The Importance of a Hierarchical Approach in Investigating the Connection Between Peripheral Artery Disease and Risk for Developing Low-Trauma Fractures: A Narrative Literature Review.

Considering that skeletal changes are often asymptomatic during routine clinical examination, these disorders are frequently overlooked in patients with peripheral artery disease (PAD). Keeping in mind the inclining prevalence of PAD and bone fragility, especially in older individuals, this narrative literature review aimed to provide a comprehensive overview of skeletal alterations in patients with PAD, focusing on the importance of the multi-scale and multidisciplinary approach in the assessment of the bone hierarchical organization. Several observational studies have shown a connection between PAD and the risk of developing low-trauma fractures, but numerous ambiguities remain to be solved. Recent data indicate that evaluating additional bone properties at various levels of bone hierarchical structure may help in understanding the factors contributing to bone fragility in individuals with PAD. Further research on bone structural alterations (especially on micro- and nano-scale) may enhance the understanding of the complex etiopathogenesis of skeletal disorders in patients with PAD, which may lead to advancements in optimizing the clinical management of these individuals. Since osteoporosis and PAD have numerous overlapping risk factors, it is meaningful to evaluate vascular status in individuals with osteoporosis and examine bone health in individuals with PAD to identify individuals who require treatment for both diseases.