From first fracture to durable protection: a risk-, sequence-, and implementation-resolved evidence atlas for osteoporosis care

Introduction Osteoporosis care is delivered as a pathway rather than as a single prescribing decision: risk identification, fracture-risk stratification, treatment selection and sequence, persistence, secondary fracture prevention, and care delivery all matter. However, high-level evidence is commonly indexed by drug, test, or service label. It is consequently difficult to determine whether a source explicitly locates its claims in a fracture-risk phenotype, a post-fracture or maintenance time state, a patient-important outcome, or a feasible setting. We developed OSTEO-ROUTE, a reproducible evidence atlas that makes these decision coordinates inspectable while maintaining a clear boundary between evidence coverage and clinical certainty. Methods English PubMed records from database inception through 27 August 2026 were retrieved through seven complementary osteoporosis and fragility-fracture search strands. Exact queries, per-strand PMIDs, XML metadata, retrieval failures, rule-based triage fields, source data, R scripts, logs, and session information were retained. Because retrieval was restricted to English-language PubMed records, no result here estimates the global evidence base. We then assembled a bibliographically verified 50-source registry of guidance documents and high-level syntheses, selected by a fully deterministic rule from a released 506-candidate pool under pre-specified domain quotas, and assigned pre-specified, source-level descriptors for decision domain, phenotype, treatment sequence, time state, outcome label, setting, and evidence type. The atlas did not perform full-text dual screening, risk-of-bias assessment, GRADE evaluation, comparative effect pooling, or recommendation synthesis. Results The broad sensitivity probes yielded 64,601 overlapping records and the precise high-level probes yielded 4,944 overlapping hits. After PMID reconciliation, 3,521 unique records were requested, 3,493 were parsed, and 245 became the priority candidate queue defined by the published rule set. The 50-source registry covered general prevention (n=9), very-high-risk or treatment-sequence decisions (n=8), secondary prevention and fracture liaison services (n=7), persistence and implementation (n=7), secondary or drug-induced osteoporosis (n=7), sex and age inclusion (n=7), and non-pharmacological prevention or care delivery (n=5). Across domains, explicit reporting of phenotype, time, sequence, outcome, and setting was uneven; unspecified categories were retained rather than inferred. Discussion OSTEO-ROUTE is an auditable resource for building living evidence systems, specifying review questions, and designing trials or implementation studies that preserve risk, timing, sequence, outcome, and setting. It does not establish comparative treatment effectiveness or replace a completed multi-database systematic review, a certainty assessment, or a clinical guideline.