Harry Hodgson
Junior Clinical Fellow in Trauma & Orthopaedics, Imperial College Healthcare NHS Trust

This is the winning essay from the 2021 BOTA Junior Essay Competition

A vision of sustainability for orthopaedics: what does the future hold?

“Twelve, thirteen, fourteen… where’s the fifteenth swab?”. The hemi-arthroplasty had gone well, but these words sent shivers down everyone’s spine. Four overflowing clinical waste bags were emptied onto the floor, and everyone searched through the mountain of drapes, gowns, and packaging to find the swab. The culprit was found, and everything stuffed back into the bags. It was only at this point that I paused to consider: how can one operation lead to such an enormous amount of waste?

Climate change is one of the greatest threats to the health of the global population1. The NHS is responsible for an astonishing 5.4% of UK carbon emissions2. Surgery is particularly energy intensive, and orthopaedics has additional demands associated with device production, transport, and disposal. Yet, sustainability –delivering healthcare in a way that doesn’t deplete resources for the future – is still finding its place within the discipline. Keeping up with the increasing demands of an ageing population is particularly relevant to orthopaedics. Thankfully, the British Orthopaedic Association recognise its importance in their vision statement for a ‘vibrant, sustainable, representative orthopaedic community’3. This essay reviews how sustainability in orthopaedics can be improved through the mantra: ‘reduce, reuse, recycle’.


The most effective way of reducing orthopaedic energy consumption is through preventing bone disease and injury prevention. Osteoporosis treatment could prevent up to 25% of hip fractures4. This is also the most difficult aspect of sustainability to address and there is no simple solution. Implementing and supporting public health policies that focus on promoting bone health and educating patients on prevention of injuries is essential5.

Anaesthesia contributes 88% of the carbon footprint of the operating theatre6, 90% of which is due to nitrous oxide alone7. Nitrous oxide has traditionally been used when reducing fractures, but orthopaedic practitioners should consider using alternatives such as methoxyflurane (Penthrox) which is significantly better for the environment8. Halogenated anaesthetic gases contribute to both ozone depletion and greenhouse warming, with startling differences in environmental impact between agents. For example, desflurane has a carbon footprint 20 times greater than sevoflurane9. The ‘Anaesthetic Gases Calculator10 may be used to guide anaesthetic choice on the basis of environmental impact. Local anaesthetics, nerve blocks and ‘total IV anaesthesia’ are more sustainable than inhaled anaesthetics and should be used whenever possible11.


The majority of NHS emissions are associated with medical instruments and equipment12. Reusable textiles including scrub gowns and drapes use approximately 30-50% as much energy as disposable items over the product’s lifetime, whilst being similar in cost, comfort, protection, and effectiveness in preventing infection13,14. Reducing single-use equipment in theatre is fundamental to sustainability.

Recycling external fixation components is safe, cost-effective and well received by patients15, but uncommon in practice largely due to logistics associated with reprocessing16. A national protocol for recycling would streamline the process and make it easier for hospitals to recycle hardware, using less energy and fewer resources than producing new components. Other initiatives, such as optimising instrument trays by reducing the number of instruments requiring sterilisation have been shown to reduce energy consumption for procedures such as total knee arthroplasty17,18.

Walking aids provided by fracture clinic and A&E can be easily decontaminated and reused. However, only 21% of crutches are returned19. Schemes such as the ‘crutch amnesty’ introduced at Mid Essex NHS Trust19 have been successful in increasing returns of such items, and should be rolled out on a national basis.


Operating theatres contribute 50% of hospital waste20. Whilst 99% of non-contaminated waste from primary joint arthroplasty is recyclable, almost none of this is recycled21, instead being incinerated or going to landfill. This is often due to a lack of recycling bins in theatres. Domestic waste is often not separated from clinical waste, and everything ends up in clinical waste bags that need to be destroyed by energy intensive incineration. Incinerating waste is also considerably more expensive than disposing of recyclable waste22.

Introducing recycling facilities into theatres, alongside a national policy and framework for recycling in theatres would be the first step in combatting this problem. Education about appropriate waste segregation and how to reduce waste in theatre is important, and may be prompted by displaying posters in theatre areas, such as the eye-catching ‘Which Waste Bin Flowchart’ by RCP London23.

Changing the culture

Awareness of the adverse environmental impact of healthcare is low among healthcare professionals24. Raising awareness and changing the culture is essential for introducing sustainable initiatives, particularly for those that may initially be more expensive and labour intensive, such as reprocessing orthopaedic devices.

Stakeholder engagement is key, and in theatre the team brief offers an excellent opportunity to discuss how to have a sustainable day in theatre. Novel teaching methods such as podcasting on green surgery are an excellent example of encouraging junior doctor involvement25. Events such as the ‘Green Surgery Challenge’26 encourage teams of junior doctors to compete against each other for the best sustainable quality improvement project. Introducing a dedicated sustainability officer within the orthopaedic department may be useful for implementing and auditing sustainable changes in the long run.


Climate change is the biggest threat to global health and on the current trajectory, the future health of global populations is likely to suffer. Orthopaedic surgery is energy intensive and reducing the environmental impact through sustainable initiatives is everyone’s responsibility, including the Trust, orthopaedic staff, and orthopaedic device companies. Many solutions require no additional resources and could be implemented immediately, particularly optimising resource and waste management. Initiatives requiring additional up-front costs, especially those regarding prevention, are likely to reduce energy use and lead to long term savings.

Changing behaviour is essential. The trend for single-use equipment is unsustainable and assumptions that it is required from an infection control point of view are outdated. Orthopaedic surgeons must consider the whole lifecycle environmental impact when purchasing equipment, and should leverage suppliers’ dependence on the NHS to encourage sustainability in the industry. As orthopaedic research advances, future technologies such as robotic surgery and 3D printing must be designed and implemented with sustainability as a priority.

  1. Watts N, Amann M, Arnell N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet. 2021;397(10269):129-70.
  2. Health Care Without Harm. Health care climate footprint report. 2019 [cited 2021 Oct 11]. Available from: https://noharm-global.org/documents/health-care-climate-footprint-report.
  3. British Orthopaedic Association - About Us. [cited 2021 Sep 29]. Available from: www.boa.ac.uk/about-us.html.
  4. National Institute for Health and Care Excellence (NICE). 2018 NICE impact falls and fragility fractures. Available from: www.bgs.org.uk/resources/2018-nice-impact-report-on-falls-and-fragility-fractures.
  5. Halim A. Preventative Care in Orthopedics: Treating Injuries Before They Happen. Am J Orthop (Belle Mead NJ). 2018;47(7).
  6. Shahi A, Kellish AS, Tornsberg H, Miller L. What Is Orthopaedic Surgery’s Environmental Impact? AAOS NOW. Available from: www.aaos.org/aaosnow/2021/mar/managing/managing01.
  7. Campbell M, Pierce JMT. Atmospheric science, anaesthesia, and the environment. Contin Educ Anaesth Crit Care Pain. 2015;15(4):173-9.
  8. Hass SA, Andersen ST, Sulbaek Andersen MP, Nielsen OJ. Atmospheric Chemistry of Methoxyflurane (CH3OCF2CHCl2): Kinetics of the gas-phase reactions with OH radicals, Cl atoms and O3. Chem Phys Lett. 2019;722:119-23.
  9. Armstrong F, Sebastian J. Is it time to stop using desflurane? Br J Hosp Med (Lond). 2020;81(4):1-2.
  10. Association of Anaesthetists. Anaesthetic gases calculator. [cited 2021 Oct 11]. Available from: https://anaesthetists.org/Home/Resources-publications/Environment/Guide-to-green-anaesthesia/Anaesthetic-gases-calculator.
  11. Kuvadia M, Cummis CE, Liguori G, Wu CL. “Green-gional” anesthesia: the non-polluting benefits of regional anesthesia to decrease greenhouse gases and attenuate climate change. Reg Anesth Pain Med. 2020;45(9):744-5.
  12. Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The Carbon Footprint of Surgical Operations: A Systematic Review. Ann Surg. 2020;272(6):986-95.
  13. Overcash M. A Comparison of Reusable and Disposable Perioperative Textiles: Sustainability State-of-the-Art. Anesth Analg. 2012;114(5):1055-66.
  14. Vozzola E, Overcash M, Griffing E. An Environmental Analysis of Reusable and Disposable Surgical Gowns. AORN J. 2020;111(3):315-25.
  15. Mahapatra S, Rengarajan N. Use of recycled external fixators in management of compound injuries. Expert Rev Med Devices. 2017;14(1):83-5.
  16. Thamyongkit S, Bachabi M, Thompson JM, Shafiq B, Hasenboehler EA. Use of reprocessed external fixators in orthopaedic surgery: a survey of 243 orthopaedic trauma surgeons. Patient Saf Surg. 2018;12(1):1-7.
  17. Marchand KB, Taylor KB, Salem HS. Surgical Tray Optimization and Efficiency: The Impact of a Novel Sealed Sterile Container and Instrument Tray Technology. Surg Surg Technol Int. 2020;37:349-55.
  18. Farelly JS, Clemons C, Witkins S, et al. Surgical tray optimization as a simple means to decrease perioperative costs. J Surg Res. 2017;220:320-6.
  19. GOV.UK. NHS to reuse more medical equipment. [cited 2021 Oct 12]. Available from: www.gov.uk/government/news/nhs-to-reuse-more-medical-equipment.
  20. McLeod R. ASA Presidential Address: Greening the Operating Room. Ann Surg. 2021;274(3):403-5.
  21. P. Pavlou, J. Gardiner, D. Pili, E. Tayton. THE ENVIRONMENTAL INPACT OF LARGE JOINT ARTHROPLASTY. Orthopaedic Proceedings. 2018;92-B:Suppl.IV.
  22. Royal College of Physicians. Less waste, more health: A health professional’s guide to reducing waste. 2018 [cited 2021 Oct 11]. Available from: www.rcplondon.ac.uk/projects/outputs/less-waste-more-health-health-professionals-guide-reducing-waste.
  23. Royal College of Physicians. “Which waste bin?” - sustainability flow chart. [cited 2021 Oct 11]. Available from: www.rcplondon.ac.uk/projects/outputs/less-waste-more-health-health-professionals-guide-reducing-waste.
  24. Sherman JD, Thiel C, MacNeill A, et al. The Green Print: Advancement of Environmental Sustainability in Healthcare. Resour Conserv Recycl. 2020;161:104882.
  25. School of Surgery. How to be Greener in Surgery Part 1. 2021. [cited 2021 Oct 11]. Available from: www.podomatic.com/podcasts/schoolofsurgery.
  26. Centre for Sustainable Healthcare. Green Surgery Challenge. [cited 2021 Oct 14]. Available from: https://sustainablehealthcare.org.uk/what-we-do/green-surgery-challenge.