Bunion surgery is not a single operation. It is a family of techniques, each developed to solve different aspects of the same deformity — a bunion, or hallux valgus, where the big toe drifts towards the second toe and a bony bump forms at its base. Patients researching surgery online are often confronted with a list of unfamiliar names: Scarf, Akin, Lapidus, Lapiplasty, MICA, PECA, keyhole. Without context, it is difficult to know which term matters for an individual case, or why a surgeon might recommend one approach over another.
This article sets out the main bunion surgery techniques in current use, explains how each one corrects the deformity, and clarifies where Mr Kaser Nazir’s own approach, Rapid Bunion™ (his trademarked minimally invasive bunion correction protocol), fits within that landscape. Mr Nazir is a Harley Street, NHS Consultant specialising exclusively in bunion correction, and the explanations below draw directly on his clinical experience across both open and keyhole techniques, including the years he spent performing traditional open surgery before moving into keyhole methods.
Bunions themselves are largely genetic, with an evolutionary component: the function of the big toe has changed over time in a way that leaves an inherent weakness, causing it to deviate towards the second toe. Around a quarter of the world’s population can develop bunions, with women more affected than men, largely due to footwear choices. That deformity, and the pain and footwear difficulty it causes, is the starting point for every technique discussed below. The aim here is not to declare one technique universally superior, but to explain what each does, who it typically suits, and how a consultant decides between them.
The Scarf and Akin Procedure: The Traditional Open Standard
The Scarf procedure is, by volume, the most commonly performed bunion operation in the world. It is an open technique, meaning the surgeon works through a larger incision than keyhole methods allow, cutting the first metatarsal bone (the long bone behind the big toe) and using screw fixation to hold the corrected bone in place.
Mr Nazir performed the Scarf procedure for at least 15 years before moving into keyhole bunion surgery. “It was considered for a long time gold standard,” he explains. “It has the longest evidence base, it corrects most deformities except for very large deformities or unstable deformities. It became a widely acceptable open technique because it was more predictable than the previous techniques, it used screw fixation to hold bones”.
The Akin procedure is usually paired with the Scarf, correcting the toe bone itself when an additional angular deformity is present. Together, Scarf and Akin were traditionally performed for moderate or mild bunions.
Why Scarf/Akin Became Standard Practice
Earlier open techniques, before screw fixation became routine, were less predictable and more prone to the bone shifting out of position during healing. The Scarf procedure’s reliance on screw fixation gave surgeons a repeatable, evidence-backed method, which is part of why it built the longest evidence base of any bunion procedure and remains widely taught.
The Lapidus Procedure: Fusion for Larger and Unstable Deformities
The Lapidus procedure takes a different approach. Rather than cutting and shifting the metatarsal bone, it fuses the midfoot joint at the base of the first metatarsal, the tarsometatarsal (TMT) joint, using a plate and screws.
Traditionally, Lapidus was reserved for larger deformities, specifically where the intermetatarsal angle (the angle between the first and second metatarsal bones) exceeded 18 degrees. Where Scarf/Akin depends on having sufficient bone width to shift and realign the metatarsal, Lapidus instead fuses the joint, allowing correction of deformities that shifting alone cannot address. The trade-off is that fusion sacrifices motion at that joint, which is not always necessary in every bunion.
Where Lapidus Fits Today
Mr Nazir’s use of the Lapidus procedure has narrowed considerably as keyhole techniques have advanced. “In the past, you were performing Lapidus procedure in bunions where you were doing it for large deformities,” he notes. “Now, I only reserve that for unstable midfoot procedures”.
The indication has shifted from deformity size to joint quality. As Mr Nazir puts it, Lapidus has “a smaller set of indications in terms of instability at the first metatarsal or previous arthritis in that joint”. Otherwise, minimally invasive surgery is used for most bunions. Lapidus remains the one open procedure Mr Nazir still performs, precisely because minimally invasive surgery is not considered suitable for this specific set of cases.
MICA and the Evolution Toward Keyhole Surgery
The minimally invasive chevron Akin procedure, or MICA, marked a shift toward keyhole methods. Instead of an open incision, the bone is cut in a chevron (V-shaped) pattern and repositioned using keyhole techniques. Mr Nazir describes this as similar in principle to the Rapid Bunion™ techniques he has since adopted.
Why Fixation Generation Matters
Not all keyhole surgery is equivalent, and this is where Mr Nazir is most direct with patients. Early generations of MICA used little or no rigid fixation to hold the repositioned bone in place, whereas fourth-generation surgery uses specialist screws designed specifically for this technique.
This distinction matters because much of the historical scepticism around keyhole bunion surgery stems from outcomes in these earlier generations. “There are misconceptions in that the generation one surgeries had higher failure rates and that they labeled all types of keyhole or minimally invasive surgery as problematic, whereas generation four is almost a completely different procedure,” Mr Nazir explains. He performs only generation four keyhole minimally invasive bunion surgery, which in his assessment has “by far the latest and with the best evidence base, and it is the most advanced of keyhole bunion surgical techniques”.
This generational gap is a genuine source of patient confusion, and it feeds a separate but related myth worth addressing directly: the idea that keyhole bunion surgery is the same thing as laser bunion surgery. It is not. Lasers can reduce inflammation around the soft tissue bump but cannot remove or correct a bony deformity, and there is no proven laser method for bunion removal. Most patients who ask about “laser bunion surgery” are, in practice, describing keyhole bunion surgery. It is a distinction worth raising directly with any surgeon offering minimally invasive correction, and one addressed in more detail on bunionsurgeon.co.uk‘s FAQ page.
Rapid Bunion™: Mr Nazir’s Minimally Invasive Protocol
Rapid Bunion™ is Mr Nazir’s trademarked minimally invasive bunion correction protocol, built on fourth-generation keyhole technique and rigid screw fixation. For the majority of his patients, it has become his default recommendation rather than one option among several. “Now, for most of my patients, I only perform my rapid bunion minimally invasive technique,” he states, reserving other approaches for the small group of patients with joint instability requiring fusion.
How the Decision Is Made
Mr Nazir bases the choice of technique on factors specific to the individual patient: the severity of the deformity, the health of the joint, and the quality of the bone. In broad terms:
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Scarf/Akin was traditionally used for moderate or mild bunions.
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Lapidus was reserved for large deformities or joints showing instability.
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MICA offered an earlier bridge into minimally invasive correction for more typical cases.
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Rapid Bunion™ is now used for the large majority of Mr Nazir’s patients, with Lapidus reserved specifically for instability at the first metatarsal joint requiring fusion.
Mr Nazir reports that in 90 to 95% of bunions, keyhole bunion surgery using his Rapid Bunion™ technique provides durable results with excellent and predictable outcomes. For patients with pre-existing arthritis in the first TMT joint, or pre-existing instability, a Lapidus fusion remains the indicated procedure instead.
What Drives a Poor Outcome, Regardless of Technique
Technique selection matters, but so does execution. Asked what typically goes wrong when a patient has had a poor outcome elsewhere, Mr Nazir points to a specific pattern: “Probably one of the main things that causes recurrence is the wrong procedure for the wrong patient, mostly because there was an undercorrection which was a surgeon mistake or there was a failure of fixation during post-op recovery. There was a complication”. Recurrence, in other words, is less often about which family of technique was used, and more about whether the technique chosen matched the patient’s deformity, and whether it was executed and fixed correctly.
What This Means in Practice for Patients Comparing Techniques
For a patient weighing up bunion surgery options, the practical takeaway is straightforward: the right technique depends on the specific deformity, not on which approach is newest or most talked about.
Mild to moderate bunions with a stable joint are typically well suited to minimally invasive correction. Mr Nazir’s own case mix now favours Rapid Bunion™ for this group.
Large deformities without joint instability no longer automatically mean open surgery or fusion. Mr Nazir now uses minimally invasive surgery for most bunions, reserving open Lapidus for the smaller set of cases involving instability or pre-existing arthritis at the first TMT joint.
Instability or arthritis at the first metatarsal joint is the clearest remaining indication for the Lapidus procedure. Patients in this category should expect their surgeon to explain, specifically, why fusion rather than a bone-shifting or keyhole correction is being recommended.
Patients should expect their surgeon to base the recommendation on the severity of the deformity, the health of the joint and the quality of the bone — not on a single default technique applied to every case. Anyone previously told that keyhole surgery is unsuitable for them should ask specifically which generation of technique was being referred to, given how markedly outcomes have evolved between the first and fourth generations.
For further background on what to expect from a keyhole procedure, the NHS’s overview of bunion surgery provides a useful independent reference point on general risks and recovery expectations.
Choosing the Right Technique for the Right Deformity
Bunion surgery has moved through several distinct generations: the open Scarf/Akin procedure, which built the longest evidence base and remains a widely performed standard; the Lapidus fusion, which addresses large or unstable deformities by fusing the midfoot joint; MICA, an earlier minimally invasive approach using chevron-pattern bone cuts; and fourth-generation keyhole techniques such as Rapid Bunion™, which now form the majority of Mr Nazir’s caseload.
The consistent thread across all of these techniques is that none is universally correct. The deciding factors are the severity of the deformity, the stability of the joint, and the quality of the bone. Where a joint is stable, minimally invasive correction now offers a predictable, evidence-based alternative to open surgery for most patients, with Mr Nazir reporting durable, excellent and predictable outcomes in 90 to 95% of the bunions he treats. Where instability or arthritis is present, fusion remains the appropriate choice.
Patients considering bunion surgery are encouraged to have their specific deformity assessed on its own terms, rather than researching techniques in isolation. Mr Nazir offers consultations to review individual X-rays and clinical findings and to explain which technique, Rapid Bunion™ or otherwise, is appropriate for that patient’s bunion. Readers can find more detail on the procedure itself via the Rapid Bunion™ page on bunionsurgeon.co.uk.
Book a consultation with Mr Nazir to discuss which bunion surgery technique is right for your case.
