The management of Lisfranc injuries is challenging considering the broad spectrum of energy involved and highly variable clinical presentation. Despite the advances in surgical techniques, subtle Lisfranc injuries can lead to chronic pain and permanent disability. Surgical treatment is mandatory for all the unstable injuries; however, the best surgical technique remains controversial. The most predictive factor for a successful outcome is the maintenance of anatomic alignment; therefore, the selection of the appropriate surgical technique is of paramount importance. This article reviews the current treatment options and describes the selection of the surgical technique based on the different clinical presentations.