Sustainability means reducing waste, principally through ‘reduce-reuse-recycle’. Lean pathways for orthopaedics surgery are an example of sustainable healthcare by reducing waste. Streamlining care and processes at every stage improves patient outcomes, minimizes costs and reduces carbon emissions. Perioperative care, from the moment an operation is contemplated until full recovery, has variability in practice. Preoperative assessment should be linked to optimization. Interventions such as exercise reduce complications by between 30% and 80%. Successful interventions include: ‘surgery schools’; early detection of anaemia; pre-emptive discharge planning; preoperative introduction of walking aids; planning of intraoperative equipment; techniques that allow early mobilization/discharge and reduced use of anaesthetic vapours. New streamlined pathways should be developed with the whole multidisciplinary team (MDT) focusing on practicalities. A ‘trans-disciplinary team’ approach, sharing skills, works better than silos. A standardized pathway allows care to be individualized where needed. In trauma care, lean pathways mean common issues can be pre-empted. For example, good patient information given by the emergency department, shared decision-making in fracture clinic and planning for day-case trauma lists. Change management is difficult. Tips include: learning from other sites; creating good information for patients; analysing unit data comparative to other sites; and discussing improvements as a whole team.