Interfascial Planes Research Articles

Interfascial planes as surgical landmarks for laparoscopic upper retroperitoneal surgery: a cadaveric and retrospectively clinical study

Interfascial planes as surgical landmarks for laparoscopic upper retroperitoneal surgery: a cadaveric and retrospectively clinical study

Application of membrane anatomy theory in totally extraperitoneal inguinal hernia repair

Trocar placement and camera-dissection in the midline is the most commonly applied method for total extraperitoneal inguinal hernia repair (TEP), for which the theory of membrane anatomy has guiding significance. We hereby applies the theories and concepts, such as "fascia lining", "multi-layer", "inter-fascial planes", "combined inter-fascial plane" and "plane transition", to elucidate the key steps of TEP, for instance, space creation, hernia sac dissection, mesh flattening. Camera-dissection is performed along the posterior sheath of the rectus abdominis. Firstly, the camera enters retro-rectus space locating between the rectus abdominis and the transversalis fascia (TF). There are inferior epigastric vessels and their branches in the retro-rectus space, thus over-dissection should be avoided. Secondly, the camera goes downward through the TF into the pre-peritoneal space. The pre-peritoneal space is divided into the parietal plane and visceral plane by pre-peritoneal fascia (PPF). Both bladder and spermatic cord components locate on the visceral plane. Dissection of the median area should be implemented on the parietal plane, namely "surgical space", to protect the bladder. The parietal plane is the "holy plane" of TEP. Dissection of the indirect hernia area should be implemented on the visceral plane, namely "anatomical space", to protect the spermatic cord components. The reduction of direct hernia could be understood as the easy separation of TF and PPF. The reduction of indirect hernia is relatively difficult separation of peritoneum and spermatic cord components. During the transition of parietal and visceral planes, PPF (especially the pre-peritoneal loop) should be dissected for complete parietalization, in order to flatten the mesh.

Better understanding of interfacial planes in colorectal cancer surgery and the value of small vessels on fascia in the identification of interfacial planes

The introduction of total mesorectal excision and wider use of laparoscopic surgery pushed the field of colorectal surgery into an era of interfasical dissection. The Japanese suggestion of fascial arrangement of the trunk in a multilaminar, symmetrical and parallel way helps in better understanding of fascial relationship and interfascial planes surrounding the colon and the rectum. However, different interpretations of the multilayer retroperitoneal fascial relationship, complexity of fascial structures within the pelvis and dense adhesion between two apposed fasciae at special points make it still challenging for the surgeon to decide on the precise interfascial plane for colorectal mobilization. Small vessels on fasica propria of the rectum and various retroperitoneal fascia, especially ureterohypogastric fascia show distinctive features. The root of small vessels on fascia propria of the rectum helps to identify the anterolateral and posterolateral interfascial plane in the middle and low rectum. The longitudinal trajectory of small vessel on ureterohypogastric fascia and scarcity interfascial vascular communication between mesocolic and retroperitoneal fascia help the surgeon to find and stay in the interfacial plane during colorectal mobilization. More knowledge of fascial and interfascial plane will certainly help achieve better mesocolic mesorectal integrity and reduce the risk of injuries to autonomic nerves. More anatomical, histological and embryological studies are warranted with respect to relationship between small vessels and fasciae.

A Systematic Literature Review of the Middle Temporal Vein Anatomy: 'Venous Danger Zone' in Temporal Fossa for Filler Injections.

Treatment of a sunken appearance of the temporal region using injectable fillers is a popular procedure. The temporal fossa has very complex anatomy due to multiple vessels running in the different tissue layers. A severe complication in the form of non-thrombotic pulmonary embolism (NTPE) can occur as a result of an inadvertent injection in the middle temporal vein (MTV) while performing temporal fossa filler procedures. Therefore, in-depth knowledge and understanding of the MTV anatomy are essential for successful and safer injectable procedures of the temporal fossa. While there have been many studies to describe the arteries in this region, there is limited information about the location and course of the middle temporal vein. This literature review is aimed at providing detailed information about the course, depth, and size of the MTV to help aesthetic practitioners in performing safer temporal fossa filler injections. This information is imperative to delineate the 'venous danger zone' in the temple region. The preferred reporting items for systematic reviews and meta-analyses guidelines were used for this review. A literature search was performed to find the articles providing details about the MTV anatomy and the measurements related to its course and size. A review of the literature showed that the MTV displays a consistent course and depth in the temporal region, with high variability in its diameter. The middle temporal vein width varied between 0.5 and 9.1mm in various studies. The middle temporal vein receives many subfascial tributaries from the surface of the temporalis muscle, and for most of its course runs in the fat pad enclosed between superficial and deep layers of the deep temporal fascia. A 'venous danger zone,' in the interfascial planes of the temporal fossa, which contain the main part of the MTV and its tributaries, has been proposed in this paper. The temporal fossa filler procedures need great caution, and knowledge of the depth and course of the MTV is essential for avoiding NTPE. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Correlation between modified CT severity index and retroperitoneal extension using the interfascial planes in the grading of clinically suspected acute severe pancreatitis

BackgroundThis prospective study was conducted between January 2015 and June 2018 and included 50 patients (mean age of 52.12 ± 2.0 years), all presented with acute pancreatitis and admitted to the ICU 1–3 days after the onset. All patients underwent contrast-enhanced CT, and images are evaluated by 2 independent radiologists for the modified CTSI parameters and retroperitoneal extension parameters to detect the severity of pancreatitis. The aim of this study is to compare the results of the modified CT severity index and retroperitoneal interfascial extension CT grading system in the grading of the severity of acute pancreatitis and compare both grading systems to the clinical course of the disease and its complications.ResultsBoth grading systems show a statistical significant correlation in terms of the length of hospital stay, the need for interventions, and the development of organ failure.ConclusionIn conclusion, a good correlation was observed between the modified CTSI and retroperitoneal extension grading systems in grading the severity of acute pancreatitis. We think that we can apply Ishikawa et al. grading system as a prognostic indicator if there is a contraindication to contrast administration.

Radiological classification of retroperitoneal hematoma resulting from lumbar vertebral fracture.

Lumbar vertebral fracture (LVF) infrequently produces massive retroperitoneal hematoma (RPH). This study aimed to systematically review the clinical and radiographic characteristics of RPH resulting from LVF. For 193 consecutive patients having LVF who underwent computed tomography (CT), demographic data, physiological conditions, and outcomes were reviewed from their medical records. Presence or absence of RPH, other bone fractures, or organ/vessel injury was evaluated in their CT images, and LVF or RPH, if present, was classified according to either the Orthopaedic Trauma Association classification or the concept of interfascial planes. RPH resulting only or dominantly from LVF was found in 66 (34.2%) patients, whereas among the others, 64 (33.2%) had no RPH, 38 (19.7%) had RPH from other injuries, and 25 (13.0%) had RPH partly attributable to LVF. The 66 RPHs resulting only or dominantly from LVF were radiologically classified into mild subtype of minor median (n = 35), moderate subtype of lateral (n = 11), and severe subtypes of central pushing-up (n = 13) and combined (n = 7). Of the 20 patients with severe subtypes, 18 (90.0%) were in hemorrhagic shock on admission, and 6 (30.0%) were clinically diagnosed as dying due to uncontrollable RPH resulting from vertebral body fractures despite no anticoagulant medication. LVF can directly produce massive RPH leading to hemorrhagic death. A major survey of such pathology should be conducted to establish appropriate diagnosis and treatment.

Ultrasound-Guided Obturator Nerve Block: A Focused Review on Anatomy and Updated Techniques.

This review outlines the anatomy of the obturator nerve and the indications for obturator nerve block (ONB). Ultrasound-guided ONB techniques and unresolved issues regarding these procedures are also discussed. An ONB is performed to prevent thigh adductor jerk during transurethral resection of bladder tumor, provide analgesia for knee surgery, treat hip pain, and improve persistent hip adductor spasticity. Various ultrasound-guided ONB techniques can be used and can be classified according to whether the approach is distal or proximal. In the distal approach, a transducer is placed at the inguinal crease; the anterior and posterior branches of the nerve are then blocked by two injections of local anesthetic directed toward the interfascial planes where each branch lies. The proximal approach comprises a single injection of local anesthetic into the interfascial plane between the pectineus and obturator externus muscles. Several proximal approaches involving different patient and transducer positions are reported. The proximal approach may be superior for reducing the dose of local anesthetic and providing successful blockade of the obturator nerve, including the hip articular branch, when compared with the distal approach. This hypothesis and any differences between the proximal ONB techniques need to be explored in future studies.

Beyond Ultrasound Guidance for Regional Anesthesiology.

Despite its popularity, ultrasound (US)-guided regional anesthesiology is associated with significant limitations. The latter can be attributed to either the US machine (ie, decreased ability to insonate deep neural structures, as well as the thoracic spine) or the operator. Shortcomings associated with the operator can be explained by errors in perception (ie, ambiguous criteria for needle/catheter tip-to-nerve proximity and subparaneural local anesthetic injection) or interpretation. Perhaps the greatest confusion afflicting US-guided regional anesthesiology originates from an intellectual misconception pertaining to its application. Increasingly, authors are using US to identify interfascial planes where local anesthetic can be injected thereby "discovering" new truncal blocks. Often these novel blocks suffer from a lack of proper randomized, comparative validation.Fortunately, solutions have been proposed to remedy many shortcomings associated with US guidance. The inability of US to reliably insonate deep neural structures can be circumvented with adjunctive neurostimulation. Fluoroscopy and waveform analysis have been proven to increase the success rate of thoracic epidural blocks. For continuous nerve blocks, combined US-neurostimulation may provide an objective end point (ie, an evoked motor response) for neural proximity and subparaneural positioning of the catheter tip. Finally, the solution to the plethora of nonvalidated US-guided blocks is both elegant and simple. New nerve blocks should answer a specific clinical need, and their first descriptions should take the form of an adequately powered, observer-blinded, randomized comparison against the established standard of care or, at the very least, a large case series (eg, a Brief Technical Report).

Fascia iliaca block associated only with deep sedation in high-risk patients, taking P2Y12 receptor inhibitors, for intramedullary femoral fixation in intertrochanteric hip fracture: a series of 3 cases

ObjectiveWe present a series of 3 cases in which the impact in outcome was, first of all, related to the capacity to offer early and safer treatment to some hip fracture high-risk patients using a fascia iliaca block (FIB; ropivacaine 0,5% 20 cc and mepivacaine 1,3% 15 cc, given 30 minutes before incision) associated only with deep sedation, contributing to better practice and outcome. Case reportsAll elderly patients were American Society of Anesthesiologists IV patients, under P2Y12 receptor inhibitors, suffering from an intertrochanteric fracture, and purposed for intramedullary femoral fixation (IMF). All patients have been managed successfully through a deep sedation using a low-dose infusion of propofol and bolus of fentanyl without face mask ventilation, supraglottic device placement, or endotracheal intubation after an FIB. Bispectral index was always greater than 75, and no CO2 retention or respiratory depression was present. No signs of pain or hemodynamic instability were observed. ConclusionsIn these cases, surgery would be postponed if the choice was neuroaxial anesthesia, particularly because of P2Y12 receptor inhibitors' effect.FIB puncture site is distal to the fracture and incision site, but proximal local anesthetic migration through the interfascial planes allows for constant block of femoral nerve and lateral cutaneous of femur nerve and, less constantly, block of obturator. FIB may reduce the risk of perineural hematoma associated with several injections in nerve vicinity of different lumbar plexus branches.Frequently, indications for extramedullary or IMF are overlapping, but IMF is associated with less blood loss and may be managed using a low anesthetic depth if an FIB is done, increasing safety. This way, these less invasive surgical techniques combined with an adjusted anesthetic technique may have a crucial role in high-risk patients, particularly if taking P2Y12 receptor inhibitors. In these cases of IMF, surgical manipulation of sciatic and/or inferior subcostal nerves territories was managed with systemic analgesia and deep sedation.

Magnetic resonance imaging of retroperitoneal interfascial plane involvement in acute pancreatitis

To study the magnetic resonance imaging (MRI) features of acute pancreatitis (AP) involving the retroperitoneal interfascial planes and to analyze the correlations of interfascial plane involvement with the magnetic resonance severity index (MRSI) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system. A total of 316 consecutive patients with AP between November 2011 and August 2013 were retrospectively analyzed. The extension and path of the inflammation spreading along the retroperitoneal interfascial plane on MRI were graded from grade 0 to grade 5. The relationships between interfascial plane involvement and MRSI and APACHE II were analyzed. Of the 316 patients with AP, 293 patients (92.7%) had interfascial plane involvement, which appeared as interfascial plane edema, thickening and effusion. There were 60, 105, 78, 25, and 25 patients in grades 1, 2, 3, 4, and 5, respectively. Interfascial plane involvement strongly correlated with the MRSI score (r=0.703), but was only weakly correlated with the APACHE-II score (r=0.291). MRI depicts the characteristics of interfascial plane involvement in AP. The value of interfascial plane involvement for determining the disease severity is likely to be limited.

The retroperitoneal interfascial planes: current overview and future perspectives.

Recently, the concept of interfascial planes has become the prevalent theory among radiologists for understanding the retroperitoneal anatomy, having replaced the classic tricompartmental theory. However, it is a little known fact that the concept remains incomplete and includes embryological errors, which have been revised on the basis of our microscopic study. We believe that the concept not only provides a much clearer understanding of the retroperitoneal anatomy, but it also allows further development for diagnosis and treatment of retroperitoneal injuries and diseases, should it become an accomplished theory. We explain the history and outline of the concept of interfascial planes, correct common misunderstandings about the concept, explain the unconsciously applied therapeutic procedures based on the concept, and present future perspectives of the concept using our published and unpublished data. This knowledge could be essential to acute care physicians and surgeons sometime soon.

Infrapatellar saphenous neuralgia after TKA can be improved with ultrasound-guided local treatments.

Current opinion suggests that in some patients, chronic pain after total knee arthroplasty (TKA) has a neuropathic origin. Injury to the infrapatellar branch of the saphenous nerve (IPSN) has been implicated as a cause of medial knee pain; however, local treatments for this condition remain controversial. We sought to explore the efficacy of local treatment to the IPSN in patients with persistent medial knee pain after TKA. In this retrospective series, 16 consecutive patients with persistent medial knee pain after primary or revision TKA were identified after other potential etiologies of knee pain were excluded. Using advanced ultrasound imaging to identify the IPSN, hydrodissection of the nerve from the adjacent interfascial planes was performed followed by corticosteroid injection (local treatment). In two patients, radiofrequency ablation of the IPSN was subsequently performed for recurrent symptoms. The outcome measure of this study was patient-reported relief of medial knee pain based on a visual analog scale (VAS) score of 0 to 10 either at rest or with activity, whichever resulted in more pain for the patient. Followup was at a minimum of 6months (median, 9months; range, 6-12months). Before the procedure, the median highest VAS pain score, either at rest or with activity, was 8 of 10 (range, 6-10). Local injections to the infrapatellar saphenous nerve (one or two injections) improved medial pain after TKA to a VAS score of 0 or 1 in nine of our 16 patients. Three patients reported pain improvement to VAS levels of 3 to 4. Of the remaining four patients, two did not have improvement with VAS scores of 8, and two underwent subsequent radiofrequency ablation of the IPSN with resolution of pain in one patient. In summary, we believe injury to the IPSN may be an underappreciated cause of persistent medial pain after TKA. We report favorable preliminary results with local treatment to the nerve in nine of our 16 patients, suggesting that the neuritis is a reversible process in some patients; however, because of the possibility of a placebo effect, we believe this treatment modality should be tested in a randomized, placebo-controlled trial. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Preliminary embryological study of the radiological concept of retroperitoneal interfascial planes: what are the interfascial planes?

Recently, the radiological concept of retroperitoneal interfascial planes has been widely accepted to explain the extension of retroperitoneal pathologies. This study aimed to explore embryologically based corroborative evidence, which remains to be elucidated, for this concept. Using serial or semi-serial transverse sections from 29 human fetuses at the 5th-25th week of fetal age, we microscopically observed the development of the retroperitoneal fasciae and other structures in the retroperitoneal connective tissue. A hypothesis for the formation of the interfascial planes was generated from the developmental study and analysis of retroperitoneal fasciae in computed tomography images from 224 patients. Whereas the loose connective tissue was uniformly distributed in the retroperitoneum by the 9th week, the primitive renal and transversalis fasciae appeared at the 10th-12th week, as previous research has noted. By the 23rd week, the renal fascia, transversalis fascia, and primitive adipose tissue of the flank pad emerged. In addition, the primitive lateroconal fascia, which runs parallel to and close to the posterior renal fascia, emerged between the renal fascia and the adipose tissue of the flank pad. Conversely, pre-existing loose connective tissue was sandwiched between the opposing fasciae and was compressed and narrowed by the developing organs and fatty tissues. Through this developmental study, we provided the hypothesis that the compressed loose connective tissue and both opposed fasciae compose the interfascial planes. Analysis of the thickened retroperitoneal fasciae in computed tomography images supported this hypothesis. Further developmental or histological studies are required to verify our hypothesis.

The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options

Morel-Lavallée lesions are posttraumatic hemolymphatic collections related to shearing injury and disruption of interfascial planes between subcutaneous soft tissue and muscle. We review the pathophysiology of Morel-Lavallée lesions, clinical presentation, and potential sites of involvement. Magnetic resonance imaging (MRI) is the modality of choice for characterization. We present the MRI classification and highlight the key imaging features that distinguish the different types, focusing on the three most common: seroma, subacute hematoma, and chronic organizing hematoma. Potential mimics of Morel-Lavallée lesions, such as soft tissue sarcoma and hemorrhagic prepatellar bursitis, are compared and contrasted. Treatment options and a management algorithm are also briefly discussed.

MR cisternography/myelography of post-traumatic spinal CSF fistulae and meningeal lesions in small animals

The diagnosis of post-traumatic spinal cerebrospinal fluid (CSF) fistulae due to dural tears or lesions remains a challenge. Thus far, CT myelography is the standard test used to diagnose these complications. To evaluate the diagnostic ability of gadolinium-enhanced MR cisternography/myelography (intrathecal gadopentate dimeglumine or Gd-DTPA) in small animals that had experienced accidental spinal trauma. Four dogs and one cat suffered traumatic accidents resulting in neurological deficits underwent spinal MRI with intrathecal Gd-DTPA after routine plain films and MR images. T2-weighted SE images showed high water content in the epidural space or in the surroundings of the vertebrae in four animals. MR myelography revealed CSF leakage in all of them. In two animals CSF leaks were observed exuding from the spinal canal and tracking towards adjacent loose fat and interfascial planes. In two other animals Gd-DTPA extravasation was diffusely collected in paraspinal tissues around the vertebral arch. In the fifth animal a focal pseudomeningocele was observed adjacent to the traumatized region. Intrathecal administration of Gd-DTPA is an effective method to reveal and confirm post-traumatic spinal CSF fistulae or other dural lesions in animals with potential application in humans.

The European Association of Urology Robotic Urology Section (ERUS) survey of robot‐assisted radical prostatectomy (RARP)

To evaluate surgeons adherence to current clinical practice, with the available evidence, for robot-assisted radical prostatectomy (RARP) and offer a baseline assessment to measure the impact of the Pasadena recommendations. Recently, the European Association of Urology Robotic Urology Section (ERUS) supported the Pasadena Consensus Conference on best practices in RARP. This survey was performed in January 2012. A specific questionnaire was sent, by e-mail, to 145 robotic surgeons who were included in the mailing-list of ERUS members and working in different urological institutions. Participating surgeons were invited to answer a multiple-choice questionnaire including 24-items evaluating the main RARP surgical steps. In all, 116 (79.4%) invited surgeons answered the questionnaire and accepted to participate to the ERUS survey. In all, 47 (40.5%) surgeons performed >100 RARPs; 41 (35.3%) between 50 and 100, and 28 (24.1%) <50 yearly. The transperitoneal, antegrade technique was the preferred approach. Minimising bladder neck dissection and the use of athermal dissection of the neurovascular bundles (NVBs) were also popular. There was more heterogeneity in the use of energy for seminal vesicle dissection, the preservation of the tips of the seminal vesicle and the choice between intra- and interfascial planes during the antero-lateral dissection of the NVBs. There was also large variability in the posterior and/or anterior reconstruction steps. The present study is the first international survey evaluating surgeon preferences during RARP. Considering that the results were collected before the publication of the Pasadena recommendations, the data might be considered an important baseline evaluation to test the dissemination and effects of the Pasadena recommendations in subsequent years.

Multiple Ipsilateral Lower Extremity Masses in a 46-year-old Man

Multiple Ipsilateral Lower Extremity Masses in a 46-year-old Man

Classification of acute pancreatitis based on retroperitoneal extension: Application of the concept of interfascial planes

Objective This study aimed to provide a classification system for acute pancreatitis by applying the principle that the disease spreads along the retroperitoneal interfascial planes. Materials and methods Medical records and computed tomography (CT) images of 58 patients with acute pancreatitis treated between 2000 and 2005 were reviewed. The retroperitoneum was subdivided into 10 components according to the concept of interfascial planes. Severity of acute pancreatitis was graded according to retroperitoneal extension into these components. Clinical courses and outcomes were compared with the grades. The prognostic value of our classification system was compared with that of Balthazar's CT severity index (CTSI). Results Retroperitoneal extension of acute fluid collection was classified into five grades: Grade I, fluid confined to the anterior pararenal space or retromesenteric plane (8 patients); Grade II, fluid spreading into the lateroconal or retrorenal plane (16 patients); Grade III, fluid spreading into the combined interfascial plane (8 patients); Grade IV, fluid spreading into the subfascial plane beyond the interfascial planes (15 patients); and Grade V, fluid intruding into the posterior pararenal space (11 patients). Morbidity and mortality were 92.3% and 38.5% in the 26 patients with Grade IV or V disease, and 21.9% and 0% in the 32 patients with Grade I, II, or III disease. Morbidity and mortality were 86.7% and 33.3% in patients with disease classified “severe” according to the CTSI, and 37.5% and 9.4% in patients with disease classified “mild” or “moderate”. Conclusion Classification of acute pancreatitis based on CT-determined retroperitoneal extension is a useful indicator of the disease severity and prognosis without the need for contrast-medium enhanced CT.

Traumatic retroperitoneal hematoma spreads through the interfascial planes.

The purpose of this study was to reevaluate extension of traumatic retroperitoneal hematoma (RH) and related management strategies in light of the new concept of retroperitoneal fascias as interfascial planes communicating with three compartments. Diagnostic computed tomographic images of 169 patients with traumatic RH treated between 1997 and 2003 were retrospectively reviewed. The extension of RH was measured in relation to 10 components: 3 compartments and 7 parts of the interfascial planes. On the basis of careful horizontal and vertical assessment of computed tomographic images, distribution, extent, and volume in each component of RH were assessed. In 88.8% of patients, RH was detected in interfascial planes. Interfascial planes absorbed a large amount of hematoma (mean, 223 +/- 309 mL; range, 0-1,519 mL), whereas the anterior and posterior pararenal spaces absorbed only 5 +/- 16 mL and 21 +/- 30 mL, respectively. The volume of RH in interfascial planes accounted for 78.1% of the total volume. In all cases, RH spread within interfascial planes with regularity: transversely by means of retromesenteric planes and vertically by means of combined interfascial planes. Regular extension patterns allowed RH to be classified by bleeding source. RH originating from retrorenal or combined interfascial plane had a poor prognosis; 51.7% of such patients died as a result of uncontrollable hemorrhage. RH was based in the interfascial planes, not the three compartments. Our findings that RH extends and is largely confined within interfascial planes, regardless of cause or volume, could be useful in estimating the extent of RH and developing breakthrough strategies for RH.

A system for the surgical staging of musculoskeletal sarcoma. 1980.

Historically, an adequate surgical procedure has been the most effective means of treating the majority of primary musculoskeletal sarcomas, and amputation has figured prominently in the surgical armamentarium. 4, 7, 9, 19, 21, 29, 41 The recent evidence that certain chemotherapeutic agents may have significant anti-sarcoma activity 2, 15, 17, 38 and coincident technical advances in irradiation therapy, radiographic localization, and reconstructive surgery have fostered enthusiastic interest in extremity-saving treatments. Almost all such treatments emphasize limb salvage as an alternative to amputation and are usually performed under a protective cloak of adjunctive chemotherapy, irradiation or immunoactive agents. 20, 23, 24, 30, 37, 39 Since neither chemotherapy nor irradiation therapy alone has been shown to assure long-term local control of bulk disease, surgical intervention remains an essential step in the overall management of musculoskeletal sarcomas. 3, 9, 17, 18, 29 Questions concerning the magnitude and timing of the surgical procedure are as unanswered as those relating to the most appropriate use of the adjuncts themselves. Increasingly, the surgeon and his patient are confronted with a bewildering array of therapeutic options, the long-term outcomes of which are unknown. These relatively rare sarcomas increasingly are distributed among a variety of treatment protocols in which multiple parameters differ. This trend necessitates interinstitutional cooperation if sufficient numbers of patients are to be available for the timely evaluation of treatments in clinical use. Such cooperation and even effective interinstitutional communication are seriously hampered by the lack of uniform language, so that meaningful comparison of treatments is currently impossible. Prime factors include the lack of a consistent definition of the surgery performed and a serviceable surgical staging system encompassing bone and soft tissue. Standard terminology will assure that like and unlike treatments are appropriately compared. Although an effective staging system should serve all members of the multidisciplinary team, the biologic behavior of musculoskeletal sarcomas suggests that the most useful staging system will articulate with the surgical procedure.