All patients over 18 years undergoing BTOA surgery were identified using a list of OPCS Classification of Interventions and Procedures (OPCS V.4.8) to identify the procedures undertaken and International Classification of Diseases (ICD-10) codes to identify disease associated with the procedure(online supplemental tables 1–3).22 23 OPCS codes are used in England to classify any procedure undertaken, and are used to identify a combination of the implant and surgical subtype used in association with the anatomical area of the body where the surgery took place. For hand surgery, OPCS codes are used with combination of a generic surgical procedure codes and anatomical location.


All episodes of care for each individual prior to and following BTOA surgery were included in the extract. Patients were followed up until date of death or the end of the study period (31 March 2017). Patients who had an ICD-10 code for traumatic injury in the same episode as BTOA surgery were excluded, in order to only include patients undergoing elective surgery for longstanding BTOA. Duplicate episodes can occur over the change of financial year, and were removed during data cleaning. Each hand was considered as a separate surgical case.

All cases of BTOA surgery identified within the 19-year period were included if they were not associated with a fracture ICD diagnosis code, and were not considered to be a duplicate episode. All cases were included with the aim of identifying the full national cohort within the time frame. Minimum follow-up was set at 1 day, due to the clinical opinion of the team that further procedure or serious adverse events (SAEs) can occur very shortly after surgery (eg, acute carpal tunnel syndrome requiring decompression).

Validation: Determining the feasibility of identifying surgical procedures and BTOA cases two validation studies were undertaken in order to determine if it was possible to successfully identify surgical treatment of BTOA in this data set, and second to determine if it was possible to identify the surgical subtypes undertaken.

First, we undertook consensus discussion between surgeons, coders and NHS Digital to determine the most likely OPCS procedure codes and ICD diagnosis codes that would identify surgery for BTOA within routinely collected hospital data in England. This was an iterative process within a diverse team of stakeholders. Following this, an external validation study was then undertaken using this list of OPCS and ICD codes that identified a positive predictive value of 81% for incident BTOA with good interobserver reliability.24

Second, we undertook a further external validation study to determine if OPCS procedure codes could identify surgery subtypes within routinely collected data in the NHS in England. This was undertaken in our NHS trust using two blinded and independent reviewers (MMM and NR), who reviewed a year of surgical activity and the OPCS and ICD codes used during this time. In a year’s sample of 104 patients undergoing BTOA surgery in our institution, we demonstrated a positive predictive value of 99% in identifying surgical subtype.

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