Twenty-eight patients, with severe, acute Lisfranc dislocations, requiring operative intervention, were treated between 1989 and 1992 in a level one Trauma Center. Different treatment protocols were used by the two senior staff surgeons. This allowed ORIF to be compared to complete arthrodesis and partial arthrodesis. Twelve patients were treated with primary arthrodesis after open reduction of the dislocation. Partial (5) or complete arthrodesis (6) (depending on the type of fracture) was performed in these 12 patients. Sixteen patients were treated with open reduction and temporary fixation with stabilization and compression screw fixation (ORIF group). The subgroups were identical in age (mean 30.5 years), follow-up (30.1 months), type of fracture, type of injury and time to intervention. Anatomical reduction was achieved in eight of the 12 patients in the arthrodesis groups and in 12 of the 16 patients in the ORIF group. The Baltimore Painful foot Score (PFS) was higher in the ORIF group then in the complete arthrodesis group meaning the ORIF group had less pain. No difference in the PFS was found between the ORIF group and the partial arthrodesis group. Subsequent revision surgery was necessary in two cases in the arthrodesis groups and two cases in the ORIF group. Stiffness of the forefoot, loss of metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. Open reduction and internal fixation with screws or partial arthrodesis is the treatment of choice in severe tarsometatarsal fracture dislocations. Primary complete arthrodesis should be reserved as a salvage procedure.