Equity in waiting times for major joint arthroplasty.

OBJECTIVE: To ascertain whether waiting lists are managed in an equitable fashion in a universal health system by examining demographic, socioeconomic and clinical factors, along with 2 health systems variables. DESIGN: A prospective survey by questionnaire. SETTING: The Capital Health Region of Edmonton, Alta. PATIENTS AND METHODS: A cohort of 553 patients, who were waiting for either total hip or total knee replacement surgery, seen between Dec. 18, 1995, and Jan. 24, 1997. INTERVENTIONS: A home visit was made when the patient was first placed on the waiting list and again just before surgery to complete the questionnaires. The Western Ontario and McMaster Universities (WOMAC) instrument and the Medication Quantification Score were administered at the time the patient was placed on the waiting list. MAIN OUTCOME MEASURE: The length of waiting time, defined as the date the patient was put on the waiting list to the date the patient was operated on. RESULTS: There were no biases in waiting time with respect to age, gender, education or work status. Although pain and function were not related to waiting time, multivariate analyses found that marital status, primary language, body mass index, pain medication use and the size of the surgeons' major joint replacement practice determined waiting time for surgery. However, this model explained only 10% of the variance in waiting time. CONCLUSION: Waiting lists were managed unfairly in terms of clinical equity (clinical severity) but managed fairly in terms of social equity.     

The impact of health status on waiting time for major joint arthroplasty

This study was conducted to determine the impact of health status on waiting time for major joint arthroplasty in a universal publicly funded health system. Data were collected prospectively from a cohort of 553 patients waiting for total hip or total knee arthroplasty. The WOMAC and SF-36 health status instruments were administered at the time the patient was placed on the waiting list. The outcome measure was length of waiting time. Multivariate analyses found increased body mass index and decreased social function as the only determinants of waiting time. This model explained only 4% of the variance in waiting time. The association between health status and waiting time for arthroplasties appears to be small. These findings suggest that major joint arthroplasty is not prioritized on the basis of burden of illness.     

Changes in pain, stiffness and physical function in patients with osteoarthritis waiting for hip or knee joint replacement surgery

OBJECTIVE: Little has been reported on changes in health status in patients with osteoarthritis (OA) while waiting for hip or knee replacement surgery. In this study we assessed (1) changes in self-reported pain, stiffness and physical function in patients with OA of the hip or knee, from the decision to undergo surgery to 14 days prior to surgery, and (2) the determinants of these changes. METHODS: Among 353 baseline respondents, 170 waited >30 days for surgery, completed the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before surgery and were included in the analysis of changes; 120 with OA of the hip and 50 of the knee. We analyzed changes in WOMAC scores using the paired t test and determinants of the changes using multiple linear regression. RESULTS: Patients with OA of the hip did not change on any WOMAC scale before surgery. Knee patients deteriorated with time on the WOMAC stiffness and total scales, but not on the pain or physical function subscales. In both patient categories, higher baseline WOMAC scores were associated with smaller changes on all subscales and the total score, and female sex was associated with deterioration on the pain subscale. CONCLUSIONS: Patients with OA of the hip reported no change in pain, stiffness or physical function while waiting for joint replacement surgery, whereas patients with OA of the knee deteriorated on the stiffness and total scales of the WOMAC. This suggests a difference in patient selection, referral pattern or disease development between the patient categories.     

Single-item satisfaction scores mask large variations in pain,function and joint awareness in patients following total joint arthroplasty

European Journal of Orthopaedic Surgery & Traumatology - Single-item questions assessing patient satisfaction following total hip or knee arthroplasty (THA/TKA) provide immediate and...     

疼痛对人工膝关节表面置换术后功能康复的影响

目的：分析疼痛对人工膝关节表面置换术后膝关节功能康复水平的影响。方法术后3个月随访初次接受单侧膝关节表面置换手术的骨关节炎患者82例,根据患者出院后的回顾性VAS评分分为无～轻度疼痛组和中～重度疼痛组,测量患者大腿周径,与术前和术后5 d大腿周径进行对比,对比组间大腿周径增幅差值。测量膝关节屈伸活动度,与术后5d活动度对比,计算组间关节活动度增量差距。测量股四头肌肌力,与术后5d股四头肌肌力进行对比,计算组间股四头肌肌力增幅差异。测量30 m行走时间,了解疼痛程度对术后早期行走速度的影响。结果无痛～轻度疼痛组术后3个月大腿周径较术前增幅（0.94±0.95）％,显著低于中度～重度疼痛组[较术前增幅（8.03±1.99）％,P＜0.01]。术后5 d两组膝关节活动度相当,无痛～轻度疼痛组术后3个月屈曲活动度增至（110.93°±12.54°）,中度～重度疼痛组则减至（82.18°±12.03°）（P＜0.01）。无痛～微痛组术后3个月股四头肌肌力较术后5 d增幅（117.21±22.45）％,显著高于中度～重度疼痛组[增幅（33.78±11.71）％, P ＜0.01]。术后3个月无痛～轻度疼痛组30 m 平地行走耗时（21.01±4.86）s,显著低于中度～重度疼痛组[耗时（29.39±6.29）s,P＜0.01]。结论疼痛显著影响人工膝关节表面置换术后膝关节功能的康复水平,导致关节肿胀消退迟缓、肌力恢复延迟、关节活动度减低和行走缓慢。     

Multimodal pain management after total joint arthroplasty

Adequate postoperative pain control in patients who have undergone total joint arthroplasty allows faster rehabilitation and reduces the rate of postoperative complications. Multimodal pain management involves the introduction of adjunctive pain control methods in an attempt to control pain with less reliance on opioids and fewer side effects. Current research suggests that traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the associated cyclooxygenase type-2 (COX-2) inhibitors improve pain control in most cases. Nearly all multimodal pain management modalities have a safe side-effect profile when they are added to existing methods. The exception is the administration of DepoDur (extended-release epidural morphine) to elderly or respiratory-compromised patients because of a potential for hypoxia and cardiopulmonary events.     

Factors predisposing to thrombosis after major joint arthroplasty

BACKGROUND Total joint arthroplasty is one of the most common options for end stage osteoarthritis of major joints. However, we must take into account that thrombosis after hip/knee arthroplasty may be related to mutations in genes encoding for blood coagulation factors and immune reactions to anticoagulants [heparininduced thrombocytopenia(HIT)/thrombosis]. Identifying and characterizing genetic risk should help to develop diagnostic strategies or modify anticoagulant options in the search for etiological mechanisms that cause thrombophilia following major orthopedic surgery.AIM To evaluate the impact of patients' coagulation profiles and to study specific pharmacologic factors in the development of post-arthroplasty thrombosis.METHODS In 212(51 male and 161 female) patients that underwent primary total hip arthroplasty(100) or total knee arthroplasty(112) due to osteoarthritis during a period of 1 year, platelet counts and anti-platelet factor 4(PF4)/heparin antibodies were evaluated pre/postoperatively, and antithrombin III, methylenetetrahydrofolate reductase, factor V and prothrombin gene mutations were evaluated preoperatively. In a minimum follow-up of 3 years, 196 patients receiving either low-molecular-weight heparins(173) or fondaparinux(23) were monitored for the development of thrombocytopenia, anti-PF4/heparinantibodies, HIT, and thrombosis.RESULTS Of 196 patients, 32 developed thrombocytopenia(nonsignificant correlation between anticoagulant type and thrombocytopenia, P = 0134.) and 18 developed anti-PF4/heparin antibodies(12/173 for low-molecular-weight heparins and 6/23 for fondaparinux; significant correlation between anticoagulant type and appearance of antibodies, P = 0.005). Odds of antibody emergence: 8.2% greater in patients receiving fondaparinux than low-molecular-weight heparins. Gene mutations in factor II or V(two heterozygotes for both factor V and II) were identified in 15 of 196 patients. Abnormal low protein C and/or S levels were found in 3 of 196(1.5%) patients, while all patients had normal levels of von Willebrand factor, lupus anticoagulant, and antithrombin III. Four patients developed HIT(insignificant correlation between thrombocytopenia and antibodies) and five developed thrombosis(two had positive antibodies and two were heterozygotes for both factor II V mutations). Thrombosis was not significantly correlated to platelet counts or HIT. The correlation of thrombosis to antibodies, factor II, factor V was P = 0.076, P = 0.043, P = 0.013, respectively.CONCLUSION Screening of coagulation profile, instead of platelet monitoring, is probably the safest way to minimize the risk of post-arthroplasty thrombosis. In addition, fondaparinux can lead to the formation of anti-PF4/heparin antibodies or HIT.     

人工膝关节置换术后关节线改变的临床研究

目的观察选择保留后交叉韧带的膝关节表面置换术与不保留周围韧带的旋转膝关节置换术后关节线的改变,分析其发生原因及预防方法。方法分别选择保留后交叉韧带的膝关节表面置换术患者25例,不保留周围韧带的旋转膝关节置换患者25例,手术前、后均拍摄膝关节非负重侧位片。术前的侧位片上,平行于胫骨平台负重关节面作一条直线,测量它到胫骨结节的垂直距离（JL）;在术后的侧位片上,平行于胫骨假体负重关节面作一条直线,测量它到胫骨结节的垂直距离（JL’）。JL’和JL之间的差值（JL’-JL）为手术前后关节线的变化值,对其进行统计学处理并分析原因。结果保留后交叉韧带的膝关节表面置换后,JL’-JL为2．0mm（-1．3—7．2mm）,其中5例大于2mm;旋转膝关节置换后,JL’-JL为3．1mm（-1．5—12．3mm）,其中11例大于2mm,两者差异有统计学意义（P〈0．01）。表面置换时关节线升高的原因包括胫骨近端截骨过少、韧带的过度松解、增加股骨远端截骨、股骨假体前后径偏小等;旋转膝关节置换时,关节线的改变主要由骨缺损和缺乏韧带的限制作用所致。结论保留后交叉韧带膝关节表面置换时,虽然有某些原因可以造成关节线的改变,但是由于畸形和骨缺损相对较轻,同时周围韧带的相对完整使其关节线发生改变的几率小、程度轻。由于骨缺损相对较重,同时手术中不保留周围韧带,旋转膝关节置换时更易发生关节线位置异常,应该通过股骨内上髁等骨性标志帮助恢复正常的关节线水平。     

人工关节置换术后严重内科并发症分析

[目的]调查人工髋、膝关节置换术后严重内科并发症的特点和危险因素,为人工关节置换术的围手术期管理和临床决策提供参考。[方法]研究对象为2013年5月1日~12月31日期间行初次人工髋或膝关节置换术的患者。采集患者的基本信息、病史、麻醉、手术及术后并发症情况,分析术后并发症的特点和危险因素。[结果]共有1 050例患者行1 188个初次人工髋或膝关节置换术。患者的平均年龄为(59.9±11.9)岁,70.1%的患者为女性。人工关节置换术后严重内科并发症的发生率为4.8%,包括心梗(0.1%)、心绞痛(1.9%)、心律失常(1.2%)、心衰(0.4%)、脑梗(0.6%)、肺栓塞(0.2%)和慢性阻塞性肺病急性加重(0.4%)。90%的严重内科并发症发生于术后4 d内。年龄≥70岁(OR:2.49,95%CI:1.17~5.29)和ASAⅢ级(OR:15.97,95%CI:2.66~95.79)是严重内科并发症的危险因素。[结论]人工髋、膝关节置换术后会出现严重的内科并发症。要重视患者的围手术期管理,尤其是高龄和高ASA分级的患者。人工关节置换术后住院日不宜过短。     

Patient expectations predict greater pain relief with joint arthroplasty

We examined the relationship between patient expectations of total joint arthroplasty and functional outcomes. We surveyed 1799 patients undergoing primary hip or knee arthroplasty for demographic data and Western Ontario McMaster University Osteoarthritis Index scores at baseline, 3 months, and 1 year of follow-up. Patient expectations were determined with 3 survey questions. The patients with the greatest expectations of surgery were younger, male, and had a lower body mass index. Linear regression modeling showed that a greater expectation of pain relief with surgery independently predicted greater reported pain relief at 1 year of follow-up, adjusted for all relevant covariates (P < .05). Patient expectation of pain relief after joint arthroplasty is an important predictor of outcomes at 1 year.     

Evaluation of the Hemocue portable hemoglobinometer after major joint arthroplasty

We evaluated the potential use of the Hemocue (Hemocue AB, Sweden) portable hemoglobinometer on the 1st postoperative evening after major joint arthroplasty. We compared hemoglobinometer values with conventional Coulter counter laboratory analysis in a population of 67 patients. The hemoglobinometer proved practical, economical, and accurate in general, although 2 outlying values were severe enough as potentially to influence clinical decision making. Potential causes and solutions are discussed.     

The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Purpose

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme.

Methods

Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited.

Results

In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37–1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49–1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20–1.68 %) and incidence of PE 1.15 % (95 % CI 0.53–2.48 %).

Conclusions

We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.     

Subacute pain and function after fast-track hip and knee arthroplasty

In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1–10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30–59 mm), and 16% severe pain (VAS ≥ 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.     

Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease

Although most patients are improved after shoulder arthroplasty, the degree of improvement is variable. The factors contributing to this variability are not well understood. In particular, little information is available regarding the preoperative characteristics of the patient that may influence the quality of the result. This study correlated patient demographics, preoperative health status, and preoperative shoulder function with 3 outcome metrics: comfort, physical role function, and shoulder-specific function. One hundred thirty-four shoulders having total shoulder arthroplasty for degenerative glenohumeral joint disease had an average follow-up of 3.4 +/- 1.8 years. The SF-36 Comfort score improved from 39 to 61 (P < .0001). The SF-36 Physical Role Function score improved from 30 to 52 (P < .0001). The average number of Simple Shoulder Test functions performable (out of 12) improved from 4 to 9 (P < .0001). The strongest correlates with postoperative comfort included preoperative physical function (P < .0001), general health (P < .0001), and social function (P < .001). The strongest correlates with postoperative physical role function included preoperative physical function (P < .0001) and general health (P < .001). The strongest correlates with postoperative shoulder function included male gender (P < .0001), and preoperative physical function (P < .0001), social function (P < .0001), mental health (P < .0001) and shoulder function (P < .0001). These data indicate that the overall well-being of the patient before surgery is strongly correlated with the quality of the outcome from total shoulder arthroplasty for degenerative glenohumeral joint disease.     

合并ESR和/或CRP升高的拟行人工关节置换术患者的诊治策略

[目的]研究术前合并ESR和/或CRP升高的拟行人工关节置换手术患者的诊治流程。[方法] 2017年于本科拟行人工关节置换术合并ESR和/或CRP升高的患者93例,男25例,女68例,膝关节75例,髋关节18例。入院常规查ESR和CRP,伴有升高患者,除外内科疾病和其他器官感染后,需检查血降钙素原,并行关节穿刺,同时进行MRI检查。根据关节液细胞计数和分类、关节液培养和术中病理结果,选择人工关节置换或者清创术。[结果] 93例患者ESR平均值为(32.21±18.52) mm/h,CRP平均值为(15.63±25.72) mg/L。复查仍升高患者26例,其中诊断为内科疾病和其他器官感染8例,进行关节腔穿刺16例,拒绝关节腔穿刺2例。关节腔穿刺的患者中,关节液培养阳性8例,其中4例行关节清创术,4例行药物保守治疗。关节液培养阴性8例,其中根据术中冰冻病理行关节清创术2例,行人工关节置换术6例。术中软组织培养阳性4例,阴性8例,其中2例软组织研磨后培养瓶培养阳性。[结论]术前合并ESR和/或CRP升高的拟行人工关节置换手术患者不能除外感染性关节炎的可能性,需按照诊疗流程进行诊治,避免关节内感染的漏诊。     

藏族人群关节置换术后下肢深静脉血栓发生率及解剖分布

[目的]探讨藏族人群全髋关节置换(THA)和全膝关节置换(TKA)术后下肢深静脉血栓(DVT)的发生率及其解剖分布特点。[方法]纳入2017年3月～2018年3月行全髋、全膝关节置换术的237例藏族患者,其中THA 70例,TKA 167例。所有患者于术前、术后第1、3、7、14 d常规行双下肢静脉彩超检查,术中、术后常规使用氨甲环酸,术后常规抗凝。统计分析术后DVT的发生率、类型及其解剖分布情况。[结果]术后下肢静脉DVT发生率THA组为15/70 (21.43%),包括1例中央型,14例周围型;TKA组为51/167 (30.54%),包括49例周围型、2例混合型;两组差异有统计学意义(P0.05)。THA术后血栓:13例为孤立性,包括12例小腿肌间静脉血栓、1例腘静脉血栓;1例肌间静脉及胫后静脉血栓;1例肌间静脉及腓静脉血栓。TKA术后血栓:41例为孤立性(39例肌间静脉血栓、1例胫后静脉血栓、1例大隐静脉血栓);4例肌间静脉及胫后静脉血栓;1例腓静脉及胫后静脉血栓;1例肌间静脉及腓静脉血栓;1例肌间静脉及腘静脉血栓;1例肌间静脉及皮下静脉血栓;1例肌间静脉、腓静脉及胫后静脉血栓;1例肌间静脉、腓静脉、胫后静脉及腘静脉血栓。TKA术后DVT的发生率高于THA, THA组以孤立性静脉血栓为主,TKA组更容易同时累及多支静脉,差异有统计学意义(P0.05)。两组均未发现症状性DVT和PE病例。[结论]藏族人群在全髋关节置换术和全膝关节置换术后下肢DVT的发生率偏高,两者发生率及其解剖分布存在差异。     

Knee joint kinematics, fixation and function related to joint area design in total knee arthroplasty

The aim was to study the influence of different designs of the joint area on tibial component fixation, kinematics and clinical outcome after a cemented total knee arthroplasty (TKA). The HSS score and a special questionnaire were used at the clinical examination. Conventional radiography was done to record the positioning of the implants and development of radiolucencies. The migration and inducible displacement were evaluated using radiostereometry (RSA). The kinematics of the knee during active extension was studied using dynamic RSA. In randomised and prospective studies 87 knees in 83 patients (28 male, 55 female, age 69, range 50-83) received an AMK (DePuy, Johnson & Johnson) TKA. The patients were divided into two groups. In group 1 the patients had varus/valgus deformities of < or = 5 degrees and the PCL was retained. The PCL was resected in group 2 where the patients had deformities exceeding 5 degrees and/or fixed flexion deformities of more than 10 degrees. In group 1 a flat (F, n = 20) or a concave (C, n = 20) design was implanted (study 3). In group 2 (study 4) the patients received a concave (n = 25) or a posterior-stabilised (PS, n = 22) tibial plateau. The migration of the tibial component, positioning of the prosthesis, development of radiolucencies and the clinical outcome was evaluated after 1 and 2 years. Twenty-two patients (11 F, 11 C) in group 1 (study 1) and 22 knees in 20 patients in group 2 (study 2, 11 C, 11 PS) were examined 1 year post-operatively to evaluate the kinematics of the knee. Eleven normals served as controls. During active extension of the knee the inducible displacements of the tibial component were recorded in 16 knees (15 patients). Based on successful RSA examinations 5 knees (4 F, 1 C) from group 1 and 11 knees (5 C, 6 PS) from group 2 were selected (study 5). Abnormal kinematics and especially increased AP translations compared to normals (p < 0.0005) were recorded in all designs. The concave design showed the widest AP-translations in both studies. The clinical outcome in terms of HSS score did not differ between the flat versus the concave designs in study 1 and between the concave versus the PS implants in study 2. Up to two years the migration of the tibial component and the development of radiolucent lines were of the same magnitude for the flat versus the concave inserts in study 3 and the concave versus the PS design in study 4. Also did the positioning of the implant and the fulfillment of the patients expectations on the surgery preoperatively not differ. The AMK prosthesis migrated at about the same amount as have been reported for similar designs. In study 5 all implants showed a correlation between some of the inducible displacements (anterior-posterior tilting and maximum total point motion) and the corresponding migration 0-2 years. The more the anterior tilt the more the migration in the same direction. If the PCL was sacrificed during the knee replacement the change into increased anterior tilt occurred earlier (i.e. at more degree of flexion) if a concave insert was used compared to the PS design. When the active extension reached 25 degrees there were more anterior tilt of the tibial component in the concave design (p = 0.001) and if the tibial plateau centre had a medial position (p < 0.0005). Compared with normal knees all prosthetic designs showed abnormal pattern of motion. The extent of this abnormality was influenced by the design of the joint area. A corresponding influence on the fixation of the tibial component could not be verified. The choice of joint area and recorded kinematics had no or small influence on the clinical results. Feelings of instability could to some extent be related to the kinematics of the knee joint.     

How patients manage life and health while waiting for a liver transplant

Liver transplantation offers a lifesaving treatment for individuals with terminal disease. An extended waiting period may contribute to anxiety and undermine overall health status, jeopardizing the patient's opportunity for successful transplantation. The purpose of this grounded theory qualitative study was to discover how individuals experience life and health resources during the wait for a liver transplant. In-depth interviews, conducted with 12 adults who had awaited liver transplantation for more than a year, were transcribed verbatim and analyzed using grounded theory methods. The findings portrayed the transplant waiting period to be a process of experiencing confinement, disciplining the self, and ultimately letting go and surrendering one's self to accept available, accessible, and appropriate resources for health. Resources for life and health used by the participants included: following instructions, presenting self positively, seeking information and support, controlling symptoms, using distraction and denial, changing attitudes, setting and achieving new goals, isolating oneself and entrusting oneself to another. The findings suggest the importance of increasing supportive, health-oriented care aimed at promoting resources for everyday living and health during the transplant waiting period.     

Rural residency and the risk of mortality while waiting for liver transplantation

Our liver transplant program services a region that has a prominent rural demographic. The influence of rural residency on liver transplant wait-list mortality has not been previously studied. We hypothesized that residence in a rural setting, by imposing challenges to medical care access, might be associated with inferior survival while waiting for liver transplantation. To test this hypothesis, multivariable time-to-event analysis was performed using Cox proportional hazards and competing risks regression on data from a consecutive five-yr cohort of 159 primary liver transplant candidates, to derive covariate adjusted effect measures for the association between residence in a rural area and wait-list mortality. For the primary analysis, a standardized, census-based, definition was used to assign rural residency status. The Kaplan-Meier estimated 90-d and one-yr wait-list mortality for the cohort was 7.6% (95% CI: 4.2-13.8) and 15.6% (95% CI: 9.4-25.2). The covariate adjusted hazard ratio for the relationship between Rural and Small Town residency status and wait-list mortality was 0.497 (95% CI: 0.171-1.438, p = 0.197) for the Cox regression model and 0.628 (95% CI: 0.224-1.757, p = 0.376) for the competing risk regression model. As defined in this study, candidate residence in a rural setting was not found to be associated with inferior survival while awaiting liver transplantation.