Extra-articular deformities of the femur and tibia in conjunction with advanced knee osteoarthritis pose unique challenges for the arthroplasty surgeon. Careful preoperative planning is needed to evaluate both the intra- and extra-articular deformities and to determine the best route to total knee arthroplasty. An intra-articular compensatory correction can typically be performed if the extra-articular deformity is distant from the joint or if preoperative templating shows that bony cuts do not interfere with ligamentous attachments. Staged osteotomy followed by arthroplasty is beneficial in severe cases in which bony cuts are excessive or would interfere with soft-tissue structures and in cases with leg-length discrepancy. Osteotomies can be performed percutaneously and fixed with intramedullary nails, external fixators, or plate and screw constructs. Ligamentous laxity after correction and risk of peroneal nerve injury are increased in extra-articular deformity cases and must be considered during the knee arthroplasty procedure with increased implant constraint and patient counseling, respectively. Computer-assisted navigation has an emerging role in total knee arthroplasty in patients with extra-articular deformity.