Knee Replacement Surgery: Why 1 in 4 Patients Are Dissatisfied and How to Set Realistic Expectations
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By Dr. Jeffrey Peng, MD · Published March 5, 2026 · 6 min read
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Knee replacement surgery — formally known as total knee arthroplasty (TKA) — is one of the most common elective orthopedic procedures performed worldwide. It is generally considered the last resort for patients with end-stage knee osteoarthritis who have exhausted conservative treatments. While many patients experience significant improvement after surgery, the reality is that not everyone walks away satisfied.
A recent prospective cohort study published in Knee Surgery, Sports Traumatology, Arthroscopy found that approximately 1 in 4 patients did not have their expectations met after knee replacement surgery. This raises an important question: what drives dissatisfaction, and how can patients and physicians work together to improve outcomes?
What Do Patients Expect Before Knee Replacement Surgery?
The study by Lützner et al. analyzed data from 352 patients who underwent primary total knee arthroplasty. Before surgery, patients completed a questionnaire consisting of 31 items spanning symptoms, physical function, physical activity, quality of life, coping strategies, and activities of daily living. Each item was rated as mandatory, desirable, or not important for a successful outcome.
The results revealed that patients enter surgery with remarkably high expectations. Six expectations were rated as mandatory by more than 90% of patients: relief of knee pain, improved quality of life, better physical function, implant longevity, increased walking distance, and improved range of motion. An additional 11 expectations were considered mandatory by at least 75% of patients, including climbing stairs, knee stability, physical endurance, muscle strength of the leg, and participation in social life.
In total, 17 of the 31 expectations were marked as mandatory by over three-quarters of patients — underscoring how much patients expect from this procedure. Importantly, patients placed equal weight on knee-specific outcomes and general health-related improvements.
How Satisfied Are Patients After Knee Replacement?
Despite these high expectations, the majority of patients reported positive outcomes at the one-year follow-up. Forty percent of patients had their expectations exceeded, and 34% had their expectations met. That means roughly three out of four patients experienced a favorable result — an encouraging statistic that reflects the effectiveness of knee replacement surgery for many individuals.
However, 26% of patients reported that their outcomes fell short of what they had anticipated. For a major surgical procedure, a one-in-four chance of dissatisfaction is notable. It is worth emphasizing that this does not necessarily reflect poor surgical technique. In my practice, orthopedic surgeons perform knee replacements with exceptional skill and precision. The disconnect more often lies in the gap between expectations and achievable outcomes.
Which Expectations Are Least Likely to Be Met?
The study found that the expectations least likely to be fulfilled were related to physical function and knee-related activities. Specifically, the areas with the highest rates of unmet expectations included physical function, walking distance, climbing stairs, physical activities, physical endurance, longer standing, and preventing secondary impairments. Nearly all of these relate to persistent limitations in physical activity after surgery.
Interestingly, even among the most satisfied group, the same categories — physical function, longer standing, and preventing secondary impairments — still represented the largest areas of unmet expectations. The researchers noted that patients who were not fully satisfied tended to be older, had more comorbidities, demonstrated worse postoperative range of motion, and showed significantly lower patient-reported outcome measures both before and after surgery.
On the other hand, knee pain relief was the expectation most consistently fulfilled across both satisfied and dissatisfied groups. This is a critical finding: knee replacement surgery appears to be highly effective at reducing pain, but improving physical function and activity levels remains a more challenging goal.
How Can You Set Realistic Expectations for Knee Replacement?
Because of these findings, there is a growing emphasis among physicians on helping patients establish realistic expectations before undergoing surgery. One key area of counseling involves knee-intensive activities such as climbing stairs, gardening, dancing, squatting, and playing sports. Patients who expect significant improvement in these areas but do not achieve it are much more likely to report dissatisfaction.
If your primary symptom is pain from knee arthritis, a total knee arthroplasty may be an excellent option. The data strongly supports its effectiveness for achieving meaningful pain relief. However, if your main concern is the limitation of physical function and physical activity rather than pain itself, it is important to have a thorough conversation with your surgeon about what knee replacement can realistically accomplish.
Higher numbers of exceeded and fulfilled mandatory expectations, along with better postoperative range of motion, were significant predictors of patient satisfaction. This suggests that proactive discussions about which expectations are most likely — and least likely — to be met can meaningfully improve the patient experience.
Is Knee Replacement Surgery the Right Choice for You?
Every patient's situation is unique, and this data is not meant to tell anyone whether they should or should not pursue surgery. Rather, it provides a framework for approaching the decision. Here are a few key takeaways to discuss with your physician:
Pain as the primary symptom: If pain is your dominant complaint, knee replacement has a strong track record of delivering significant relief. Pain reduction was the most consistently fulfilled expectation in this study.
Functional limitations as the primary concern: If your main frustration is with limitations in physical activity — stair climbing, prolonged standing, sports — understand that these are the areas where expectations are least likely to be fully met. A candid conversation about realistic functional goals is essential.
The role of overall health: Patients with more comorbidities and worse baseline function tended to report lower satisfaction. Optimizing your overall health before surgery may improve outcomes.
What If You Decide Against Knee Replacement Surgery?
If you are not ready for surgery or decide it may not be the right fit, there are effective nonsurgical treatments that can simultaneously decrease pain and improve function — even for patients with advanced (stage 4) osteoarthritis of the knee.
One of the most often overlooked aspects of knee osteoarthritis treatment is the surrounding musculature. Myofascial trigger points in the quadriceps and gastrocnemius can contribute significantly to pain and dysfunction. Addressing these through targeted therapies can provide meaningful relief.
Additionally, platelet-rich plasma (PRP) injections have shown promising results in reducing symptoms related to knee osteoarthritis. PRP is a regenerative treatment that uses your body's own growth factors to promote healing and reduce inflammation. If you are interested in exploring nonsurgical options, I encourage you to schedule a consultation to discuss what approach may work best for your specific situation.
References
1. Lützner C, Beyer F, David L, Lützner J. Fulfilment of patients' mandatory expectations are crucial for satisfaction: a study amongst 352 patients after total knee arthroplasty (TKA). Knee Surg Sports Traumatol Arthrosc. 2023;31(8):3504-3514. doi:10.1007/s00167-022-07301-y
Medical Disclaimer: This content is for educational purposes only and does not substitute for the medical advice of a physician. Always consult your healthcare provider before beginning any new treatment program. The information presented reflects the opinion of Dr. Jeffrey Peng and does not represent the views of his employers or affiliated hospital systems.
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