CASE REPORT
Journal of International Surgery and Clinical Medicine (JISCM) 2026.
Volume 6.
Number 1: 5-8
E-ISSN: 2807-7008
Implant loosening after total knee replacement with pigmented villonodular synovitis:
a case report Published By :
Surgical Residency Program Universitas Syiah Kuala Azizah Mallapasi1*.
Fidelis Heru2.
Riza Aprizal3
ABSTRACT
Faculty of Medicine.
Universitas YARSI.
Indonesia Department of Orthopedic and Traumatology.
RS Bhayangkara Tk.
Pusdokkes POLRI.
Indonesia Faculty of Medicine.
Universitas YARSI.
Indonesia *Corresponding author:
Azizah Mallapasi.
Faculty of Medicine.
Universitas YARSI.
Indonesia.
azizaharmaranimllps@gmail.
Received: 2026-01-22 Accepted: 2026-04-12 Published: 2026-05-14 Introduction: Aseptic loosening after total knee replacement (TKR) defined as prosthesis loosening from bone along with macrophage-induced inflammatory response without infection or trauma that may arises due to gradual mechanical loss of fixation while pigmented villonodular synovitis (PVNS) refers to a benign disease arises from synovium.
Although the etiology of PVNS remains unclear and the underlying cause of PVNS occurrence following total knee replacement are limited in publication studies, a hypothesis of microtrauma causing recurrent hemorrhage may lead to PVNS.
To date, there is no clear consensus on the primary treatment option for PVNS and surgery is generally the primary approach.
Surgical excision with total synovectomy is considered to be the gold standard for PVNS.
Case description: A 63-year-old woman with a history of left total knee replacement (TKR) 3 years prior came to our center with initial complaints of persistent pain and progressive impairment of daily activities.
The patient later underwent a revision procedure along with open synovectomy due to suspected PVNS finding which confirmed with histopathological studies.
Three months postoperatively, the patient showed marked improvement of left knee range of motion and quality of life measured with KOOS scoring of 78 out of 100.
Conclusion: This case presenting an aseptic loosening after total knee replacement accompanied by PVNS finding confirmed by histopathologic studies.
Implant loosening is thought to be related to loss of mechanical fixation or chronic inflammation, while PVNS occurrence following the implant loosening is likely triggered by microtrauma.
Keywords: pigmented nodular synovitis, implant loosening, total knee replacement.
Cite This Article: Mallapasi.
Heru.
Aprizal.
Implant loosening after total knee replacement with pigmented villonodular synovitis: a case report.
Journal of International Surgery and Clinical Medicine 6.
: 5-8.
DOI : 10.
51559/jiscm.
INTRODUCTION
Aseptic loosening after TKR defined as prosthesis loosening from bone along with macrophage-induced inflammatory response without infection or trauma that may arises due to gradual mechanical loss of fixation or inadequate prosthesis fixation during the primary procedure1 and pigmented villonodular synovitis (PVNS) refers to a benign lesion arises from 2While the etiology of PVNS remains unclear and the underlying cause of PVNS occurrence following total knee replacement are limited in publication studies, a hypothesis of microtrauma due to implant instability, poor implant positioning, or disproportionate implant size may cause recurrent hemorrhage and form the chronic synovitis which later lead to PVNS.
3 To date, there is no clear consensus on the primary treatment option for PVNS and surgery is generally the primary approach.
Total synovectomy of the affected joint with arthroscopic approach or open surgery is considered to be the gold standard for PVNS.
CASE DESCRIPTION
A 63-years-old woman presented with a history of left total knee replacement (TKR) came to our center with initial complaints of persistent pain and progressive impairment of daily activities.
The patient has undergone the procedures three years ago after diagnosed with Kellgren-Lawrence grade 4 osteoarthritis followed by recurrence knee pain six months post-surgery.
Two years after procedure, the patient had a trouble of walking and standing notably with the stairs, also addressed hearing of AoclickingAo sound when walking.
Recent illness and change in medical status were denied.
In physical examination, the patient is clinically stable, while reduced range of motion, tenderness, and warmth observed on the left knee compared to the contralateral side.
Anthropometric status assessed with body mass index (BMI) was 33.
7 kg/m2 and quality of life (QoL) assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS) scored 37% out of 100%.
Radiographic finding shows installed implant on the left femur and the condylar emmenentia of the left tibia and bone loosening was seen in the medial and lateral condylar of the left femur .
Calcification was seen in the popliteal and infrapatela regions of the left there with decreased bone density.
While laboratory studies are in normal limits with no sign of elevated inflammation marker.
Later, the patient underwent a onestage revision procedure .
where Open access:
Published by Surgical https://jiscm.
id/index.
php/JISCM/ Residency Program Universitas Syiah Kuala | JISCM 2026.
: 5-8 | DOI: 10.
51559/jiscm.
CASE REPORT
both loose prosthetics are removed and replaced with a cemented longstem implant .
Intraoperatively, brownish-rubbery-firm synovial tissue were found and open synovectomy performed .
The synovial tissue was taken for histopathologic study which confirmed a villous and nodular structures and foamy histiocyte cells, multinucleated giant cell lymphocytes, hemosiderophages in between the structures.
It was also found a cholesterol slit with bones trabecula and congestive hyperemic blood vessels in compatible with the features of tenosynovial giants cell tumor .
igmented villonodular synoviti.
Three months follow up after revision procedure, we found that our patient had a significant improvement of left knee range of motion (ROM) from 0A extension to 110A flexion with KOOS scored to 78% out of 100%.
DISCUSSION
Based on our patient clinical features along with laboratory studies and radiographic finding of weak-link fixation of implantcement interface and bone loosening in the medial and lateral condylar of the left femur, we suggest this case interpreted as possible aseptic implant loosening with pigmented villonodular synovitis.
Aseptic loosening after TKR defined as prosthesis loosening from bone along with macrophage-induced inflammatory response without infection or trauma that may arises due to gradual mechanical loss of fixation or inadequate prosthesis fixation during the primary procedure.
Subsequently, debris from wear off particulate may lead to aseptic osteolysis and biological loss of fixation.
In this case, the implant loosening was the primary factor for one-stage TKR revision.
Intraoperatively we found brownish-rubbery-firm synovial tissue which suspected displacing the implant and radical synovectomy was done.
The tissue histopathological studies confirmed a pigmented villonodular synovitis appearance (PVNS).
PVNS is described as to a benign disease of arises from synovium and a subtype of tenosynovial giant cell and characterized by joint effusions and bony erosion with slow onset.
2 Commonly the Figure 1.
X-ray of left knee implant loosening after three years post primary TKR shown in anteroposterior and lateral projection Figure 2.
Long stem prosthesis used for the revision procedure patient present with painless swelling and reduced range of motion may caused by expanding tumor tissues in the affected It distinguished by the capacity to infiltrate subchondral 1 bone and causing erosions which affects the soft tissue lining of joints.
The etiology of PVNS remains unclear and the underlying cause of PVNS occurrence following total knee replacement are limited in publication Though, the case is exceedingly rare, a hypothesis of microtrauma due to implant instability, poor implant Published by Surgical Residency Program Universitas Syiah Kuala | JISCM 2026.
: 5-8 | DOI: 10.
51559/jiscm.
CASE REPORT
Figure 3.
X-ray of left knee shown in anteroposterior and lateral projection after revision surgery with cemented long prosthesis implanted in femur and tibia Figure 4.
Synovium tissue taken after radical synovectomy and primary TKR implant removed Figure 5.
Histopathological study of synovium tissue showing the composed of multinucleated giant cell, foamy macrophages, inflammatory cell and hemosiderin confirming PVNS .
H&E staining 4x magnification, .
H&E 10x magnification postioning, or disproportionate implant size may cause recurrent hemorrhage may form the chronic synovitis and lead to PVNS.
3 Repeated microtrauma and bleeding into the joint will lead to haemoglobin break down into iron which later deposits to the surrounding joint tissue.
6This process reflects on our histopathologic work up on the synovial tissue that reveals villous and nodular structures and foamy histiocyte cells, multinucleated giant cell lymphocytes, and hemosiderophages in between the To date, there is no clear consensus on the primary treatment option for PVNS and surgery is generally the primary 4 Surgical excision with total synovectomy of the affected joint with arthroscopic approach or open surgery is considered to be the gold standard for PVNS treatment.
7 For localized forms of PVNS, marginal excision is recommended, while for diffuse forms, total synovectomy is recommended.
In various medical centers, diffuse PVNS is treated with open or arthroscopic synovectomy, sometimes combined with external beam radiotherapy or intra-articular radiotherapy 8 although only open total synovectomy was done in our patient.
Whilst studies shows that TKR revision procedure substantially lessen the symptoms and improves daily function as well as overall survival rate after revision approximately reached 90% in 5 years and 75%-80% in 10 years with gradual reduction thereafter.
9 In our three months follow up after revision procedure, our patient marked an improvement of knee range of motion and KOOS scored 78% out of 100%.
Previous case report confirmed PVNS finding in 54 years old male patient on who undergone two stage total knee arthroplasty (TKA) revision.
was also noted a significant improvement of knee range of motion with a Knee Society Score (KSS) to 92/90 during the three-year follow up.
Despite surgical intervention.
PVNS demonstrates a recurrence rate of up to 50%, leading researchers to investigate Nevertheless, the prognostic factors associated with PVNS recurrence remain poorly defined.
11 Our reports are limited Published by Surgical Residency Program Universitas Syiah Kuala | JISCM 2026.
: 5-8 | DOI: 10.
51559/jiscm.
CASE REPORT
by its relatively short follow-up period of three months postoperatively, which may not fully capture the long-term outcome and the recurrence pattern of PVNS.
CONCLUSION
This case presenting an aseptic loosening after total knee replacement accompanied by PVNS finding confirmed by histopathologic studies.
Implant loosening is thought to be related to loss of mechanical fixation or chronic inflammation, while PVNS occurrence following the implant loosening is likely triggered by microtrauma.
This patient treated with a one-stage revision TKR and open total synovectomy resulted in significant clinical improvement at three months follow up.
However, given the high risk of PVNS recurrence and unclear prognostic factors, long-term follow up is CONFLICT OF INTEREST The authors declare that the study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
AUTHOR CONTRIBUTION
Conceptualization and study design:
Mallapasi A.
Heru F.
Writing Ae original draft: Mallapasi A.
Writing Ae review & editing: all authors.
ACKNOWLEDGMENTS
None.
REFERENCE