It took Margaret "Maggie" Warner five years and four doctors to find relief from the pain of a bunion in her right foot.

"It was a painful process," said Mrs. Warner, 53, of Scott. "I'm a custodian in the [Chartiers Valley] schools so I'm on my feet all day.

"One doctor, he would shoot it up ... with some organic stuff he said would be absorbed," she added. "It took the pain away momentarily, like seven to 10 days.

"Another doctor wanted to operate right away." When she declined to have surgery on the lump protruding from the side of her foot, he prescribed orthotics. "I spent over $600 on them and there wasn't much comfort in them.

"And then the other doctor, she was really weird," Mrs. Warner continued. "She taped my feet to hold my bones together. ... I thought 'This poor old lady, she doesn't even know it's not really working.' She didn't believe in surgery."

Then someone recommended Dr. Stephen Conti, the orthopedic surgeon who serves as director of the Division of Foot and Ankle Surgery at Allegheny General Hospital.

"I felt so confident that he knew what he was talking about," Mrs. Warner said. "And it was just time to do it."

On March 3, Dr. Conti surgically repaired the bunion, which occurs when the metatarsal, or second, bone of the big toe rolls out of its natural position parallel to the other metatarsals into an angle pushing outward against the skin. He used a procedure called a "proximal first metatarsal osteotomy," which means he cut the metatarsal in half, repositioned the bone pieces so they were once again parallel to the other metatarsals and inserted two screws to hold the pieces in place while they heal. He also moved the sesamoid bones that normally are located beneath the first metatarsal back into position.

It was outpatient surgery, so Mrs. Warner was able to go home on crutches just a few hours after the procedure. She is not allowed to put weight on the foot for eight weeks dating from the surgery.

Bunions can be a congenital deformity, the result of trauma, or, most commonly, acquired in later years. Mrs. Warner's was acquired.

The four doctors interviewed for this piece all believe that acquired bunions are caused by a mixture of hereditary and wearing poorly designed fashionable shoes. Since he sees bunion patients in a ratio of 9 to 1 women to men, Dr. Conti said "it's either related to hormones or shoefit," but other doctors thought fewer men seek relief because they wear more practical, better-fitting shoes.

"Bunions are hereditary unless they're traumatic, where something injured the foot," said Dr. Stanley Bosta, a partner in Allegheny Podiatry who also is part of the surgical staff at UPMC South Side. "I've found that about 80 percent of my bunion surgery is on women because the type of shoes they wear aggravates the bunion or hammer toes, what have you.

"Men can get into wider shoes. They don't care if they wear tennis shoes. Women want to wear shoes that fit the eyes, not the feet, and then the bunion that was hereditary becomes a philosophy."

There are dozens of surgical procedures for removing bunions and correcting other conditions, like arthritis or bone spurs, which can be caused by them. The procedures have names like the Austin bunionectomy, the Lapidus procedure (see sidebar), a Keller bunionectomy, silver bunionectomy and closing wedge osteotomy.

"Surgery varies from patient to patient and each patient's situation is different so each bunion is an individual procedure," said Dr. Robert Mendicino, a podiatric surgeon, director of the Foot and Ankle Institute of Western Pennsylvania, and chairman of foot and ankle surgery at West Penn Hospital.

And when should a person with an obvious bunion seek to have it surgically removed?

"There are five reasons to do bunion surgery," said Dr. Dane Wukich, chief of foot and ankle surgery and medical director of UPMC Comprehensive Foot & Ankle Center. "The first one is pain relief. The second one is pain relief. The third one is pain relief. You get the picture. If you're doing a cosmetic bunion, you're going to be unhappy."

Dr. Conti said he didn't like to see patients wait so long that arthritis sets in to the joint.

Once removed, will bunions return?

"Rarely, if the proper procedure is taken," Dr. Bosta said.

"Once in a blue moon you will get one that comes back," Dr. Mendicino agreed.

As with any surgery, there also can be complications, but they too are the exception rather than the rule.

"Generally in our practice," Dr. Mendicino said, "we have a less-than-1-percent complication rate and that includes recurrence, infections, scarring, the whole list. ... [and] a lot of that is directly related to two issues: noncompliant patients and acts of God or stupidity. If you fall down a flight of steps, it's an act of God. If you get drunk at a Pirate game and fall down a set of bleachers, that's an act of stupidity."

Are there differences between orthopedic surgery and podiatric surgery?

"They use the same surgeries," Dr. Bosta said. "I don't think there's a big difference, to tell you the truth."

Nevertheless, care should be taken in selecting a surgeon, whether you choose to use an orthopedist or a podiatrist.

Dr. Mendocino, former president of the American College of Foot and Ankle Surgeons, recommends choosing a surgically trained podiatrist who is "preferably board-certified in foot surgery by the American Board of Podiatric Surgery." If you want an orthopedist, get one who has done a fellowship in foot and ankle surgery through the American Orthopedic Foot and Ankle Society, he added.

"Either way you've got the highest qualified in the poiatric world or the highest qualified in the orthopedic world."

Mrs. Warner has been delighted with her surgery and her surgeon. By March 13, when Dr. Conti took X-rays and changed her bandage, she had been pain-free for eight of the 10 days since the procedure and getting out and about on crutches.

"I think [Dr. Conti] was amazed," she said. "He said it all looked good. Everything's fine."