A colleague of mine regularly operated on college and professional athletes. No matter what came through the door — the routine scope or the career-threatening tear — he had one line: “We’re going to get you back.” Confident, motivating, and exactly what an injured athlete wants to hear.
A version of that line exists in joint replacement surgery. A patient asks whether they’ll run another marathon, and the easiest answer — the one everyone in the room wants to hear — is “good as new, no restrictions.” We want patients walking in confident, not frightened. Sometimes we believe it ourselves. But a 68-year-old’s knee replacement is not a 20-year-old’s ACL reconstruction, and “good as new” is a promise the operation can’t always keep.
It turns out that gap — between what a patient is led to expect and what surgery actually delivers — is one of the most reliable predictors of whether they’ll call the result a success.
Most of the research discussed here comes from hip and knee replacement, one of the areas of orthopedics in which the relationship between expectations and satisfaction has been studied most extensively. But the underlying challenge is familiar across orthopedics: patients judge success not only by the technical result, but by whether recovery allows them to return to the life they expected.
The satisfaction problem hiding in a success story
Joint replacement is one of medicine's most effective operations. And yet, depending on the study, somewhere between 10 and 20% of knee replacement patients report dissatisfaction — some even when the operation, by every technical and radiographic measure, went well. Hip replacements do somewhat better than knees, but the pattern holds: a well-executed operation does not guarantee a satisfied patient.
When you look at what separates the satisfied patient from the dissatisfied one, whether the patient’s expectations were met emerges as one of the strongest and most consistent predictors. In one large study, patients whose expectations went unfulfilled were roughly ten times more likely to be dissatisfied (Bourne, 2010) — the strongest predictor in that analysis, ahead of pain scores and complications.
I’ve watched this play out in my own practice. Some of the least satisfied patients I’ve cared for had, by every objective measure, excellent results — the imaging looked great, the joint worked the way it should — but the road to recovery was harder, or simply different, than they’d expected. The operation was a success. The experience wasn’t the one they’d been picturing, and that was what stayed with them. I have to own that as their surgeon.
Satisfied with what?
Before going further, it’s worth being precise about a word we use loosely. “Satisfaction” can mean different things: satisfaction with the information and preparation a patient received, satisfaction with the care experience, and satisfaction with the surgical result itself. They aren’t the same, and the evidence treats them differently. Education is most directly positioned to improve the first two. Influencing the third — satisfaction with the outcome — is harder, and it largely depends on whether what happened matched what the patient expected.
And here the research draws an important distinction: the level of expectation is not the same as the fulfillment of expectation. Having high expectations does not necessarily lead to dissatisfaction. What matters is whether those expectations are ultimately met. A synthesis of hip and knee studies found that expectation fulfillment was associated with satisfaction in 93% of studies, whereas expectation level was associated with satisfaction in only half (Hafkamp, 2020).
Dissatisfaction grows in the gap between the recovery patients expect and the recovery they experience.
So does educating patients fix it?
Generic preoperative education has an underwhelming track record. The landmark Cochrane review of education for hip and knee replacement (McDonald, 2014) found little evidence that the usual handouts, classes, and standard videos improved pain, function, or anxiety beyond usual care — and most of those trials didn’t even measure satisfaction with the result. Nor does putting information on a screen guarantee a better result: in a randomized trial of more than 400 knee replacement patients, a supplemental e-learning tool did not improve either expectations or satisfaction at 1 year (Culliton, 2018).
The takeaway isn’t that education doesn’t work — it’s that the medium isn't the active ingredient, and simply making more information available isn't enough. The more important question is whether education helps patients form realistic expectations that remain useful through recovery. The trials designed to do that are the interesting ones.
What actually moved the needle
The trials that did improve satisfaction had something in common. They didn’t just hand patients more information — they set out to actively reshape what patients expected of recovery, and to do it before those expectations had hardened.
In one randomized trial, adding a module on realistic expectations to standard knee replacement education increased the proportion of satisfied patients at more than a year from 65% to 83% (Nam, 2023), with the greatest benefit among patients with the highest central sensitization scores. A second trial found a higher proportion of “very satisfied” patients after expectation-focused education, although the difference was statistically significant in the per-protocol analysis rather than the intention-to-treat analysis (Tolk, 2021). Together, the trials suggest that expectation-focused education can improve satisfaction, but the effect is neither automatic nor uniform.
The findings are promising but not definitive, and a later follow-up of one trial found that the advantage was no longer statistically significant at two years (Lee, 2025). A single conversation before surgery may not be enough to carry a months-long recovery. And “calibrating expectations” does not mean talking patients down. The goal isn’t a gloomier patient; it’s an accurately prepared one — confident about the improvement that’s genuinely likely, and clear-eyed about the expected results and how long recovery may take.
What this asks of patient education
If expectation fulfillment is one of the strongest levers, patient education should address it — and most education doesn’t. These findings suggest several principles for better patient education.
It must be specific. Generic material about “a knee replacement” cannot calibrate expectations for the protocol, recovery timeline, and restrictions a patient’s own care team will use. Patients aren’t preparing for a procedure in the abstract; they’re preparing for the care their team will actually deliver.
It must speak to the outcomes patients use to judge success — pain over time, sleep, driving, return to work, the activities that may stay difficult — not just the clinical checklist.
It must be durable. Patients do not reliably retain everything said in a consultation, and recall fades over time. Education that appears once, before surgery, and never again is fighting the way memory works.
And it has to span the episode, not stop at the operating room door. Expectations are fulfilled — or not — over the weeks and months of recovery at home, which is exactly where preparation tends to thin out.
Why this matters now
Patient experience is no longer a soft metric. HCAHPS captures how patients experience communication with clinicians, staff responsiveness, care coordination, medication discussions, discharge preparation, information about symptoms, the hospital environment, and the hospital overall. Newer episode-based models, such as CJR-X and TEAMS, extend that emphasis by incorporating patient-reported outcomes. These measures are not identical to satisfaction with the surgical result, but they demonstrate a broader shift: what patients understand, experience, and report now carries operational and financial weight.
The opportunity for orthopedic education
OrthoSkool is intentional about giving every patient a consistent, complete, optimistic yet realistic picture of preparation, surgery, and recovery. We prepare patients not just for the procedure, but for how their own care team delivers it and what recovery is likely to ask of them. Of all the levers that influence whether a patient walks away satisfied, honest preparation may be one of the most underused.
Selected references
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57–63.
Culliton SE, Bryant DM, MacDonald SJ, Hibbert KM, Chesworth BM. Effect of an e-Learning Tool on Expectations and Satisfaction Following Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty. 2018;33(7):2153–2158.
Hafkamp FJ, Gosens T, de Vries J, den Oudsten BL. Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients. EFORT Open Rev. 2020;5(4):226–240.
Hamilton DF, Lane JV, Gaston P, et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open. 2013;3:e002525.
Lee SH, Yoo HJ, Nam HS, Ho JPY, Lee YS. The preoperative education on realistic expectations does not continually improve patients’ satisfaction after total knee arthroplasty? A randomized controlled trial with serial assessment. Knee Surg Sports Traumatol Arthrosc. 2025;33(11):3853–3865.
McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev. 2014;(5):CD003526.
Nam HS, Yoo HJ, Ho JPY, Kim YB, Lee YS. Preoperative education on realistic expectations improves the satisfaction of patients with central sensitization after total knee arthroplasty: a randomized-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2023;31(11):4705–4715.
Tolk JJ, Janssen RPA, Haanstra TM, van der Steen MC, Bierma-Zeinstra SMA, Reijman M. The influence of expectation modification in knee arthroplasty on satisfaction of patients: the EKSPECT randomized controlled trial. Bone Joint J. 2021;103-B(4):619–626.
Centers for Medicare & Medicaid Services. Hospital CAHPS (HCAHPS). Updated April 21, 2025. https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/hospital-cahps-hcahps.
Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Expanded (CJR-X) Model. https://www.cms.gov/priorities/innovation/innovation-models/cjr-x.
