Bringing Sustainability to Orthopaedics: Greening the Individual and the Clinic

2023 was the warmest year on Earth since global records began being tracked in 1850. Rising temperatures and natural disasters have led to greater recognition of the negative impacts of all industries on the environment and the health of communities. Orthopaedic surgeons share a goal of improving patients’ health and quality of life. In the process of doing so, surgeons generate significant waste and emissions, some of which are redundant or unnecessary. There are meaningful opportunities to reduce the toll that the orthopaedic profession takes on the planet. Orthopaedic surgeons can lead the way toward greener, more efficient practices in their lives and workplaces. This article aims to inspire and empower members of the orthopaedic community to adopt green practices at home, in the clinic, in the OR, and as leaders in their communities.

Greening the individual
A carbon footprint is defined as the quantity of carbon dioxide–equivalent greenhouse gasses produced by an individual, population, business, or other entity. An individual’s total environmental impact includes a variety of factors, including waste, pollutant production, and resource consumption; however, carbon footprint is one of the most widely used and applicable metrics. Free calculators, such as UC Berkeley’s CoolClimate tool, estimate unique emission profiles for households and businesses and explore means of reducing emissions.

The most direct control individuals can have over climate change is in their own daily lives and behaviors. According to a survey by the American Psychological Association, more than two-thirds of Americans experience some degree of climate anxiety. Taking action is the most powerful response to the stress garnered from an uncertain future. Physicians have a commitment to public health and have the trust of their communities, offering a unique opportunity to learn about sustainable practices and to share them with their patients, workplaces, and communities.

Globally, carbon footprints tend to be inversely proportional to socioeconomic status. Ten percent of the world’s population emits 48 percent of global carbon emissions. Individuals with wealth, and therefore financial influence, should consider how to be good stewards of that privilege. Investments in sustainable funds, charities, and organizations empower broad change. Buying electricity from companies that utilize solar, wind, and geothermal energy promotes further investment and innovation in these areas. Purchasing goods from certified B Corps, companies committed to a positive environmental and social impact, pushes the market toward environmentally minded companies.

There remains room for significant improvement in individual emissions. The most impactful changes that an American can make toward a sustainable lifestyle are regarding transportation, electricity, and food.

Transportation is the most significant source of greenhouse gas emissions in the United States. Almost half of these emissions come from personal vehicles. Carpooling, taking public transportation, walking, biking, and reducing air travel are ways that all Americans can reduce their footprints. Although the production of a new electric vehicle (EV) requires 80 percent more greenhouse gas emissions than a gas-powered car, EVs and hybrids have less lifetime emissions than gas-powered cars. One model predicted that the carbon parity point at which a gas vehicle (Toyota Corolla) overtakes an EV (Tesla Model 3) in lifetime emissions ranges from driving the car 8,400 miles (EV charged with renewable hydropower in Norway) to 78,000 miles (EV charged with coal-fired plants in China or Poland).

The generation of electricity is the second greatest contributor to carbon footprints in the United States. Although wind and solar have overtaken fossil fuels as the cheapest primary sources of energy, more than half of the United States’ electricity is still generated from fossil fuels. Unplugging devices when not in use, turning off lights, and avoiding extreme thermostat settings represent easy opportunities to reduce electricity use at home. Replacing air conditioners and gas furnaces with heat pumps can simultaneously reduce a home’s carbon footprint and save money in most cities. To hasten the transition to renewable energy sources, people can also sign up for green pricing programs or have solar panels installed.

Finally, food must be considered in one’s carbon footprint. More than 30 percent of food in the United States is wasted. Thoughtful grocery shopping and meal preparation and prioritization of local food sources and plant-based foods can help reduce emissions.

Greening the clinic
Orthopaedic clinics have an appreciable carbon footprint, stemming from transportation, energy use, and material purchasing and disposal. Reducing that environmental impact often leads to cost savings, which is an important motivator for medical centers. Transportation of staff and patients to and from clinic visits is a substantial source of carbon emissions. One life-cycle assessment demonstrated that 99 percent of emissions from an average orthopaedic office visit result from the patient’s commute. Surgeons can encourage patients and staff to walk or cycle, use public transit, carpool, or use an EV. Building bus stops, bicycle racks, and EV charging stations near the clinic can make sustainable travel more feasible.

Emissions can also be reduced by restructuring traditional clinic formats. Telehealth visits eliminate emissions from patient travel and save time for patients and providers. Patients who have stable injuries, live in remote locations, or have an uncomplicated postoperative course all benefit from this option. Following the pandemic, telehealth often reimburses at the same or a similar level as an in-person office visit. Satellite clinics can substantially reduce travel distances for patients. One Veterans Affairs satellite clinic in California shortened patient commutes by an average of 60 miles per appointment.

Like in the home, energy use can be optimized in the office. Staff can be encouraged to turn off lights and computers at the end of the day, and automation via timers or motion sensors makes this practice much easier. Relaxing climate controls during off hours is especially impactful. Surgeons can advocate for the importance of sustainability and align with administrators who have the power to teach staff and implement environmentally friendly changes in clinic practices.

Finally, it is important to consider material usage and disposal to minimize both carbon footprint and waste generation from the clinic. Healthcare saw a massive shift from reusable to disposable items in the 1980s during the HIV/AIDS epidemic. Because only 5 percent of “recycled” plastic in the United States is turned into new items, surgeons should focus on eliminating non-essential items and transitioning to reusable items wherever possible. Appropriately separating regular waste (clear bag) from biohazard waste (red bag) is important because processing of the latter is much more energy intensive and expensive. Even removing the needle from the syringe before putting the needle in the sharps container will avoid unnecessary and costly processing of syringes. Educational signage can cue staff to properly separate waste.

Small changes in daily habits at home and at work add up to significant reductions in individual carbon footprints. Modeling such behaviors can promote awareness and adoption by colleagues, patients, and friends in other specialties. Important changes can be made without sacrificing the quality of care orthopaedic patients receive. Several sustainable clinic practices (summarized in Table 1) not only reduce waste and emissions but also promote efficiency and reduce costs. By making small changes, orthopaedic surgeons can help turn the tides in favor of a healthier, greener future for themselves, their patients, and future generations.

Ian D. Engler, MD, is an orthopaedic sports medicine surgeon at Central Maine Medical Center in Lewiston and Auburn, Maine.

Katherine Velicki, MD, is an orthopaedic surgery resident at Oregon Health and Science University in Portland, Oregon.

Laura L. Bellaire, MD, is a pediatric orthopaedic and spine surgeon at the University of Utah in Salt Lake City, Utah.

Lorraine A.T. Boakye, MD, is an orthopaedic foot and ankle surgeon at the University of Pennsylvania in Philadelphia.

Jason R. Saleh, MD, is an orthopaedic surgeon at VA Palo Alto, California.

1. NASA: NASA Analysis Confirms 2023 as Warmest Year on Record. Available at: https://www.nasa.gov/news-release/nasa-analysis-confirms-2023-as-warmest-year-on-record/. Accessed May 8, 2024.
2. Saleh J, Mitchell A, Kha S, et al: The environmental impact of orthopaedic surgery. JBJS 2023;105(1):74-82.
3. Parker E, Bluman A, Pruneski J, et al: American Orthopaedic Foot and Ankle Society Annual Meeting all-in-person attendance results in immense carbon expenditure. CORR 2023;481(12):2469-80.
4. Barker NDJ, Tukkers C, Nelissen RGHH: What’s important (arts and humanities): shouldn’t our GOAL! be to find a better way? J Bone Joint Surg Am 2024;106(7):639-42.
5. Engler I, Curley A, Fu F, et al: Environmental sustainability in orthopaedic surgery. J Am Acad Orthop Surg 2022;30(11):504-11.
6. Brander M: Greenhouse Gases, CO2, CO2e, and Carbon: What Do All These Terms Mean? Available at: https://ecometrica.com/assets/GHGs-CO2-CO2e-and-Carbon-What-Do-These-Mean-v2.1.pdf. Accessed May 8, 2024.
7. CoolClimate Network. CoolClimate Calculator. Available at: https://coolclimate.berkeley.edu/calculator. Accessed Jan. 28, 2024.
8. U.S. Environmental Protection Agency: Carbon Footprint Calculator. Available at: https://www3.epa.gov/carbon-footprint-calculator. Accessed Jan. 28, 2024.
9. Collier S: If climate change keeps you up at night, here’s how to cope. Available at: https://www.health.harvard.edu/blog/is-climate-change-keeping-you-up-at-night-you-may-have-climate-anxiety-202206132761#. Accessed Jan. 21, 2024.
10. Chancel L: Global carbon inequality over 1990–2019. Nat Sustain 2022;5:931-8.
11. Gates B: How to Avoid a Climate Disaster: The Solutions We Have and the Breakthroughs We Need. New York, NY: Knopf Doubleday Publishing Group; 2021.
12. Moseman A: Are electric vehicles definitely better for the climate than gas-powered cars? Available at: https://climate.mit.edu/ask-mit/are-electric-vehicles-definitely-better-climate-gas-powered-cars. Accessed Jan. 21, 2024.
13. Lienert P: When do electric vehicles become cleaner than gasoline cars? Available at: https://www.reuters.com/business/autos-transportation/when-do-electric-vehicles-become-cleaner-than-gasoline-cars-2021-06-29/. Accessed Jan. 21, 2024.
14. Hall D, Pavlenko N, Lutsey N: Beyond road vehicles: survey of zero-emission technology options across the transport sector. Available at: https://theicct.org/publication/emerging-policy-approaches-to-electrify-ride-hailing-in-the-united-states/. Accessed May 8, 2024.
15. U.S. Energy Information Administration: Frequently Asked Questions (FAQs). Available at: https://www.eia.gov/tools/faqs/faq.php?id=427&t=3. Accessed Jan. 21, 2024.
16. International Energy Agency: Renewables 2023: Executive Summary. Available at: https://www.iea.org/reports/renewables-2023/executive-summary#. Accessed Jan. 21, 2024.
17. U.S. Department of Agriculture: Food Waste FAQs. Available at: https://www.usda.gov/foodwaste/faqs. Accessed Jan. 21, 2024.
18. Heller M, Keoleian G: Greenhouse gas emissions estimates of U.S. dietary choices and food loss. J Ind Ecol 2015;19(3):391-401.
19. Thiel CL, Mehta N, Sejo CS, et al: Telemedicine and the environment: life cycle environmental emissions from in-person and virtual clinic visits. NPJ Digit Med 2023;6(1):87.
20. Saleh JR: The environmental impact of a satellite clinic in a veterans health system. Presented at the AAOS 2023 Annual Meeting, Las Vegas, Nevada, March 7-11, 2023.
21. Jenkins JM, Halai M: CORR synthesis: what evidence is available for the continued use of telemedicine in orthopaedic surgery in the post-COVID-19 era? Clin Orthop Relat Res 2021;479(4):747-54.
22. Kagoma Y, Stall N, Rubinstein E, et al: People, planet and profits: the case for greening operating rooms. Can Med Assoc J 2012;184(17):19905-11.
23. Sullivan L: Recycling Plastic Is Practically Impossible—and the Problem Is Getting Worse. Available at: https://www.npr.org/2022/10/24/1131131088/recycling-plastic-is-practically-impossible-and-the-problem-is-getting-worse. Accessed May 8, 2024.