For the extended iliofemoral approach, after the identification and division of avascular fascial periosteal layer at the iliac crest, the musculature along the iliac wing’s external surface released up to the superior border of the greater sciatic notch and anterior superior side of the hip joint capsule. As a superior gluteal neurovascular bundle exits the greater sciatic notch so a surgeon has to be more careful of the identification and protection of the superior gluteal neurovascular bundle.
The lateral femoral cutaneous nerve and most of its branches, the distal limb of the incision is carried through the fascial sheath of the tensor fascia lata muscle so that it can be protected. The fascia and rectus sheath are exposed while reflecting the muscle off its posterior fascia and retracting laterally. Then small vessels of the superficial circumflex artery are divided. And these are coagulated in the middle of the inferior and superior spines. The rectus fascia is divided. Then the muscles with reflected and direct heads are retracted medially so that the aponeurosis over the vastus lateralis muscle can be exposed, herein coagulation of a small vascular pedicle is required.
To expose the ascending branches of the lateral circumflex vessels, the aponeurosis over the vastus lateralis is divided lengthwise which needs to be isolated and ligated. Then the iliopsoas muscle’s thin sheath is exposed and incised longitudinally. Stripping of the muscle from the anterior and inferior aspects of the hip capsule can be done by using an elevator. The tendons of the gluteus minimus and medius need to be identified and split leaving small cuffs. The abductor muscle flap is retracted so that the external fixator can be exposed. The internal iliac fossa and acetabulum can be accessed through subperiosteal dissection of the sartorius and direct head of the rectus, or by the iliac spines osteotomy. Then with a marginal capsulotomy, the acetabular articular surface is exposed in the absence of capsular disruption. A cuff of tissue is left for repair. Distraction can be attained using a femoral distractor or using cannulated cancellous screws placed into the femoral neck. Considerable soft-tissue flaps are created by this approach which must be kept moist during the entire procedure.
Before closure, suction drains are put in the posterior column zone and vast lateral muscle along the external surface of the iliac wing. A third drain needs to be placed in the internal iliac fossa has also been exposed. The exit of all the drains should be anterior. First, the hip capsule is repaired, then the tendinous insertions of the short external rotators and gluteal muscles are reattached to the greater trochanter. Lastly, the reattachment of tensor fascia lata and gluteal muscles is carried out with their origins on the iliac crest. In case of medial exposure, the reattachment of origins of the sartorius and direct head of the rectus femoris muscles is also required which will be done by drill holes, and if osteotomies have been done then by lag screws. The fascia overlapping the proximal thigh is repaired and a subcutaneous drain is placed. Then a superficial closure is carried out.
However, many exposures have been suggested but out of those, the most useful exposures are the modified Stoppa anterior approach of Cole and Bolhofner and the extensile triradiate approach of Mears and Rubash.