Patients who undergo prolonged surgeries and become hypothermic are more likely to develop complications. We therefore advocate for diligent adherence to strategies to prevent hypothermia and recommend limiting operative time in clinical circumstances where intraoperative measures are unlikely to adequately prevent hypothermia.

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Introduction: Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons. Methods: Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions. Results: All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days. Conclusion: While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.

Purpose: To assess the outcomes of double fascial flap stabilization in managing ulnar nerve subluxation after a simple decompression procedure for cubital tunnel syndrome. Methods: We conducted a retrospective review of 20 patients who experienced ulnar nerve subluxation after simple decompression and were treated with double fascial flap stabilization between 2016 and 2018. Fascial flaps were harvested from the flexor carpi ulnaris and the septum between the triceps and biceps. Patients were classified using McGowan criteria and outcomes were measured using the visual analog scale, grip strength, and the criteria of Messina and Messina for recovery. In addition, we assessed ulnar nerve instability after in situ decompression in 10 fresh cadavers. Tang's grading and measuring system was used to measure ulnar instability. Results: There were 13 excellent and 7 good outcomes (65% and 35%, respectively). Mean follow-up duration was 9.1 months (range, 3e23 months). Mean visual analog scale scores improved significantly from 5.8 before to 1.3 after surgery. Mean QuickeDisabilities of the Arm, Shoulder, and Hand scores improved significantly from 37.9 before to 10.9 after surgery. Mean grip strength compared with the contralateral side improved significantly from 73.9% before to 89.6% after surgery. Anatomic cadaveric dissection revealed that 6 of 10 cadavers (60%) met the criterion of moderate to severe ulnar nerve instability. Conclusions: Double fascial flap stabilization with simple decompression resulted in excellent short-term clinical results. This technique provides an alternative strategy to prevent ulnar nerve instability with the advantage of preserving nerve vascularity. Long-term follow-up is required to evaluate the potential impact on recurrence or failure of simple decompression. Type of study/level of evidence: Therapeutic IV.