Single Event Multilevel Surgery (SEMLS)

Gillette Children’s Specialty Healthcare is a leader in providing orthopedic single-event multilevel surgery (SEMLS). During a single SEMLS intervention, we can correct multiple bone and soft tissue problems using the expertise of a highly skilled orthopedic surgery team.

Caring for the Child Who Has Cerebral Palsy - Video Series

Our three-part video series includes an overview, Caring for the Child who has Cerebral Palsy, and two videos that focus on specific treatment options, Orthopedic Care for Children Who Have Cerebral Palsy and Spasticity Treatment Options for Cerebral Palsy.

Why Choose Gillette?

  • Gillette is a nationally and internationally recognized leader in pediatric orthopedics.
  • Our specialists can correct multiple soft tissue and bone problems during one interventionoften resulting in fewer surgery visits and less rehabilitation time.
  • We offer one of the nation’s largest teams of pediatric orthopedists, which allows our surgeons to specialize in specific parts of the body and in highly complex procedures.
  • Our facilities and technologyincluding state-of-the-art surgery suites and one of the nation’s first and busiest centers for gait and motion analysisare designed specifically for your needs.
  • We believe that people who have disabilities deserve a lifetime of excellent health care—from birth through adulthood.


Many patients who have cerebral palsy, spina bifida or other neurologic conditions that affect the brain or spinal cord might experience pain or have difficulty walking. Left untreated, these conditions can cause painful, arthritic joints. After we’ve completed gait and motion analysis and assessed joint development, our specialists determine whether a patient might benefit from surgeries on their lower extremities (hips, knees, ankles and/or feet).

These lower-extremity operations are called a single-event multilevel surgery (SEMLS) because they correct all existing soft tissue and bone problems during one operation. The technique typically results in fewer surgeries overall and just one phase of rehabilitation.

Patients often have the following outcomes after a SEMLS surgery:

  • Improved or preserved walking abilities
  • Enhanced mobility skills
  • Decreased consumption of oxygen (so patients tire less easily)
  • Preserved joint mobility
  • Reduced risk of issues associated with misaligned muscles and bones
  • Reduced risk of pain as patients grow older

Candidates for Single Event Multilevel Surgery (SEMLS)

We perform SEMLS to treat children of all ages who have cerebral palsy, spina bifida or other neurologic conditions that affect the brain or spinal cord. In children who have cerebral palsy, we prefer to perform a SEMLS after we reduce muscle tone so that deformities don’t recur with a growth spurt.

We evaluate potential candidates for SEMLS individually. Our specialists monitor patients’ growth, assess their individual challenges and gauge their expected outcomes. This information, in combination with the information our specialists collect from gait and motion analysis, determines whether we might recommend surgical or non-surgical treatment.

Patients who’ve undergone a selective dorsal rhizotomy (SDR) for cerebral palsy can still have problems with bone and joint alignment. A SEMLS can help correct bone or joint deformities, allowing for more balanced muscle and joint function.

Preparing for Single Event Multilevel Surgery (SEMLS)

We work closely with patients and families to prepare them for what to expect before, during and after surgery. We also help clarify short- and long-term expectations for outcomes following a SEMLS. Once we’ve determined that a patient is a good candidate for surgery, we help families plan a time for surgery and rehabilitation that will work with their schedules. We also offer classes for families of children scheduled for SEMLS. Search Conferences and Events to find upcoming dates.

About a week before surgery, we’ll call patients to:

  • Obtain a health history, including details about medicines (name, dose, frequency), pharmacy and primary care doctor
  • Discuss what to expect on the day of surgery and during the hospital stay
  • Let patients know what they will  need when they leave the hospital

Managing Diet and Activity

Overall health can affect how well and how quickly a child recovers from a SEMLS. Patients should maintain regular levels of activity and physical therapy before surgery. We also recommend eating adequate amounts of food with iron, calcium and vitamins C and D (fresh colorful fruits and vegetables, dairy food, and other products with added iron and calcium).

Alerting Us to Latex Allergies

Gillette is a latex-free facility, but it’s still important to tell doctors if a child has a latex allergy or has ever had a severe reaction to latex.

Addressing Stress

Sometimes fears, behavior or expectations related to the upcoming surgery cause stress for patients and families. We recommend contacting the patient’s primary health care provider or Child and Family Services for assistance. We can locate resources that might help reduce anxiety. Our child life specialists can provide emotional support and distractions (such as toys and movies we can bring to the preoperative waiting area before surgery begins). Child life specialists also can meet with a child’s siblings to address their feelings and concerns.

See Preparing for Surgery to get more information and resources to help plan for a hospital stay.

During Single Event Multilevel Surgery (SEMLS)

Our Perianesthesia staff greets SEMLS patients upon arrival. We'll weigh patients and ask them to change into hospital gowns. We’ll also check temperature, pulse and blood pressure. A child life specialist helps prepare children for surgery and offers toys, crafts or movies to help them feel more at ease.

Next, patients meet with the surgery team: the operating room nurse, surgeon, nurse anesthetist and anesthesiologist. You may raise any questions or concerns at this time. Also, tell the nurse and anesthesiologist about experiences with pain. Patients can request medicines and other techniques to help decrease anxiety. The anesthesiologist will explain how we use anesthesia and pain medicines during surgery.

Right before surgery, the surgeon marks the places on the patient’s body where incisions will be made. Patients then inhale anesthesia through a mask or receive it through an intravenous (IV) tube. After the patient is unconscious, we insert a breathing tube. If we haven’t placed an IV tube previously, we do it now. Patients receive anesthesia and fluids through the IV tube during and after surgery. Our staff monitors breathing throughout the surgery.

The procedure usually lasts several hours. We update families and caregivers on a patient’s progress during surgery.

After Single Event Multilevel Surgery (SEMLS)

After surgery, patients start out at the postanesthesia care unit (PACU). Depending on age, they then move to the Orthopedics/Surgical Unit or the Adult Unit. Once the patient is conscious, the nurses will ask how much pain the patient is feeling. We give medicine to provide as much comfort as possible. The surgeon also meets with the patient’s family or caregivers to discuss the surgery and recovery process.

After surgery, you might notice temporary changes in a patient’s appearance. For example, the face and hands might be puffy because of the body’s position during surgery. There might be redness around the eyes and lips. That’s because we often place protective tape over the eyes and around the mouth to keep the breathing tube in place.

We typically start physical therapy three to four days after surgery. A medical team — including doctors, nurses, therapists, social workers and other medical specialists — will discuss the patient’s progress and decide when the patient is ready to leave the hospital. Before patients leave the hospital, we’ll give specific guidelines — including instructions for recovering at home and scheduling follow-up appointments. We’ll also provide details about diet, incision care, cast care and equipment.

A physical therapist will discuss activity guidelines with patients, their family and caregivers. A physician or nurse will explain how, when and for how long patients should take pain medicine and what side effects, if any, they should watch for. Patients typically stay in the hospital for five to seven days after surgery.

Rehabilitation and Recovery for Single Event Multilevel Surgery (SEMLS)

Rehabilitation and full recovery following surgery can take up to one year. Breaking down the stages of rehabilitation, however, helps patients set rehabilitation goals and reasonable expectations.

Patients will require significant help from family members or caregivers (with things like dressing, eating and toileting) for at least three to six weeks after surgery.

Before patients leave the hospital, a physical therapist will teach caregivers how to:

  • Move patients from a bed to a wheelchair
  • Roll patients safely in bed
  • Use equipment after the hospital stay
  • Help patients with exercises that prevent stiffness
  • Move patients to and from vehicles

Physical Therapy: First Three Weeks After Surgery

Range of Motion

During this time, the patient will work on:

  • Maintaining or increasing range of motion in the joints
  • Preventing stiffness while healing

If recommended by doctors, we’ll teach parents or caregivers how to use passive range-of-motion exercises to help patients move. We’ll help make sure parents or caregivers feel comfortable using the techniques before leaving Gillette.


We teach parents or caregivers how to help patients move to and from a bed, a wheelchair and a vehicle. Caregivers might use a sliding board to decrease strain on the back. The specific transfer techniques will depend on individual restrictions after surgery. Some patients can bear weight on the legs. Most patients are immobilized and unable to move independently for three weeks after surgery.


We’ll teach parents or caregivers about appropriate activities for patients after leaving the hospital. It’s not easy for patients to travel at first, so we help prepare them for activity restrictions. We’ll also explain any adjustments patients might need in their living situation. A Gillette social worker will help with the transition from the hospital.

Pain Control During Physical Therapy

Patients might feel anxiety or pain during physical therapy sessions, especially the first time they move their legs after surgery. We recommend taking pain medicine before each session. Patients should let their therapist know if they’re feeling pain. Our therapists will work closely with patients and their nurses to manage pain.

Three to Six Weeks After Surgery

Doctors usually lift precautions and encourage activity beginning three to six weeks after surgery.

Range of Motion

We’ll add active exercises to range-of-motion training. The overall goal will be full use of all the joints. Then we’ll add strengthening exercises.

Patients can gain strength by:

  • Doing exercises
  • Changing positions (such as moving from lying down to sitting up, kneeling or standing)
  • Practicing mobility (rolling and crawling)

Patients also might start using a three-wheeled or stationary bike.

Weight-Bearing Activities

If the surgery involved the bones, patients won’t be able to put weight on their legs for at least three weeks after surgery. Patients might begin bearing weight at three weeks if X-rays reveal adequate healing. Patients also might receive new shortleg casts at that time. If a patient had soft-tissue operations (such as muscle lengthening), an ankle-foot orthosis (AFO) can provide ankle support. Patients who could walk independently before surgery typically begin using a walker or crutches. Re-educating the muscles and learning new walking patterns takes time. Patients will need to adjust to a new sense of balance and alignment.

Continuing Physical Therapy

Depending on their preoperative mobility, patients will participate in physical therapy two to three times a week. They’ll also need to do stretching and strengthening exercises at home. Patients can receive physical therapy at any Gillette site, or they can work with a provider in their community. Sessions at schools, however, typically aren’t sufficient as the only source of physical therapy.

Six to 12 Weeks After Surgery

Patients will continue strengthening and mobility activities, which will help them return to the level of activity they experienced before surgery.

Braces and Exercises

If patients have a second set of casts, we’ll remove them at approximately six weeks after surgery. At that point, patients usually need braces (orthoses) for support, but they’ll also work on strengthening exercises without the braces. The amount of time patients need to wear a brace, and the type of brace patients will need, might change once walking ability stabilizes.

Ask the patient’s doctor how often — and for how long — patients should wear braces. Patients should continue doing strengthening exercises two to three times per week. As patients grow stronger, they might use increased resistance (weights). Neuromuscular electrical stimulation (NMES) might improve muscle power, walking patterns and posture.


Because the patient no longer wears casts, their activities can now include swimming, therapeutic horseback riding, biking without AFOs, and other types of exercise. As their endurance improves, patients can increase how far they walk. The amount of time patients use a walker or crutches depends upon how quickly they recover. Some might go directly from using a walker to walking independently. Some might move from a walker to crutches. Patients will need an assistive device until they’re strong enough to overcome trunk sway (leaning to one side when lifting the opposite leg).

12 Weeks to One Year After Surgery

Patients continue to work on strengthening and endurance to return to their previous level of functional mobility. Physical therapists work with patients to help them achieve the goals that were set before surgery—including goals related to walking.

When patients achieve the goals the surgeon set, or if they meet activity goals, we might stop physical therapy. We typically recommend that patients continue regular stretching and periodic strengthening programs. To maintain fitness, we recommend that patients take part in some form of aerobic exercise (such as biking or swimming).

Our Single Event Multilevel Surgery (SEMLS) Services

Successfully selecting patients, performing surgery and providing rehabilitation care require the collaboration of a highly skilled team. At Gillette, our patients have access to a full range of services and extensive family support. Together, we promote the highest standards of patient care.

Services and specialties most often associated with SEMLS planning and rehabilitation include:

In addition, Gillette offers a vast array of child and family support services to help patients cope with their hospital stays and make the most of their rehabilitation care. Some of our services include:

For more information about our collaborative services, search Conditions and Care. For information about our hospital amenities, visit Patient Preparation and Support.

Publications and Resources

Gillette offers resources to help families understand and prepare for orthopedic single-event multilevel surgery (SEMLS). We want you to feel prepared and supported throughout your experience with us.

Educational Binder

All About Your Single-Event Multilevel Surgery (SEMLS)

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