Should a patient with Lisfranc widening, planning to undergo a first and second Tarsometatarsal (TMT) joint fusion, be nonweightbearing prior to surgery?

Preoperative Weight-Bearing Status for Lisfranc Injuries Requiring TMT Fusion

Patients with Lisfranc widening awaiting first and second TMT joint fusion should be made non-weightbearing prior to surgery to prevent further displacement and worsening of the injury. 1, 2, 3

Rationale for Non-Weightbearing Status

Prevention of Further Displacement

• Weight-bearing forces can worsen Lisfranc instability and increase displacement at the TMT joints, potentially complicating surgical reduction and worsening outcomes. 1, 3
• The American College of Radiology specifically notes that weight-bearing radiographs reveal dynamic instability and displacement that manifests under physiologic load—this same principle means continued weight-bearing can propagate injury. 1, 3
• In unstable Lisfranc injuries, 98% demonstrate medial cuneiform-second metatarsal instability intraoperatively, and 76% have multiple joint instability, indicating the fragility of these injuries under load. 4

Diagnostic Evidence Supporting Non-Weightbearing

• While weight-bearing radiographs are the gold standard for diagnosis of Lisfranc injuries (revealing instability not apparent on non-weightbearing films), this diagnostic principle actually argues against continued weight-bearing once the injury is identified. 1, 2, 3
• The fact that non-weightbearing radiographs are "unreliable for detecting subtle injuries" demonstrates that weight-bearing stresses unmask and potentially worsen displacement. 1, 2, 3

Preoperative Management Protocol

Immediate Immobilization

• Immediate immobilization should be employed while awaiting surgery if weight-bearing is not feasible or contraindicated. 1
• Non-weightbearing radiographs are acceptable when the patient cannot bear weight due to pain, limited mobility, or when there is risk of further displacement of joints and/or bones—all of which apply to confirmed Lisfranc injuries awaiting surgery. 1

Specific Preoperative Instructions

• Patients should be placed in a below-knee cast or boot with strict non-weightbearing status using crutches or other assistive devices. 5, 1
• The goal is to maintain the current alignment and prevent further soft tissue injury or displacement prior to definitive surgical fixation. 2, 6

Surgical Planning Considerations

Timing of Surgery

• While the ACR/AAHKS guidelines for joint arthroplasty suggest proceeding without delay in appropriate candidates, this applies to elective arthroplasty for arthritis, not acute traumatic injuries requiring anatomic reduction. 5
• For Lisfranc injuries, the priority is achieving optimal anatomic reduction and stability—failure to do so leads to post-traumatic arthritis, foot deformities, and significant disability. 2, 6

Preoperative Optimization

• Surgery should not be unnecessarily delayed, but patients should be optimized regarding glycemic control if diabetic and counseled on nicotine cessation if applicable, as these factors increase surgical complications. 5
• Prophylactic antibiotics should be administered prior to incision (such as cefazolin) for extremity trauma. 2

Common Pitfalls to Avoid

Do Not Allow Continued Weight-Bearing

• The single most critical error would be allowing continued weight-bearing on a confirmed unstable Lisfranc injury, as this can convert a reducible injury into one requiring more extensive reconstruction or primary arthrodesis. 1, 2, 6
• Even "subtle" Lisfranc injuries demonstrate significant instability intraoperatively (90% show C1-M2 abnormalities), meaning clinical appearance underestimates true instability. 4

Avoid Delayed Diagnosis Leading to Delayed Immobilization

• Up to 20% of Lisfranc fracture-dislocations are missed or diagnosed late, especially low-energy or purely ligamentous injuries—once identified, immediate non-weightbearing is essential. 6
• Do not assume non-weightbearing films showing minimal displacement mean the injury is stable—weight-bearing would reveal the true extent of instability. 1, 4

Patient Education

• Patients must understand that non-compliance with non-weightbearing status can lead to rerupture or worsening displacement—this principle is demonstrated in Achilles tendon repairs where documented non-compliance led to rerupture. 5
• Emphasize that the preoperative non-weightbearing period is temporary but critical for optimizing surgical outcomes and preventing conversion to a more severe injury pattern. 2, 6