Sustainability in foot and ankle surgery: Top tips and review of practices

Abstract

Orthopaedic surgery, particularly in foot and ankle procedures, generates significant waste, with the World Health Organization highlighting the potential for greener healthcare to benefit patient and worker health. This article reviews sustainability in foot and ankle surgery through the three pillars: Environmental, social, and economic. It examines cost-effective surgical practices, resource utilization, and operating theatre routines, noting the environmental impact of orthopaedic surgeries, such as the carbon emissions of up to 23.96 kg per lower limb arthroplasty. A gap in sustainability research specific to foot and ankle surgery was identified. Based on a narrative literature review of relevant studies, recommendations were developed for more sustainable practices in foot and ankle operations, including theatre practices, pre-operative setup, and post-operative care. The review collaborates existing literature to provide practical recommendations for optimizing surgical outcomes while reducing environmental impact.

Key Words: Foot and ankle; Sustainability; Orthopaedic surgery; Green surgery; Planet

Core Tip: The article covers the use of implants in foot and ankle surgery, with an emphasis on balancing effective outcomes and sustainability. The article critically analyzes the cost-effectiveness and necessity of laminar airflow in every case. It questions whether this infection prevention system is always needed, given its expense, and whether there are scenarios where it might not offer significant benefits. There’s a focus on using reusable drapes and patient setup devices to reduce waste in the operating room, aligning with more sustainable practices. The article explores eco-friendly alternatives for post-operative immobilization and casting, aiming to reduce the environmental impact of traditional materials.

INTRODUCTION

Orthopaedics, amongst all surgical specialities, produces the most waste associated with operative procedures themselves[1,2]. The World Health Organization states greener health care operations can generate patient and worker health benefits while also saving energy, mitigating climate risks and creating long-term cost savings[1]. This article reviews the three pillars of sustainability - environmental, social and economic from a foot and ankle point of view[1]. This includes cost-effective alternative surgical practices, review of utilisation of resources and addresses current routines in the operating theatre. Existing literature on the environmental impact of orthopaedic surgeries from lower limb arthroplasty quotes CO₂ emissions of up to 23.96 kg per procedure[2]. We identified a gap in the literature on sustainability measured in foot and ankle surgery. Our recommendations are focused on foot and ankle operations, theatre practices, pre-operative setup routines, and post-operative care. We rigorously reviewed our practices with existing literature and have formulated recommendations for optimal surgical outcomes with sustainable benefits[3-6].

A narrative literature review was conducted to identify publications addressing sustainability in surgical practice. Searches were performed in PubMed and Google Scholar using title-based keywords related to sustainability (e.g., sustainability, environmental impact, carbon footprint, waste reduction, green surgery) combined with surgery, orthopaedics, and foot and ankle. Titles were screened for relevance, and articles focusing on environmental sustainability, resource utilisation, or waste reduction in surgical or peri-operative settings were included. Reference lists of key articles were hand-searched to identify additional sources. Peer-reviewed articles, reviews, guidelines, and relevant English-language grey literature were considered. Findings were synthesised narratively to inform the practical recommendations and “Top Tips” presented in this review.

OPERATIVE PRACTICES

Evidence-based operative practices are fundamental in any form of surgery. Practices ranging from procedure selection to the routine use of equipment packaged in multiple layers of plastic were examined through a review of the existing literature and evaluation of current practice.

Instrument trays and sterilisation

Parker et al[7] demonstrated that reconfiguration of surgical instrument sets to include only essential items allowed for the elimination of excess drapes and towels. This work highlights how more selective equipment choice in foot and ankle surgery may reduce unnecessary resource use without compromising operative standards. Consideration of instrument selection may be incorporated into the team brief, supported by the Royal College of Surgeons England Green Surgery Checklist[8]. For procedures associated with a low risk of infection, such as excision of simple skin and soft tissue lesions and other minor operations, the use of smaller instrument trays with minimal draping and swabs may be appropriate. Importantly, no changes to surgical site preparation or operative technique were reported in this study[8].

Choice of procedures

We conducted our own research on one such more sustainable and effective procedure. Two operative techniques were compared for Scarf Osteotomies for the first metatarsal. This included long (two screws) vs short (one screw) scarf osteotomy for hallux valgus correction. The cost of a two-screw scarf osteotomy was pounds sterling 395.14 compared to a single-screw osteotomy costing pounds sterling 197.57. The cost and the packaging used/opened are doubled for a double screw osteotomy vs a single screw osteotomy[9-11]. This study showed that the single-screw scarf osteotomy is non-inferior to the two-screw scarf osteotomy. Although these findings have not been widely proven, two-screw scarf osteotomies cost roughly double that of single-screw scarf osteotomies[12]. This highlights a potential approach to reducing healthcare expenditures while maintaining patient care through financial and sustainable solutions. Based on this example, we would encourage foot and ankle surgeons to conduct reviews of their own surgical practices, including procedures, equipment and operative techniques to ensure foot and ankle surgery remains sustainable in the long term[12].

Laminar flow systems

Laminar flow: In orthopaedic practices, we use Laminar flow air filtration systems primarily for procedures involving implant-based surgery. Commonly used in arthroplasty but not exclusive to, Laminar flow systems offer air changes of up to 300 times an hour and thus reduce colony forming units/m cubed of bacteria. Turning off laminar flow when not required is a safe alternative. Turning off theatre ventilation systems overnight has shown to save 15-36 tonnes of CO₂e/year per theatre[13] as well as an estimated cost saving of pounds sterling 30000 per theatre per year. Furthermore, foot and ankle surgeons carry out procedures that may not involve inserting metalwork or implants. For these cases, being mindful of the need for laminar flow would need to be considered, given the infection risk of the procedure and the patient. Research from the British Orthopaedic Association evaluated the use of Laminar flow in lower-limb arthroplasty, and its role in reducing infection rates is still unclear[3]. There is a case to be put forward for low infection risk cases not need Laminar flow. These include, but are not limited to, cases that do not involve implants, metalwork or insertion of foreign material - removal of metalwork, excision of soft tissue lesions such as Morton’s neuroma, Lipoma excision and other smaller soft tissue procedures.

Tourniquet use for lower limb surgery

Tourniquets - it is common practice to use limb tourniquets for foot and ankle elective and trauma procedures. There are British Orthopaedic Association guidelines[14] on the careful use of tourniquets in lower limb (and upper limb) operating. However, reusable tourniquets can provide a cost-effective, greener alternative in foot and ankle surgery when appropriate[4]. They need to be cleaned thoroughly to prevent cross-infection between patients. In cases where thorough cleaning is not possible, they would need to be discarded. Being mindful of safe and effective tourniquet use following British Orthopaedic Association Standards for Trauma guidelines[14] and re-using thoroughly cleaned tourniquets can be cost-effective and reduce waste in lower limb operations.

Positioning adjuncts and operating table devices

Limb supporting devices are often used to elevate the operating limb into a different plane than the contralateral limb for adequate image intensifier exposure. A sandbag or hip elevation bump is used to provide internal rotation of the limb to gain better access to the lateral side of the lower leg, ankle and foot. This generally tends to be non-sterile and re-usable making it a sustainable part of our daily operative practice. A sterile bump is often used[6] to elevate the patient’s leg or foot to avoid the contralateral limb in the image intensifier’s line of X-ray. A sterile bump can be created by using 1 or 2 drapes wrapped around a pack of swabs or a sterile gown set and secured with sterile tape. With waste associated with additional drapes, packs and kidney-dishes taken into account for this, we utilise non-sterile positioning adjuncts such as a cushioned platform and/or radiolucent triangles positioned prior to preparation and draping. Reusable devices, such as positioning adjuncts, can significantly reduce waste. In our hospital, we recommend a modular component of the operating table (positioning cushion) as an elevation device, which proved equally adequate.

Consumables and drapes

Typical positioning and draping of foot and ankle surgeries involve isolating the tourniquet from the operative area, paramount to stop prep solution from seeping under the tourniquet. The carbon footprint of drapes (disposable vs reusable) and clinical effectiveness have been studied recently[12] and found re-usable cloth drapes were not inferior to disposable drapes. This is an area currently up for discussion, and a final consensus has not yet been reached. Other research has shown reusable gowns are approximately 25% the cost of disposable gowns, which may result in less waste output and landfill use. However, cost-effective methods of laundering would need to be implemented[12].

At our hospital, we use disposable drapes but are conscious of the carbon footprint involved and are systematic with the number and size of drapes used. The purpose and utilisation of draping in our routine foot and ankle surgeries are described below: (1) Priority of the drape is to isolate the tourniquet from the sterile field. This is often done using a non-sterile “U-shaped” drape; (2) Once this is on the limb in routinely prepped with cleaning solution. An approach drape can be used to prevent contamination of gowns when preparing the limb; (3) The toes are often isolated with a sterile glove or swab and tape to prevent contamination from toes in towards the operating site; (4) Drapes required include: Non-sterile “U-shaped” isolation drape - to prevent cleaning solution seeping under the tourniquet; approach drape (large square to cover the end of the table when preparing). Used to prevent decontamination of the surgeon by the table; a holed drape for the limb; and small tape or small adhesive drape around the hole to prevent the hole sliding up and down; and (5) A total of 4 drapes - non-sterile × 1 and sterile × 3 are the minimum required for typical foot and ankle surgery. Further drapes and sterile covers are used to protect the C-arm of image intensifiers. We recommend the above drapes and, in particular, the use of a holed drape or U drapes, which provide an adequate sterile circumferential seal. This can reduce the number of drape packages opened, thus reducing plastic waste as well as providing strict sterility and infection control.

Post-operative immobilisation and supports

Immobilisation of the operated limb can be required after several foot and ankle procedures. Methods of immobilisation include, but are not limited to: Boots, shoes and plaster casts. One study that analysed the cost effectiveness of boots vs plaster showed[10] the difference was negligible and can be left to the patient and clinicians’ discretion. Furthermore, a more recent study showed that using a boot could be more cost-effective than a plaster cast for patients requiring lower limb immobilization[10]. We do not require specialised shoes such as a Barouk shoe or Podalux shoe for lesser toe operations. The British Orthopaedic Foot and Ankle Society published results on no superior outcomes for specialised shoes vs standard post-operative shoes in patient outcomes after forefoot surgery[15,16]. We recommend the use of a standard post-operative shoe, which can be cheaper and more environmentally friendly.

The relevant shoes are described below: (1) Barouk shoe is a rigid, rocker-bottom postoperative shoe that offloads the forefoot by shifting weight to the heel. Commonly used after forefoot surgeries like bunion or toe procedures; (2) Podalux shoe is lightweight postoperative shoe with a flat, stiff sole that distributes pressure evenly across the foot. They are used for general foot protection after surgery or injury; and (3) Standard post-operative shoes are simple, open-toe shoes with a semi-rigid sole designed to protect dressings and allow limited weight-bearing.

LIMITATIONS AND IMPROVEMENTS

Further areas of detailed analysis are required, including calculating accurate carbon footprints of the kit used for different procedures, as this would help illustrate to surgeons the environmental impact (long and short term) of simple surgical practices, whilst at the same time providing optimal patient outcomes. We acknowledge geographical based cost and usage policies will differ between hospitals, regions, and countries, and hence we have shared our practices locally to serve as a discussion point for foot and ankle surgeons.

CONCLUSION

We conclude this review of current literature and top tips to improve sustainability in foot and ankle surgery by providing 5 key take-home messages to change practices in foot and ankle surgery. This is summarised in Table 1 below.

Table 1 Providing 5 key take-home messages to change practices in foot and ankle surgery.

Areas of improvement	Current practices	Recommendations
Operative practices	Standard surgical techniques are used routinely without consideration of sustainability impacts	Consider lower-impact alternatives that maintain clinical effectiveness (e.g., single-screw fixation where appropriate)
Theatre set-up	Routine use of laminar flow for all cases	Review the need for laminar flow in low-risk, non-implant procedures
Positioning adjuncts	Frequent use of single-use items for positioning adjuncts	Prioritise the use of reusable positioning adjuncts over single-use sterile alternatives where feasible
Drapes	Standard draping practices may involve multiple disposable drapes without procedure-specific consideration	Optimise drape type, size, and number; consider reusables
Post-operative immobilisation	Device choice driven by habit or availability	Review policies to improve cost-effectiveness and reduce carbon footprint