally displaced relative to the first metatarsophalangeal joint, resulting in 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.

[0067] Although the techniques and devices are described herein with particular reference to the TMT joint of the foot, these techniques and / or devices may also be used with other similar bones separated by joints in the hand or foot. For example, these techniques and devices may be performed on the carpometacarpal joint of the hand. As another example, one or more techniques and / or devices may be used on the metatarsals and / or phalanges, for example, across the metatarsophalangeal joint. In various implementations, these devices and / or techniques may be used as part of bone alignment, osteotomy, fusion, fracture repair, and / or other procedures in which one or more bones are to be prepared and / or moved to a desired position.

[0068] Additionally, although the techniques and devices described herein are generally discussed in connection with preparing and fusing the second and / or third TMT joints, the devices and techniques are not limited to being performed in these particular anatomical locations or together. In various examples, the devices and / or techniques of the present disclosure can be utilized to prepare and promote fusion across a single TMT joint (e.g., the first TMT joint, the second TMT joint, the third TMT joint, the fourth TMT joint, the fifth TMT joint), and / or any combination of TMT joints (e.g., the first and second TMT joints, the second and third TMT joints, the first, second and third TMT joints, the first and fourth TMT joints, the first, second and fourth TMT joints, etc.).

[0069] To further understand the exemplary techniques of the present disclosure, the anatomy of the foot will first be described with reference to Figures 1-3, along with exemplary misalignments that may occur and be corrected in accordance with the present disclosure. As previously discussed, bone misalignment may be caused by metatarsal adduction, hallux valgus (bunion), and / or other conditions that may manifest as misalignment of one or more bones in the foot.

[0070] 1A and 1B are top and front views, respectively, of a foot 10 illustrating normal metatarsal alignment. The foot 10 is composed of multiple bones, including a first metatarsal 12, a second metatarsal 14, a third metatarsal 16, a fourth metatarsal 18, and a fifth metatarsal 20. The first metatarsal 12 is located on the medial side of the foot, and the fifth metatarsal 20 is located on the lateral side. The metatarsals are connected distally to phalanges 22, and more specifically, each is connected to a respective proximal phalange. The joints 24 between the metatarsals and the corresponding opposing proximal phalanges are referred to as metatarsophalangeal ("MTP") joints. The first MTP joint is labeled as joint 24 in FIG. 1A, but the second, third, fourth, and fifth MTP joints are also shown in series adjacent to the first MTP joint.

[0071] The first metatarsal 12 is proximally connected to the medial cuneiform 26, the second metatarsal 14 is proximally connected to the intermediate cuneiform 28, and the third metatarsal 16 is proximally connected to the lateral cuneiform 30. The fourth and fifth metatarsals 18, 20 are proximally connected to the cuboid 32. The joints between the metatarsals and the opposing bones (cuneiforms, cuboid) are referred to as tarsometatarsal ("TMT") joints. FIG. 1A shows the first TMT joint 34, the second TMT joint 36, the third TMT joint 38, the fourth TMT joint 40, and the fifth TMT joint 42. The angle between adjacent metatarsals is referred to as the intermetatarsal angle ("IMA").

[0072] 1A and 1B, foot 10 is illustrated as having generally normally aligned metatarsals. Normal metatarsal alignment may be characterized, among other attributes, by a small intermetatarsal angle (e.g., 9 degrees or less, e.g., 5 degrees or less) between the first and second metatarsals. Additionally, the lesser metatarsal may be generally parallel to the long axis that bisects the foot from proximally to distally.

[0073] FIG. 3A illustrates various anatomical planes of the foot 10, including a frontal plane 52, a transverse plane 54, and a sagittal plane 56. The frontal plane 52, also known as the coronal plane, is generally considered to be any vertical plane that divides the body into anterior and posterior sections. In the context of the foot 10, the frontal plane 52 is a plane that extends vertically and is perpendicular to an axis extending from proximal to distal along the length of the foot. The transverse plane 54, also known as the horizontal, axial, or transaxial plane, is considered to be any plane that divides the body into superior and inferior sections. In the context of the foot 10, the transverse plane 54 is a plane that extends horizontally and is perpendicular to an axis extending dorsally to plantarly (top to bottom) across the foot. Additionally, the sagittal plane 56 is a plane that is parallel to the sagittal suture, dividing the body into left and right halves. In the foot 10, the sagittal plane 56 is a plane that extends vertically and intersects an axis that extends from proximal to distal along the length of the foot.

[0074] In patients suffering from metatarsal adduction, at least one or more of the lesser metatarsals (second through fifth metatarsals) may be medially deviated in the transverse plane (e.g., in addition to or instead of being rotated in the frontal plane and / or deviated in the sagittal plane relative to the normal anatomical alignment clinically defined for a standard patient population). Figures 2A and 2B are top and front views, respectively, of a foot 10 illustrating an exemplary metatarsal adduction bony misalignment. As shown in this example, the metatarsals are medially deviated relative to the axis that bisects the foot. This may result in an abnormal biomechanical structure that may benefit from surgical intervention. Figure 3B shows that the metatarsal adduction of the foot 10 from Figures 2A and 2B is characterized by a metatarsal adduction angle 50.

[0075] Bone positioning techniques and instruments can be useful for correcting one or more bone misalignments, such as metatarsal adduction and / or metatarsal misalignment in hallux valgus. Figure 4 is a flow diagram illustrating an exemplary technique for preparing the TMT joint for fusion and realigning one or more (e.g., multiple) metatarsals to treat at least metatarsal adduction deformity. This technique is described in conjunction with the bone numbering introduced in conjunction with Figures 1A and 1B, but may also be performed for other bones. For purposes of discussion, the technique of Figure 4 is discussed in conjunction with various exemplary images, but may be performed without such instruments or with different instruments, as discussed herein.

[0076] Referring to FIG. 4, an exemplary technique includes surgically accessing (100) at least the second and third TMT joints. To surgically access the joints, a clinician may make one or more incisions (e.g., on the dorsum of the foot) to expose the second and third TMT joints. The clinician may dissect the skin, subcutaneous tissue, and fascia. The clinician may mobilize the extensor hallucis brevis muscle belly and contract the muscles. Soft tissue and / or overgrown bone may be removed to facilitate visualization of the joints.

[0077] In cases where the clinician also performs a first metatarsal correction, the clinician may also surgically access the first TMT joint. While the clinician may make a single incision spanning the first, second, and third TMT joints, a dual incision approach may avoid unnecessary cutting and trauma. In a dual incision approach, the clinician may make one incision providing dorsal (e.g., dorsolateral and dorsomedial) access (and / or in other instances medial access) to the first TMT joint and a second incision providing dorsal (e.g., dorsolateral and dorsomedial) access to the second and third TMT joints, resulting in an intermediate portion of the skin between the first and second incisions. When using a dual incision, the surgeon may surgically access the first TMT joint before, after, or simultaneously with surgical access to the second and third TMT joints.

[0078] In practice, it can be difficult for a clinician to quickly and accurately identify the location of one or more TMT joints in a patient's foot, especially one or more minor TMT joints that may be offset due to bony deformities. Clinicians may utilize a joint locating guide (e.g., an incision guide) to assist in locating the TMT joint, for example, to assist in locating the joint subcutaneously before and / or after incision through the skin. As an example, the joint locating guide may be an instrument made at least in part from a radiopaque material to designate the location of the TMT joint under imaging. For example, the joint locating guide may include one or more radio-distinguishable marking lines that are distinguishable from the remainder of the guide under imaging. The one or more radio-distinguishable marking lines may be formed from a different material than the remainder of the guide, may have a different thickness than the remainder of the guide, and / or may otherwise be distinguishable from the remainder of the guide under imaging. In either configuration, the clinician may align the radio-distinguishable marking features (e.g., lines) with the TMT joint under imaging and then designate a location for accessing the joint. The clinician may take fluoroscopic (e.g., x-ray) images of at least a portion of the foot 10 encompassing the target TMT joint before and / or after making the incision. The clinician may designate the location of the joint using radio-discernible markings on the joint location guide, for example, and then make an incision over the joint and / or release the joint at the designated location.

[0079] As another example, the joint location guide may take the form of a tool configured (e.g., sized and / or shaped) to allow a clinician to physically explore the area of ​​the TMT joint until the tool drops into the TMT joint. For example, the joint location guide may be a flat head screwdriver, rod, or other instrument. Because the tool may contact bone while exploring the TMT joint, the tool may have a blunt tip and / or may be selected to minimize or prevent cutting or other bone removal. The clinician may use the tool to explore the joint before and / or after making the incision.

[0080] Thus, in various examples, a clinician may identify the TMT joint space by visual and / or tactile inspection and / or through x-ray (e.g., fluoroscopic) imaging. Whether or not the clinician utilizes one or more joint locating guides to assist the clinician in locating the TMT joints, the clinician may make an incision to surgically expose the joint. With the joint exposed, the clinician may optionally release soft tissue from each accessed TMT joint (e.g., by inserting a cutting instrument into the joint) to assist in mobilizing the joint for subsequent realignment.

[0081] With access to the TMT joint space, the technique of FIG. 4 includes preparing the end faces of the bones that form the second TMT joint 36 at the third TMT joint 38. In particular, the clinician may prepare (102) the end of the second metatarsal 14 that faces the second TMT joint, prepare (104) the end of the third metatarsal 16 that faces the third TMT joint, prepare (106) the end of the middle cuneiform 28 that faces the second TMT joint, and / or further prepare (108) the end of the lateral cuneiform 30 that faces the third TMT joint. While FIG. 4 schematically illustrates an exemplary order in which the bones defining the second and third TMT joints may be prepared, it should be understood that the surgical technique is not limited to any particular order of preparation. For example, the clinician may prepare one or both cuneiform bones before preparing one or more metatarsals, may prepare one or both metatarsals before preparing one or more cuneiform bones, may prepare the ends of one metatarsal and one cuneiform bone that define one TMT joint before preparing the end bone of the other TMT joint, or may perform the bone preparations in yet another order.

[0082] Generally, a clinician can prepare the ends of each bone forming the TMT joint to promote fusion of the bone ends across the TMT joint following realignment. Bone preparation can include using a tissue removal instrument, which can also be referred to as a cutting instrument, to apply force to the end surface of the bone to create a hemorrhagic bone surface to promote subsequent fusion. Exemplary tissue removal instruments that can be used include, but are not limited to, saws, rotary drilling instruments, rongeurs, reamers, osteotomes, curettes, and the like. The tissue removal instrument can be applied to the end surface of the bone being prepared to remove cartilage and / or bone. For example, the tissue removal instrument can be applied to the end surface to remove cartilage down to the subchondral bone (e.g., all of the cartilage). Additionally or alternatively, the tissue removal instrument can be applied to cut, fenestrate, mortar, and / or otherwise reshape the end surface of the bone and / or to create a hemorrhagic bone surface to promote fusion. When a cutting operation is performed to remove an end of a bone, the cut may be performed freehand with the aid of a cutting guide having guide surfaces positionable over the portion of the bone to be cut, and / or with the aid of a bone preparation template. When a cutting guide is used, a cutting instrument may be inserted relative to the guide surfaces (e.g., between a slot defined between two guide surfaces) to guide the cutting instrument for bone removal. When a bone preparation template is used, the bone preparation template may be used to mark or otherwise designate where on one or more bones a preparation step (e.g., a cut) should be performed. The clinician may then preform a freehand bone preparation step (e.g., a cut) at the indicated location through the use of the bone preparation template.

[0083] In some instances, the clinician cuts at least one bone defining the second TMT joint (e.g., one or both of the second metatarsal 14 and the medial cuneiform 28) and at least one bone defining the third TMT joint (e.g., one or both of the third metatarsal 16 and the lateral cuneiform 30). The clinician may cut both bones defining the second TMT joint, or may cut only one bone defining the joint and perform a different preparation technique on the other bone. Similarly, the clinician may cut both bones defining the third TMT joint, or may cut only one bone defining the joint and perform a different preparation technique on the other bone.

[0084] When a clinician cuts at least one bone that forms a TMT joint, each such cut may be parallel or non-parallel to the end of the bone being cut in one or more of the frontal, transverse, and sagittal planes. For example, the cut may be angled relative to the end face of the bone in the transverse plane or parallel to the end face of the bone in the frontal plane. As other examples, the cut may be curved, arcuate, spherical, zigzag, or define any other desired cut shape to facilitate realignment and fusion of one bone to another bone portion. In some examples, the end faces of the two bones that define the TMT joint are each prepared by cutting the end of each bone to create a shaped opening between the end faces. The opening may have a shape that allows the bones to be repositioned relative to each other (e.g., to partially or completely close the opening created during the realignment process) to facilitate realignment and subsequent fusion.

[0085] In one example, a clinician may cut the end of a bone being prepared in a transverse plane at an angle to the end surface to create a wedge-shaped section of bone that is free from the remaining portion of the bone being cut. This may create a wedge-shaped opening between the newly defined end of the bone being cut and the bone on the opposite side of the TMT joint being prepared. The wedge-shaped opening may widen moving from the medial side of the TMT joint to the lateral side of the TMT joint. For example, the wedge-shaped bone portion and corresponding opening may have a generally triangular shape. The wedge-shaped opening may provide a gap across the TMT joint that can be closed by subsequent pivoting of the metatarsal in the transverse plane. However, again, other shaped cuts may be made in one or both bones facing the TMT joint without departing from the scope of this disclosure. Exemplary bone cutting shapes and configurations that may be used in one or more of the bone ends that define the TMT joint are described in U.S. Pat. No. 10,512,470, entitled "OSTEOTOMY PROCEDURE FOR CORRECTING BONE MISALIGNMENT," issued December 24, 2019, and U.S. Pat. No. 10,582,936, entitled "DEVICES AND TECHNIQUES FOR PERFORMING AN OSTEOTOMY PROCEDURE ON A FIRST METATARSAL TO CORRECT A BONE MISALIGNMENT," issued March 10, 2020, the entire contents of both of which are hereby incorporated by reference into this specification.

[0086] 5A is a top view of a foot 10 showing an exemplary cutting guide 150 positioned over the second and third TMT joints to illustrate exemplary bone wedges that may be cut during joint preparation. In this example, the cutting guide 150 is shown defining a first guide surface 152 (shown as a cutting slot) positioned over the portions of the second metatarsal 14 and third metatarsal 16 to be cut. The cutting guide 150 is also shown defining a second guide surface 154 (shown as a cutting slot) positioned over the portions of the middle cuneiform 28 and lateral cuneiform 30 to be cut. A clinician can advance a cutting instrument parallel to the first guide surface 152 to cut the end of the second metatarsal 14 and the end of the third metatarsal 16. A clinician can also advance a cutting instrument parallel to the second guide surface 154 to cut the ends of the middle cuneiform 28 and lateral cuneiform 30. In different implementations, the guide surface of the cutting guide 150 may define a straight, curved, and / or other shape, and thus guiding a cutting instrument parallel to the guide surface may result in a straight cut, a curved cut, or a cut of other shape across the bone.

[0087] In the example of FIG. 5A , the first guide surface 152 is shown angled in a cross-section spanning the second and third metatarsals 14, 16. The first guide surface 152 is shown angled from the medial proximal side of the second metatarsal 14 toward the lateral distal side of the third metatarsal 16. The lateral distal side of the third metatarsal 16 is relatively distal to the proximal location on the second metatarsal, but may still be on the proximal half of the metatarsal. By preforming an angled cut relative to the end face of the bone being cut, a wedge-shaped bone portion may be released from the bone. In FIG. 5A , a wedge-shaped section 156 of the second metatarsal 14 is released when cutting the second metatarsal. Additionally, a wedge-shaped section 158 of the third metatarsal 16 is released when cutting the third metatarsal. Each wedge-shaped section of bone removed via the cut may have a narrow width (e.g., apex) on the inside of the bone being cut and a wider width (e.g., base) on the outside of the bone being cut. The degree of angulation in a particular dimension of the bone wedge formed during the cut may vary depending on the patient's anatomy and the degree of deformity being corrected. In either case, the bone wedge so cut may be removed from the TMT joint space to define a wedge-shaped opening relative to the opposing bone.

[0088] In the example of FIG. 5A , a clinician may use second guide surface 154 to guide a cutting instrument to cut the ends of middle cuneiform 28 and lateral cuneiform 30 to promote fusion following metatarsal realignment. The cuts made to middle cuneiform 28 and lateral cuneiform 30 may be generally parallel to the end faces of the bones being cut (e.g., in the transverse plane) or may be angled relative to the end faces of the bones being cut. In yet other examples, one or both end faces of middle cuneiform 28 and lateral cuneiform 30 may not be cut, but may be prepared using a different technique (e.g., fenestration) as discussed above.

[0089] In some instances where the second and third metatarsals 14 and 16 are prepared by cutting, the metatarsals may be cut using a single continuous cut across both metatarsals. For example, the clinician may guide the cutting instrument linearly from the medial side of the second metatarsal 14 toward the lateral side of the third metatarsal 16, or from the lateral side of the third metatarsal toward the medial side of the second metatarsal. In either case, the clinician may form a continuous cut line across the ends of the second and third metatarsals. Such a continuous cut across the bases of the second and third metatarsals may be useful to facilitate a reliable reduction in the metatarsal adduction angle during subsequent bone realignment. In applications where the middle cuneiform 28 and lateral cuneiform 30 are cut in addition to or instead of the ends of the metatarsals, the two cuneiforms may or may not be cut using such a continuous cut across the ends of the two metatarsals.

[0090] In other applications of the surgical technique, the ends of the second and third metatarsals 14 and 16 may be cut independently (e.g., without moving the cutting instrument in a continuous cut across the two metatarsals). For example, if a patient exhibits a significant step-like misalignment (e.g., distal offset) between the ends of the middle cuneiform 28 and the lateral cuneiform 30, the ends of the opposing second and third metatarsals 14, 16 may be prepared independently (e.g., through two separate cuts) instead of making a continuous cut across the ends of the two metatarsals. The ends of the opposing second and third metatarsals 14, 16 may also be prepared independently for other reasons, such as to provide independent control / adjustability over the cut angle on the second and third metatarsals.

[0091] While FIG. 5A illustrates one exemplary cutting guide 150 and one exemplary cutting configuration that can be used to prepare the ends of the second and third TMT joints, it should be appreciated that the techniques disclosed herein are not limited to such exemplary guides or cutting configurations. For example, the techniques disclosed herein may be performed freehand (without the use of a cutting guide) or with cutting guides having different configurations. In addition to or instead of using a cutting guide, a clinician may position a bone preparation template on one or more bone portions to be subsequently cut. The bone preparation template may be configured (e.g., sized and / or shaped) to indicate locations on the underlying bone where the bone should be cut or otherwise prepared. Positioning the bone preparation template on the underlying bone may mark or otherwise indicate on the bone where the bone should be prepared, and / or the clinician may use the bone preparation template to mark where on the bone the bone should be prepared. The clinician may subsequently remove the bone preparation template and pre-form bone preparation steps (e.g., cuts) at the locations marked or otherwise indicated using the template.

[0092] 5A shows angled cuts being made at the ends of the second and third metatarsals 14 and 16, such angled cuts are not required. Generally, either or both of the metatarsals and cuneiform bones forming the TMT joint being prepared may be cut to establish openings for rotating the metatarsals in one or more planes (e.g., the transverse plane) and / or to facilitate realignment of one or more bones. The other of the bones forming the TMT joint may also be prepared by cutting, or may be prepared using a different bone preparation technique.

[0093] As one example, a clinician may remove a wedge-shaped section of bone 156 from the second metatarsal and a wedge-shaped section of bone 158 from the third metatarsal. The clinician may cut, fenestrate, and / or otherwise prepare the ends of the opposing middle cuneiform 28 and lateral cuneiform 30. In another example, a clinician may remove a wedge-shaped section of bone from the middle cuneiform 28 and / or a wedge-shaped section of bone from the lateral cuneiform 30. The clinician may cut, fenestrate, and / or otherwise prepare the ends of the opposing second metatarsal 14 and third metatarsal 16. In yet another example, a clinician may remove a wedge-shaped section of bone from a cuneiform bone at one of the second and third TMT joints and a wedge-shaped section of bone from the other metatarsal bone at the other of the second and third TMT joints. The opposing bone end faces may be prepared parallel to the bone end faces, at an angle, and / or in other ways (e.g., with or without cutting). For example, a clinician may remove both wedge-shaped sections from the ends of both bones that form the TMT joint. In either case, the opening created between the bone ends defining the TMT joint may be defined by the cumulative amount of bone removed from both bone ends. As noted above, depending on the characteristics of the patient undergoing the surgical procedure, in still other embodiments, a clinician may not cut the bone end faces defining the second and third TMT joints, or may perform bone cuts parallel to the bone end faces. Furthermore, although the foregoing examples are described as being performed by removing wedge-shaped sections of bone, sections of bone having other shapes may be removed, as described herein.

[0094] In instances where a clinician cuts an end surface of a bone, the clinician may or may not perform one or more additional preparation steps on the end surface before or after cutting the end surface. In some instances, the clinician fenestrates the newly formed end surface of the bone after cutting the bone. The clinician may use a drill to fenestrate the newly formed end surface of the bone being cut, which may help promote subsequent fusion of the bone following realignment. The clinician may fenestrate the bone surface by creating multiple openings (e.g., drill holes) in the bone surface to provide multiple bleeding points at the end of the bone surface. Each drill hole may be relatively small relative to the cross-sectional area of ​​the end surface, for example, less than 10% of the cross-sectional area of ​​the end surface, less than 5% of the cross-sectional area of ​​the end surface, or less than 1% of the cross-sectional area of ​​the end surface. The multiple openings may be arranged at different locations across the end surface to provide locations for promoting fusion across the end surface. The number of holes formed during fenestration may vary and, in some instances, may be greater than 5, e.g., greater than 10.

[0095] As another example of a preparation step that may be performed, a clinician may remove one or more protruding bone portions extending into and / or across the second and / or third TMT joint lines. The protruding bone portions may extend distally into the joint cavity from the cuneiform bone and / or proximally into the joint cavity from the metatarsal bone. For example, as discussed in more detail in connection with FIG. 29 , certain patients may exhibit a significant step-like misalignment, or distal offset, between adjacent joint planes (e.g., between the planes defining the second and third TMT joints). This may inhibit relative movement between the two joints for subsequent realignment and / or may inhibit insertion of a cutting guide into one or both joint cavities. For these and other reasons, a clinician may remove one or more protruding bone portions to create, for example, a pocket or continuous joint line extending across the second and third TMT joints. The clinician may remove one or more protruding bone portions using a cutting instrument, either freehand and / or with the aid of a cutting guide, such as cutting guide 292, discussed in more detail in connection with FIG. 30.

[0096] As another example, a clinician may typically visualize the position of the cutting guide and / or bone preparation template under x-ray imaging (e.g., fluoroscopy) to ensure, for example, that one or more guide planes or other guide features are properly positioned relative to one or more underlying bones. The clinician may adjust the position of the cutting guide or bone preparation template under imaging, for example, until one or more guide planes or other alignment features are positioned over the desired portion or region of the underlying bone to be marked, cut, and / or otherwise prepared.

[0097] 5B-5E illustrate exemplary bone preparation steps that may be performed on a foot 10 using an exemplary configuration of a cutting guide 150 in accordance with the disclosed technology. In particular, FIGS. 5B and 5C are perspective and top (dorsal) views of the foot 10 showing the cutting guide 150 positioned on the dorsal side of the foot. Specifically, the cutting guide 150 is shown having a first guide surface 152 positioned over the portions of the second metatarsal 14 and third metatarsal 16 to be cut, and a second guide surface 154 positioned over the portions of the middle cuneiform 28 and lateral cuneiform 30 to be cut. In this example, the cutting guide 150 defines at least one fixation aperture positionable over each of the second metatarsal 14, third metatarsal 16, middle cuneiform 28, and lateral cuneiform 30. A clinician can insert fixation pins through one or more (eg, all) of the fixation apertures to secure the cutting guide to the underlying bone.

[0098] In use, a clinician can guide a cutting instrument along first guide surface 152 to cut the end of second metatarsal 14 and the end of third metatarsal 16. A clinician can also guide a cutting instrument along second guide surface 154 to cut the ends of middle cuneiform 28 and lateral cuneiform 30. FIG. 5D is a perspective view of a foot showing exemplary bone portions that may be removed after cutting, specifically showing an exemplary wedge-shaped section 156 removed from second metatarsal 14 and an exemplary wedge-shaped section 158 removed from third metatarsal 16. Additional sections of bone may be removed from middle cuneiform 28 and lateral cuneiform 30. FIG. 5E illustrates an exemplary opening 157 formed between the second metatarsal 14 and the middle cuneiform 28 upon removal of one or more bone portions, and an exemplary opening 159 formed between the third metatarsal 16 and the lateral cuneiform 30 upon removal of one or more bone portions.

[0099] With further reference to FIG. 4 , an exemplary technique includes moving (110) the second and third metatarsals 14, 16 in at least one plane. While FIG. 4 schematically illustrates an exemplary order in which the second and third metatarsals 14, 16 are moved after preparing the end faces of the metatarsals 14, 16 and the opposing medial and lateral cuneiforms 28, 30, other orders of bone preparation and movement may be performed. For example, a clinician may move the second and / or third metatarsals 14, 16 before preparing one or more metatarsals and / or one or more cuneiforms (e.g., before preparing the end faces of all bones). For example, a clinician may move the second and / or third metatarsals 14, 16, and then prepare the end faces of the metatarsals 14, 16 and the opposing medial and lateral cuneiforms 28, 30. In these implementations, after preparing the end faces of the metatarsals and cuneiform bones, the clinician may or may not further move the second and / or third metatarsals 14, 16. As another example, the clinician may prepare the end faces of one or more bones (e.g., one or more metatarsals and / or cuneiform bones), move one or both of the second metatarsal 14 and the third metatarsal 16, and then prepare the end faces of one or more other bones (e.g., one or more metatarsals and / or cuneiform bones).

[0100] Independent of the order of movement and bone preparation, the clinician may move the second and third metatarsals 14, 16 in one or more planes, such as the transverse plane, by, for example, pivoting the metatarsals about their proximal ends and moving the distal ends of the metatarsals laterally in the transverse plane. In instances where a wedge-shaped opening is formed at the second and / or third TMT joint during bone formation, lateral rotation of the distal ends of the second and third metatarsals may close the wedge-shaped opening (or, in instances where a non-wedge-shaped opening is created, may close a differently shaped opening). For example, lateral translation of the distal ends of the second and third metatarsals 14, 16 in the transverse plane may align the ends of the second metatarsal 14 and the opposing medial cuneiform 28 and the third metatarsal 16 and the opposing lateral cuneiform 30 in a generally parallel fashion. In addition to or instead of translating one or both bones in the transverse plane, the clinician may translate the second and / or third metatarsals in the frontal and / or sagittal planes. For example, the clinician may rotate one or both bones in the frontal plane and / or translate one or both bones (e.g., dorsally) in the sagittal plane.

[0101] Generally, translation of the second and third metatarsals 14, 16 in the transverse plane can close the metatarsal adduction angle. The metatarsal adduction angle can be the angular measurement formed between a line bisecting the second metatarsal and a vertical line bisecting the lesser foot on a supine radiograph. In some instances, the second and third metatarsals 14, 16 are translated until the metatarsal adduction angle for each metatarsal is 15° or less, e.g., 12° or less, 10° or less, 7° or less, 5° or less, or 3° or less.

[0102] The second metatarsal 14 and the third metatarsal 16 may be moved individually or together (e.g., as a bone block). Moving the second and third metatarsals 14, 16 as a jointed group may help achieve a more natural realignment of the metatarsals and correction of metatarsal adduction deformity. To support moving the second and third metatarsals 14, 16 as a jointed group, the ligaments between the two metatarsals may be preserved during preparation of the second and third TMT joints. For example, the plantar TMT ligament and the ligament between the second and third metatarsals 14, 16 may be preserved (e.g., left uncut or unruptured) during preparation and movement of the second and third metatarsals. Preserving the ligament structure may help avoid instability of the second and third TMT joints during deformity reduction, which may improve anatomical realignment of the bony structures.

[0103] FIG. 6 is a schematic diagram illustrating the ligamentous structure of the foot. As shown, the plantar TMT ligaments include the second plantar metatarsal ligament between the medial cuneiform 26 and the second and third metatarsals 14, 16. The plantar TMT ligaments also include the third plantar metatarsal ligament between the lateral cuneiform 30 and the third metatarsal 16. The first plantar metatarsal ligament extends between the second and third metatarsals 14, 16. Ligamentous attachments between the second and third metatarsals, such as the second and third plantar metatarsal ligaments and the first plantar metatarsal ligament, may be preserved during preparation and movement of the second and third metatarsals to correct metatarsal adduction. This may allow the two metatarsals to move together as a joined bone group.

[0104] To move the second and third metatarsals 14, 16, either alone or in combination, the bones may be pivoted about their proximal bases, causing the distal ends of the bones to translate laterally in the transverse plane. When moving the second and third metatarsals 14, 16 as a group, the clinician may pivot the second and third metatarsal blocks about the proximal medial portion of the second metatarsal 14. The clinician may move the second and third metatarsals 14, 16 as a combined group in the transverse plane, with or without simultaneously rotating both bones in the frontal plane and / or adjusting the sagittal position of the bones. In some implementations, the clinician moves the second and third metatarsals 14, 16 as a group around the Lisfranc ligament, with the second metatarsal remaining attached to the Lisfranc ligament. Thus, the Lisfranc ligament may function as a hinge or pivot point about which the second and third metatarsal groups can rotate in the transverse plane.

[0105] In other examples, the clinician may move the second and third metatarsals 14, 16 substantially independently (e.g., by applying separate movement forces to each metatarsal). For example, the clinician may apply a force to move the third metatarsal 16 in one or more planes, such as in two or more planes or in all three planes, followed by a force to move the second metatarsal 14 in one or more planes (or alternatively, move the second metatarsal 14 followed by move the third metatarsal). The clinician may or may not cut or otherwise release one or more ligament attachments interconnecting the second and third metatarsals 14, 16 to help facilitate independent repositioning of the two bones.

[0106] Regardless of whether the clinician moves the second and third metatarsals 14, 16 together or independently, the intermetatarsal angle between the second and third metatarsals may or may not change during the correction of metatarsal adduction. In other words, the intermetatarsal angle between the second and third metatarsals 14, 16 may or may not be compressed from the intermetatarsal angle before the correction to the intermetatarsal angle exhibited after the correction. In some implementations, the second and third metatarsals 14, 16 are pivoted as a group in the transverse plane without substantially changing the intermetatarsal angle between the second and third metatarsals. For example, the intermetatarsal angle between the second and third metatarsals may change (e.g., decrease) by less than 5°, e.g., less than 2°, or less than 1°, from the angle exhibited before the correction of metatarsal adduction to the angle exhibited after the correction technique is performed.

[0107] To help facilitate movement of the second and third metatarsals in the transverse plane, the clinician may perform a soft tissue release between the third metatarsal 16 and the fourth metatarsal 18. The soft tissue release may mobilize the third metatarsal relative to the adjacent fourth metatarsal, allowing the joined second-third metatarsal block to be pivoted in the transverse plane.

[0108] In addition to shifting the second and third metatarsals in the transverse plane, the clinician may also shift the fourth and fifth metatarsals 18, 20 in one or more planes (e.g., one or more of the transverse, frontal, and sagittal planes), for example, to close the metatarsal adduction angle exhibited by those lesser metatarsals. Indeed, shifting the second and third metatarsals 14, 16 in one or more planes (e.g., the transverse plane) may naturally correct the fourth and fifth metatarsals in the same one or more planes (e.g., the transverse plane) without requiring separate surgical intervention on the fourth and fifth metatarsals 18, 20. For example, when the clinician rotates the distal ends of the second and third metatarsals 14, 16, either alone or in combination, the distal ends of the fourth and fifth metatarsals 18, 20 may also shift laterally. The proximal base of the fourth metatarsal 18 and the proximal base of the fifth metatarsal 20 may turn relative to the cuboid 32 to close the metatarsal adduction angle of the fourth and fifth metatarsals. Without wishing to be bound by any particular theory, it is believed that forces applied to the second and / or third metatarsals during locomotion are transmitted through the tissue and ligamentous structures interconnecting such metatarsals to the fourth and fifth metatarsals, tensioning and realigning the lesser metatarsals.

[0109] The positions of the fourth metatarsal 18 and the fifth metatarsal 20 may be corrected without surgically accessing and preparing the metatarsals (in response to correcting the second metatarsal 14 and / or the third metatarsal 16). However, in other applications, a clinician may surgically access and prepare the bones defining the fourth TMT joint 40 and / or the fifth TMT joint 42 in addition to or instead of preparing one or more other TMT joints. For example, a clinician may surgically access and prepare the bones defining the fourth TMT joint 40 and / or the fifth TMT joint 42 before or after moving the fourth metatarsal 18 and / or the fifth metatarsal 20 in one or more planes (e.g., separately from or in combination with moving the second metatarsal 14 and / or the third metatarsal 16). The clinician may decide whether to access and prepare the bones defining the fourth TMT joint 40 and / or fifth TMT joint 42 depending, for example, on the nature of the deformity being corrected and their perception of the need to prepare the joint for bone realignment and / or fusion.

[0110] The clinician may prepare the ends of the fourth and / or fifth metatarsals 18, 20 and / or the end of the cuboid bone 32 opposite the ends of the fourth and / or fifth metatarsals to facilitate realignment and / or fusion. The clinician may prepare one or more of the bone ends using any of the bone preparation techniques discussed herein. In various examples, the clinician may prepare the ends of the fourth and fifth metatarsals 18, 20 independently, or may prepare the ends of the metatarsals together (e.g., by positioning a single continuous cutting guide plane on both ends to make successive cuts, as discussed in connection with the preparation of the second metatarsal 14 and the third metatarsal 16). Additionally or alternatively, the clinician may prepare the portions of the end faces of the cuboid bone 32 facing the fourth and / or fifth metatarsals 18, 20, either together or through separate preparation steps.

[0111] In instances where a clinician accesses and prepares the bones defining the fourth TMT joint 40 and / or the fifth TMT joint 42, one or both of the fourth metatarsal 18 and the fifth metatarsal 20 may be realigned in one or more planes in response to forces applied to the second and / or third metatarsal 14, 16 (e.g., by translating forces through tissue and ligament structures interconnecting the metatarsals). Additionally or alternatively, the clinician may apply forces to the fourth metatarsal 18 and / or the fifth metatarsal 20 to move one or both metatarsals in one or more planes, such as two or more planes or all three planes. The fourth and fifth metatarsals 18, 20 may be moved as a joined bone block (e.g., bone blocks connected to or separate from the bone blocks of the second and third metatarsals 14, 16) and / or may be moved substantially independently of one another (e.g., by applying separate movement forces to each metatarsal). Additionally, the clinician may apply a force that displaces only one of the fourth or fifth metatarsals.

[0112] In a typical metatarsal adduction deformity, the metatarsals may exhibit a substantially uniplanar deviation in the transverse plane (but may also deviate in the frontal and / or sagittal planes). For this reason, the exemplary technique of FIG. 4 has been generally described as correcting the second and third metatarsals 14, 16 (and optionally the fourth and fifth metatarsals 18, 20) in the transverse plane. To correct a generally uniplanar deviation, a clinician may move the metatarsals only in the transverse plane. Alternatively, a clinician may move one or more of the realigned metatarsals (e.g., multiple or all of the realigned metatarsals) in more than one plane. For example, in addition to or instead of realigning the metatarsals in the transverse plane, a clinician may adjust the rotation angle of the metatarsals in the frontal plane and / or adjust the angle of the metatarsals in the sagittal plane.

[0113] When a clinician performs a multiplanar realignment, the clinician may simultaneously move one or more metatarsals in multiple planes through a single movement, for example, by moving the metatarsals in an arc or other path of movement to adjust the position of the metatarsals in multiple planes. Optionally, the clinician may further refine the moved position of one or more metatarsals, for example, with the aid of a bone positioning device and / or by manually grasping the metatarsals (e.g., with the aid of pins inserted into the metatarsals) to confirm the position of the metatarsals before fixation.

[0114] In other examples, the clinician may perform different movement steps to move one or more metatarsals in different planes. For example, the clinician may first move one or more metatarsals in one or two planes (e.g., the transverse, frontal, or sagittal plane), then move one or more metatarsals in one or two other planes (e.g., another of the transverse, frontal, or sagittal planes), and optionally follow this with moving one or more metatarsals in a third plane. In other words, the clinician may perform different actions to move one or more metatarsals in different planes. Each movement step may be performed with the aid of a bone positioning device (which may be the same device or different devices for the different movement steps) and / or by manually grasping the metatarsal (e.g., with the aid of a pin inserted into the metatarsal).

[0115] In some instances, in addition to or instead of translating the metatarsals laterally, the clinician may translate one or more of the metatarsals being realigned (e.g., the second metatarsal 14 and / or the third metatarsal 16) proximally in the transverse plane toward the opposing bone. For example, the clinician may simultaneously translate the metatarsals being realigned (e.g., the second metatarsal 14 and / or the third metatarsal 16) laterally and proximally in an arc (e.g., a parabola) to establish the translated position of one or both metatarsals.

[0116] The clinician can move one or more metatarsals being realigned (e.g., the second metatarsal 14 and / or the third metatarsal 16) by hand and / or with the aid of one or more instruments. For example, the clinician can grasp the second and / or third metatarsal and advance the distal ends of the metatarsals laterally to decrease the metatarsal adduction angle. The clinician can insert one or more pins into the metatarsals being realigned (e.g., the second and / or third metatarsal) to provide a joystick or structure that can be grasped to manipulate the bone movement. Additionally or alternatively, the clinician can utilize a tenon or tongs to grasp one or both of the second and third metatarsals to facilitate the realignment.

[0117] In some instances, a clinician may use a bone positioning guide (also referred to as a bone positioning device) to assist in applying force to the metatarsals (e.g., the second metatarsal 14 and / or the third metatarsal 16) to facilitate realignment. The bone positioning guide may include one end that engages the metatarsal to which force is being applied (e.g., a provisionally anchored or unlocked contact point) and another end that engages a different bone (e.g., a provisionally anchored or unlocked contact point). For example, the bone positioning guide may have one end that engages the second metatarsal 14 and / or the third metatarsal 16 and another end that engages a bone other than the second and / or third metatarsals (e.g., the lesser metatarsal, cuneiform, or cuboid). The bone positioning guide may have a mechanism that biases the two ends toward each other to reduce the metatarsal adduction angle. Exemplary bone positioning guide engagement mechanisms that can function to move the two ends of the guide toward each other include a screw or threaded rod, a ratchet, a rack and pinion, and / or other features that translate force applied by the clinician to move the two ends of the bone positioning guide toward each other. Details of exemplary bone positioning guides that can be used are described in U.S. Patent No. 9,936,994, issued April 10, 2018, and entitled "BONE POSITIONING GUIDE," the entire contents of which are incorporated herein by reference.

[0118] FIG. 7A is a side perspective view of an exemplary bone positioner 60 (also referred to as a bone positioning device) that can be used to move a metatarsal bone relative to an adjacent bone. In some implementations, the bone positioning device includes a metatarsal engagement member, a tip, and a mechanism for moving the metatarsal engagement member and the tip relative to one another in one or more planes. For example, the mechanism may move the metatarsal engagement member and the tip toward one another (e.g., moving the metatarsal engagement member toward the tip, moving the tip toward the metatarsal engagement member, or moving both simultaneously). The bone positioning device may also include an actuator for actuating the mechanism. When engaged, the mechanism can move a metatarsal engaged with the metatarsal engagement member to correct alignment in at least one plane with a second bone in contact with the tip.

[0119] In the embodiment of FIG. 7A , bone positioning device 60 includes a body member 62, a shaft 64, and a metatarsal engagement member 66 connected to the shaft, with a tip 68 connected to the body member. Generally, body member 62 may be sized and shaped so as not to interfere with anatomical structures or other instruments (e.g., pins and guides) while being positioned on a patient. In the embodiment of FIG. 7A , body member 62 is generally C-shaped. Although bone positioning device 60 is shown as being formed from two components, body member 62 and shaft 64, a guide may be made from more components (e.g., three, four, or more) joined together to form the guide.

[0120] The shaft 64 may be movably connected to the body member 62. In some embodiments, the shaft 64 includes threads 70 that engage the body member 62 such that rotation of the shaft translates the shaft relative to the body member. In other embodiments, the shaft may slide within the body member and be fixed there in a desired position with a set screw. In still other embodiments, the shaft may be moved relative to the body by a ratchet mechanism or other mechanism that rotates and / or linearly translates the metatarsal engagement member 66 relative to the tip 68. In the illustrated embodiment, the shaft moves along an axis that intersects with the tip. In other embodiments, the shaft and / or metatarsal engagement member are offset from the tip.

[0121] Generally, metatarsal engagement member 66 may be configured (e.g., sized and / or shaped) to be positioned in direct or indirect contact with the metatarsal to be repositioned. For example, depending on the size and / or shape of metatarsal engagement member 66, the metatarsal engagement member may be positioned subcutaneously in contact with the metatarsal to be realigned, or in contact with the lateral side of the skin covering the metatarsal to be realigned. For example, in either configuration, metatarsal engagement member 66 may be positioned on the medial side of the metatarsal to be realigned (e.g., the medial side of second metatarsal 14, third metatarsal 16, fourth metatarsal 18, fifth metatarsal 20), with tip 68 positioned in contact with (e.g., with or without provisional fixation to) another bone, such as a lateral bone.

[0122] The metatarsal engagement member 66 may define a concave shape to generally fit around and / or partially encase the underlying cylindrical bone. The concave shape may include defining a continuous radius of curvature, a V-shape, flat areas between outwardly extending side walls, and / or other shapes with recesses. In yet other examples, the metatarsal engagement member 66 may be planar.

[0123] The tip 68 can be useful for contacting a bone, such as a bone different from the bone being moved by the bone positioning device 60. For example, if the metatarsal engagement member 66 is positioned on the medial side of one metatarsal, the tip can be positioned with the lateral side of a different metatarsal (e.g., the third, fourth, or fifth metatarsal) in direct contact with that bone or on the lateral side of the skin overlying such metatarsal. In different configurations, the tip 68 can be straight or tapered to facilitate percutaneous insertion and contact with the bone. The tip can also include a textured surface, such as serrated, roughened, cross-hatched, knurled, etc., to reduce slippage between the tip and the bone. In the illustrated embodiment, the tip 68 further includes a depth stop 74. The depth stop 74 can limit the depth of insertion between the metatarsals (e.g., by contacting the dorsal side of the metatarsal where the tip 68 is intended to be positioned).

[0124] As shown in FIG. 7A , bone positioning device 60 may also include an actuator (e.g., a knob or handle) 76 for actuating the mechanism, which in this embodiment is associated with the shaft. In the illustrated embodiment, the actuator may be useful for allowing a user to rotate the shaft relative to body member 62. Actuator 76, shaft 64, and / or metatarsal engagement member 66 may include cannulae 78 extending therethrough to allow placement of fixation wires (e.g., K-wires) through these components and into or through the bone engaged with the metatarsal engagement member. For example, a fixation wire may be placed into the bone engaged with metatarsal engagement member 66 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 an adjacent bone to maintain the position of the bone in contact with the metatarsal engagement member and the adjacent bone. Although the shaft 64 and actuator 76 are shown as protruding away from the side of the body member 62, one or both features may be positioned in a different location (e.g., extending dorsally beyond the body member 62 via a mechanical linkage) to facilitate positioning of the bone positioning guide 60 (e.g., particularly the metatarsal engagement member 66) in the intermetatarsal space.

[0125] Any of the instrument embodiments described herein (e.g., cutting guides, bone preparation templates, bone positioners) may include or be made of any suitable material (e.g., metal, plastic). In certain embodiments, instruments such as bone positioners are made at least in part from radiolucent materials, such as thermoplastics and carbon fiber materials, so as to be relatively transparent to x-rays and other forms of radiation. Such materials are useful so that when the instrument is positioned on the bone, it does not interfere with visualization of the bone using an imaging device.

[0126] Another type of bone positioning guide that can be used to move metatarsals in one or more planes, such as those used to move the second and third metatarsals 14 and 16 in at least the transverse plane, is a compressor instrument. For example, if an opening (e.g., a wedge-shaped opening) is created in the second and third TMT joints during epiphyseal preparation, a compressor may be attached to the second and / or third metatarsals and to another bone, such as the middle cuneiform and / or lateral cuneiform, respectively. The compressor may apply a distal-to-proximal force across the second and / or third TMT joints, causing the wedge-shaped opening created across the joints to close. When the wedge-shaped opening closes, the distal end of the second and / or third metatarsal 14 and / or 16 may pivot in the transverse plane. In use, the compressor may also compress the ends of the bone surfaces together to facilitate subsequent fusion, for example, by compressing the middle cuneiform 28 and second metatarsal 14 together and / or by compressing the lateral cuneiform 30 and third metatarsal 16 together.

[0127] 7B is a diagram of an exemplary compressor device 160 engaged with the foot 10 to facilitate movement of the second and third metatarsals. In this example, the compressor device 160 has a first end 162 that engages the second metatarsal and a second end 164 that engages the middle cuneiform bone. Notably, in the illustrated configuration, the first and second ends 162, 164 of the compressor device 160 are shown as being pinned to the bone. The compressor device 160 can be actuated by a clinician to move the first and second ends 162, 164 of the compressor toward each other. This draws the ends of the second metatarsal and middle cuneiform bones to which the compressors are attached toward each other, closing the wedge-shaped opening in the TMT joint space and translating the distal end of the second metatarsal laterally. As shown in Figure 7, a force applied across the second TMT joint can also close the wedge-shaped opening at the third TMT joint, displacing the second and third metatarsals as a group of bones. This can then displace the fourth and fifth metatarsals as well, at least in the transverse plane, reducing their metatarsal adduction angles.

[0128] Additional details regarding exemplary compressor structures that may be used in accordance with the present disclosure are described in U.S. Patent Application Publication No. 2020 / 0015856, filed July 11, 2019, and entitled "COMPRESSOR-DISTRACTOR FOR ANGULARLY REALIGNING BONE PORTIONS," the entire contents of which are incorporated herein by reference. Additionally, while the exemplary compressor device 160 in FIG. 7B is shown as being mounted across the second TMT joint, the compressor may additionally or alternatively be mounted across the third TMT joint (e.g., with a first end 162 attached to the third metatarsal 16 and a second end 164 attached to the lateral cuneiform 30), or across yet another set of bones (e.g., across the fourth TMT joint 40 and the fifth TMT joint 42).

[0129] With further reference to FIG. 4 , an exemplary technique is shown that includes provisionally fixing (112) the displaced positions of the second and third metatarsals. For example, after displacing the second and third metatarsals to a desired realigned position in one or more planes, such as the transverse plane (which may also include displacing the fourth and fifth metatarsals), the clinician may optionally provisionally fixate the displaced positions. Provisional fixation may maintain the displaced positions of one or more bones to facilitate subsequent surgical steps, such as applying one or more permanent fixation devices and / or performing additional surgical steps (e.g., realigning the first metatarsal).

[0130] To temporarily fixate the displaced position of one or more bones, the clinician may insert one or more pins into and / or through the displaced bone and into an adjacent bone. For example, the clinician may insert a pin through the second metatarsal bone and into an adjacent bone (e.g., the cuneiform bone) and / or insert a pin through the third metatarsal bone and into an adjacent bone. The pins may take the form of rods and / or wires (K-wires) and may or may not be configured to apply compression across the joint between the bones into which they are inserted, for example, by having an enlarged region of the pin that presses the tip of the pin against the outer surface of the bone into which it is inserted, thereby applying compression.

[0131] 8A is a rear view of an exemplary x-ray image showing an exemplary temporary fixation pin configuration. In this example, a first fixation pin 170 is inserted into the distal base of the second metatarsal 14 and through it into the lateral cuneiform. A second fixation pin 172 is inserted into the distal base of the third metatarsal 16 and through it into the medial cuneiform.

[0132] In the illustrated configuration, the first and second pins 170, 172 are shown as intersecting, with the shaft of the first fixation pin 170 extending in a proximal medial to distal lateral direction and the shaft of the second fixation pin 172 extending in a proximal lateral to distal medial direction. In other cases, the first and second pins 170, 172 do not intersect but instead may be oriented parallel, such as with the shafts of both pins extending in a distal medial to proximal lateral direction. Figure 8B is a rear view of another exemplary x-ray image showing a temporary fixation pin configuration in which the first and second pins 170, 172 are both positioned extending in a proximal medial to distal lateral direction.

[0133] The clinician may use different numbers, configurations, and / or positioning of fixation pins. For example, depending on the number of TMT joints being prepared, the clinician may insert temporary fixation pins through the ends of one or more of the second metatarsal 14, the third metatarsal 16, the fourth metatarsal 18, and / or the fifth metatarsal 20, with the pins extending into and / or through the ends of the metatarsals and further into another bone, such as the opposing cuneiform and / or cuboid. Additionally or alternatively, the clinician may insert temporary fixation pins through the side (e.g., medial, lateral) of one metatarsal being fixed and into an adjacent metatarsal.

[0134] Independent of whether the clinician places a temporary fixation device, the clinician may apply one or more permanent fixation devices to facilitate fusion of the second and third TMT joints following reduction of the metatarsal adduction angle (step 114 of FIG. 4 ). One or more fixation devices may extend across the second and / or third TMT joints (and / or other TMT joints in instances where different TMT joints are prepared for fusion) to secure and hold the opposing epiphysis together for fusion. For example, the clinician may apply a first fixation device across the second TMT joint and a second fixation device across the third TMT joint.

[0135] A bone fixation device may be any feature or combination of features that holds two bone portions in a fixed relationship to one another to facilitate fusion of the bone portions during subsequent healing. Any one or more bone fixation devices that may be used include, but are not limited to, bone screws (e.g., compression bone screws), bone plates, bone staples, external fixators, intramedullary implants, and / or combinations thereof. Depending on the type of bone fixation device selected, the bone fixation device may be attached to the exterior surface of the bone portions being fixed or may be placed inside the bone portions as an intramedullary device.

[0136] In one example, a clinician may place a first bone plate across the second TMT joint. The first bone plate may be secured to the second metatarsal 14 on one side and secured to the middle cuneiform 28 on the other side, spanning the second TMT joint. The clinician may place a second bone plate across the third TMT joint. The second bone plate may be secured to the third metatarsal 16 on one side and secured to the lateral cuneiform 30 on the other side, spanning the third TMT joint. Additionally or alternatively, the clinician may apply a U-shaped plate or other shaped plate that spans both the second and third TMT joints (e.g., such that the U-shaped plate is attached to the middle and lateral wedges at the base of the U and the legs of the U are attached to the metatarsals). Independent of the number of plates used, each bone plate may be secured to the underlying bone using one or more screws, staples, and / or other fixation mechanisms. When bone plates are used, each bone plate may be linear or may have a non-linear shape, such as a Y-shape, L-shape, T-shape, U-shape, and / or other geometric profile. It should be understood that when the terms "first" and "second" are used herein to modify nouns, such use is intended merely to distinguish one item from another and is not intended to dictate a pre-determining order of treatment steps, unless otherwise specified.

[0137] As briefly discussed above, metatarsal adduction deformity can manifest as hallux valgus misalignment in some patients. Therefore, a clinician who performs a metatarsal adduction correction procedure may also perform a hallux valgus correction on the patient being treated. In the exemplary FIG. 4 , the exemplary technique is shown as including a first metatarsal realignment step (116). While the technique in FIG. 4 shows the first metatarsal realignment being performed after reduction and permanent fixation of the second and third TMT joints, a different surgical sequence may be performed. For example, the first metatarsal may be realigned before shifting the lesser metatarsals (e.g., the second and third metatarsals), or after shifting the lesser metatarsals (e.g., the second and third metatarsals) but before permanently fixating the lesser TMT joints.

[0138] While the order of surgical procedures can vary, in some applications it is useful to correct the alignment of one or more lesser metatarsals (e.g., the second and / or third metatarsals) before correcting the alignment of the first metatarsal. By first correcting the position of the lesser metatarsals, such as the second and third metatarsals (and in some instances, also correcting the position of the fourth and fifth metatarsals), the clinician may be able to more anatomically realign the first metatarsal relative to the aligned lesser metatarsals. Correcting the alignment of one or more of the lesser metatarsals may change the degree of misalignment of the first metatarsal, which can then be further corrected during a subsequent step of realigning the first metatarsal.

[0139] To correct the alignment of the first metatarsal 12, the clinician may surgically access the first TMT joint as discussed above. Once accessed, the clinician may prepare the end of the first metatarsal 12 and the opposing end of the medial cuneiform 26. The clinician may prepare the ends of the bones with or without cutting (e.g., using any of the preparation techniques discussed herein), as discussed above in connection with the preparation of the ends of the second metatarsal 14 and the third metatarsal 16. In instances where the clinician prepares one or more epiphysis using a cutting instrument, the clinician may or may not utilize a cutting guide to guide the controlled cutting of the epiphysis and / or a bone preparation template to indicate where the bone preparation should occur.

[0140] Either before or after preparing one or both ends of the first metatarsal 12 and the medial cuneiform 26, the clinician may move the first metatarsal 12 in at least one plane (e.g., the transverse plane, the frontal plane) to close the intermetatarsal angle between the first metatarsal and the second metatarsal 14. In some instances, the clinician moves the first metatarsal in multiple planes, such as the transverse plane, the frontal plane, and / or the sagittal plane. The clinician may or may not utilize a bone positioning guide to facilitate movement of the first metatarsal relative to the second metatarsal and / or the medial cuneiform. Once the first metatarsal has been moved to the desired position, the clinician may optionally provisionally fix the moved position of the first metatarsal and then permanently fix the moved position using one or more bone fixation devices, such as those described above. Additional details about exemplary first metatarsal realignment instruments and techniques that may be used are described in U.S. Patent No. 9,622,805, entitled "BONE POSITIONING AND PREPARING GUIDE SYSTEMS AND METHODS," issued April 18, 2017.

[0141] 9A and 9B are dorsal x-ray images of an exemplary foot 10 before and after, respectively, a therapeutic procedure performed according to the exemplary surgical technique described above with respect to FIG. 4. FIG. 9A illustrates the foot 10 with metatarsal adduction and hallux valgus deformity. FIG. 9B illustrates the foot 10 after realignment of the second and third metatarsals in at least the transverse plane and multiplanar correction of the first metatarsal in all three planes. FIG. 9B illustrates three bone plates applied across the first, second, and third TMT joints to facilitate fusion across the three joints.

[0142] 4 has been generally described with reference to preparation of the second TMT joint 36 and the third TMT joint 38 and movement of both the second metatarsal 14 and the third metatarsal 16 (optionally in combination with movement of the fourth metatarsal 18 and the fifth metatarsal 20), the technique and / or device may also be performed on a single TMT joint and / or different TMT joints without departing from the scope of this disclosure. For example, the technique of FIG. 4 may be performed on a single minor TMT joint, such as only the second TMT joint 36, only the third TMT joint 38, only the fourth TMT joint 40, or only the fifth TMT joint 42, in each case optionally combined with preparation of the first TMT joint 34 and realignment of the first metatarsal. Other combinations of joint preparations are also possible.

[0143] In applications where a clinician prepares only a single smaller TMT joint for fusion (again, optionally as part of a procedure that also prepares a first TMT joint), the clinician may move the lesser metatarsal associated with that TMT joint in one or more planes, for example, using the devices and / or techniques discussed herein. Repositioning the metatarsal associated with the smaller TMT joint being prepared may or may not move one or more metatarsals adjacent to the lesser metatarsal being moved through ligamentous tissue. For example, if a clinician prepares a second TMT joint 36 and moves the second metatarsal 14, repositioning the second metatarsal may cause realignment of the third metatarsal 16, the fourth metatarsal 18, and / or the fifth metatarsal 20.

[0144] As discussed above, bone realignment techniques according to the present disclosure may include cutting the end of a cuneiform bone and / or the end of an opposing metatarsal bone. In such applications, a clinician may perform the cuts freehand or with the aid of one or more cutting guides (interchangeably referred to herein as cutting guides). The use of cutting guides may facilitate more accurate and reproducible cuts between patients and promote more consistent clinical results across a wide range of patients with anatomical variations. When cutting guides are used, the cutting guide may define at least one guide surface positionable generally on the side of the bone to be cut, such as the dorsal side. A clinician may place a cutting instrument adjacent to, and optionally in contact with, the guide surface and translate the cutting instrument relative to the guide surface to perform the cut in a plane parallel to the guide surface. For example, a clinician may place a cutting instrument in contact with the guide surface and then translate the cutting instrument relative to the guide surface, e.g., from the plantar side toward the bone and / or in a medial or lateral direction. The guide surface may constrain movement of the cutting instrument in a desired cutting direction.

[0145] FIG. 10 is a top view of foot 10 showing an exemplary cutting guide 150 introduced in connection with FIG. 5A above. Cutting guide 150 includes at least one guide surface positionable on the dorsal side of the bone to be cut. For example, cutting guide 150 includes guide surface 152A positionable on the dorsal side of second metatarsal 14 and third metatarsal 16. Guide surface 152A may extend linearly (e.g., parallel) or at an angle in a dorsal-to-plantar direction (i.e., in the sagittal plane) to guide a cutting tool in a direction defined by the guide surface. In use, a clinician can place a cutting tool in abutting relationship with guide surface 152A and advance the cutting tool relative to the guide surface to remove the end of the metatarsal bone being cut (e.g., second metatarsal 14 and / or third metatarsal 16).

[0146] In some examples, the cutting guide 150 defines a single guide surface. In other examples, the cutting guide 150 may include multiple guide surfaces spaced apart from one another to define a cutting slot between the guide surfaces, for example. In the illustrated example, the cutting guide 150 is shown having a first metatarsal guide surface 152A and a second metatarsal guide surface 152B parallel to the first guide surface, defining a cutting slot between the two guide surfaces. A clinician can insert a cutting tool, such as a saw blade, into the cutting slot to guide removal of a portion of the end of the second metatarsal 14 and a portion of the end of the third metatarsal 16.

[0147] As discussed above in connection with FIG. 4 , a clinician may prepare one or more lesser metatarsals (e.g., the second metatarsal 14 and the third metatarsal 16) independently and / or may prepare the ends of one or more lesser metatarsals together, for example, by making a continuous cut across the two metatarsals. In applications where a clinician desires to make a continuous cut across two metatarsals, the cutting guide 150 may be configured with a guide surface 152A (or a pair of guide surfaces 152A, 152B, as shown) that extends across multiple metatarsals, such as both the second metatarsal 14 and the third metatarsal 16. For example, the guide surface may define a continuous guide surface that extends from the medial-most portion of the second metatarsal 14 to the lateral-most portion of the third metatarsal 16. This may allow a clinician to utilize the guide surface to cut the entire second and third metatarsals in a medial-lateral direction. If so configured, the guide surface (e.g., cutting slot) may be sized to terminate at the medial-most portion of the second metatarsal 14 and / or the lateral-most portion of the third metatarsal 16, or may extend beyond such boundaries. Oversizing the guide surface allows the cutting guide 150 to be used with a wider set of patient populations. However, oversizing the guide surface may require closer attention from the clinician when utilizing the guide surface to make one or more cuts.

[0148] 11 is a top view of a foot 10 illustrating another example cutting guide 150 configuration in which the cutting guide is not configured with a continuous guide surface extending across multiple metatarsals (e.g., the second and third metatarsals 14 and 16), but instead has a discontinuous guide surface, i.e., two guide surfaces, separately positionable on each of the metatarsals. When so configured, the cutting guide 150 has guide surface regions positionable on each of the two lesser metatarsals (e.g., the second and third metatarsals 14 and 16), but may have a discontinuity or interruption between the guide surface regions that prevents a continuous cut across both metatarsals. One guide surface may extend from the medial to lateral side of one lesser metatarsal (e.g., the second metatarsal 14), and another guide surface may extend from the medial to lateral side of another lesser metatarsal (e.g., the third metatarsal 16). Parallel and offset guide surfaces 152B may be provided to define cutting slots, such as cutting slots on the second and / or third metatarsal bones.

[0149] 10 and 11, cutting guide 150 is also shown as having guide surfaces 154A positionable on the dorsal sides of middle cuneiform 28 and lateral cuneiform 30. Guide surfaces 154A may extend linearly (e.g., parallel) or angled in a dorsal-to-basal direction (in the sagittal plane) and may guide a cutting tool in a plane parallel to the guide surfaces. In use, a clinician can place a cutting tool in abutting relationship with guide surfaces 154A and advance the cutting tool relative to the guide surfaces to remove the ends of opposing cuneiform / cuboid bones, such as middle cuneiform 28 and lateral cuneiform 30.

[0150] Like metatarsal guide surface 152A, cuneiform guide surface 154A may define a single guide surface or may include multiple guide surfaces spaced apart from one another to, for example, define a cutting slot between the guide surfaces. In the illustrated example, cutting guide 150 is shown having a first cuneiform guide surface 154A and a second cuneiform guide surface 154B parallel to the first guide surface to define a cutting slot between the two guide surfaces. A clinician can insert a cutting tool, such as a saw blade, into the cutting slot to guide removal of a portion of the ends of medial cuneiform 28 and lateral cuneiform 30.

[0151] In some examples, the cuneiform guide surface 154A (or the pair of guide surfaces 154A, 154B as shown) extends across both the middle cuneiform 28 and the lateral cuneiform 30. For example, the guide surface may define a continuous guide surface extending from the medial-most portion of the middle cuneiform 28 to the lateral-most portion of the lateral cuneiform 30. This allows a clinician to utilize the guide surface to perform continuous cuts to cut the ends of both the middle and lateral cuneiforms. When so configured, the guide surface (e.g., cutting slot) may be sized to terminate at the medial-most portion of the middle cuneiform 28 and the lateral-most portion of the lateral cuneiform 30, or may extend beyond these boundaries to be oversized.

[0152] In other embodiments, the cutting guide is not configured with a continuous guide surface extending across the middle cuneiform 28 and the lateral cuneiform 30, but instead has a discontinuous guide surface, i.e., two guide surfaces, separately positionable on each of the cuneiform and / or cuboid bones. When so configured, the cutting guide 150 may have guide surface regions positionable on each of multiple bones, such as the middle cuneiform 28 and the lateral cuneiform 30, but may have a discontinuity or interruption between the guide surface regions that prevents a continuous cut across both cuneiform bones. One guide surface may extend from the medial to the lateral side of the middle cuneiform 28, and another guide surface may extend from the medial to the lateral side of the lateral cuneiform 30. Parallel, offset guide surfaces 154B may be provided to define cutting slots, such as cutting slots on the middle cuneiform and / or lateral cuneiform bones.

[0153] Although cutting guide 150 is shown as having both metatarsal guide surface 152A and cuneiform guide surface 154A, in alternative implementations, the cutting guide may be configured with guide surfaces for cutting only one or more metatarsals and / or one or more cuneiform / cuboid bones. One or more separate cutting guides may be utilized for cutting the other of the metatarsals or cuneiform bones. Alternatively, the clinician may perform the cuts freehand or may perform bone preparation steps that do not involve cutting bone.

[0154] As yet another example, instead of being configured to be positioned across multiple metatarsals and / or cuneiforms, the cutting guide may be configured to be positioned across a single TMT joint to cut a single metatarsal and / or cuneiform. Figures 12A and 12B are top views of foot 10 illustrating alternative configurations of cutting guide 150, in which the cutting guide is configured (e.g., sized and / or shaped) to be positioned across the second and third TMT joints, respectively. Cutting guides configured to be positioned across other smaller TMT joints (e.g., the fourth and fifth TMT joints) may also be included.

[0155] 12A, the cutting guide 150 has a metatarsal guide surface 152A (shown as a cutting slot) that extends from the medial-most side of the second metatarsal 14 to the lateral-most side of the second metatarsal 14. The cutting guide also has a cuneiform guide surface 154A (also shown as a cutting slot) that extends from the medial-most side of the middle cuneiform 28 to the lateral-most side of the cuneiform.

[0156] 12B, cutting guide 150 is shown having a metatarsal guide surface 152A (illustrated as a cutting slot) that extends from the medial-most side of the third metatarsal 16 to the lateral-most side of the metatarsal. The cutting guide also has a cuneiform guide surface 154A (also shown as a cutting slot) that extends from the medial-most side of the lateral cuneiform 30 to the lateral-most side of the cuneiform.

[0157] The cutting guide 150 in Figures 12A and 12B may be the same cutting guide that is moved between the second and third TMT joints. Alternatively, a clinician may have two identical cutting guides 150 utilized at different TMT joints. In yet other applications, two different cutting guides 150 may be provided, each configured differently at the third TMT joint relative to the second TMT joint. The cutting guides may be configured differently by having different sizes and / or shapes, such as different angular orientations of the guide surfaces.

[0158] In configurations in which the cutting guide 150 has both a metatarsal guide surface and an opposing bone-side guide surface (e.g., a cuneiform guide surface), the guide surfaces may be parallel to one another, angled relative to one another (e.g., defining a wedge-shaped region), or otherwise oriented relative to one another to achieve a desired cutting pattern. When using an angled guide surface configuration, the relative angle between the two guide surfaces may define the size and shape of the bone wedge removed utilizing the cutting guide 150. In some instances, the angle between the metatarsal guide surface and the cuneiform guide surface is constant. In other words, the angle between the metatarsal guide surface and the cuneiform guide surface is set during the design and manufacture of the cutting guide and cannot be changed by the clinician. In these instances, the clinician may be provided with a system having multiple cutting guides 150 (e.g., two, three, four, five, or more), where each cutting guide defines a different angle between the guide surfaces. A clinician can select a cutting guide with a desired angle from a system of various guides based on the needs of a particular patient undergoing a procedure. However, in other examples, the angle between the metatarsal guide surface and the cuneiform guide surface may be adjustable. This may provide the clinician with the flexibility to adjust the angular orientation between the metatarsal guide surface and the cuneiform guide surface for patient-specific anatomical considerations.

[0159] 13 is a top view of an exemplary configuration of a cutting guide 150 in which the angle 250 between the cutting guide's most distal guide surface 152A (when positioned over a metatarsal bone) and its most proximal guide surface 154A (when positioned over a cuneiform or cuboid bone) is constant. For many clinical applications, the angle 250 may be less than 75 degrees, e.g., less than 60 degrees, less than 45 degrees, less than 35 degrees, less than 20 degrees, less than 15 degrees, less than 10 degrees, or less than 5 degrees. For example, the angle 250 may be in the range of 1 degree to 20 degrees, e.g., about 5 degrees to about 20 degrees, about 5 degrees to about 10 degrees, or about 6 degrees to about 9 degrees. In other examples, the angle 250 may be 0 degrees (providing parallel guide surfaces) to allow for reciprocating planing, e.g., in mild cases. Bone wedges cut and / or removed in accordance with surgical techniques according to the present disclosure may define angles within any of the aforementioned angle limits (or even different limits), whether or not they are cut using a cutting guide according to the present disclosure (including, for example, when cut freehand and / or with the aid of a bone preparation template). Additionally, any cutting guide described herein having two guide surfaces angled relative to one another may implement any of the aforementioned angles or angle ranges (or even different limits).

[0160] 14A is a top view of another exemplary configuration of a cutting guide 150 in which the angle 250 between the cutting guide's distal-most guide surface 152A (when positioned over a metatarsal bone) and its proximal-most guide surface 154A (when positioned over a cuneiform or cuboid bone) is variable. The two guide surfaces (shown as guide slots in the illustrated example) may be hingedly or otherwise movably connected together and allowed to rotate relative to one another about a pivot axis 252. The ends of the two guide surfaces opposite the pivot axis 252 may or may not be connected together. In the illustrated example, the opposite ends of the two guide surfaces are movably connected together via a sliding connection 254. The adjustable cutting guide configuration may be adjustable within any of the exemplary ranges of angles discussed above.

[0161] A lock 256 may be provided to lock the desired angular orientation of the two guide surfaces relative to one another. The lock 256 may be implemented as a threaded or other moving feature against a surface to provide a frictional engagement to lock the angular orientation of the guide surfaces. As another example, the lock 256 may be a protrusion or recess that engages with one of a series of detents to lock the angular orientation of the guide surfaces. Other features providing a locking function may also be used without departing from the scope of this disclosure. If the cutting guide 150 is configured without the sliding connection 254 and / or the lock 256, one or both of the guide surfaces may have an associated pin hole that allows each guide surface to be pinned to the underlying bone to temporarily fix the position of the guide surfaces during a surgical procedure. The cutting guide 150 in FIG. 14A illustrates one exemplary configuration for implementing an adjustable cutting guide, although other implementations are possible.

[0162] For example, Figure 14B shows an example of a cutting guide 150 having separate guide surfaces for cutting the second and third metatarsals, where the angular positions of the guide surfaces are both adjustable. As shown, the two guide surfaces are connected by a joint bar, allowing the angles of the two guide surfaces to be adjusted together (e.g., so that each guide surface defines the same angle). In other examples, the guide surfaces may be independently adjustable (e.g., by omitting the joint bar).

[0163] To facilitate positioning of the cutting guide 150 over one or more bones to be cut, the cutting guide may include one or more alignment features. The alignment features may be insertable into the bone and / or joint space between adjacent bones to provide an anatomical reference position for orienting the cutting guide 150 relative to the anatomy of the patient's foot undergoing a clinical procedure. For example, the cutting guide 150 may include one or more pins and / or spacers associated with the cutting guide and used to assist in orienting the cutting guide relative to the patient's anatomy.

[0164] As used in this disclosure, a locating pin associated with a cutting guide generally refers to a feature that can be inserted into a bone and used to assist in positioning the cutting guide relative to the bone to be cut. In contrast, a spacer associated with a cutting guide generally refers to a feature that can be inserted into a joint space between adjacent bones and used to assist in positioning the cutting guide relative to the bone to be cut. Each feature described as a locating pin or spacer may have any suitable size and cross-sectional shape, including arc-shaped (e.g., circular, oval), polygonal (e.g., square, rectangular, T-shaped), and / or a combination of arc-shaped and polygonal shapes. The term locating feature encompasses both locating pins and / or spacers. Each locating feature may have a shaft that is insertable into the bone and / or joint space.

[0165] If the cutting guide 150 includes one or more associated pins and / or spacers, such features may be integral with (e.g., permanently connected to) the body of the cutting guide or may be detachable and separable from the cutting guide. It may be useful to configure the cutting guide 150 to be used with at least one positioning feature, such as a spacer and / or pin, each of which may be separately placed within a joint space between bones or within a bone. When so configured, the spacer and / or pin may be placed within the bone structure independently of the cutting guide, and the cutting guide may then be engaged with the inserted spacer and / or pin. For example, the cutting guide may be slid over the positioning feature, attached to the side of the positioning feature, or otherwise operably connected to the positioning feature. Once the cutting guide is placed on the positioning feature, the connection between the cutting guide and the positioning feature may be fixed (e.g., preventing relative movement between the two features) or may be a relatively movable connection (e.g., allowing rotation or other relative movement between the two features). In either case, the spacers and / or pins can be used to identify anatomical landmarks for positioning the cutting guide 150, which is then engaged with the spacers and / or pins.

[0166] FIG. 15 is a perspective view of foot 10 illustrating an exemplary alignment feature 260, shown in the form of a spacer, that can be used with cutting guide 150. In use, a clinician inserts alignment feature 260 into the joint space between adjacent bones and then engages bone cutting guide 150 with the alignment feature, for example, by sliding the bone cutting guide over the spacer. In the example of FIG. 15, alignment feature 260 is shown as being inserted into the joint space between medial cuneiform 26 and middle cuneiform 28. FIG. 16 shows cutting guide 150 engaged with and advanced in a plantar direction along alignment feature 260 to assist in orienting the bone guide over one or more bones to be cut. In particular, in the example of FIG. 16, cutting guide 150 is shown as being oriented over the dorsal sides of both the second and third metatarsals and the middle and lateral cuneiforms.

[0167] As described above, the cutting guide 150 may have one or more associated pins and / or spacers, each of which may be permanently secured to and / or separable from the body of the cutting guide. In FIG. 16 , the cutting guide 150 is shown as including a first positioning feature 260, from which the body of the cutting guide is separable, and a second positioning feature 262, also shown in the form of a spacer, that is permanently secured to the body of the cutting guide. The second positioning feature 262 is positioned on a different portion of the cutting guide, specifically the outer half of the cutting guide in the illustrated example. Once the cutting guide 150 is engaged with the first positioning feature 260 (e.g., by being advanced in a plantar direction over the positioning feature 260), the clinician may rotate the cutting guide about the positioning feature 260 in the transverse plane to position the second positioning feature 262 over the target insertion location. The target insertion location may be the third TMT joint space, as shown, or any other joint space and / or bone insertion location.

[0168] A cutting guide 150 according to the present disclosure may include any suitable number of alignment features, which may be permanently affixed to the body of the cutting guide and / or may be separable from the body of the cutting guide. For example, the cutting guide 150 may include a single alignment feature or multiple alignment features (e.g., two, three, or more). When configured with one or more alignment features, the one or more alignment features may be located at different positions along the body of the cutting guide.

[0169] For example, when the cutting guide is positioned over a bone to be cut, one alignment feature may be on the inner half (e.g., the inner quarter) of the cutting guide and / or one alignment feature may be on the outer half (e.g., the outer quarter) of the cutting guide. Additionally or alternatively, one such alignment feature may be on the distal side of the cutting guide (e.g., distal to a TMT joint when the cutting guide is positioned over the joint) and / or one alignment feature may be on the proximal side of the cutting guide (e.g., proximal to a TMT joint when the cutting guide is positioned over the joint). In use, a clinician may rotate the cutting guide 150 with and / or about the attached alignment feature to adjust the alignment of one or more guide surfaces with one or more bones to be cut. In some examples, the cutting guide (e.g., its associated guide surface) has a length extending from a first end to a second end, and the alignment feature is positioned at or adjacent the end of the guide to allow the guide to rotate thereabout.

[0170] The one or more alignment features associated with cutting guide 150 can be positioned within any desired bone and / or joint cavity suitable for positioning the cutting guide over one or more target bones to be cut. Correspondingly, cutting guide 150 may be configured (e.g., sized and / or shaped) to position one or more guide surfaces of the cutting guide over one or more target bones to be cut when the one or more alignment features are positioned at their target locations and the cutting guide is engaged therewith.

[0171] 23A-23I illustrate exemplary target locations on the foot for inserting one or more alignment features associated with cutting guide 150 and positioning the cutting guide over one or more bones to be cut. A clinician can insert the shaft of the alignment feature into the illustrated joint cavity, for example, with cutting guide 150 attached and / or with the cutting guide engageable with the alignment feature after insertion into the joint cavity. While each of FIGS. 23A-23I illustrates a single joint cavity location for inserting an alignment feature associated with cutting guide 150, any combination of two or more of the illustrated joint cavity locations may be utilized in combination (e.g., for cutting guides employing multiple alignment features). Each alignment feature of cutting guide 150 may be configured (e.g., sized and / or shaped) to be positioned within a particular target bone and / or joint cavity.

[0172] Figure 23A shows the medial corner of the proximal base of the second metatarsal and the intermediate cuneiform as target locations for the positioning function. Figure 23B shows the second TMT joint as a target location for the positioning function. Figure 23C shows the third TMT joint as a target location for the positioning function. Figure 23D shows the combination of the second and third TMT joints as a target location for the positioning function. Figure 23E shows the space between the proximal bases of the second and third metatarsals as a target location for the positioning function. Figure 23F shows the space between the third and fourth metatarsals as a target location for the positioning function. Figure 23G shows the space between the intermediate and lateral cuneiform as a target location for the positioning function. Figure 23H shows the space between the interpositional cuneiform and intermediate cuneiform as a target location for the positioning function. Figure 23I shows the fourth TMT joint as a target location for the positioning function.

[0173] 15 and 16, in some configurations of the cutting guide 150, the cutting guide may be freely rotatable about the alignment feature (e.g., capable of rotating 360° about the spacer or pin). In other configurations, the rotation of the cutting guide relative to the spacer or pin may be limited to a limited angular range of movement, such as less than 90°, less than 45°, or less than 25°. Figures 17 and 18 show two different configurations of the cutting guide 150 in which the cutting guide is limited to a limited range of rotational movement relative to an alignment feature that is insertable into the underlying bony structure.

[0174] In the example of Figure 17, the alignment feature 260 is shown defining a slot 270 into which a portion of the body of the cutting guide 150 is inserted. The cutting guide 150 can rotate within a limited range of movement defined by the size of the slot 270. In the example of Figure 18, the alignment feature 260 is shown inserted into a slot 272 defined by the body of the cutting guide 150. Again, the cutting guide 150 can rotate within a limited range of movement defined by the size of the slot 272. In some examples, the limited range of rotational movement is a bounded range of less than 90 degrees, such as less than 60 degrees, less than 45 degrees, less than 30 degrees, or less than 15 degrees.

[0175] 13-18 , the cutting guide 150 may include one or more fixation holes 264 that allow the cutting guide to be provisionally fixed to the underlying bone. The one or more fixation holes may be configured to receive fixation pins. In use, a clinician may place the cutting guide 150 over one or more bones to be cut and / or adjust the orientation of one or more guide surfaces of the cutting guide until such one or more guide surfaces are properly positioned relative to the portion of the bone to be cut. For example, the clinician may rotate the cutting guide 150 about an alignment feature (e.g., a pin or spacer), such as alignment feature 260, until the rotational position of the cutting guide properly aligns one or more guide surfaces of the cutting guide relative to the bone to be cut. Depending on the configuration of the cutting guide 150, the clinician may further adjust the relative angle 250 between the guide surfaces. In either case, once the cutting guide 150 is properly positioned relative to the bone to be cut, the clinician may insert a pin through each of the one or more fixation holes 264 and into the underlying bone. One or more fixation pins placed through fixation holes 264 can secure and hold cutting guide 150 in a desired position so that a clinician can later utilize the cutting guide to guide the movement of a cutting instrument.

[0176] In some examples, the cutting guide 150 includes at least two parallel fixation holes 264, such as two holes positioned to be located on the dorsal sides of two different bones (e.g., a metatarsal and an opposing cuneiform) separated by a joint. In use, a clinician can insert fixation pins through the two holes to attach the cutting guide to the metatarsal and cuneiform, respectively. After use, the clinician may remove the cutting guide (e.g., by sliding the cutting guide up and away from the parallel fixation pins) while leaving the parallel fixation pins in place. The clinician may then insert a second instrument having two parallel fixation holes downward onto the parallel fixation pins still remaining in the bone and back into place. For example, the clinician may insert a bone positioner and / or compressor downward onto the parallel fixation pins. The clinician may then use the instrument to apply force through the pins to move the bone. In addition to or instead of having two parallel fixation holes, the cutting guide 150 may define one or more fixation holes that are angled (at a non-zero angle) or otherwise distorted relative to one or more (e.g., two parallel) fixation holes.

[0177] In some configurations, the position of one or more (optionally all) of the fixation holes 264 defined by the cutting guide 150 is fixedly (e.g., non-movably) disposed relative to the body of the cutting guide. However, in practice, the position of the surface of the patient's bone relative to the fixation holes 264 defined by the cutting guide may vary depending on the patient's anatomy and the degree of deformity of the patient's bone. For these and other reasons, the cutting guide 150 may be configured with one or more adjustable fixation holes 264. The fixation holes may be adjustable in that they are movable relative to the length and / or width of the body of the cutting guide 150 and / or rotatable to adjust the orientation of the fixation hole relative to the orientation of one or more guide surfaces defined by the cutting guide.

[0178] Figure 24 is a perspective view of an exemplary configuration of a cutting guide 150 having at least one adjustable fixation hole 264. The cutting guide 150 in Figure 24 is shown as having multiple fixation holes 264A-264D, each capable of receiving a fixation pin. The cutting guide 150 includes at least one adjustable fixation hole 264, which is shown implemented by two adjustable fixation holes 264A, 264B located on different sides of the cutting guide. The cutting guide may also include at least one non-adjustable fixation hole, which is shown implemented by two non-adjustable fixation holes 264C, 264D located on different sides of the cutting guide.

[0179] Each adjustable fixation hole 264A, 264B in the cutting guide 150 of FIG. 24 may be defined by a hole body 180 that bounds and defines the fixation hole. The hole body 180 may be attached to an arm 182 to position the hole body 180 offset from the remainder of the body defining the cutting guide (e.g., the portion of the cutting guide that defines the guide surface). The hole body 180 may be operatively and movably connected to the cutting guide body, such as via a rail 184 along which the arm 182 may translate. Thus, the adjustable fixation hole 264A, 264B may move relative to the length of the body defining the cutting guide to reposition the hole at a different relative location along the body.

[0180] Figure 25 is a top view of the example cutting guide 150 of Figure 24 showing example positions to which the adjustable fastening holes 264A, 264B can be moved. In particular, Figure 25 shows the first adjustable fastening hole 264A positioned at a first position (e.g., an inner position) along the range of movement for the length of the cutting guide and the second fastening hole 264B positioned at a second position (e.g., an outer position) along the range of movement for the length of the cutting guide. The adjustable fastening holes 264A, 264B may be moved to positions different from those shown and / or have different adjustability or lengths of travel without departing from the scope of the present disclosure.

[0181] As mentioned above, configuring cutting guide 150 with one or more adjustable fixation holes can be useful to allow the fixation holes to be moved relative to the underlying bone in order to pin the cutting guide to the bone. When cutting guide 150 is positioned over one or more target bones to be prepared, the positions of the fixation holes defined by the cutting guide relative to the underlying bone can change depending, for example, on the location of the holes and / or the anatomy of the patient undergoing the procedure. By providing one or more adjustable fixation holes, the fixation holes can be moved to better align with the patient's anatomy prior to inserting pins through the fixation holes.

[0182] For example, Figures 26A and 26B are top-view images of an exemplary foot showing the cutting guide 150 of Figures 24 and 25 positioned on the foot. Figure 26A shows an exemplary configuration in which the adjustable fixation hole 264A is offset relative to a centerline along the length of the underlying bone (in this example, the third metatarsal 16). Figure 26B shows the adjustable fixation hole 264A repositioned so that it is substantially centered on the centerline of the underlying bone.

[0183] The cutting guide 150 may be configured with one or more adjustable fixation holes 264A, 264B. When the cutting guide 150 includes multiple adjustable fixation holes, each of the adjustable fixation holes may move independently of one another. Alternatively, at least two adjustable fixation holes may be operatively connected to one another and configured to move together. For example, FIGS. 27A and 27B are top views of an exemplary configuration of the cutting guide 150, showing an exemplary linkage between two adjustable fixation holes 264A, 264B. In the illustrated example, a mechanical linkage in the form of a bridge 186 connects the two adjustable fixation holes 264A, 264B. The bridge 186 may extend outward to the side (e.g., lateral side) of the cutting guide 150 and / or onto the cutting guide (e.g., superior dorsal side). In either case, the bridge may mechanically interconnect the two adjustable fixation holes 264A, 264B such that the fixation holes move as a joined pair. Other types of connections between the fixation holes may also be used.

[0184] While the adjustable fixation holes associated with the cutting guide 150 have generally been described and illustrated as being translatable along (e.g., parallel to) the length of the cutting guide, the adjustable fixation holes may be adjustable in other dimensions relative to the cutting guide in addition to or instead of being adjustable relative to the length. As one example, the adjustable fixation holes may be adjustable relative to the width of the cutting guide (e.g., from proximal to distal when the cutting guide is positioned on the foot). For example, the arm 182 connecting the adjustable fixation holes to the cutting guide body may have an adjustable length, and / or the adjustable fixation holes may be attached to a rail or other feature that is adjustable relative to the width of the cutting guide body.

[0185] As another example, in addition to or instead of being adjustable relative to the length and / or width of the cutting guide body, the adjustable fixation holes may be angularly adjustable (e.g., rotatable in the coronal plane) relative to the cutting guide body. For example, the adjustable fixation holes may be rotatable about an axis of rotation to adjust the angle at which a pin is inserted through the fixation hole and into the underlying bone, e.g., independently of the position of the fixation hole relative to the length and / or width of the cutting guide body.

[0186] 28A and 28B are top views of an exemplary configuration of cutting guide 150, showing exemplary rotational readjustment positions for adjustable fixation holes. In particular, FIG. 28A shows adjustable fixation hole 264A angularly oriented to be coplanar with adjustable fixation hole 264B. FIG. 28B shows adjustable fixation hole 264A rotationally readjusted to position a fixation hole that is not coplanar with adjustable fixation hole 264B. When configured to be rotationally adjustable, the adjustable fixation hole may rotate 360 ​​degrees or may rotate by a smaller angle of rotation within a bounded arc, such as over a range of 180 degrees or less, e.g., 120 degrees or less, 90 degrees or less, or 45 degrees or less.

[0187] When one or more adjustable fixation holes are used, a set screw, a series of detents to which the arm 182 can be moved, and / or other engaging / locking features may be used to hold the position to which the adjustable fixation holes are moved. Thus, in use, a clinician may use one or more guide surfaces defined by the cutting guide to position the cutting guide 150 over one or more bone portions to be cut. The clinician may then adjust the position (e.g., in one or more dimensions) of the cutting guide's one or more adjustable fixation holes relative to the underlying bone. The clinician may adjust the position of the adjustable fixation holes so that a pin subsequently inserted therethrough is substantially centered about the centerline of the underlying bone. Once adjusted to the desired position, the clinician may lock the adjusted position of the fixation holes and then insert a fixation pin through the adjusted fixation hole and into the underlying bone.

[0188] The cutting guide 150, as discussed above, may have a variety of different configurations. For example, the cutting guide 150 may have one or more associated alignment features (e.g., pins and / or spacers), each of which may be permanently affixed to the body of the cutting guide or may be detachable from the body. The pins and / or spacers may serve as alignment features insertable into bone and / or joint spaces between adjacent bones to provide anatomical reference positions for orienting the cutting guide 150 relative to the anatomy of the patient's foot undergoing a clinical procedure. FIG. 19 is a perspective view of another exemplary implementation of the cutting guide 150 having an associated alignment feature 280, shown as a spacer in the form of a keel. The spacer 280 may be permanently affixed to the cutting guide 150 or may be removably connectable thereto. The spacer 280 may be configured (e.g., sized and / or shaped) to be positioned within one or more joint spaces to span multiple joint spaces of one or more bones to be cut.

[0189] As discussed above, the cutting guide 150 may include one or more guide surfaces configured to extend across multiple bones to be cut, such as across the second and third metatarsals 14 and 16, and / or across the middle and lateral cuneiform bones 28 and 30. Accordingly, the spacer 280 may be configured to be at least partially positionable within multiple joint spaces, such as at least partially within the second tarsometatarsal joint space (between the second metatarsal 14 and the middle cuneiform bone 28) and at least partially within the third tarsometatarsal joint space (between the third metatarsal 16 and the lateral cuneiform bone 30). The spacer 280 may span the intermetatarsal space between the second and third metatarsals 14 and 16. Configuring the spacer 280 to be simultaneously positionable in two tarsometatarsal joint spaces may be useful for properly aligning the cutting guide 150 with respect to the bones to be cut on either side of both joint spaces.

[0190] 20 is a front perspective view of foot 10 showing cutting guide 150 positioned on the dorsal side of one or more bones to be cut, with spacer 280 inserted (plantarly) into the two tarsometatarsal joint spaces. In particular, in the illustrated example, spacer 280 is at least partially positioned within the second and third metatarsal joint spaces, with the spacer spanning the intermetatarsal space between second metatarsal 14 and third metatarsal 16. In some examples, spacer 280 is configured to contact at least the medial quarter, e.g., at least the medial half, of the end face of second metatarsal 14 and the opposing end face of middle cuneiform 28, or the entire end faces of the second metatarsal and middle cuneiform. Additionally or alternatively, the spacer 280 may be configured to contact at least the lateral quarter, e.g., at least the lateral half, of the end face of the third metatarsal 16 and the opposing end face of the lateral cuneiform 30, or the entire end faces of the third metatarsal and lateral cuneiform. The spacer 280 may span the intermetatarsal space between the two tarsometatarsal joint spaces.

[0191] In practice, certain patients may exhibit a significant step misalignment, or distal offset, between adjacent joint surfaces (e.g., between the surface defining the second TMT joint and the plane defining the third TMT joint). As a result, the patient may exhibit a protruding bone segment across the combined joint space into which the spacer 280 is targeted to be inserted. This may make it difficult for a clinician to insert the spacer 280 across the adjacent joint spaces.

[0192] 29 is an image of an exemplary patient's foot 10 showing a distal offset between the second TMT joint 36 and the third TMT joint 38. In this example, a protruding bone portion 290 protrudes at least partially across the area between the second TMT joint 36 and the third TMT joint 38, which is targeted for insertion of the spacer 280. In particular, the illustrated example shows a proximal protruding bone tip 290 on the lateral side of the second metatarsal 14 and a distal protruding bone tip 290 on the medial side of the third metatarsal 16. To facilitate insertion of the spacer 280, a clinician may remove one or more of the protruding bone portions 290 to, for example, create a pocket or continuous joint line extending across the second and third TMT joints to receive the spacer 280.

[0193] In some instances, the clinician removes one or more protruding bone portions 290 freehand (e.g., without the aid of a cutting guide). However, in other instances, the clinician may utilize a cutting guide to assist in removing one or more protruding bone portions. FIG. 30 is a perspective view of an exemplary cutting guide 292 that can be used as a planing guide to remove protruding bone portions. FIG. 31 is a top view of a foot illustrating exemplary positioning of the cutting guide of FIG. 30. As shown in this example, the cutting guide 292 may define at least one guide surface 294A along which a cutting instrument can be guided. For example, the cutting guide may define a pair of guide surfaces 294A, 294B that define a cutting slot therebetween through which a cutting instrument can be inserted.

[0194] At least one guide surface 294A of the cutting guide 292 may be configured to extend at least partially across one or more bones and / or joint cavities to remove protruding bone. For example, the cutting guide may be sized to extend from the medial side of one or more bones (e.g., the second metatarsal 14) to the lateral side of one or more bones (e.g., the third metatarsal 16). For example, the at least one guide surface 294A may be sized relative to the size of a corresponding placement feature 280 of the cutting guide 150 to be placed after opening the joint cavity using the preliminary cutting guide 292. The at least one guide surface 294A may have a length (medial to lateral direction) at least as long as the width (medial to lateral direction) of the spacer 280.

[0195] In use, a clinician may position the cutting guide 292 to at least partially span a pair of adjacent joint spaces (e.g., the second TMT joint space 36 and the third TMT joint space 38). For example, the clinician may position the cutting guide 292 on the dorsum of the foot substantially centered between the two joint spaces (e.g., substantially centered on the intersection between the proximal bases of the second metatarsal 14 and the third metatarsal 16). The clinician may then guide a cutting instrument along at least one guide surface 294A to remove the protruding bone portion. This may create an opening or pocket into which the spacer 280 may then be inserted.

[0196] To aid in positioning the cutting guide 292 across one or more joint spaces, the cutting guide may include one or more alignment features. For example, the cutting guide 292 may include a first alignment feature 296A on the medial side of the cutting guide and a second alignment feature 296B on the lateral side of the cutting guide. The two alignment features may have a relatively small cross-sectional area and be separated by a gap. As a result, the first alignment feature 296A may be positioned on the medial side of the second TMT joint space 36 and the second alignment feature 296B may be positioned on the lateral side of the third TMT joint space 38, with the gap spanning any protruding bone portions to be resected using the cutting guide.

[0197] While cutting guide 292 can be useful for opening a receiving cavity between adjacent joint cavities for later insertion of a positioning feature, cutting guide 292 can also be used for other purposes. For example, cutting guide 292 can be used as an axillary instrument to remove a portion of the epiphysis, e.g., as part of a revision procedure or trimming at the epiphysis, after removing an initial portion of the bone using cutting guide 150. As another example, a clinician may use cutting guide 292 to prepare a joint for fusion, e.g., by making a substantially planing cut on both end faces of the bone facing the joint cavity to promote fusion. This can be useful, for example, in preparing an arthritic joint for fusion, and may be performed with or without realignment of the bones defining the joint before or after preparing the epiphysis.

[0198] Additionally, cutting guide 292 is shown as having an optional handle 298 extending upward and outward, away from at least one guide surface of the cutting guide. Any cutting guide described herein may or may not have a handle, such as handle 298, to assist a clinician in manipulating the cutting guide. In use, the handle may be permanently and integrally connected to the remainder of the cutting guide, or may be removably connected to the remainder of the cutting guide (e.g., to allow the handle to be removed after positioning the remainder of the cutting guide in a desired location). If desired, a clinician can grasp the handle to hold the cutting guide in place (e.g., with or without pinning the cutting guide to the underlying bone) while making one or more cuts.

[0199] 19, the cutting guide 150 includes at least one guide surface positionable on the dorsal side of the bone to be cut. In the illustrated example of FIG. 19, the cutting guide 150 includes a first metatarsal guide surface 152A and a second metatarsal guide surface 152B parallel to the first guide surface, defining a cutting slot between the two guide surfaces. The cutting guide also includes a third metatarsal guide surface 152C and a fourth metatarsal guide surface 152D parallel to the third guide surface, defining a second cutting slot between the two guide surfaces. The second cutting slot is positioned distal to the first cutting slot.

[0200] 19 includes a first cuneiform guide surface 154A and a second cuneiform guide surface 154B parallel to the first guide surface, defining a cutting slot between these two guide surfaces. The cutting guide also includes a third cuneiform guide surface 154C and a fourth cuneiform guide surface 154D parallel to the third guide surface, defining a second cutting slot between these two guide surfaces. The second cuneiform cutting slot is positioned proximal to the first cuneiform cutting slot. The cutting guide 150 may have a different number or configuration of guide surfaces, as discussed above.

[0201] Configuring the cutting guide 150 with multiple guide surfaces (e.g., cutting slots) offset from one another (e.g., proximally or distally) can be useful to provide the clinician flexibility in selecting the amount of bone to remove. The clinician can select one of multiple parallel guide surfaces (e.g., two, three, four, or more guide surfaces) based on the desired amount of bone to remove and guide the cutting instrument along the selected guide surface to remove the desired amount of bone. Configuring the cutting guide 150 with multiple guide surfaces is also useful to allow for repeat cuts. For example, after the clinician removes an initial amount of bone using one guide surface, the clinician may determine that additional bone removal is appropriate to achieve the desired correction. Thus, the clinician can reuse the same cutting guide and select a different guide surface farther along the length of the bone to remove an additional portion of bone. Any of the configurations of cutting guide 150 described herein may include multiple guide surfaces (e.g., cutting slots) that may or may not be aligned parallel to one another and spaced apart (e.g., proximally and / or distally) to facilitate removing different amounts of bone depending on the particular guide surface selected by the clinician.

[0202] 19 , the cutting guide 150 may be configured with a continuous guide surface configured to extend across two bones to be cut (e.g., from the medialmost side of the second metatarsal 14 to the lateralmost side of the third metatarsal 16), or it may have a discontinuous guide surface with separate portions configured to be positioned on the separate bones to be cut. In either case, the cutting guide 150 may define a non-zero angle 282 between one or more guide surface portions configured to be positioned on the medial bone to be cut (e.g., the second metatarsal 14, the middle cuneiform 28) and one or more guide surface portions configured to be positioned on the lateral bone to be cut (e.g., the third metatarsal 16, the lateral cuneiform 30). Angling the medial and lateral portions of the cutting guide 150 relative to one another may be useful for orienting the guide surface defined by the guide relative to the anatomical contours of the foot, for example, as shown in FIG. 20 . In some examples, the cutting guide 150 defines an angle 282 between the guide surface to be positioned on the medial bone and the guide surface to be positioned on the adjacent lateral bone in the range of 90 to 179 degrees, such as 110 to 175 degrees, 125 to 170 degrees, or 135 to 165 degrees.

[0203] When the cutting guide 150 is configured with an angled shape between the medial and lateral portions of the cutting guide, both the bottom side of the cutting guide (e.g., the bone-contacting surface of the cutting guide) and the back side of the cutting guide (e.g., the outward-facing side of the cutting guide) may be angled. For example, FIG. 19 shows that both the bone-contacting side 284 of the cutting guide 150 and the outward-facing side 286 of the cutting guide are angled at substantially the same angle 282. This arrangement can be useful so that the bone-contacting side 284 of the cutting guide 150 conforms to the profile of the underlying bone, which profile is observable to the clinician through the mirrored profile of the outward-facing side 286 of the cutting guide. However, in other examples, one or both sides 284, 286 of the cutting guide may be straight (e.g., not angled), or the bone-contacting side 284 may be angled at a different angle than the outward-facing side 286 of the cutting guide.

[0204] While cutting guide 150 may define a sharp transition between different surfaces defining the bone-facing and / or outward-facing surfaces of the cutting guide, in other instances, the cutting guide may define curved bone-facing and / or outward-facing surfaces to provide a transition between different surfaces defined by the bone. For example, bone-facing surface 284 of cutting guide 150 may define a curved profile that positions the bone-facing surface in contact with the dorsal side of the underlying bone. Outward-facing surface 286 may or may not mirror the curved bone-facing surface.

[0205] In practice, it may be useful to angle and / or curve the outward-facing surface 286 of the cutting guide 150 so that the lateral portion of the cutting guide is offset plantarly relative to the medial portion of the cutting guide. This may assist the clinician in visualizing the sagittal plane offset between the second and third metatarsals. For example, the clinician may be instructed to move the cutting instrument perpendicular to the outward-facing surface of the cutting guide 150, resulting in an angular reorientation of the cutting instrument as it moves into the angled lateral portion of the cutting guide. This may help prevent the clinician from inadvertently cutting into the adjacent fourth metatarsal.

[0206] A blocking or fence element may be positioned on the side (e.g., lateral side) of the cutting guide to help guide the clinician's cutting motion and / or prevent inadvertent cutting of an adjacent metatarsal. FIG. 32 is a perspective view of a foot showing an exemplary cutting guide 150 and blocking element 288, where the blocking element is positioned to limit the movement of the cutting instrument and help prevent inadvertent cutting of an adjacent metatarsal. The blocking element may be a pin, osteotome, or other feature. The blocking element 288 may be connected to the cutting guide 150 or may be a separate feature from the cutting guide. The blocking element 288 may define a length that extends above the top surface of the cutting guide 150. For example, the blocking element 288 may extend to a height above the dorsal side of the metatarsal that is at least twice the height to which the top surface of the cutting guide 150 extends. In the illustrated example, the blocking element is inserted between the third metatarsal 16 and the fourth metatarsal 18. In either case, the blocking element 288 may act as a visual and / or tactile barrier to limit outward movement of the cutting instrument by the clinician.

[0207] In use, the spacer 280 may be at least partially positioned within two different adjacent joint cavities, each space separating two opposing epiphysis. This may orient one or more guide surfaces of the cutting guide 150 on the dorsal side of the adjacent epiphysis to be cut. FIG. 21 is a top view of the foot 10 showing an exemplary configuration of the cutting guide 150 positioned on the adjacent epiphysis to be cut, with the spacer 280 inserted into the adjacent joint cavities defined by the epiphysis to be cut. While the cutting guide 150 in FIG. 21 is shown as having a single cuneiform cutting slot and a single metatarsal cutting slot, it may have different designs as discussed above.

[0208] Generally, spacer 280 may extend from a first end attached or attachable to cutting guide 150 to a second end insertable plantarly into an adjacent joint space. In some examples, such as the example of FIG. 19 , spacer 280 may taper in width (e.g., the distance the spacer spans the adjacent joint space) and / or thickness from the first end to the second end. In other examples, spacer 280 may have a constant width and / or thickness along the length of the spacer.

[0209] In FIG. 19 , the spacer 280 is shown as a block insertable into adjacent tarsometatarsal joint spaces, where the spacer block spans between the two tarsometatarsal joint spaces. In other examples, the cutting guide 150 may be attached or attachable to two spacers that are separately positionable in adjacent joint spaces, with a gap or void space between the two spacers. For example, FIG. 22 is a perspective view of another configuration of the cutting guide 150, showing the cutting guide in association with two spacers 280A, 280B. Spacer 280A may be positioned in the first tarsometatarsal joint space (e.g., between the second metatarsal 14 and the middle cuneiform 28), and spacer 280B may be positioned in the second tarsometatarsal joint space (e.g., between the third metatarsal 16 and the lateral cuneiform 30).

[0210] While the foregoing description of the cutting guide 150 and associated positioning features has generally focused on configurations for positioning on the second and third tarsometatarsal joints, the cutting guide may be configured to cut any tarsometatarsal joint or combination of joints. For example, the cutting guide 150 and associated positioning features (if used) may be configured to position one or more guide surfaces on one or more epiphysis defining the third and fourth tarsometatarsal joints, or the fourth and fifth tarsometatarsal joints, instead of the second and third tarsometatarsal joints. Accordingly, discussion of instruments and techniques for preparing the end of the second metatarsal 14 and / or the end of the middle cuneiform 28 (and / or the end of the third metatarsal 16 and / or the end of the lateral cuneiform 30) should be understood to apply to other lesser tarsometatarsal joint spaces and / or other epiphysis as well.

[0211] Additionally, references herein to the metatarsal side and cuneiform side of any device (e.g., bone positioner, cutting guide) are intended to describe the relative position and orientation of the features when the device crosses the TMT joint with the metatarsal on one side and the cuneiform on the other side. When a device is placed across two different bones, such as the fourth metatarsal and cuboid, or even two other bones or bone segments (e.g., two bone segments separated by a joint), the terminology may be modified based on the anatomy.

[0212] While the foregoing description of techniques and instruments includes discussion of exemplary cutting guides, it should be understood that some or all of one or more techniques can be performed without the use of a cutting guide. For example, techniques according to the disclosure may be performed freehand (without the use of a cutting guide) or with the aid of a bone preparation template in addition to or instead of using a cutting guide. Generally, a bone preparation template may be a device configured (e.g., sized and / or shaped) to overlay one or more bone sections to be subsequently cut. The bone preparation template may be configured to indicate where on the underlying bone the bone should be cut or otherwise prepared. Positioning the bone preparation template over the underlying bone can mark or otherwise indicate on the bone where the bone should be prepared, and / or the clinician can use the bone preparation template to mark where on the bone the bone should be prepared. The clinician may then remove the bone preparation template and pre-form bone preparation steps (e.g., cuts) at the locations marked or otherwise indicated using the template.

[0213] As an example, the bone preparation template may have a sharpened surface, such as a sharpened surface that protrudes toward the bottom side on the bone-contacting side of the bone preparation template. The sharpened surface may be implemented as a chisel, score line, or other feature that imparts an indication mark on a surface (e.g., a bone surface) contacted by the feature. A clinician can position the template relative to one or more bones to be prepared using, for example, one or more alignment features and / or other orientation features to position the template relative to one or more target anatomical locations on the patient. When the template contacts one or more bone surfaces (e.g., by the clinician pressing the template downward against the bone surface and / or sliding the template back and forth relative to the bone), the sharpened surface can impart an indication mark to the bone. Additionally or alternatively, a clinician may apply energy (e.g., radio frequency current, laser energy) through and / or adjacent to the template to burn, cut, and / or otherwise form an indication mark in one or more bones. The clinician can then perform freehand bone preparation (eg, cutting) using tissue removal instruments that follow or conform to the instruction marks.

[0214] As another example, a bone preparation template may include a light source (e.g., an integrated laser light or other light targeting device) that displays an illumination template at and / or on one or more bones. The light source may be positioned relative to one or more bones to be prepared, for example, using one or more alignment and / or other directing features to position the light source relative to one or more target anatomical locations on the patient. The light source may be activated to display one or more light rays or other indicator light marks at and / or on one or more bones to be prepared. A clinician can perform freehand bone preparation (e.g., cutting) using a tissue removal instrument that follows or tracks the marks or lines broadcast by the light source.

[0215] As another example, a bone preparation template may be a molded structure (e.g., made of metal or plastic) having one or more guide surfaces (e.g., optionally without slots) that can be used to guide a marking source. The guide surface for guiding a marking instrument can be positioned relative to one or more bones to be prepared, e.g., using one or more alignment and / or other orientation features to position the surface relative to one or more target anatomical locations on the patient. A clinician can then use the template to guide a marking source (e.g., a surgical marker pen, scalpel, or other sharp instrument that scribes or marks the bone surface) to impart one or more instruction marks to the bone surface to be prepared. The clinician can then perform freehand bone preparation (e.g., cutting) using a tissue removal instrument that follows or tracks the instruction marks. FIG. 33 is a perspective view of an exemplary bone preparation template 300 defining one or more guide surfaces 302 that can be used to guide a marking instrument.

[0216] In any configuration of the bone preparation template, the template can be used to designate bone preparation locations (e.g., one or more cutting lines) that can be used by a clinician to prepare one or more bone ends. The bone preparation locations can be those discussed above with respect to the cutting guide, resulting in, for example, a removed bone portion and / or a glenoid opening, as discussed above with respect to the cutting guide. Also, the alignment features used with the bone preparation template can be those discussed above with respect to the cutting guide. The bone preparation templates as described herein can be used to prepare any bone or combination of bones, including the first metatarsal and / or one or more lesser metatarsals.

[0217] Various embodiments have been described. These and other embodiments are within the scope of the following claims. [Configuration 1] 1. A method for treating metatarsal adduction, comprising: cutting an end of at least one of a second metatarsal bone and a middle cuneiform bone to create an opening between the end of the second metatarsal bone and the middle cuneiform bone; cutting an end of at least one of a third metatarsal bone and a lateral cuneiform bone to create an opening between the end of the third metatarsal bone and the lateral cuneiform bone; moving the second metatarsal and the third metatarsal at least in a transverse plane to close a metatarsal adduction angle; and fixing the displaced positions of the second metatarsal and the third metatarsal. [Configuration 2] 2. The method of claim 1, wherein moving the second metatarsal and the third metatarsal includes moving the second metatarsal and the third metatarsal together as a joint bone group. [Configuration 3] 3. The method of claim 2, wherein moving the second metatarsal and the third metatarsal together as a joint bone group includes preserving ligamentous attachments between the second metatarsal and the third metatarsal. [Configuration 4] 3. The method of claim 2, wherein moving the second metatarsal and the third metatarsal together as a joint bone group includes moving the second metatarsal and the third metatarsal without significantly changing the intermetatarsal angle between the second metatarsal and the third metatarsal. [Configuration 5] 10. The method of claim 1, wherein moving the second metatarsal and the third metatarsal in at least the transverse plane to close the metatarsal adduction angle comprises moving the second metatarsal and the third metatarsal in the transverse plane until the metatarsal adduction angle of each of the bones is 15 degrees or less. [Configuration 6] 10. The method of claim 1, wherein moving the second and third metatarsals at least in the transverse plane comprises pivoting the second and third metatarsals in the transverse plane about a medial surface of the second metatarsal. [Configuration 7] preparing the other end of the second metatarsal and the intermediate cuneiform; 10. The method of any one of the preceding configurations, further comprising: preparing the other end of the third metatarsal and the lateral cuneiform. [Configuration 8] 8. The method of claim 7, wherein cutting the end of at least one of the second metatarsal and the intermediate cuneiform bone and preparing the end of the other of the second metatarsal and the intermediate cuneiform bone comprises cutting the end of the second metatarsal and preparing the end of the intermediate cuneiform bone. [Configuration 9] 9. The method of claim 8, wherein preparing the end of the middle cuneiform bone comprises fenestrating the end of the middle cuneiform bone. [Configuration 10] 10. The method of claim 1, wherein cutting the end of at least one of the second metatarsal and the intermediate cuneiform bone and preparing the end of the other of the second metatarsal and the intermediate cuneiform bone comprises cutting the end of the second metatarsal and cutting the end of the intermediate cuneiform bone. [Configuration 11] 11. The method of claim 10, further comprising, after cutting the end of the second metatarsal and cutting the end of the middle cuneiform, fenestrating the end of the second metatarsal and fenestrating the end of the middle cuneiform. [Configuration 12] 10. The method of claim 1, wherein cutting the end of at least one of the third metatarsal and the lateral cuneiform bone and preparing the end of the other of the third metatarsal and the lateral cuneiform bone comprises cutting the end of the third metatarsal and preparing the end of the lateral cuneiform bone. [Configuration 13] 12. The method of claim 11, wherein preparing the end of the lateral cuneiform comprises fenestrating the end of the lateral cuneiform. [Configuration 14] 10. The method of claim 1, wherein cutting the end of at least one of the third metatarsal and the lateral cuneiform bone and preparing the end of the other of the third metatarsal and the lateral cuneiform bone comprises cutting the end of the third metatarsal and cutting the end of the lateral cuneiform bone. [Configuration 15] 15. The method of claim 14, further comprising fenestrating the end of the third metatarsal and the end of the lateral cuneiform after cutting the end of the third metatarsal and cutting the end of the lateral cuneiform. [Configuration 16] cutting the end of at least one of the second metatarsal bone and the intermediate cuneiform bone to create the opening includes cutting the end of at least one of the second metatarsal bone and the intermediate cuneiform bone to create a wedge-shaped opening; 10. The method of claim 1, wherein cutting the end of at least one of the third metatarsal bone and the lateral cuneiform bone to create the opening comprises cutting the end of at least one of the third metatarsal bone and the lateral cuneiform bone to create a wedge-shaped opening. [Configuration 17] cutting the end of at least one of the second metatarsal bone and the intermediate cuneiform bone to create the wedge-shaped opening comprises making an angled cut in the transverse plane to create a wedge-shaped section of bone, and further comprising removing the wedge-shaped section of bone before moving the second metatarsal bone; 17. The method of claim 16, wherein cutting the end of at least one of the third metatarsal and the lateral cuneiform to create the wedge-shaped opening comprises making an angled cut in the transverse plane to create a wedge-shaped section of bone, and further comprising removing the wedge-shaped section of bone before moving the third metatarsal. [Configuration 18] moving the second metatarsal in the transverse plane includes closing the wedge-shaped opening between the end of the second metatarsal and the intermediate cuneiform; 18. The method of claim 16 or 17, wherein moving the third metatarsal in the transverse plane includes closing the wedge-shaped opening between the end of the third metatarsal and the lateral cuneiform. [Configuration 19] 10. The method of claim 1, further comprising compressing the end of the second metatarsal against the end of the middle cuneiform and compressing the end of the third metatarsal against the end of the lateral cuneiform before fixing the displaced position. [Configuration 20] 10. The method of claim 1, further comprising engaging a bone positioning guide with at least one of the second metatarsal and the third metatarsal and a bone other than the second metatarsal and the third metatarsal, and wherein moving the second metatarsal and the third metatarsal in the transverse plane comprises engaging the bone positioning guide. [Configuration 21] The bone positioning guide is a compressor, and engaging the bone positioning guide with at least one of the second metatarsal and the third metatarsal bone causes the compressor to: the intermediate cuneiform bone and the second metatarsal bone, and 21. The method of claim 20, comprising attaching to at least one of the lateral cuneiform bone and the third metatarsal bone. [Configuration 22] 21. The method of claim 20, wherein the bone positioning guide is engaged with (a) at least one of the medial side of the second metatarsal and the medial side of the third metatarsal, and (b) the lateral side of a bone spaced laterally therefrom. [Configuration 23] 10. The method of claim 1, wherein moving the second and third metatarsals in at least the transverse plane to close the metatarsal adduction angle further comprises moving a fourth and fifth metatarsal in at least the transverse plane. [Configuration 24] 10. The method of any one of the preceding configurations, further comprising releasing soft tissue between the third and fourth metatarsals prior to moving the second and third metatarsals. [Configuration 25] 10. The method of any one of the preceding configurations, further comprising provisionally fixing the displaced positions of the second metatarsal and the third metatarsal. [Configuration 26] 26. The method of claim 25, wherein temporarily fixing the displaced positions of the second metatarsal and the third metatarsal includes inserting a pin through the third metatarsal into the middle cuneiform bone. [Configuration 27] Fixing the displaced positions of the second metatarsal bone and the third metatarsal bone includes: applying at least one fixation device across a second tarsometatarsal joint between the second metatarsal and the middle cuneiform; and applying at least one fixation device across the third tarsometatarsal joint between the third metatarsal and the lateral cuneiform. [Configuration 28] applying at least one fixation device across the second tarsometatarsal joint includes attaching a first plate to the second metatarsal and the middle cuneiform; 28. The method of claim 27, wherein applying at least one fixation device across the third tarsometatarsal joint includes attaching a second plate to the third metatarsal and the lateral cuneiform. [Configuration 29] at least, Preparing the end of the first metatarsal bone; preparing an end of the medial cuneiform bone facing the first metatarsal bone; moving the first metatarsal at least in the transverse plane to close an intermetatarsal angle between the first metatarsal and the second metatarsal; 10. The method of any one of the preceding configurations, further comprising realigning the first metatarsal by: fixing the displaced position of the first metatarsal. [Configuration 30] 30. The method of claim 29, wherein moving the first metatarsal in at least the transverse plane further comprises rotating the first metatarsal in a frontal plane. [Configuration 31] 31. The method of claim 30, wherein realigning the first metatarsal includes realigning the first metatarsal after moving the second metatarsal and the third metatarsal. [Configuration 32] making an incision in the patient's foot to provide access to the second and third tarsometatarsal joints; 10. The method of any one of the preceding configurations, further comprising mobilizing the extensor digitorum brevis from the extensor hallucis brevis and contracting the extensor digitorum brevis. [Configuration 33] 10. The method of claim 1, further comprising: positioning a cutting guide defining a guide surface on a dorsal side of the second metatarsal bone and on a dorsal side of the third metatarsal bone; and using the guide surface to advance a cutting tool along the guide surface to remove a portion of the end of the second metatarsal bone and a portion of the end of the third metatarsal bone. [Configuration 34] 34. The method of claim 33, wherein the guide surface comprises a continuous guide surface extending from the medial most part of the second metatarsal to the lateral most part of the third metatarsal. [Configuration 35] 34. The method of claim 33, wherein the guide surfaces define a first guide surface and further include a second guide surface parallel to the first guide surface, the second guide surface defining a cutting slot between the first guide surface and the second guide surface, and wherein advancing the cutting tool using the guide surfaces in a plane parallel to the guide surfaces includes advancing the cutting tool in the cutting slot. [Configuration 36] Using the guide surface and advancing the cutting tool along the guide surface to remove a portion of the end of the second metatarsal bone and to remove a portion of the end of the third metatarsal bone, translating the cutting tool laterally parallel to the guide surface to cut the end of the second metatarsal bone and then cut the end of the third metatarsal bone; or The method of any one of aspects 33 to 35, comprising translating the cutting tool inwardly parallel to the guide surface to cut the end of the second metatarsal bone and then cutting the end of the third metatarsal bone. [Configuration 37] Positioning the cutting guide on the dorsal side of the second metatarsal bone and on the dorsal side of the third metatarsal bone comprises: inserting a pin associated with the cutting guide into a bone; and inserting a spacer associated with the cutting guide between adjacent bones. [Configuration 38] The at least one of the pin and the spacer is separable from the cutting guide, and inserting the at least one of the pin and the spacer comprises: inserting the pin into the bone and sliding the bone cutting guide onto the pin; 38. The method of claim 37, comprising at least one of: inserting the spacer between adjacent bones; and sliding the bone cutting guide onto the spacer. [Configuration 39] 39. The method of claim 37 or 38, wherein the bone cutting guide includes at least one fixation hole, and further comprising, after sliding the bone cutting guide onto the at least one of the pin and the spacer, inserting a pin through the at least one fixation hole into the underlying bone to fix the position of the bone cutting guide. [Configuration 40] 40. The method of any one of aspects 37 to 39, wherein the at least one of the pin and the spacer is integral with the cutting guide. [Configuration 41] cutting the end of at least one of the second metatarsal and the intermediate cuneiform bone and preparing the other end of the second metatarsal and the intermediate cuneiform bone comprises cutting the end of the second metatarsal and the end of the intermediate cuneiform bone, and cutting the end of at least one of the third metatarsal and the lateral cuneiform bone and preparing the other end of the third metatarsal and the lateral cuneiform bone comprises cutting the end of the third metatarsal and the end of the lateral cuneiform bone, Positioning a cuneiform guide surface of a cutting guide on the dorsal side of the middle cuneiform and on the dorsal side of the lateral cuneiform; positioning a metatarsal guide surface of the cutting guide on the dorsal side of the second metatarsal and on the dorsal side of the third metatarsal; Using the cuneiform bone guide surface, advancing a cutting tool parallel to the cuneiform bone guide surface to remove a portion of the end of the middle cuneiform bone and a portion of the end of the lateral cuneiform bone; The method of any one of the preceding configurations, further comprising: using the metatarsal guide surface to advance the cutting tool parallel to the metatarsal guide surface to remove a portion of the end of the second metatarsal and to remove a portion of the end of the third metatarsal. [Configuration 42] 42. The method of claim 41, wherein the cuneiform guide surface comprises a continuous cuneiform guide surface extending from the medial most portion of the middle cuneiform to the lateral most portion of the lateral cuneiform. [Configuration 43] 43. The method of any one of claims 41 to 42, wherein the metatarsal guide surface comprises a continuous metatarsal guide surface extending from the medial most part of the second metatarsal to the lateral most part of the third metatarsal. [Configuration 44] 42. The method of claim 41, wherein the metatarsal guide surface includes a first cuneiform guide surface extending across the second metatarsal and a second cuneiform guide surface extending across the third metatarsal. [Configuration 45] the cuneiform guide surfaces define a first cuneiform guide surface and further include a second cuneiform guide surface parallel to the first cuneiform guide surface to define a cuneiform cutting slot therebetween, and advancing the cutting tool using the cuneiform guide surfaces in a plane parallel to the cuneiform guide surfaces includes advancing the cutting tool within the cutting slot of the cuneiform guide surfaces; 42. The method of claim 41, wherein the metatarsal guide surfaces define a first metatarsal guide surface and further include a second metatarsal guide surface parallel to the first metatarsal guide surface, defining a metatarsal cutting slot therebetween, and wherein advancing the cutting tool using the metatarsal guide surfaces in a plane parallel to the metatarsal guide surfaces includes advancing the cutting tool within the cutting slot in the metatarsal guide surfaces. [Configuration 46] 46. ​​The method according to any one of aspects 41 to 45, wherein the angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is constant. [Configuration 47] 46. ​​The method of any one of configurations 41 to 45, wherein an angle between the cuneiform guide surface and the metatarsal guide surface is adjustable, and further comprising setting the angle between the cuneiform guide surface and the metatarsal guide surface before advancing the cutting tool using the cuneiform guide surface and using the metatarsal guide surface. [Configuration 48] Positioning the cuneiform guide surface of the cutting guide on the dorsal side of the middle cuneiform and the dorsal side of the lateral cuneiform, and positioning the metatarsal guide surface of the cutting guide on the dorsal side of the second metatarsal and the dorsal side of the third metatarsal, inserting a pin associated with the cutting guide into a bone; and inserting a spacer associated with said cutting guide between adjacent bones. [Configuration 49] The at least one of the pin and the spacer is separable from the cutting guide, and inserting the at least one of the pin and the spacer comprises: inserting the pin into the bone and sliding the bone cutting guide onto the pin; 49. The method of embodiment 48, comprising at least one of: inserting the spacer between adjacent bones; and sliding the bone cutting guide onto the spacer. [Configuration 50] 50. The method of claim 48 or 49, wherein the bone cutting guide includes at least one fixation hole, and further comprising, after sliding the bone cutting guide onto the at least one of the pin and the spacer, inserting a pin through the at least one fixation hole into the underlying bone to fix the position of the bone cutting guide. [Configuration 51] 51. The method of any one of aspects 48-50, wherein the at least one of the pin and the spacer is integral with the cutting guide. [Configuration 52] 1. A method for treating metatarsal adduction, comprising: Positioning the cuneiform guide surface of the cutting guide on the dorsal side of the middle cuneiform and on the dorsal side of the lateral cuneiform; Positioning the metatarsal guide surface of the cutting guide on the dorsal side of the second metatarsal bone facing the middle cuneiform bone and on the dorsal side of the third metatarsal bone facing the lateral cuneiform bone; using the cuneiform guide surface to advance a cutting tool along the cuneiform guide surface to remove a portion of the medial cuneiform and a portion of the lateral cuneiform; using the metatarsal guide surface to advance the cutting tool along the metatarsal guide surface to remove a portion of the second metatarsal and a portion of the third metatarsal; moving the second metatarsal and the third metatarsal in a transverse plane to close the metatarsal adduction angle; Temporarily fixing the moved positions of the second metatarsal bone and the third metatarsal bone; and permanently fixing the displaced positions of the second metatarsal and the third metatarsal. [Configuration 53] 1. A bone cutting guide for use in treating metatarsal adduction, said bone cutting guide comprising: a cuneiform guide surface configured to be positioned on the dorsal side of both the middle cuneiform and the lateral cuneiform of the foot, the cuneiform guide surface configured to guide a cutting instrument to cut the middle cuneiform and the lateral cuneiform; a metatarsal guide surface configured to be positioned on the dorsal side of both a second metatarsal and a third metatarsal of the foot, the metatarsal guide surface configured to guide the cutting instrument to cut the second metatarsal and the third metatarsal; The cuneiform guide surface and the metatarsal guide surface are spaced apart from each other by a distance configured to cross a second metatarsal joint between the middle cuneiform and the second metatarsal bone and a third metatarsal joint between the lateral cuneiform and the third metatarsal bone. [Configuration 54] 54. The bone cutting guide of claim 53, wherein the cuneiform bone guide surface comprises a continuous cuneiform bone guide surface configured to extend from the innermost portion of the middle cuneiform to the outermost portion of the lateral cuneiform. [Configuration 55] 55. The bone cutting guide of any one of configurations 53-54, wherein the metatarsal guide surface comprises a continuous metatarsal guide surface configured to extend from the medial most part of the second metatarsal to the lateral most part of the third metatarsal. [Configuration 56] A bone cutting guide according to any one of configurations 53 to 55, wherein the metatarsal side guide surface includes a first cuneiform side guide surface configured to extend across the second metatarsal, and a second cuneiform side guide surface configured to extend across the third metatarsal. [Configuration 57] the cuneiform guide surface defines a first cuneiform guide surface and further includes a second cuneiform guide surface parallel to the first cuneiform guide surface, defining a cuneiform cutting slot therebetween; 57. The bone cutting guide of any one of configurations 53 to 56, wherein the metatarsal side guide surface defines a first metatarsal side guide surface and further includes a second metatarsal side guide surface parallel to the first metatarsal side guide surface, defining a metatarsal side cutting slot therebetween. [Configuration 58] 58. The bone cutting guide according to any one of configurations 53 to 57, wherein the angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is constant. [Configuration 59] 59. The bone cutting guide according to any one of configurations 53 to 58, wherein the angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is adjustable. [Configuration 60] 60. The bone cutting guide of aspect 59, further comprising a lock configured to lock the adjustable angle. [Configuration 61] 61. The bone cutting guide of any one of configurations 53 to 60, wherein the angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is in the range of 1 to 40 degrees, such as 5 to 20 degrees. [Configuration 62] 62. The bone cutting guide of any one of configurations 53 to 61, further comprising at least one positioning feature associated with the bone cutting guide, the at least one positioning feature configured to be inserted into at least one of a bone and a joint between an adjacent bone to position the bone cutting guide. [Configuration 63] 63. The bone cutting guide of claim 62, wherein the positioning feature includes a spacer configured to be positioned at least partially within both the second metatarsal joint and the third metatarsal joint and to span between the second metatarsal joint and the third metatarsal bone. [Configuration 64] 64. The bone cutting guide of aspect 63, wherein the spacer tapers in a dorsal to plantar direction along its length. [Configuration 65] 65. The bone cutting guide of any one of configurations 53 to 64, further comprising at least one fixation hole configured to receive a fixation pin for pinning the bone cutting guide to the underlying bone, wherein the at least one fixation hole is adjustable in at least one dimension. [Configuration 66] 66. The bone cutting guide of aspect 65, wherein the fixation holes are adjustable along the length of the bone cutting guide. [Configuration 67] A bone cutting guide, the bone cutting guide comprising: a cuneiform guide surface configured to be positioned on at least one cuneiform bone of the foot, the cuneiform guide surface configured to guide a cutting instrument to cut the at least one cuneiform bone; a metatarsal guide surface configured to be positioned on at least one metatarsal bone, the metatarsal guide surface configured to guide the cutting instrument to cut the at least one metatarsal bone; and and at least one fixation hole configured to receive a fixation pin for pinning the bone cutting guide to an underlying bone, wherein the at least one fixation hole is adjustable in at least one dimension. [Configuration 68] 68. The bone cutting guide of aspect 67, wherein the fixation holes are adjustable along the length of the bone cutting guide. [Configuration 69] 69. The bone cutting guide of aspect 67 or 68, wherein the fixation hole is rotationally adjustable relative to the bone cutting guide. [Configuration 70] 69. The bone cutting guide of any one of Aspects 67-69, wherein the at least one fixation hole that is adjustable in at least one dimension includes a fixation hole configured to be positioned on the metatarsal bone. [Configuration 71] 71. The bone cutting guide of any one of configurations 67-70, wherein the at least one fixation hole that is adjustable in at least one dimension includes at least two fixation holes that are adjustable in at least one dimension. [Configuration 72] 72. The bone cutting guide of any one of configurations 67-71, further comprising at least one fixed position fixation hole configured to receive a fixation pin for pinning the bone cutting guide to the underlying bone. [Configuration 73] 73. A bone cutting guide according to any one of claims 67 to 72, wherein the cuneiform bone side guide surface is configured to be positioned on the middle and lateral cuneiform bones of the foot, and the metatarsal bone side guide surface is configured to be positioned on the second and third metatarsal bones of the foot.

Claims

1. 1. A bone cutting guide for use in treating metatarsal adduction, said bone cutting guide comprising: a cuneiform guide surface configured to be positioned on the dorsal side of both the middle cuneiform and the lateral cuneiform of the foot, the cuneiform guide surface configured to guide a cutting instrument to cut the middle cuneiform and the lateral cuneiform; a metatarsal guide surface configured to be positioned on the dorsal side of both a second metatarsal and a third metatarsal of the foot, the metatarsal guide surface configured to guide the cutting instrument to cut the second metatarsal and the third metatarsal; The cuneiform guide surface and the metatarsal guide surface are spaced apart from each other by a distance configured to cross a second metatarsal joint between the middle cuneiform and the second metatarsal, and a third metatarsal joint between the lateral cuneiform and the third metatarsal.

2. The bone cutting guide of claim 1 , wherein the cuneiform guide surface comprises a continuous cuneiform guide surface configured to extend from a medial-most portion of the middle cuneiform to a lateral-most portion of the lateral cuneiform.

3. 3. The bone cutting guide of claim 1, wherein the metatarsal guide surface comprises a continuous metatarsal guide surface configured to extend from the medial most part of the second metatarsal to the lateral most part of the third metatarsal.

4. The bone cutting guide according to any one of claims 1 to 3, wherein the metatarsal side guide surface includes a first cuneiform side guide surface configured to extend across the second metatarsal, and a second cuneiform side guide surface configured to extend across the third metatarsal.

5. the cuneiform guide surface defines a first cuneiform guide surface and further includes a second cuneiform guide surface parallel to the first cuneiform guide surface, defining a cuneiform cutting slot therebetween; 5. The bone cutting guide of claim 1, wherein the metatarsal guide surfaces define a first metatarsal guide surface and further include a second metatarsal guide surface parallel to the first metatarsal guide surface, defining a metatarsal cutting slot therebetween.

6. The bone cutting guide according to any one of claims 1 to 5, wherein an angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is constant.

7. The bone cutting guide according to any one of claims 1 to 6, wherein the angle between the cuneiform bone side guide surface and the metatarsal bone side guide surface is adjustable.

8. The bone cutting guide of claim 7 , further comprising a lock configured to lock the adjustable angle.

9. 9. The bone cutting guide according to claim 1, wherein an angle between the cuneiform guide surface and the metatarsal guide surface is in the range of 1 to 40 degrees, such as 5 to 20 degrees.

10. 10. The bone cutting guide of claim 1, further comprising at least one alignment feature associated with the bone cutting guide, the at least one alignment feature configured to be inserted into at least one of a bone and a joint between adjacent bones to position the bone cutting guide.

11. 11. The bone cutting guide of claim 10, wherein the alignment feature includes a spacer configured to be positioned at least partially within both the second metatarsal joint and the third metatarsal joint and to span between the second metatarsal joint and the third metatarsal bone.

12. The bone cutting guide of claim 11 , wherein the spacer tapers in a dorsal to plantar direction along its length.

13. 13. The bone cutting guide of claim 1, further comprising at least one fixation hole configured to receive a fixation pin for pinning the bone cutting guide to the underlying bone, wherein the at least one fixation hole is adjustable in at least one dimension.

14. The bone cutting guide of claim 13 , wherein the fixation holes are adjustable along the length of the bone cutting guide.

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