which one do you think comes first? Wanted to get clinical opinions and experiences, articles, publications about this subject. Would love to get more Attendings to comment rather than residents or students, but whoever has knowledge about this, please chime in....

Please stick to the topic... (no comments about "double-bundle ACL grafting in post-menopausal women")

This one can be debated ad nauseum and is good discussion (although I wasn't aiming to start a debate in that other thread). It's a bit presumptious for a student who has never even scrubbed in to give his take, but anyways :D...

From my present knowledge base, I'm more keen to the Root/Hansen/Catzanzariti/Meyerson way of thinking that hypermobility causes/worsens bunions and Lapidus is the way to go for big bunions in good surgical candidates. The Coughlin/Rush argument that bunions with high IMA stretch the MCJ ligaments and increase mobility certainly makes sense also, but I don't really know about doing a prox crescenteric or Juvara in an even somewhat hypermobile bunion case since recurrence seems more likely (due to either 1: post-op gradual IMA correction loss increasing hypermobility or 2: the fact that you were wrong and the MCJ hypermobility - which a base procedure does little/nothing to address - was indeed causing the HAV).

In the end, I'm just not sure it matters, though. For bunions with a high IM (or high effective IMA in the case of met adductus) where an Austin-Akin or even a Kalish or Scarf won't give enough correction, then a Lapidus is still probably the way to go as long as the patient doesn't have a pre-op XR/age/condition that would throw a red flag up and warn the clinician of possible malunion or excessive shortening. If Lapidus holds the IMA correction better than a base wedge over the long term, then it's probably the best procedure for most high IMA HAV patients regardless of hypermobility being from HAV or HAV from hypermobility...

Hass Z, Hamilton G, Sundstrom D, Ford L. Maintenance of correction of first metatarsal closing base wedge osteotomies versus modified lapidus arthrodesis for moderate to severe hallux valgus deformity. J Foot Ankle Surg 46(5):358-65, 2007.

Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 28(7):759-77, 2007.

Catanzariti AR, Mendicino RW, Lee MS, Gallina MR. The modified Lapidus arthrodesis: a retrospective analysis. J Foot Ankle Surg 38(5):322-32, 1999.

Meyerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle 13:107-115, 1992.

Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262–266, 1989.

Root ML, Orien WP, Weed JH. Muscle function of the foot during locomotion. Clinical Biomechanics, vol 2. Los Angeles, 1977.

Interesting classic (yet well written and still very applicable) article on the subject:

Schoenhaus HD, Cohen RS. Etiology of the bunion. J Foot Surg. 1992 Jan-Feb;31(1):25-9.

^This one was brought to my attention by a resident who is a Temple alumni, and I am going to be presenting it for a journal club at my Barry clinic next week to help teach the 3rd years (who haven't finished surgery courses yet). The author is an attending at my Oct clerkship, Penn-Presby.

The orig McBride (1928, 1967) and Lapidus (1934, 1960) articles are also pretty good. Those guys were way ahead of their time, and as Sig Hansen notes in his text, Lapidus' situation was pretty tragic: having the right idea yet the fixation didn't arrive until decades later. The Lapidus paper in Clin Ortho 1960 has a few parts that are downright hilarious...

"Bunions are very common, especially in females, who, using their feet primarily for sex appeal, locomotor function being given only secondary consideration, succumb to the dictates of fashion and develop the deformity..." :laugh: (...but sadly, true in many cases) :o

actually I don't think Schoenhaus is at Penn-Presby anymore. I read that he left recently, but theo ther attendings are great such as Dr.Malay.

actually I don't think Schoenhaus is at Penn-Presby anymore. I read that he left recently, but theo ther attendings are great such as Dr.Malay.Schoenhaus is on staff and does cases at Penn-Presbyterian. Nice guy.