Intraosseous lipoma of the calcaneus：A Case Report and Literature Review

Intraosseous lipoma of the calcaneus：A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Intraosseous lipoma of the calcaneus：A Case Report and Literature Review yu wang, Zihao Wang, Xin Yang, Yihao Yang, Yinghan Guo, Jie Ou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3791122/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Intraosseous lipoma is a rare, benign primary tumor occurring in the bone. It typically occurs in long bones, such as the femur, tibia, and fiblua. While irregular bone and flat bones occur very rarely. Patients with intraosseous lipomas are asymptomatic in the early stages, but symptoms may appear in the later stages, accompanied by complications such as pain and fracture. On the X-ray plain, an intraosseous lipoma presents as an osteolytic lesion with well-circumscribed, and accompanied with a sclerotic margin and unevenly calcified parts. Recurrence and malignant transformation of intraosseous lipoma are extremely rare, and usually not requiring surgery. The possibility of malignant transformation and recurrence may be low, and usually not requiring surgery. In this article, we report a case of intraosseous calcaneal lipoma complicated with pathological fractures that was treated by curettage of the lesion and bone grafting , and local plate osteosyntheses showed good results. Combining this case with similar cases at home and aboard and reviewing related literature, we formed conclusions based on the manifestations, diagnosis, treatment, and prognosis of this disease and provided treatments and a new idea for the study of similar cases. Intraosseous Lipoma calcaneus surgery benign bone tumor Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Background Intraosseous lipomas are a rare primary benign bone tumor, with an estimated prevalence of around 0.1% of primary bone tumors[1]. which is mostly found in the epiphysi（32%）and metaphyseal region of long bones（80%）[2]. Cornills first reported the disease in 1880[3] .The disease can occur in all age groups, adults are more common, there is no significant difference in the incidence of male and female.It is most often found between 40 and 50 years of age have a better prognosis and rarely malignant transformation[4].The majority of patients with intraosseous lipoma have no obvious symptoms, so it is often misdiagnosed. Most of the confirmed patients are accidentally found by imaging examination for the diagnosis and treatment of other diseases. Very few patients may present with bone pain and other non-specific Presentation[5].In this report, we present a case of intraosseous lipoma of the calcaneus in a 53-year-old men who in diagnosis and treatment evaluation prognosis. The study and analysis of the case improved the knowledge of this tumor, and related literature was incorporated to improve the understanding of the disease. 2. Case presentation 2.1 Preoperative diagnosis : The patient was a 53-year-old freelancer who was admitted to the hospital in July 2020 due to severe pain caused by sudden left foot sprain. Following physical examination, we found that mild swelling of the left foot, obvious tapping tenderness with limited movement of the left ankle joint and reflexes, sensation, and blood flow of the affected limb were normal.Lateral digital radiography (DR) of the left foot (Fig. 1 A) revealed a 1.8cm×1.7cm well-defined nodular low-density lesion with fracture line shadow and inhomogeneous internal calcification in the left calcaneal bone, known as the Cockade sign[ 6 ]. Later, the patient were performed the magnetic resonance imaging (MRI) examination showed a round nodules in the left calcaneus, with sclerotic edges and low signal intensity, there was a short T1 signal mixed with T2 signal inside, namely fatty degeneration(Figs. 1 B, 1 C) .To be conservative,we also performed single-photon emission computed tomography (SPECT) (Fig. 1 D), which indicated an abnormal left calcaneal metabolism. Other tests showed no obvious abnormalities. In conclusion, we considered benign lesions according to the above physical examination and imaging examination, and clinically preferred intraosseous lipoma (Milgram stage II). 2.2 Operation method: According to the patient's preoperative MRI findings and "Cockade sign" shown by DR, we considered that he had calcaneal intraosseous lipoma and pathological fracture, and chose to perform surgical treatment for him, including "calcaneal mass curettage", "allogeneic bone implantation" and "calcaneal plate internal fixation". We made an "L" incision through the lateral approach of the left ankle joint to free the sural nerve and protect the peroneus longus and peroneus brevis muscles. A soft tissue cavity in the calcaneus was observed by exposing the posterior fenestrum of the calcaneus 2cm×1cm. A complete curettage of the lesion within the calcaneus revealed a small amount of adipose tissue and some sclerosing osteoid tissue (Fig. 2 A). A complete curettage of the lesion within the calcaneus revealed a small amount of adipose tissue and some sclerosing osteoid tissue (Fig. 2 A). After that, the tumor cavity was inactivated with absolute alcohol and allogeneic bone was implanted. Meanwhile, calcaneus plate internal fixation was performed to reconstruct stability (Fig. 2 B). The lesion specimen was sent to the pathology department for further examination. 2.3 Postoperative recovery: The wound was closed and wrapped with gauze. The patient was instructed to immobilise the left foot. DR examination was performed on the third day after surgery (Fig. 3 A), which showed normal shape of the left calcaneus with dense filling shadow.Postoperative pathological specimens (Figs. 3 B, 3 C) showed a large number of adipocytes, trophoblast vessels, and pathological calcification of some cell-free structures, with inflammatory cell infiltration in the focal area, suggesting intracellular lipoma, which further confirmed our diagnosis. The patient was discharged on the sixth postoperative day, resumed full weight-bearing walking 8 weeks later, and resumed all daily activities 12 weeks later with no complaints of other discomfort. 2.4 Follow-upresults : With a follow-up of 23 months, he participated in normal activities and without recurrence.DR Examination (Fig. 4 A) showed no special abnormalities, and computed tomography (CT) (Fig. 4 B) showed a dense filling of the calcaneus with normal morphology and good fracture healing. DR examination (Fig. 4 A) didn’t show any abnormality, and computed tomography (CT) (Fig. 4 B) showed filling of calcaneal dense shadow, normal shape, and good fracture healing. DR plain film review was performed after removal of plate and screw internal fixation (Fig. 4 C). 3. Literature review To review the cases of Intraosseous lipoma of Calcaneus at home and abroad in recent years, we used ' intraosseous lipoma 'and' calcaneus' as keywords to search Pubmed® for publications from the preceding 10 years. Using the strategy, we were reviewed a total of 13 literatures and the medical records of 16 cases were reported and reviewed. For details regarding age, treatment method, clinical characteristics, and follow-up, see Table 1 . Table 1 Literature review of intraosseous lipoma of the calcaneus References Sex Age(year) Clinical symptoms Milgram staging Treatment Follow-up time Follow-upresults Onset Diagnosis First evaluation Duringfollow-up Azarsinaet al.[ 20 ] F NM 45 Pain Improved II Curettage andbone grafting and internal fixation 3mths Cure Powell et al.[ 21 ] Case 1 M 14 18 Pain Improved III follow-up 4yrs Improved Case 2 M NM 58 No. No. III follow-up NM NC Alnoohet al.[ 22 ] F 33.5 34 Chronic pain Improved I Curettage andbone grafting 3mths Cure Sharmaet al.[ 5 ] F 35 45 Pain for 3 monthsafter trauma Improved I Curettage and bone cement filling 3yrs Cure Cao.[ 23 ] M 35.5 36 Dull pain Improved I Curettage andbone grafting and internal fixation 14mths Cure Bousbaa et al.[ 24 ] M NM 40 Intermittent pains Improved II Symptomatic treatment 3mths Improved Mawardi etal.[ 25 ] M NM 50 Occult pain Improved NM Curettage and bone cement filling 1mths Cure Balbouziset al.[ 8 ] F NM 56 Pain aggravated for 3 months Gradual improved II Curettage andbone grafting 5yrs Cure Aumar et al.[ 26 ] M 64 68 Pain and swelling Incomplete improved II Curettage andbone grafting 15mths Improved Frangežet al.[ 27 ] F 42.5 44 Pain and aggravation Improved I Curettage andbone grafting and internal fixatio and bone cement filling 1yrs Cure Pappas et al.[ 28 ] M NM 38 No. NC I Curettage andbone grafting and internal fixatio 14mths Cure Muramatsuet al.[ 29 ] Case 1 F NM 43 NM Improved NM Curettage and bone cement(Superpore®) filling 6mths Cure Case 2 F NM 43 NM Improved NM Curettage and bone cement(Biopex®) filling 5yrs Improved Hooghe et al.[ 30 ] Case 1 M NM 22 Pain Improved II Curettage byspinal needle andbone graft chips 1yrs Cure Case 2 M NM 22 Pain Improved I Curettage byspinal needle andbone graft chips 1yrs Cure This case M 53 53 Pain Improved II Curettage andbone grafting and internal fixation 23 mths Cure M:Male;F:Female;mths:months; yrs:years; NM:Not Mentioned. NC: No change;NO.:No pain 4. Discussion With the improvement of imaging level and the development of other diagnostic techniques, the number of reported cases of intraosseous lipoma has increased to a certain extent, but there are still only 100 cases reported worldwide in the past 10 years.Intraosseous lipoma is extremely rare, and patients usually have no symptoms and obvious etiology. Therefore, it has become an urgent need for scholars from all over the world to reach a consensus on diagnosis and treatment of intraosseous lipoma. In 1988, Milgram[ 7 ] reported the clinical, radiological and histological features of 66 patients with intraosseous lipomas, which were found to be widespread throughout the axial and vertical bones, mainly in the proximal femur (35%), tibia and fibula (21%), calcaneus (8%) and iliac crest (8%). Obviously, Intraosseous lipoma of the calcaneus is extremely low incidence and only less than 20 cases have been reported in the literature in the past 10 years. Intraosseous lipomas are mesenchymal-derived benign tumors that has a very low incidence and is rare in clinic, Thus, the etiology and pathogenesis of this disease has been no definite consensus in the current academic curriculum. At present, numerous hypotheses and conjectures have been proposed. Most of the scholars believed that intraosseous lipoma originated from bone cysts. For example, it was put forward by Balbouzis et al. that the formation mechanism of Intraosseous lipomas was the degraded content of the cysts was gradually replaced by adipose tissue which[ 8 , 9 ], in turn, results in the lipomatosis degeneration. Similarly to the mechanism, In a patient with the bone cyst of calcaneal reported by Malghem et al[ 10 ]. The bone cyst from hypointense hydropic lesions developed into steatosis mixed with hydropic lesions on MRI T1W was found after a 7-year follow-up, the proposed mechanism of “Cyst-Lipomas transformation” by above scholars is further confirmed. Attention worthy, Trauma hypotheses have been formulated that several cases of deep-seated lipomas were analyzed by Forsmann et al. it retraction for effects stimulates pro-inflammatory cells and inflammatory cytokines release under leading to immature adipocytes differentiation and mature adipocytes pile up to form lipoma[ 11 ]. However in this case, the patients have not suffered any type of chronic and long-term trauma at the focal point. Thus, this hypothesis needs to be further verified. Imaging examinations are considered to be effective in diagnosing intraosseous lipomas[ 1 ], which often show well-defined osteolytic changes on DR plain films; soft tissue steatosis can be seen on CT and MRI.However, its manifestations are usually non-characteristic and therefore need to be differentiated from chondromas, aneurysmal bone cysts, simple bone cysts, fibrous dysplasia, and bone infarcts[ 12 ]. Among them, the disease usually appears as a clear-cut area with clear borders on DR scans, and showing osteolytic lesions, which may be accompanied by marginal sclerosis and thicker calcified or ossified dense matrix[ 5 , 6 ]. The tumor morphology was round, regular or irregular, and some are lobulated, nodular calcification and trabecular bone of varying thickness can be seen in the lesions. However, the disease is difficult to be diagnosed qualitatively on DR plain film because of the overlapping tissue structure in coronal and sagittal positions and the low resolution of tissue density, which often cannot estimate the components of the transparent area, and the disease is similar to the DR scanning performance of simple bone cyst, post-traumatic cyst, chondroid fibroma and osteoblastoma, which is easy to be misdiagnosed and missed[ 13 ]. In addition, cortical erosion may occur in very few cases[ 14 ]. Malignant bone tumors should usually be suspected when causing rapid and extensive destruction of surrounding tissues. In such cases, it is particularly important to distinguish them from malignant bone tumors. In addition, CT and MRI can help establish a more specific histological diagnosis[ 15 ].CT can calculate the tissue density and express it in Hounsfield units in the scan. Adipocytes have a lower tissue density than fibrous or neoplastic cells. Therefore, rays can be transmitted. The CT value is in the range of -27HU-127HU, and the lesions mostly show osteolytic lesions in bone, with different shapes and sizes. The lesions show a single fat density shadow or a density reduction area dominated by fat density, and nodular, plaque, thread, and small dot high-density calcification shadow can also be seen in the center of the lesion. The calcification may come from the necrosis and saponification of adipose tissue or metaplasia of mesenchymal tissue, and may be accompanied by continuous or intermittent Sclerotic margin with different thickness, clear lesion boundary, no soft tissue mass and periosteal reaction, but some edges are irregular. CT film can clearly show the density of adipose tissue and calcification in the lesion, which is conducive to improving the discrimination and diagnostic accuracy of intraosseous lipoma. MRI imaging is mainly used to show the adipose tissue in the tumor, especially when the fat content in the tumor is low. On this imaging, the signal of a fat component in the tumor is consistent with that of subcutaneous adipose tissue. On plain scan, it shows short T1, medium and long T2 abnormal signal areas. When fat suppression sequence is applied, the lesion changes to the low signal. Some lesions with fibrous septa in the tumor showed slightly low signal on T1 weighted imaging and T2 weighted imaging. When enhanced scanning, the adipose tissue itself had no enhancement, but the intratumoral septa could be slightly enhanced. Dystrophic calcification showed low signal on all sequences. When cystic changes appeared in individual cases, this area showed low and high signal on T1 weighted imaging and T2 weighted imaging, respectively.In conclusion, it may not be too difficult to confirm the diagnosis of intraosseous lipoma by CT scan and MRI follow-up after the initial diagnosis. Finally, bone scan examination of intraosseous lipoma can show slight increase in radioactive uptake or normal radioactive uptake[ 2 ]. Therefore, the authors believe that this examination is expected to play a role as a supplementary examination for the differential diagnosis with bone malignancies. Histologically, the gross appearance of intraosseous lipoma is very similar to that of soft tissue lipoma. The cavity of osteoma is filled with yellowish adipose like tissue, and the boundary with the surrounding bone is clear. Microscopically, there are a large number of mature adipocytes with a small amount of connective tissue and small bone beams. If the adipose tissue is degenerative and necrotic, myxoid lipoma cells and calcification can be seen. A large number of fat cell necrosis, calcification, focal reactive new bone and cystic cavity can be seen in a few cases. Milgram staged intraosseous lipomas according to the radiological and pathological findings of the lesions[ 7 ]. In stage I, there were viable and uniform mature adipocytes without necrosis inside the tumor. The imaging examination showed that the lesion was bright. In stage II, due to necrosis and calcification of some adipocytes, the local radiological density increased. Histologically, mature adipocytes surrounded the calcified area were shown in the center or periphery. Stage III is characterized by massive fat cell necrosis and calcification, cystic degeneration, calcification and reactive new bone formation to varying degrees. At this time, the diagnosis of the lesion is more difficult, even on magnetic resonance imaging, and the histological performance is similar to that of bone infarction. Cockade sign is a typical manifestation of calcaneal intraosseous lipoma, which can be seen in Milgram stage II lesions [ 6 , 16 ]. It is a well-defined osteolytic lesion with central calcification, which is consistent with the case reported in this article. At present, there is no consensus on the treatment of intraosseous lipoma. For patients with asymptomatic or no risk of pathological fracture, we advocate conservative observation. Because some of the intraosseous lipoma have a tendency of spontaneous degeneration [ 17 ], most patients can achieve good results by taking conservative management. For the presence of 1) pathological pain; 2) There is a risk of pathological fractures; 3) There is a risk of the malignant transformation; 4) Patients who require pathological diagnosis are indications for surgical treatment. Intraosseous lipoma rarely relapses or becomes malignant. Therefore, the surgical methods mainly include focus curettage, combined with artificial bone implantation, bone cement filling α- or β- implantation of tricalcium phosphate bioactive bone cement, etc. In this patient, we performed lesion curettage and allogeneic bone implantation. At the same time, due to the pathological fracture of the patient's calcaneus, we used calcaneal plate for internal fixation and achieved good results. Although immediate stability cannot be achieved after implantation of allogeneic bone, and the rejection reaction still needs further observation. It has a bone tissue structure similar to that of the human body and excellent prognosis. The internal fixation inserted for pathological calcaneal fractures in patients, which is sufficient to compensate for its shortcomings and may have more promising long-term prognosis for patients (Table 1 ). In addition, Khal and other scholars[ 18 ] carried out focus curettage and bone cement implantation for a patient who also suffered from intracalcaneal Lipoma, and also achieved good results. Salgado et al[ 18 ] replaced bone cement with a non-toxic triglyceride (Kriptonite) on this basis ®), By utilizing its excellent plasticity and strong adhesion, better prognosis results have been achieved. In the report of a case of calcaneal intraosseous lipoma by Balbouzis et al[ 8 ], it is believed that filling the contents are not necessary for most bone defects caused by benign bone tumors. In the opinion of the author of this article, this conclusion needs to be discussed. Because calcaneus is the main weight bearing bone of the whole body weight, and the principal stress, normal stress and Shear stress are large during exercise, bone filler can be used to fill the cavity after surgery to prevent the fracture to the greatest extent. In summary, regardless of the material used, it is usually necessary to fill the load-bearing bones of the body to provide mechanical and structural support and prevent collapse[ 19 ] . In this case report, we performed surgical curettage of the lesion, artificial bone filling, and calcaneal plate internal fixation, which further improved the patient's prognosis. However, developing a standardized treatment plan for this disease is still the current research direction. 5. Conclusions Intraosseous lipoma of calcaneus is a rare disease in the world. Pain in the affected area is the only possible symptom. It is usually not difficult to diagnose it under CT and MRI examination. Treatment can be divided into Conservative management and surgical treatment. At present, surgery is the only way to cure the disease, and patients often have a good prognosis. Abbreviations M:Male; F:Female;mths:months; yrs: years; NM: Not Mentioned. NO.: No pain；NC: No change. Declarations Consent The patient and the families were informed that related data and attached images in the case would be submitted for publication. Since they had signed the Informed Consent Form, its copy can be provided to the journal. Competing interests The authors declare that they have no competing interests. Author’contributions YW collected the data of the case, reviewed the literature, and drafted the manuscripts. ZHW and YHG help to collect the data of the case and pathological pictures as well as modifying the manuscripts. TY, XY, YHY and YW carried out the operation. TY and YW revised the manuscript. OJ and XKM collected the medical images. All authors read and approved the final manuscript. Acknowledgements This research was supported in part by grants (no. 202201AT070012) from the Yunnan Provincial Department of Science and Technology Fund Project, a grant (no. 2023B10) from Doctoral Innovation Fund project of Kunming Medical University. Author details Bone and Soft Tissue Tumors Research Center of Yunnan Province, Department of Orthopaedics, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, No 519, Kunzhou Road, Xishan District, Kunming, Yunnan Province, 650118 , People’s Republic of China. Ethical Approval The patient and the families were informed that related data and attached images in the case would be submitted for publication. Since they had signed the Informed Consent Form, its copy can be provided to the journal. Funding This research was supported in part by grants (no. 202201AT070012) from the Yunnan Provincial Department of Science and Technology Fund Project, a grant (no. 2023B10) from Doctoral Innovation Fund project of Kunming Medical University. Availability of data and materials The authors confirm that the data supporting the findings of this study are available within the article [and/or its supplementary materials]. Images （1）Preoperative DR, MRI, SPECT; （2）Intraoperative gross specimen, intraoperative C-arm fluoroscopy; （3）Postoperative follow-up DR, postoperative pathological images; （4）Long term follow-up DR and CT. References Kang HS, Kim T, Oh S, Park S, Chung SH. Intraosseous Lipoma: 18 Years of Experience at a Single Institution. 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Symptomatic intraosseous lipoma in the calcaneus. Anticancer research 2014; 34(2): 963-6. D'Hooghe P, Krivokapic B, Dzendrowskyj P, Hassoun K, Bukva B, Landreau P. Endoscopic surgery in athletes with a symptomatic calcaneal lipoma. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2017; 25(6): 1873-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3791122","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":263623958,"identity":"f25611bb-ed41-40e5-be5c-c60cf90e41a4","order_by":0,"name":"yu wang","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"yu","middleName":"","lastName":"wang","suffix":""},{"id":263623959,"identity":"a5ee4ab8-9072-4c91-9e26-b7a811602589","order_by":1,"name":"Zihao Wang","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Zihao","middleName":"","lastName":"Wang","suffix":""},{"id":263623960,"identity":"c2f0e36d-b913-41c9-b6d8-96d429e8075a","order_by":2,"name":"Xin Yang","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Yang","suffix":""},{"id":263623961,"identity":"394c6b23-bf90-441a-b907-499f853168fc","order_by":3,"name":"Yihao Yang","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Yihao","middleName":"","lastName":"Yang","suffix":""},{"id":263623962,"identity":"3f7939d5-1044-4baf-adae-0b3822e1a384","order_by":4,"name":"Yinghan Guo","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Yinghan","middleName":"","lastName":"Guo","suffix":""},{"id":263623963,"identity":"af4f0ee1-fc79-4ed0-9b33-9c8f6a9ea51a","order_by":5,"name":"Jie Ou","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Ou","suffix":""},{"id":263623964,"identity":"f2407901-e17b-465d-82a1-9afd060c49aa","order_by":6,"name":"Xingkui Mo","email":"","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":false,"prefix":"","firstName":"Xingkui","middleName":"","lastName":"Mo","suffix":""},{"id":263623966,"identity":"803a0f3b-0178-44bf-a638-22a249fae232","order_by":7,"name":"Tao Yuan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBADOTZm/oePwUxm5gbC6g8wMBjzs/MwGzMwGAC1MBKnJXFmPw+bNFgLAwEtBjeSnz3+UGPDuOEw77Hqgoo/0fztQC0/Krbh0ZJmbnDgWBqzwWG+tNszzhjkzjjM2MDYc+Y2Hi0JZhIH2A6zGRxmMLvN22aQ2wDUwszYhk9L+jeJA/8O84C0FIO0zCesJcdM4mDbYQnJZh4zZpCWDYS0SJ55UyZxti/NgJ+ZLVma54xx7kagloP4/MJ3PH2bRMU3m/o2/sMHP/NUyOXOO3/44IMfFbi1KBzAJopVEAbkG/DJjoJRMApGwSgAAQAhalrWulOP7gAAAABJRU5ErkJggg==","orcid":"","institution":"Yunnan Cancer Hospital（the Third Affiliated Hospital of Kunming Medical University）,orthopaedics","correspondingAuthor":true,"prefix":"","firstName":"Tao","middleName":"","lastName":"Yuan","suffix":""}],"badges":[],"createdAt":"2023-12-22 09:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3791122/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3791122/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49089578,"identity":"cda7b743-3598-44e3-adc5-30c13a90dace","added_by":"auto","created_at":"2024-01-03 01:38:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95163,"visible":true,"origin":"","legend":"\u003cp\u003eA: Lateral DR Plain film of the calcaneus shows a well-defined nodular low-density lesion with fracture line shadow and a small area of inhomogeneous calcification in the center, known as Cockade sign. B/C: MRI T1W and T2W sagittal images of the calcaneus showed partial sclerosis with low signal intensity and short T1 mixed T2 signals inside. D: SPECT imaging of the calcaneus showed hyperactive calcaneus metabolism.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3791122/v1/2451f9e844ca09e8f37b687d.jpg"},{"id":49091030,"identity":"2a1e48a6-33a9-4431-ba7b-cb3f405ebb60","added_by":"auto","created_at":"2024-01-03 01:46:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":112409,"visible":true,"origin":"","legend":"\u003cp\u003eA: Intraoperative complete curettage of lesion specimen; B: Image of focal curettage and internal fixation of the heel bone; C: Intraoperative C-arm fluoroscopy observed the effect of allogeneic bone filling and the position of internal fixation.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3791122/v1/e0a664109ca2b14178dbb1e7.jpg"},{"id":49089577,"identity":"aca9a892-1c2d-45ed-ba26-22fc5c9b85ba","added_by":"auto","created_at":"2024-01-03 01:38:30","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":71256,"visible":true,"origin":"","legend":"\u003cp\u003eA: DR plain film after calcaneal surgery, showing normal shape and internal dense shadow filling; B, C: Postoperative pathological specimens showed a large number of adipocytes, calcification, proliferation of nourishing blood vessels and infiltration of inflammatory cells (B: 10×40; C: 10×100).\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3791122/v1/10dc0992f1a3a8291205942d.jpg"},{"id":49089581,"identity":"222cac25-5d90-44fc-bcf4-e2395b8c02b2","added_by":"auto","created_at":"2024-01-03 01:38:31","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":58380,"visible":true,"origin":"","legend":"\u003cp\u003eA: Oblique imaging plane of calcaneal at 23 months follow-ups after the operation; B: A sagittal slice from a CT scan of the calcaneus that showed normal morphology and no locoregional recurrence or distant metastases were observed. C: Imaging DR plane of calcaneal that the plate and screws were removed in 23 months after operation.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3791122/v1/daa1fff6cb917af308d68885.jpg"},{"id":49568131,"identity":"37af3808-1325-4018-996f-6564b5fbb19c","added_by":"auto","created_at":"2024-01-13 14:37:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":556935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3791122/v1/bd63fb29-0e52-4304-9c0e-5a8b1e81475d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraosseous lipoma of the calcaneus：A Case Report and Literature Review","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIntraosseous lipomas are a rare primary benign bone tumor, with an estimated prevalence of around 0.1% of primary bone tumors[1]. which is mostly found in the epiphysi（32%）and metaphyseal region of long bones（80%）[2]. Cornills first reported the disease in 1880[3]\u003csup\u003e\u0026nbsp;\u003c/sup\u003e.The disease can occur in all age groups, adults are more common, there is no significant difference in the incidence of male and female.It is most often found between 40 and 50 years of age have a better prognosis and rarely malignant transformation[4].The majority of patients with intraosseous lipoma have no obvious symptoms, so it is often misdiagnosed. Most of the confirmed patients are accidentally found by imaging examination for the diagnosis and treatment of other diseases. Very few patients may present with bone pain and other non-specific Presentation[5].In this report, we present a case of intraosseous lipoma of the calcaneus in a 53-year-old men who in diagnosis and treatment evaluation prognosis. The study and analysis of the case improved the knowledge of this tumor, and related literature was incorporated to improve the understanding of the disease.\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003e \u003cb\u003e2.1 Preoperative diagnosis\u003c/b\u003e: The patient was a 53-year-old freelancer who was admitted to the hospital in July 2020 due to severe pain caused by sudden left foot sprain. Following physical examination, we found that mild swelling of the left foot, obvious tapping tenderness with limited movement of the left ankle joint and reflexes, sensation, and blood flow of the affected limb were normal.Lateral digital radiography (DR) of the left foot (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) revealed a 1.8cm\u0026times;1.7cm well-defined nodular low-density lesion with fracture line shadow and inhomogeneous internal calcification in the left calcaneal bone, known as the Cockade sign[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Later, the patient were performed the magnetic resonance imaging (MRI) examination showed a round nodules in the left calcaneus, with sclerotic edges and low signal intensity, there was a short T1 signal mixed with T2 signal inside, namely fatty degeneration(Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB,\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC) .To be conservative,we also performed single-photon emission computed tomography (SPECT) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD), which indicated an abnormal left calcaneal metabolism. Other tests showed no obvious abnormalities. In conclusion, we considered benign lesions according to the above physical examination and imaging examination, and clinically preferred intraosseous lipoma (Milgram stage II).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Operation method:\u003c/h2\u003e \u003cp\u003eAccording to the patient's preoperative MRI findings and \"Cockade sign\" shown by DR, we considered that he had calcaneal intraosseous lipoma and pathological fracture, and chose to perform surgical treatment for him, including \"calcaneal mass curettage\", \"allogeneic bone implantation\" and \"calcaneal plate internal fixation\". We made an \"L\" incision through the lateral approach of the left ankle joint to free the sural nerve and protect the peroneus longus and peroneus brevis muscles. A soft tissue cavity in the calcaneus was observed by exposing the posterior fenestrum of the calcaneus 2cm\u0026times;1cm. A complete curettage of the lesion within the calcaneus revealed a small amount of adipose tissue and some sclerosing osteoid tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). A complete curettage of the lesion within the calcaneus revealed a small amount of adipose tissue and some sclerosing osteoid tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). After that, the tumor cavity was inactivated with absolute alcohol and allogeneic bone was implanted. Meanwhile, calcaneus plate internal fixation was performed to reconstruct stability (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The lesion specimen was sent to the pathology department for further examination.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Postoperative recovery:\u003c/h2\u003e \u003cp\u003eThe wound was closed and wrapped with gauze. The patient was instructed to immobilise the left foot. DR examination was performed on the third day after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA), which showed normal shape of the left calcaneus with dense filling shadow.Postoperative pathological specimens (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC) showed a large number of adipocytes, trophoblast vessels, and pathological calcification of some cell-free structures, with inflammatory cell infiltration in the focal area, suggesting intracellular lipoma, which further confirmed our diagnosis. The patient was discharged on the sixth postoperative day, resumed full weight-bearing walking 8 weeks later, and resumed all daily activities 12 weeks later with no complaints of other discomfort.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.4 \u003cb\u003eFollow-upresults\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eWith a follow-up of 23 months, he participated in normal activities and without recurrence.DR Examination (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA) showed no special abnormalities, and computed tomography (CT) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) showed a dense filling of the calcaneus with normal morphology and good fracture healing. DR examination (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA) didn\u0026rsquo;t show any abnormality, and computed tomography (CT) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) showed filling of calcaneal dense shadow, normal shape, and good fracture healing. DR plain film review was performed after removal of plate and screw internal fixation (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Literature review","content":"\u003cp\u003eTo review the cases of Intraosseous lipoma of Calcaneus at home and abroad in recent years, we used ' intraosseous lipoma 'and' calcaneus' as keywords to search Pubmed\u0026reg; for publications from the preceding 10 years. Using the strategy, we were reviewed a total of 13 literatures and the medical records of 16 cases were reported and reviewed. For details regarding age, treatment method, clinical characteristics, and follow-up, see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLiterature review of intraosseous lipoma of the calcaneus\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReferences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAge(year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eClinical symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMilgram staging\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003etime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-upresults\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnset\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFirst evaluation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDuringfollow-up\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAzarsinaet al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting and internal fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePowell et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003efollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003efollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlnoohet al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChronic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSharmaet al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain for 3 monthsafter trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage and bone cement filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCao.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDull pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting and internal fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBousbaa et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntermittent pains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSymptomatic treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMawardi\u0026nbsp;etal.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOccult pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage and bone cement filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalbouziset al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain aggravated for 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGradual improved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAumar et al.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain and swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIncomplete improved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrangežet al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain and aggravation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting\u003c/p\u003e \u003cp\u003eand internal fixatio and bone cement filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePappas et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting and internal fixatio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuramatsuet al.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage and bone cement(Superpore\u0026reg;) filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage and bone cement(Biopex\u0026reg;) filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHooghe et al.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage byspinal needle andbone graft chips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage byspinal needle andbone graft chips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurettage andbone grafting and internal fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23 mths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eM:Male;F:Female;mths:months; yrs:years; NM:Not Mentioned. NC: No change;NO.:No pain\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWith the improvement of imaging level and the development of other diagnostic techniques, the number of reported cases of intraosseous lipoma has increased to a certain extent, but there are still only 100 cases reported worldwide in the past 10 years.Intraosseous lipoma is extremely rare, and patients usually have no symptoms and obvious etiology. Therefore, it has become an urgent need for scholars from all over the world to reach a consensus on diagnosis and treatment of intraosseous lipoma. In 1988, Milgram[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported the clinical, radiological and histological features of 66 patients with intraosseous lipomas, which were found to be widespread throughout the axial and vertical bones, mainly in the proximal femur (35%), tibia and fibula (21%), calcaneus (8%) and iliac crest (8%). Obviously, Intraosseous lipoma of the calcaneus is extremely low incidence and only less than 20 cases have been reported in the literature in the past 10 years.\u003c/p\u003e \u003cp\u003eIntraosseous lipomas are mesenchymal-derived benign tumors that has a very low incidence and is rare in clinic, Thus, the etiology and pathogenesis of this disease has been no definite consensus in the current academic curriculum. At present, numerous hypotheses and conjectures have been proposed. Most of the scholars believed that intraosseous lipoma originated from bone cysts. For example, it was put forward by Balbouzis et al. that the formation mechanism of Intraosseous lipomas was the degraded content of the cysts was gradually replaced by adipose tissue which[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in turn, results in the lipomatosis degeneration. Similarly to the mechanism, In a patient with the bone cyst of calcaneal reported by Malghem et al[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The bone cyst from hypointense hydropic lesions developed into steatosis mixed with hydropic lesions on MRI T1W was found after a 7-year follow-up, the proposed mechanism of \u0026ldquo;Cyst-Lipomas transformation\u0026rdquo; by above scholars is further confirmed. Attention worthy, Trauma hypotheses have been formulated that several cases of deep-seated lipomas were analyzed by Forsmann et al. it retraction for effects stimulates pro-inflammatory cells and inflammatory cytokines release under leading to immature adipocytes differentiation and mature adipocytes pile up to form lipoma[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However in this case, the patients have not suffered any type of chronic and long-term trauma at the focal point. Thus, this hypothesis needs to be further verified.\u003c/p\u003e \u003cp\u003eImaging examinations are considered to be effective in diagnosing intraosseous lipomas[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which often show well-defined osteolytic changes on DR plain films; soft tissue steatosis can be seen on CT and MRI.However, its manifestations are usually non-characteristic and therefore need to be differentiated from chondromas, aneurysmal bone cysts, simple bone cysts, fibrous dysplasia, and bone infarcts[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Among them, the disease usually appears as a clear-cut area with clear borders on DR scans, and showing osteolytic lesions, which may be accompanied by marginal sclerosis and thicker calcified or ossified dense matrix[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The tumor morphology was round, regular or irregular, and some are lobulated, nodular calcification and trabecular bone of varying thickness can be seen in the lesions. However, the disease is difficult to be diagnosed qualitatively on DR plain film because of the overlapping tissue structure in coronal and sagittal positions and the low resolution of tissue density, which often cannot estimate the components of the transparent area, and the disease is similar to the DR scanning performance of simple bone cyst, post-traumatic cyst, chondroid fibroma and osteoblastoma, which is easy to be misdiagnosed and missed[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, cortical erosion may occur in very few cases[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Malignant bone tumors should usually be suspected when causing rapid and extensive destruction of surrounding tissues. In such cases, it is particularly important to distinguish them from malignant bone tumors. In addition, CT and MRI can help establish a more specific histological diagnosis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].CT can calculate the tissue density and express it in Hounsfield units in the scan. Adipocytes have a lower tissue density than fibrous or neoplastic cells. Therefore, rays can be transmitted. The CT value is in the range of -27HU-127HU, and the lesions mostly show osteolytic lesions in bone, with different shapes and sizes. The lesions show a single fat density shadow or a density reduction area dominated by fat density, and nodular, plaque, thread, and small dot high-density calcification shadow can also be seen in the center of the lesion. The calcification may come from the necrosis and saponification of adipose tissue or metaplasia of mesenchymal tissue, and may be accompanied by continuous or intermittent Sclerotic margin with different thickness, clear lesion boundary, no soft tissue mass and periosteal reaction, but some edges are irregular. CT film can clearly show the density of adipose tissue and calcification in the lesion, which is conducive to improving the discrimination and diagnostic accuracy of intraosseous lipoma. MRI imaging is mainly used to show the adipose tissue in the tumor, especially when the fat content in the tumor is low. On this imaging, the signal of a fat component in the tumor is consistent with that of subcutaneous adipose tissue. On plain scan, it shows short T1, medium and long T2 abnormal signal areas. When fat suppression sequence is applied, the lesion changes to the low signal. Some lesions with fibrous septa in the tumor showed slightly low signal on T1 weighted imaging and T2 weighted imaging. When enhanced scanning, the adipose tissue itself had no enhancement, but the intratumoral septa could be slightly enhanced. Dystrophic calcification showed low signal on all sequences. When cystic changes appeared in individual cases, this area showed low and high signal on T1 weighted imaging and T2 weighted imaging, respectively.In conclusion, it may not be too difficult to confirm the diagnosis of intraosseous lipoma by CT scan and MRI follow-up after the initial diagnosis. Finally, bone scan examination of intraosseous lipoma can show slight increase in radioactive uptake or normal radioactive uptake[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, the authors believe that this examination is expected to play a role as a supplementary examination for the differential diagnosis with bone malignancies.\u003c/p\u003e \u003cp\u003eHistologically, the gross appearance of intraosseous lipoma is very similar to that of soft tissue lipoma. The cavity of osteoma is filled with yellowish adipose like tissue, and the boundary with the surrounding bone is clear. Microscopically, there are a large number of mature adipocytes with a small amount of connective tissue and small bone beams. If the adipose tissue is degenerative and necrotic, myxoid lipoma cells and calcification can be seen. A large number of fat cell necrosis, calcification, focal reactive new bone and cystic cavity can be seen in a few cases. Milgram staged intraosseous lipomas according to the radiological and pathological findings of the lesions[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In stage I, there were viable and uniform mature adipocytes without necrosis inside the tumor. The imaging examination showed that the lesion was bright. In stage II, due to necrosis and calcification of some adipocytes, the local radiological density increased. Histologically, mature adipocytes surrounded the calcified area were shown in the center or periphery. Stage III is characterized by massive fat cell necrosis and calcification, cystic degeneration, calcification and reactive new bone formation to varying degrees. At this time, the diagnosis of the lesion is more difficult, even on magnetic resonance imaging, and the histological performance is similar to that of bone infarction. Cockade sign is a typical manifestation of calcaneal intraosseous lipoma, which can be seen in Milgram stage II lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It is a well-defined osteolytic lesion with central calcification, which is consistent with the case reported in this article.\u003c/p\u003e \u003cp\u003eAt present, there is no consensus on the treatment of intraosseous lipoma. For patients with asymptomatic or no risk of pathological fracture, we advocate conservative observation. Because some of the intraosseous lipoma have a tendency of spontaneous degeneration [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], most patients can achieve good results by taking conservative management. For the presence of 1) pathological pain; 2) There is a risk of pathological fractures; 3) There is a risk of the malignant transformation; 4) Patients who require pathological diagnosis are indications for surgical treatment. Intraosseous lipoma rarely relapses or becomes malignant. Therefore, the surgical methods mainly include focus curettage, combined with artificial bone implantation, bone cement filling α- or β- implantation of tricalcium phosphate bioactive bone cement, etc. In this patient, we performed lesion curettage and allogeneic bone implantation. At the same time, due to the pathological fracture of the patient's calcaneus, we used calcaneal plate for internal fixation and achieved good results. Although immediate stability cannot be achieved after implantation of allogeneic bone, and the rejection reaction still needs further observation. It has a bone tissue structure similar to that of the human body and excellent prognosis. The internal fixation inserted for pathological calcaneal fractures in patients, which is sufficient to compensate for its shortcomings and may have more promising long-term prognosis for patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, Khal and other scholars[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] carried out focus curettage and bone cement implantation for a patient who also suffered from intracalcaneal Lipoma, and also achieved good results. Salgado et al[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] replaced bone cement with a non-toxic triglyceride (Kriptonite) on this basis \u0026reg;), By utilizing its excellent plasticity and strong adhesion, better prognosis results have been achieved. In the report of a case of calcaneal intraosseous lipoma by Balbouzis et al[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], it is believed that filling the contents are not necessary for most bone defects caused by benign bone tumors. In the opinion of the author of this article, this conclusion needs to be discussed. Because calcaneus is the main weight bearing bone of the whole body weight, and the principal stress, normal stress and Shear stress are large during exercise, bone filler can be used to fill the cavity after surgery to prevent the fracture to the greatest extent. In summary, regardless of the material used, it is usually necessary to fill the load-bearing bones of the body to provide mechanical and structural support and prevent collapse[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eIn this case report, we performed surgical curettage of the lesion, artificial bone filling, and calcaneal plate internal fixation, which further improved the patient's prognosis. However, developing a standardized treatment plan for this disease is still the current research direction.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIntraosseous lipoma of calcaneus is a rare disease in the world. Pain in the affected area is the only possible symptom. It is usually not difficult to diagnose it under CT and MRI examination. Treatment can be divided into Conservative management and surgical treatment. At present, surgery is the only way to cure the disease, and patients often have a good prognosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eM:Male; F:Female;mths:months; yrs: years; NM: Not Mentioned. NO.: No pain；NC: No change.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient and the families were informed that related data and attached images in the case would be submitted for publication. Since they had signed the Informed Consent Form, its copy can be provided to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYW collected the data of the case, reviewed the literature, and drafted the manuscripts. ZHW and YHG help to collect the data of the case and pathological pictures as well as modifying the manuscripts. TY, XY, YHY and YW carried out the operation. TY and YW revised the manuscript. OJ and XKM collected the medical images. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported in part by grants (no. 202201AT070012) from the Yunnan Provincial Department of Science and Technology Fund Project, a grant (no. 2023B10) from Doctoral Innovation Fund project of Kunming Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBone and Soft Tissue Tumors Research Center of Yunnan Province, Department of Orthopaedics, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, No 519, Kunzhou Road, Xishan District, Kunming, Yunnan Province, 650118 , People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient and the families were informed that related data and attached images in the case would be submitted for publication. Since they had signed the Informed Consent Form, its copy can be provided to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported in part by grants (no. 202201AT070012) from the Yunnan Provincial Department of Science and Technology Fund Project, a grant (no. 2023B10) from Doctoral Innovation Fund project of Kunming Medical University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article [and/or its supplementary materials].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImages\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e（1）Preoperative DR, MRI, SPECT; （2）Intraoperative gross specimen, intraoperative C-arm fluoroscopy; （3）Postoperative follow-up DR, postoperative pathological images; （4）Long term follow-up DR and CT.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKang HS, Kim T, Oh S, Park S, Chung SH. 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Endoscopic surgery in athletes with a symptomatic calcaneal lipoma. \u003cem\u003eKnee surgery, sports traumatology, arthroscopy : official journal of the ESSKA\u003c/em\u003e 2017; 25(6): 1873-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intraosseous Lipoma, calcaneus, surgery, benign bone tumor","lastPublishedDoi":"10.21203/rs.3.rs-3791122/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3791122/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntraosseous lipoma is a rare, benign primary tumor occurring in the bone. It typically occurs in long bones, such as the femur, tibia, and fiblua. While irregular bone and flat bones occur very rarely. Patients with intraosseous lipomas are asymptomatic in the early stages, but symptoms may appear in the later stages, accompanied by complications such as pain and fracture. On the X-ray plain, an intraosseous lipoma presents as an osteolytic lesion with well-circumscribed, and accompanied with a sclerotic margin and unevenly calcified parts. Recurrence and malignant transformation of intraosseous lipoma are extremely rare, and usually not requiring surgery. The possibility of malignant transformation and recurrence may be low, and usually not requiring surgery. In this article, we report a case of intraosseous calcaneal lipoma complicated with pathological fractures that was treated by curettage of the lesion and bone grafting , and local plate osteosyntheses showed good results. Combining this case with similar cases at home and aboard and reviewing related literature, we formed conclusions based on the manifestations, diagnosis, treatment, and prognosis of this disease and provided treatments and a new idea for the study of similar cases.\u003c/p\u003e","manuscriptTitle":"Intraosseous lipoma of the calcaneus：A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 01:38:26","doi":"10.21203/rs.3.rs-3791122/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90278059-6a63-4746-9bcb-50006fb772de","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-18T01:14:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 01:38:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3791122","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3791122","identity":"rs-3791122","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}