The aim of this study was to determine whether femoral neck preserving total hip arthroplasty would become less difficult and more efficient during the first 20 cases and to identify potential pitfalls during the introduction of this procedure. The difficulty and efficiency of the initial 20 procedures performed by four surgeons was prospectively determined by analysing a total of 68 video recordings using time-action analysis. This method measures the duration and efficiency of individual actions needed for a surgeon to achieve his or her goal. Afterwards, we reviewed all actions with a long duration and discussed possible causes of delay with the surgeons to identify possible pitfalls. We found a decrease of difficulty and an increase of efficiency during the first 20 cases and a more consistent execution after the initial five cases. Estimating the correct osteotomy level and stem curvature was often difficult, which resulted in a variable stem position. Radiologic analysis demonstrated a tendency for varus position and increased leg length throughout the series, even after the surgeons demonstrated technical proficiency.