Ankle instability may be the result of chronic ankle injuries and sprains. Surgical indications for lateral ankle stabilisation include persistent pain and functional disability such as recurrent sprains and instability. Surgical decision making for ankle instability involves an evaluation of anatomical predisposing factors, clinical exam findings, radiographic imaging, and treatment of associated injuries and conditions. Anatomical predisposing factors include hindfoot varus and generalised ligamentous laxity conditions. Associated injuries and conditions can be classified as intra and extra-articular. These include peroneal tendon injuries, osteochondral defects of the talus, posterior and lateral joint impingement. Surgical options for reconstruction include anatomical direct repair, anatomical reconstruction with use of autograft or allograft, non-anatomical lateral ligament reconstruction, and arthroscopic ligament repair. Adjunct procedures include ankle and foot osteotomies, ankle joint arthroscopy and the use of biologics are also reviewed. Guidelines are provided to assist clinicians in the surgical decision making of patients with lateral ankle instability.