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Thumb replantation following thumb amputation is the standard of care. When replantation is impossible, microneurovascular great toe transplantation is a well-established option.A retrospective review was conducted to evaluate functional outcome following isolated thumb replantation or great toe transplantation for thumb reconstruction. From 1974 to 1993, 384 thumb amputations were treated and 110 great toe-to-thumb transplantations were performed.Ninety-one patients with isolated thumb amputation had an 85% survival rate. Failed replants usually resulted from crushing or avulsing injuries. Function of replanted thumbs was better in sharp compared with crush/avulsion injuries. Forty-three isolated thumb reconstructions had a 93% success rate. Function was comparable with thumb replants from sharp injuries. Interphalangeal motion was significantly better in great toe transplants than in replanted thumbs of the crush/avulsion type.Amputated thumbs should be replanted. When replantation is not possible or unsuccessful, a transplanted great toe functions as well as, or better than, a replanted thumb.