Abstract Purpose Lisfranc injuries are potentially career‐threatening for athletes, yet optimal management of unstable ligament and fracture‐dislocation injury patterns remains debated. This study integrates an international expert consensus with a systematic review to evaluate current surgical strategies and outcomes, aiming to establish evidence‐based recommendations for the treatment of elite athletes and to optimize recovery and return to play. Methods A systematic review evaluated post‐operative outcomes following suture button fixation (SBF), open reduction internal fixation (ORIF) and arthrodesis of unstable ligament and fracture‐dislocation Lisfranc injuries. In addition, a consensus process was conducted using a modified Delphi technique. All consensus questions were generated by an initial survey sent to the expert panel. General consensus was defined as 75%–85% agreement, strong consensus as 86%–99% agreement and unanimous consensus as 100% agreement. Results Sixteen studies ( n = 406 athletes) were included. In the unstable ligament group, SBF ( n = 46) versus ORIF ( n = 203) yielded higher American Orthopaedic Foot and Ankle Society (95.5 vs. 89.4), lower complications (10.9% vs. 18.2%), zero failures (0% vs. 4.9%) and fewer secondary procedures (0% vs. 30.5%), with 93.5% of ORIF reoperations being hardware removal. In fracture‐dislocation injury patterns, ORIF ( n = 123) and arthrodesis ( n = 31) showed similar complication (30.8% vs. 35.5%) and failure rates (13.8% vs. 12.9%), with secondary procedures more frequent after ORIF (90.2% vs. 22.6%). The consensus process generated 16 statements: 12 achieved unanimous agreement and 4 achieved strong consensus. Conclusion Elite athletes who present with unstable ligament Lisfranc injuries and indications for surgical intervention should undergo fixation rather than fusion. For bony and fracture‐dislocation Lisfranc injuries, ORIF is preferred when joint surfaces are salvageable and arthrodesis when long‐term preservation is not feasible. However, the findings of this study underscore the importance of individualized treatment strategies to optimize surgical outcomes and functional recovery. Level of Evidence Level V.
Balboni et al. (Fri,) studied this question.