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Fig. 1 Comparison of greenhouse gas emissions
Courtesy of Alec S. Kellish, BS

AAOS Now

Published 3/24/2021
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Alisina Shahi, MD, PhD; Alec S. Kellish, BS; Haley Tornsberg, BS; Lawrence Miller, MD, FAAOS

What Is Orthopaedic Surgery’s Environmental Impact?

Health care is one of the largest sectors of the U.S. economy, accounting for nearly 18 percent of the gross domestic product, with more than $3.5 trillion in annual spending. U.S. healthcare spending is an important issue, with a global economic and environmental impact. Although orthopaedic surgery encompasses a significant component of healthcare spending, the environmental impact of the specialty is poorly described.

A carbon footprint quantifies environmental impact and greenhouse gas emissions (GHGE), providing an estimate of the direct and indirect GHGE associated with the process of creating and using a product or service. The carbon footprint of the U.S. healthcare sector contributes to 8 percent of the nation’s total GHGE. Hospitals themselves account for a third of the environmental impact and are the sector’s largest contributor to acidification, smog, air toxins, and ecotoxicity. Energy demand and anesthetic choice have been shown to contribute to 88 percent of the carbon footprint of ORs; the average carbon footprint per OR per year was found to be 146 kg to 232 kg CO2 equivalents (CO2e) per case.

In 2020, Cooper University Hospital, a tertiary level 1 trauma center, completed approximately 4,800 orthopaedic surgeries. Utilizing previously published data (average CO2e per case, 189 kg CO2e; reported by MacNeil et al.), the authors of that article estimated that orthopaedic surgery procedures alone have contributed more than 909 metric tons of CO2e. This amount is the equivalent of more than 102,000 gallons of gasoline or driving 196 cars for one year (Fig. 1), but this may underestimate the true production, as procedures such as open hysterectomies produce 285 kg CO2e on average without using implants and with an operative time of less than two hours.

The anesthetic chosen is a significant source of GHGE, as some halogenated anesthetics have 2,000 times (200,000 percent) the global warming potential of CO2, which is significantly greater than regional anesthetics. Neuraxial and peripheral nerve blocks are often used for orthopaedic procedures and contribute significantly less GHGE. In 2019, Hospital for Special Surgery (HSS) performed 96 percent of its primary arthroplasty procedures under regional anesthesia, reducing the amount of GHGE from those procedures by the equivalent of 27,000 pounds of coal. Although the study performed at HSS demonstrates the feasibility of dramatically reducing the use of desflurane in favor of regional anesthesia, those strategies may not be applicable to smaller institutions that lack the resources to incorporate such widespread change. As the number of orthopaedic procedures is expected to continue to increase, a shift toward more environmentally friendly anesthetics could lead to massive reductions in GHGE.

Only a few studies have evaluated waste generation and the carbon footprint of orthopaedic surgery, with only a handful examining the footprint of individual surgical specialties. Alam et al. found that the average amount of waste generated by orthopaedics was 154 kg, 60 percent greater than the next closest hospital service. A 2018 study by Pavlou et al. found that an average of 5.2 kg of noncontaminated waste is generated per primary arthroplasty procedure, 99 percent of which is recyclable. Similarly, Southorn et al. found that the average waste generated from total hip arthroplasty was 12.0 kg, 5.8 kg of which is recyclable; for total knee arthroplasty, the number was 11.6 kg of waste, 5.3 kg of which is recyclable. This finding represents an area for significant improvement with both economic and environmental benefits. Proper recycling of the waste generated from arthroplasty procedures alone could reduce the carbon footprint by 75 percent—the equivalent of millions of kilograms of waste.

Another area where orthopaedic surgeons could improve their carbon footprints is through optimization of their surgical trays and recycling of hardware, such as external fixators. Reducing the number of redundant or unnecessary instruments on a tray decreases not only tray weight but also the number of trays that need to be reprocessed, with Marchand et al. finding a cost savings exceeding $249,000 annually. The “lean and green” surgery initiative from the American Association of Hand Surgery, an initiative aimed at reducing surgical cost and waste without compromising patient care and safety, has already been implemented at various institutions, decreasing turnover time between cases by nearly an hour, while simultaneously decreasing the number of trays and saving the institutions thousands of dollars. That initiative serves as an excellent example of the resourcefulness of orthopaedic surgeons to streamline surgical procedures and reduce environmental impact without compromising patient care. In contrast, although recycling orthopaedic hardware is cost-effective and environmentally friendly, it raises concerns over infection risk and patient safety.

The environmental impact of health care is a critical issue and must be addressed to minimize the carbon footprint, especially because procedure volumes are expected to continue to rise. With orthopaedic surgery having one of the highest procedure volumes performed annually, the responsibility of pushing surgeons to adopt more environmentally friendly practices falls on orthopaedic surgeons. Although few studies have quantified the carbon footprint of orthopaedic surgeries, studies aimed at improving process efficiency and cost-effectiveness have been performed and may unintentionally reduce GHGE. Orthopaedic surgery is a significant contributor of GHGE, and the specialty must take steps to determine and reduce its carbon footprint.

Alisina Shahi, MD, PhD, is currently a post-graduate year-3 in the orthopaedic surgery residency program at Cooper University Hospital in Camden, N.J., and plans to pursue a career in joint reconstruction with an interest in complex revisions and periprosthetic joint infections.

Alec S. Kellish, BS, is currently a fourth-year medical student at Cooper Medical School of Rowan University in Camden, N.J., and is planning to pursue a career in orthopaedic surgery.

Haley Tornsberg, BS, is currently a medical student at Cooper Medical School of Rowan University in Camden, N.J., and is planning to pursue a career in orthopaedic surgery.

Lawrence Miller, MD, FAAOS, is a senior orthopaedic surgeon at Cooper Bone and Joint Institute. His practice mainly consists of complex sport-related procedures, including meniscal transplants. He is also an avid environmentalist.

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