https://doi.org/10.1177/1071100720945703 Foot & Ankle International® 2020, Vol. 41(12) 1546–1552 © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1071100720945703 journals.sagepub.com/home/fai Article Introduction Recurrent ankle instability following a lateral ankle ligament reconstruction may be present after any type of reconstructive procedure. Many surgical procedures have been described, including direct anatomical repair/reconstruction (DAR) procedures 2,16,22,25,34 and nonanatomical repair/reconstruction (NAR). Both DAR and NAR procedures may involve the use of autograft, 4,28,39 allograft, 14,20,38 or synthetic ligament. 23 Many of the surgical procedures described use the peroneus brevis tendon as a static 12,17,19,21,30,40 or as a dynamic tenodesis. 9 Broström advocated anatomical repair of the lat- eral ankle ligaments, even at a late stage, as end-to-end repair of the ruptured ligaments is possible several years after the initial injury. 7,8,29,31 However, healing with intervening scar tissue or lengthening may cause insufficiency of the repaired 945703FAI XX X 10.1177/1071100720945703Foot & Ankle InternationalPintore et al research-article 2020 1 Department of Orthopaedic Surgery, Istituto Clinico Mediterraneo, Agropoli (Salerno), Campania, Italy 2 Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy 3 Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, Baronissi (SA), Italy 4 Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, England 5 School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England Corresponding Author: Nicola Maffulli, MD, MS, PhD, FRCS (Orth), Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England. Email: n.maffulli@qmul.ac.uk Extensor Retinaculum Flap and Fibular Periosteum Ligamentoplasty After Failed Surgery for Chronic Lateral Ankle Instability Ernesto Pintore, MD 1 , Lucio Cipollaro, MD 2,3 , Raffaele Pintore, MD 1 , Francesco Oliva, MD, PhD 2,3 , and Nicola Maffulli, MD, MS, PhD, FRCS (Orth) 2,3,4,5 Abstract Background: The anterior talofibular ligament and the calcaneofibular ligament are 2 of the most frequently injured structures in sports, being damaged in 30% to 45% of all sports injuries. Most reconstructive procedures are successful but can deteriorate with time and can lead to low-grade radiographic degeneration. Methods: We operated on 26 consecutive patients from 2001 to 2008 who had failed previous surgical procedures for the lateral ligamentous complex of the ankle, with an average of 104 (range, 75-140) months. Results: The overall functional rating was excellent in 14 ankles, good in 10, fair in 1, and poor in 1. Twenty-four patients (92.3%) were satisfied with the procedure and 15 (57.7%) were able to return to their preinjury level of activity. Local complications were detected in 2 patients who presented with skin necrosis; 1 patient developed severe reflex sympathetic dystrophy. Conclusion: Revision surgery for the management of failure after surgical treatment of chronic lateral ankle instability is under debate, and the literature is devoid of clinical studies with long-term follow-up. The technique described offers a high rate of long-term excellent and good results, with a low rate of complications and a good rate of return to preinjury level. Level of Evidence: Level IV, retrospective case series. Keywords: chronic lateral ankle instability, revision surgery, fibular periosteum ligamentoplasty, inferior extensor retinaculum flap