Pediatric Orthopaedic Engagement with Environmental Health: Surgeon Interviews Reveal Challenges and Opportunities Across the United States and Europe.

Background: Children are particularly vulnerable to the effects of environmental degradation and pollution, particularly those living in low-income areas. Although interest in reducing healthcare's environmental impact is growing, systemic top-down reforms often face substantial barriers that limit progress. By contrast, surgeon-led, bottom-up initiatives have been highly effective in improving patient outcomes and reducing surgical cost. This study evaluates the opportunities and challenges encountered by pediatric orthopaedic surgeons in implementing sustainable practices within their local health systems. Methods: Pediatric orthopaedic surgeons from the United States and Europe were recruited using snowball sampling and interviewed using a semistructured questionnaire. Interviews were recorded, and transcribed verbatim then coded and analyzed using thematic analysis. Geographic subgroup analyses were performed. Results: Interviews were conducted with 25 surgeons. All participants reported personal environmentally conscious personal behaviors. Only 4 American and 3 European surgeons stated their health systems prioritize sustainability. Education and awareness campaigns were identified as top enablers of sustainable change among surgeons, with financial incentives and promotion of temporal efficiency perceived as health system enablers. Intergenerational differences and lack of transparency were identified as challenges and sources of friction to change, both between surgeons and with hospital leadership. Conclusions: Pediatric orthopaedic surgeons share a desire to promote environmental stewardship but are challenged by surgical culture, time and resource constraints, and lack of knowledge and awareness. Sustainability efforts contribute to tensions between individual and organizational values, with implications for health system allegiance, physician burnout, and distrust related to greenwashing. Attention and action to control the environmental harm generated by healthcare activities will shape future pediatric population health outcomes. Level of Evidence: Level III qualitative study (descriptive study, narrowly defined study population). See Instructions for Authors for a complete description of levels of evidence.