Recurrent femoral stem fractures in Dorr A femurs: Lessons learned and a call for alternative strategies.

We report a unique case of bilateral femoral stem fractures in a patient with Dorr A femoral morphology, underscoring the need for a critical reassessment of implant selection strategies. The initial failure involved a cemented revision stem placed using the cement-within-cement technique combined with an extended trochanteric osteotomy (ETO). A second revision was subsequently performed using a cortical window osteotomy and a distally fixed uncemented stem, which resulted in successful recovery. A similar approach was used to treat a subsequent contralateral stem fracture, also with favorable outcomes. This case emphasizes three key considerations: First, that standard-length cemented stems may lead to oversizing and increased stress concentration in Dorr A femurs with narrow canals; second, that ETO may compromise femoral integrity and contribute to implant failure; and third, that cortical window osteotomy enables safer implant removal and reimplantation. Based on these findings, we advocate for an individualized approach to implant selection that may include cemented short stems, uncemented short stems, or modular solutions depending on femoral anatomy and patient-specific factors, and we encourage further investigation into optimal fixation strategies for patients with Dorr A femoral morphology.