USE LESS, a Comparative Cohort Study of Climate Change Impact From Orthopedic Surgery (USELESS)

USE LESS, a Comparative Cohort Study of Climate Change Impact From Orthopedic Surgery.

A prospective comparative cohort study with the objective to quantify and compare carbon dioxide equivalent (CO₂e) emissions from orthopedic surgeries performed in two different operating room (OR) settings using different sets of materials and staff.

Study Overview

• Status: Recruiting
• Conditions: Environment; Waste Output

Detailed Description

Background: Human health depends on the stability of Earth's ecological systems. Healthcare, guided by the principle "first do no harm," paradoxically contributes to this destabilization: globally, it accounts for ~5% of greenhouse gas (GHG) emissions, with orthopedic care among the most resource-intensive domains. It is imperative that the health sector finds ways to reduce emissions while still providing care with preserved quality and quantity. Use of single-use materials has been found to yield a significant part of emissions from orthopedic surgeries. Performing minor surgeries in procedure rooms instead of the operating room can reduce emissions and waste. Moreover, a small portion of products accounts for most of an operation's carbon footprint, suggesting that targeted measures may have substantial impact.

Carbon emission represents only one dimension of healthcare's environmental burden. Life Cycle Assessment (LCA) enables quantification of impacts across categories such as toxicity, particulate matter formation, resource depletion, water consumption, land use, ozone formation, and ecosystem effects. These categories are relevant in orthopedics, where products commonly contain e.g. polyvinyl chloride (PVC), di(2-ethylhexyl) phthalate (DEHP), and per- and polyfluoroalkyl substances (PFAS). Moreover, large quantities of nonrecyclable plastics are used. Transitioning from single-use to reusable products can reduce GHG emissions significantly, though further studies are needed to ensure clinical safety.

Carbon emission represents only one dimension of healthcare's environmental burden. Life Cycle Assessment (LCA) enables quantification of impacts across categories such as toxicity, particulate matter formation, resource depletion, water consumption, land use, ozone formation, and ecosystem effects. These categories are relevant in orthopedics, where products commonly contain e.g. polyvinyl chloride (PVC), di(2-ethylhexyl) phthalate (DEHP), and per- and polyfluoroalkyl substances (PFAS). Moreover, large quantities of nonrecyclable plastics are used [9]. Transitioning from single-use to reusable products can reduce GHG emissions significantly, though further studies are needed to ensure clinical safety. Population: Age ≥18 years undergoing release of carpal tunnel or trigger finger, wound revision or amputation of finger or toe, extraction of osteosynthesis material or suturing of extensor tendon (hand or foot) at Danderyd's Hospital. There are no exclusion criteria.

Intervention: Procedures performed in a procedure room using a reduced material set at the outpatient clinic under local anesthetics only. Control: Procedures performed in an operating room (OR) using a standard OR set up with available anesthesiology assistance.

This study hopes to answer the question: How do climate change impact differ between minor orthopedic procedures performed in a conventional operating theatre compared with procedures in an outpatient clinic procedure room with a reduced set of material?

Primary outcome: CO₂e per functional unit. Secondary outcomes: Complications (infection, readmission), combustible waste (kg) and costs (staff and material). Hotspot analysis identifying major contributors to emissions. The functional unit is defined as one performed surgery.

Environmental impacts will be assessed using Life Cycle Assessment (LCA) according to the four standard phases: (1) goal and scope definition, (2) life cycle inventory (LCI), (3) life cycle impact assessment (LCIA), and (4) interpretation including sensitivity and uncertainty analyses. System boundaries will be cradle-to-grave when complete data are available and otherwise gate-to-gate for single-use products lacking published LCAs. Identical system boundaries will be applied within each study to ensure comparability between intervention and control groups. Life cycle inventories will include materials, pharmaceuticals, reusable and single-use equipment, sterilization, energy consumption, waste handling, inpatient care, and staffing. Detailed inventories of surgical procedures will be collected prospectively at Danderyd Hospital, including article numbers, quantities, and weights of materials, as well as disposal weights. CO₂e emissions will primarily be calculated using manufacturer LCAs; where unavailable, emissions will be estimated from material composition and weight using established databases (e.g., Inventory of Carbon and Energy) and published templates for reusable materials and energy use. Mean emissions per procedure or treatment pathway will be calculated and compared between groups.

• Study Type: Observational
• Enrollment (Estimated): 80

Contacts and Locations

• Study Contact: Name: Marianne Smith, MD; Phone Number: +46737803594; Email: marianne.smith@regionstockholm.se

Study Locations

• Sweden
  • Stockholm, Sweden
    • Recruiting
    • Danderyd's Hospital
    • Contact: Marianne Smith; Phone Number: +46737803594; Email: marianne.smith@regionstockholm.se

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

All patients above the age of 18 undergoing stated procedures at Danderyd's hospital.

Description

Inclusion Criteria:

• The following surgeries will be included: release of carpal tunnel or trigger finger, wound revision or amputation of finger or toe, extraction of osteosynthesis material or suturing of extensor tendon (hand or foot) at Danderyd's Hospital.

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Control group; Patients undergoing surgical procedures in an operating room at the day surgery department
Intervention group; Patients undergoing surgical procedures in the procedure room at the orthopedic outpatient clinic

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Climate change impact	Mean carbon dioxide equivalent (CO₂e) emissions expressed in kgs per functional unit defined as one performed surgery. All single-use materials consumed during an operation will be registrered, categorized, weighted and converted into CO₂e using exsisting LCAs or databases. Energy comsuption for machines in the OR, heating and ventilation of the OR and for sterilization of reusable materials will be converted into CO2e using existing databases. Water usage for sterilization will be calculated and converted into CO₂e using databases.	Data cwill be collected during 12 months for each group

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Readmission	Readmission to hospital within 90 days of the procedure. Admission cause must be related the surgical proceure, e.g. surgical site infection demanding iv antibiotics.	within 90 days of the performed sugery
Combustible waste	Weight of waste generated after each surgery measured in kgs. Staff in the OR will collect all waste in one or two plastic bags and weigh them using a hade scale INF model KBE-BHC025-11 D hand scale. The weight is recorded in kilograms in the study protocol in the OR.	All consecutive suergeries for twelve months in each group
Costs	Difference in costs for material and staff. Costs for all singe-use items will be collected from the purcahse department and recorded in SEK intitiallt before conversion to € at the time or data analysis. Costs for reuseable items will be collected and a value calculated for each usage will be obtained. Energy usage will be calculated in kWh and water consumtion will be measured in cubic meters and a converted into SEK/€ using price lists obtained from the Hospital. A mean value for costs for each staff category (e.g. doctor, nurse) per hour will be obtained from the hospital and mutiplied by the OR time.	All consecutive suergeries for twelve months in each group
Infections	Surgical site infection following the procedure. Patients charts will be examined after 90 days and if any antibiotics covering skin pathogens (e.g. Flukloxacillin, Clindamycin) has been perscribed by any caregiver during the period it will be assumed to be a positive value.	Within 90 days of surgery

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hotspot analysis	Identification of major contributors to emissions by categorizing all activity data that contributes to emissions and calculated as a percentage of the primary endpoint; CO₂e expressed i kgs per fuctional unit (one surgery). Categories will include but not be restricted to; single-use items, manufacturing and usage of reusable items, egergy comsuption by machines in the OR, energy comsuption for heating and ventilation and energy and water consumption for sterilization of resuable items.	All consecutive suergeries for twelve months in each group

Collaborators and Investigators

• Sponsor: Karolinska Institutet

Publications and helpful links

General Publications

• Keil M, Viere T, Helms K, Rogowski W. The impact of switching from single-use to reusable healthcare products: a transparency checklist and systematic review of life-cycle assessments. Eur J Public Health. 2023 Feb 3;33(1):56-63. doi: 10.1093/eurpub/ckac174.
• 8: Ted Schettler, M., Polyvinyl chloride in health care. 2020.
• 7: WOLF, M.-A., et al., International reference life cycle data system (ILCD) handbook-general guide for life cycle assessment-detailed guidance. 2010.
• 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 Jun;116(6):199-213. doi: 10.1177/01410768231166135. Epub 2023 Apr 13.
• Grothaus O, Jorgensen A, Maughan G, Anto M, Kazmers NH, Garcia BN. Carbon Footprint of Open Carpal Tunnel Release Surgery Performed in the Procedure Room Versus Operating Room Setting. J Hand Surg Am. 2024 Jun;49(6):576-582. doi: 10.1016/j.jhsa.2024.03.014. Epub 2024 May 6.
• Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The Carbon Footprint of Surgical Operations: A Systematic Review. Ann Surg. 2020 Dec;272(6):986-995. doi: 10.1097/SLA.0000000000003951.
• 3: Boiko, P., et al., Environmental life cycle assessment of surgical versus conservative care pathways for an anterior cruciate ligament injury. Journal of cleaner production, 2025. 535: p. 147136.
• Eidmann A, Geiger F, Heinz T, Jakuscheit A, Docheva D, Horas K, Stratos I, Rudert M. Our Impact on Global Warming: A Carbon Footprint Analysis of Orthopaedic Operations. J Bone Joint Surg Am. 2024 Nov 6;106(21):1971-1977. doi: 10.2106/JBJS.24.00212. Epub 2024 Sep 19.
• 1:Pichler, P.-P., et al., International comparison of health care carbon footprints. Environmental research letters, 2019. 14(6): p. 064004
• Shah S, Morris H, Thiagarajah S, Gordon A, Sharma S, Haslam P, Garcia J, Ali F. Handling 'carbon footprint' in orthopaedics. Ann R Coll Surg Engl. 2024 Jul;106(6):498-503. doi: 10.1308/rcsann.2023.0052. Epub 2024 Apr 2.

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2025
• Primary Completion (Estimated): August 31, 2027
• Study Completion (Estimated): December 1, 2027

Study Registration Dates

• First Submitted: June 11, 2026
• First Submitted That Met QC Criteria: June 17, 2026
• First Posted (Actual): June 18, 2026

Study Record Updates

• Last Update Posted (Actual): June 18, 2026
• Last Update Submitted That Met QC Criteria: June 17, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: environment; Climate change impact; greenhouse gases; Life Cycle Assessment; Single-use materials
• Other Study ID Numbers: 2025-02587-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No