Free Standard AU & NZ Shipping For All Book Orders Over $80!
Register      Login
Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
Shopping Cart: ( empty )
You are here: Home > Journals > AH > AH24154
RESEARCH ARTICLE
Online Early

The carbon footprint of total knee replacements

Forbes McGain A B C * , Kasun Wickramarachchi D , Lu Aye E , Brandon G. Chan B , Nicole Sheridan B , Phong Tran F G and Scott McAlister A
+ Author Affiliations
- Author Affiliations

A Department of Critical Care, Medicine, Dentistry and Health Sciences, University of Melbourne, Vic, Australia.

B Department of Anaesthesia, Western Health, Melbourne, Vic, Australia.

C Department of Intensive Care, Western Health, Footscray, Melbourne, Vic 3011, Australia.

D Department of Anaesthesia and Perioperative Medicine, Royal Melbourne Hospital, Melbourne, Vic, Australia.

E Department of Infrastructure Engineering, University of Melbourne, Melbourne, Vic, Australia.

F Department of Orthopaedic Surgery, Western Health, Melbourne, Vic, Australia.

G Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Victoria University, St. Albans, Melbourne, Vic, Australia.

* Correspondence to: Forbes.mcgain@wh.org.au

Australian Health Review https://doi.org/10.1071/AH24154
Submitted: 27 May 2024  Accepted: 10 October 2024  Published: 29 October 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.

Abstract

Objective

Detailed quantifications of the environmental footprint of operations that include surgery, anaesthesia, and engineering are rare. We examined all such aspects to find the greenhouse gas emissions of an operation.

Methods

We undertook a life cycle assessment of 10 patients undergoing total knee replacements, collecting data for all surgical equipment, energy requirements for cleaning, and operating room energy use. Data for anaesthesia were sourced from our prior study. We used life cycle assessment software to convert inputs of energy and material use into outputs in kg CO2e emissions, using Monte Carlo analyses with 95% confidence intervals.

Results

The average carbon footprint was 131.7 kg CO2e, (95% confidence interval: 117.7–148.5 kg CO2e); surgery was foremost (104/131.7 kg CO2e, 80%), with lesser contributions from anaesthesia (15.0/131.7 kg CO2e, 11%), and engineering (11.9/131.7 kg CO2e, 9%). The main surgical sources of greenhouse gas emissions were: energy used to disinfect and steam sterilise reusable equipment (43.4/131.7 kg CO2e, 33%), single-use equipment (34.2/131.7 kg CO2e, 26%), with polypropylene alone 13.7/131.7 kg CO2e (11%), and the knee prosthesis 19.6 kg CO2e (15%). For energy use, the main contributors were: gas heating (6.7 kg CO2e) and heating, cooling, and fans (4 kg CO2e).

Conclusions

The carbon footprint of a total knee replacement was equivalent to driving 914 km in a standard 2022 Australian car, with surgery contributing 80%. Such data provide guidance in reducing an operation’s carbon footprint through prudent equipment use, more efficient steam sterilisation with renewable electricity, and reduced single-use waste.

Keywords: carbon footprint, circular economy, environmental footprint, healthcare sustainability, life cycle assessment, low value care, surgery, waste.

References

1  Intergovernmental Panel on Climate Change (IPCC). Sixth Assessment Report. 2024. Available at https://www.ipcc.ch/assessment-report/ar6/ [accessed November 2023].

2  Eckelman MJ, Sherman J. Environmental Impacts of the US Health Care System and Effects on Public Health. PloS One 2016; 11(6): e0157014.
| Crossref | Google Scholar | PubMed |

3  Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5(2): e84-e92.
| Crossref | Google Scholar | PubMed |

4  Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018; 2(1): e27-e35.
| Crossref | Google Scholar | PubMed |

5  McGain F, Burnham JP, Lau R, Aye L, Kollef MH, McAlister S. The carbon footprint of treating patients with septic shock in the intensive care unit. Crit Care Resusc 2018; 20(4): 304-312.
| Google Scholar | PubMed |

6  MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1(9): e381-e388.
| Crossref | Google Scholar | PubMed |

7  Winter Beatty J, Pegna V. Transitioning toward greener surgery: why and how surgeons must lead the change. Br J Surg 2024; 111(1): znad414.
| Crossref | Google Scholar | PubMed |

8  Thiel CL, Eckelman MJ, Guido R, et al. Environmental Impacts of Surgical Procedures: Life Cycle Assessment of Hysterectomy in the US. Environ Sci Technol 2015; 49(3): 1779-1786.
| Crossref | Google Scholar | PubMed |

9  McGain F, Jarosz KM, Nguyen MN, Bates S, O’Shea CJ. Auditing Operating Room Recycling: A Management Case Report. A A Case Rep 2015; 5(3): 47-50.
| Crossref | Google Scholar | PubMed |

10  The International Standards Organisation (ISO). ISO-14040. 2006. Available at www.iso.org/obp/ui/#iso:std:iso:14040:ed-2:v1:en [verified April 2024].

11  Drew J, Christie SD, Rainham D, Rizan C. HealthcareLCA: an open-access living database of health-care environmental impact assessments. Lancet Planet Health 2022; 6(12): e1000-e1012.
| Crossref | Google Scholar | PubMed |

12  Shelton CL, Knagg R, Sondekoppam RV, McGain F. Towards zero carbon healthcare: anaesthesia. BMJ 2022; 379: e069030.
| Crossref | Google Scholar |

13  Grinberg D, Buzzi R, Pozzi M, et al. Eco-audit of conventional heart surgery procedures. Eur J Cardiothorac Surg 2021; 60(6): 1325-1331.
| Crossref | Google Scholar | PubMed |

14  Morris D, Wright T, Somner J, Connor A. The carbon footprint of cataract surgery. Eye 2013; 27: 495-501.
| Crossref | Google Scholar | PubMed |

15  Delaie C, Cerlier A, Argenson J-N, et al. Ecological Burden of Modern Surgery: An Analysis of Total Knee Replacement’s Life Cycle. Arthroplast Today 2023; 23: 101187.
| Crossref | Google Scholar | PubMed |

16  McGain F, Moore G, Black J. Steam sterilisation’s energy and water footprint. Austral Health Rev 2016; 41(1): 26-32.
| Crossref | Google Scholar | PubMed |

17  Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of surgical operations: a systematic review. Ann Surg 2020; 272(6): 986-995.
| Crossref | Google Scholar | PubMed |

18  Drew J, Christie SD, Tyedmers P, Smith-Forrester J, Rainham D. Operating in a climate crisis: a state-of-the-science review of life cycle assessment within surgical and anesthetic care. Environ Health Perspect 2021; 129(7): 076001.
| Crossref | Google Scholar | PubMed |

19  Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage 2015; 23(10): 1664-1673.
| Crossref | Google Scholar | PubMed |

20  Rizan C, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of products used in five common surgical operations: identifying contributing products and processes. J R Soc Med 2023; 116(6): 199-213.
| Crossref | Google Scholar | PubMed |

21  Stall NM, Kagoma YK, Bondy JN, Naudie D. Surgical waste audit of 5 total knee arthroplasties. Can J Surg 2013; 56(2): 97-102.
| Crossref | Google Scholar | PubMed |

22  McAlister S, Barratt A, Bell K, McGain F. How many carbon emissions are saved by doing one less MRI? Lancet Planet Health 2024; 8(6): e350.
| Crossref | Google Scholar | PubMed |

23  McGain F, Sheridan N, Wickramarachchi K, Yates S, Chan B, McAlister S. Carbon footprint of general, regional, and combined anesthesia for total knee replacements. Anesthesiology 2021; 135(6): 976-991.
| Crossref | Google Scholar | PubMed |

24  Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg 2012; 114(5): 1055-1066.
| Crossref | Google Scholar | PubMed |

25  McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaesth Intensive Care 2010; 38(3): 538-44.
| Crossref | Google Scholar | PubMed |

26  Parvatker AG, Tunceroglu H, Sherman JD, Coish P, Anastas P, Zimmerman JB, Eckelman MJ. Cradle-to-Gate Greenhouse Gas Emissions for Twenty Anesthetic Active Pharmaceutical Ingredients Based on Process Scale-Up and Process Design Calculations. ACS Sustain Chem Eng 2019; 7(7): 6580-6591.
| Crossref | Google Scholar |

27  McAlister S, Ou Y, Neff E, Hapgood K, Story D, Mealey P, McGain F. The Environmental footprint of morphine: a life cycle assessment from opium poppy farming to the packaged drug. BMJ Open 2016; 6(10): e013302.
| Crossref | Google Scholar | PubMed |

28  Chakladar A, White S. Unnecessary electricity consumption by anaesthetic room monitors. Anaesthesia 2010; 65(7): 754-755.
| Crossref | Google Scholar | PubMed |

29  Barwise JA, Lancaster LJ, Michaels D, Pope JE, Berry JM. Technical communication: An initial evaluation of a novel anesthetic scavenging interface. Anesth Analg 2011; 113(5): 1064-1067.
| Crossref | Google Scholar | PubMed |

30  National Transport Commission (Australia). Carbon Dioxide Emissions Intensity for New Australian Light Vehicles. 2022. Available at https://www.ntc.gov.au/sites/default/files/assets/files/CO2%20Emissions%20Intensity%20for%20New%20Australian%20Light%20Vehicles%202022.pdf [verified 15 May 2024].

31  McGain F, Moore G, Black J. Hospital steam sterilizer usage: could we switch off to save electricity and water? J Health Serv Res Policy 2016; 21(3): 166-71.
| Crossref | Google Scholar | PubMed |

32  McGain F, McAlister S. Reusable versus single-use ICU equipment: what’s the environmental footprint? Intensive Care Med 2023; 49(12): 1523-1525.
| Crossref | Google Scholar | PubMed |

33  Dunne B, Forrester M, Kayak E. It’s time for Australian hospitals to be all-electric (and powered by 100% renewable energy). Med J Aust 2023; 219(11): 559.
| Crossref | Google Scholar | PubMed |

34  Friedericy HJ, van Egmond CW, Vogtländer JG, van der Eijk AC, Jansen FW. Reducing the environmental impact of sterilization packaging for surgical instruments in the operating room: a comparative LCA of disposable versus reusable systems. Sustainability 2022; 14(1): 430.
| Crossref | Google Scholar |

35  Zheng J, Suh S. Strategies to reduce the global carbon footprint of plastics. Nat Clim Chang 2019; 9(5): 374-378.
| Crossref | Google Scholar |

36  Dettenkofer M, Scherrer M, Hoch V, et al. Shutting down operating theater ventilation when the theater is not in use: infection control and environmental aspects. Infect Control Hosp Epidemiol 2003; 24(8): 596-600.
| Crossref | Google Scholar | PubMed |

37  Australian Government Department of Climate Change, Energy, the Environment, and Water. National Greenhouse Accounts Factors. 2023. Available at https://www.dcceew.gov.au/climate-change/publications/national-greenhouse-accounts-factors-2023 [verified January 23 2024].

38  UK Health Alliance on Climate Change. Green Surgery: Reducing the environmental impact of surgical care. 2023. Available at https://ukhealthalliance.org/sustainable-healthcare/green-surgery-report/ [verified 22 January 2024].

39  Engler ID, Curley AJ, Fu FH, Bilec MM. Environmental sustainability in orthopaedic surgery. J Am Acad Orthop Surg 2022; 30(11): 504-511.
| Crossref | Google Scholar | PubMed |

40  Climate Scorecard. Natural Gas Consumption and Production in France. 2022. Available at https://www.climatescorecard.org/2022/06/natural-gas-consumption-and-production-in-france/ [verified 9 January 2024].

41  Australian Government Department of Climate Change, Energy, the Environment, and Water. Renewables. 2023. Available at https://www.energy.gov.au/energy-data/australian-energy-statistics/renewables

42  The International Energy Agency. Global Energy Review: CO2 Emissions in 2021. 2022. Available at https://www.iea.org/reports/global-energy-review-co2-emissions-in-2021-2 [verified 3 February 2024].

43  Rizan C, Bhutta MF, Reed M, Lillywhite R. The carbon footprint of waste streams in a UK hospital. J Clean Product 2021; 286: 125446.
| Crossref | Google Scholar |