The Layer + Model: Incorporating Psychosocial Considerations into Hip Preservation Surgery

The Layer Concept is a widely used model that provides an excellent anatomic framework with which to systematically diagnose and treat non-arthritic hip pain. More recently, there is a growing body of evidence highlighting the significant impact that psychosocial factors can have on both the presentation of various hip disorders and clinical outcomes following hip preservation surgery (HPS). Herein we propose the Layer + Model as a simple modification to help clinicians better diagnose and treat patients presenting with non-arthritic hip pain.

Building on the original four layers (osseous, inert, contractile, neuromechanical), the Layer + Model adds in a fifth layer, the psychosocial layer, to contextualize the numerous non-mechanical factors that influence perceived pain and patient-reported outcomes. Such psychosocial variables can include everything from pain level and chronicity to quality of life, mental health, social and family health, cultural contributions and many more factors that we are just learning about. This systematic review summarizes the existing evidence supporting the inclusion of a psychosocial layer. Additionally, we highlight early multidisciplinary efforts aimed at addressing each of these factors around the time of HPS. For patients presenting with non-arthritic hip pain, a complete understanding of all five layers is essential to make an accurate diagnosis and subsequently customize therapeutic recommendations to each patient's unique needs. By recognizing the importance of such psychosocial factors, the Layer + model may also help to support the continued research and development of multidisciplinary strategies to screen for (and treat) psychosocial risk factors around the time of HPS.