Combined Gastrocnemius Release with Gracilis and Toe Flexor Release Offers a Targeted Multi-Level Approach within Single Event Multi-Level Surgery for Correcting Unilateral Lower Limb Deformities in Spastic Hemiplegic Cerebral Palsy.

INTRODUCTION: Spastic hemiplegic cerebral palsy (CP) often causes multi-level lower limb deformities, impairing gait and mobility. Single-level surgeries yield suboptimal results due to persistent spasticity elsewhere. CASE SERIES: We report outcomes in 15 ambulatory patients (aged 4-18 years, gross motor function classification system [GMFCS] I-III) undergoing combined gastrocnemius release, gracilis release, and toe flexor lengthening as part of single-event multi-level surgery (SEMLS) in spastic hemiplegic CP. RESULTS: Ankle dorsiflexion improved from -10° to +10° (P < 0.05), knee flexion reduced from 24° to 6° (P < 0.05), and toe clawing resolved in all. Gait symmetry, step length, and GMFCS levels were enhanced; complications were minimal (overcorrection in 1, weakness in 1). CONCLUSION: This multi-level soft-tissue release effectively restores biomechanics with low recurrence, supporting SEMLS principles. Gastrocnemius, gracilis, and toe flexor release is a safe and effective SEMLS strategy significantly improving gait, functional mobility, and quality of life. STUDY DESIGN: Case Series (Level of Evidence: Level IV).