Bringing Sustainability to Orthopaedics: Greening the Future of Orthopaedics and Healthcare

The success of society and the orthopaedic specialty depends on how the planet’s limited resources are managed. Interest in sustainability in healthcare is growing, reflecting a broader recognition that protecting the environment promotes long-term well-being. The sustainable practice of orthopaedics is not only a consideration for the future but rather a tangible, time-sensitive matter that surgeons should address.

Why does ESG matter?
Environmental, social, and governance (ESG) considerations have emerged as the pillars of sustainability-focused reporting in major industries across the globe. Scrutiny of ESG performance is growing among regulatory bodies and conscious consumers. Environmental factors include water and waste management, energy production, and greenhouse gas emissions. Social concerns involve adherence to fair labor standards and the promotion of equity and human rights. Governance considerations assess how organizational leadership and systems design can enable sustainable change.

ESG reporting requires careful inspection, as it is susceptible to both bias and “greenwashing,” which is when sustainability reporting conveys a false appearance of progress. Nonetheless, genuine efforts to bolster environmental stewardship should be rewarded. Opportunities to promote sustainable orthopaedic practices in the clinical setting are outlined in Fig. 1.

Shifting perspectives in healthcare
Healthcare payment models have undergone a paradigm shift during recent years, with an increased emphasis on value and quality of care. Calculations of healthcare value require an assessment of total costs borne by patients and systems. There is, however, growing recognition that many healthcare costs are non-financial and are displaced to communities and the planet more broadly. This idea has led to the emergence of the sustainable “triple bottom line” concept: an inclusive cost assessment that incorporates the financial, environmental, and social costs borne by wider populations. This has potential ramifications for health system evaluations and reimbursement.

Emerging regulations reward companies making progress within sustainability metrics. In 2023, the Climate Corporate Data Accountability Act (S.B. 253) mandated emissions reporting in California. The European Union’s Corporate Sustainability Reporting Directive requires similar disclosures. The National Health Service in the United Kingdom has elected to adhere to an ambitious strategy aimed at reaching net zero emissions by 2040, with mandatory “Green Plans” for each health system. In early 2024, the Joint Commission launched a voluntary Sustainability Certification. This certificate includes three primary requirements: collection of baseline emissions data, development of an action plan to reduce emissions, and 24 months of data that demonstrate emissions reduction.

Innovations in orthopaedics
Working in one of the most resource-intensive specialties in medicine, orthopaedic surgeons can promote sustainable implant and supply design by making careful selections in the OR. Surgeons dictate most utilization trends and can encourage sustainable shifts in industry partners’ practices through feedback and usage patterns. Implant, tool, and tray selections are complex and multifactorial, reflecting the specific ergonomic needs and preferences of the surgeon, the anatomic variations of the patient, and the resources and contracts available within a specific health system. By adding ESG-related concerns to this list, surgeons can use their knowledge, influence, and purchasing power to promote sustainable products and companies.

Generally, it is best to limit the use of disposable devices in favor of reusable surgical items, with exceptions. This promotes circularity, which maximizes reuse while minimizing waste. Regrettably, the single-use device (SUD) market continues to grow, with many vendors promoting and health systems favoring their convenience and reduced burden on reprocessing facilities, as the entire kit can be thrown away rather than requiring time for cleaning and facilitating reuse. Further research and improvements are needed to reduce the burden of reprocessing and sterilization pathways, including tray optimization, water conservation, and increased reliance on renewable energy sources.

For surgeons who elect to use SUDs, opportunities are emerging to reprocess these items with significant associated savings in waste and cost. For SUDs not currently eligible for reprocessing, many contain components that may be reused; a burgeoning field of companies are buying back these items for reuse in medical and non-medical products.

Another important consideration for orthopaedic surgeons is minimizing overage (i.e., sterile items that are opened but unused). When surgeons and their teams evaluate and streamline trays, preference cards, and custom surgical packs, overage can be significantly reduced. Opening only essential items leads to lower consumption of energy and water during sterilization. Machine learning algorithms have been introduced to compare individual surgeons’ emissions and waste metrics based on their preference cards; such technology will enable systematic changes.

Surgical innovation is fueled by efforts to optimize outcomes for patients, and future efforts can be directed at optimizing outcomes for communities and for the planet as well. Medical supply companies have begun to re-imagine surgical instrumentation and supplies, and orthopaedic surgeons’ decisions to adopt or reject such technologies will largely determine their success. Surgeons have a responsibility to advocate for the reduction of the environmental impact of device creation, reprocessing, and disposal.

The discussion around environmental stewardship in healthcare has begun, and orthopaedic surgeons can lead this conversation. Environmental sustainability initiatives offer opportunities to reduce the environmental impact of orthopaedics while also increasing efficiency and mitigating the growing costs of healthcare in the United States.

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

Caellagh D. Catley, MD, is an orthopaedic surgery resident at Oregon Health and Science University in Portland, Oregon.

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

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

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

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