Accessibility Tools
Hide

The Evidence

Dr Dean Olsen, Orthopedic Surgeon, Burnsville Dakota County, Shakopee Scott County, Bloomington Hennepin County, MN >> The Quiet Knee Protocol >> The Evidence

How Often Are Patients Unhappy After a Knee Replacement?

An honest look at the published data — including the parts that complicate the picture.

This page exists because I quote a dissatisfaction rate elsewhere on this site, and you deserve to see where the number comes from — including the parts that cut against me.

The short answer

For decades, the standard figure in the orthopedic literature has been that 15–20% of patients are dissatisfied after a total knee replacement. That is the number most surgeons were taught, and it is still widely quoted.

More recent evidence suggests it is too high. The best current estimates put the contemporary rate closer to 10–13%, depending on when you ask and how dissatisfaction is defined.

I could quote the older, larger number and let my own results look better by comparison. I would rather show you both, and let the 3% stand against the harder benchmark.

Historical benchmark: 15–20% dissatisfied
Best current evidence: ~10% (7.3% excluding complications)
My rate using the Quiet Knee Protocol: ~3%

Historical versus updated estimates

The widely quoted ~20% figure comes from earlier systematic reviews and became a longstanding benchmark in the orthopedic literature.1,2

A 2023 systematic review by DeFrance and Scuderi re-examined it directly and found the average dissatisfaction rate was 10% — or 7.3% when complications are excluded — concluding that the 20% figure likely overestimates current dissatisfaction.3 A 2025 meta-analysis of more than 27,000 patients found a dissatisfaction rate of 10.2%.4

At longer follow-up the number drifts upward. A large U.S. multicenter study (the FORCE-TJR consortium, 4,402 patients across 23 states) reported 12.7% dissatisfaction at five years.5 A 2026 study from the same consortium found 84% of patients satisfied at one year — about 16% dissatisfied — though notably, only 64% met the CMS-defined threshold for surgical "success."6

That last finding is worth sitting with: satisfaction and success are not the same thing. A patient can be happy with a knee that has not, by objective measure, succeeded — and the reverse.

What predicts dissatisfaction

Across studies, the most consistently identified predictors are:

  • Persistent pain and functional limitation — the two reasons patients themselves cite most often7
  • Younger age (under 65), higher BMI, and lower income3,5,8
  • Depression, anxiety, and pain catastrophizing3,4
  • Milder arthritis at the time of surgery — a lower Kellgren-Lawrence grade3,4
  • Non-White race3,5
  • Concurrent back pain, or pain in other joints of the leg5,9
  • Unmet preoperative expectations3,2

The ACR Appropriateness Criteria notes that 10–30% of patients report ongoing pain or dissatisfaction, which reflects how much the answer depends on what you measure.10

Why this matters for your surgery

Two of the strongest predictors on that list — persistent pain and unmet expectations — are precisely what the Quiet Knee Protocol is built to address. The pain protocol targets the first. Pages like this one target the second.

Improved preoperative counseling, optimizing what can be optimized (mental health, BMI), and setting expectations honestly are the strategies shown to reduce dissatisfaction.3,8 That is a large part of why this section of the website exists at all.

My own dissatisfaction rate using this protocol is approximately 3%. That is my personal experience with my own patients — not a published trial, not a controlled comparison, and not a promise of what will happen to you.

It is below the historical 15–20% figure. It is also below the more conservative contemporary estimate of roughly 10%. I think the second comparison is the one that matters.

References

  1. Price AJ, Alvand A, Troelsen A, et al. Knee Replacement. Lancet. 2018;392(10158):1672-1682.
  2. Gunaratne R, Pratt DN, Banda J, et al. Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature. J Arthroplasty. 2017;32(12):3854-3860.
  3. DeFrance MJ, Scuderi GR. Are 20% of Patients Actually Dissatisfied Following Total Knee Arthroplasty? A Systematic Review of the Literature. J Arthroplasty. 2023;38(3):594-599.
  4. De C, Tahir M, Pierce T, Awasthi P, Fonseca PC. Why Are Patients Without Identifiable Etiology of Failure Dissatisfied Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Knee Surg. 2025.
  5. Ayers DC, Yousef M, Zheng H, Yang W, Franklin PD. The Prevalence and Predictors of Patient Dissatisfaction 5-Years Following Primary Total Knee Arthroplasty. J Arthroplasty. 2022;37(6S):S121-S128.
  6. Zheng H, Ash AS, Liu SH, et al. Satisfied but Failed: Patient Satisfaction Compared With Total Knee Arthroplasty Success Defined by the U.S. Centers for Medicare & Medicaid Services. J Bone Joint Surg Am. 2026;108(10):721-728.
  7. Halawi MJ, Jongbloed W, Baron S, et al. Patient Dissatisfaction After Primary Total Joint Arthroplasty: The Patient Perspective. J Arthroplasty. 2019;34(6):1093-1096.
  8. Strahl A, Delsmann MM, Simon A, et al. A Clinical Risk Score Enables Early Prediction of Dissatisfaction 1 Year After Total Knee Arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2025;33(1):252-264.
  9. Rissolio L, Sabatini L, Risitano S, et al. Is It the Surgeon, the Patient, or the Device? J Clin Med. 2021;10(12):2599.
  10. Walker EA, Fox MG, Blankenbaker DG, et al. ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty: 2023 Update. J Am Coll Radiol. 2023;20(11S):S433-S454.
  • TRIA
  • St Francis
  • Microport