Greening orthopaedics: A surgeon's call for sustainability

By Preetham Kodumuri
Consultant Orthopaedic Hand and Wrist Surgeon

In the fast-paced world of orthopaedics, where the mending of bones and restoration of mobility reign supreme, there's an often-overlooked shadow looming in the background—a carbon footprint. As surgeons, we wield precision instruments to heal, but it's high time we turned our attention to the environmental consequences of our craft.

Orthopaedics, with its heavy reliance on implants, labour-intensive production processes, transportation, and disposal costs, contributes significantly to the colossal carbon footprint of the healthcare sector. It's our duty as healthcare professionals not only to empower patients with preventative health practices but also to encourage our colleagues to reshape clinical procedures, reducing the clinical waste generated in hospitals.

Within the realm of healthcare, the surgical carbon footprint casts a long shadow, accounting for up to 70% of the total within an acute hospital. The operating theatre, the heart of surgical practice, bears the brunt of this environmental burden.

Orthopaedics, as the third-largest surgical specialty in the UK, holds a substantial share of this responsibility. 825,000 operative orthopaedic procedures were performed in the UK in 2021–22. However, we face a pressing issue—limited knowledge regarding the carbon emissions associated with common orthopaedic procedures.

The plastic predicament

Plastic, the primary villain in the healthcare sector's carbon footprint, poses a dire threat to our environment. Of the staggering 8,300 million metric tonnes of virgin plastic produced, only 30% remains in use. The rest pollutes our oceans as plastic soup, litters landfills as indestructible microplastics, and even finds its way into the human body, raising concerns about health impacts.

Toxic compounds associated with plastics have been discovered in numerous consumer products, linking microplastics to cancer, diabetes, and developmental toxicity. The rise of disposable surgical instruments, driven initially by fears of iatrogenic CJD transmission, has evolved into a £3.7 billion industry in 2020. But with such growth comes a pressing need for a cultural shift in the procurement, utilisation, and disposal of surgical consumables.

The healthcare industry, including the NHS, faces a moral obligation to embrace ethical procurement practices. Companies committed to fair trade and humane working conditions should take precedence in the supply chain. The UK Government's 'Supplier Registration Service' supports this endeavour, encouraging shared decision-making within departments and fostering a commitment to sustainable healthcare.

Greening operating theatres

Operating theatres, although physically small within a hospital, account for a disproportionate 20–30% of an institution's waste. The largest portion of this waste arises from poorly managed packaging and consumables, such as items that are often unused, inadequately segregated, and inefficiently recycled or disposed of.

Reusable instruments, gowns, and drapes provide a more sustainable, triple-bottom-line solution for patients, the planet, and profits. Small changes within the operating theatre, such as streamlining surgical instrument trays and drapes, can significantly reduce the carbon footprint (Figures 1 and 2).

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Figure 1. Carpal tunnel surgical set rationalisation.

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Figure 2. Reduction in the drapes and minimal use of single use items.
Pioneering sustainable hand surgery: The lean and green model

In the ongoing quest for sustainability within the medical field, the 'lean and green' model applied in hand surgery has emerged as a beacon of innovation. This model, guided by principles of environmental responsibility, has led to transformative techniques like WALANT (Wide Awake Local Anesthesia No Tourniquet), which serve as shining examples of sustainable healthcare practices. These approaches provide efficient patient care but also reduce waste and energy consumption, thereby lessening the environmental impact of surgical procedures.

The adoption of the lean and green model has ushered in a remarkable era of sustainability in hand surgery. Studies and real-world applications have shown that this approach can significantly reduce the carbon footprint associated with routine hand surgical procedures.

One of the primary contributors to this reduction is the streamlining of essential surgical instruments and the utilisation of smaller drapes. By avoiding the unnecessary excess of surgical tools and materials, surgeons practicing the lean and green approach are making a substantial reduction in the carbon footprint of carpal tunnel release by 80% (Figure 3). This streamlined approach minimises energy-intensive production processes and reduces the waste generated, aligning perfectly with sustainable healthcare principles. In comparison to traditional surgical methods, the lean and green approach proves to be approximately two-thirds cheaper (Figure 4).

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Figure 3. Significant reduction of carbon footprint of carpal tunnel release by 80% by applying lean and green model.

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Figure 4. Cost analysis of a lean and green model prove to be 2/3 cheaper per each case.


The impact of adopting sustainable hand surgery practices reaches far beyond the operating room. It sends a powerful message to the medical community and society. Furthermore, the success of these sustainable practices serves as a compelling example for other surgical specialties and medical disciplines to follow suit. It highlights that innovative solutions exist to reduce the carbon footprint of healthcare without compromising the quality of patient care (Figure 5).

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Figure 5. The Triple Bottomline of positive impact of sustainable systems within healthcare.

Greener patient pathways

Patient, staff, and visitor travel contribute significantly to the NHS's carbon footprint, costing £345 million and impacting society annually. Streamlining patient pathways, promoting one-stop clinics, and utilising remote and virtual consultations can reduce hospital visits, thereby shrinking the carbon footprint.

Digitisation is a powerful tool for reducing the carbon footprint. Electronic letters, appointments, investigations, and referrals not only save paper but also improve carbon efficiency. Despite ambitious targets, only a fraction of NHS hospitals have achieved full digitisation.

Energy consumption in healthcare buildings, particularly for heating and lighting, contributes to 10% of the carbon footprint. Hospitals often lose significant energy during non-working hours, highlighting the need for better energy management.

Cultivating a culture of sustainability

For sustainable change to take root, it must permeate every facet of clinical practice. A culture of sustainability requires engagement from all stakeholders, from leadership to the staff on the ground. Sustainability should thread through every clinical encounter and decision.

As we stand on the precipice of a climate crisis, the need for sustainable healthcare has never been more urgent. The orthopaedic community, by embracing sustainability, can lead the charge towards a greener future. Let our legacy be one of healing not only individuals but also our precious planet, leaving a healthier world for generations to come.