By Gareth Chan1, Lucy Sinclair2, Chantelle Rizan3, Stephen Bendall4, Mahmood F Bhutta5 and Benedict Rogers6

1Specialty Registrar, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Lecturer, Brighton & Sussex Medical School.
2Clinical Librarian, University Hospitals Sussex NHS Foundation Trust.
3ENT Research Fellow, University Hospitals Sussex NHS Foundation Trust, Surgical Research Fellow, Royal College of Surgeons of England, Honorary Clinical Lecturer, Brighton & Sussex Medical School.
4Consultant Orthopaedic Surgeon, University Hospitals Sussex NHS Foundation Trust.
5Honorary Consultant ENT Surgery & Green Lead, University Hospitals Sussex NHS Foundation Trust, Chair in ENT Surgery, Brighton & Sussex Medical School.
6Consultant Orthopaedic Surgeon, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Professor, Brighton & Sussex Medical School.

Corresponding author e-mail: [email protected]

Published 18th October

The drive to improve sustainability in all aspects of our lives has never been greater, with calls for action galvanised by the upcoming United Nations Climate Change Conference (COP26) which will be held on the backdrop of 38 countries declaring a climate emergency1.  Climate change poses a threat to both planetary health and public health, and over 200 health journals recently published a joint editorial warning of ‘catastrophic harm to health’ from climate change2.  Despite this surgery, and healthcare in general, remains one of the last sectors to address its own considerable environmental impact; the NHS overall accounts for 4-5% of the country’s carbon emissions; equivalent to Croatia’s total annual emissions3.  Furthermore, the COVID-19 pandemic has highlighted our reliance on single-use plastics and its associated carbon footprint4, with around 200,000 tonnes carbon dioxide equivalents generated per year associated with distribution of personal protective equipment for use by health and social care services in England during the pandemic5.  

The Royal College of Surgeons of England has sought to lead this drive by forming the 'Sustainability in Surgery' group to guide the embedding of all three elements of the triple bottom line of sustainability (environmental, financial, and social sustainability) into all aspects of surgical life6.  Both the British Orthopaedic Trainees Association (BOTA) and Association of Surgeons in Training (ASiT) have developed clear sustainability aims, but this has not yet permeated through to the National Speciality and Sub-Speciality organisations such as the British Orthopaedic Association (BOA). 

A recent systematic review by Rizan et al. of eight studies evaluating the carbon footprint of surgical operations found the largest source of greenhouse gas emissions were electricity consumption (for maintenance of the operating theatre environment), single-use items, and anaesthetic gases7.  This indicates a particular challenge for orthopaedic surgeons given the maintenance of laminar flow operating theatres in conjunction with use of large volumes of single-use items (in particular gowns, hoods, surgical drapes, alongside items such as cement mixers, pulsed lavage systems and electrosurgical devices).

Single-use items contribute significantly to the approximately 14Kg of waste generated from a standard primary total knee replacement (TKR), with the bulk of this attributable to plastic wrappers, gowns, drapes and covers8.  Surgical activity generates up to 70% of a hospital’s total waste9, with large volumes of waste indicative of high carbon burden (associated with upstream emissions involved in the raw material extraction, manufacture, distribution, and downstream waste disposal). 'Overage', the number of items opened and/or prepared for an operation but not used10, adds not only to the financial costs of an operation but to its carbon footprint.  For a TKR this is commonly due to unused sterile gloves, swabs and gowns8.  Attempts have been made to reduce overage in routine hand surgery with the development of 'minimal pack[s]' of key surgical instruments resulting in a 55% reduction in instrument costs but also a 13% reduction in waste (by kilogram) generated11.  Such initiatives should be made standard practice if surgeons are to meaningfully reduce our carbon footprint.  However, an even greater impact would be made if we substituted single-use equipment with reusable equivalents12, including those commonly used before the single-use plastic healthcare market explosion13.  It behoves us to rise to meeting this behaviour change.

As the widely lauded World War II scientist Rear Admiral Grace Hopper said “the most dangerous phrase in the language is, 'we’ve always done it this way'”, and this may reflect some of the decisions we make with regards to clinical practice.  The commonly cited 1987 study by Lidwell et al. for the use of laminar flow theatres, reported the incidence of prosthetic joint infections to be lower in patients given peri-operative antibiotics and treated in standard air flow theatres compared to those without antibiotics in laminar flow theatres14.  A recent meta-analysis by Gastmeier et al. hinted that laminar flow may in fact be associated with higher prosthetic joint infection rates15.  With NICE recently reporting the evidence for laminar flow theatres to be “low to very low quality” and the air systems analysed in the 1980s to be different to those utilised in modern-day theatres.  As such the NICE review committee refused to draw firm conclusions on the use of ultra-clean air (e.g. laminar flow) form the available RCT data16.  Despite this, most arthroplasty surgeons would at the very least hesitate, if not refuse to operate in a non-laminar flow theatre. 

Surgical practice is not immune to wider environmental issues, and we require collective action from across the orthopaedic community to transition to sustainable modes of surgical delivery using an evidenced-based approach.  The status quo simply cannot continue.  The BOA in conjunction with Brighton and Sussex Medical School, are seeking to quantify the perceptions and willingness of Orthopaedic Surgeons to consider changes in clinical practice to mitigate their carbon footprint.  A questionnaire will soon be disseminated via BOA communications, and the team would be grateful for your engagement in how we tackle “the biggest threat to security modern humans have ever faced”17.


  1. Fiona Harvey, ‘UN Secretary General Urges All Countries to Declare Climate Emergencies’ The Guardian (2020). Available at:
  2. Wise J. Climate Crisis: Over 200 Health Journals Urge World Leaders to Tackle “Catastrophic Harm”. BMJ. 2021 Sep 5;374:n2177.
  3. NHS England (2020). Delivering a “Net Zero” National Health Service. Available at:
  4. European Environment Agency (2021). COVID-19 and Europe’s Environment: Impacts of a Global Pandemic. Available at:
  5. Rizan C, Reed M, Bhutta MF. Environmental Impact of Personal Protective Equipment Distributed for Use by Health and Social Care Services in England in the First Six Months of the COVID-19 Pandemic. J R Soc Med. 2021 May;114(5):250-63.
  6. Royal College of Surgeons of England (2021). Sustainability in Surgery Strategy 2021. Available at:
  7. Rizan C,  Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The Carbon Footprint of Surgical Operations: A Systematic Review. Ann Surg. 2020 Dec;272(6):986-95.
  8. Stall NM, Kagoma YK, Bondy JN, Naudie D. Surgical Waste Audit of 5 Total Knee Arthroplasties. Can J Surg. 2013 Apr;56(2):97-102.
  9. PACIFIC ENVIRONMENTAL SERVICES INC HERNDON VA. Medical Waste Incinerator Waste Management Plan: Malcom Grow Medical Center, Building 1056, Andrews Air Force Base, Maryland. Available at:
  10. Rosenblatt WH, Chavez A, Tenney D, Silverman DG. Assessment of the Economic Impact of an Overage Reduction Program in the Operating Room. J Clin Anesth. 1997 Sep;9(6):478-81.
  11. Thiel CL, Carvalho RF, Hess L, Tighe J, Laurence V, Bilec MM, Baratz MMinimal Custom Pack Design and Wide-Awake Hand Surgery: Reducing Waste and Spending in the Orthopedic Operating Room. Hand (N Y). 2019 Mar;14(2):271-6.
  12. Drew J, Christie SD, Tyedmers P, Smith-Forrester J, Rainham D. Operating in a climate crisis: a state-of-the-science review of life cycle assessment within surgical and anesthetic care. Environ Health Perspect. 2021;129(7):07600.
  13. Rizan C, Mortimer F, Stancliffe R, Bhutta MFPlastics in Healthcare: Time for a Re-Evaluation. J R Soc Med. 2020 Feb;113(2):49-53.
  14. Lidwell OM, Elson RA, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Ultraclean Air and Antibiotics for Prevention of Postoperative Infection: A Multicenter Study of 8,052 Joint Replacement Operations. Acta Orthop Scan. 1987 Feb;58(1):4-13.
  15. Gastmeier P, Breier AC, Brandt C. Influence of Laminar Airflow on Prosthetic Joint Infections: A Systematic Review. J Hosp Infect. 2012 Jun;81(2):73-8.
  16. National Institute for Health and Care Excellence (2020). Joint Replacement (Primary): Hip, Knee and Shoulder. [I] Evidence Review for Ultra-Clean Air. NICE guideline NG157. Available at:
  17. United Nations Security Council (2021). Climate Change “Biggest Threat Modern Humans Have Ever Faced”, World-Renowned Naturalist Tells Security Council, Calls for Greater Global Cooperation. Available at: