Background Among the proximal humeral fractures,the incidence of isolated fractures has been reported to be approximately 14% to 21%.In addition,during rotator cuff injury,as a result of a strong pulling power,fractures of the greater tuberosity occur frequently during avulsion fracture of the rotator cuff.Particularly,a strong external rotation power acts on the greater tuberosity,and thus avulsion fracture may occur during anterior shoulder dislocation.Some authors have reported that greater tuberosity fractures were associated with approximately 10% to 30% of shoulder joint dislocation cases.Several arthroscopic and open techniques utilizing screws,wire or sutures through bone have been described for reduction and internal fixation of the greater tuberosity to the proximal humerus.But these are often inadequate in the presence of comminution and may prevent accurate restoration of the tuberosity-head relation.Bhatia have performed open reduction–internal fixation by use of the double-row suture anchor fixation technique in 21 cases of comminuted and displaced fractures of the greater tuberosity,and the long-term results suggest a satisfactory outcome in most patients.However,the retrospective study or follow-up data about the surgical treatment of displaced humeral greater tuberosity fractures is still very limited.The purpose of this retrospective study is to evaluate the therapeutic outcomes of the open reduction and internal fixation using double-row fixation with suture anchors for the treatment of humeral greater tuberosity fractures.Methods The study included 10 patients with isolated greater tuberosity fractures.The cases were reviewed at a mean post-operative follow-up duration is 12.3 months (range from 7 to 18 months) from 2010 to 2013.The average age of the patients was 48.2 years old (range:41 to 63 years old),including 4 males and 6 females.Among them,3 patients were associated with anterior dislocation of the shoulder joint.All radiographs were examined by a single observer.The displacement was more than 5 mm in X-ray plain film.All patients were operated by a single surgeon and with the same surgical technique.All the patients were treated by double-row anchor suture fixation through a mini-open approach and the operations were carried out in 2 to 21 days after trauma.The skin incision was made in Langer’s lines just medial to the anterolateral aspect of the acromion.The deltoid was split from the anterolateral corner of the acromion distally for 4-5 cm,without detaching the origin of the deltoid.The greater tuberosity fragment with the attached cuff was located and tagged with traction sutures through the cuff tendon.After the fractured bone surface on the proximal humerus was cleared of soft tissue,and two anchors (TwinFix) were inserted at the proximal margin of the humeral fracture surface.The strands of each suture were passed through the tendinous part of the attached cuff.The sutures were tied as mattress sutures with the arm in a neutral position.A second row of suture-anchors was passed distal to the humeral fracture surface.Two sutures were passed through the tendon between the first row of mattress sutures and the bone fragments.The strands from these two sutures were used to buttress the greater tuberosity fragments to the proximal humerus by tying these to four strands from the second row of anchors.The arm was suspended by a strap for 2 weeks postoperatively,during which the shoulder started to do the pendulum exercise passively.Then they were required to do the abduction and flexion exercise over 90°after 6 weeks.The patients were evaluated by interview,physical examination,and radiographs at 7-18 months,with a mean follow-up of 12.3 months.Details of complications and additional procedures were obtained from the clinical and operative records of the patients.The reductions and healing condition of the fractures were assessed by X-ray examination postoperatively.Then we use the Constant Score and UCLA shoulder rating scale to evaluate the function of shoulders.Results According to the intro-operative findings in the ten patients,five of them were communicated fracture,and there were soft tissues,such as periosteal membrane and rotator cuff,connecting the fractured fragments.Therefore,there is not significant separation between the fragments if the soft tissue around was properly protected during the exposure of fracture site.Moreover,the affected fracture area of the ten patients did not go over the greater tuberosity and the thickness of all the fracture fragments was within 0.8 cm.All the patients’ wound got healed.The X-ray showed an anatomic reduction with no re-displacement during the follow-up.Radiographic union of the tuberosity below the level of the articular surface of the humeral head was seen in all of 10 fractures.There was no heterotopic bone formation in any patient.All patients with radiographic union were satisfied with the outcome and the overall mean Constant score was 90.3 and the final mean UCLA score was 32.2.There were no neurological complications,infections or complications of wound healing.Conclusions Greater tuberosity fracture are well described and frequently discussed.They can be considered as an avulsion fracture of the rotator cuff. Suture anchors have recognized as an effective fixation of rotator cuff injury.The double-row anchors are more mechanically reliable,compared with single-row anchors.This technique has several advantages:First,biomechanical and clinical evaluation of the double-row fixation technique in arthroscopic rotator cuff repair has demonstrated significantly better biomechanical properties and structural outcome compared to other techniques; Second,proximal mattress sutures accurately restore the tuberosity-head relationship by approximating the bone-tendon junction to the proximal edge of the humeral fracture surface; Third,proximal fixation repairs the partial-thickness articular-surface tears of the supraspinatus tendon which may be associated with greater tuberosity fractures; Fourth,distal sutures serve as a tension band to effectively buttress the tuberosity fragments against the humeral fracture surface.The application of double-row anchors is clinically effective to treat the displaced greater tuberosity fractures.With the development of arthroscopic techniques,the outcome of double-row anchor suture fixation under arthroscopy is really to be expected.