Naaman orthopaedics: avoiding the complex option

Ferdinand Bol, Elisha refusing the gifts of Naaman, 1661. Rembrandthuis, Amsterdam

Most orthopaedic surgeons are renowned biblical scholars, so they will be aware that the earliest example of "keep it simple, stupid" in medicine, was probably in the Book of Kings in the Old Testament, so around 600 BC.

The story in question is that of Naaman. A recap:

Naaman was a general in the pagan Syrian army, and a confidant of the king. Unfortunately he was also a leper, a big deal then (and now). he happened to have a slave girl who was a captured Israelite, who pointed out that back where she came from - Samaria - there was a prophet who could cure him, Elisha. As nothing else had worked, Naaman went for it. He loaded up with gifts and a fancy retinue, and headed south. His first mistake was to go to the king of Israel, who got mad when Naaman quizzed him, on the reasonable grounds that he couldn't cure leprosy, so the Syrians were clearly at it.

Elisha got wind and sent a message to have Naaman visit him. So the whole convoy ended up at Elisha's place. I'll let the scripture take over here:

Elisha sent a messenger to him, saying, “Go and wash in the Jordan seven times, and your flesh shall be restored to you and be clean.” 11 But Naaman was furious and went away and said, “Behold, I thought, ‘He will surely come out to me, and stand and call on the name of the LORD his God, and wave his hand over the place, and cure the leper.’ 12 “Are not Abanah and Pharpar, the rivers of Damascus, better than all the waters of Israel? Could I not wash in them and be clean?” So he turned and went away in a rage.

I can understand it, I suppose. However, the unnamed slave girl was not impressed:

“My father, had the prophet told you to do some great thing, would you not have done it? How much more then,when he says to you, ‘Wash, and be clean’?” 

So he did, and it worked. No more leprosy. And I believe that the long term clinical outcome remained satisfactory, although I don't have the PROMS data.

Thank you for sticking with me this far. Why does this matter in orthopaedics? Well, here are a few examples:

1. The CSAW RCT showed that operating on subacromial pain was not really any better than not operating

2. The PROFHER trial, even at 5 years, showed no benefit in operating on proximal humeral fractures than not operating (I accept that there will be some self-evident exceptions to this)

3. The DRAFFT RCT found no benefit of locking plate fixation over MUA and K wires for distal radius fractures (I accept that there will be some self-evident exceptions to this, too)

4. (my favourite) Complex, expensive and fiddly revision femoral stems are no better than the unfashionable monobloc ones, which are also much easier to use. Modular may also have more implant specific complications.

I am very far from being a surgical Luddite, nor do I tend to favour conservative management - although it's a skill we need to teach more in certain areas. But...

...there is no intrinsic merit in complicating treatments, although there are many intrinsic potential risks.