December 2001 Bulletin

Complementary and alternative medicine

AAOS website describes impact on orthopaedics

By Carolyn Rogers

Now that words like ‘gingko biloba’, ‘St. John’s Wort’ and ‘ginseng’ have become part of the national lexicon, the wide range of healing philosophies, approaches and therapies collectively known as "complementary and alternative medicine" (CAM) no longer can be ignored by mainstream medicine.

With more than half of all Americans currently using some form of CAM, the Academy sees an increasing need for orthopaedic surgeons to become familiar with various alternative modalities so they can effectively and intelligently answer patients’ questions regarding their effectiveness or potential dangers.

According to Jonathan Moss, MD, PhD, professor of anesthesia and critical care at the Pritzker School of Medicine, University of Chicago, "Herbal medications can be very biologically important and should really be treated as drugs." There are no placebo-controlled double blind trials on the effect of herbals on surgical outcomes and side effects. However, he said the active ingredient in herbal products purchased in a grocery store or pharmacy has a 200% variability rate, which means the herbal intake may interfere with bleeding control and anesthetic medications. "If you get a paper cut and are taking ginkgo, it’s no big deal," Dr. Moss said. "But if you’re taking ginkgo and you have a hip replacement, it may be a big deal."

To assist Academy members, a "Complementary and Alternative Medicine" web page–tailored to the concerns of orthopaedic surgeons–is now posted on the AAOS web site ( Just click on the "medical education" tab, then click on"learning resources."

The new site, developed by the Academy’s Committee on Complementary and Alternative Medicine, houses a wealth of information on CAM as it relates to the practice of orthopaedics–including herb/drug interactions, available scientific evidence, frequently asked questions and useful web links.

In July and August of 2001, the committee surveyed the available allopathic and CAM literature to develop a list of commonly used herbals and supplements that may pose potential hazards–such as those that alter coagulation and interact with frequently used medicines. After reviewing the literature on more than 40 herbs, the committee singled out 13 that orthopaedic surgeons should watch out for prior to surgery. The supplements–along with their uses, potential problems and drug interactions–are highlighted in a chart available on the CAM web site.

The chart can help orthopaedic surgeons frame questions they ask patients prior to surgery. For example, "Are you now taking Donq quai, echinacea or gingko biloba?" Patients who answer in the affirmative would then be advised to cease using these supplements for at least two weeks prior to surgical intervention due to the herbs’ anticoagulant properties.

Information contained in the CAM/drug interaction chart also may be used to warn patients who take one of the identified herbal supplements–ephedra (Ma Huang), for example–that it may pose serious health hazards such as seizures and adverse cardiovascular events. The chart will be updated as more empirical evidence becomes known.

Descriptions of common CAM modalities that orthopaedic patients may be using–such as acupuncture, massage, magnets and meditation are also posted on the site. Alternative medical systems and traditional healing practices such as naturopathy, homeopathy, ayurveda and oriental/chinese medicine are defined, and links to additional resources are provided. The committee plans to add more content in the future.

Frequently asked "CAM questions" are answered in detail, such as

While a vast amount of CAM-related information is available, much of it is found in the lay press, and is anecdotal and highly subjective. Yet, with growing public interest and considerable public funding, a significant body of CAM research is evolving that is peer-reviewed and evidence-based. As this body of scientific research grows, the CAM Committee is learning–occasionally to its surprise–that evidence suggests value and efficacy in areas with which orthopaedic surgeons are unfamiliar. The committee plans to continue to survey the evidence objectively, and will report its findings to members of the Academy through the web site and elsewhere.

If you’re interested in learning more about CAM in a casual, interactive atmosphere, the committee is sponsoring a one-hour "Up Close and Personal" session at the Annual Meeting in Dallas. The informal gathering is scheduled for Wednesday evening, Feb. 13, 2002 from 6 to 7 p.m. Various alternative treatments and case studies will be discussed in relation to carpal tunnel, reflex sympathetic dystrophy pain management and other conditions. Moderator Harris Gelman, MD, will speak about homeopathy, Jeff Shapiro, MD, will discuss acupuncture, Rick Rogachefsky, MD will report on the use of magnets, and Bill Arnold, MD, will share his knowledge of nutritional supplements.

JAMA reports that between 1990 and 1997:

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