Can Orthopaedic Surgery Go Green? Environmental Footprint of Disposable Versus Reusable Instruments in TKA

The environmental impact of surgical instruments and procedures is attracting increasing attention. Single-use instruments are gaining adoption across various healthcare settings, including in orthopaedic surgery, because of their convenience and immediate availability. However, the replacement of reusable instruments, whether kept in stock (RI-S) or procured on loan (RI-L), with single-use instruments has raised obvious ecologic concerns, such as waste management, greenhouse gas emissions, and resource depletion.

Our study aimed (1) to assess the environmental impact (as estimated by acidification, climate change, freshwater eutrophication, water depletion, and resource depletion) of both single-use instruments and RI-S or RI-L employed in TKA procedures and (2) to identify whether one option is more ecologically sustainable (as determined by a life cycle assessment [LCA]).

A comprehensive LCA was conducted according to ISO 14040/44 guidelines to calculate the environmental impact of single-use instruments and reusable instruments by considering raw material extraction, manufacturing, distribution, reprocessing (where applicable), and end-of-life waste management. Data were collected both from a 5-year retrospective audit of the manufacturer and from our hospital's sterile facility. Reusable instruments were assessed under two scenarios: RI-S and RI-L. To determine which option was more ecologically sustainable, environmental impacts were quantified using the LCA software GaBi 6 TS and the LCA database Ecoinvent 3.5 and analyzed according to the International Reference Life Cycle Data System.

Our analysis of environmental impacts indicates that, per procedure, RI-S, RI-L, and single-use instruments were associated with 44.3, 66.5, and 62.9 kg CO 2 equivalent (eq), respectively. Single-use instruments had the lowest contribution to water depletion (6.3·10 -1 m 3 eq), while RI-S and RI-L accounted for 2.1 and 3 m 3 eq, respectively. Finally, regarding resource depletion, RI-S, RI-L, and single-use instruments corresponded to 5.2·10 -3 , 7.7·10 -3 , and 2.2·10 -3 kg Sb eq, respectively. The environmental impact of single-use instruments was mainly attributed to raw material production, which contributed to 73% of its carbon footprint and 64% of its total resource depletion impact. On the other hand, for reusable instruments, the sterilization phase was a major contributor to water depletion, accounting for 71% in RI-S and 80% in RI-L, as well as for carbon footprint, where it accounted for 35% in RI-S and 38% in RI-L. No single scenario outperformed across all environmental categories, with RI-L being the least favorable option. Both single-use instruments and RI-S involved tradeoffs. In comparison to RI-S, single-use instruments generated an additional 18.6 kg CO 2 eq per procedure, which is equivalent to an 85-km trip with a fuel-powered car, but saved 1.5 m 3 of water (corresponding to eight bathtubs).

Our analysis suggests that the RI-L should be avoided and that certain compromises should be made, whether utilizing RI-S or single-use instruments, because the environmental impact must be considered as a whole by looking at all impact categories. One approach would be to reduce the number of items in reusable instrument trays through patient-specific surgical planning. The other would be to use single-use instruments while trying to minimize other disposable consumables.

Given the high volume of orthopaedic surgeries, surgeons can contribute to environment protection by implementing greener practices. Strategies include using bespoke reusable instrument trays containing only the essential items for each procedure or employing single-use instruments while limiting other disposable consumables.