Lower Extremity Allotransplantation: Are We Ready for Prime Time?

With the success of upper extremity and face transplantation, the field of vascularized composite allotransplantation (VCA) is preparing to expand into other reconstructive areas of the body. Lower extremity allotransplantation has the potential to offer patients improved function over current prosthetics, reduce phantom limb pain, and reduce prosthetic associated complications. However, these benefits must be weighed against the obstacles of slow-paced nerve regeneration, difficult perioperative management, and lifelong immunosuppression. Four cases of lower extremity transplantation have been performed with increasingly high-risk operations, marked by deaths of the last 2 recipients. As lower extremity allotransplantation proceeds, selecting the appropriate candidates to optimize outcomes is critical. We propose a classification system of lower extremity allotransplantation based on the extent of preservation of recipient muscular innervation and detail a practical next recipient. If a safe and thoughtful approach is taken, we believe lower extremity allotransplantation can achieve similarly positive results to those seen in hand and face allotransplantation.