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Rationale and Objectives Subchondral insufficiency fractures (SIF), previously termed spontaneous osteonecrosis of the knee, are marked by a sudden onset of severe pain. Other than the size of the lesion, prediction for progression to joint replacement is difficult. The objective was to determine if quantitative analysis of bone texture using digital tomosynthesis imaging would be useful in predicting more rapid progression to joint replacement. Materials and Methods Tomosynthesis studies of 30 knees with documented SIF were quantified by fractal, mean intercept length (MIL), and line fraction deviation analyses. Fractal dimension, lacunarity, MIL, and line fraction deviation variables measured from these analyses were then correlated to short interval progression to joint replacement surgery. Results Higher odds for joint replacement were related to higher values of the standard deviation of slope lacunarity and to morphometric measures (eg, MIL). Conclusions Using digital tomosynthesis images for bone texture assessment may help distinguish condylar bone response in SIF, potentially acting as a clinically relevant predictive tool. In the future, contrasting SIF to the more gradual long-term process of osteoarthritis, there may be a better understanding of the different mechanisms for the two conditions.