Subchondral bone remodeling is related to clinical improvement after joint distraction in the treatment of ankle osteoarthritis F. Intema, T.P. Thomas,

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Subchondral bone remodeling is related to clinical improvement after joint distraction in the treatment of ankle osteoarthritis F. Intema, T.P. Thomas, D.D. Anderson, J.M. Elkins, T.D. Brown, A. Amendola, F.P.J.G. Lafeber, C.L. Saltzman Osteoarthritis and Cartilage Volume 19, Issue 6, Pages 668-675 (June 2011) DOI: 10.1016/j.joca.2011.02.005 Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions

Fig. 1 An Ilizarov external fixator was used to apply distraction to the ankle (left). Radiographic view of the distracted ankle (right). Osteoarthritis and Cartilage 2011 19, 668-675DOI: (10.1016/j.joca.2011.02.005) Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions

Fig. 2 A. Surface created from a cloud of segmented points, with the patch placed on the weight-bearing area (upper left). Bone density calculations were performed at 1mm intervals beneath the bone surface, along the surface normals and extending subchondrally up to 8mm. Adjacent to the joint surface was a high-density area where the cortical plate was located, gradually extending to trabecular bone with lower density (schematic drawing in the upper right). B. Mean density (±SD) was measured up to 8mm from joint surface at the different time points in all patients (n=26). Density gradually decreased further from the joint surface. At 1 and 2 years of follow-up, overall density decreased in both tibia and talus. All time points differed statistically significantly from baseline (all P<0.001). Osteoarthritis and Cartilage 2011 19, 668-675DOI: (10.1016/j.joca.2011.02.005) Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions

Fig. 3 A. Representative CT scans of two patients before and two years after distraction, showing severe bone pathology at baseline (upper panels) with cysts and sclerosis in the weight-bearing area. At 2 years of follow-up (lower panels) there is a decrease of density in the sclerotic area while subchondral cysts diminished (within ovals) and the cartilage layer seemed to increase B. Change in density of the low-density areas (<400HU at baseline) for individual patients. A mean increase (solid lines) can be observed at one and two years of follow-up. Osteoarthritis and Cartilage 2011 19, 668-675DOI: (10.1016/j.joca.2011.02.005) Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions

Fig. 4 After two years of distraction, the normalization of bone densities is evident on CT (left). The change in bone density (2yr-baseline) in the weight-bearing area of the tibia (mean from 1–3mm depth), right, depicts the increase in density near cysts (white arrow), and a decrease in density in sclerotic regions (black arrow). Osteoarthritis and Cartilage 2011 19, 668-675DOI: (10.1016/j.joca.2011.02.005) Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions

Fig. 5 A. Clinical outcome presented by the AOS score (mean±SD). Subscales pain and disability are shown on a scale of 0–100 (100 being the worst outcome). ∗∗ indicates P-values <0.001 compared to baseline. B. Correlations between percentage change in AOS subscale and change in density in low-density areas (sum of change of the tibia and talus). Osteoarthritis and Cartilage 2011 19, 668-675DOI: (10.1016/j.joca.2011.02.005) Copyright © 2011 Osteoarthritis Research Society International Terms and Conditions