What Is a Good Outcome? Managing Expectations

Part of The Joint Replacement Guide — Phase 5: Recovery and Rehabilitation · Article 36 of 44 · Hip & Knee

Key Points

  • Most patients report meaningful improvement after hip or knee replacement, but no operation can guarantee complete pain relief or a joint that feels entirely natural.
  • Improvement, satisfaction, implant survival and a technically successful operation describe different aspects of the outcome.
  • Patient-Reported Outcome Measures (PROMs) assess pain and function from the patient’s perspective, but no questionnaire can define success for every individual.
  • Outcomes reported after hip replacement are, on average, more consistently favourable than those reported after knee replacement.
  • A useful preoperative discussion identifies the activities that matter to you and considers how realistic each goal is in your individual circumstances.

What Does “Successful” Mean?

There is no single definition of a successful joint replacement.

From a surgical perspective, success may include a well-positioned, stable implant without infection, fracture or another major complication. From a patient’s perspective, success is more likely to mean less pain, better sleep, improved independence and being able to return to activities that matter.

These perspectives usually overlap, but not always. An implant can appear sound on an X-ray while the patient still has pain or functional limitations. Conversely, someone may have some residual symptoms but still consider the operation highly worthwhile because their overall quality of life has improved substantially.

A good outcome should therefore be judged using both clinical assessment and the patient’s own experience.

What the National Data Shows

The NHS in England collects questionnaires before and after NHS-funded hip and knee replacements. Among respondents in the final 2023/24 data:

  • 84.2% of hip replacement patients felt “much better” and another 10.0% felt “a little better”
  • 73.6% of knee replacement patients felt “much better” and another 15.7% felt “a little better.”[1]

These figures are reassuring, but they are population averages rather than a personal prediction. Not every eligible patient completes both questionnaires, and the figures do not capture every feature of recovery or explain why an individual patient may have a different result.

They also show an important distinction: saying that a patient feels “better” is not the same as saying that the joint is perfect, completely pain-free or entirely forgotten.

Pain Relief and Joint Awareness

Many patients obtain substantial pain relief, and some become largely unaware of the replaced joint during ordinary activities. Others continue to notice stiffness, aching, clicking, numbness around the scar or discomfort with particular movements.

Residual awareness is especially common after knee replacement. It does not automatically mean that the implant has failed, although new, severe or worsening symptoms should still be assessed.

Complete pain relief is possible, but it cannot be promised. Equally, it would be too pessimistic to suggest that some pain is inevitable for everyone. The appropriate expectation is a meaningful overall improvement, with the final degree of relief varying between individuals.

Hip and Knee Outcomes Are Not Identical

Population data generally shows greater average improvement and higher satisfaction after hip replacement than after knee replacement.[1] Knee replacement nevertheless produces worthwhile improvement for most patients.

The reasons for this difference are likely to be multifactorial. They may include the complexity of knee movement, soft-tissue balance, preoperative symptoms, residual pain and differences in what patients expect from each procedure. It should not be reduced to one simple anatomical explanation or assumed to reflect poorer surgical quality.

Published knee satisfaction figures also vary according to the questionnaire, timing and definition used. The often-repeated statement that “one in five” knee replacement patients is dissatisfied should therefore be treated as an approximate historical figure rather than a fixed modern rate. A more recent systematic review reported an average dissatisfaction rate of approximately 10%, while acknowledging considerable variation between studies.[2]

What PROMs Measure

Patient-Reported Outcome Measures are questionnaires completed by patients rather than clinicians. In England, the national PROMs programme uses:

  • the Oxford Hip Score
  • the Oxford Knee Score
  • the EQ-5D, which considers broader health and quality of life.

The Oxford scores contain 12 questions about pain and everyday function. Scores are collected before surgery and at least six months afterwards, allowing health improvement to be examined from the patient’s perspective.[3]

PROMs are useful for:

  • measuring change over time
  • comparing outcomes across large groups
  • supporting quality improvement
  • helping structure an individual clinical conversation.

They also have limitations. A single total score may not capture the one activity that matters most to you, and patients with the same score may have quite different priorities. PROMs should support clinical assessment and discussion rather than replace them.

Expectations and Satisfaction

Satisfaction partly reflects the relationship between what a person hoped surgery would achieve and what they subsequently experience. It is therefore sensible to discuss likely benefits, limitations, risks and recovery before deciding on surgery.

However, the research is more nuanced than saying that “realistic expectations cause better outcomes.” A 2024 systematic review found possible associations between preoperative expectations and some later measures of pain or function, but most included studies had a high risk of bias and the relationship with overall satisfaction remained uncertain.[4]

What is more consistently associated with satisfaction is whether important expectations are eventually met.[5] That does not mean patients should simply lower their hopes. It means expectations should be made:

  • specific — what exactly do you want to improve?
  • individualised — is that goal realistic for your health and starting function?
  • informed — what are the likely benefits, limitations and uncertainties?
  • shared — does your clinical team understand which outcomes matter most to you?

Good counselling is intended to support an informed choice, not to persuade patients to accept a poor result.

Defining Your Own Good Outcome

Before surgery, it can help to identify a small number of personal goals, such as:

  • sleeping with less pain
  • walking to the shops
  • managing stairs more confidently
  • returning to work
  • playing golf
  • cycling or swimming
  • reducing reliance on pain medication
  • looking after yourself independently.

Your surgeon can then discuss which goals are reasonably likely, which remain uncertain and which may be unrealistic or unsuitable after joint replacement.

For many people, a good outcome means substantial pain reduction and worthwhile improvement in daily life—not necessarily the complete disappearance of every symptom or a return to every previous activity.

Recovery Takes Time

Outcome depends partly on when it is measured. Pain, swelling, strength and confidence continue to change for months after surgery, particularly following knee replacement.

An early plateau or difficult week does not establish the final result. At the same time, persistent or worsening problems should not simply be dismissed as requiring more time. If recovery is not following the expected course, clinical review can identify treatable causes and provide additional support.

If the Outcome Is Not What You Expected

Ongoing pain or dissatisfaction does not mean that the patient has failed at rehabilitation, nor does it automatically mean that the operation was performed incorrectly. Possible contributors include:

  • infection, loosening, instability or another implant-related problem
  • stiffness or soft-tissue pain
  • pain referred from the back or another joint
  • nerve-related pain
  • sensitisation associated with longstanding pain
  • other health conditions
  • a mismatch between the improvement achieved and the activities the patient hoped to regain.

Persistent symptoms deserve careful assessment rather than blame. Sometimes a specific treatable cause is found; in other cases, management may focus on rehabilitation, pain management and improving function even when further surgery is not appropriate.

In More Depth

A genuinely good outcome is broader than a normal X-ray, a high questionnaire score or a satisfied response on a survey. It combines implant safety, symptom improvement, function and progress towards the patient’s own informed goals.

Population data is valuable because it describes what happens to large groups. It cannot guarantee what will happen to one person. The most legally and clinically sound discussion therefore combines national evidence with an individual assessment and acknowledges both the high likelihood of improvement and the possibility of residual symptoms or disappointment.

This article provides general information and does not replace individual clinical advice. Your surgeon can discuss what outcomes are reasonably achievable in your particular circumstances.

References

  1. NHS England. Patient Reported Outcome Measures (PROMs) in England: final 2023/24 data. Published 13 February 2025. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/patient-reported-outcome-measures-proms/final-2023-24-data
  2. DeFrance MJ, Scuderi GR. Are 20% of patients actually dissatisfied following total knee arthroplasty? A systematic review of the literature. Journal of Arthroplasty. 2023;38(3):594–599. doi: 10.1016/j.arth.2022.10.011
  3. NHS England. A guide to PROMs methodology. Published 13 June 2023. Available at: https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/patient-reported-outcome-measures-proms/a-guide-to-proms-methodology
  4. Mooiweer Y, Roling L, Vugrin M, Ansmann L, Stevens M, Seeber GH. Influence of patients’ preoperative expectations on postoperative outcomes after total knee or hip arthroplasty: a systematic review. EFORT Open Reviews. 2024;9(2):107–118. doi: 10.1530/EOR-23-0087
  5. Haanstra TM, van den Berg T, Ostelo RWJG, et al. Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients. EFORT Open Reviews. 2020;5(4):226–240. doi: 10.1302/2058-5241.5.190015

← Back to the Joint Replacement Guide · Previous: Returning to Sport and Activity · Next: Medications and Perioperative Balance