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

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

“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’.

Reduce

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 Calculator’¹⁰ 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.

Reuse

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 infection^13,14. 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 arthroplasty^17,18.

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.

Recycle

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.

Conclusion

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.

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