Cmc arthroplasty cpt

My doctor states he did a CMC interpostion arthroplasty with trapezial excision and STT interpostion arthroplasty. The report reads: Dissection was carried out at the base of the 1st metacarpal as well as around the trapezium. Using an oscillating saw, a four-quadrant cut was made into the trapezium. using a rongeur, the trapezium was fully ...

Cmc arthroplasty cpt. For CMC arthroplasty complications include infection and nerve damage. Before surgery your doctor will review the possible risks and complications of surgery with you. What to Expect Before Procedure. The day of the procedure, you will need to arrange for a ride to and from the procedure and arrange for help at home. Wear comfortable clothing.

41. Best answers. 0. Jun 25, 2008. #3. Code 25447. Code 25447, Arthroplasty, interposition, intercarpal or carpometacarpal joints, represents an interposition arthroplasty of either intercarpal or carpometacarpal joints. It is performed by excising part of one or more of the respective bones and then inserting soft tissue, such as an anchovy of ...

The CPT code 25447 (arthroplasty, interposition, intercarpal or carpometacarpal) was the most common billing code for treatment of CMC arthritis. This procedural code included all interposition procedures, whether with tendon, allograft, or artificial material.Nov 23, 2012 · OBJECTIVE. The purpose of this article is to provide a radiologic guide to surgical treatment of first carpometacarpal osteoarthritis, a common problem especially in older women. CONCLUSION. Knowledge of the indications, surgical technique, component design, normal postoperative imaging assessment, and imaging findings of complications is important to providing a meaningful radiologic ... In the world of medical billing and coding, accuracy is crucial. One small error in assigning a Current Procedural Terminology (CPT) code can lead to significant consequences, incl...The CMC Mini TightRope procedure allows the surgeon to stabilize the thumb with a strong suture and small buttons following removal of the trapezium bone. ... tendon fixation, basal joint, trapezium, fcr (flexor carpi radialis), cmc arthroplasty, arthritis, thumb cmc, thumb, hand & wrist, tendon arthroplasty, tenodesis, arthrex, tightrope ...Due to the time limitations, the CPT and ICD-9 codes and scenarios are not all inclusive. Arthro=joint +. -plasty=repair or restoration of a part or function. Combined simply means surgical repair of a joint in order to relieve pain, restore function, restore motion. Generally done for arthritis, joint ankylosis.Revision CMC arthroplasty surgery rates are estimated at 2.6% to 4.6% and have satisfactory out-comes in 50% to 85% of patients after revision surgery. Before performing revision CMC arthroplasty, surgeons must identify any missed pathology (eg, scaphotrapezoidal arthritis) or complication from the initial procedure (eg, neuroma).Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 25449 : Revision of arthroplasty, including removal of implant, wrist joint . 26530 : Arthroplasty, metacarpophalangeal joint; each joint . 26531 : Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint . 26535

Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) (25446) Interposition arthroplasty, intercarpal or carpometacarpal joints (25447) Revision of arthroplasty, including removal of implant, wrist joint (25449) Arthrodesis and resection of radioulnar joint (25830)Although several previous reports have indicated that excision arthroplasty has been effective in the treatment of basal joint arthritis of the thumb by relieving pain and preserving motion, 1,2,3,4,5,6,7 others have indicated that arthroplasty of the thumb by excision of the trapezium alone causes a substantial loss of thumb strength and stability. 5,6,7 Luria et al 8 demonstrated that the ...Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600) Basal Joint Arthroplasty. Arthroplasty with prosthetic replacement, trapezium (25445) Interposition arthroplasty, intercarpal or carpometacarpal joints (25447) Partial Trapezoid excision.Get ratings and reviews for the top 12 lawn companies in Ham Lake, MN. Helping you find the best lawn companies for the job. Expert Advice On Improving Your Home All Projects Featu...Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600) Basal Joint Arthroplasty. Arthroplasty with prosthetic replacement, trapezium (25445) Interposition arthroplasty, intercarpal or carpometacarpal joints (25447) Partial Trapezoid excision.

Introduction. Thumb carpometacarpal joint (CMCJ) arthritis is a painful and debilitating condition with a preponderance for women and clinically affecting around 1.4% of the population. 1 Surgical treatment options include trapeziectomy, interposition arthroplasty, arthrodesis, or total joint replacement. Despite the use of total joint …Carpometacarpal Osteoarthritis (CMC) is a common condition in adults with a long history of manual activities. Suspension arthroplasty of the first finger is the most frequent surgical reconstruction for arthrosis of the upper limb. 1, 2 Every wrist pain symptoms join into differential diagnosis with fractures, especially in osteoporotic patients.The OrthoIllustrated® animation for thumb CMC suspensionplasty is an educational tool to help patients better understand the diagnosis and treatment of this ...The implant arthroplasty failure rates per 100 procedure-years were total joint replacement (2.4), hemiarthroplasty (2.5), interposition with partial trapezial resection (4.5), interposition with complete trapezial resection (1.7), and interposition with no trapezial resection (4.5). ... Implant arthroplasty of the carpometacarpal joint of the ...Check out this preview of Sanjeev (Sanj) Kakar, Professor of Orthopedic Surgery, perform a Left Thumb Trapeziectomy and Tightrope Suspension Arthroplasty. Yo...

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We defined three exclusive categories for surgical treatment: (1) partial/complete trapeziectomy with ligament reconstruction and tendon interposition (LRTI) (CPT codes - 25447, 25447 and 20924, 25210 and 20924), (2) simple complete trapeziectomy (CPT code - 25210), and (3) thumb CMC arthrodesis or thumb CMC prosthetic arthroplasty (due to ... The Ensemble CMC™ is manufactured from On-X ® Carbon (pyrocarbon) – a proven biocompatible, low modulus, and durable material that has been shown to cause less bone wear compared to metal or ceramic implants. The Ensemble CMC™ is available in three sizes. A simple instrument set is also available. The Ensemble CMC is an interpositional ...Carpometacarpal Suspensionplasty is performed on patients who suffer from basal joint arthritis found within the trapezium bone of the carpometacarpal (CMC) joint, resulting …Surgical treatment of arthritis at the carpometacarpal (CMC) joint, or base of the thumb, is called arthroplasty. There are many variations in how the procedure can be performed, including: Hematoma distraction arthroplasty. Ligament reconstruction & tendon interposition. Suspensionplasty with mini tight rope.

The CPT code 25447 (arthroplasty, interposition, intercarpal or carpometacarpal) was the most common billing code for treatment of CMC arthritis. This procedural code included all interposition procedures, whether with tendon, allograft, or artificial material.CMC Arthroplasty Rehabilitation Protocol Thumb carpometacarpal joint arthritis can cause significant pain and instability. In general, it is a ... intervention is an outpatient procedure that generally takes approximately 45 minutes to an hour to perform. The patient on the day of surgery is awakened from anesthesia in a postoperative splint.Indication - previous trapeziectomy and suspension arthroplasty of the right first CMC joint, which resulted in settling of the first metacarpal onto the scaphoid and painful thumb. Procedure - ...the skin is incised over the volar radial aspect of the thumb metacarpal and extending down to the wrist. Dissection is carried out about the base of ...When the cartilage shock absorber wears away, surgeons may recommend an arthroplasty to remove and replace the joint with a skin graft or an artificial implant made out of silicone, metal, or pyrocarbon. Recovering from CMC joint replacement. As with any traditional surgery procedure, patients are advised to follow a strict protocol to promote ...Fashion influencer Camila Coelho opens up with followers about epilepsy and pregnancy. Trusted Health Information from the National Institutes of Health Fashion icon Camila Coelho ...Results. Average follow up at 31.5 months post-op (range of 12-57 months) Average number of therapy sessions 16.8 (range of 10-20 sessions) Pre to post-op grip strength had 50% improvement. Lateral pinch improved 25% at post-op and 29% by the final visit. Increase in palmar ABD by 30% at the final visit. Surgical Procedure. This procedure is recommended for advanced stages of thumb CMC joint arthritis and/or instability of the thumb CMC joint. The procedure is performed by first removing the trapezium. A reconstruction of the CMC joint is then performed by utilizing a tendon as the soft tissue interpositional arthroplasty. There are several options for the surgical treatment for arthritis of the thumb CMC joint. One type of surgery, called CMC Arthroplasty, involves reconstructing the joint. The surgery …Best answers. 0. Jan 25, 2017. #1. Good morning! We've had a little back and forth going on in my office regarding a patient's surgery. The doctor wants us to bill 25447 along with 20650 for insertion of the k-wire. Based on the documentation/abstract (below) he had gone in intending to do a LRTI procedure (25447) but after excising the ...

In the healthcare industry, accurate coding is essential for proper billing and reimbursement. Two important coding systems used are CPT codes and diagnosis codes. These codes play...

25109= excision of tendon in forearm, flexor or ext ensor. 24910= nerve repair with conduit 64911= neurorrhaphy w/veingraft. 69990 is inclusive to above nerve repairs, not allowable. Other newer CPT codes. 24910= nerve repair with conduit. 69990 is inclusive to above nerve repairs, not allowable. The Mini TightRope technique provides a unique method for stabilization of the thumb metacarpal following trapezial resection or removal for the treatment of CMC arthritis. The Mini TightRope technique can also be used as an adjunct and stabilizer in CMC instability and in the case of revision with proximal migration after tendon reconstruction.The Mini TightRope technique supports and ... The Ensemble CMC™ is manufactured from On-X ® Carbon (pyrocarbon) – a proven biocompatible, low modulus, and durable material that has been shown to cause less bone wear compared to metal or ceramic implants. The Ensemble CMC™ is available in three sizes. A simple instrument set is also available. The Ensemble CMC is an interpositional ...Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 25449 : Revision of arthroplasty, including removal of implant, wrist joint . 26530 : Arthroplasty, metacarpophalangeal joint; each joint . 26531 : Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint . 26535The official description of CPT code 25447 is: “Arthroplasty, interposition, intercarpal or carpometacarpal joints.”. 3. Procedure. The 25447 procedure involves the following steps: Administration of anesthesia to the patient. A dorsoradial incision is made along the line of the first metacarpal joint and extended medially to the palm.July was Heathrow Airport's busiest month since the coronavirus pandemic brought the travel industry to a halt. July was Heathrow Airport's busiest month since the coronavirus pand...Loss of strength in gripping or pinching activities. Swelling and tenderness at the base of the thumb. Aching discomfort after prolonged use of the thumb. An enlarged, "out-of-joint" appearance at the base of the thumb. Development of a bony prominence or bump over the basal joint at the base of the thumb. Limited motion in the thumb.

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Resection arthroplasty is an old, and yet reliable, solution for the isolated osteoarthritis (OA) of some joints of the hand. With complication low rates, this technically undemanding option is ideal for scapho-trapezial-trapezoidal joint OA, as well as for the OA of the carpometacarpal joints of the fingers. This paper reviews its indications, surgical …My doctor states he did a CMC interpostion arthroplasty with trapezial excision and STT interpostion arthroplasty. The report reads: Dissection was carried out at the base of the 1st metacarpal as well as around the trapezium. Using an oscillating saw, a four-quadrant cut was made into the trapezium. using a rongeur, the trapezium was fully ...Oct 20, 2008 · A CMC joint arthroplasty of the thumb is a commonly performed procedure. The base procedure described by 26447 is as follows. A curvilinear incision is made over the radial aspect of the proximal first metacarpal extending proximally over the trapezium and trapezio-scaphoid joint. The Ensemble CMC™ is manufactured from On-X ® Carbon (pyrocarbon) – a proven biocompatible, low modulus, and durable material that has been shown to cause less bone wear compared to metal or ceramic implants. The Ensemble CMC™ is available in three sizes. A simple instrument set is also available. The Ensemble CMC is an interpositional ...My friend and I are always bonding over our love for guys in plaid shirts. I don’t know what it is, but the My friend and I are always bonding over our love for guys in plaid shirt...Case Report: We treated a 52-year-old female pianist who complained of pain in her left thumb carpometacarpal (CMC) joint. She had undergone two previous ligament reconstruction and tendon interposition arthroplasty procedures on the joint, for which strips of the flexor carpi radialis tendon and the abductor pollicis longus tendon were …procedure performed: revision arthroplasty of cmc joint, rt thumb, with removal of interpositional implant at the base of the thumb metacarpal. revision cmc arthroplasty using the flexor carpi radialis tendon and a slip of the abductor pollicis longus tendon. not sure if i should code 25447,25310,20680 or 25449,25310!!A suspensory button approach. Carpometacarpal Suspensionplasty is performed on patients who suffer from basal joint arthritis found within the trapezium bone of the carpometacarpal (CMC) joint, resulting in joint space narrowing, instability, and dislocation. Partial or full Trapeziectomies are performed to remove the diseased tissue from the ...Jun 6, 2022 · At 6 months after surgery, patient satisfaction with the clinical appearance of the thumb is significantly better after thumb CMC total joint replacement compared to trapeziectomy and interposition arthroplasty . This can probably be contributed to the correction of thumb length, metacarpal base subluxation and MCP hyperextension. Procedure - CMC Arthroplasty; Procedure - Basal joint Thumb CMC Arthroplasty; Procedure - Ring / Small CMC Arthroplasty. Indications. Examples. Problems ….

In October 2015, the Centers for Medicare & Medicaid Services transitioned from the 9th version of the International Classification of Diseases (ICD-9) codes for reporting patient diagnosis and medical procedures to the 10th version (ICD-10). The multitude of coding options for total joint arthroplasty in ICD-10-procedural coding (ICD …Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain. Selective Thumb … We defined three exclusive categories for surgical treatment: (1) partial/complete trapeziectomy with ligament reconstruction and tendon interposition (LRTI) (CPT codes - 25447, 25447 and 20924, 25210 and 20924), (2) simple complete trapeziectomy (CPT code - 25210), and (3) thumb CMC arthrodesis or thumb CMC prosthetic arthroplasty (due to ... Thumb CMC Joint Arthritis • 3rd most common joint with arthritis • Most common operation for arthritis in the arm/hand • More common in women than men (about 4 to 1) SpeedSpiral for Thumb CMC Arthroplasty • Tightly rolled acellular human collagen • Advantage: maintains height, instant, easy, pinch strength • 3 sizes – 13mm, 15mm, 17mmOct 20, 2008 · A CMC joint arthroplasty of the thumb is a commonly performed procedure. The base procedure described by 26447 is as follows. A curvilinear incision is made over the radial aspect of the proximal first metacarpal extending proximally over the trapezium and trapezio-scaphoid joint. Surgical treatment of arthritis at the carpometacarpal (CMC) joint, or base of the thumb, is called arthroplasty. There are many variations in how the procedure can be performed, including: Hematoma distraction arthroplasty. Ligament reconstruction & tendon interposition. Suspensionplasty with mini tight rope. Procedure - CMC Arthroplasty; Procedure - Basal joint Thumb CMC Arthroplasty; Procedure - Ring / Small CMC Arthroplasty. Indications. Examples. Problems. Procedures Home Page; American Society for Surgery of the Hand assh.org The Best Resource For Your Hands, Period.UWMC clinic staff are also available to help. Weekdays, 8 a.m. to 4:30 p.m.: Call the Hand Center at 206-598-4263. After office hours and on weekends and holidays: Call the hospital operator at 206-598-6190. Ask for the Hand Fellow on call to be paged. Your call will be returned.suspension arthroplasty for CMC arthritis. The senior author (A.P.C.W.) performed all surgical procedures between 2008 and 2015, and a minimum of 2-year follow-up was required for inclusion into the study. In our practice, all patients who have undergone a thumb CMC arthroplasty for symptomatic CMC arthritis are routinely followed at 6 … Cmc arthroplasty cpt, A small longitudinal split was created in the mid substance of the FCR tendon distally, adjacent to its insertion, and a 2-0 Prolene suture was used to secure the proximal edge of this split, to prevent proximal propagation and migration of the suspension. Then, the APL slip was weaved through this split, and while traction was held at the thumb and …, Summary. Basilar Thumb Arthritis is a form of arthritis that causes pain at the base of the thumb and difficulty with pinching and grasping due to carpal-metacarpal (CMC) joint arthritis. Diagnosis is made clinically with a painful CMC grind test and radiographs of the hand showing osteoarthritis of the 1st CMC joint. , Suspensionplasty, Arthroplasty, Interposition, Intercarpal or Carpometacarpal Joints. Suspensionplasty, Arthroplasty, Interposition. Intercarpal, or Carpometacarpal Joints is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma., We additionally collected prospective patient reported outcomes in 75% of our patients and had a lower proportion of patients undergo CMC arthroplasty at time of procedure (53% vs 70%). In a different study, Novoa-Parra et al 7 reviewed 9 patients who underwent MCP joint arthrodesis using the XMCP system at a fixed angle of 25° between 2012 ..., We used CPT code 25447 (arthroplasty, interposition, inter-carpal, or CMC joints) to search the database for patients who underwent thumb CMC interposition arthroplasty. Although this code does not specify thumb, we are unaware of any pro-cedure (other than thumb CMC interposition arthroplasty) typically given this code., Dec 12, 2020 · Carpometacarpal Osteoarthritis (CMC) is a common condition in adults with a long history of manual activities. Suspension arthroplasty of the first finger is the most frequent surgical reconstruction for arthrosis of the upper limb. 1, 2 Every wrist pain symptoms join into differential diagnosis with fractures, especially in osteoporotic patients. , SpeedSpiral CMC Allograft Implant. Anika’s SpeedSprial ® CMC Allograft System utilizes a pre-shaped, dense, strong, and flexible allograft implant to treat thumb CMC joint pain and/or instability caused by osteoarthritis (OA). The SpeedSpiral is sterile, decellularized and freeze-dried (no rehydration necessary) and is designed to augment ..., Surgical treatment of arthritis at the carpometacarpal (CMC) joint, or base of the thumb, is called arthroplasty. There are many variations in how the procedure can be performed, including: Hematoma distraction arthroplasty. Ligament reconstruction & tendon interposition. Suspensionplasty with mini tight rope., Introduction. Thumb carpometacarpal joint (CMCJ) arthritis is a painful and debilitating condition with a preponderance for women and clinically affecting around 1.4% of the population. 1 Surgical treatment options include trapeziectomy, interposition arthroplasty, arthrodesis, or total joint replacement. Despite the use of total joint …, suspension arthroplasty for CMC arthritis. The senior author (A.P.C.W.) performed all surgical procedures between 2008 and 2015, and a minimum of 2-year follow-up was required for inclusion into the study. In our practice, all patients who have undergone a thumb CMC arthroplasty for symptomatic CMC arthritis are routinely followed at 6 …, CMC Joint Arthroplasty For the Carpometacarpal (CMC) Joint Arthroplasty procedure, codes 25447 for an Arthroplasty, interposition, intercarpal or carpometacarpal joints and code 25310 for a Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon OR code 26480 for a Transfer or transplant of, Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain. Selective Thumb …, Cons: The procedure stabilizes the joint but does not repair damaged cartilage or bone. Ligament Reconstruction and Tendon Interposition (LRTI) In use for more than 40 years, LRTI is the most commonly performed surgery for thumb arthritis. The damaged joint surfaces are removed and replaced with a cushion of tissue that keeps the bones ... , The average cost for thumb surgery may range from $3,000 to upward of $7,000. A cost analysis review in 2021 found U.S. national averages for LRTI and hematoma and distraction arthroscopy spanned ..., The modified suture suspension sling arthroplasty technique developed by Arnold Peter C Weiss was performed on three patients with CMC joint arthritis. In this procedure, after trapeziectomy, a nonabsorbable suture is performed to create a hammock between the abductor pollicis longus and flexor carpi radialis tendon to rest the thumb …, Purpose: To investigate the clinical outcome of thumb carpometacarpal arthroplasty with entire-thickness flexor carpi radialis (FCR) ligament reconstruction and tendon interposition and to investigate the isokinetic wrist flexion/extension torque and flexion fatigue strength of the surgically treated wrist compared with the nonsurgically treated wrist., I need help with the above. Physician gave me 25447 x 2 with 25310. Insurance only paid on one 25447. I'm thinking 26480 instead of 25310. I'm also not sure if this is 2-25447., Summary. Basilar Thumb Arthritis is a form of arthritis that causes pain at the base of the thumb and difficulty with pinching and grasping due to carpal-metacarpal (CMC) joint arthritis. Diagnosis is made clinically with a painful CMC grind test and radiographs of the hand showing osteoarthritis of the 1st CMC joint. , STABLYX ® CMC Arthroplasty System Surgical Technique Guide; Skeletal Dynamics, Inc. 7300 North Kendall Drive, Suite 800 Miami, FL 33156. Toll-free: 877-753-5396, Osteoarthritis of the first carpometacarpal joint is common. When nonoperative measures fail, surgery may provide long-term pain relief. There are many surgical options in the management of carpometacarpal joint arthritis. Trapeziectomy with hematoma arthroplasty is technically simple, inexpensive, and has withstood the test of time. It is an excellent option for advanced carpometacarpal joint ..., Procedure for CMC Arthroplasty with TightRope. In general, CMC arthroplasty surgery with TightRope will involve the following steps: You will lie on your back on the operating table under regional or local anesthesia with your arm held in a specific position. Your surgeon cleans the treatment area with an antiseptic solution and an incision is ..., Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain. Selective Thumb …, Apr 7, 2023 · CMC arthroplasty is used to treat CMC joint arthritis. It may help you perform movements that are currently causing you pain, like grasping objects or making a pinching motion. , Weilby Technique for Interpositional Arthroplasty of Thumb Carpometacarpal Joint☆. Thumb interposition is an accepted technique for the treatment of stage 2-4 arthritis of the trapeziometacarpal joint of the thumb. With the usage of the Weilby suspension technique, the flexor carpi radialis is used to suspend the thumb metacarpal using an ..., Apr 7, 2023 · CMC arthroplasty is used to treat CMC joint arthritis. It may help you perform movements that are currently causing you pain, like grasping objects or making a pinching motion. , after your procedure with one of your surgeon’s Physician Assistants. Your sutures and splint will be removed at this appointment, and you will be placed into a cast. Scheduled on: __/__/__ at __:__am/pm • Your second post-operative appointment will be approximately four weeks after your procedure and will be with your surgeon. Your cast ..., Future potential areas of investigation include earlier mobilization (<4 weeks) or comparing in-person therapy after CMC arthroplasty to a virtual or self-directed therapy program. The safety …, Nov 5, 2018 · I would like an expert opinion on which CPT code is most appropriate for what looks like a "suspension version" of a CMC arthroplasty. Per op report: "...A marked amount of arthritis at the trapezial carpometacarpal joint was identified. The trapezium was osteotomized in 3 places with an osteotome, and the bone was removed in fragments completely. , In the healthcare industry, accurate documentation and coding are crucial for maximizing revenue and ensuring proper reimbursement. One important aspect of this process is the Nati..., Procedure - CMC Arthroplasty; Procedure - Basal joint Thumb CMC Arthroplasty; Procedure - Ring / Small CMC Arthroplasty. Indications. Examples. Problems. Procedures Home Page; American Society for Surgery of the Hand assh.org The Best Resource For Your Hands, Period. , The ligament reconstruction tendon interposition (LRTI) procedure, originally described by Burton and Pellegrini, 11 is usually reserved for mild-to-moderate CMC OA. This procedure, which usually utilizes the radial portion of the flexor carpi radialis (FCR) tendon, has three main principles described by Tomaino et al 12 including removal of ..., 1. Introduction. Arthritis of the thumb base (first carpometacarpal joint) is a very common condition and its prevalence increases with age. By the age of 50 radiographic evidence can be seen in 5.8% of males and 7.3% of females, rising to 33.1% and 39.0% by age 80. 1 A clinical diagnosis is established in greater that one-percent of the population. 2 Given the aging population the number of ..., Can technology save people from storms? Find out about 10 ways technology is saving people from storms. Advertisement Whether you're along the seacoast or in the middle of the U.S....