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Published on: January 13, 2026
Fixation of the Achilles tendon insertion using suture button technology
Nathan J Fanter1, Edward W Davis, Champ L Baker
1Hughston Clinic, 6262 Veterans Parkway, PO Box 9517, Columbus, GA 31908-9517, USA.
Background:
In the operative treatment of Achilles insertional tendinopathy, no guidelines exist concerning which form of fixation of the Achilles tendon insertion is superior.
Hypothesis:
Transcalcaneal drill pin passage does not place any major plantar structures at risk, and the addition of a Krackow stitch and suture button to the fixation technique provides a significant increase in ultimate load to failure in Achilles tendon insertional repairs.
Study Design:
Controlled laboratory study.
Methods:
The Achilles tendon insertions in 6 fresh-frozen cadaveric ankles were detached, and transcalcaneal drill pins were passed. Plantar dissection took place to evaluate the drill pin relationship to the plantar fascia, lateral plantar nerve and artery, flexor digitorum longus tendon, and master knot of Henry. The Achilles tendons were then repaired with a double-row suture anchor construct alone or with a suture button and Krackow stitch added to the double-row suture anchor construct. The repairs were then tested to maximum load to failure at 20 mm/min. The mode of failure was recorded, and the mean maximum load to failure was assessed using the Student t test for distributions with equal variance.
Results:
Transcalcaneal drill pin passage did not place any selected anatomic structures at risk. The mean maximum load to failure for the suture bridge group was 239.2 N; it was 391.4 N for the group with the suture button (P = .014). The lateral plantar artery was the structure placed at greatest risk from drill pin placement, with a mean distance of 22.7 mm (range, 16.5-29.2 mm) between the pin and artery.
Conclusion:
In this laboratory study, transcalcaneal drill pin passage appeared to be anatomically safe, and the use of suture button technology with a Krackow stitch for Achilles tendon insertional repair significantly increased repair strength.
Clinical Relevance:
Achilles tendon insertional repair with suture button fixation and a Krackow stitch may facilitate the earlier institution of postoperative rehabilitation and improve clinical outcomes.