Biomechanical and functional outcomes of high-burden and low-burden multilevel surgery in young people with cerebral palsy.

The study was retrospective and did not randomise surgical burden, so children selected for more procedures may have differed in ways not measured. Gait analysis timing relative to surgery varied and was not controlled, which can affect baseline and postoperative scores. The high-burden group was older than the low-burden group at surgery, and age may influence recovery and outcomes. The analysis controlled relatively few comorbidities and did not consider cause of cerebral palsy. Strength, motor control, cognition, behaviour, family support, weight-bearing protocols, and rehabilitation details were not fully measured. Walking activity data were missing for 32% of patients before or after surgery. The missing data reduced power for that outcome. Walking activity is a community-based measure of performance and may be affected by environmental factors. Postoperative rehabilitation was given with surgery, and individual surgical procedures were not analysed, so the contribution of any single component cannot be separated.

Do not conclude surgical burden alone caused the functional differences. The high-burden group was older, had more procedures per surgery event, and received postoperative rehabilitation with surgery, so the contribution of age, individual procedures, timing, and rehabilitation cannot be separated.