Dangers of the extended iliofemoral approach
This approach risks injury to the vessels and nerves that exit through the greater sciatic notch. The superior gluteal artery and its accompanying veins lie on the deep surface of the gluteal muscles. During elevation and posterior reflection of the glutei, the vessels may be torn, typically where they lie against the ilium at the top of the notch. If torn, they may retract into the pelvis. Bleeding from the superior gluteal vessels may be difficult to control. The surgeon should remember that packing the notch may help, followed by angiographic embolization, or, alternatively, the use of an anterior vascular approach.
During flap retraction, the vessels may lose flow and become thrombosed, leading to necrosis of the gluteal flap. This must be avoided by continued assessment of the vessels during the surgery and care must be taken to avoid aggressive retraction of the glutei during exposure, reduction and fixation.
Additionally, the superior gluteal nerve runs with the superior gluteal vessels, and is itself at risk of injury during exposure, retraction, and during efforts to control bleeding. The sciatic nerve, which usually exits the notch distal to the piriformis muscle, is also at risk of injury, typically from retractors or prolonged stretching.
The risk of neurovascular injury is increased during exposure of older fractures, and when fracture lines run parallel to the course of vessels and nerves.