Revisiting the fundamentals: Survivorship is not satisfaction – Revisiting a landmark paper in knee arthroplasty

Background: Total knee arthroplasty (TKA) is widely regarded as a highly successful procedure based on excellent implant survivorship and low revision rates. However, the landmark study by Bourne et al . (2010) highlighted a critical disconnect between objective surgical success and patient satisfaction, reporting that a substantial proportion of patients remain dissatisfied despite well-functioning implants. Purpose: The purpose of this study was to revisit this seminal work and evaluate its continued relevance in contemporary arthroplasty practice, with emphasis on evolving determinants of patient satisfaction and contextual factors influencing outcomes. Methods: This narrative revisitation integrates the original findings of Bourne et al . with contemporary evidence on patient-reported outcome measures (PROMs), psychological determinants, alignment philosophies, and culturally specific functional expectations. Results: Bourne et al . demonstrated that nearly 19% of patients were dissatisfied or neutral following TKA, with unmet expectations identified as the strongest predictor of dissatisfaction, outweighing implant and surgical variables. Subsequent research has consistently validated these findings and further identified psychological factors, pain perception, and functional variability as key contributors. Advances in PROMs, including the Forgotten Joint Score, and the emergence of digital and artificial intelligence-driven assessments have improved outcome measurement but have not eliminated the persistent dissatisfaction plateau. In addition, regional and cultural differences, particularly in Asian and Indian populations, introduce unique functional expectations such as squatting and kneeling, which are often inadequately captured in conventional outcome tools. Conclusion: The central message remains unchanged: survivorship is not satisfaction. Contemporary arthroplasty must adopt a patient-centered approach that aligns surgical success with individual expectations, cultural context, and lived functional experience.