Skip to main content


Log in

Replantation versus transplantation: Where do we stand?

  • General Review
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript



Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss.


Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation.


Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use.


While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others


  1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R (2008) Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 89(3):422–429.

    Article  PubMed  Google Scholar 

  2. Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB (2011) Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg 36(11):1835–1840.

    Article  Google Scholar 

  3. Reavey PL, Stranix JT, Muresan H, Soares M, Thanik V (2018) Disappearing digits: analysis of national trends in amputation and replantation in the United States. Plast Reconstr Surg 141(6):857e

    Article  CAS  PubMed  Google Scholar 

  4. Pet MA, Morrison SD, Mack JS et al (2016) Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation versus prosthetic rehabilitation. Injury 47(12):2783–2788.

    Article  PubMed  Google Scholar 

  5. Ramji M, Steve AK, Premji Z, Yeung J (2020) Functional outcomes of major upper extremity replantation: a scoping review. Plast Reconstr Surg Glob Open 8(10):e3071.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Jang CH, Yang HS, Yang HE et al (2011) A survey on activities of daily living and occupations of upper extremity amputees. Ann Rehabil Med 35(6):907–921.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Biddiss EA, Chau TT (2007) Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int 31(3):236–257.

    Article  PubMed  Google Scholar 

  8. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR (2009) Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil 88(9):742–751.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Raichle KA, Hanley MA, Molton I et al (2008) Prosthesis use in persons with lower-and upper-limb amputation. J Rehabil Res Dev 45(7):961–972

    Article  PubMed  PubMed Central  Google Scholar 

  10. Dolezal JM, Vernick SH, Khan N, Lutz D, Tyndall C (1998) Factors associated with use and nonuse of an AK prosthesis in a rural, southern, geriatric population. Int J Rehabil Health 4(4):245–251.

    Article  Google Scholar 

  11. Hagberg K, Brånemark R (2001) Consequences of non-vascular trans-femoral amputation: a survey of quality of life, prosthetic use and problems. Prosthet Orthot Int 25(3):186–194.

    Article  CAS  PubMed  Google Scholar 

  12. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK (2012) Reoperations following combat-related upper-extremity amputations. J Bone Joint Surg Am 94(16):e1191–e1196.

    Article  PubMed  Google Scholar 

  13. Sheehan TP, Gondo GC (2014) Impact of limb loss in the United States. Phys Med Rehabil Clin N Am 25(1):9–28.

    Article  PubMed  Google Scholar 

  14. Harrison JH, Merrill JP, Murray JE (1956) Renal homotransplantation in identical twins. Surg Forum 6:432–436

    CAS  PubMed  Google Scholar 

  15. Foroohar A, Elliott RM, Kim TW, Breidenbach W, Shaked A, Levin LS (2011) The history and evolution of hand transplantation. Hand Clin 27(4):405–409.

    Article  PubMed  Google Scholar 

  16. Petruzzo P, Dubernard JM (2011) The international registry on hand and composite tissue allotransplantation. Clin Transpl 2011:247–53

    Google Scholar 

  17. Wells MW, Rampazzo A, Papay F, Gharb BB (2022) Two decades of hand transplantation: a systematic review of outcomes. Ann Plast Surg 88(3):335–344.

    Article  CAS  PubMed  Google Scholar 

  18. Hein RE, Ruch DS, Klifto CS et al (2020) Hand transplantation in the United States: a review of the organ procurement and transplantation network/united network for organ sharing database. Am J Transplant 20(5):1417–1423.

    Article  PubMed  Google Scholar 

  19. Heineman J, Bueno EM, Kiwanuka H et al (2020) All hands on deck: hand replantation versus transplantation. SAGE Open Med 8:2050312120926351.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Jablecki J, Kaczmarzyk L, Patrzalek D, Domanasiewicz A, Chełmoński A (2009) A detailed comparison of the functional outcome after midforearm replantations versus midforearm transplantation. Transplant Proc 41(2):513–516.

    Article  CAS  PubMed  Google Scholar 

  21. Landin L, Bonastre J, Casado-Sanchez C et al (2012) Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review. Transpl Int 25(4):424–432.

    Article  PubMed  Google Scholar 

  22. Sugun TS, Ozaksar K, Ada S et al (2009) Long-term results of major upper extremity replantations. Acta Orthop Traumatol Turc May-Jul 43(3):206–213.

    Article  Google Scholar 

  23. Azoury SC, Milbar N, Kimia R et al (2020) Four-year follow-up of the world’s first pediatric bilateral hand-forearm transplants: Do they grow as expected? Plast Reconstr Surg 146(6):1325–1329.

    Article  CAS  PubMed  Google Scholar 

  24. Cendales LC, Kanitakis J, Schneeberger S et al (2008) The Banff 2007 working classification of skin-containing composite tissue allograft pathology. Am J Transplant 8(7):1396–1400.

    Article  CAS  PubMed  Google Scholar 

  25. Dobbs D. The devastating allure of medical miracles. Wired Magazine.

  26. Efanov JI, Tchiloemba B, Izadpanah A, Harris PG, Danino MA (2022) A review of utilities and costs of treating upper extremity amputations with vascularized composite allotransplantation versus myoelectric prostheses in Canada. JPRAS Open 32:150–160.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Composite tissue transplant of hand or arm: a health technology assessment. Ont Health Technol Assess Ser. 2016;16(13):1-70

  28. Brügger U, Plessow R, Hess S et al (2014) The health technology assessment of the compulsory accident insurance scheme of hand transplantation in Switzerland. J Hand Surg (European Volume) 40(9):914–923.

    Article  Google Scholar 

  29. Kasiske BL, Cohen D, Lucey MR, Neylan JF (2000) Payment for immunosuppression after organ transplantation. JAMA 283(18):445–2450.

    Article  Google Scholar 

  30. Chan A, Kwok E, Bhuanantanondh P (2013) Cost of ownership of upper limb prostheses: a retrospective analysis. CMBES proceedings. p 36

  31. Blough DK, Hubbard S, McFarland LV, Smith DG, Gambel JM, Reiber GE (2010) Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF. J Rehabil Res Dev 47(4):387–402.

    Article  PubMed  Google Scholar 

  32. Cypel M, Yeung JC, Machuca T et al (2012) Experience with the first 50 ex vivo lung perfusions in clinical transplantation. J Thorac Cardiovasc Surg 144(5):1200–1207.

    Article  PubMed  Google Scholar 

  33. Constantinescu MA, Knall E, Xu X et al (2011) Preservation of amputated extremities by extracorporeal blood perfusion; a feasibility study in a porcine model. J Surg Res 171(1):291–299.

    Article  PubMed  Google Scholar 

  34. Kueckelhaus M, Dermietzel A, Alhefzi M et al (2017) Acellular hypothermic extracorporeal perfusion extends allowable ischemia time in a porcine whole limb replantation model. Plast Reconstr Surg 139(4):922e–932e.

    Article  CAS  PubMed  Google Scholar 

  35. Werner NL, Alghanem F, Rakestraw SL et al (2017) Ex situ perfusion of human limb allografts for 24 hours. Transplantation 101(3):e68–e74.

    Article  PubMed  Google Scholar 

Download references


There was no funding for completion of this manuscript.

Author information

Authors and Affiliations


Corresponding author

Correspondence to L. Scott Levin.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to disclose.

Ethical approval

This is a review article and did not require institutional approval for completion.

Informed consent in the manuscript

The lead author obtained consent for use of photographs and videos from included patients.

Consent for publication

This manuscript was written in compliance with ethical standards. The submitted work is original and has not been submitted or published elsewhere in any form or language

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Video 1: 35-year-old patient 6 years out from bilateral hand transplant in this photo and now 7 years out form her transplant. She is the first bilateral hand transplant patient to have a baby post-transplant. She is able to hold and change her baby's diaper with her transplanted hands, which has more meaning to her than she could achieve with a prosthesis. Photo and video content provided by senior author LS Levin and permission for publication has been obtained from patient (MP4 5658 KB)

Video 2: 48-year-old patient 4 years out from bilateral hand transplant in this photo. Her ability to drive gives her independence that she has not had in many years. Video content provided by senior author LS Levin and permission for publication has been obtained from patient. (MP4 6555 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Janes, L.E., McAndrew, C. & Levin, L.S. Replantation versus transplantation: Where do we stand?. Eur J Orthop Surg Traumatol (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: