Sir I think he can be taken up for BL TKR

How would you address the deformity in the right femoral shaft and existing K nails?

Two-stage surgery. First, removal of  nails. Second, TKR. The varus deformity of the right femoral shaft is a problem. A previously correction osteotomy is a very delicate procedure and I do not believe the patient (and surgeon !) will accept such an approach. So one should implant the prosthesis  in this position but should prepare the distal femur end with removing more bone laterally. 

Thank you Panayot for your inputs. Since the patient was not agreeable for removal of existing nail, we chose to do his bilateral simultaneous TKA using CT base customized zigs for doing his TKA.

Lateral view

Left lateral view

This is a good solution and a fine procedure done.

Thank you.

Bilateral TKR's were the answer. This could be done either with the way described (special personalized jigs with either CT or MRI scans - CT more appropriate due to the presence of metal) or with navigating knee surgery. Removal of K-nails that are in place for a long time are notoriously difficult as they have the tendency to "refuse" extraction. Present solution is great. very well done

Thanks. I agree with your views.

It was good choice the bilateral TKA; maybe ii woul have better remove nail before to

make knee alignment easier.

   The x-ray control looks great.

Thanks Carlos

If computer assistance (CAOS) is available, you can operate both knees without removing the nails. If not, I suggest removing the nails. The screws in the right femur may remain in place. The left knee seems easy, but the right knee is a challenge: Take a true anterior-posterior long hip-knee-ankle x-ray with a calibration object on it. Imagine were you can place the intramedullary rod. Measure the distance from the entry point to the point where the rod will abut on the lateral cortex of the femur. Measure the HKFS-angle (hip-knee-intramedullary rod angle). Then ask your supplier or technician to deliver an intramedullary rod that is not too long. Finally, during the operation, set the distal cut at the HKFS-angle you already measured on the x-ray. The rest should be like a standard procedure.

Thank you, Eirik for your inputs. We did this case with patient specific blocks made from pre-operative CT scan images.

Good! How many degrees of deviatioan from the mechanical axis, measured on long hip-knee-ankle x-rays did yoy get?

Retiro de material sintesis derecho.

protesis estabilizada posterior cementada izquierda.

protesis estabilizada posterior cementada der. a los 3 meses

Navigation should be used as CAOS to avoid removing previous nailing. Fully agree with Eirik Aunan.