Hip Arthroscopy Traction Time and Total Operative Time Decreases with Surgical Experience

Hip Arthroscopy Traction Time and Total Operative Time Decreases with Surgical Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hip Arthroscopy Traction Time and Total Operative Time Decreases with Surgical Experience Caleb J. Bischoff, Samuel D. Gieg, Steven F. DeFroda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6422661/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To evaluate the impact of surgical experience, measured by years of practice and case volume, on operative and traction times in hip arthroscopy procedures for acetabular labral repair and reconstruction Methods: A retrospective review was conducted of hip arthroscopy cases performed by a single fellowship-trained surgeon between August 16, 2021, and August 16, 2024. Patients included underwent primary hip arthroscopy for acetabular labral repair or reconstruction. Spearman correlation analyses assessed the relationship between years of surgical experience, number of labral anchors used, and operative and traction times. Data were divided into repair and reconstruction cohorts. Statistical significance was set at p<0.05. Results: A total of 117 cases (102 repairs, 15 reconstructions) in 106 patients (mean age 29.9 years, mean BMI 28.1) were analyzed. In the repair cohort, operative and traction times significantly decreased from 149.1 to 124.7 minutes and 64.0 to 56.1 minutes over three years, respectively. Significant negative correlations were found between both years of experience and case volume with operative (r = -0.424, p<0.0001) and traction times (r = -0.435, p<0.0001). No significant associations were observed in the reconstruction cohort or between anchor number and time measures. Conclusion: Surgical experience and increasing case volume significantly reduce operative and traction times in acetabular labrum repair, with improvements continuing beyond the 100-case mark. No such association was observed for more complex labral reconstructions. Hip arthroscopy surgical experience learning curve operative time traction time acetabular labral repair Figures Figure 1 Figure 2 Introduction Hip arthroscopy has become a widely utilized surgical technique for treating intra-articular hip pathology, particularly femoroacetabular impingement (FAI) and labral tears. Its use has expanded dramatically, with reports noting a 600% increase in procedure volume between 2005 and 2010, driven by better recognition of pathology and improvements in diagnostic imaging [ 1 ]. The literature has reflected this trend, with citations on hip arthroscopy increasing by more than 500% during the same period [ 2 , 3 ]. Despite these advancements, hip arthroscopy remains technically demanding due to the complex anatomy and depth of the hip joint. Access to the joint requires precise portal placement, often using landmarks such as the greater trochanter or the anterosuperior iliac spine. However, dense surrounding musculature and joint depth complicate this process, and misplacement can lead to complications such as neurovascular injury, labral damage, or inadequate visualization. Studies report major complication rates of up to 0.58% and reoperation rates as high as 6.3% [ 4 , 5 ]. This emphasizes the need for refined technique and substantial experience to perform the procedure safely and efficiently [ 6 ]. In orthopedic surgery, greater surgical experience has been associated with improved outcomes across a range of procedures, including joint arthroplasty and shoulder surgery [ 6 – 10 ]. While some hip arthroscopy studies suggest competency is achieved after approximately 30 cases [ 11 ], others propose a threshold beyond 100 cases for improved outcomes [ 12 , 13 ]. However, the duration of the learning curve and the potential for continued gains in efficiency remain unclear. This study evaluates the impact of surgical experience, measured by both years in practice and case volume, on operative and traction times during acetabular labrum repair and reconstruction. We hypothesize that increased experience will correlate with improved procedural efficiency without a clearly defined plateau after early training. Materials and Methods Study Design and Patient Selection This study was conducted as a retrospective analysis following institutional review board (IRB) approval. It focused on hip arthroscopy procedures performed by a single fellowship-trained orthopedic surgeon over a three-year period, from August 16, 2021, to August 16, 2024. This timeframe was selected to capture the surgeon’s initial years of independent practice, providing a structured evaluation of the early learning curve associated with hip arthroscopy. Patient selection was based on electronic medical records and operative logs using current procedural terminology (CPT) codes to identify individuals who underwent primary hip arthroscopy for acetabular labral pathology. Eligible cases were categorized into two cohorts: acetabular labrum repair and acetabular labrum reconstruction. Patients with a history of prior hip surgery, underlying dysplasia, or incomplete medical records were excluded to ensure a homogenous study population and minimize confounding variables. Surgical Indications and Methodology Surgical intervention was indicated for patients presenting with hip pain and radiographic evidence of acetabular labral pathology. The decision to perform labral repair versus reconstruction was based on the severity of damage, assessed preoperatively via magnetic resonance imaging (MRI), intraoperative inspection, and probing. For reconstruction cases, either fresh meniscus or tibialis anterior tendon allograft was selected based on availability and surgeon preference. Grafts were prepared by a surgical assistant while the senior surgeon addressed intra-articular pathology and prepared the recipient site. Hip arthroscopy was performed under general anesthesia with the patient positioned supine on a post-less traction table [ 14 ], an approach designed to mitigate perineal soft tissue complications that were historically associated with post-based traction methods. The surgical site was prepared and draped in a sterile fashion, and an assistant applied axial distraction to facilitate central compartment access, with intraoperative fluoroscopy used to confirm appropriate joint distraction. Standard arthroscopic portals were placed under fluoroscopic guidance. After portal establishment, a capsulotomy was performed to optimize visualization and instrument access. Central compartment procedures, labral repair or reconstruction and acetabuloplasty, were completed before releasing traction. A T-capsulotomy was then performed to access the peripheral compartment, where additional pathology such as cam deformities was addressed. To ensure labral integrity and hip stability, a dynamic range of motion (ROM) assessment and a “suction seal” test were conducted before closure. The suction seal test assessed the labrum’s ability to maintain negative intra-articular pressure under in-line traction. Capsular plication and closure of the capsulotomy were then performed using standard arthroscopic techniques, followed by layered skin closure. Operative and Traction Time Definitions Operative time was defined as the total duration from the initial surgical incision to the final surgical closure, reflecting the time actively spent performing the procedure. This metric excluded preoperative preparation and postoperative patient care in order to provide a direct measure of intraoperative efficiency. Traction time was recorded as the duration from the onset of traction application to the release of traction at the conclusion of the central compartment intervention. This measurement is particularly relevant in hip arthroscopy, as prolonged traction has been associated with increased risks of postoperative neuropraxia and soft tissue complications. The number of labral anchors placed during acetabular labral repair or reconstruction was meticulously documented for each procedure to evaluate whether anchor placement had an impact on operative or traction times. Data Collection Comprehensive demographic and clinical data were collected for each patient, including age, gender, and body mass index (BMI). Surgical experience was quantified by years in practice and cumulative case volume, allowing for assessment of progressive efficiency improvements over time. The following key variables were recorded for each procedure: Operative time (minutes) Traction time (minutes) Number of labral anchors used Type of procedure performed (repair vs. reconstruction) Statistical Analysis A comprehensive statistical analysis was conducted to evaluate the relationship between surgical experience and intraoperative efficiency. Bivariate Spearman correlation analyses were performed to determine associations between: Years of surgical experience (YOS) and operative time YOS and traction time Number of cases performed and operative time Number of cases performed and traction time Number of anchors placed and operative/traction time The dataset was divided into two cohorts (acetabular labrum repair and reconstruction) to allow for comparative analysis. Spearman correlation coefficients (ρ) were computed to assess the strength and direction of associations, with exact p-values calculated to determine statistical significance. A p-value of less than 0.05 was considered indicative of statistical significance. To further visualize trends, locally estimated scatterplot smoothing (LOESS) curves were applied to scatter plots depicting the relationship between surgical experience and operative/traction times. Outliers in traction time were identified and excluded based on an interquartile range (IQR) method, where values falling outside [Q1–3 * IQR, Q3 + 3 * IQR] were removed to minimize potential skewing of results. Additionally, descriptive statistics were employed to summarize mean operative and traction times across the three years of surgical experience in both the repair and reconstruction cohorts. These analyses provided a quantitative assessment of the learning curve associated with hip arthroscopy, allowing for an evaluation of whether efficiency gains plateaued over time. Results Patient Demographics and Case Distribution A total of 117 hip arthroscopy procedures were analyzed, performed in 106 patients over the course of three years. The patient population had a mean age of 29.9 years and a mean BMI of 28.1 kg/m². Among the cohort, 69 patients (59%) were female and 48 (41%) were male. The surgical procedures were divided into two distinct groups based on the type of labral intervention performed: 102 cases (87.2%) involved acetabular labral repair, while 15 cases (12.8%) required labral reconstruction. Operative and Traction Time Trends Over Three Years In the repair cohort, the distribution of cases across the three-year study period demonstrated a progressive increase in procedural volume, with 17 cases performed in Year 1, 35 in Year 2, and 50 in Year 3. Analysis of operative time revealed a steady decline over this period, with mean operative durations of 149.1 minutes (± 29.2) in Year 1, 139.6 minutes (± 23.4) in Year 2, and 124.7 minutes (± 25.4) in Year 3, yielding an overall mean operative time of 133.9 minutes (± 27.1). A similar trend was observed in traction time, with durations of 64.0 minutes (± 11.3) in Year 1, 65.3 minutes (± 21.8) in Year 2, and 56.1 minutes (± 15.6) in Year 3, resulting in an overall mean traction time of 60.5 minutes (± 17.9) (Table 1 ). Table 1 Operative and Traction Times by Year in the Repair Cohort Year Number of Cases Operative Time (minutes) Traction Time (minutes) Year 1 17 149.1 ± 29.2 64.0 ± 11.3 Year 2 35 139.6 ± 23.4 65.3 ± 21.8 Year 3 50 124.7 ± 25.4 56.1 ± 15.6 Overall 102 133.9 ± 27.1 60.5 ± 17.9 data presented as mean ± standard deviation. In contrast, the Recon cohort exhibited fewer cases distributed across the study period, with 1 case performed in Year 1, 7 in Year 2, and 7 in Year 3. The mean operative time in Year 1 was 284.0 minutes (± 0.0), 186.9 minutes (± 43.8) in Year 2, and 189.6 minutes (± 35.3) in Year 3, producing an overall mean operative time of 194.6 minutes (± 45.3). Similarly, traction time declined from 192.0 minutes (± 0.0) in Year 1 to 131.0 minutes (± 32.3) in Year 2 and 124.5 minutes (± 36.0) in Year 3, with an overall mean traction time of 132.6 minutes (± 38.3) (Table 2 ). Table 2 Operative and Traction Times by Year in the Reconstruction Cohort Year Number of Cases Operative Time (minutes) Traction Time (minutes) Year 1 1 284.0 ± 0.0 192.0 ± 0.0 Year 2 7 186.9 ± 43.8 131.0 ± 32.0 Year 3 7 189.6 ± 35.3 124.5 ± 36 Overall 15 194.6 ± 45.3 132.6 ± 38.3 data presented as mean ± standard deviation or mean. Effect of Case Volume on Operative and Traction Times A bivariate Spearman correlation analysis was conducted to assess the relationship between case volume and operative/traction times. In the repair cohort, a significant negative correlation was found between the number of cases performed and operative time (r = -0.424, p < 0.0001), as well as between case volume and traction time (r = -0.435, p < 0.0001) (Fig. 1 ). These findings indicate that as the number of cases performed increased, both operative and traction times progressively decreased, supporting the presence of a learning curve. Overall, Loess trends demonstrate a continuous learning effect with no plateau over three years, highlighting the impact of surgical experience and case volume on procedural efficiency. Conversely, in the Recon cohort, no significant correlation was identified between case volume and operative time (r = -0.413, p = 0.126) or traction time (r = -0.455, p = 0.104) (Fig. 2 ). This suggests that increased case volume alone did not significantly contribute to efficiency gains in reconstruction procedures, potentially due to the increased procedural complexity associated with graft preparation, fixation, and patient-specific variability. Collectively, these results indicate that neither surgical experience nor case volume significantly influenced operative or traction times in reconstruction cases. Effect of Years of Surgical Experience on Operative and Traction Times The relationship between YOS and procedural efficiency was also assessed. In the repair cohort, a significant negative correlation was found between YOS and operative time (r = -0.424, p < 0.0001), as well as between YOS and traction time (r = -0.434, p < 0.0001) (Fig. 1 ). These results demonstrate that as the surgeon’s experience increased over time, both operative and traction times significantly declined, reinforcing the concept that surgical proficiency improves progressively with increased clinical exposure and repetition. However, in the Recon cohort, no significant correlation was observed between YOS and operative time (r = -0.419, p = 0.120) or traction time (r = -0.462, p = 0.096) (Fig. 2 ). The absence of a statistically significant relationship in this subgroup suggests that operative efficiency in reconstruction cases may be influenced by additional variables beyond years of surgical experience, such as technical complexity, patient-specific anatomical variations, and differences in graft preparation techniques. Effect of Labral Anchor Placement on Operative and Traction Times To evaluate whether the number of anchors used in labral repair or reconstruction impacted surgical efficiency, Spearman correlation analyses were conducted. In the repair cohort, no meaningful relationship was observed between the number of anchors placed and operative time (r = 0.041, p = 0.681) or traction time (r = 0.073, p = 0.469). Similarly, in the Recon cohort, no significant correlation was found between anchor usage and operative time (r = -0.114, p = 0.687) or traction time (r = 0.016, p = 0.958). These results indicate that the number of labral anchors utilized does not appear to influence the duration of operative or traction times, suggesting that other procedural factors, such as case complexity, surgical technique, and tissue quality, may play a more substantial role in determining overall efficiency. Discussion This study demonstrates a significant negative correlation between both years of surgical experience and case volume with operative and traction times in acetabular labrum repair, supporting our hypothesis that increased experience contributes to greater procedural efficiency. However, no clear threshold of cases was identified where a plateau in efficiency occurred. Instead, Loess curve analysis revealed ongoing reductions in operative and traction times up to the 3-year mark, with no evidence of plateauing. These findings suggest a sustained learning effect and contrast with prior studies that reported a proficiency plateau after approximately 50 cases [ 11 , 15 ]. Our data, based on 117 cases, indicate that continuous exposure and repetition are key to improving efficiency beyond early benchmarks. These results align with broader orthopedic literature, where increased surgical experience correlates with improved outcomes across procedures such as total joint and shoulder arthroplasty [ 6 , 7 , 9 ]. While previous hip arthroscopy studies proposed 30 to 100 cases as thresholds for competency [ 11 , 13 , 15 ], our findings suggest that the learning curve extends further. In a high-volume setting with complex case demands, our data support the idea that operative metrics can continue to improve well beyond previously proposed case volumes. The lack of significant correlations in labrum reconstruction cases contrasts with our hypothesis, which anticipated similar reductions in operative and traction times. This discrepancy may reflect the greater technical complexity of reconstruction procedures. Graft selection, preparation, and variability in pathology likely limit the ability to achieve similar time reductions with experience alone. Reducing operative and traction times yields meaningful clinical benefits. Shorter traction times reduce risks such as nerve injury, muscle damage, and prolonged postoperative discomfort related to joint distraction [ 5 ]. Similarly, shorter operative durations minimize risks of infection and anesthesia-related complications, accelerating recovery and enabling quicker return to activity, an important consideration in athletic populations [ 13 , 16 ]. Improved surgical efficiency also enhances resource utilization, increases procedural capacity, and may help reduce healthcare costs [ 16 ]. Limitations This study is not without limitations. It reflects the experience of a single surgeon, which controls for variability in surgical technique but limits generalizability. The findings may reflect this surgeon’s specific training and operative style. Additionally, the small sample size in the reconstruction cohort limited statistical power, possibly obscuring correlations that might emerge in larger samples. The complexity and variability inherent in labral reconstruction, including graft handling and extent of pathology, may further influence outcomes independently of surgical experience. This study was also conducted in a teaching environment, where residents and fellows contributed to key steps, including portal placement and suture management. Trainee involvement may have influenced operative efficiency depending on their experience level. Finally, no universally accepted standard defines the number of cases or years required to achieve proficiency in hip arthroscopy, underscoring the need for ongoing study of the learning curve. Future research should validate these findings through multicenter studies that include surgeons with diverse backgrounds and case volumes. Additional analysis is needed to identify factors that influence efficiency in reconstruction procedures—such as graft type, surgical technique, and pathology complexity. Furthermore, studies should investigate how experience affects other outcomes, including complications, patient-reported measures, and revision rates. Together, these efforts will contribute to optimizing surgical training, procedural performance, and patient safety in hip arthroscopy. Conclusion This study underscores the significant role of surgical experience and case volume in reducing operative and traction times in acetabular labrum repair. The findings suggest continued efficiency improvements beyond 100 cases. Statements & Declarations Funding The authors did not receive support from any organization for the submitted work. Ethics approval Approval of this observational, retrospective study was obtained from the ethics committee of the University of Missouri (August 20, 2024/No. 2114846). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Patient consent statement A full HIPAA waiver was acquired through the above ethics approval. References Maradit Kremers H, Schilz SR, Van Houten HK, Herrin J, Koenig KM, Bozic KJ, et al. Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013. J Arthroplasty 2017;32:750–5. https://doi.org/10.1016/j.arth.2016.09.004. Bozic KJ, Chan V, Valone FH, Feeley BT, Vail TP. Trends in Hip Arthroscopy Utilization in the United States. J Arthroplasty 2013;28:140–3. https://doi.org/10.1016/j.arth.2013.02.039. Ayeni OR, Chan K, Al-Asiri J, Chien T, Sprague S, Liew S, et al. Sources and quality of literature addressing femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2013;21:1795. https://doi.org/10.1007/s00167-012-2236-7. Maldonado DR, Chen JW, Walker-Santiago R, Rosinsky PJ, Shapira J, Lall AC, et al. Forget the Greater Trochanter! Hip Joint Access With the 12 O’clock Portal in Hip Arthroscopy. Arthrosc Tech 2019;8:e575–84. https://doi.org/10.1016/j.eats.2019.01.017. Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2013;29:589–95. https://doi.org/10.1016/j.arthro.2012.11.003. Baker P, Jameson S, Critchley R, Reed M, Gregg P, Deehan D. Center and Surgeon Volume Influence the Revision Rate Following Unicondylar Knee Replacement: An Analysis of 23,400 Medial Cemented Unicondylar Knee Replacements. JBJS 2013;95:702. https://doi.org/10.2106/JBJS.L.00520. Malik AT, Jain N, Scharschmidt TJ, Li M, Glassman AH, Khan SN. Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review. J Arthroplasty 2018;33:3329–42. https://doi.org/10.1016/j.arth.2018.05.040. Prkić A, Vermeulen NP, Kooistra BW, The B, van den Bekerom MPJ, Eygendaal D. Is there a relationship between surgical volume and outcome for total elbow arthroplasty? A systematic review. EFORT Open Rev 2023;8:45–51. https://doi.org/10.1530/EOR-22-0087. Jain N, Pietrobon R, Hocker S, Guller U, Shankar A, Higgins LD. The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty. JBJS 2004;86:496. Testa EJ, Brodeur PG, Lama CJ, Hartnett DA, Painter D, Gil JA, et al. The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures. JAAOS Glob Res Rev 2023;7:e22.00242. https://doi.org/10.5435/JAAOSGlobal-D-22-00242. Hoppe DJ, De Sa D, Simunovic N, Bhandari M, Safran MR, Larson CM, et al. The Learning Curve for Hip Arthroscopy: A Systematic Review. Arthrosc J Arthrosc Relat Surg 2014;30:389–97. https://doi.org/10.1016/j.arthro.2013.11.012. Go CC, Kyin C, Maldonado DR, Domb BG. Surgeon Experience in Hip Arthroscopy Affects Surgical Time, Complication Rate, and Reoperation Rate: A Systematic Review on the Learning Curve. Arthrosc J Arthrosc Relat Surg 2020;36:3092–105. https://doi.org/10.1016/j.arthro.2020.06.033. Mehta N. Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship n.d. https://doi.org/10.1177/0363546517749219. Woodard DR, Richards JA, Knake K, DeFroda S. Patient Positioning for Postless Hip Arthroscopy. Arthrosc Tech 2024;13:102969. https://doi.org/10.1016/j.eats.2024.102969. Souza BGSE, Dani WS, Honda EK, Ricioli W, Guimarães RP, Ono NK, et al. Do Complications in Hip Arthroscopy Change With Experience? Arthrosc J Arthrosc Relat Surg 2010;26:1053–7. https://doi.org/10.1016/j.arthro.2009.12.021. Bovonratwet P, Boddapati V, Nwachukwu BU, Bohl DD, Fu MC, Nho SJ. Increased hip arthroscopy operative duration is an independent risk factor for overnight hospital admission. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 2021;29:1385–91. https://doi.org/10.1007/s00167-020-06170-7. Additional Declarations Competing interest reported. Author C.J.B. and S.D.G. declare they have no financial interests. Author S.F.D. has received funding grants from Arthroscopic Association of North America and Orthopaedic Research and Education Foundation. S.F.D. has received speaking and lecture financial support from AO North America. S.F.D. has a consulting or advisory role with Stryker. S.F.D. is an Editor for Arthroscopy: The Journal of Arthroscopy and Related Surgery. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6422661","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":447293561,"identity":"b10174ab-933f-425a-acfd-154cdc82c795","order_by":0,"name":"Caleb J. Bischoff","email":"data:image/png;base64,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","orcid":"","institution":"University of Missouri","correspondingAuthor":true,"prefix":"","firstName":"Caleb","middleName":"J.","lastName":"Bischoff","suffix":""},{"id":447293562,"identity":"c2a44f91-b98f-4bf4-8f93-0420163ce031","order_by":1,"name":"Samuel D. Gieg","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"D.","lastName":"Gieg","suffix":""},{"id":447293563,"identity":"1094c052-9de6-4f11-b05b-51123adeb656","order_by":2,"name":"Steven F. DeFroda","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"F.","lastName":"DeFroda","suffix":""}],"badges":[],"createdAt":"2025-04-10 18:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6422661/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6422661/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82078904,"identity":"f5cc51b7-aeae-4a10-85c9-9be253ea2bbe","added_by":"auto","created_at":"2025-05-06 14:09:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":191175,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure illustrates the correlation between surgical experience (in years) and case volume with both traction time (top row) and operative time (bottom row) in acetabular labrum repair. Each panel presents a scatter plot with a Loess curve fit (red line) and 95% confidence interval (gray shaded area) to depict trends\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTop Left Panel:\u003c/strong\u003e Significant negative correlation between years of experience and traction time (ρ = −0.4342, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTop Right Panel:\u003c/strong\u003e Significant negative correlation between case volume and traction time (ρ = −0.4346, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBottom Left Panel:\u003c/strong\u003e Significant negative correlation between years of experience and operative time (ρ = −0.4238, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBottom Right Panel:\u003c/strong\u003e Significant negative correlation between case volume and operative time (ρ = −0.4243, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.0001).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6422661/v1/d2d2b5eaeccb1074e5eb8289.png"},{"id":82078905,"identity":"79021ed8-773b-42a2-9243-f1dbc564dc56","added_by":"auto","created_at":"2025-05-06 14:09:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":174237,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure illustrates the relationship between surgical experience—measured both in years and total case volume—and traction and operative times within the acetabular labrum reconstruction cohort. Each panel shows a scatter plot of individual cases (black dots) alongside a Loess curve fit (red line) and 95% confidence interval (gray shaded area) to capture trend lines over time and case volume\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTop Left Panel:\u003c/strong\u003e No significant correlation was found between years of experience and traction time (ρ = −0.4620, \u003cem\u003ep\u003c/em\u003e = 0.0962).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTop Right Panel:\u003c/strong\u003e No significant correlation was observed between case volume and traction time (ρ = −0.4549, \u003cem\u003ep\u003c/em\u003e = 0.1044).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBottom Left Panel:\u003c/strong\u003e The relationship between years of experience and operative time was not statistically significant (ρ = −0.4186, \u003cem\u003ep\u003c/em\u003e= 0.1204).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBottom Right Panel:\u003c/strong\u003e No significant correlation was found between case volume and operative time (ρ = −0.4129, \u003cem\u003ep\u003c/em\u003e = 0.1261).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6422661/v1/1eb0743e678ca1d98931795f.png"},{"id":94042931,"identity":"dd6d230f-6db9-4a0b-ae92-a4622ec16491","added_by":"auto","created_at":"2025-10-21 19:16:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1000799,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6422661/v1/a4a2df7d-1557-46db-9f4d-51cc07f81d36.pdf"}],"financialInterests":"Competing interest reported. Author C.J.B. and S.D.G. declare they have no financial interests. Author S.F.D. has received funding grants from Arthroscopic Association of North America and Orthopaedic Research and Education Foundation. S.F.D. has received speaking and lecture financial support from AO North America. S.F.D. has a consulting or advisory role with Stryker. S.F.D. is an Editor for Arthroscopy: The Journal of Arthroscopy and Related Surgery.","formattedTitle":"Hip Arthroscopy Traction Time and Total Operative Time Decreases with Surgical Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHip arthroscopy has become a widely utilized surgical technique for treating intra-articular hip pathology, particularly femoroacetabular impingement (FAI) and labral tears. Its use has expanded dramatically, with reports noting a 600% increase in procedure volume between 2005 and 2010, driven by better recognition of pathology and improvements in diagnostic imaging [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The literature has reflected this trend, with citations on hip arthroscopy increasing by more than 500% during the same period [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite these advancements, hip arthroscopy remains technically demanding due to the complex anatomy and depth of the hip joint.\u003c/p\u003e \u003cp\u003eAccess to the joint requires precise portal placement, often using landmarks such as the greater trochanter or the anterosuperior iliac spine. However, dense surrounding musculature and joint depth complicate this process, and misplacement can lead to complications such as neurovascular injury, labral damage, or inadequate visualization. Studies report major complication rates of up to 0.58% and reoperation rates as high as 6.3% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This emphasizes the need for refined technique and substantial experience to perform the procedure safely and efficiently [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn orthopedic surgery, greater surgical experience has been associated with improved outcomes across a range of procedures, including joint arthroplasty and shoulder surgery [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While some hip arthroscopy studies suggest competency is achieved after approximately 30 cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], others propose a threshold beyond 100 cases for improved outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the duration of the learning curve and the potential for continued gains in efficiency remain unclear.\u003c/p\u003e \u003cp\u003eThis study evaluates the impact of surgical experience, measured by both years in practice and case volume, on operative and traction times during acetabular labrum repair and reconstruction. We hypothesize that increased experience will correlate with improved procedural efficiency without a clearly defined plateau after early training.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patient Selection\u003c/h2\u003e \u003cp\u003e This study was conducted as a retrospective analysis following institutional review board (IRB) approval. It focused on hip arthroscopy procedures performed by a single fellowship-trained orthopedic surgeon over a three-year period, from August 16, 2021, to August 16, 2024. This timeframe was selected to capture the surgeon\u0026rsquo;s initial years of independent practice, providing a structured evaluation of the early learning curve associated with hip arthroscopy.\u003c/p\u003e \u003cp\u003ePatient selection was based on electronic medical records and operative logs using current procedural terminology (CPT) codes to identify individuals who underwent primary hip arthroscopy for acetabular labral pathology. Eligible cases were categorized into two cohorts: acetabular labrum repair and acetabular labrum reconstruction. Patients with a history of prior hip surgery, underlying dysplasia, or incomplete medical records were excluded to ensure a homogenous study population and minimize confounding variables.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Indications and Methodology\u003c/h3\u003e\n\u003cp\u003eSurgical intervention was indicated for patients presenting with hip pain and radiographic evidence of acetabular labral pathology. The decision to perform labral repair versus reconstruction was based on the severity of damage, assessed preoperatively via magnetic resonance imaging (MRI), intraoperative inspection, and probing.\u003c/p\u003e \u003cp\u003eFor reconstruction cases, either fresh meniscus or tibialis anterior tendon allograft was selected based on availability and surgeon preference. Grafts were prepared by a surgical assistant while the senior surgeon addressed intra-articular pathology and prepared the recipient site.\u003c/p\u003e \u003cp\u003eHip arthroscopy was performed under general anesthesia with the patient positioned supine on a post-less traction table [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], an approach designed to mitigate perineal soft tissue complications that were historically associated with post-based traction methods. The surgical site was prepared and draped in a sterile fashion, and an assistant applied axial distraction to facilitate central compartment access, with intraoperative fluoroscopy used to confirm appropriate joint distraction.\u003c/p\u003e \u003cp\u003eStandard arthroscopic portals were placed under fluoroscopic guidance. After portal establishment, a capsulotomy was performed to optimize visualization and instrument access. Central compartment procedures, labral repair or reconstruction and acetabuloplasty, were completed before releasing traction. A T-capsulotomy was then performed to access the peripheral compartment, where additional pathology such as cam deformities was addressed.\u003c/p\u003e \u003cp\u003eTo ensure labral integrity and hip stability, a dynamic range of motion (ROM) assessment and a \u0026ldquo;suction seal\u0026rdquo; test were conducted before closure. The suction seal test assessed the labrum\u0026rsquo;s ability to maintain negative intra-articular pressure under in-line traction. Capsular plication and closure of the capsulotomy were then performed using standard arthroscopic techniques, followed by layered skin closure.\u003c/p\u003e\n\u003ch3\u003eOperative and Traction Time Definitions\u003c/h3\u003e\n\u003cp\u003eOperative time was defined as the total duration from the initial surgical incision to the final surgical closure, reflecting the time actively spent performing the procedure. This metric excluded preoperative preparation and postoperative patient care in order to provide a direct measure of intraoperative efficiency.\u003c/p\u003e \u003cp\u003eTraction time was recorded as the duration from the onset of traction application to the release of traction at the conclusion of the central compartment intervention. This measurement is particularly relevant in hip arthroscopy, as prolonged traction has been associated with increased risks of postoperative neuropraxia and soft tissue complications.\u003c/p\u003e \u003cp\u003eThe number of labral anchors placed during acetabular labral repair or reconstruction was meticulously documented for each procedure to evaluate whether anchor placement had an impact on operative or traction times.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eComprehensive demographic and clinical data were collected for each patient, including age, gender, and body mass index (BMI). Surgical experience was quantified by years in practice and cumulative case volume, allowing for assessment of progressive efficiency improvements over time.\u003c/p\u003e \u003cp\u003eThe following key variables were recorded for each procedure:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOperative time (minutes)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTraction time (minutes)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNumber of labral anchors used\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType of procedure performed (repair vs. reconstruction)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eA comprehensive statistical analysis was conducted to evaluate the relationship between surgical experience and intraoperative efficiency. Bivariate Spearman correlation analyses were performed to determine associations between:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eYears of surgical experience (YOS) and operative time\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eYOS and traction time\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNumber of cases performed and operative time\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNumber of cases performed and traction time\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNumber of anchors placed and operative/traction time\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe dataset was divided into two cohorts (acetabular labrum repair and reconstruction) to allow for comparative analysis. Spearman correlation coefficients (ρ) were computed to assess the strength and direction of associations, with exact p-values calculated to determine statistical significance. A p-value of less than 0.05 was considered indicative of statistical significance.\u003c/p\u003e \u003cp\u003eTo further visualize trends, locally estimated scatterplot smoothing (LOESS) curves were applied to scatter plots depicting the relationship between surgical experience and operative/traction times. Outliers in traction time were identified and excluded based on an interquartile range (IQR) method, where values falling outside [Q1\u0026ndash;3 * IQR, Q3\u0026thinsp;+\u0026thinsp;3 * IQR] were removed to minimize potential skewing of results.\u003c/p\u003e \u003cp\u003eAdditionally, descriptive statistics were employed to summarize mean operative and traction times across the three years of surgical experience in both the repair and reconstruction cohorts. These analyses provided a quantitative assessment of the learning curve associated with hip arthroscopy, allowing for an evaluation of whether efficiency gains plateaued over time.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Demographics and Case Distribution\u003c/h2\u003e\n \u003cp\u003eA total of 117 hip arthroscopy procedures were analyzed, performed in 106 patients over the course of three years. The patient population had a mean age of 29.9 years and a mean BMI of 28.1 kg/m\u0026sup2;. Among the cohort, 69 patients (59%) were female and 48 (41%) were male. The surgical procedures were divided into two distinct groups based on the type of labral intervention performed: 102 cases (87.2%) involved acetabular labral repair, while 15 cases (12.8%) required labral reconstruction.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eOperative and Traction Time Trends Over Three Years\u003c/h3\u003e\n\u003cp\u003eIn the repair cohort, the distribution of cases across the three-year study period demonstrated a progressive increase in procedural volume, with 17 cases performed in Year 1, 35 in Year 2, and 50 in Year 3. Analysis of operative time revealed a steady decline over this period, with mean operative durations of 149.1 minutes (\u0026plusmn;\u0026thinsp;29.2) in Year 1, 139.6 minutes (\u0026plusmn;\u0026thinsp;23.4) in Year 2, and 124.7 minutes (\u0026plusmn;\u0026thinsp;25.4) in Year 3, yielding an overall mean operative time of 133.9 minutes (\u0026plusmn;\u0026thinsp;27.1). A similar trend was observed in traction time, with durations of 64.0 minutes (\u0026plusmn;\u0026thinsp;11.3) in Year 1, 65.3 minutes (\u0026plusmn;\u0026thinsp;21.8) in Year 2, and 56.1 minutes (\u0026plusmn;\u0026thinsp;15.6) in Year 3, resulting in an overall mean traction time of 60.5 minutes (\u0026plusmn;\u0026thinsp;17.9) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOperative and Traction Times by Year in the Repair Cohort\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Cases\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOperative Time (minutes)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraction Time (minutes)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e149.1\u0026thinsp;\u0026plusmn;\u0026thinsp;29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e139.6\u0026thinsp;\u0026plusmn;\u0026thinsp;23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e124.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.1\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e133.9\u0026thinsp;\u0026plusmn;\u0026thinsp;27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.5\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003edata presented as mean \u0026plusmn; standard deviation.\u003c/p\u003e\n\u003cp\u003eIn contrast, the Recon cohort exhibited fewer cases distributed across the study period, with 1 case performed in Year 1, 7 in Year 2, and 7 in Year 3. The mean operative time in Year 1 was 284.0 minutes (\u0026plusmn;\u0026thinsp;0.0), 186.9 minutes (\u0026plusmn;\u0026thinsp;43.8) in Year 2, and 189.6 minutes (\u0026plusmn;\u0026thinsp;35.3) in Year 3, producing an overall mean operative time of 194.6 minutes (\u0026plusmn;\u0026thinsp;45.3). Similarly, traction time declined from 192.0 minutes (\u0026plusmn;\u0026thinsp;0.0) in Year 1 to 131.0 minutes (\u0026plusmn;\u0026thinsp;32.3) in Year 2 and 124.5 minutes (\u0026plusmn;\u0026thinsp;36.0) in Year 3, with an overall mean traction time of 132.6 minutes (\u0026plusmn;\u0026thinsp;38.3) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOperative and Traction Times by Year in the Reconstruction Cohort\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Cases\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOperative Time (minutes)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraction Time (minutes)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e284.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e192.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e186.9\u0026thinsp;\u0026plusmn;\u0026thinsp;43.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e131.0\u0026thinsp;\u0026plusmn;\u0026thinsp;32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYear 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e189.6\u0026thinsp;\u0026plusmn;\u0026thinsp;35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e124.5\u0026thinsp;\u0026plusmn;\u0026thinsp;36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e194.6\u0026thinsp;\u0026plusmn;\u0026thinsp;45.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e132.6\u0026thinsp;\u0026plusmn;\u0026thinsp;38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003edata presented as mean \u0026plusmn; standard deviation or mean.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eEffect of Case Volume on Operative and Traction Times\u003c/h2\u003e\n \u003cp\u003eA bivariate Spearman correlation analysis was conducted to assess the relationship between case volume and operative/traction times. In the repair cohort, a significant negative correlation was found between the number of cases performed and operative time (r = -0.424, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), as well as between case volume and traction time (r = -0.435, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). These findings indicate that as the number of cases performed increased, both operative and traction times progressively decreased, supporting the presence of a learning curve.\u003c/p\u003e\n \u003cp\u003eOverall, Loess trends demonstrate a continuous learning effect with no plateau over three years, highlighting the impact of surgical experience and case volume on procedural efficiency.\u003c/p\u003e\n \u003cp\u003eConversely, in the Recon cohort, no significant correlation was identified between case volume and operative time (r = -0.413, p\u0026thinsp;=\u0026thinsp;0.126) or traction time (r = -0.455, p\u0026thinsp;=\u0026thinsp;0.104) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). This suggests that increased case volume alone did not significantly contribute to efficiency gains in reconstruction procedures, potentially due to the increased procedural complexity associated with graft preparation, fixation, and patient-specific variability.\u003c/p\u003e\n \u003cp\u003eCollectively, these results indicate that neither surgical experience nor case volume significantly influenced operative or traction times in reconstruction cases.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eEffect of Years of Surgical Experience on Operative and Traction Times\u003c/h2\u003e\n \u003cp\u003eThe relationship between YOS and procedural efficiency was also assessed. In the repair cohort, a significant negative correlation was found between YOS and operative time (r = -0.424, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), as well as between YOS and traction time (r = -0.434, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). These results demonstrate that as the surgeon\u0026rsquo;s experience increased over time, both operative and traction times significantly declined, reinforcing the concept that surgical proficiency improves progressively with increased clinical exposure and repetition.\u003c/p\u003e\n \u003cp\u003eHowever, in the Recon cohort, no significant correlation was observed between YOS and operative time (r = -0.419, p\u0026thinsp;=\u0026thinsp;0.120) or traction time (r = -0.462, p\u0026thinsp;=\u0026thinsp;0.096) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The absence of a statistically significant relationship in this subgroup suggests that operative efficiency in reconstruction cases may be influenced by additional variables beyond years of surgical experience, such as technical complexity, patient-specific anatomical variations, and differences in graft preparation techniques.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eEffect of Labral Anchor Placement on Operative and Traction Times\u003c/h2\u003e\n \u003cp\u003eTo evaluate whether the number of anchors used in labral repair or reconstruction impacted surgical efficiency, Spearman correlation analyses were conducted. In the repair cohort, no meaningful relationship was observed between the number of anchors placed and operative time (r\u0026thinsp;=\u0026thinsp;0.041, p\u0026thinsp;=\u0026thinsp;0.681) or traction time (r\u0026thinsp;=\u0026thinsp;0.073, p\u0026thinsp;=\u0026thinsp;0.469). Similarly, in the Recon cohort, no significant correlation was found between anchor usage and operative time (r = -0.114, p\u0026thinsp;=\u0026thinsp;0.687) or traction time (r\u0026thinsp;=\u0026thinsp;0.016, p\u0026thinsp;=\u0026thinsp;0.958).\u003c/p\u003e\n \u003cp\u003eThese results indicate that the number of labral anchors utilized does not appear to influence the duration of operative or traction times, suggesting that other procedural factors, such as case complexity, surgical technique, and tissue quality, may play a more substantial role in determining overall efficiency.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates a significant negative correlation between both years of surgical experience and case volume with operative and traction times in acetabular labrum repair, supporting our hypothesis that increased experience contributes to greater procedural efficiency. However, no clear threshold of cases was identified where a plateau in efficiency occurred. Instead, Loess curve analysis revealed ongoing reductions in operative and traction times up to the 3-year mark, with no evidence of plateauing. These findings suggest a sustained learning effect and contrast with prior studies that reported a proficiency plateau after approximately 50 cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our data, based on 117 cases, indicate that continuous exposure and repetition are key to improving efficiency beyond early benchmarks.\u003c/p\u003e \u003cp\u003eThese results align with broader orthopedic literature, where increased surgical experience correlates with improved outcomes across procedures such as total joint and shoulder arthroplasty [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While previous hip arthroscopy studies proposed 30 to 100 cases as thresholds for competency [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], our findings suggest that the learning curve extends further. In a high-volume setting with complex case demands, our data support the idea that operative metrics can continue to improve well beyond previously proposed case volumes.\u003c/p\u003e \u003cp\u003eThe lack of significant correlations in labrum reconstruction cases contrasts with our hypothesis, which anticipated similar reductions in operative and traction times. This discrepancy may reflect the greater technical complexity of reconstruction procedures. Graft selection, preparation, and variability in pathology likely limit the ability to achieve similar time reductions with experience alone.\u003c/p\u003e \u003cp\u003eReducing operative and traction times yields meaningful clinical benefits. Shorter traction times reduce risks such as nerve injury, muscle damage, and prolonged postoperative discomfort related to joint distraction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, shorter operative durations minimize risks of infection and anesthesia-related complications, accelerating recovery and enabling quicker return to activity, an important consideration in athletic populations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Improved surgical efficiency also enhances resource utilization, increases procedural capacity, and may help reduce healthcare costs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study is not without limitations. It reflects the experience of a single surgeon, which controls for variability in surgical technique but limits generalizability. The findings may reflect this surgeon\u0026rsquo;s specific training and operative style. Additionally, the small sample size in the reconstruction cohort limited statistical power, possibly obscuring correlations that might emerge in larger samples. The complexity and variability inherent in labral reconstruction, including graft handling and extent of pathology, may further influence outcomes independently of surgical experience.\u003c/p\u003e \u003cp\u003eThis study was also conducted in a teaching environment, where residents and fellows contributed to key steps, including portal placement and suture management. Trainee involvement may have influenced operative efficiency depending on their experience level. Finally, no universally accepted standard defines the number of cases or years required to achieve proficiency in hip arthroscopy, underscoring the need for ongoing study of the learning curve.\u003c/p\u003e \u003cp\u003eFuture research should validate these findings through multicenter studies that include surgeons with diverse backgrounds and case volumes. Additional analysis is needed to identify factors that influence efficiency in reconstruction procedures\u0026mdash;such as graft type, surgical technique, and pathology complexity. Furthermore, studies should investigate how experience affects other outcomes, including complications, patient-reported measures, and revision rates. Together, these efforts will contribute to optimizing surgical training, procedural performance, and patient safety in hip arthroscopy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the significant role of surgical experience and case volume in reducing operative and traction times in acetabular labrum repair. The findings suggest continued efficiency improvements beyond 100 cases.\u0026nbsp;\u003c/p\u003e"},{"header":"Statements \u0026 Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApproval of this observational, retrospective study was obtained from the ethics committee of the University of Missouri (August 20, 2024/No. 2114846). The procedures used in this study adhere to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient consent statement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA full HIPAA waiver was acquired through the above ethics approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMaradit Kremers H, Schilz SR, Van Houten HK, Herrin J, Koenig KM, Bozic KJ, et al. Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013. J Arthroplasty 2017;32:750\u0026ndash;5. https://doi.org/10.1016/j.arth.2016.09.004.\u003c/li\u003e\n \u003cli\u003eBozic KJ, Chan V, Valone FH, Feeley BT, Vail TP. Trends in Hip Arthroscopy Utilization in the United States. J Arthroplasty 2013;28:140\u0026ndash;3. https://doi.org/10.1016/j.arth.2013.02.039.\u003c/li\u003e\n \u003cli\u003eAyeni OR, Chan K, Al-Asiri J, Chien T, Sprague S, Liew S, et al. Sources and quality of literature addressing femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2013;21:1795. https://doi.org/10.1007/s00167-012-2236-7.\u003c/li\u003e\n \u003cli\u003eMaldonado DR, Chen JW, Walker-Santiago R, Rosinsky PJ, Shapira J, Lall AC, et al. Forget the Greater Trochanter! Hip Joint Access With the 12 O\u0026rsquo;clock Portal in Hip Arthroscopy. Arthrosc Tech 2019;8:e575\u0026ndash;84. https://doi.org/10.1016/j.eats.2019.01.017.\u003c/li\u003e\n \u003cli\u003eHarris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2013;29:589\u0026ndash;95. https://doi.org/10.1016/j.arthro.2012.11.003.\u003c/li\u003e\n \u003cli\u003eBaker P, Jameson S, Critchley R, Reed M, Gregg P, Deehan D. Center and Surgeon Volume Influence the Revision Rate Following Unicondylar Knee Replacement: An Analysis of 23,400 Medial Cemented Unicondylar Knee Replacements. JBJS 2013;95:702. https://doi.org/10.2106/JBJS.L.00520.\u003c/li\u003e\n \u003cli\u003eMalik AT, Jain N, Scharschmidt TJ, Li M, Glassman AH, Khan SN. Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review. J Arthroplasty 2018;33:3329\u0026ndash;42. https://doi.org/10.1016/j.arth.2018.05.040.\u003c/li\u003e\n \u003cli\u003ePrkić A, Vermeulen NP, Kooistra BW, The B, van den Bekerom MPJ, Eygendaal D. Is there a relationship between surgical volume and outcome for total elbow arthroplasty? A systematic review. EFORT Open Rev 2023;8:45\u0026ndash;51. https://doi.org/10.1530/EOR-22-0087.\u003c/li\u003e\n \u003cli\u003eJain N, Pietrobon R, Hocker S, Guller U, Shankar A, Higgins LD. The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty. JBJS 2004;86:496.\u003c/li\u003e\n \u003cli\u003eTesta EJ, Brodeur PG, Lama CJ, Hartnett DA, Painter D, Gil JA, et al. The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures. JAAOS Glob Res Rev 2023;7:e22.00242. https://doi.org/10.5435/JAAOSGlobal-D-22-00242.\u003c/li\u003e\n \u003cli\u003eHoppe DJ, De Sa D, Simunovic N, Bhandari M, Safran MR, Larson CM, et al. The Learning Curve for Hip Arthroscopy: A Systematic Review. Arthrosc J Arthrosc Relat Surg 2014;30:389\u0026ndash;97. https://doi.org/10.1016/j.arthro.2013.11.012.\u003c/li\u003e\n \u003cli\u003eGo CC, Kyin C, Maldonado DR, Domb BG. Surgeon Experience in Hip Arthroscopy Affects Surgical Time, Complication Rate, and Reoperation Rate: A Systematic Review on the Learning Curve. Arthrosc J Arthrosc Relat Surg 2020;36:3092\u0026ndash;105. https://doi.org/10.1016/j.arthro.2020.06.033.\u003c/li\u003e\n \u003cli\u003eMehta N. Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship n.d. https://doi.org/10.1177/0363546517749219.\u003c/li\u003e\n \u003cli\u003eWoodard DR, Richards JA, Knake K, DeFroda S. Patient Positioning for Postless Hip Arthroscopy. Arthrosc Tech 2024;13:102969. https://doi.org/10.1016/j.eats.2024.102969.\u003c/li\u003e\n \u003cli\u003eSouza BGSE, Dani WS, Honda EK, Ricioli W, Guimar\u0026atilde;es RP, Ono NK, et al. Do Complications in Hip Arthroscopy Change With Experience? Arthrosc J Arthrosc Relat Surg 2010;26:1053\u0026ndash;7. https://doi.org/10.1016/j.arthro.2009.12.021.\u003c/li\u003e\n \u003cli\u003eBovonratwet P, Boddapati V, Nwachukwu BU, Bohl DD, Fu MC, Nho SJ. Increased hip arthroscopy operative duration is an independent risk factor for overnight hospital admission. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 2021;29:1385\u0026ndash;91. https://doi.org/10.1007/s00167-020-06170-7.\u003csup\u003e\u003c/sup\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hip arthroscopy, surgical experience, learning curve, operative time, traction time, acetabular labral repair","lastPublishedDoi":"10.21203/rs.3.rs-6422661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6422661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To evaluate the impact of surgical experience, measured by years of practice and case volume, on operative and traction times in hip arthroscopy procedures for acetabular labral repair and reconstruction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective review was conducted of hip arthroscopy cases performed by a single fellowship-trained surgeon between August 16, 2021, and August 16, 2024. Patients included underwent primary hip arthroscopy for acetabular labral repair or reconstruction. Spearman correlation analyses assessed the relationship between years of surgical experience, number of labral anchors used, and operative and traction times. Data were divided into repair and reconstruction cohorts. Statistical significance was set at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 117 cases (102 repairs, 15 reconstructions) in 106 patients (mean age 29.9 years, mean BMI 28.1) were analyzed. In the repair cohort, operative and traction times significantly decreased from 149.1 to 124.7 minutes and 64.0 to 56.1 minutes over three years, respectively. Significant negative correlations were found between both years of experience and case volume with operative (r = -0.424, p\u0026lt;0.0001) and traction times (r = -0.435, p\u0026lt;0.0001). No significant associations were observed in the reconstruction cohort or between anchor number and time measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Surgical experience and increasing case volume significantly reduce operative and traction times in acetabular labrum repair, with improvements continuing beyond the 100-case mark. No such association was observed for more complex labral reconstructions.\u003c/p\u003e","manuscriptTitle":"Hip Arthroscopy Traction Time and Total Operative Time Decreases with Surgical Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 14:09:54","doi":"10.21203/rs.3.rs-6422661/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d6c3133-9b5c-4b1f-a75c-d00e64e0e47e","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-21T19:08:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 14:09:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6422661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6422661","identity":"rs-6422661","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}