The Complex Origins of Expectations in TKA

Expectations have long been recognized as a critical determinant of outcomes in total knee arthroplasty (TKA). Despite advances in implant design and surgical technique, research has shown that up to 1 in 5 patients remains dissatisfied after surgery, often because their expectations were not met1. The study by Mancuso and colleagues provides timely insight into where these expectations originate from and how they intersect with the psychosocial and clinical profiles of patients. This prospective preoperative cohort included 232 patients who completed a validated 19-item expectations survey, the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), and the Positive and Negative Affect Schedule (PANAS). As anticipated, expectations were high: nearly all patients expected pain relief and major functional restoration, and more than half expected complete improvement across most domains. What distinguishes this work is its exploration of the sources of these expectations. Patients reported deriving expectations from their personal surgical history, outcomes observed in their family or peers, conversations with surgeons and other health-care providers, internet information, and even general optimism. Importantly, these sources correlated with measurable factors: patients with better preoperative function expected more improvement; those with less positive affect cited more sources; and those with higher positive affect were more likely to attribute expectations to optimism. Several themes stand out. First, expectations are rarely shaped by the surgeon’s counsel alone. Social networks and online resources exert considerable influence, often in ways that can amplify either optimism or concern. For the practicing surgeon, this underscores the need to ask not only what a patient expects but also where that expectation comes from. Addressing external influences directly—by validating accurate impressions and clarifying misconceptions—may prevent disappointment later. Second, the associations with affective disposition are particularly thought-provoking. Patients who were more influenced by unfavorable outcomes in others had greater negative affect, and those who reported more sources had less positive affect. In contrast, patients who cited personal experiences and optimism had more positive affect. These findings suggest that a brief assessment of the affective state of patients could help to identify those who are the most at risk for an expectation-outcome mismatch. This dimension of psychosocial evaluation is rarely emphasized in arthroplasty practice, yet it may prove as relevant as radiographs or comorbidity scores. Third, the study highlights the importance of language in setting expectations. Patients often frame expectations around daily function—walking, using stairs, recreation, independence—whereas surgeons often think in technical terms, such as range of motion or implant stability. The survey used in the study provides a structured way to shift the discussion toward patient-centered activities and the extent of improvement that is realistic. Prior work by the same group has shown that targeted preoperative education can recalibrate expectations in a measurable way2. The present study reinforces that such strategies are not optional but essential. The work is not without limitations. The single-institution design and relatively well-educated cohort may underrepresent the role of socioeconomic diversity and lower health literacy in influencing patient expectations. The cross-sectional design also precludes causal inference. Nonetheless, the strengths of the analysis—particularly the integration of qualitative and quantitative methods—make this an important contribution to our understanding of patient perspectives. The planned longitudinal follow-up of this cohort will be highly valuable. Linking preoperative expectation sources to postoperative fulfillment could identify modifiable levers for improving satisfaction. In the meantime, the present study reminds us that preoperative counseling must extend beyond procedural details. It must engage with the narratives, experiences, and dispositions of patients. In summary, Mancuso et al. have advanced the conversation by systematically characterizing the origins of patient expectations in TKA. Their findings challenge surgeons to move beyond the technical and into the experiential domain—listening to patients’ sources of information, calibrating expectations with evidence, and framing outcomes in terms that matter to daily life. Doing so is not peripheral to the operation; it is central to delivering on the promise of TKA.