Treatment of an Amputated Digit in a Patient with Smoking History
For patients with an amputated digit and a history of smoking, immediate smoking cessation, prompt surgical evaluation for possible replantation, and a comprehensive multidisciplinary approach are essential for optimal outcomes and to reduce the risk of replantation failure. 1
Initial Management
Immediate Actions
- Proper preservation of the amputated digit:
- Wrap in saline-moistened gauze
- Place in sealed plastic bag
- Keep cool (not directly on ice) 2
- Avoid preserving in plain saline solution or ethanol (increases failure risk) 2
- Urgent surgical evaluation within 4-6 hours of injury
Surgical Considerations
- Assess feasibility of replantation based on:
- Level of amputation
- Mechanism of injury (crush/avulsion injuries have worse outcomes)
- Patient factors including smoking history 2
- During replantation procedure (if performed):
- Bone stabilization
- Tendon repair
- Arterial anastomoses
- Venous anastomoses
- Nerve coaptation
- Skin coverage 3
Risk Factors for Replantation Failure
Smoking-Related Risks
- Smoking significantly increases risk of replantation failure 2
- Causes vasoconstriction and microvascular compromise
- Impairs wound healing and increases infection risk 1
Other Risk Factors
- Crush or avulsion mechanism (vs. clean-cut)
- High platelet count
- Improper preservation of amputated part
- Need for vein grafting 2
Post-Operative Management
Pharmacologic Treatment
- Antiplatelet therapy (aspirin) is essential 4
- Consider anticoagulation in high-risk cases
- Appropriate pain management
Wound Care
- Negative pressure wound therapy (NPWT) can be used after revascularization and minor amputation when primary or delayed secondary closure is not feasible 1
- Maintain moist wound bed while controlling drainage and exudate 1
- Regular debridement of necrotic tissue 1
Rehabilitation
- Begin protective motion protocol after 5-7 days of digital viability 4
- Focus on tendon glide and joint motion
- May require specialized hand therapy
Smoking Cessation
Critical Importance
- Immediate smoking cessation is mandatory 1
- Patients should be advised by each clinician to stop smoking 1
- Offer comprehensive smoking cessation interventions:
- Behavior modification therapy
- Nicotine replacement therapy
- Bupropion 1
Follow-up Care
- Regular wound assessment during follow-up 1
- Monitor for signs of vascular compromise
- Evaluate for infection
- May require secondary procedures for optimal function 3
Special Considerations
If Replantation Not Possible
- Consider revision amputation with appropriate closure
- Focus on preserving length and function
- Ensure adequate soft tissue coverage
Monitoring for Complications
- Venous congestion or occlusion
- Arterial thrombosis
- Infection
- Late digital replantation failure (can occur even weeks after initially successful replantation in smokers) 5
The patient's smoking history significantly impacts treatment decisions and outcomes in digit replantation. While smoking does not absolutely contraindicate replantation, it substantially increases the risk of failure and complications. Immediate smoking cessation and close postoperative monitoring are essential components of care that can improve outcomes in these challenging cases.