More than 100 different bunionectomies -- bunion removals -- are described in orthopedic surgery literature. On this snowy day in March, the middle-aged woman under sedation in one of the surgical suites in UPMC South Side hospital is awaiting Dr. Dane Wukich to perform a combination of two of them on her right foot.

One of them is called a Lapidus procedure after Paul Lapidus, the surgeon who first used it some 50 to 60 years ago.

During this procedure, the doctor removes the cartilage between the tarsal-metatarsal joint in the mid-foot and then fuses the two bones with two screws or a metal plate. Other surgeons use removable wire. For this particular patient, Dr. Wukich will use the screws.

Dr. Wukich, chief of foot and ankle surgery and medical director of the UPMC Comprehensive Foot & Ankle Center, is using the Lapidus procedure to correct hypermobility and instability in the patient's mid-foot, conditions that helped lead to formation of the bunion.

A bunion is caused when the metatarsal, or second, bone in the big toe rolls from its position parallel to the other four metatarsals to an angle pointing outward, past the normal outline of the foot. Rubbing on shoes, it develops calcium deposits, and, after fusing the joint to bring the metatarsal back into parallel alignment with the other metatarsals, Dr. Wukich will shave off any bone or deposit still protruding.

The woman, though unconscious, wiggles her foot when Dr.Wukich begins making the first of three small incisions, so he asks for more anesthesia. When the foot remains still, he makes the three cuts: one on the bunion, one on the tarsal-metatarsal joint, and one in between the big toe and second toe. There is no blood, thanks to a well-placed tourniquet. The view of bone and tissue is clear and clean.

He takes a close look at the bunion, beside which he finds a small piece of floating bone he calls an "exotosis," which he removes. But he only shaves a tiny bit of capsule, which is tissue that has thickened around the joint.

"The bumpectomy is a very small part of the surgery," he says. "You've got to correct what caused the bunion."

He moves on to the joint between the metatarsus and tarsus and cuts away the cartilage that prevents the bones from rubbing against one another in pieces no larger than a sliver of sliced almond. "You don't want to do too much," he says. "You can always take more."

Schooled in his philosophy, the scrub nurse hands him his scalpels with the sharp part of the blade up. He cuts with upward strokes, too, rather than risk cutting away too much by slicing down.

When the cartilage has been removed, he asks for X-rays. They show that the metatarsal bone already has started to move back into the proper position.

Now he goes on to drill tiny holes through which he eventually will thread the two screws. It is a painstaking process, during which he uses guidepins, which are small sharp-pointed pins that hold the toe in place and allow him to test the proper alignment of the screws. He wants them in an "L" shape so that they are crossing at 90 degrees. These are very small pins, measuring only 1.5 mm, and easily can be repositioned prior to drilling larger holes for the screws.

Unsatisfied with the position of the toe after his initial placement of the guidepins, he asks for fluoroscopic images, which are live, real-time X-rays, and then redirects the guidepins. Satisfied this time, he enlarges the holes and inserts the screws.

Again Dr. Wukich asks for X-rays, and this time, he is pleased. He calls the "L" alignment "beautiful," and Dr. Kurt Weiss, the chief orthopedic resident at South Side and the first assistant surgeon today, concurs.

Now Dr. Wukich turns his attention back to the big toe, where he meticulously saws away tiny sections of the bunion to bring it into a smooth line with the rest of the outside of the foot.

That finished, he stitches closed the first layer of tissue over the metatarsal. Then he turns the needle and thread over to Dr. Weiss to finish closing up.

"I'm not saying this because you're here," Dr. Wukich tells his observers, "but this may be the best bunionectomy I've ever done."