Surgical management of Lisfranc injuries: a narrative review of open reduction and internal fixation, primary arthrodesis, and flexible fixation.

Lisfranc injuries are complex midfoot injuries that, if inadequately managed, produce lasting pain, deformity and functional loss. Operative management has historically centred on open reduction and internal fixation (ORIF) and primary arthrodesis (PA), and more recently on flexible fixation (FF) constructs such as suture button devices, the InternalBrace and nitinol staples. This narrative review consolidates contemporary evidence on these three strategies to support surgical decision-making. Across direct comparisons, ORIF and PA yield broadly comparable functional outcomes and complication rates, with outcome governed chiefly by the achievement and maintenance of anatomic reduction; PA tends to reduce reoperation and loss of reduction, particularly in purely ligamentous injuries and complete fracture-dislocations, whereas ORIF preserves midfoot motion but commonly requires planned hardware removal. Flexible fixation produces excellent functional scores and minimal planned hardware removal in isolated ligamentous injuries, with early-recovery advantages over rigid fixation that largely attenuate by one year. The evidence base remains limited by short follow-up, small sample sizes and heterogeneity. No single construct is universally superior; anatomic reduction and patient selection by injury pattern are the principal determinants of outcome.