The “Bilhaut-Cloquet” Technique for Treatment of Thumb Duplication

Abstract

The presentation of thumb duplication is variable depending on the level of bifurcation, the relative sizes of the two thumbs and their possible symmetry along a longitudinal axis. Resection of the supernumerary thumb often leads to disappointing results when both thumbs are hypoplastic. The principle of the "Bilhaut-Cloquet" procedure involves central resection of the duplication followed by fusion of the remaining lateral portions, in order to obtain a thumb of satisfactory volume. Thirteen children with unilateral thumb duplication were treated using the "Bilhaut-Cloquet" procedure. Nine cases involved duplication of the distal phalanx (Wassel type II). Five of these duplications were symmetrical and four were asymmetrical with an associated proximal delta phalanx. In these cases, a corrective osteotomy of the delta phalanx was performed at the same time. Four cases involved symmetrical duplications of both proximal and distal phalanges (Wassel type IV). The mean age at time of surgery was 11.5 months. Patients were reviewed with a mean follow-up of four years. The aesthetic aspect of the nail was judged as good in 12 cases. In one case, the aesthetic aspect of the nail was judged as fair due to a prominent longitudinal ridge. Bony fusion was obtained in all cases but one. The alignment was corrected in all cases but four, involving asymmetrical duplications. Joint mobility was limited in all patients. The "Bilhaut-Cloquet" technique leads to a satisfactory volume of the thumb in selected cases. Good correction of preoperative angular deformity is obtained in symmetrical cases. A precise technique of bone and nail approximation yields good functional and aesthetic results. The "Bilhaut-Cloquet" technique is indicated in balanced and symmetrical duplications, when the two thumbs are severely hypoplastic. It can be used either in the distal or proximal phalangeal types of thumb duplication.

Prognostic value of age and Wassel classification in the reconstruction of thumb duplication

“…Generally, excision of the radial thumb is recommended, as in our protocol [1, 9, 13, 14]. Otherwise, the Bilhaut–Cloquet technique may be put into practice in types I, II, and III deformities when the sizes of the two thumbs are similar and with restricted IP joint motion but good MCP/carpometacarpal (CMC) joint motion [1, 6, 9, 12, 13, 18, 19]. We do not use this technique because, first, the aesthetic results are only fair, and, second, it is a much more demanding technique with final functional results equivalent to those of other techniques.…”

“…Although the mean age of our patients was 20 months, similar to that in the literature, most of our patients were operated at ages between 6 and 12 months (42 % of our patients). Most authors [13, 14, 18, 21–23] operate at around 12–18 months of age. The difference in age between our mean age (20 months) and that in other studies may be due to our long waiting list, which delays surgery.…”

Results after surgical treatment of thumb duplication: A retrospective review of 33 thumbs

“…The Bilhaut-Cloquet procedure often gives a larger thumb with a nail fissure, but the thumb has a good cosmetic form. The presence of this nail fissure is why some authors propose a microsurgical suture of the nail bed and of the germinal matrix [15], whereas others prefer - as we do - to leave the nail fixed on the bed and only suture the nail [7]. In comparison to the Bilhaut-Cloquet procedure, following resection, the thumbs are more often shorter and thinner because of hypoplasia of the duplicated thumbs existing before surgery.…”

“…In terms of type II duplication, we suggest that the Bilhaut–Cloquet procedure is an appropriate technique if both thumbs are symmetric and hypoplastic. This procedure creates a thumb that is well aligned and stable and with a good volume [7, 8, 15, 16]. In such cases, simple resection can be more and more abandoned and is associated with reconstruction techniques [17].…”

“…This procedure limits the range of motion in type IV duplications [15], but it usually creates a stable thumb with a good volume and on a good axis and, when the alignment of the different structures is correct, a good cosmetic result. Therefore, some authors, as Samson et al [7], propose using this technique in type IV duplications when both thumbs are hypoplastic and symmetric. Other authors, such as Kato et al [15], use a modified procedure: the nail is withdrawn and then the germinal matrix and the nail bed are sutured with a microscope; bone resection is done without going to the epiphysis and to the joint surface; then both parts are joined together and maintained with two K-wires.…”