Abstract
Aims
This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices.
Methods
Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries.
Results
The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices.
Conclusion
This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices.
Cite this article: Bone Jt Open 2024;5(9):742–748.
Take home message
This study calculated the carbon footprint of a total hip arthroplasty within a UK hospital.
It also serves a starting point for tackling the environmental global impact of surgery and healthcare.
Introduction
The escalating concern over global climate change necessitates a comprehensive evaluation of carbon emissions across various sectors, including healthcare.1-3 As societies strive to transition to a sustainable future, it is imperative to examine the environmental impact of healthcare practices and identify areas where improvements can be made.4 Within the realm of healthcare, joint arthroplasty surgery has gained considerable attention due to its widespread use and potential for significant carbon emissions.5
Hailed as the operation of the century, total hip arthroplasty (THA) has witnessed an exponential growth over the years.6,7 The ageing population, coupled with the rising prevalence of musculoskeletal conditions, has led to an increased demand for these surgeries.8 While joint arthroplasty surgeries undoubtedly improve patients’ quality of life, there is growing recognition that the environmental consequences associated with these procedures must be considered.9 There is, however, a lack of comprehensive data pertaining to the carbon footprint of this commonly performed orthopaedic procedure.
Understanding the environmental impact of joint arthroplasty surgery is crucial for healthcare professionals, policy-makers, and patients alike.10,11 It allows us to make informed decisions and implement sustainable strategies within the orthopaedic community. By quantifying and evaluating the carbon footprint associated with these procedures,12 we can identify areas for improvement and propose sustainable interventions without compromising patient outcomes.
This study aims to evaluate the carbon footprint of THA by adopting a life-cycle assessment approach. By understanding the environmental consequences of these procedures, we can drive the adoption of sustainable orthopaedic practices, reduce carbon emissions, and contribute to the global effort to combat climate change.
Methods
This study evaluted the carbon footprint associated with a THA patient’s journey from anaesthetic room to transfer to recovery room. Data were collected prospectively during ten primary hybrid (Stryker Trident and Exeter; Stryker, USA) and ten uncemented R3 and Polar stem; Smith & Nephew, UK) THAs from June to August 2023 at a single hospital (Wrexham Maelor Hospital, Wrexham, UK) under spinal anaesthesia supplemented with sedation. The carbon emissions were divided into different components, including anaesthesia, surgical instruments, and consumables.
We focused on scope 1 and scope 2 emissions,13 which encompass direct emissions and energy consumption. Scope 3 emissions, which include manufacturing, transport, and waste management, were not included due to the unavailability of accurate manufacturing cost information from the industry.
A detailed inventory of each component involved in THA was created. The information for each item was based on the type of material used. Items such as surgical instruments, implants, and drapes were individually weighed using a calibrated digital weighing machine to obtain accurate measurements. The carbon factors for hip trays were divided by 2,040 to give an accurate estimate in line with a previous study.14 Each case observed in this study was attended by three anaesthetic colleagues, three members of the surgical team who scrubbed in, and three more support staff, in a laminar airflow theatre situated within an orthopaedic theatre suite.
Scope 1 emissions for inventory items were calculated using life-cycle carbon factors,using life-cycle carbon factors, published by the Centre for Sustainable Healthcare.15 Scope 2 emissions, linked to operating theatre energy consumption, included lights, ventilation, heating, water, and resterilization for each THA (Table I). The energy consumed from lights was estimated, combining the operating lights, and the ambient lights in operating, anaesthetic, and scrub rooms. The energy consumed for heating was estimated for a volume of 210 m3 of theatre suite for 90 minutes (which was the average time taken to perform a THA). The water usage for each case was calculated by measuring scrub time with a full tap flow system by all the theatre scrub team. The laminar airflow (Howmedica (now Stryker, USA) ExFlow 90) use for the full day was divided by the number of cases per day to give an estimate of the energy use directly from the ventilation unit. The energy used during resterilization was estimated by multiplying the number of cycles required to complete the resterilizing of the hip trays. All this information was converted into CO2-equivalent emissions.
Table I.
Scope 2 calculations in this study.
| Variable | Watts | Number | Duration, mins | kwH | Footprint kg CO2e |
|---|---|---|---|---|---|
| Operating light | |||||
| Halogen (ALM X ten) | 100 | 128 | 12.8 | 2.98 | |
| LED (KLS Matrin marLED) | 24 | 104 | 2.496 | 0.58 | |
| Non-operating lights T5 Longlast GE F49W | 49 | ||||
| Theatre | 44 | 3.234 | 0.75 | ||
| Anaesthetic room | 12 | 0.882 | 0.2 | ||
| Prep room | 4 | 0.294 | 0.06 | ||
| Ventilation | |||||
| Howmedica ExFlow 90 | 90 | 13 | 3.03 | ||
| Heating (British Thermal Unit calculation) | |||||
| Volume | 210 m3 | 90 | 24 | 5.59 | |
| Water consumption | |||||
| Handwash | |||||
| First case | 14 l | ||||
| Subsequent | 8 l | ||||
| Average per case | 9.5 l | X 3 people | 28.5 l | 8.49 | |
| 1 l = 0.298 Co2 | |||||
| Sterilization cost | |||||
| 11 trays - 2 cycles | 1.531 | X11 | 16.84 | ||
| Total | 37.7 |
We measured the clinical waste generated after each case and divided this into recyclable and non-recyclable waste (Figure 1).
Fig. 1
Waste generated from packaging alone in a total hip arthroplasty.
Results
The carbon footprint for a THA, categorized by different areas within the operating theatre, is as below.
The consumables used in the anaesthetic room included syringes, needles, cannulas, masks, and drugs administered for anaesthesia induction. The cumulative carbon footprint of these consumables for each THA amounted to 3.05 kg CO2e (Table II). This did not include the carbon footprint from the manufacturing of the anaesthetic drugs.
Table II.
Anaesthetic consumable related carbon footprint during a total hip arthroplasty.
| Variable | Weight, kg | Conversion factor | Footprint kg CO2e |
|---|---|---|---|
| Anaesthetic room | |||
| 50 ml syringe (plastic) | 0.036 | 4.49 | 0.16 |
| 20 ml syringe (plastic) | 0.016 | 4.49 | 0.07 |
| 10 ml syringe (plastic) | 0.007 | 4.49 | 0.03 |
| Blunt needle × 2 | 0.002 | 6.145 | 0.01 |
| Spinal needle (plastic + metal) | 0.002 | 6.145 | 0.01 |
| 20 G cannula (plastic + metal) | 0.007 | 6.145 | 0.04 |
| Spinal anaesthesia administration set | 0.15 | 4.49 | 0.67 |
| ChloraPrep wand | 0.013 | 4.49 | 0.06 |
| Cannula dressing | 0.001 | 4.49 | 0.01 |
| Hudson mask and tubing (plastic) | 0.063 | 4.49 | 0.28 |
| Y connector (plastic) | 0.048 | 4.49 | 0.22 |
| IV fluids 500 ml (plastic bag) | 1.08 | 4.49 | 0.17 |
| Prefilled metaraminol syringe | 0.002 | 4.49 | 0.01 |
| 200 mg propofol vial (glass) | 0.034 | 0.1277 | 0.01 |
| 10 ml 0.5% levobupivacaine (plastic) | 0.017 | 4.49 | 0.07 |
| 5 ml 1% lidocaine (plastic) | 0.01 | 4.49 | 0.04 |
| 1.5 gm cefuroxime (glass) | 0.034 | 4.49 | 0.12 |
| 80 mg gentamicin × 3 (glass) | 0.006 × 3 = 0.018 | 4.49 | 0.08 |
| 500 mg TXA × 4 (glass) | 0.006 × 4 = 0.024 | 4.49 | 0.1 |
| 30 mg ketorolac (glass) | 0.006 | 4.49 | 0.02 |
| 100 ml paracetamol infusion (plastic) | 0.13 | 6.145 | 0.79 |
| 20 mmol MgSO4 (plastic) | 0.014 | 6.145 | 0.08 |
| Total | 3.05 |
-
IV, intravenous; TXA, tranexamic acid.
In total, 77 out of 78 items in the operating theatre excluding surgical trays were single-use items. This included scrub brushes, gowns, covers, and various ancillary items required for surgical preparation. Four scrub gowns were used per THA, one by the anaesthetist while performing spinal anaesthetic and three by the surgical team (surgeon, assistant, and scrub nurse). These preparatory consumables for each THA contributed to a total carbon footprint of 3.46 kg CO2e (Table III).
Table III.
Carbon footprint of preparatory consumables.
| Variable | Material | Weight, kg | Conversion factor | Footprint kg CO2e |
|---|---|---|---|---|
| Scrub brush × 3 | Polypropylene | 0.016 × 3 = 0.048 | 4.49 | 0.22 |
| Gowns × 4 (3 surgeons + 1 anaesthetist) | Non-woven polypropylene | 0.282 × 4 = 1.128 | 0.905 | 1.02 |
| Hood covers × 3 | Plastic + polypropylene | 0.125 × 3 = 0.375 | 4.49 | 1.68 |
| Hair trimmer blade | Metal + plastic | 0.005 | 4.49 | 0.22 |
| Slide canvas | Polypropylene | 0.205 | 4.49 | 0.92 |
| ChloraPrep stick | Hard plastic + cotton | 0.07 | 4.49 | 0.31 |
| Total | 3.46 |
Intraoperative consumables such as drapes, draping materials, surgical instruments, sutures, dressings, and gloves were required for the surgical procedure. Their collective carbon footprint for each THA was 17.24 kg CO2e (Table IV).
Table IV.
Intraoperative consumables related carbon footprint in total hip arthroplasty.
| Variable | Material | Weight, kg | Conversion factor | Footprint kg CO2e |
|---|---|---|---|---|
| Green U drape | Polypropylene | 0.16 | 4.49 | 0.72 |
| Ioban × 2 | Polypropylene | 0.096 × 2 = 0.192 | 4.49 | 0.86 |
| Saw blade | Metal | 0.025 | 6.145 | 0.15 |
| Pulse lavage | Polypropylene | 0.842 | 4.49 | 3.78 |
| Pulse lavage extension brush | Polypropylene | 0.041 | 4.49 | 0.18 |
| Diathermy tip | Metal | 0.257 | 6.145 | 1.58 |
| Diathermy pad | Polypropylene | 0.016 | 4.49 | 0.1 |
| Marker pen | Plastic | 0.01 | 4.49 | 0.04 |
| 2.5 mm drill bit | Metal | 0.011 | 6.145 | 0.1 |
| Aqueos chlorhex wash | 1.1 | 0.1277 | 0.96 | |
| Chlorherxidine | Plastic | 0.559 | 4.49 | 2.51 |
| Normal saline wash | 3.198 | 0.1277 | 0.17 | |
| Mepliex surgical dressing | Plastic + cotton | 0.018 | 4.49 | 0.08 |
| Elective local (drugs + 3 needles and syringe) | Hard plastic+ stainless steel | 0.22 | 4.49 | 0.99 |
| Surgeon gloves × 15 | Polypropylene | 0.035 × 15 = 0.525 | 4.49 | 2.36 |
| Cement restrictor | Plastic | 0.223 | 4.49 | 1.0 |
| Blue pressuriser | Polypropylene | 0.043 | 4.49 | 0.19 |
| Size 10 suction catheter | Polypropylene | 0.012 | 4.49 | 0.05 |
| Ribbon gauze | Cotton | 0.029 | 6.78 | 0.20 |
| Palacos R40 Cement | PMMA | 0.34 | 8.43 | 2.86 |
| Total | 17.24 |
-
PMMA, polymethyl methacrylate.
The hip pack, including drapes, bowls, needles, syringes, and other necessities, made a substantial contribution to the carbon footprint for each THA at 21.41 kg CO2e (Table V).
Table V.
Constituents of a hip pack and their carbon footprint.
| Variable | Material | Weight, kg | Conversion factor | Footprint kg CO2e |
|---|---|---|---|---|
| Hip Pack | ||||
| Drape 150 × 240 cm | Polypropylene | 0.271 | 4.49 | 1.22 |
| Hip drape | Polypropylene | 1.133 | 4.49 | 5.09 |
| Adhesive op sheet 260 × 175 cm | Polypropylene | 0.334 | 4.49 | 1.50 |
| Op sheet 90 × 150 cm x 4 | Polypropylene | 0.102 × 4 = 0.408 | 4.49 | 1.83 |
| Table covers 150 × 190 cm x 3 | Polypropylene | 0.185 × 3 = 0.55 | 4.49 | 2.49 |
| Bowls 500 ml × 2 (plastic) | Plastic | 0.035 × 2 = 0.07 | 4.49 | 0.31 |
| Hypodermic needle | Hard plastic + stainless steel | 0.002 | 6.145 | 0.01 |
| Bowls 250 ml × 5 (plastic) | Plastic | 0.01 × 5 = 0.05 | 4.49 | 0.22 |
| Blades 23 × 2 | Stainless steel | 0.001 × 2 = 0.002 | 6.145 | 0.01 |
| Spinal needle | Hard plastic + stainless steel | 0.002 | 6.145 | 0.01 |
| 60 ml syringe × 4 | Plastic | 0.033 × 4 = 0.132 | 4.49 | 0.59 |
| Sharp holder set (plastic) | Plastic | 0.049 | 4.49 | 0.22 |
| Bandage 15 cm | Cotton | 0.064 | 6.78 | 0.43 |
| Suction cannula | Polypropylene | 0.016 | 4.49 | 0.07 |
| Suction tubing | Polypropylene | 0.141 | 4.49 | 0.63 |
| 5 × gauze (7.5 × 10 cm) | Wool | 0.004 × 5 = 0.02 | 6.78 | 0.14 |
| 10 × gauze (30 × 30 cm) | Wool | 0.019 × 10 = 0.19 | 6.78 | 1.29 |
| Light handle covers × 2 | Plastic | 0.004 × 2 = 0.008 | 4.49 | 0.04 |
| Skin stapler | Stainless steel | 0.07 | 6.145 | 0.43 |
| Diathermy holder | Plastic | 0.05 | 4.49 | 0.22 |
| Kidney bowls 800 ml × 2 | Plastic | 0.034 × 2 = 0.068 | 4.49 | 0.31 |
| Stockinette 31 × 122 cm | Polypropylene + wool | 0.141 | 6.78 | 1.00 |
| Mayo stand cover 79 × 145 cm reinforced × 3 | Polypropylene | 0.178 × 3 = 0.534 | 4.49 | 2.40 |
| Tray wrap 130 × 150 cm plastic | Polypropylene | 0.117 | 4.49 | 0.53 |
| Plastic outer cover | Plastic | 0.091 | 3.31 | 0.30 |
| Blade size 23 | 0.001 | 6.145 | 0.006 | |
| Ethibond no. 5 | Stainless steel + suture material | 0.009 | 4.49 | 0.04 |
| Vicryl no. 2 × 2 | 0.007 | 4.49 | 0.031 | |
| Vicryl 2/0 | 0.004 | 4.49 | 0.017 | |
| Prolene on straight needle | 0.004 | 4.49 | 0.017 | |
| Monocryl 3/0 | 0.004 | 4.49 | 0.017 | |
| Skin glue | Plastic | 0.004 | 4.49 | 0.017 |
| Total | 21.41 |
Table VI.
Carbon footprint of the surgical instruments used in a hybrid total hip arthroplasty.
| Variable | Material | Weight, kg | Conversion factor | Footprint kg CO2e | Divided by 2,040 |
|---|---|---|---|---|---|
| Uncemented instruments | |||||
| Basic hip 1 | Stainless steel | 4.2 | 6.145 | 25.81 | 0.002 |
| Basic hip 2 | Stainless steel | 4.7 | 6.145 | 28.89 | 0.002 |
| Extra instruments | Stainless steel | 3.15 | 6.145 | 19.36 | 0.001 |
| Stryker drill | Stainless steel | 4.8 | 6.145 | 29.50 | 0.002 |
| R3 Instruments | Stainless steel | 9.3 | 6.145 | 57.15 | 0.003 |
| R3 reamers | Stainless steel | 7.6 | 6.145 | 46.70 | 0.002 |
| R3 trials | Stainless steel | 7.9 | 6.145 | 48.54 | 0.002 |
| Polar stem instruments | Stainless steel | 13.6 | 6.145 | 83.58 | 0.004 |
| Trial liner sets | Stainless steel | 4.14 | 6.145 | 25.44 | 0.001 |
| Mallet heavy | Stainless steel | 1.08 | 6.145 | 6.34 | 0.001 |
| Total | 0.02 |
Table VII.
Carbon footprint of the surgical instruments used in a hybrid total hip arthroplasty.
| Variable | Material | Weight, kg | Conversion factor | Footprint kg CO2e | Divided by 2,040 |
|---|---|---|---|---|---|
| Uncemented instruments | |||||
| Basic hip 1 | Stainless steel | 4.2 | 6.145 | 25.8 | 0.002 |
| Basic hip 2 | Stainless steel | 4.7 | 6.145 | 28.881 | 0.002 |
| Extra instruments | Stainless steel | 3.15 | 6.145 | 19.356 | 0.002 |
| Stryker drill | Stainless steel | 4.8 | 6.145 | 29.496 | 0.002 |
| Exeter hip femoral Instruments | Stainless steel | 7.3 | 6.145 | 44.858 | 0.004 |
| Exeter modular rasps | Stainless steel | 9.3 | 6.145 | 57.148 | 0.005 |
| Trident reamers | Stainless steel | 4.1 | 6.145 | 25.194 | 0.002 |
| Trident instruments | Stainless steel | 7.8 | 6.145 | 47.931 | 0.004 |
| Trident liner impactor | Stainless steel | 0.378 | 6.145 | 2.322 | 0.0001 |
| Exeter plug trial sets | Stainless steel | 4.162 | 6.145 | 25.575 | 0.002 |
| Contemporary remaers | Stainless steel | 7.14 | 6.145 | 43.875 | 0.003 |
| Cement vaccum | Stainless steel | 3.37 | 6.145 | 20.708 | 0.001 |
| Cement gun extension | Stainless steel | 0.149 | 6.145 | 0.915 | 0.0005 |
| Mallet heavy | Stainless steel | 1.08 | 6.145 | 6.636 | 0.0005 |
| Charnley weight and chain | Stainless steel | 1.475 | 6.145 | 9.063 | 0.0007 |
| Total | 0.03 |
Reusable instrument sets – comprising basic hip sets, R3 instruments, and Polar stem instruments in an uncemented THA – make a minimal contribution, with a combined carbon footprint of 0.02 kg CO2e (Tables V and VII). This was 0.03 kg CO2e in hybrid THA, using the Trident Exeter for each case. We found that 112 (66%) out of 170 instruments were not used regularly during THA.
We could not accurately calculate the emissions related to manufacturing of the implants and cement due to a lack of information available from the industry.
Surgical waste assessment revealed distinct categories: unclean, non-recyclable clinical waste; recyclable waste; and biological waste. For uncemented THA cases, the average waste was 13.5 kg (73% non-recyclable, 12% recyclable, 15% biological), resulting in a carbon footprint of 20 kg CO2e. Hybrid THA cases had an average waste of 14.8 kg, contributing to a carbon footprint of 22 kg CO2e (Table VIII).
Table VIII.
Waste generated for each total hip arthroplasty in this study.
| Case | Black (non-recyclable), kg | Black (recyclable), kg | Yellow (clinical waste), kg | Biological waste, kg | Sharps, kg | Suction canister, kg | Total, kg |
|---|---|---|---|---|---|---|---|
| 1 | 2.8 | 1.28 | 5.5 | 0.32 | 0.38 | 0.85 | 11.13 |
| 2 | 4.5 | 1.92 | 10.3 | 0.17 | 0.46 | 0.88 | 18.23 |
| 3 | 3.9 | 1.56 | 6.4 | 0.23 | 0.96 | 0.58 | 13.63 |
| 4 | 3.0 | 1.8 | 5.1 | 0.33 | 0.89 | 1.1 | 12.22 |
| 5 | 2.4 | 1.28 | 8.8 | 0.34 | 0.25 | 0.64 | 13.71 |
| 6 | 2.4 | 1.58 | 7.7 | 0.55 | 0.59 | 0.45 | 13.27 |
| 7 | 2.5 | 2.03 | 7.3 | 0.12 | 0.36 | 1.22 | 13.53 |
| 8 | 3.4 | 2.02 | 6.8 | 0.2 | 0.43 | 0.68 | 13.53 |
| 9 | 1.7 | 2.18 | 6.8 | 0.46 | 0.47 | 0.51 | 12.12 |
| 10 | 3.7 | 1.54 | 7.2 | 0.3 | 0.53 | 0.84 | 14.11 |
| 11 | 1.2 | 0.99 | 8.9 | 0.7 | 0.48 | 0.30 | 12.57 |
| 12 | 3.7 | 1.4 | 7.3 | 0.4 | 0.27 | 0.73 | 13.80 |
| 13 | 5.6 | 3.13 | 9.3 | 0.6 | 0.63 | 0.87 | 20.13 |
| 14 | 3.8 | 1.71 | 7.1 | 0.4 | 0.38 | 1.2 | 14.59 |
| 15 | 3.1 | 1.8 | 9.1 | 0.3 | 0.31 | 0.83 | 15.44 |
| 16 | 2.9 | 1.7 | 8.0 | 0.4 | 0.54 | 0.9 | 14.44 |
| 17 | 3.8 | 1.61 | 6.0 | 0.6 | 0.55 | 1.2 | 13.76 |
| 18 | 5.2 | 1.74 | 5.9 | 0.4 | 0.56 | 1.07 | 14.87 |
| 19 | 3.0 | 1.52 | 7.4 | 0.4 | 0.45 | 0.53 | 13.30 |
| 20 | 3.5 | 2.4 | 8.8 | 0.2 | 0.13 | 0.77 | 15.80 |
Scope 2 emissions attributable to energy consumption during THA arise from various sources, including water usage, resterilization, electricity consumption, ventilation (inclusive of laminar airflow), and heating. The total scope 2 emissions were 37.7 kg CO2e for each THA (Table I). Among these, resterilization and water usage stood out as the primary contributors, accounting for 45% (16.84 kg CO2e) and 22% (8.50 kg CO2e) of scope 2 emissions, respectively. We found that change from halogen to LED operating theatre lights reduced the energy consumption by 81% (from 2.98 to 0.58 kg CO2e).
When considering all the components mentioned above, the cumulative carbon footprint associated with an uncemented THA amounted to 100.02 kg CO2e and this increased marginally to 104.89 kg CO2e in a hybrid THA. This can be compared to driving 600 miles in a diesel car. It requires five trees for one year to capture 100 kg CO2e.
Discussion
In this study, we have reported the carbon footprint of a THA inside an operating theatre. These findings not only shed light on the immediate carbon emissions associated with surgery, but also serve as a starting point for considering the broader ecological consequences of orthopaedic healthcare practices.
The carbon footprint of joint arthroplasty surgery extends beyond the operating theatre, encompassing various stages along the surgical pathway. These include preoperative activities such as diagnostic tests, consultations, and pre-surgical planning, as well as intraoperative procedures, postoperative care, and rehabilitation. Each stage contributes to the overall carbon emissions, resulting from energy-intensive processes, transportation, sterilization practices, anaesthesia administration, waste generation, and the sourcing of materials and implants.
Our study emphasizes the prevalence of single-use items in operating theatres, with 77 out of 78 items, excluding patient-monitoring equipment, designated for single use. This trend, initially driven by concerns about Creutzfeldt-Jakob disease transmission during adenotonsillectomy procedures,16 led to the growth of a £3.7 billion disposable surgical device market by 2020.17 Despite environmental concerns and proven advantages of reusable gowns in impact penetration,18 water resistance, and a 93% reduction in solid waste production,19 hesitations persist due to infection risk and adherence to established norms.
Streamlining preassembled hip packs to minimize unnecessary items can have a positive impact on both cost and environmental sustainability. We found that approximately 66% of surgical instruments in our hip trays were not routinely used. Collaboration among surgical teams is pivotal to formalizing these trays effectively. Several studies highlight that this can reduce the carbon footprint of a surgical procedure by approximately one third.14,20 Considering optional trial trays for acetabular shell and liners can contribute to inventory reduction. Familiarity with these systems plays a crucial role in their successful implementation. Preoperative templating can enhance surgical precision while minimizing waste. Innovative technologies such as patient-specific instrumentation and robot-guided surgery may have a carbon-intensive footprint, but their long-term benefits in reducing single-use instruments and improving surgical outcomes should be carefully considered. Evaluating the environmental impact of these technologies is critical in assessing their long-term sustainability benefits.
Addressing the issue of poor waste-recycling practices in the UK healthcare system is paramount. Several studies have highlighted the need for proper segregation of recyclable waste in the operating theatre.20-23 We found that a THA case on average generated 14.1 kg of waste, of which only 12% was recyclable. Implementing separation at the source and providing dedicated spaces for different waste streams in the planning of new or existing operating theatre facilities can facilitate effective waste segregation.
Several important limitations must be acknowledged when interpreting the results of this study. One notable constraint lies in the exclusion of scope 3 emissions from the analysis. Emissions from implant manufacturing, transportation, and waste contribute considerably to the carbon footprint. The lack of precise manufacturing cost data hampered inclusion of scope 3 emissions in this study. Cappucci et al24 reported 56.4 kg CO2e to be associated with the manufacturing of a titanium femoral stem prosthesis by an additive manufacturing process. Addressing this limitation would provide a more holistic view of the environmental impact and a much larger number of CO2 emissions associated with THA. Better engagement, transparency, and innovation focused on sustainability by leading industry partners is crucial to measure the real impact of this procedure.
Additionally, variations in energy consumption and cost data across different healthcare settings may influence the generalizability of the study’s findings. Recognizing these variations is crucial, as it underscores the need for context-specific sustainability initiatives tailored to individual healthcare facilities.
The estimated carbon emissions for uncemented THA stand at approximately 100.02 kg CO2e, with a minor increase to 104.89 kg CO2e for hybrid THA. The study identifies actionable areas for reducing carbon emissions, including energy-efficient buildings, transitioning to LED lighting, instrument rationalization, improving waste-recycling practices, and educating healthcare teams on sustainability.
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Author contributions
P. Kodumuri: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing
P. Joshi: Data curation, Formal analysis, Writing – review & editing
I. Malek: Data curation, Formal analysis, Methodology, Writing – review & editing
Funding statement
The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: Awyr Las North Wales Charity.
ICMJE COI statement
I. Malek discloses lecture fees from Bonesupport that are unrelated to this work.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request
Open access funding
The authors report that the open access funding for this manuscript was self-funded.
© 2024 Kodumuri et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
