by Kahlenberg in its revision of the literature (88.9%); nevertheless, this must be interpreted carefully because their results are based on a great heterogeneity of studies where out of 208 studies only 27 used “validated” scales.[1]

We attribute the program’s satisfaction with surgery results to three main maneuvers, first the implementation of a multimodal analgesia as proposed by Halawi et al. all patients undergoing joint replacement surgery have a previous consultation with the surgeon where expectations, fears and limitations of the surgery are extensively discussed. One hour before the surgery, 1000 mg of intravenous paracetamol/acetaminophen and 40 mg of intravenous parecoxib are administered, once in the operating room the surgery is performed under sedation and a combined spinal anesthesia using a combination of hyperbaric bupivacaine and morphine for the subarachnoid space and ropivacaine 7.5% for the epidural space, in the case of TKR a series of ultrasonography guided peripheral nerve blocks are performed including femoral and the adductor canal using ropivacaine 7.5% plus clonidine. For both hips and knees before first incision is made, we infiltrate both the subcutaneous and joint space with a combination of xylocaine/epinephrine and morphine with the intent of blocking directly nociceptors before they are stimulated. In the postoperative phase, the peridural catheter is used for continuous administration of ropivacaine 0.15% for 24 h, parecoxcib is continued every 12 h and paracetamol/acetaminophen every 8 h. After discharge, patients are instructed to use acetaminophen/tramadol tablets every 6–8 h as needed for 1 week. The rehabilitation program starts the same day of the surgery and patients are assigned to a specific rehabilitator who is in charge for each individual through hospitalization (2–3 days) and after discharge, patients are seen at least once a week for the 1st month by this personal physiotherapist. In agreement with the surgeon, it is decided when the sessions can be made at home and without further supervision. Although this a social assistance program, patients have access to one of the group physicians at every time for any doubts. Consultations are made at 10 days, then 2 weeks, 6 and 12 weeks, at any point if needed the patient is explored between these intervals, making the doctor–patient relationship a priority probably resulting in better satisfaction scores.[1,10,12]

Because all surgeries were performed by the same orthopedic surgeon, we avoided a possible performance bias. The SAPS and postoperative HHS/KSS were evaluated by the first author who is not part of the reconstruction team and did not participate in any of the surgeries; as such, he is not influenced in the veracity of the results published.

The heterogeneity in the base diagnoses of the patients’ OA and IJD usually involves different age groups. The former being elderly patients while the latter are usually younger. It should be noted that patients with the diagnosis of IJD obtained a satisfaction rate of 100% (95% confidence interval from 86 to 100%) regardless of the joint operated on, and despite having a lower average score on the functional scales pre‐ and post‐operatively than OA patients. These results concur with those found by Minator et al. where after 12 months of surgery, they concluded that satisfaction indices were not different between these groups. Although Minator et al. did not use validated scales to evaluate satisfaction as they only compared the Oxford Knee Score and the Knee Injury and OA Outcome Score, which are not specific satisfaction measurement tools.[13,14]

It was hard to understand our results, as we expected that patients with IJD would have worst satisfaction indices compared to those with OA. This presumption was based on the fact that IJD patients usually have worst functional outcomes, stiffness and more propensity to present with postoperative complications. We thought this should reflect in worst satisfaction indices. Yet in our study they are more satisfied than those with OA. A possible explanation for this result is that patients’ expectations were addressed before surgery, and because of the type of patient our clinic attends to, they usually have severe disease. The severity of their preoperative conditions may have led to a perception of wellness even though their range of motion (ROM) and functional scales were not ideal.[15,16]

For the correct interpretation of this study, it is important to take into account several limitations. Although patients with simple complications such as wound infection, postoperative fever, bleeding, and neural deficit were all included, there were three patients with severe complications that were excluded from this study, this could lead to a bias in the results. When running the statistical analysis giving these three excluded patients, the worst possible outcome of surgery was 91.84 satisfaction rate. There could be an “interviewer” bias, even though satisfaction surveys were answered anonymously; if there was any doubt about the questionnaire, the same researcher was in charge of solving them. Another possible bias is that patients responded what the researcher wanted to hear. Attempts to control these biases were made by explaining the anonymous nature of their responses and that no one but the main researcher and themselves would know the answers. At all times, the importance of the veracity of their responses was emphasized so that this would help the program’s continuous improvement.

The characteristics of the studied population must be analyzed before attempting to extrapolate to other populations. This sample presents a wide dominance of the female gender (91.2%) and patients with an average age of 62.5 years. It is worth mentioning that the average age of our patients is lower than other international records which varies between 69 and 71 years.[17] In a study made by Fang M where their objective was to describe age‐related differences in outcomes among older adults undergoing THR or TKR they found out that compared to younger patients, older THR and TKR recipients were more likely to experience postoperative complications, admission to the intensive care unit and longer hospitalizations, which can possibly be reflected on worst satisfaction indices.[18]

We had a higher prevalence of females undergoing these procedures, compared to a similar paper by Kwon et al., with an incidence of 70.9% of females, it is not illogical to think that the physical demand and expectations of an elder population and mainly females are different from other age groups and gender.[8‐10,19‐23]

Measuring satisfaction remains a great challenge, currently there are only two “truly” validated scales for joint replacement: the SAPS and the KSKSS (non was found for THR) and even this two are far from an ideal scale, as they both failed assessment for content validity due to lack of patient involvement during their development and testing.[11]