Relative Clamp for Bunion Surgery Notes

Experienced foot and ankle surgeon (20 years) in a DPM training ortho group.
Performs a high volume of bunion surgeries due to patient referrals.
Elective surgery focus shifting towards bunion procedures.
Experience with various Lapidus procedure techniques:
- Handheld reduction.
- Point-to-point clamps.
- Company X and Company Y clamps.
Designed the Relative Clamp to address shortcomings of existing clamps.

Radiolucent: Allows visualization of sesamoids and reduction under X-ray.
No Incisions: Unlike other clamps that require additional incisions.
Quick and Easy Application: Designed for use even by second-year residents.
Three-Plane Correction: Corrects deformity in all three anatomical planes (frontal, transverse, sagittal).
Correction Across the Fusion Site: Facilitates accurate reduction at the fusion site.
Unobstructed Hardware Placement: Designed to stay out of the way during hardware placement.
Avoids Loss of Correction: Addresses the issue of losing correction when removing clamps for hardware placement.
Sterile Pack: Comes in a sterile package.

Initial Pin Placement:
- One pin in the second metatarsal.
- One pin in the first metatarsal, inserted at a $30$ to $45$ degree angle.
Frontal Plane Correction: Rotate the clamp to correct frontal plane deformity and lock down thumb screw number one (over toe number one).
Transverse Correction: Squeeze the tabs to reduce the intermetatarsal angle (IMA) and lock down thumb screw number two.
Sagittal Plane Correction: The clamp allows for sagittal plane correction to eliminate gapping. Lock down thumb screws number three and number four.
Compression: The clamp allows for distraction and compression across the joint. A guide wire is typically placed, followed by a compression screw for joint compression.
Hardware Placement: The clamp is designed to be out of the way for plate and screw placement.

Incision Size: Approximately a three-centimeter incision over the first TMT joint is sufficient for plate placement.
Cuneiform Obliquity Removal:
- Critical to remove the obliquity of the cuneiform to prevent bounce-back.
- Insert a wire perpendicular to the segment of the tarsal and use a saw parallel to the wire to remove the obliquity.
- Studies suggest $40$ to $50$ percent of first ray motion comes from the navicular-cuneiform joint, contributing to potential bounce-back.

Mark the first metatarsophalangeal joint (MPJ) and draw a line five millimeters behind it.
Palpate the second metatarsal to determine the pin insertion point.
Ensure the clamp is straight across the foot and not canted.
Insert the second metatarsal pin in the center of the metatarsal.
Verify the pin is in the distal part of the slot, allowing for dorsiflexion.
Avoid skewering the sesamoids with the first metatarsal pin to allow for frontal plane rotation.

Take an X-ray to visualize the sesamoid position and confirm adequate correction.
Apply fixation of choice (staples, screws, plate and screws) while the clamp remains in place.

The Relative Clamp can be used for MIS bunion correction.
Technique involves performing a transverse osteotomy from the third to the first metatarsal.
The clamp is used to frontal plane rotate and reduce the capital fragment.
Thumb screws number three and four are locked down to maintain sagittal plane position.
Helpful for surgeons new to MIS or those without assistance, acting as an extra set of hands.
Addresses the common challenge in MIS of holding the capital fragment in the desired position during screw placement, preventing plantarflexion.

Lisfranc fracture dislocations: A pin in the cuneiform and second metatarsal are secured with the clamp.

Experienced surgeons may not find it necessary but acknowledge its benefits.
Benefits include acting as an extra set of hands and maintaining first ray position until fixation.
Users reported better correction compared to point-to-point clamps or temporary fixation methods.
Can help avoid elevation of the first ray or incomplete removal of the obliquity of the cuneiform.

The trend shows a shift from traditional Chevron/Scarf osteotomies towards Lapidus and MIS procedures.
Estimates suggest less than half are traditional, $25$ – $30$ % Lapidus, and a growing percentage of MIS.
MIS and Lapidus are increasingly replacing traditional Chevron procedures.

One-centimeter incision technique for mild to $18$ degree intermetatarsal angle(IMA) corrections.
The guide sits on the side of the foot.
Involves pre-drilling for screw placement from the top to ensure accurate fragment positioning.
Capital fragment is moved over, held with a Steinmann pin, and fixed with a screw.
Not suitable for patients with hypermobility or significant frontal plane deformity.
Provides an easier entry point into MIS by allowing surgeons to visualize the cuts in their initial cases.

Fourth Quarter: Sterile pack Lapidus system with the Relative Clamp, two screws, and two staples (dorsal and medial).
First Quarter: Sterile pack plate and screws system with the clamp, and potentially the cutting guide (pending legal clearance).
Two/Three TMT fusion system.

Designed to address the obliquity of the cuneiform, ensuring a straight foundation for the first metatarsal.
The body of the cutting guide aligns with the second ray.
A radio-opaque marker indicates alignment on X-ray.
A pin is inserted in the second metatarsal.
The cuts in the cuneiform are dialed in using a thumb screw.
An olive wire aids in sagittal plane cut positioning.
Slots provide stability during cuneiform cuts.
Surgeons can customize the cut depth based on the intermetatarsal angle (IMA).
The cutting guide can be paired with the Relative Clamp.
The cutting guides uses two pins.