Rapid Communication|Articles in Press

Double Row Fixation is More Costly and Does Not Have Clinical Benefit Over Single Anchor for Insertional Achilles Tendon Surgery

Published:January 17, 2023DOI:


      Surgical repair of insertional Achilles tendinosis is indicated in the face of failed conservative measures. Several methods for this repair have been described, and the optimal method is not universally agreed upon. In addition, the cost of medical care is important, and should be considered when determining the surgical repair for each patient. The purpose of this study is to compare implant costs between a single anchor or 4 anchor, double row repair, and evaluate associated outcomes. A retrospective comparative trial was performed for this purpose. The entire study encompassed 110 patients, 78 with a single anchor repair, and 32 with a double row repair. The average implant cost of the single anchor repair was $391.18 ± $272.10 and the double row repair was $1811.2 9 ± $169.47, p < .001. The groups did not have a statistically significant difference in complications (9% with single anchor vs 6.3% with double row, p = 1.0) or revisions 6.4% with single anchor vs 3.1% with double row, p = .67). The only difference in demographics between the groups was that the single anchor group had a higher percentage of female patients (p = .04). While the double row repair has been shown to have favorable biomechanical results, the present study did not show a benefit in complications or revisions and was a more costly repair technique. Surgeons should take these findings in consideration when choosing the repair technique when surgery is indicated.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Shakked RJ
        • Raikin SM
        Insertional tendiopathy of the Achilles: debridement, primary repair, and when to augment.
        Foot Ankle Clin. 2017; 22: 761-780
        • Irwin TA
        Current concept review: insertional Achilles tendinopathy.
        Foot Ankle Int. 2010; 31: 933-939
        • Paavola M
        • Kannus P
        • Javinen TA
        Achilles tendinopathy.
        J Bone Joint Surg Am. 2002; 84: 2062-2076
        • Myerson MS
        • McGarvey W
        Disorders of the insertion of the Achilles tendon and Achilles tendinits.
        J Bone Joint Surg Am. 1998; 80: 1814-1824
        • Thompson JM
        • Nguyen K
        • Ahluwalia J
        • Casciato D
        • Tewilliager T
        • So E
        • Prissel M
        Surgical takedown approaches to insertional Achilles tendinopathy: a systematic review.
        J Foot Ankle Surg. 2021; 60: 1217-1221
        • Greenhagen RM
        • Shinabarger AB
        • Pearson KT
        • Burns PR
        Intermediate and longterm outcomes of the suture bridge technique for the management of insertional Achilles tendinopathy.
        Foot Ankle Spec. 2013; 6: 185-190
        • Witt BL
        • Hyer CF
        Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series.
        J Foot Ankle Surg. 2012; 51: 487-493
        • Kolodziej P
        • Glisson RR
        • Nunley JA
        Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study.
        Foot Ankle Int. 1999; 20: 433-437
        • McGarvey WC
        • Palumbo RC
        • Baxter DE
        • Leibman BD
        Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach.
        Foot Ankle Int. 2002; 23: 19-25
        • Wagner E
        • Gould JS
        • Kneidel M
        • Fleisig GS
        • Fowler R
        Technique and results of Achilles tendon reconstruction for insertional Achilles tendinosis.
        Foot Ankle Int. 2006; 27: 677-684
        • DeVries JG
        • Summerhays B
        • Guehlstorf DW
        Surgical correction of Halgund's triad using complete detachment and reattachment of the Achilles tendon.
        J Foot Ankle Surg. 2009; 48: 447-451
        • Beitzel K
        • Mazzocca AD
        • Obopilwe E
        • Boyle JW
        • McWIlliam J
        • Rincon L
        • Dhar Y
        • Arciero RA
        • Amendola A
        Biomechanical properties of double- and single-row suture anchor repair for surgical treatment of insertional Achilles tendinopathy.
        Am J Sports Med. 2013; 41: 1642-1648
        • Pilson H
        • Brown P
        • Stitzle J
        • Scott A
        Single-row versus double-row repair of the distal Achilles tendon: a biomechanical comparison.
        J Foot Ankle Surg. 2012; 51: 762-766
        • Rigby RB
        • Cottom JM
        • Vora A
        Early weightbearing using Achilles suture bridge technique for insertional Achilles tendinosis: a review of 43 patients.
        J Foot Ankle Surg. 2013; 52: 575-579
        • Saxena A
        • Mafulli N
        • Jin A
        • Isa E
        • Arthur WP
        • Wahl A
        Insertional Achilles tendinopathy: analysis of 166 procedures and return to activity.
        J Foot Ankle Surg. 2021; 60: 1117-1123
        • Molloy A
        • Heyes G
        Cost-effectiveness of surgical techniques in hallux valgus.
        Foot Ankle Clin. 2020; 25: 19-29
        • Hyer CF
        • Glover JP
        • Berlet GC
        • Lee TH
        Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis.
        J Foot Ankle Surg. 2008; 47: 13-18
        • Albright RH
        • Waverly BJ
        • Klein E
        • Weil Jr, L
        • Weil Sr, LS
        • Fleischer AE
        Percutaneous Kirschner wire versus commercial implant for hammertoe repair: a cost-effectiveness analysis.
        J Foot Ankle Surg. 2018; 57: 332-338
        • Reb CW
        • Berlet GC
        Experience with navigation in total ankle arthroplasty. Is it worth the cost?.
        Foot Ankle Clin. 2017; 22: 455-463
        • Courville XF
        • Hecht PJ
        • Tosteson AN
        Is total ankle arthroplasty a cost-effective alternative to ankle fusion?.
        Clin Orthop Relat Res. 2011; 469: 1721-1727
        • Tucker WA
        • Barnds BL
        • Morris BL
        • Tarakemeh A
        • Mullen S
        • Schroeppel JP
        • Vopat BG
        Nationwide analysis of total ankle replacement and ankle arthrodesis in medicare: trends, complications, and cost.
        Foot Ankle Spec. 2022; 15: 201-208
        • Clement RC
        • Land PJ
        • Pettett BJ
        • Overman RA
        • Ostrum RF
        • Tennant JN
        Sanders II/III calcaneus fractures in laborers: a cost-effectiveness analysis and call for effectiveness research.
        J Orthop Trauma. 2017; 31: 299-304
        • White TO
        • Bugler KE
        • Appleton P
        • Will E
        • McQueen MM
        • Court-Brown CM
        A prospective randomized controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients.
        Bone Joint J. 2016; 98-B: 1248-1252
        • Juutilanen T
        • Pätiälä H
        • Ruuskanen M
        • Rokkanen P
        Comparison of costs in ankle fractures treated with absorbable or metallic fixation devices.
        Arch Orthop Trauma Surg. 1997; 116: 204-208
        • Wolf J
        • Fallat L
        • Coffey M
        Outcomes and material cost comparison of transosseous versus suture anchor fixation of the Achilles tendon: a retrospectivce study.
        J Foot Ankle Surg. 2022; 61: 12-16
        • T-+wersky RS
        • Showan AM
        Office based anesthesia update: guidelines, education and support are invaluable.
        ASA Newsl. 1999; 4: 4-7
        • Fleisher LA
        Role of the anesthesiologist in the next millennium: perioperative gatekeeper?.
        ASA Newsl. 1999; 5: 17-19
        • McGoldrick KE
        SAMBA: advocating for patients as we look toward the future.
        ASA Newsl. 2004; 10: 10-12
        • Hartman M
        • Martin AB
        • Benson J
        • Catlin A
        • National Health Expenditure Accounts Team
        National health care spending in 2018: growth driven by accelerations in Medicare and private insurance spending.
        Health Aff (Millwood). 2020; 39: 8-17