Bone Anchor–Associated Morbidity in Achilles Tendon Repair: A Systematic Review of Patterns, Mechanisms, and Management

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.