Review Question - QID 218114

A 17-year-old female basketball player suffers a non-contact knee injury during practice. On exam, she has a moderate effusion, grade 2B Lachman, positive lateral McMurray's test, mild laxity with a firm endpoint with a valgus stress test, and genu recurvatum of 5-10 deg with 130 deg of flexion and normal limb alignment. She undergoes ACL reconstruction using a 9mm quadriceps tendon autograft and meniscus repair. She returns to play 10 months postoperatively. One year after surgery she reinjured her ACL during a game. Figure A shows her current X-rays and her calculated tibial slope is 8 degrees. Which of the following factors put this patient at risk for graft failure?