A new study recently published in Injury [1] has demonstrated that tibial fracture-related infections (FRIs) are associated with a substantial environmental burden, driven primarily by increased hospital stay, antibiotic use, and surgical interventions.

Led by expert trauma surgeons Willem-Jan Metsemakers and Peter Giannoudis, this study is among the first to quantitatively link FRIs with environmental impact, advancing the concept of “sustainable surgery.” It demonstrates that improving clinical outcomes (i.e., preventing infections) has dual benefits: reducing patient morbidity and lowering the environmental burden associated with healthcare activity.

Study background

Healthcare systems are major contributors to the global environmental burden, accounting for approximately 5% of greenhouse gas emissions, alongside substantial water consumption and waste generation. Orthopaedic and trauma surgical care is resource-intensive and plays a significant role in this footprint, especially when considering complications such as tibial fracture-related infections (FRIs).

While the clinical and economic consequences of FRIs are long established, their environmental impact is not well documented. This study aimed to leverage healthcare resource utilization data to evaluate the environmental impact of tibial FRIs amongst patients undergoing surgical treatment.

Study Overview 

An environmental impact model was developed using inputs informed from a systematic literature review and synthesized in a meta-analysis. Healthcare resource utilization data were used to compare the environmental impact for patients with and without a tibial FRI in relation to key healthcare activities including:

• Hospital and ICU length of stay
• Hospital readmissions and reoperations
• Emergency room visits and outpatient consultations
• Duration of antibiotic therapy
• Imaging examinations

A subgroup analysis was conducted to examine the environmental implications of more severe open fractures complicated by FRI, to supplement the mixed (open/closed) fracture population presented in the base case. Outcomes assessed were greenhouse gas emissions (kg CO₂ equivalent), water consumption (m³) and waste generation (kg).

Key Findings

The environmental impact assessment demonstrated that one case of tibial FRI is estimated to generate 1025.3 kg CO₂e,1778.6 m³ water use and 79.4 kg of waste compared to patients without an FRI.

Results of the subgroup analysis further substantiated the environmental impact associated with tibial FRIs. Data stratified by the Gustilo–Anderson (GA) classification showed that patients with GA III(B/C) open tibial fracture faced the highest cumulative environmental impact due to FRI, with estimated of 3421.7kg CO₂e, 5442.4 m³ water use, and 338.0kg of waste.

The largest contributors to environmental impact (greenhouse gas emissions, water use, and waste generation) were found to be:

1. Hospital length of stay (dominant driver)
2. Antibiotic therapy
3. Reoperations

Clinical Significance

Preventing a single FRI can lead to meaningful reductions in carbon emissions, water consumption, and waste generation. Interventions that reduce the incidence of tibial FRIs could contribute to the global goal of environmental sustainability while improving patient outcomes.

The findings in this study support a paradigm shift in healthcare sustainability, from focusing only on reducing waste and energy use to preventing avoidable complications across the care pathway. This aligns clinical excellence with environmental responsibility and provides actionable evidence for policymakers, hospitals, and surgeons to prioritize infection prevention strategies as part of climate-conscious healthcare systems.

References

1. Giannoudis P, Trouiller J-B, Kocaman M, Walczyk-Mooradally A, Battaglia S, Kane S, Tong C, Blauth M, Metsemakers W-J. The environmental impact of tibial fracture-related infections. Injury 2026; 57.