Preoperative Expectations Associated With Postoperative Dissatisfaction After Total Knee Arthroplasty

A Cohort Study

Hassan M. K. Ghomrawi, PhD, MPH; Lily (Yuo-yu) Lee, MS; Benedict U. Nwachukwu, MD, MBA; Deeptee Jain, MD, MPH; Timothy Wright, PhD; Douglas Padgett, MD; Kevin J. Bozic, MD, MBA; Stephen Lyman, PhD


J Am Acad Orthop Surg. 2020;28(4):e145-e150. 

In This Article

Abstract and Introduction


Introduction: Unfulfilled expectations, assessed postoperatively, have been consistently associated with dissatisfaction after total knee arthroplasty (TKA). However, identifying these expectations preoperatively has been a challenge. We aimed at identifying specific expectations that are most likely to affect postoperative dissatisfaction.

Methods:We included all patients in our institutional registry with a body mass index of <40 kg/m2 who underwent primary unilateral TKA and had a minimum 2-year follow-up. Preoperatively, patients completed the 19-item Hospital for Special Surgery Expectations Survey, Short Form-12, Knee Injury and Osteoarthritis Outcomes Score and EuroQol 5-D. Two years postoperatively, patients reported their dissatisfaction on five domains. We estimated logistic regression models to identify the expectation items associated with each domain.

Results: A total of 2,279 TKA patients (mean age: 65.3 ± 9.2 years; mean body mass index: 30.2 ± 5.9 kg/m2) met our inclusion/exclusion criteria. The association between expectations and dissatisfaction was domain specific, that is, subsets of 4 to 5 items were markedly associated with each dissatisfaction domain, and these expectations differed depending on the dissatisfaction domain examined. Of those, expectations predicting dissatisfaction on multiple domains included kneeling ability and leg straightening and participation in recreation and sports.

Discussion: We identified a subset of expectations most likely to affect dissatisfaction after TKA. Our findings should inform preoperative patient education approaches on those expectations to realistically orient patient expectations and increase satisfaction.

Level of Evidence: Level II


Total knee arthroplasty (TKA) is a clinically successful and cost-effective surgical procedure for the management of chronic knee osteoarthritis. Yet, numerous reports have shown that between 10% and 20% of patients who undergo TKA are dissatisfied with the outcome of the procedure.[1] With the projected multi-fold increase in the number of surgeries performed over the next 2 decades,[2] the number of dissatisfied patients is also likely to increase substantially, and reports show that unsatisfied patients may be litigious.[3] Therefore, it is important to understand the drivers of this dissatisfaction and to address them as early as possible.

Dissatisfaction after surgery is not always tied to the technical success of the operation. In one recent study, Nam et al[4] found no relationship between advances in prosthesis design and reduction in patient dissatisfaction. Yet, growing evidence suggests that dissatisfaction is tied to patients' expectations being unmet. A number of studies have shown that unmet expectations, assessed postoperatively, were by far the strongest predictor of dissatisfaction, even in technically sound procedures.[1,5–20] These studies highlight the importance of meeting patient expectations, but the findings are of little clinical value because both unmet expectations and satisfaction were assessed postoperatively.

Being able to identify these expectations preoperatively provides the opportunity to intervene to realistically set expectations. The association between preoperative expectations and postoperative satisfaction has been explored in multiple studies of total joint arthroplasty patients,[5,6,9,21–33] yet the findings of these studies are inconsistent and therefore provide little guidance to clinicians. Moreover, although previous studies have identified a large number of expectations that TKA patients have before surgery, none has explored the relative importance of these expectations to postoperative dissatisfaction. Identifying these expectations preoperatively and targeting them with preoperative guidance and education may reduce dissatisfaction because previous evidence from a randomized clinical trial has shown that educational interventions can change preoperative expectations.[34] In another study, patients' expectations assessed after the preoperative educational class were more aligned with those of their surgeon.[35] Therefore, this study aimed at exploring 19 validated TKA expectations in a large cohort of patient and identifying the expectations that most critically affect dissatisfaction among patients undergoing TKA.