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Background: Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown., Methods: A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate., Results: 2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12., Discussion: Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF., Level of Evidence: Level III Retrospective Cohort Study., (Copyright © 2018. Published by Elsevier Ltd.)