How Can We Make Hand Surgery Carbon Neutral?

Abstract

Background

Climate change is a major public health threat worldwide. Operating theaters are responsible for extensive waste production due to the resource-intensive nature of surgery, including hand surgery.

Methods

An online literature search was performed to ascertain the approaches that surgeons may undertake to positively impact the environment.

Results

Surgeons can make hand surgery more carbon neutral through various measures that have been categorized as pre-, intra-, and postoperative interventions. With all changes, the aims are to minimize waste and costs while optimizing patient outcomes.

Conclusions

Administrative obstacles to implementing pro-climate hospital changes may be overcome by also considering likely cost benefits with many environmentally friendly measures. New measures in hand surgery should consider patient safety, clinical efficacy, cost effectiveness, and the environmental impact.

Introduction

Climate change is a major threat to all living things worldwide. Global warming due to human activities so far has caused intense heatwaves, storms, and floods, as well as the evolution of new infectious diseases. ¹ Human activities are currently estimated to result in a further global temperature increase of 1.5^oC between 2030 and 2052. ² Such changes may increase disease and mortality, force populations to migrate elsewhere and obliterate entire ecosystems. The Intergovernmental Panel on Climate Change caution that to minimize the worst effects of climate change with a 1.5^oC increase, a 50% fall in carbon dioxide emissions is needed by 2030. ²

The healthcare industry in England (National Health Service [NHS]) produced 25 megatons of carbon dioxide in 2019. ³ The majority of emissions (59%) are from procurement, with 22% of emissions arising from building energy use and 18% from travel. ⁴ Operating rooms are the source of approximately 25% to 50% of all hospital waste. ⁵ Such extensive waste production is due to the resource-intensive nature of surgical procedures, including hand surgeries. This is a sector within the healthcare system with opportunities to reduce carbon dioxide emissions. The goals are to reduce waste, optimize patient safety, improve patient satisfaction, and minimize costs.

Preoperative Interventions

Anesthetic gases alone account for over 2% of NHS emissions. ⁶ Of these, desflurane is one of the most commonly used and most harmful agents with a global warming effect equivocal to burning 440 kg of coal. ⁶ University Hospitals Bristol Trust are encouraging the use of lower carbon agents such as sevoflurane in patients requiring general anesthesia. ⁶ In some patients requiring hand surgery, it is possible to entirely avoid general anesthesia. Wide-awake local anesthesia no tourniquet (WALANT) involves injection of lidocaine and adrenaline into a surgical site to exert local analgesic and vasoconstrictive effects. ⁷ WALANT has been safely used in the management of hand injuries including fractures, tendon injuries, carpal tunnel, and cubital tunnel syndromes.^8,9 Its ease of use enables some surgeries to be performed in a minor operating room, reducing facility and material waste that would otherwise occur in a major operating theater. During the coronavirus crisis, the British Society for Surgery of the Hand and British Orthopaedic Association supported the use of WALANT in the management of urgent orthopedic hand conditions.^10,11 Compared with general anesthesia, patients receiving WALANT have a shorter postoperative hospital stay and reduced analgesic needs, further minimizing hospital energy consumption. ¹² Cost analyses also demonstrate a benefit with WALANT for hand procedures. ¹² Increased use of WALANT in hand surgery may therefore effectively reduce carbon emissions while also saving hospital costs and optimizing patient care.

Hand injuries necessitate surgical intervention, careful screening of patients requiring surgery in main rather than minor theater reduces hospital waste. Cases that may be performed in a minor operating theater setting include nail bed injuries, carpal tunnel release, some fracture fixations, and some dogbites. ¹³

Carbon emissions may also be reduced through the concept of “minor field sterility.” This involves a single drape, mask and gloves without a surgical gown or antibiotics. ¹³ It is estimated to generate one-tenth of the waste resulting from standard hand surgeries in main theaters. ¹³ The safety and low infection risk with minor field sterility was demonstrated in a multi-center study of 1504 carpal tunnel releases. All cases were performed using this approach with no resulting deep infections and only 6 superficial infections. ¹³

Preparing surgical packs preoperatively is another intervention to minimize waste. Van Demark et al re-designed their surgical packs to specifically include only the instruments required for hand surgeries. Over a 2-year period including 1,099 hand cases this lead to a 2.8-ton decrease in waste production and cost savings of $13,250. ¹⁴ Similarly, Thiel et al demonstrated a 13% reduction in waste and 55% cost-saving by performing hand surgeries using WALANT with custom packs instead of with sedation and standard surgical packs. ¹⁵ Unused instruments from standard packs can also be donated to hospitals in developing countries for re-use.

Re-use of medical devices within a hospital would further reduce hospital waste and expenses. Single-use devices were introduced due to concerns regarding risk of blood-borne-virus transmission with re-use of devices. ¹⁶ However, plastic surgery devices such as biopsy forceps, carpal tunnel blades, burrs, trocars, and pneumatic tourniquets may be safely re-used. ¹⁷ Though not as effective at preventing infections as disposable drapes, re-use, and washing of surgical gowns is also a safe measure that halves energy used and reduces solid waste production. ¹⁸

Intraoperative Interventions

Hand surgeries involve bone, ligaments, tendons, nerves, and blood vessels. Carbon emissions and waste may be reduced when handling each of these tissue types. Bone fracture fixation devices used for the hand include K-wires and various plates and screws. When using double-ended K-wires, often only one end is used by the surgeon with the remainder discarded. Waste can be minimized by judicious use of available equipment. Carbon emissions may also be reduced by careful selection of the materials used intra-operatively. Plates and screws are most commonly made from stainless steel and titanium alloys. Stainless steel implants contain nickel and molybdenum to provide strength, chromium to resist in-vivo corrosion, and a low carbon content to minimize inter-granular corrosion. ¹⁹ Titanium implants contain Ti-6Al-7Nb and Ti-6Al-4v alloys. ¹⁹ Alternatives to these devices include implants made from biomaterials. Examples include dissolvable plates and screws made from magnesium, calcium, polylactic acid, polycaprolactone, polydioxanone, and/or polyglycolic acid. ²⁰ These have combined bioactive and biodegradable effects and were initially used for craniofacial procedures. Unlike metallic implants, their degradation by-products are non-cytotoxic and their production is more carbon friendly. ²¹ They also reduce stress shielding, promote bone tissue regeneration, maintain structural integrity, eliminate hardware removal procedures, and enable postoperative imaging without metal artifact. ²⁰ Their lack of full integration into NHS practice may be due to reports of infection. ²² However, these plates and screws have been used in fracture fixation procedures including hand injuries, with resulting low postoperative infection rates (4% of 3,200 patients), good function and patient satisfaction reports as well as cost benefits. ²³

Biomaterials have also been used for repair of ulnar collateral ligament injuries of the thumb (24). As well as being environmentally friendly, these are associated with low risk of neurovascular injury during meniscus fixation. ²⁴ Tendon repairs may be less wasteful with careful patient selection. Most patients with flexor tendon injuries undergo primary repair. ²⁵ However, 10% of all primary repairs fail due to adherence or rupture. ²⁶ Re-repair involves secondary grafting with pulley reconstruction and/or skin replacement. ²⁵ If the finger is significantly traumatized, swollen, infected, or demonstrates skin breakdown, re-repair is likely to fail. ²⁵ A silicone tendon rod may instead be temporarily inserted then replaced by a graft at a later date. ²⁵ Carefully selecting patients appropriate for either silicone-rod or 2-staged tendon repair optimizes the patient’s results and limits the need for further procedures, which would use hospital resources and generate waste. However, both of these repair options involve several surgical interventions with patient down-time and one-handed life for several months. ²⁵ Full tendon repair with 1 surgery could reduce hospital admissions and improve quality of life. In select cases, this has been achieved using single-stage flexor grafting; Cavadas et al used vascularised tendon transfers for 36 finger flexor and 4 flexor pollicis longus repairs. They reported comparable functional outcomes to those treated with staged tendon grafting, and a lower complication rate. ²⁷ However, this is not popular practice and should only be performed where strictly indicated, with cautious patient selection and with adherence to core surgical principles. ²⁸

The gold standard treatment for peripheral nerve injuries is direct, tension-free, microsurgical repair using end-to-end sutures. ²⁹ Where this is not possible, nerve grafts are required. Nerve grafts may be artificial or autologous. ²⁹ Materials used for artificial nerve tubes include collagen, chitosan and poly(DL-lactide-ε -caprolactone), available as 1 to 3 cm grafts. ³⁰ Advantages of artificial grafts include their use where there is limited donor tissue availability and/or multiple nerve lesions requiring repair. However, their preparation requires processing that uses resources, and their use is typically limited to 3 cm nerve deficits. ³¹ Where there is adequate donor tissue, autologous nerve grafting minimizes resource waste. Donor grafts may be harvested from the anterior and posterior interosseous nerves, medial and lateral antebrachial cutaneous nerves, great auricular nerve, lateral femoral cutaneous nerve, or sural nerve. ³² Alternatively, human nerve allografts are available as 5 cm tubes. ³⁰ These can be used for larger nerve deficits, with less preparation, processing, and waste production than with artificial nerve tube use.

Waste is often a byproduct of vessel handling in plastic and reconstructive surgery but can be minimized. Backgrounds are often used to provide clear visualization of the vessel undergoing repair. However, it is possible to achieve the same anastomoses without backgrounds. When using coupling devices for anastomoses, the handle is thrown away. Re-design of these devices with consideration to the environment may prevent this waste. Venflon is also discarded after use but can be safely substituted with re-usable metal probes. Sutures and gauze are often disposed of prematurely so should be used to the maximum.

Clinical waste with infectious potential accounts for 10% to 25% of all operating room waste.^14,33 Its processing, which often involves incineration, requires several times more energy than for other waste and releases carcinogens and greenhouse gases into the environment. ³³ Up to 90% of waste placed in bags for potentially infectious material is not covered in blood or bodily fluids, does not appear soiled, and is “safe” waste. ³⁴ This suggests that the many staff members in the operating room are unsure as to what constitutes as infectious waste. Studies have also shown that staff are often unsure about what can be recycled. ³⁵ Many operating theaters only have bins for contaminated waste, unregulated waste and linen. Introduction of a recycling bin and staff education may improve categorization of waste, reduce incorrect waste disposal, and improve recycling of paper and plastic.

Postoperative Interventions

Upon completion of a hand procedure, use of simple dressings may reduce carbon emissions by minimizing equipment wasted. Simple dressings may be changed at home by the patient or in the community, thereby reducing emissions caused by patient travel to and from the hospital. In the postoperative period, other measures to reduce carbon emissions may include the use of thermal splints instead of set splints or casts. Advantages of thermal splints include that they are lighter, durable, can be molded with patient progress and are re-useable.

Hospital travel may also be reduced by the introduction of telemedicine to follow-up care. Telemedicine is the use of information and communications technologies for the exchange of information for diagnosis and treatment of injuries. ³⁶ A report commissioned by the NHS Midlands and Lancashire estimated that implementing telemedicine for 15% of all follow-up consultations would generate a potential annual reduction in carbon dioxide emissions of 533,535 kg. ³⁷ Similar benefits have been demonstrated outside of the United Kingdom. The carbon dioxide emissions for travel to and from hand surgery clinics in Ontario, Sweden, and New Mexico were assessed by Masino et al, ³⁸ Holmner et al, ³⁹ and Whetten et al, ⁴⁰ respectively. All studies compared carbon dioxide emissions to those produced by video synchronous telemedicine for follow-up of patients after hand surgery. Authors concluded that telemedicine has a significantly smaller carbon footprint. Where in-person patient review is needed, carbon emissions can be minimized by arranging follow-up appointments with physiotherapy sessions on the same day.

Preventative Measures

Carbon emissions may also be reduced by minimizing hospital admissions due to avoidable injuries. Burns caused by barbeque flames or patio heaters as well as gardening, do-it-yourself, and cooking injuries may be prevented with increased public awareness. Improved mental health perception and support may also reduce admissions caused by self-harm. Strategies that increase public health understanding include campaigns, community action initiatives, and projects to raise awareness with consideration to barriers such as language, literacy, and unequal access to resources.

Conclusion

Interventions that hand surgeons can implement pre-, intra-, and postoperatively have been discussed. Despite the benefits described, logistical difficulties may be encountered when attempting to implement these changes. Hospital administrators should therefore also be encouraged to rethink current practice. Material waste often correlates with monetary waste. Highlighting cost benefits with environmentally beneficial interventions may be a more compelling argument. In the same way that new healthcare measures consider patient safety, clinical efficacy, and cost effectiveness, the environmental impact should also be understood.