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Silver Procedure: Resection of Medial Eminence

- Discussion:
      - Silver procedure involves simple exostectomy;
      - it is typically performed along w/ other hallux valgus reconstructive procedures such as chevronMcbride, or proximal osteotomy;
             - in the case of a proximal osteotomy, the bone graft resected from the medial eminence may be used as bone graft for an opening wedge proximal osteotomy;
      - indications: younger pts w/ prominent "bunion" w/ mild IMA & HVA,
      - if excessive medial metatarsal head eminence is excised, medial instability of MP joint results because of deficient medial support;
           - result is hallux varus;

- Technique:
    - there is some controversey as to where and how to perform the resection;
    - resection at the saggital groove:
           - some argue that the excision begins at the saggital groove, which is the groove between the normal joint cartilage and the uncovered cartilage on the medial side of the eminence;
           - others argue that the resection should not be performed thru sagittal groove, since the relative position of this groove is variable;
                   - often w/ severe deformities, the saggital groove will be located at the center of the metatarsal head;
                   - w/ less severe deformities, the groove is located more medially;
           - excessive resection of eminence, may result in medial subluxation of sesamoids;
    - resection flush w/ medial border of foot:
           - probably the better method is to resect the medial eminence flush w/ the medial border of the foot;
           - some recommend that resection of medial eminence is performed flush w/ the medial aspect of metatarsal shaft;
                  - w/ this approach, however, a painful bony prominence may remain along the medial side of the foot;
    - the saw blade should be directed from dorsal to plantar direction to give a more precise cut