Abstract
Background
Bone anchors are increasingly utilized in Achilles tendon surgery due to their ability to provide stable fixation, minimize incision size, and facilitate early rehabilitation. However, their growing use introduces unique complications, including postoperative pain and anchor-related morbidity. This systematic review evaluates the frequency, mechanisms, and management of postoperative pain and other complications associated with bone anchors in Achilles tendon repair and reattachment procedures.
Methods
A comprehensive PRISMA-guided search of PubMed, Google Scholar, and the Cochrane Library was conducted. Studies were included if they involved adult patients undergoing Achilles tendon surgery with bone anchor fixation and reported anchor-related complications, pain, or revision surgery outcomes. Of 125 studies initially identified, 10 met the inclusion criteria, encompassing 259 patients.
Results
Calcaneal stress reactions were the most common complication (∼13%), typically resolving with conservative management within six months. More serious complications included infection, sinus tract formation, osteomyelitis, and delayed hypersensitivity, which mostly resolved following anchor removal. Bioabsorbable anchors were frequently associated with osteolysis, whereas metallic and knotless anchors were linked to localized irritation. Importantly, no studies reported Achilles tendon re-rupture directly attributable to anchor failure, and the majority of patients regained functional outcomes (∼95%) after appropriate management.
Conclusion
Bone anchors remain a valuable method for Achilles tendon repair. Awareness of potential complications, careful implant selection, and postoperative monitoring are essential to minimize inflammation and pain. When complications persist, anchor removal is an effective and reliable intervention. Further prospective studies are warranted to clarify the long-term implications of different anchor materials and surgical techniques.
Introduction
The Achilles tendon, the strongest tendon in the human body, remains highly susceptible to rupture and degenerative conditions, particularly in active adults. Surgical management is the standard of care for complete ruptures and advanced insertional pathology, with techniques evolving from traditional open repair to limited-incision and minimally invasive approaches that aim to reduce wound complications while ensuring durable fixation. Minimally invasive methods have been associated with improved outcomes relative to open repair. Among these, newer techniques employ proximal sutures anchored into distal interference screws in the calcaneus, providing strong fixation while minimizing surgical trauma and facilitating early mobilization. , Bone anchors were developed to secure tendons and ligaments in anatomically challenging or high-stress locations. Their use allows for stable fixation, promotes tendon healing, and reduces complications related to extensive exposure. Bioabsorbable anchors, composed of polylactic acid (PLA), polyglycolic acid (PGA), poly-L/D-lactide (PLDLA), and bio-composites, aim to mitigate issues associated with metallic anchors, such as migration, loosening, and imaging artifacts. ,
Despite these advantages, anchor-related complications are increasingly reported. Calcaneal stress reactions occur in roughly 13% of minimally invasive cases and have been observed in patients treated with proximal suture–distal interference screw constructs. More severe outcomes, including infection, draining sinus tracts, chronic osteomyelitis, and delayed hypersensitivity reactions, may necessitate anchor removal and revision surgery. , These complications can delay recovery, increase costs, and, in some cases, negate the intended benefits of anchor fixation. Given the widespread adoption of anchor fixation in Achilles tendon surgery and the potential for pain and complications, understanding the patterns, mechanisms, and clinical implications of anchor-related morbidity is critical. This review aims to synthesize current evidence, categorize complication patterns, and highlight surgical considerations to optimize outcomes and minimize anchor-related complications.
Methods
A comprehensive search of electronic databases, including PubMed, Google Scholar, and the Cochrane Library, was conducted without restriction on publication date. The review followed a systematic methodology in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The objective was to identify studies reporting the use of bone anchors in Achilles tendon surgery with documented complications or pain-related outcomes. The search strategy utilized a text-word query and was performed on August 5, 2025.
Eligible studies included case reports, retrospective clinical series, and systematic reviews that reported clinical outcomes, complications, or revision procedures related to bone anchor fixation in Achilles tendon repair or reconstruction. Studies were included if participants were aged ≥18 years and had a minimum follow-up of one year. Exclusion criteria encompassed studies that did not specifically evaluate Achilles tendon procedures or failed to report complication or outcome data. The primary outcomes of interest were anchor-related pain, migration, infection, hypersensitivity reactions, and revision surgery. Case reports and retrospective studies were included to capture the breadth of available clinical evidence, acknowledging that higher-level studies on this specific complication profile remain limited. A total of 125 studies were identified, with only those meeting the inclusion criteria incorporated into the final analysis ( Fig. 1 ).
Systematic review of bone anchor-associtated morbidity in Achilles tendon repair according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
Results
Of the 125 studies reviewed in this systematic review, 10 articles met the inclusion criteria, with a total of 259 patients who underwent Achilles tendon repair using bone anchors ( Table 1 ). The included studies were primarily Level 3 or 4 evidence, consisting of retrospective reviews and case series. The mean age across studies ranged from 36 to 55 years, with an average follow-up of approximately 12 months, though one series extended to 60 months.
Table 1
Summary of studies on bone anchor–associated morbidity in Achilles tendon repair: patient characteristics, surgical techniques, and outcomes.
| Study | Sample Size (# of patients) | Age (mean-years) | Study Type and Level | Indication | Surgical Intervention/ Anchor Use | Outcomes/ Complications | Post-operative Management | Follow-up (average) |
|---|---|---|---|---|---|---|---|---|
| Shoap et al., 2020 | 30 | 36.93 | Retrospective, 4 | Mid-substance Achilles rupture | Distal calcaneal interference screws | ● Calcaneal stress reaction | Non-operative; all resolved by 5–6 months | 12 months |
| Lewis et al., 2016 | 3 | 53 | Case series, 4 | Achilles reattachment | Bioabsorbable anchors | ● Infection/osteolysis, draining sinus tracts, and painful anchors | Debridement + anchor removal → healed | 12 months |
| Clifton et al., 2020 | 2 | 55 | Case series, 4 | Achilles tendon repair | Anchors + suture tape | ● Delayed hypersensitivity, sterile abscess, anchor-site pain, erythema, drainage | Removal of anchors and suture; culture (-) → healed | 28–45 weeks |
| Xue et al., 2024 | 17 | 37.8 ± 6.2 years | Retrospective Review | Acute Achilles tendon rupture defects | Transversal calcaneal anchored autogenous semitendinosus tendon graft |
● Mean AOFAS: 53.94 (preoperative) → 83.41 (postoperative)
● Mean ATRS: 24.47 (preoperative) → 68.59 (postoperative) ● Mean VAS: 5.35 (preoperative) → 1.18 (postoperative) ● Delayed wound healing (3), sural nerve injury (1), and no re-rupture |
2, 4, 6, 8 weeks; 3, 6, 12 months post-op | 12 months |
| Wolf et al., 2022 |
Suture anchor group=16
Transosseous group=27 |
Suture anchor group=50.5
Transosseous group=53.0 |
Retrospective, 3 | Acute Achilles tendon rupture | Transosseous vs. suture anchor fixation |
● Suture anchor: 1 calcaneal fracture @ 10 months
● Transosseous: 1 DVT @ 1 month; similar post-operative pain |
NWB in CAM boot or below-knee case; protected WB after suture removal | 12 months |
| Sessions et al., 2020 | 4 | 58.25 | Case series, 4 | Insertional Achilles tendinopathy | Insertional double-row | ● Draining sinus, osteomyelitis, osteolysis | I& D + anchor removal, antibiotics → healed | 12 months |
| Brué et al., 2025 | 21 | 55 | Retrospective, 4 | Insertional Achilles tendinopathy | Open insertional debridement + double-row knotless anchors |
● 3 anchor discomfort, 1 infection, 1 DVT
● Mean VAS: 9.26 (preoperative) → 2.5 (postoperative) |
Anchor removal for pain; debridement for infection | 16 months |
| Conle et al., 2022 | 60 | 51.5 | Retrospective, 3 | Insertional Achilles tendon repair | Bioabsorbable suture anchors |
● 1 DVT, 1 infection, 3 hypertrophic scars, 1 subQ suture reaction
● Mean VISA-A: 94.4 (postoperative) |
Below-knee cast w/ heel wedges, NWB 4 weeks, WB in CAM boot 6 weeks, PT at 10 weeks, RTA 5 months | 12 months |
| Çetin Işik et al., 2017 | 21 (12 suture anchor, 9 novel technique) | 40 | Case series, 4 | Achilles tendon avulsion | Suture anchor vs. novel technique |
● Anchor displacement
● Mean AOFAS: 84.4 (suture anchor); 91.6 (novel technique) ● VAS: 1.1–2.2 |
Cast removed 1 week, ankle brace, PT, full WB end of week 6 | 60 months |
| Mishra et al. 2024 | 38 | 40.42 | Prospective, 4 | Acute Achilles tendon tear | Suture anchor repair via open repair |
● 3 superficial infections, 1 ankle stiffness
● Mean AOFAS: 90.97 (postoperative) |
Immobilization 2 weeks, PT, full WB by week 4 | 12 months |
| Total | 239 | ∼48.0 |
2 Level III studies
8 Level IV studies |
●
Mean AOFAS score
…
improved to a
…
post-operative
…
average of 86.3 (Xue et al., Çetin Işik et al., Mishra et al.)
● Mean VAS score improved from a pre-operative average of 7.3 to 2.0 postoperatively (Xue et al., Brué et al., Çetin Işik et al.) ● Mean ATRS improved from 24.5 preoperatively to 68.6 postoperatively (Xue et al.) ● 0% reported re-rupture rate directly attributable to anchor failure ● ∼95% return to full activity and sport (Conle et al., Brué et al.) ● The majority of complications were resolved conservatively or with anchor removal |
16.8 |
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