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Background: Patient education in connection with hip replacement is intended to prepare patients for surgery, discharge and postoperative recovery. Patients experience symptoms and emotions due to disease or upcoming surgery which can affect how their knowledge expectations are fulfilled. Objectives: To describe the differences between received and expected knowledge in patients undergoing elective hip replacement in three Nordic countries, and to analyse how these differences are related to patients' characteristics, preoperative symptoms and emotions. Design: A descriptive, prospective survey with two data collection points; before admission and at hospital discharge after surgery. Settings: Two Finnish, three Icelandic and two Swedish hospitals. Participants: The population consisted of patients on a waiting list for hip replacement. Of the consecutively included patients, 320 answered questionnaires both before admission and at discharge and were included in the study. The mean age of the patients was 64 years, and 55% were women. Methods: Structured questionnaires were used; the knowledge expectations of hospital patients scale and self-reported scales for symptoms and emotions before admission and received knowledge of hospital patients scale at discharge. Fulfilment of knowledge expectation was assessed by calculating the difference between received and expected knowledge with a paired sample t-test. A multiple stepwise regression model was used to explain the variance of fulfilled knowledge expectations. Results: Patients expected more knowledge than they received (p < 0.001) and 77% of them had unfulfilled knowledge expectations. Patients with a higher level of education were more likely to have unfulfilled knowledge expectations. A higher level of education was also related to a greater difference between received and expected knowledge. The difference was more correlated with patients' emotions than their symptoms. A depressive state was the major predictor of the variance in the difference between received and expected knowledge. Conclusions: In order to better support patients by education it is necessary to assess their emotional state, educational level and knowledge expectations before surgery [ABSTRACT FROM AUTHOR]