【作者】 齐振熙；

【导师】 张安桢；

【作者基本信息】 福建中医学院 ， 中医骨伤科学， 2004， 博士

【摘要】 一．背景：非创伤性股骨头缺血坏死的发病率呈逐年上升趋势，而糖尿病(DM)作为发病因素之一，目前对其病变特征及病理机制尚未阐明，临床防治缺乏理论依据。 二．目的：探讨DM引发股骨头缺血性坏死(ANFH)的基本病理过程，初步阐释糖尿病性股骨头缺血坏死(DANFH)的发病机制，为其临床有效防治提供客观的理论依据。 三．方法： 1．建立实验动物病理模型：采用腹腔内1次注射60mg／kg体重链脲佐菌素(STZ)的方法，建立速发型链脲佐菌素SD大鼠DM模型。 2．具体分组：160只大鼠按性别随机抽取56只(雌雄各半)分为4组，每组14只，作为空白对照组，其余104只进行STZ造模。每天测尿糖1次，48小时后剪尾法取血测非空腹血糖1次，1周后再次剪尾取血测血糖1次。然后取尿糖始终在+++以上，两次血糖均超过16.7mmol／L者为DM造模成功鼠。随机抽取DM造模成功鼠56只(雌雄各半)，按性别随机分为4组，每组14只，作为DANFH实验组。8组动物分别于4、8、12、24周时分批处死取材。 3．检测指标：以组织病理学、超微形态学、生物力学、骨及血尿生化学、血液流变学、骨代谢、微循环、氧自由基代谢等为指标进行对照研究。 四．结果： 1．实验组动物电镜下均可见骨小梁表面成骨细胞减少，活性降低，光镜下见股骨头软骨层较薄，软骨下骨小梁变细，间距增大，非常稀疏，结构紊乱，部分断裂甚至消失。股骨头压缩强度及应变能力明显降低，各实验组的股骨头极限载荷与同期对照组比较降低非常显著(P＜0.01或P＜0.05)。同时，各实验组大鼠与同期对照组比较，代表骨吸收的尿Ca、P、HOP排泄量均有显著或非常显著的增多(P＜0.01或P＜0.05)；而代表骨形成指标的血清BGP水平均明显降低，尤其是在第12周和第24周时降低更为显著 (P<0.05);血钙及钙磷乘积显著下降(P<:0 .01);骨Ca、HOP含量及Ca/HOP比值均有显著和非常显著的降低(P<0.05或P<0 .0:[)。 2.实验组动物于透射电镜下观察可见股骨头骨细胞呈不同程度的坏死，细胞器结构模糊不清，胞质内出现大小不等的脂滴，骨髓组织增生减低，脂肪细胞增多、增大。光镜下可见髓内造血组织减少，骨细胞变性坏死，空缺骨陷窝数从第4周起即有增多现象，至第8周时显著增多(P<0 .05)，从第12周开始增多极其显著，空缺骨陷窝计数高达19.8%，比较同期对照组有极其显著性差异(P<0.001)。肝细胞脂肪变性，在肝细胞中可见脂肪滴，肝细胞内出现大小不等的脂肪空泡，胞体肿胀，胞核被压至一边，呈气球样变。各实验组与同期对照组比较TC、TG含量均有显著和非常显著升高(P<0.05或P<0.01)，其中第8周实验组的TG含量与同期对照组比较升高非常显著(P<0 .01)，其升高的幅度接近1倍。同时，存在全血低切粘度、全血高切粘度、血浆粘度、红细胞聚集率、红细胞压积、纤维蛋白原升高的特点，与同期对照组比较均有显著和非常显著的差异性(P<0 .05或P<0 .01);红细胞变形指数与同期对照组比较呈显著降低(P<0 .05或P(0 .01)。 3.实验组动物与同期对照组比较血浆ET一1、TXBZ水平以及T/K比值均有显著或非常显著的升高(P<0.05或P<0.01)，而6一Keto一PGFI。水平则显著降低(P<0.05)，ET一1与TXBZ、6一Keto一PGFI。、T/K比值呈高度相关性。同时，实验组大鼠血清SOD活性与同期对照组比较显著降低(P<0 .05)，而MDA含量则显著增高(P<0 .05)，两者呈显著负相关。 五.结论: 1 .DM骨矿物质代谢紊乱，骨吸收增加，骨形成不足，引发骨质疏松。股骨头因应力的作用出现显微骨折及软骨下骨压缩而.塌陷，压迫骨内微血管引起缺血，这是导致DANFH的一个重要病理过程和发病原因。 2.DM脂质代谢紊乱，引起高脂血症。由于骨内血管的脂肪栓塞、髓内高压静脉回流受阻、骨细胞“占位性”脂肪变性、股骨头内小动脉炎等多因素的累积效应，使血供中断，最终导致DANFH。 3.DM血液流变学异常，血液呈高粘滞状态。由于血流癖滞，微循环减缓或障碍，导致股骨头的血供减少，缺血而坏死。同时，血流变异常的早期出现，提示其可能较早参与了DANFH的发生与发展。 4.DM长期糖代谢紊乱，高糖血症引发血浆ET一1、TXBZ以及T/K值的平衡失调参与 2忿和促使微血管病变的发生，微血管强烈而持久的收缩作用直接影响股骨头的微循环和物质代谢，最终导致其缺血坏死。同时，自由基代谢异常，脂质过氧化反应可能加速了微血管病变，加剧了股骨头微循环障碍，促进了DANFH的发生。 5.DM引发ANFH的一系列病理改变应归责于气滞血癖和痰阻血癖。由于其符合血癖证的病证实质，因此，DAN阳应以血癖为定论，以活血化癖为治疗大法，且应贯穿于DANFH中医治疗的全过程。更多还原

【Abstract】 Background The incidence of Non-trauma necrosis of femoral head is ascending year by year. Diabetes mellitus is one of etiopathogenesises of femoral head necrosis. By now, the pathological characters and the pathogenesy of diabetic avascular necrosis of femoral head (DANFH) are not clarified, and its theoretic foundations of clinic prevention and cure are absent.Objective To explore the basic pathology and the primary pathogenesy of DANFH, and provide objective theoretic foundations for clinic prevention and cure of DANFH.Methods1. Establish experimental animal model: The SD mice were used as experimental model animal in this study, and the immediate diabetes mellitus was established by injecting STZ (60mg/kg) into the abdomen of mice.2. Grouping: 56 mice (the male and female were half and half) were selected randomly from 160 mice and then divided into 4 groups which were recognized as control group, while the other 104 mice were injected STZ to establish the model of DM. The urinary glucose of 104 mice wrer examined daily, and the blood glucose were examined 48 hours and one week after injected STZ using the blood got from tail.Then the mice, whose urinary glucose were always over +++ and the blood glucose were over 16.7mmol/l were recognized as DM animal model. 56 (the male and female were half and half) of the DM animal model were divided randomly into 4 groups which were recognized as DANFHexperimental group, and each group had 14 mice. All mice in 8 groups were executed separately at the 4th,8th,12th,24th week after injected STZ, and the research samples were got at the same time.3. Research Indexes: The indexes of histopathology, ultratructure, biome-chanics, biochemistry of bone metabolism, hemorrheology, micro-circulation and oxidative free radical were spected contractly in the research.Results1. The experimental group shown that the osteoblast amount and the activation of osteoblast were reduce at the surface of trabeculae observed by electron microscope. Observed by microscope, the experimental group shown that the cartilago of femoral head and the trabeculae under femoral head were slender, and the interval of trabeculae was increased, and the structure of trabeculae was rarefaction and disorder, even more, some of trabeculae were broken or disappear. The capability of strain and the intensity of stress of femoral head were lower, and the maximum load of all femoral heads of experimental groups were significantly lower than the control one (P<0.01 or P<0.05). In all experimental groups, the excretion of Ca,P,HOP in urine, as bone assimilation indexes, ascended obvously (P<0.01 or P<0.05), and BGP in serum, as bone shaping index, fell obviously especially at the 12th and 24th week after injected STZ. The product of Ca and P in serum was strongly lowered (P<0.01), and the same results were shown on Ca,HOP,Ca/HOP of bone (P<0.05 or P<0.01).2. Osteocyte necrosis, disarranging formation of cell organs, appearing of big or small fat drops, deducing of myeloid tissue, and increasing amount and amass of lipocytes were shown by transmission eletron microscope in femoral head tissues. Less hematopoietic tissue in myeloid, osteocyte degeneration and necrosis, empty osteocyte lacuna were observed in femoral head tissues by microscope at the 4th week after injected STZ. And the empty osteocyte lacuna was notable increased at the 4th week after injected STZ, and it reached 19.8% at the 12th week after injected STZ. The amount of empty osteocyte lacuna hadsignificant difference between experimental group and control group (P<0.01). The liver cells were getting fatty degeneration, and the fat drops, empty lipocytes and balloon degeneration of cells were also shown in liver cells by ecletron microscop. The nucleus of the liver cell was pushed aside. The levels of TC,TG had notable difference between experimental group and control one (P<0.05 or P<0.01). And the level of TC of experimental group ascended obviously (P<0.01) at the 8th week after injected STZ, it was almost twice of that of the更多还原