The article by Mike Harley ('Bone of contention', page 22, 17 May) has highlighted some of the pressures facing orthopaedic surgeons but has failed to appreciate the advances that have occurred since 1984 and the effect they have had on throughput.

The developments in fracture management, for example, have meant that many fractures now require complex operations to obtain internal fixation, virtually anatomical reduction and early mobilisation compared with 14 years ago. Then the patient may have been treated in plaster or on traction, which would have required a fraction of the operating theatre time now required for complex reconstruction. Fractures of the extremities are the commonest cause of disability in the working age group and improved methods of fixation with early mobilisation should reduce long-term disability and allow patients to return to work.

The net effect is that surgeons can treat many fewer patients per period than they previously could. Therefore, two or three surgeons may be required to treat the same number of patients but the outcome from the patients' perspective will be greatly improved.

The waiting-list initiatives were so designed that they could only temporarily reduce waiting times.

The basic problem with the concept was that the surgeons and the team required for surgery were paid overtime to operate in the evening or at weekends, usually in private hospitals, on patients who had been waiting a long time for surgery.

This money was not being invested in the building of new operating theatres, the creation of more beds, nor the appointment of additional staff.

Therefore, as soon as the initiative ceased, the overtime work ceased and the numbers on waiting lists started to increase.

Many surgeons were prepared to spend their time off undertaking waiting-list initiatives because of their concern for patients waiting a long time for surgery.

However, as the money was not being invested and the problem recurred every time waiting list initiatives ceased, many surgeons felt reluctant to spend the rest of their lives working during their time off.

Furthermore, the European working time directive may now make it illegal for surgeons and other staff to carry out waiting-list initiative lists, as it will frequently mean working for more than 48 hours a week.

Third, there is the demand, and rightly so, that patients need to have more time with the consultant to discuss their condition and the proposed treatment, particularly if surgery may be required.

This means that fewer patients can be seen in each clinic. The British Orthopaedic Association has recommended minimum times that should be spent with each patient.

These times are a minimum and many patients will require a longer time with the consultant.

Nevertheless, because of the pressures on consultants, in many orthopaedic clinics there are still too many patients being seen.

The duration of training of registrars has reduced with the Calman training programme.

The current specialist registrars are in training for less than half the time of their predecessors.

As a result, they are less experienced and require more intensive training if the next generation of consultants is to be as good as, and ideally better than, the current one.

This takes consultant time.

The BOA is very concerned that the increased number of consultants has not kept pace with the increased demand for services and that disorders of the musculoskeletal system are a Cinderella area compared with the investment in heart disorders, cancers and so on.

Charles S B Galasko President British Orthopaedic Association London WC2