Arab Orthopaedic Board MCQs - Part 37

Which zone of articular cartilage has the highest concentration of water and lowest concentration of proteoglycans?

A 28-year-old female presents with knee pain. Radiographs reveal an eccentric, lytic, epiphyseal-metaphyseal lesion in the proximal tibia extending to the subchondral bone without a sclerotic rim. Biopsy shows multinucleated giant cells in a stroma of mononuclear cells. Which of the following is the primary neoplastic cell in this lesion?

According to the Young and Burgess classification, which of the following pelvic ring injuries is most highly associated with massive retroperitoneal hemorrhage requiring angioembolization?

In total hip arthroplasty, standard gamma irradiation and cross-linking of polyethylene can generate free radicals. Which post-irradiation process is most commonly used to completely eliminate these free radicals and prevent oxidation, despite slightly decreasing mechanical strength?

An 11-year-old obese boy presents with right thigh pain and a limp for 3 weeks. Radiographs confirm a stable slipped capital femoral epiphysis (SCFE). During in situ single screw fixation, where should the screw be positioned within the epiphysis to minimize the risk of joint penetration and maximize stability?

A 65-year-old male presents with deteriorating hand dexterity and a broad-based gait. Examination reveals hyperreflexia in the lower extremities and a positive Hoffmann sign. Which of the following MRI findings is most indicative of a poor prognosis for neurological recovery following surgical decompression for cervical spondylotic myelopathy?

Following a knee dislocation (KD-III), a patient undergoes multiligament knee reconstruction including the posterolateral corner (PLC). Which of the following anatomical structures forms the primary static stabilizer to external tibial rotation at 30 degrees of knee flexion?

A rock climber feels a pop in his ring finger while pulling on a crimp hold. He presents with pain and bowstringing of the flexor tendons on resisted flexion. Disruption of which pair of pulleys will result in the most significant bowstringing and loss of mechanical advantage?

A 24-year-old male sustains a midfoot injury. Radiographs show widening of the space between the base of the 1st and 2nd metatarsals. The primary restraint to lateral displacement of the second metatarsal base is the Lisfranc ligament. What is the precise anatomical attachment of the Lisfranc ligament?

A 45-year-old male sustains a Schatzker Type VI tibial plateau fracture. During surgical approach, the surgeon utilizes a dual-incision technique (anterolateral and posteromedial). Which structure is at greatest risk of iatrogenic injury during the superficial dissection of the posteromedial approach?

During secondary (indirect) bone healing, the fracture callus undergoes several physiological stages. Which type of collagen is predominately synthesized during the soft callus (chondrogenic) phase?

In the Ponseti method for correcting idiopathic clubfoot, what is the proper sequence of deformity correction?

A 40-year-old female presents with persistent pain in the proximal volar forearm and weakness in the thumb and index finger. She is unable to make an 'OK' sign, instead demonstrating a flat pinch. Sensation in the hand is completely normal. Which of the following structures is most likely compressing the affected nerve?

A 68-year-old male is evaluated for a painful total knee arthroplasty 3 years after the index surgery. According to the 2018 International Consensus Meeting (ICM) criteria for diagnosing Periprosthetic Joint Infection (PJI), which of the following minor criteria provides the highest number of points toward the diagnostic score?

A 32-year-old male falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the anatomical disruptions defining a Hawkins III fracture?

In an isthmic spondylolisthesis (Wiltse Type II) at L5-S1, the primary pathology is a defect in the pars interarticularis. Which exiting nerve root is most commonly compressed, and where does the compression typically occur?

The Superior Shoulder Suspensory Complex (SSSC) is a bone-and-soft-tissue ring attached to the axial skeleton. Which of the following combinations of injuries constitutes a 'double disruption' of the SSSC, often necessitating surgical intervention to prevent a drooping shoulder?

A 55-year-old obese woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel raise, flexible hindfoot valgus, and forefoot abduction. According to the Johnson and Strom classification (modified by Myerson), what stage of posterior tibial tendon dysfunction (PTTD) does this represent?

Low-molecular-weight heparin (LMWH) is frequently used for DVT prophylaxis following orthopedic surgery. Which of the following best describes the primary mechanism of action of LMWH compared to unfractionated heparin?

A 19-year-old male presents with dull, aching back pain that is worse at night. Radiographs and CT demonstrate a 2.5 cm radiolucent lesion with a sclerotic margin in the posterior elements of L4. Biopsy shows woven bone trabeculae lined by prominent osteoblasts in a vascular connective tissue stroma. What is the most likely diagnosis?

A 7-year-old girl with a history of neglected Developmental Dysplasia of the Hip (DDH) presents with a severely subluxated, incongruent hip joint. The acetabulum is extremely shallow and unable to adequately cover the femoral head using redirectional techniques. The surgeon decides to perform a salvage pelvic osteotomy that relies on the interposition of the joint capsule to provide coverage and medialize the hip center of rotation. Which of the following procedures is planned?

A 14-year-old boy is diagnosed with high-grade intramedullary osteosarcoma of the distal femur. He undergoes 10 weeks of neoadjuvant chemotherapy followed by wide surgical resection and endoprosthetic reconstruction. Which of the following is the most important independent prognostic factor for his overall survival?

During the anterior (ilioinguinal) approach for open reduction and internal fixation of an unstable pelvic ring injury, life-threatening hemorrhage is encountered just superior to the superior pubic ramus. The source is identified as the 'corona mortis'. This vascular structure represents an anatomic anastomosis between which of the following vascular systems?

A 55-year-old male presents with deteriorating manual dexterity and gait instability. On examination, 'flicking' the nail of his middle finger downward elicits a reflexive flexion of his thumb and index finger. This positive Hoffmann sign indicates an upper motor neuron lesion within which of the following spinal tracts?

In a posterior-stabilized Total Knee Arthroplasty (TKA), the trial components demonstrate a knee that is perfectly balanced and symmetric in full extension but is excessively tight in flexion, causing liftoff and preventing flexion past 80 degrees. The joint line and patellar tracking are acceptable. Which of the following is the most appropriate intraoperative step to balance the knee?

Following a primary Zone II flexor tendon repair using a four-strand core suture and a running epitendinous repair, an early active motion rehabilitation protocol is initiated. During which postoperative timeframe is the repaired tendon at its weakest biomechanically, placing it at the highest risk for spontaneous rupture?

A 24-year-old athlete presents 4 months following an anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft. He complains of a painful clunk and an inability to achieve terminal extension. MRI reveals a focal, nodular mass situated anterior to the tibial tunnel. Histologically, this lesion is primarily composed of:

A 60-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot. Peripheral pulses are bounding. Radiographs reveal prominent periarticular debris, fragmentation of the navicular, and subluxation of the midtarsal joint. There are no skin ulcerations. What is the most appropriate initial management?

Bone morphogenetic proteins (BMPs), such as rhBMP-2, are used clinically to stimulate osteoinduction during spinal fusion and fracture nonunion repair. Upon binding to their transmembrane serine/threonine kinase receptors, BMPs initiate intracellular signaling primarily via phosphorylation of which of the following molecules?

A 35-year-old male sustains a severe Schatzker IV tibial plateau fracture with a large, displaced posteromedial fragment. The surgeon elects to perform a direct posteromedial approach for optimal buttress plating. This surgical approach utilizes an internervous/intermuscular interval primarily between which two structures?

In a patient presenting with a unilateral Slipped Capital Femoral Epiphysis (SCFE), which of the following risk factors is the strongest clinical indication for performing a prophylactic in situ pinning of the asymptomatic contralateral hip?

A 50-year-old active male underwent a total hip arthroplasty (THA) utilizing a ceramic-on-ceramic bearing surface. Two years postoperatively, he presents complaining of an audible 'squeaking' sound emanating from his hip during deep flexion activities. Which of the following component malpositions is most strongly associated with the development of this phenomenon?

A 30-year-old male sustains a complete laceration of the median nerve at the wrist joint level. Despite the complete transection, physical examination reveals partially preserved function of the thenar musculature. This clinical finding is most likely explained by the presence of which of the following anomalous neural interconnections?

A spinal surgeon is evaluating a 45-year-old patient for an isthmic spondylolisthesis at L5-S1. Radiographic measurements reveal a Pelvic Incidence (PI) of 60 degrees and a Pelvic Tilt (PT) of 25 degrees. Based on the established geometric relationship of spinopelvic parameters, what is the patient's Sacral Slope (SS)?

Denosumab has emerged as an important pharmacological treatment for advanced, recurrent, or unresectable Giant Cell Tumor (GCT) of bone. This monoclonal antibody exerts its therapeutic effect by specifically binding to and inhibiting which of the following targets?

A 65-year-old woman sustains a nondisplaced fracture of the distal radius. She is treated nonoperatively in a well-molded short-arm cast. Six weeks later, immediately after cast removal, she is unable to actively extend her thumb interphalangeal joint. What is the most widely accepted primary etiology for this delayed extensor pollicis longus (EPL) tendon rupture in the setting of a nondisplaced fracture?

During a biomechanical testing study of human ligaments, a graft is rapidly stretched to a specific, constant length. Over an extended period of observation, the testing machine records that the amount of force required to maintain that specific length gradually decreases. This viscoelastic material property is formally known as:

A 52-year-old obese woman presents with a flexible, painful flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs reveal more than 40% uncovering of the talonavicular joint and significant forefoot abduction. According to the Johnson and Strom classification modified by Myerson, what is the most appropriate surgical management for this Stage IIb Posterior Tibial Tendon Dysfunction (PTTD)?

In evaluating a patient for an arthroscopic meniscal repair, understanding the vascular anatomy is crucial for determining healing potential. The meniscal blood supply originates primarily from the medial and lateral geniculate arteries. In a mature adult, what specific portion of the meniscus is well-vascularized?

When treating an infant with idiopathic clubfoot (talipes equinovarus) utilizing the Ponseti method of serial casting, the components of the deformity must be addressed in a specific order to prevent midfoot breach and achieve optimal correction. What is the correct sequence of deformity correction?

Which of the following clinical or radiographic findings is a strict contraindication to performing a cervical laminoplasty for a patient with cervical spondylotic myelopathy?

When revising a total hip arthroplasty to reduce the risk of postoperative dislocation, increasing the femoral head size (e.g., from 28 mm to 36 mm) primarily improves stability by increasing the impingement-free range of motion and increasing which of the following parameters?

A 35-year-old male sustains a high-energy coronal plane fracture of the lateral femoral condyle (Hoffa fracture). What is the biomechanically optimal screw fixation construct for this specific fracture pattern?

A 45-year-old manual laborer presents with chronic wrist pain and a known scaphoid nonunion. Radiographs demonstrate arthritis at the radioscaphoid and capitolunate joints, with preservation of the radiolunate joint. What is the SNAC stage and most appropriate definitive surgical treatment?

A 12-year-old boy is diagnosed with a stable left Slipped Capital Femoral Epiphysis (SCFE). Which of the following patient characteristics is an absolute indication for prophylactic in-situ pinning of the contralateral asymptomatic right hip?

During an isolated Posterior Cruciate Ligament (PCL) reconstruction using an anterolateral tibial tunnel technique, the 'killer turn' is associated with which of the following complications?

A 55-year-old poorly controlled diabetic patient presents with a massively swollen, erythematous, and warm left foot. Radiographs reveal periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage does this represent, and what is the standard of care?

A 60-year-old male undergoes a core needle biopsy of a painless, slowly enlarging deep mass in his anterior thigh. Pathology returns as a high-grade pleomorphic sarcoma. Staging CT scans of the chest, abdomen, and pelvis are negative for metastasis. What is the most appropriate definitive management?

A 28-year-old hypotensive male is brought to the trauma bay following a motorcycle crash. An AP pelvis radiograph demonstrates an 'open book' (APC-III) pelvic ring injury. A pelvic binder is ordered. At what specific anatomic landmark should the binder be centered to optimally reduce the pelvic volume?

During a primary Total Knee Arthroplasty utilizing measured resection, the surgeon notes that with the trial components in place, the knee is well-balanced and stable in extension but excessively tight in flexion. Which of the following maneuvers is the most appropriate next step to balance the knee?

A 3-year-old girl is diagnosed with a neglected left Developmental Dysplasia of the Hip (DDH). Radiographs confirm a completely dislocated, high-riding femoral head with a false acetabulum. What is the most appropriate surgical management?

A 35-year-old male sustains an L1 burst fracture. He is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and recommended treatment?

In Dupuytren's disease, the spiral cord is responsible for proximal interphalangeal (PIP) joint contracture. As it contracts, it characteristically displaces the digital neurovascular bundle in which direction?

A 40-year-old male undergoes non-operative management with an early functional rehabilitation protocol for an acute Achilles tendon rupture. Based on high-level evidence, which of the following outcomes is most accurate when comparing this approach to traditional open surgical repair?

A 25-year-old elite baseball pitcher presents with deep shoulder pain and decreased throwing velocity. Physical exam reveals a positive O'Brien's test and a 'peel-back' sign. MR arthrogram confirms a Type II SLAP tear. After 3 months of failed physical therapy focusing on periscapular stabilizers, what is the most appropriate surgical treatment?

A 32-year-old cyclist sustains an acute, closed, midshaft clavicle fracture after a fall. Which of the following clinical or radiographic findings is considered an absolute indication for open reduction and internal fixation?

In normal articular cartilage, which structural zone is characterized by the highest concentration of water, the lowest concentration of proteoglycans, and collagen fibers that are densely packed and oriented parallel to the joint surface?

A 62-year-old female with a metal-on-metal total hip arthroplasty placed 8 years ago presents with new-onset groin pain. A MARS MRI reveals a solid pseudotumor and fluid collection around the hip joint. Laboratory tests show elevated serum cobalt and chromium. Aspiration yields clear fluid with 200 WBCs/uL and 10% PMNs. What is the definitive management?

A 14-year-old boy is diagnosed with conventional high-grade osteosarcoma of the distal femur. After staging, which of the following factors represents the single most significant predictor of overall survival?

A 68-year-old female presents with severe neurogenic claudication secondary to L4-L5 central spinal stenosis. She has no significant mechanical back pain, and dynamic flexion-extension radiographs show no measurable spondylolisthesis or instability. After failing 6 months of conservative management, what is the most appropriate surgical intervention?

A 55-year-old diabetic male presents with progressive back pain, fever, and bilateral leg weakness. MRI shows an epidural abscess from L2 to L4 with severe thecal sac compression. What is the most appropriate initial management?

A 28-year-old male presents with a slowly enlarging, painful mass near his knee joint. Radiographs reveal a soft tissue mass with stippled calcifications. Biopsy demonstrates a biphasic pattern of epithelial and spindle cells. Which specific chromosomal translocation is characteristic of this tumor?

When comparing ceramic-on-ceramic (CoC) to metal-on-polyethylene (MoP) total hip arthroplasties, which of the following is an established advantage of the CoC articulation?

In the acute management of a hemodynamically unstable patient with an anteroposterior compression (APC) type III pelvic ring injury, what is the correct anatomical landmark for the placement of a circumferential pelvic sheet or binder?

A cyclist complains of isolated weakness in the interosseous muscles of the hand and a claw deformity of the ring and small fingers. He has completely normal sensation in the small finger and the ulnar half of the ring finger. Compression of the ulnar nerve is most likely occurring in which zone of Guyon's canal?

A 12-year-old obese male is diagnosed with a unilateral left Slipped Capital Femoral Epiphysis (SCFE). Which of the following is the strongest indication for prophylactic pinning of the asymptomatic right hip?

A patient sustains a posterolateral corner (PLC) knee injury and develops a complete foot drop. Exploration of the common peroneal nerve is planned. The nerve is most vulnerable to tethering and injury at which anatomical site?

A 60-year-old diabetic patient presents with a warm, swollen, and erythematous left foot. Radiographs show osseous fragmentation, joint subluxation, and periarticular debris at the midfoot. According to the Eichenholtz classification, what is the most appropriate initial management?

Bone morphogenetic proteins (BMPs) initiate their intracellular osteoinductive signaling cascade primarily through which of the following mechanisms?

An 82-year-old male sustains a Type II odontoid fracture with 2 mm of displacement after a low-energy fall. A decision is made regarding non-operative treatment. Compared to a rigid cervical collar, the use of a halo vest in this specific age group is most strongly associated with:

A 65-year-old male presents with deep sacral pain and recent-onset bowel/bladder dysfunction. MRI demonstrates a destructive midline mass arising from the sacrum. Biopsy reveals large cells with prominent intracytoplasmic vacuoles (physaliferous cells) in a myxoid background. What is the most appropriate definitive management for this lesion?

A 65-year-old female presents with a painful 'catch' and a palpable pop at 30 to 45 degrees of knee flexion as she actively extends her knee, one year following a posterior-stabilized (PS) total knee arthroplasty. What implant design factor is most heavily implicated in the pathogenesis of this condition?

In the natural history of a scaphoid nonunion advanced collapse (SNAC) pattern of the wrist, which of the following articulations is classically the LAST to develop degenerative changes?

In a coronal shear fracture of the lateral femoral condyle (Hoffa fracture), which of the following structures remains attached to the osteochondral fragment and predominantly contributes to its posterior and distal displacement?

During the Ponseti method for correcting idiopathic clubfoot (talipes equinovarus), the manipulation sequence dictates a highly specific order of correction. Which of the following components of the deformity is corrected FIRST?

A 14-year-old boy presents with frequent ankle sprains, peroneal spasticity, and a rigid flatfoot. Radiographs reveal a continuous 'C' sign on the lateral view. Which of the following is the most likely diagnosis?

In healthy articular cartilage, which structural zone is characterized by the highest concentration of proteoglycans, the lowest concentration of water, and collagen fibers oriented perpendicular to the articular surface?

A 22-year-old baseball pitcher presents with vague, deep shoulder pain and a 'dead arm' feeling. An MRI arthrogram reveals a Type II SLAP (Superior Labrum Anterior and Posterior) tear. What is the defining anatomical characteristic of a Type II SLAP tear?

A 65-year-old male complains of bilateral leg pain, heaviness, and fatigue when walking. The symptoms are consistently relieved when leaning forward on a shopping cart or riding a stationary bicycle. On physical examination, which of the following findings is most likely to be present?

A 70-year-old female presents with insidious onset of back pain and anemia. Radiographs demonstrate 'punched-out' lytic lesions in the skull and a compression fracture of T12. Laboratory tests show a monoclonal spike on serum protein electrophoresis. Which of the following is currently the most sensitive whole-body imaging modality for detecting skeletal involvement in this disease?

A 14-year-old boy presents with thigh pain and a low-grade fever. Radiographs show a permeative diaphyseal lesion of the femur with a 'periosteal onion-skin' reaction. A biopsy confirms sheets of small round blue cells. Which of the following genetic translocations is most characteristic of this patient's diagnosis?

Seven years after undergoing a primary non-cemented total hip arthroplasty using a titanium stem, a cobalt-chromium head, and a highly cross-linked polyethylene liner, a 62-year-old man presents with progressive groin pain. Radiographs show a well-fixed stem and cup with no osteolysis. Metal ion testing reveals elevated cobalt levels that are disproportionately higher than chromium levels. MRI with metal artifact reduction shows a cystic fluid collection. What is the primary mechanism of failure?

A 35-year-old male laborer presents with chronic right wrist pain. Radiographs demonstrate a scaphoid nonunion with marked sclerosis, joint space narrowing at the radioscaphoid joint, and arthritic changes at the capitolunate joint. The radiolunate joint space is completely preserved. According to the Scaphoid Nonunion Advanced Collapse (SNAC) staging system, what is the correct stage of this patient's wrist?

A 40-year-old man falls from a height of 10 feet and sustains an L1 burst fracture. He is neurologically intact (ASIA E). MRI confirms that the posterior ligamentous complex (PLC) is intact. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is his score and the recommended management?

During the initial phase of the Ponseti method for correcting idiopathic clubfoot in an infant, the cavus deformity must be addressed first. Which specific anatomical structure serves as the fulcrum for the thumb of the physician while supinating the forefoot to correct the cavus?

A 25-year-old male sustains a high-energy knee dislocation. It is closed-reduced in the emergency department. Post-reduction, his pulses are symmetric and bounding. The Ankle-Brachial Index (ABI) is measured at 0.85. What is the most appropriate next step in management?

A 34-year-old male is involved in a motorcycle collision and sustains an Anteroposterior Compression Type II (APC-II) pelvic ring injury. Based on the Young-Burgess classification, which of the following ligamentous structures is entirely disrupted in an APC-II injury but intact in an APC-I injury?

A 22-year-old collegiate football player sustains an acute purely ligamentous Lisfranc injury of the midfoot with a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. He wishes to return to play as safely and definitively as possible. Based on recent Level I evidence, which surgical intervention provides the lowest rate of hardware removal and best long-term outcome for this purely ligamentous injury?

During the normal process of secondary fracture healing, the soft callus phase is crucial for stabilizing the fracture site. Which type of collagen is predominately synthesized and deposited by chondrocytes during this specific phase?

A surgeon is performing a cruciate-retaining total knee arthroplasty (CR-TKA). With the trial components in place, the knee is found to be perfectly balanced in full extension, but abnormally tight in 90 degrees of flexion. Which of the following maneuvers is most appropriate to resolve this specific kinematic mismatch?

A 28-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal phalanx, resulting in a Zone II flexor tendon injury. To prevent functionally limiting bowstringing of the repaired flexor tendons, preservation or reconstruction of which two pulleys is absolutely biomechanically critical?

A 68-year-old man presents with a 6-month history of deteriorating handwriting, difficulty buttoning his shirt, and an unsteady gait. On physical examination, he demonstrates hyperreflexia in the lower extremities, a positive Hoffmann's sign bilaterally, and an inverted brachioradialis reflex. What is the most definitive imaging study to confirm the suspected diagnosis?

A 13-year-old obese male presents with a 3-week history of left knee and thigh pain. He is able to bear weight but walks with an externally rotated gait. Radiographs reveal widening of the left proximal femoral physis, and a line drawn along the superior neck of the femur (Klein's line) fails to intersect the epiphysis. Which of the following is the standard of care for this condition?

A 15-year-old girl diagnosed with osteosarcoma of the distal femur completes a course of neoadjuvant chemotherapy, followed by wide surgical resection. Pathological analysis of the resected tumor specimen reveals 95% tumor necrosis. In the context of osteosarcoma management, what does this specific pathological finding indicate?

A 24-year-old elite baseball pitcher complains of deep shoulder pain that worsens during the late cocking phase of throwing. Magnetic resonance arthrography (MRA) demonstrates a superior labral tear with detachment of the biceps anchor. During arthroscopy, an extreme external rotation maneuver reveals the superior labrum dropping medially over the glenoid edge (peel-back sign). What is the specific classification of this injury?

A 32-year-old man sustains a severe closed diaphyseal tibia fracture. Six hours later, he develops excruciating leg pain that is unresponsive to IV narcotics. The most prominent clinical sign is severe pain upon passive stretching of the extensor hallucis longus. To definitively diagnose acute compartment syndrome, compartment pressure measurements are obtained. Which of the following pressure profiles is the accepted threshold for performing an emergency fasciotomy?

A 55-year-old male with long-standing poorly controlled diabetes mellitus presents with a red, hot, swollen, and painless right foot. He denies trauma or skin ulceration. His WBC count is normal, and ESR is mildly elevated at 25 mm/hr. Weight-bearing radiographs show fragmentation of the navicular, subluxation of the tarsometatarsal joints, and bony debris. What is the most appropriate initial management for this acute presentation?

A patient presents with weakness in their dominant hand. Upon physical examination, they are asked to make an 'OK' sign by pinching the tips of their thumb and index finger together. Instead of a round circle, the patient forms a 'flat' pinch, exhibiting an inability to flex the interphalangeal (IP) joint of the thumb and the distal interphalangeal (DIP) joint of the index finger. Sensation in the hand is entirely normal. Which nerve is compressed, and what is the corresponding syndrome?

When applying a locking plate to a comminuted diaphyseal fracture using bridge plating techniques, secondary bone healing (callus formation) is desired. To promote this healing, the construct requires a certain degree of flexibility. Which of the following technical modifications will best increase the 'working length' of the plate to achieve appropriate interfragmentary motion?

During the final trial phase of a total knee arthroplasty (TKA), the surgeon observes lateral subluxation of the patella during knee flexion. The 'no thumb' test shows the patella popping out of the trochlear groove laterally. Which of the following iatrogenic component malrotations is the most likely cause of this abnormal patellar tracking?