SPECIAL TECHNICAL ARTICLE
An Anatomic Technique for Establishing Leg Length During
the Anterior Approach to Total Hip Arthroplasty
Andrea Halim, MD, Matthew L. Webb, AB, and Kristaps J. Keggi, MD, Dr Med (H.C.)
Summary: Leg-length discrepancy following total hip arthroplasty is a
common challenge to the treating surgeon. A multitude of surgical
techniques and measurement strategies have been described to reduce
the likelihood of undesirable leg and hip length. We present a simple
intraoperative technique using the capsule (Y-ligament) to minimize
this problem. After its exposure, the hip capsule is incised in line with
the long axis of the femoral neck and dissected from its insertion on the
anterior intertrochanteric line. This allows excellent exposure of the
hip. At the end of the replacement, the position of the released capsule
indicates gain, loss, or unchanged length of the hip. It is an effective
intraoperative way to check the desired hip length without fluoroscopy
or cumbersome measuring devices. The ease and efficacy of this
technique have proven to be another advantage of the anterior
approach to hip arthroplasty.
Key Words: leg-length discrepancy—anterior approach—Y-ligament.
(Tech Orthop 2014;29: 113–117)
F ollowing total hip arthroplasty (THA), leg-length discrep-
ancies can cause functional impairments. Complications
associated with leg-length discrepancy include peroneal, sciatic,
and femoral nerve palsies, lower back pain, and gait ab-
normalities.36–41 Reports suggest that surgeons should aim for
postoperative leg-length discrepancies of <10 mm.3 Multiple
methods have been used to address this problem, including
preoperative templating, measurement of the excised femoral
head and neck, use of intraoperative fluoroscopy, and various
manual measurement techniques.5–7 We propose a simple ana-
tomic intraoperative technique that can be used during the
anterior approach to hip arthroplasty.
The anterior approach to THA was first presented to the
American Academy of Orthopaedic Surgeons in 1977.1 The
senior author has been using it since the early 1970s. One of
the advantages of the anterior approach, performed in an
anatomic supine position, has always been a greater ability to
judge limb length by palpation and visualization of the iliac
crests, patellas, ankles, and toes. During the last 10 years, this
approach has also been supplemented with preservation of the
anterior capsule for extra stability and hip-length assessment.
The anterior hip capsule is exposed, and incised in line
with the long axis of the femoral neck. This incision can also
include a transection of the rectus reflected head. The capsule
is then released from its insertion on the anterior inter-
trochanteric line. Retraction of the capsule with cobra re-
tractors allows excellent exposure of the femoral neck and
acetabulum for hip replacement procedure. Once the trial
From the Department of Orthopaedics, Yale University, New Haven, CT.
The authors declare that they have nothing to disclose.
Address correspondence and reprint requests to Andrea Halim, MD,
Yale Physician’s Building, 800 Howard Avenue, New Haven, CT 06510.
E-mail: andrea.halim@yale.edu.
Copyright r 2014 by Lippincott Williams & Wilkins
Techniques in Orthopaedics$  Volume 29, Number 2, 2014
components are in place and reduced, the position of the distal
capsular cut is examined. If it falls upon the anterior inter-
trochanteric line of its release, there has been no loss or gain of
length. If it overlaps the line, the hip is short; whereas if there
is a gap, the hip is long.
Results using this technique have been satisfactory and
clinically significant leg-length difference has become a rarity.
It is, however, important to understand the importance of
hip stability and emphasize preoperatively to the patient that
absolutely equal leg lengths must be occasionally sacrificed to
avoid an unstable, dislocating hip.
ANATOMIC/RADIOLOGIC DEMONSTRATION
A preserved cadveric hemipelvis with femur, hip joint,
and joint capsule from the Yale University Anatomy Depart-
ment was used to illustrate this method. The joint capsule of
the specimen was incised and released from its insertion as
previously described. The specimen was then prepared to
accept a conventional noncemented total hip prosthesis. Necks
of 0, + 4, and + 8 length were mounted on the femoral com-
ponent and anteroposterior radiographs of each variation in its
reduced position obtained (Fig. 1).
RESULTS
With a femoral neck length of 0 mm, the free edges of the
joint capsule perfectly overlap the line of their release, indi-
cating desired implant length (Figs. 2A, B). With length of + 4,
there is a gap between the capsular cut and its original line of
insertion, indicating that the implant is too long (Figs. 3A, B).
With a neck length of + 8, the free edges of the joint capsule
are significantly shorter, indicating that the implant is sig-
nificantly longer than desired (Figs. 4A, B).
DISCUSSION
Leg-length differences make up a substantial percentage of
complications after THA. In 2003, leg-length issues accounted
for 4.7% of reportable medical errors.2 One recent report of 210
unilateral THAs using a posterolateral approach noted that
patients complained of a sensation of leg lengthening in
approximately 5% of cases.4 Another study found 24% of
patients to require a shoe lift after THA.8 A survey of the
American Association of Hip and Knee Surgeons found that
limb-length discrepancy was the second most commonly cited
source of litigation behind nerve injury.32 For patients, a dif-
ference in leg length may have significant implications on pain
and function. A survey study of Medicare participants older than
65 found that at 6 years following elective total hip replacement
(THR), patients who perceived leg-length discrepancies were
twice as likely to also report poor functional status.35
In many cases, perceived leg-length discrepancy does not
indicate a true difference in limb length or reflect surgical error
in technique. A survey of 1114 patients 5 to 8 years following
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Halim et al Techniques in Orthopaedics$  Volume 29, Number 2, 2014

FIGURE 1. A, Prepared specimen, which has been marked to demonstrate the area of the capsule to be incised. B, After capsulotomy,
the femoral neck has been exposed.

elective THR found that 30% (329) reported a perceived limb-
length discrepancy, whereas radiographs revealed that only
36% of these 329 patients had an actual difference in leg
length. Another small study of 20 patients found that a
patient’s perception of discrepancy did not correlate with gait
analysis and kinematics or with the actual amount of leg
lengthening.42 Despite the difficulty, therefore, of eliminating
all problems associated with perceived leg-length difference, it
is necessary to avoid causing a true limb-length discrepancy
(LLD) after THA, and to this purpose many methods have
been previously described.
Among the methods used to decrease the likelihood of
creating a leg-length difference after THA, preoperative
planning is one of the most commonly used. Preoperative
planning relies on the use of radiographs and implant templates
in an attempt to determine the size and position of implants
needed to maintain or restore anatomic leg length.10 However,
this requires careful technique, accurate radiographs, and
templates, and does not take intraoperative factors such as soft-
tissue tension into account. One retrospective study found that
the most common errors in preoperative templating resulted in
excessive limb lengthening and offset discrepancy.11
Surgeons may deviate from their preoperative plans for a
variety of reasons. If the location of the femoral neck cut
differs from the planned cut, if the cut is modified to provide
better implant fit, if a component fails to fully seat, or if actual
implants differ in size or offset the template, the surgeons may
be forced to deviate from the preoperative plan. In a pro-
spective study of 110 consecutive THAs in which actual
implant sizing was compared to that of the preoperative plan,
the plan predicted the sizing for only 69% of acetabular cups
and 42% of cementless stems.12 However, preoperative plan-
ning may still be useful to give the surgeon an estimate of what
size to expect, and to help prevent gross mismatch. A review of

FIGURE 2. A, Radiograph of the specimen, demonstrating implant in place with a + 0 neck. B, Specimen with appropriate amount of
overlap with + 0 neck in place. C, Demonstration of anatomic capsular alignment with appropriate neck size in this specimen.

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2014 Lippincott Williams & Wilkins
Techniques in Orthopaedics$  Volume 29, Number 2, 2014 Anatomic Technique for Establishing Leg Length

FIGURE 3. A, Radiograph of the specimen, demonstrating implant in place with + 4 neck. B, Specimen with gap between capsule
border and its prior attachment at the anterior intertrochanteric line.

139 THAs with radiographic preoperative planning found that
only 78% of planned femoral component sizes matched the
final implants, but >99% of components were within 1 size of
the prediction.14 For these reasons, a review of leg-length
discrepancy after THA suggests that preoperative templating
should be combined with a reliable intraoperative method to
obtain optimal length.13
In addition to preoperative templating techniques, many
intraoperative techniques have been described.15–17,22,30,31
Several studies have described the placement of screws or pins
into the pelvis to be used as landmarks for measurements
before and after implant placement.18–21 In 1 report, use of a
pin device in conjunction with a carpenter’s level resulted in
lengthening of >12 mm in only 5% of hips, whereas 31% were
lengthened >12 mm without the device.23
The use of calipers in combination with pelvic pins has
also been described. A prospective case-control study found
that a mechanical measurement device fixed to the pelvis can
significantly decrease deviations from target length (2.31 vs.
6.96 mm; P = 0.0013) and offset (3.96 vs. 10.16 mm; P =
0.0199) during THA performed on a posterolateral approach
compared to freehand.24 Another study found that among 56
patients with hip disease no shoe lifts were required and there
were no complaints of leg-length discrepancy when a calipers
dual pin retractor was used during THA.25
Computer-assisted navigation in THR has been shown to
significantly decrease the prevalence of radiographic leg-
length discrepancy, but increased operative time without
improvement of Harris Hip Score or Western Ontario and
McMaster University Osteoarthritis Index.26 A matched-paired
study of computer-assisted versus freehand techniques for
short modular femoral stem implantation also found longer
operative times with computer-assist with similar outcomes
and dislocation rates.27 A comprehensive prospective study of
robotic-assisted versus manual THR found no difference in
Harris or Mayo clinical scores at 24 months after surgery with

FIGURE 4. A, Radiograph of the specimen, demonstrating implant in place with + 8 neck. B, Specimen with larger gap between capsule
border and its prior attachment at the anterior intertrochanteric line.

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Halim et al
significantly better leg-length equality in the robotic-assisted
operations (LLD, 0.18 ± 0.30 vs. 0.96 ± 0.93 cm) but sig-
nificantly more hip dislocations, longer operative times, and a
much greater rate of revision surgery in the robotic-assisted
group.28 It has recently been reported that the major advantage
of computer navigation is the obviation of femoral and pelvic
pin insertion which is associated with potential complica-
tions.29 Our intraoperative technique does not rely on the
insertion of pins.
Occasionally, revision surgery is indicated to correct leg-
length discrepancy.33,34 A study found that revision surgery for
nerve complaints following leg lengthening after hip replace-
ment was only successful in eliminating dyesthetic pain in 9 of
17 revisions and was only successful in restoring full motor
function in 3 of 11 revisions.33
One study found that after revision, a reduction in leg-
length discrepancy was associated with marked improvement
in walking capacity, especially in patients younger than 65
years.43 A temporary, artificial LLD of Z2 cm in halthy vol-
unteers increased oxygen consumption and perceived exertion,
whereas Z3 cm induced significant quadriceps fatigue sug-
gesting that a postoperative leg-length discrepancy of Z2 cm
may cause clinically significant gait abnormalities.41
Our method, used with the anterior approach to total hip
arthroplasty, has many advantages over alternative methods of
measuring leg length intraoperatively. It is simple to perform,
depends upon anatomic landmark, does not necessitate intra-
operative fluoroscopy, and does not increase operative time.
The reliable results of this method have consistently demon-
strated that it is an effective means of ensuring minimal leg-
length difference postoperatively. Even though we have used it
only with the anterior approach it should also have applications
with the anterolateral approach.
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