Evidence

OrthoPath includes 10 clinical modules, each with a dedicated evidence manifest cited in the module cards and run outputs.

Last updated: 2026-03-09

Assistive-Only Disclaimer

OrthoPath is an assistive clinical decision support tool only. All evidence citations are provided for transparency and clinician review. They do not constitute clinical endorsement or replace clinical judgement.

Do not enter patient identifiers or any Protected Health Information (PHI) into this tool.

Evidence Model

Each OrthoPath module is grounded in a peer-reviewed evidence base. Every rule in a module is linked to at least one entry in that module's evidence manifest. The manifest records:

• Citation — full bibliographic reference.
• Locator — DOI, PMID, or journal reference.
• Year — publication year.
• Superseded — whether the evidence has been superseded by a newer source.
• URL (optional) — resolvable link to the source (e.g. DOI, PubMed); shown as a clickable link on the module card where provided.

Evidence Sources by Module

Ottawa Ankle & Knee Imaging Rules

Primary sources include the original Ottawa Ankle Rules (Stiell et al., JAMA 1993) and Ottawa Knee Rules (Stiell et al., Ann Emerg Med 1995), their prospective validations, systematic reviews (Bachmann et al., BMJ 2003), and ACR Appropriateness Criteria (2020). Paediatric applicability is supported by Dowling et al. (2009) and Vijayasankar et al. (2009).

Regional Anesthesia & Anticoagulation

Primary source is the American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Advisory on Neuraxial Anesthesia and Anticoagulation, 5th edition. Supplementary references include ESAIC/ESRA guidelines and platelet threshold studies.

Open Fracture Initial Management & Antibiotics

Primary sources include EAST Practice Management Guidelines, BOAST/BSSH guidelines, published RCTs and systematic reviews on antibiotic prophylaxis in open fractures, and ACIP tetanus prophylaxis recommendations.

Pathologic Fracture Risk & Treatment (Mirels)

Primary source is Mirels (1989), which proposed the scoring system for diagnosing impending pathologic fractures in metastatic long-bone lesions (site, pain, lesion type, size). Supporting evidence includes Damron et al. (2003) and Van der Linden et al. (2003) on predictive validity; ASTRO Evidence-Based Guideline (Lutz et al., 2017) for palliative radiation; and literature on operative management and preoperative embolization (e.g. Fuchs et al., Snyder et al., Chatziloannou et al.). The module uses risk tiers (low / intermediate / high) to support assistive suggestions for observation, radiotherapy, or prophylactic fixation with postoperative RT.

Periprosthetic Joint Infection (PJI) — Criteria (Hip/Knee)

Primary sources are the Infectious Diseases Society of America (IDSA) clinical practice guidelines (Osmon et al., Clin Infect Dis 2013), the 2018 International Consensus Meeting (ICM) definition (Parvizi et al., J Arthroplasty 2018), and the European Bone and Joint Infection Society (EBJIS) definition (McNally et al., Bone Joint J 2021). Supporting evidence includes alpha-defensin (Wyatt et al., EFORT Open Rev 2019) and comparison of ICM vs EBJIS definitions (Sigmund et al., Bone Joint Res 2022). The module supports criteria-based assessment only; final determination remains with clinical judgement.

ETC vs DCO — Physiology-Guided Fixation Timing (Core Snapshot)

Primary sources include Early Appropriate Care (Vallier et al., J Orthop Trauma 2015) for physiologic thresholds (lactate, pH, base deficit) and safe definitive fixation within 36 hours; ETC versus damage control concepts (Ratto et al., Med Intensiva 2013); EAST resuscitation endpoints (Samuels et al., J Trauma 2001); trauma-induced coagulopathy and INR (Brohi et al., Verma et al.); and the lethal triad — hypothermia, acidosis, coagulopathy (Brohi, Cohen, Semin Thromb Hemost 2013). Delphi consensus (Peralta et al., Injury 2024) supports early fixation in stable patients and DCO principles in borderline physiology.

Ortho VTE Prophylaxis

Primary sources include NICE NG89, ACCP 9th ed., ASH guidelines, the 2022 International Consensus Meeting (ICM) on VTE in orthopedic surgery, COA-ACO 2025, and systematic reviews on aspirin vs LMWH/DOAC. Regional anesthesia timing and bleeding/contraindication overrides follow ASRA 5th edition (2025). Renal and platelet thresholds draw on UK Kidney Association and hematology consensus. The evidence manifest links to PMC, PubMed, and institutional guidelines (e.g. Ryder Trauma, VUMC, NNUH) where applicable.

Malignant Musculoskeletal Tumor Imaging Criteria

Primary sources are the American College of Radiology (ACR) Appropriateness Criteria: Suspected Primary Bone Tumors (2024), Soft-Tissue Masses (2022), and Malignant or Aggressive Primary Musculoskeletal Tumor — Staging and Surveillance (2022). The module covers pre-biopsy local staging (radiographs, ultrasound for superficial soft-tissue, MRI for bone and deep/large soft-tissue), lung and extrapulmonary staging (CT chest, selective PET/CT), and local/lung/systemic surveillance. Internal safety gates address insufficient data and emergency red flags; contraindication handling (MRI/gadolinium/iodinated contrast) follows ACR guidance.

ETC/DCO Conversion Timing (Pro)

Shares the ETC vs DCO evidence base (Early Appropriate Care, damage control physiology, resuscitation endpoints, coagulopathy and lethal triad). The Pro module extends to conversion timing and physiologic reassessment for definitive fixation; evidence manifest cites Vallier et al., Ratto et al., Brohi et al., and related trauma literature.

Metastatic Bone Disease (MBD) Management — Pro (Long Bones + Reassessment)

Primary sources include ASTRO and ESTRO ACROP guidelines for palliative radiotherapy of bone metastases; MSTS/AAOS and MSTS humeral clinical practice guidelines; Mirels (1989) and validation studies (Damron et al., Benca et al., Tat et al., Hoban et al.); prophylactic fixation and postoperative RT (Epstein-Peterson, Rosen, Townsend); fractionation and SBRT (Chow, van der Velden, SABR-COMET, Nguyen et al.); NICE NG234 (spinal metastases); platelet transfusion (AABB 2025); Surviving Sepsis Campaign 2021; and preoperative embolization (Geraets et al., EFORT Open Rev 2020). The module supports assistive suggestions for observation, radiotherapy, or prophylactic fixation with postoperative RT by risk tier.

Limitations

• Evidence is current as of the "Last updated" date for each module.
• Clinical guidelines evolve; evidence manifests will require periodic review and updating.
• The evidence manifest covers rules only — it does not capture all literature related to a clinical topic.
• Superseded evidence entries are retained for audit purposes but are not used as the primary basis for current rules.