One hundred seventy-two patients with advanced knee osteoarthritis scheduled for total knee arthroplasty were randomized to receive either standard preoperative education (n=85) or standard education plus an additional module on realistic expectations (n=83). The primary outcome was patient satisfaction. Secondary outcomes included SF-36 scores, WOMAC domains (pain, stiffness, function), crepitus score, and range of motion, assessed at 3 months, 6 months, and more than 1 year. At >1 year, 83.3% of patients in the intervention group were satisfied compared with 65.0% in the control group. The intervention group also showed better WOMAC pain and improved SF-36 PCS and MCS and WOMAC stiffness at 6 months. The subgroup with high central sensitization inventory scores had particularly greater benefit from expectation education. Overall, the results revealed that thorough preoperative education on realistic expectations increased long-term satisfaction, especially among patients with central sensitization. These findings suggest expectation management should be integrated into TKA preparation.