Sustainable Surgery: Green Orthopaedics

Visual Element: An infographic illustrating the "Carbon Footprint of a Hip Replacement," breaking down emissions into procurement (manufacturing), energy use (theatre HVAC), anaesthetic gases, and waste disposal.

The Carbon Cost of Healing

The healthcare sector is a paradoxical contributor to the global climate crisis. While dedicated to protecting health, it is responsible for approximately 4.4% of global net carbon emissions—a footprint comparable to the aviation industry. Within the hospital ecosystem, the Operating Theatre (OR) is the most resource-intensive environment, consuming three to six times more energy per square meter than the rest of the facility and generating up to 30% of total hospital waste.

As orthopaedic surgeons, we are among the heaviest users of resources. The "heavy metal" nature of our specialty—involving implant manufacturing, sterilization of large instrument trays, and significant use of disposables—means our individual carbon footprint is substantial. A single total knee arthroplasty (TKA) can generate over 10-13 kg of waste, much of which is plastic and single-use metal.

This article explores the evidence-based strategies for "Green Orthopaedics," moving beyond token gestures to high-impact interventions that reduce environmental harm without compromising patient safety.

The "Single-Use" Culture: A Critical Analysis

The shift towards single-use items (SUIs) over the last three decades was driven by two primary factors:

1. Infection Control: The theoretical reduction of prion transmission (vCJD) and surgical site infection (SSI).
2. Convenience: Eliminating the logistical burden of sterilization and reprocessing.

However, the pendulum has arguably swung too far. The environmental cost of manufacturing, packaging, transporting, and disposing of SUIs is immense.

Evidence Corner: Life Cycle Assessment (LCA) studies comparing reusable vs. disposable surgical instruments consistently show that reusables have a significantly lower carbon footprint, even when accounting for the water and energy used in sterilization. For example, a reusable Scissor can have 1/10th the carbon impact of its disposable counterpart over its lifetime.

The Problem with Blue Wrap

Polypropylene wrap ("blue wrap") is ubiquitous in orthopaedics. It is derived from petroleum, is non-biodegradable, and despite being technically recyclable, it is frequently discarded into clinical waste streams due to logistical barriers.

• Impact: It constitutes up to 20% of OR waste by volume.
• Solution: Rigid sterilization containers. These aluminum or steel containers last for years, eliminate the need for wrap, and reduce the risk of instrument contamination from tears in the wrap.

Waste Segregation: The Low-Hanging Fruit

Waste in the OR is typically categorized into three streams, each with vastly different carbon and financial costs:

1. General Waste (Black/Clear bag): Low cost, low carbon (often sent to landfill or energy-from-waste).
2. Recycling (Green/Clear bag): Lowest carbon impact if processed correctly.
3. Clinical/Infectious Waste (Yellow/Red bag): Highest cost (5-10x general waste), highest carbon (requires high-temperature incineration).

The Segregation Failure

Audits consistently show that 30-50% of waste in "Clinical" bins is actually non-hazardous general waste or packaging. Throwing a clean cardboard implant box or a sterile plastic wrapper into the clinical waste bin is an environmental crime.

Clinical Pearl: "If it hasn't touched the patient, it's probably not clinical waste." Set up a recycling and general waste station before the case starts. Open all non-sterile packaging into these bins before scrubbing.

Rationalizing Instrument Trays

One of the most effective "Green" interventions is the optimization of instrument sets.

• The Bloat: A standard hip replacement tray might contain 80-100 instruments. A surgeon might use 20.
• The Cost: Every unused instrument must still be washed, inspected, repacked, and sterilized. This consumes water, electricity, and staff time.

Implementing "Lean" Trays

1. Audit: Track instrument usage over 10-20 cases.
2. Review: Remove instruments that are used <20% of the time. Package them separately as "supplementary" peel-packed items.
3. Result: Hospitals that have implemented tray rationalization report reduction in sterilization costs by 40% and setup times by 20%.

Visual Element: Bar chart comparing "Standard Tray" vs "Rationalized Tray" in terms of weight, number of instruments, and sterilization cycle energy cost.

Anaesthetic Choices: The Silent Polluter

While surgeons focus on solid waste, the anaesthetist manages an invisible but potent source of emissions. Volatile anaesthetic gases are potent greenhouse gases.

• Desflurane: The worst offender. It has a global warming potential (GWP) 2,540 times that of CO2. Using Desflurane for one hour is equivalent to driving a car for 200-400 miles.
• Sevoflurane: Significantly better, with a GWP of ~130.
• Propofol (TIVA): Total Intravenous Anaesthesia has a negligible carbon footprint compared to volatiles.

Trap: Assuming Regional Anaesthesia is always "greener." While it avoids gases, the plastic waste from single-use neuronal blockade kits is significant. However, on balance, Regional Anaesthesia and TIVA are the most environmentally friendly options.

WALANT: A Paradigm Shift

Wide Awake Local Anaesthesia No Tourniquet (WALANT) surgery represents the pinnacle of sustainable practice in hand and foot surgery.

• No Sterility Compromise: Using "field sterility" rather than full main theatre protocols for minor procedures.
• Resource Reduction: Eliminates the need for an anaesthetic machine, recovery room staff, main theatre ventilation (HVAC), and extensive draping.
• Patient Benefit: No fasting, no sedation risks, immediate discharge.

Moving carpal tunnel releases and trigger fingers out of the main OR and into procedure rooms is perhaps the single most effective carbon-reduction strategy for a hand unit.

The Role of Industry and Procurement

Surgeons have purchasing power. We can drive change by demanding sustainability metrics from our suppliers.

• Packaging: Ask representatives why an implant comes in three boxes and four plastic layers.
• Recycling Programs: Support companies that offer take-back schemes for single-use devices (e.g., harvesting platinum from catheter tips or recycling harmonic scalpel handles).
• Metal Recycling: Explanted prostheses are high-quality metal (Titanium, Cobalt-Chrome). These should be sent for metal recycling, not clinical waste incineration. Note: Many hospitals now have "implant recycling" buckets.

Conclusion: A Call to Action

Sustainable orthopaedics is not about compromising quality; it is about defining value to include environmental cost. The "Green Theatre" of the future is efficient, lean, and conscious of its footprint.

Your 5-Step Action Plan:

1. Switch Gases: Advocate for TIVA or Sevoflurane over Desflurane.
2. Rationalize Trays: Cut the fat from your instrument sets.
3. Segregate: Ensure recycling bins are available and used for pre-incision waste.
4. Rigid Containers: Move away from blue wrap where possible.
5. WALANT: Move minor cases out of the main OR.

We have a duty of care to our patients, but we also have a duty of care to the planet they live on.

References

1. Sherman JD, et al. "The environmental cost of infection control: disposable vs. reusable instruments." JAMA Surgery. 2020.
2. Rasanen K, et al. "Carbon footprint of operating theatres: a systematic review." European Journal of Anaesthesiology. 2023.
3. Wyssusek KH, et al. "The carbon footprint of the operating room: a review of the literature." Journal of Clinical Anesthesia. 2019.
4. Australian Orthopaedic Association. "Strategy for Sustainable Surgery." 2024.