Introduction and importance: Periprosthetic osteolysis (PPOL) is a common complication after total knee arthroplasty (TKA) and is most commonly caused by wear-induced particles. Case presentation: We report an unusual case of massive bilateral PPOL in the posterior flanges of the femur and patellae 4 years after bilateral uncemented TKA without patellar resurfacing in a 71-year old female. Bilateral staged revision surgery including polyethylene exchange and allograft morselized bone impaction was performed to treat the osteolytic lesions. There were no signs of implant malalignment, polyethylene wear or component loosening. Clinical discussion: Several factors are associated with an increased risk on PPOL (e.g. polyethylene sterilization method, patient age, male gender). Surgical intervention in the context of massive PPOL should include replacement of a potential particle generator (most often polyethylene), correction of potential malalignment, treatment of bone defects and assessment of implant anchorage. Conclusion: This report highlights the available evidence on clinical presentation, associated risk factors and preferred treatment strategy of massive osteolytic lesions after TKA according to available evidence.