Hybrid fixation with a double-row suture and low-profile plate for comminuted or avulsed greater tuberosity fractures

BACKGROUND: Isolated greater tuberosity (GT) fractures account for approximately 20% of proximal humeral fractures and are frequently associated with glenohumeral dislocation and rotator cuff injuries. Displacement exceeding 5 mm is recommended for surgery to prevent subacromial impingement and functional impairment. Current fixation methods, such as cannulated screws, suture anchors, and locking plates, each have limitations, including inadequate stability for comminuted fractures, risk of impingement, and suboptimal anatomical adaptation. This underscores the necessity of a hybrid technique that integrates the benefits of both soft tissue and rigid fixation. METHODS: This retrospective study analyzed 12 patients with comminuted split-type or avulsion-type greater tuberosity fractures treated with a hybrid surgical technique from January 2023 to June 2025. A deltopectoral approach was utilized to achieve fracture reduction, which was temporarily stabilized via K-wires. Two anchors were placed at the greater tuberosity, and a double-row suture technique was employed, with the sutures secured through an external row anchor arranged in a parachute configuration. A low-profile anatomic locking plate was subsequently applied to provide buttress support, resulting in a composite construct referred to as a "suture plate." The outcomes measured included operative time, blood loss, Constant-Murley and ASES scores, VAS pain scores, and radiographic healing status. RESULTS: All patients were followed up for a mean duration of 11.3 ± 5.0 months. The mean operative time was 82.5 ± 15.8 min, and the mean blood loss volume was 170.8 ± 52.6 ml. All fractures achieved clinical union at a mean of 11.0 ± 1.5 weeks, with no instances of anchor pullout, suture cutout, or implant failure. The Constant-Murley scores improved from 30.5 ± 4.8 preoperatively to 90.3 ± 3.7, the ASES scores improved from 32.1 ± 5.8 to 89.4 ± 3.6, and the VAS scores decreased from 6.8 ± 2.1 to 1.0 ± 0.6. Excellent or good outcomes were observed in 91.7% (11/12) of the patients. CONCLUSION: The combination of the double-row parachute suture technique and a low-profile anatomic locking plate provides a hybrid fixation system that integrates flexible and rigid stabilization. This construct can provide reliable fixation, supporting early rehabilitation, and yielding satisfactory short-term functional outcomes for comminuted split-type or avulsion-type greater tuberosity fractures, representing a potentially feasible alternative to conventional methods, although further high-level studies are required to confirm its long-term efficacy and safety.