Fifteen patients with ankylosing spondylitis who had developed a severe flexion deformity of the cervical spine which restricted their field of vision to their feet, were treated by an extension osteotomy at the C7/T1 level. The operation was performed under general anaesthesia with the patient in the prone position and wearing a halo-jacket. Three had internal fixation using a Luque rectangle and wiring. Their mean age was 48 years. Before operation the mean cervical kyphosis was 23°; this was corrected to a mean of 31° of lordosis, a mean correction of 54°. All the patients were able to see straight ahead. One patient with normal neurology soon after operation became quadraparetic after one week; two others had unilateral palsy of the C8 root, which improved. There was subluxation at the site of osteotomy in four patients, and two of them developed a pseudarthrosis which required an anterior fusion

Background and purpose of the study. Dropped Head Syndrome (DHS) is characterized by a chin on chest flexion neck deformity that is passively correctible. The condition is rare and literature on surgical and conservative management is focused on case studies and theoretical evidence. Purpose of the study. The purpose of this study was to investigate the value of physiotherapy in the treatment of DHS by case series analysis. Methods. The effectiveness of physiotherapy was examined in six patients, some of whom were still under treatment and evaluation. Photographs were taken of some of the patients in order to gain further insight into the condition. Conservative management was provided in the form of physiotherapy and the use of a collar. Physiotherapy treatment involved a focus on sagittal balance and treatment included education, manual therapy, exercises, postural and mirror work and modification of sitting and lying positions. Results. In the first completed case study the patient reported an improvement in the ability to correct their deformity and improved appearance following physiotherapy. Photographs taken before and after treatment appear to support this. At one year follow up this patient still followed the advice given and did the exercises taught and reported to find them beneficial in managing DHS. The same approach was applied with the other patients in the case series with treatment and analysis evolving as further insight into the condition was gained. Conclusion. The case series supports other reported cases in the literature which report benefit from the use of physiotherapy as well as raising questions around the potential causes and management of DHS. Conflicts of interest – No conflicts of interest. Sources of funding – No funding obtained

Few studies have examined the order in which a spinal osteotomy and total hip replacement (THR) are to be performed for patients with ankylosing spondylitis. We have retrospectively reviewed 28 consecutive patients with ankylosing spondylitis who underwent both a spinal osteotomy and a THR from September 2004 to November 2012. In the cohort 22 patients had a spinal osteotomy before a THR (group 1), and six patients had a THR before a spinal osteotomy (group 2). The mean duration of follow-up was 3.5 years (2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy segment was corrected from a pre-operative kyphosis angle of 32.4 (SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p < 0.001). Significant improvements in pain, function and range of movement were observed following THR. In group 2, two of six patients had an early anterior dislocation. The spinal osteotomy was performed two weeks after the THR. At follow-up, no hip has required revision in either group. Although this non-comparative study only involved a small number of patients, given our experience, we believe a spinal osteotomy should be performed prior to a THR, unless the deformity is so severe that the procedure cannot be performed.

Cite this article: Bone Joint J 2014;96-B:360–5.