Clinical Application Of "cocktail" Analgesic Mixture After Wrist Arthroscopy Of Triangle Fibrocartilage Complex

Background: The triangular fibrocartilage complex(TFCC)was a complex anatomical structure located on the ulnar side of the wrist.The main function of the TFCC was to stabilize the distal radioulnar joint and cushion the pressure on the ulnar joint.TFCC mainly includes fibrocartilage disc,meniscus,ulnar carpal ligament of carpal palm,carpal radiulnar ligament,ulnar collateral ligament and base of extensor tendon sheath canal 5 and 6 [1].After injury,patients will have ulnar wrist pain,limited wrist movement,decreased hand muscle strength and other problems,which will greatly affect the function of the patient’s hand and daily life.After TFCC injury,conservative treatment such as plaster fixation or sealing therapy often cannot achieve satisfactory results.In surgical treatment,compared with traditional open surgery,arthroscopic surgery is characterized by clear intraoperative field of vision,less surgical trauma,and better postoperative wrist motion [2].However,there are still complications after arthroscopy,such as wrist stiffness.Some wrist stiffness is caused by postoperative delay and incorrect functional exercise,among which postoperative pain is the main cause of postoperative functional exercise in corresponding patients.According to literature reports,6 weeks after TFCC repair,patients still feel pain,in addition to wrist swelling and a series of disused joint and muscle function loss and other problems.In particular,postoperative pain will cause severe discomfort to patients,affecting their satisfaction and comfort level,and stress response can induce or aggravate the original underlying diseases,hinder early joint activity,and not conducive to postoperative rehabilitation of patients [3].Therefore,the methods and advantages of postoperative analgesia have attracted more and more attention from clinicians in the perioperative period [4].Postoperative application of "cocktail" analgesic agents has been widely used in clinical surgery,but the types and dosages of drugs are not the same,usually made from the mixture of multiple analgesic drugs,but there is no unified standard for the types and dosages of drugs used in different situations [5].There are various schemes for the allocation of cocktail analgesic mixture,among which local anesthetics are the main components and combined with sympathetic nervous system regulators,corticosteroids,opioids,etc.,the principle of which is analgesia and local anti-inflammatory,so as to prevent and control postoperative pain [6].In this study,according to the characteristics of "wrist arthroscopic treatment of TFCC injury",such as small surgical wound,less blood loss and small wrist joint,the formula of "cocktail" was adjusted accordingly.The ingredients of "cocktail" used in this study mainly included ropivacaine,compound betamethasone and dilution of normal saline.In addition to its analgesic effect,ropivacaine is special for its vasoconstriction and less scar toxicity [7].In addition,studies have shown that ropivacaine analgesia applied to surgical incisions can effectively reduce postoperative pain and opioid demand,which are especially useful in surgical operations [7].Local injections of corticosteroids into musculoskeletal tissues and joints have been widely used without affecting wound healing or other complications[5].Compound Betamethasone,as a classic corticosteroid,has an effective local anti-inflammatory effect and can reduce the local stress response to surgical trauma.By effectively inhibiting these physiological responses to surgery,pain can be relieved and functional recovery can be promoted [8].In addition to adjusting the formulation of "Cocktail" analgesic mixture,this study also focused on the administration method and injection site of "cocktail" analgesic mixture,which was injected into the wrist cavity,around the joint capsule,periosteum and soft tissue around the bone canal,and the subcutaneous tissue of the incision.This study will evaluate the effectiveness of "cocktail" analgesic mixture in terms of postoperative pain,muscle strength of affected limb,wrist range of motion,adverse reactions and incision conditions.Because local analgesics do not metabolize through the liver and kidney,and have little toxicity to the liver and kidney,compared with the systemic drug approach,analgesia takes effect quickly,directly acts on the target,and is more convenient for nursing.Therefore,local injection of "cocktail" after wrist arthroscopy for TFCC injury provides a new medication method for clinical analgesia,and is also an ideal drug delivery route,which is expected to improve patients’ perioperative recovery and create opportunities for early limb functional exercise.Objective: The objective of this study was to investigate the analgesic effect,function recovery and safety of "cocktail" ropivacaine and compound betamethasone analgesic injection in joint cavity and local infiltration during wrist arthroscopic TFCC repair,and to provide reference for clinical treatment.Methods: Patients who were diagnosed with TFCC Atzei2 or 3 type injuries and received wrist arthroscopic treatment in the Fifth Department of Manual Surgery,Central Hospital Affiliated to Shenyang Medical College from October 1,2019 to January 31,2022.Twenty subjects were divided into two groups(n=10)according to the method of computer random sampling table.The experimental group was the "cocktail" analgesic group(group A): 4m L of 1% ropivacaine and 0.2m L of 0.7% compound betamethasone were mixed into normal saline to form 10 m L "cocktail" analgesic mixture.2m L "cocktail" analgesic mixture was injected into the incision subcutaneous tissue,periosteum and soft tissue.A 4m L "cocktail" of analgesics was injected into the wrist cavity and around the capsule under arthroscopic supervision.The control group was the normal saline injection group(Group B): the same amount of normal saline,the injection method and dose were the same as the experimental group.Analgesic drug use: Postoperative analgesic drugs were not routinely used in the two groups.If postoperative pain was felt,oral acetaminophen dihydrocodeine tablets could be used for analgesia,and the applied dose was recorded. Observation indicators:(1)Patient’s age,height,weight,body mass index(BMI),gender,course of disease,and operation time.(2)Pain: 1)The static visual analog score(VAS)was used to evaluate the pain.The score was 0-10,and the higher the score was,the more obvious the pain was.The resting pain of each patient was evaluated and recorded at 5 time points,including preoperative and postoperative 12,24,48 and 72 h.(3)Kneading force: kneading force between thumb indicator fingers of patients was measured before surgery,1d,2d and 3d after surgery.3)Satisfaction with analgesia.Before discharge,patients were asked about their satisfaction with the analgesia effect on the operative side,which was divided into three levels: satisfaction,general and dissatisfaction.(4)Analgesic drug use: postoperative analgesic drugs were not routinely used in the two groups.If postoperative pain was felt,oral acetaminophen dihydrocodeine tablets could be used for analgesia,and the applied dose was recorded.(5)Wrist range of motion measurement,preoperative and postoperative 1Y wrist range of motion measurement.(6)Wrist joint function evaluation.PRWE score was used to evaluate the wrist joint function of patients before and 1Y after surgery.(7)Postoperative adverse reactions: the changes of skin blood flow around the incision and incision healing,urinary retention,respiratory depression,drug allergy,nausea and vomiting were recorded.The number of patients with the above adverse reactions in the experimental group and the control group before discharge after surgery was recorded.SPSS statistical software was used for analysis.Measurement data using x±s said that the comparison between the group by group t test.Count data rate(%),compares the c2 test.P<0.05 for the difference was statistically significant.Results: The number of participants was analyzed according to intentionality analysis.All 20 patients were included in the result analysis,and no one withdrew from the treatment.(1)Comparison of general data between the two groups: there were no differences between the two groups in basic data(gender,age,height,weight,body mass index),preoperative pain,preoperative pinch force,preoperative wrist flexion and extension range of motion,radioulnar deviation range of motion,forearm rotation,preoperative wrist function and operation time(P>0.05,Table 1).(2)Comparison of postoperative resting VAS scores between the two groups: The resting pain of experimental group at 12 h,24h and 48 h after surgery was lower than that of control group,with statistical significance(P<0.05,Table 2).And there was no difference in pain between the two groups at 72 h after surgery(P >0.05,Table 2).(3)the comparison of two groups of postoperative pinch strength: experimental group patients in postoperative 1 d,2 d and 3 d limb hand between thumb and index finger were significantly higher than that of control group,difference has statistical significance(P <0.01,table 3).(4)two groups of postoperative analgesic usage control patients postoperative analgesia drug use was significantly higher than the experimental group,difference has statistical significance(P <0.01,table 4).Although there was no statistical difference in the number of patients who had taken analgesic drugs between the two groups after surgery(P>0.05,Table 4),the number of patients in the control group who took analgesic drugs after surgery reached 90%,while that in the experimental group was only 10%.(5)Comparison of satisfaction with postoperative analgesia between the two groups: The survey of satisfaction degree of patients with postoperative analgesia showed that the satisfaction degree of the experimental group was higher than that of the control group,the difference was statistically significant(P<0.05,Table 5).The satisfaction degree of the experimental group reached 70%,while that of the control group was only 40%.(6)Comparison of wrist range of motion and wrist function 1Y after surgery between the two groups: Wrist range of motion was reviewed 1Y after surgery between the two groups,and wrist function was evaluated.There were no statistically significant differences in flexion and extension motion,radioulnar deviation motion,rotational motion of the forearm and wrist function between the two groups(P >0.05,Table 6).(7)Comparison of general postoperative conditions between the two groups: no redness,swelling,cracking and other phenomena occurred in the postoperative incisions of the two groups,indicating grade A healing.Postoperative adverse reactions such as urinary retention,respiratory depression,drug allergy,nausea and vomiting did not occur in both groups(Table 7).Conclusion: Intraarticular and local infiltration injection with "cocktail" analgesic mixture during arthroscopic restoration of triangle fibrocartilage complex can achieve good pain control in the early postoperative period,reduce the amount of postoperative analgesic drugs,and the clinical application is safe.