Tokuda Hospital Sofia


Total Hip Replacement

When you have considered the treatment option and/or made the decision along with your orthopedist to have your hip replaced, the information below will help you understand the benefits and limitations of a total hip endoprosthesis procedure.

Advantages of Tokuda Hospital Sofia

Our hospital offers comprehensive medical care from diagnostics, to pre-procedural preparation, to the treatment procedure, to post procedural care and rehabilitation for a wide range of patients with diseases and traumas affecting the muscle-skeletal system including those with hip joint problems.   

We perform primary and revisionary endoprothesis (hip implantation) procedures based upon world recognized surgical techniques such as minimally invasive hip replacement methodologies, while applying the latest innovations in contemporary medical hip implant technologies.

Why choose to read on about hip replacement therapy?

Our goal is to inform you about the normal function of the hip joint, causes for hip pain, what to expect during a hip replacement surgery, and what rehabilitation exercises and   activities can help to restore hip and leg mobility to return you a normal way of life. Please take the time to read all the information provided which for your convenience have created sub sections according to frequently asked questions from our patients as well as the stages of the total hip replacement treatment process.

What types of symptoms to look out for?

If your hip joint is affected by arthrosis, fractures, or other diseases your normal activities such as walking, standing and sitting can become very painful, difficult, and if the condition is left untreated these routine activities can become nearly impossible.  In some cases, a hip joint can be so affected such that is becomes nearly impossible to put on socks or shoes. Additionally, it is possible to have continuous hip pain even during periods of inactivity during rest.

When should one consider surgical hip replacement treatment?

If medications, lifestyle adjustments to daily routines, physical therapies, and even walking aids don’t resolve your hip condition then you should consider hip replacement surgery. Choosing to undergo surgery to replace your diseased or damaged hip joint with an artificial implant can allow you live pain free, restore free movement, and allow you to enjoy normal physical activities once again. 

History and patient quality of life contribution of hip replacement surgery.

The first hip replacement surgery was performed in 1960, and has gone on to become one of the most significant medical advances in surgery of the last century.  Since 1960, advances in both surgical techniques and medical technology have greatly improved the effectiveness of hip replacement surgeries.  Today it has become one of the most widely implemented surgical procedures and has brought relief and restored the quality of life for millions around the world. Based on its success other surgical joint replacement procedures have been developed including for the knee, shoulder, and elbow.

Our orthopedic specialists offer computer based surgical navigation during joint replacement procedures.

Our computer navigation system uses infra-red cameras, tracking devices and 3-D imaging systems. The system provides very precise images and measurements of the patient’s skeletal structures with very sensitive sensors, which allows our medical team to implant artificial joints with maximum precision.

 “Navigation is a key benefit for the patient, because with the systems capabilities the implanted artificial joints have a longer effective life”, commented department chief Dr. Yablanski. He added that the system enables our surgeons’ precision to be maximized during endoprosthesis procedures.

Our computer navigation systems have numerous patient benefits including: smaller surgical incisions, dramatically reduced patient recovery time, and less operative trauma, which reduces the risk of post procedural embolisms and reduces post procedural complications.

You can email your inquiries to our orthopedic medical team directly at the following address:

Hip Joint Anatomy

Hip Joint X-Ray

The hip joint is one of the largest joint structures which supports the entire weight of the body. The joint consist of two main parts: the femoral head which is the upper section of the femur or thigh bone which fits into the circular convex area of the hip bone called the acetabulum. Numerous very strong ligaments connect the two parts of the joint together called the capsule which ensures the stability and strength of the joint.

The bone surfaces of the femoral head and the acetabulum are covered in smooth and dense bone cartilage, which ensures free movement without friction in the joint.  

A thin a smooth layer called the synovial membrane covers all the other surfaces of the hip joint. In a healthy joint this membrane secretes small about of a liquid which lubricates and prevents friction in the joint. All these parts and structures work in harmony together to ensure free and pain free movement.

Common causes for hip pain and hip movement loss

The most common cause of chronic hip pain and impaired hip function is joint arthrosis due to osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, which are the most frequent causes of this disease as follows:


  • Osteoarthritis: Also know as primary arthrosis or coxarthrosis, the condition commonly affects people around 50 years of age and older and often its runs in families with a history of arthritis.  This condition can be due to or aggravated by developmental hip joint disorders. In this form of the disease the cartilage covering the bone joint surfaces is worn down or is even missing so that bone surfaces rub into each other causing pain and stiffness.

  • Rheumatoid arthritis: This condition is an autoimmune disease in which the synovial membrane is inflamed, thickened, and doesn’t produce enough joint fluid which leads to damage of the joint cartilage, causing pain, and stiffness.
  • Post-traumatic arthritis typically results from serious injuries or fractures. Fractures of the femoral neck can lead to a condition known as osteonecrosis, which also can be caused by other factors. In these cases, the joint cartilage is damaged over time and causes pain and stiffness











Are you a candidate for surgical hip replacement?

When surgical hip replacement is medically necessary, we recommended that your choice to agree to the procedure be considered fully and decided by you along with the assistance of your family, your GP and your orthopedic surgeon. When making such a decision, we suggest that you and your relatives seek guidance and an initial medical evaluation from an orthopedist to be fully informed.

Despite the fact that the large majority of candidates routinely undergoing hip replacement surgeries are aged between 60-80 years, each patient case must be assessed individually. Our medical assessments and physician recommendations to undergo hip replacement treatment are based upon the level of experienced hip pain, the level of functional joint impairment, and the overall patient health condition.  We don’t consider patient age a crucial decision factor rather we assess the overall patient health condition.

You can benefit from hip replacement treatment if you experience the following:

  • Hip joint pain which limits your everyday activities such as walking and bending
  • Hip joint pain that is continuous day and night and persists even when resting
  • Hip joint stiffness that restricts your ability to move or lift your leg
  • No or little pain reduction results from taking  anti-inflammatory, pain killers, and/or glucosamine-sulfate medications
  • Experiencing disabling or unpleasant side effects from medication therapies
  • No or little pain reduction results from physical therapies or usage of walking aids or braces

Orthopedic assessment

Your orthopedic surgeon shall evaluate and assess your examination results, to determine whether a surgical hip replacement surgery is the best treatment to relieve hip pain and restore function for your specific case. Other treatment options such as medications, physical therapy, and other treatments shall be considered as well.

Your orthopedic surgeon shall explain all the potential risks and complications related to the hip replacement surgery during the procedure as well as those which can occur directly after the future or with the passage of time.

The orthopedic assessment generally consists of the following:

  • Medical history report in which your overall health condition, current health problems, hip joint pain level, and degree of impairment to normal function is complied  
  • Exam to assess joint mobility, positioning, and overall integrity of the hip joint 
  • X-ray images to evaluate the level of damage or deformation of the hip joint  
  • Blood tests, other clinical tests, MRIs or other bone scans may be needed to determine the status of the bones or soft tissues around the hip joint. 

What to expect from undergoing a hip replacement surgery

A key decision factor to decide to undergo a hip replacement surgery is to fully understand what realistic outcomes can be expected from the procedure.

People that have undergone the hip replacement procedure often share that they experience a dramatic reduction in hip pain and gain significant mobility improvements leading to normal everyday activities and a return to their normal way of life. Despite these vast improvements from the hip replacement surgery, the procedure cannot allow one to do more than they were able to before developing hip joint problems.

After the surgical procedure, you will be provided physician recommendations and advice to avoid certain activities such as running and contact sports. Additionally, you will be advised to avoid certain joint positions to prevent any hip dislocations.

Under normal conditions and normal use, artificial hip joints do wear our over time. If you engage in contact sports, exercise vigorously, or are overweight these factors can lead to speeding up the normal hip joint wear process and or cause the artificial hip joint to become loosened which can become painful

Surgical treatment preparation

Medical assessment

Upon deciding to undergo the surgical hip replacement surgery, you will be advised and will received recommendations to have a complete medical examination done by your general practitioner before your procedure. This examination is necessary to assess your overall health condition, to detect and clarify any existing health issues which may conflict with or complicate your surgical intervention or recovery process.


Several tests are needed to be completed in order to plan your operation: blood indicators, blood clotting indicators, urine tests, electrocardiogram, and lung x-rays. 

Skin condition

Several health conditions involving skin infections and inflammations must be cleared up before performing the surgical procedure.

Blood donations

You may be advised to secure blood donors or to purchase a packet to store your own blood before your procedure.


Please inform your orthopedic surgeon about all the medications you are currently and have taken in the past. Based on this information, your surgeon will advise you of what medications to stop taking or to continue taking before your procedure. 

Weight reduction

If you are overweight, your physician may recommend or require that you lose weight before your procedure to reduce the stress on your new artificial joint and/or to reduce the risk of undergoing the surgical procedure.

Dental examinations

Despite the fact that infections post hip replacement surgeries are not common, the risk of infections can be increased if bacteria get into the bloodstream. Bacteria can be introduced into the bloodstream during dental interventions, therefore we advise that any needed dental treatment be performed especially tooth extractions or periodontal procedures before your hip replacement surgery. We also advice that routine gum and teeth cleanings be postponed for at least several weeks after your operation.

Urine tests

Patients with a history of recent or chronic urinary infections or men with prostrate disease must be examined by an urologist before the procedure. Routine clinical sterile urine testing is standard to rule out any urinary infections before undergoing the hip replacement procedure.  

Post procedural care planning

Even though you will be able to walk with crutches or a walker shortly after your procedure, you will need assistance for activities such as cooking, shopping, showering, doing laundry, and other routine daily activities. If you live alone we advise that you have someone to help you with these activities until you have fully recovered.  To help you with this, we offer extended stays in our ward to allow you additional time to recover to be able to perform these normal daily activities before you go home.

Home planning

We have prepared the following list of equipment and recommendations to have ready in your home to help you during the first days after of recovery after you have been discharged from the hospital.

  • Secure handles and hold rails in your bath, shower, and bathroom
  • Stable hand rails on all your stairways  
  • A stable chair for your early recovery period with a firm seat, firm back, and hand grips which allows your knees to be lower than your hip joint  when sitting
  • Raised toilet seat  
  • Stable seat or chair for the shower or bath  
  • Self aid devices to help you do normal activities alone such as extended  shoe horns to help to put your shoes on and take them off without bending your hip joints Пособия за
  • A firm seat cushion or a car seat insert to help to sit with your knees below the level of your hip joints
  • Remove all carpets, floor mats, electric and other cables and anything else which may cause you to trip when moving around your house.

Your operation

You will be admitted to our inpatient department the day before your surgery, and you will receive a consultation with an anesthesiologist. The most commonly administered types of anesthesia for hip replacement is spinal which allows you to breathe normally and not have sensation from the waist down or general anesthesia in which you are unconscious during the procedure and are on artificial respiration. Our anesthesiologist teams shall discuss the options with you to decide which method is most appropriate for your needs and specific medical case.  

Your hip replacement surgery typically will take a several hours. During the procedure, your orthopedic surgeon will remove the damaged portions of your joint and implant new artificial joint elements which can be metallic, polyethylene, or ceramic depending on the case. Also the surgeon corrects the positioning and function of your hip joint during the intervention. 

Cement fixation total hip joint 


A wide range of structures and materials are currently used for artificial joints. However all of the structures consist of two main components: the head made of super strong and highly polished metal or ceramic, and the cup made of polyethylene, ceramic or metal which may have a metal covering or shell.

A specialized surgical cement is used for this type of cement fixation to attach the artificial joint elements to the living bone tissue.

Cementless fixation total hip joint 













Implants without cement fixation to the bones structures can be offered and most commonly they are used in younger more active patients with healthy bone structures. The implants in these cases are coated with porous metal or bone like substances, which allow the normal bone tissue to grow into the implant.

We also offer a combination of the methods for example a cement fixation head with a cement-less fixed cup.

Your orthopedic surgeon will select type of joint implant, which best fits the needs of your damaged hip joint.

After your operation, you will be transferred to medical in-patient department to be monitored as you recover from your anesthesia. 

Minimally invasive hip replacement

Over the last several years orthopedic surgeons have developed new minimally invasive surgical techniques to insert total hip implants through small incisions.

It has been shown, but not yet fully proven, that these methods result to a shorter and less painful recovery period and a quicker return to a normal everyday function and activity levels. Minimally invasive and small incision hip replacement surgery is a rapidly develop area of orthopedic surgery. Some of the developed techniques have been proved to be safe and effective, however others have increased risk of complications such as nerve and artery damage, problematic surgical wound healing, infections, hip fractures, improper placement of implants leading to accelerated implant wear, and hip joint loosing and dislocation. 

Patients whom have severe joint deformation, or have high body weights, or have very developed muscles, or have other health conditions affecting healing all have increased risk of developing complications from these types of procedures.

Your orthopedic surgeon’s skill and experience in minimally invasive hip replacement surgery should be considered and discussed with you fully when weighing the benefits and risks of choosing these types of minimally invasive procedures.

Your hospital stay

Typically the hospital stay duration after a hip replacement surgery is several days. After the operation it is normal to have pain in the hip joint, and your doctor will give you pain relieve medications to make you feel as comfortable as possible during your recovery.

To avoid congestion in your lungs after the procedure, you will be instructed to breathe deeply and to cough to keep your lungs clear.

To protect your hip joint during the early recovery period and maximize healing, you may be instructed use various tools and techniques such as placing a triangular pillow between your thighs.

Walking and light exercises are crucial to ensure your full recovery and are begun on the day after your surgery The majority of patients after their hip replacement surgery begin to stand and to walk with walking aids with the assistance and guidance of a physical therapist on the day after the procedure. Our physical therapist rehabilitation specialists will teach you specific exercises to strengthen and heal the hip joint muscles to restore your mobility to be able walk freely and do normal daily activities.

Possible complications

The rate of complications from hip replacement surgeries is relatively low. Serious complications such as joint infections occur in less than 2% of patients. Major complications such as heart ischemia or strokes have an even lower rate. However, the presence of chronic diseases may increase the potential for developing complications. Although rare, complications can prolong, compromise, and limit full recovery. 

Blood clots in the veins of the lower legs or pelvis are the most common complications from hip replacement surgeries. Your orthopedic surgeon shall numerous precautions to prevent blood clots from forming, and if clots do form he will take preventative measures to prevent them from causing complications. The methods used to prevent complications are wearing special stockings, using inflatable leg covers, doing specialized exercises, and administering anticoagulant medications.  

Differences in the lengths between the legs may exist, occur, or worsen after hip replacement surgery. Your orthopedist will take this into consideration during the treatment process along with other factors such as hip joint stability and joint biomechanics. Some patients may get benefit from using elevated shoes after the procedure to correct any length differences.

Other complications such as dislocation, nerve damage, blood vessel damage, bleeding, fractures, and stiffness can also affect the outcome of the surgery. Amongst a small number of patients after the procedure, hip pain can persist or new hip pains can appear.

With the passage of time the hip joint implants can wear or become loosened. This problem has been and continues to be reduced with the introduction of new improved implant materials and surgical techniques. When an implant wears out, small particles from the implant can damage and cause bone tissue loss, this process is called osteolysis.








The recovery process and preventative measures

The success of your operation depends largely on how closely you follow your post-procedural instructions prescribed by your orthopedic surgeon during the first weeks after your hip replacement surgery, which have been generalized and listed below:

Surgical wound care

After your procedure you will have stitches, staples, or subcutaneous sutures, which hold your surgical incisions closed. The stitches or staples shall be removed approximately 2 weeks after the procedure. Avoid getting the stitches or staples wet or dirty during the healing process. During the entire two week period, a sterile bandage is necessary to cover and protect the surgical wound from contamination or irritation from clothing.

Diet recommendations

For several weeks after your operations you may have a loss of appetite, which is quite common. To support the healing process, we recommend eating a balanced diet fortified with iron which is essential for proper tissue healing and restoration of muscle strength, and also be sure to drink plenty of fluids.

Activity exercises

Exercises are a vital recovery element to be done at home, especially during the first several weeks after the procedure. As a milestone, you should in the condition to do normal light activities from your normal daily routine within 3-6 weeks after your operation. It is normal to experience discomfort when active and moving, as well as during the night for the first few weeks after the procedure.

Your daily activity goals should include the following

  • Increasing the amount of walking, first at home and then outside
  • Gradually increasing mobility and stamina
  • Doing normal domestic activities  
  • Sitting, standing, walking up and down stairs  
  • Specific exercises to restore joint mobility - several times a day
  • Specific exercises to strengthen the hip joint - several times a day.
  • You should consider having a physical therapist give home therapy

To avoid post operative problems

Preventing blood clot formation

Please strictly follow the instructions from your orthopedic surgeon to reduce the potential risk of forming blood clots, which can occur during the first couple of weeks after the operation.  

Warning signals

After your procedure, please pay attention to the possible blood clot warning signals. If you experience any of the signals listed below, please contact your treating physician immediately for medical assistance.

  • Pain in the calves or thighs, which isn’t related to the operation wound  
  • Tenderness, soreness, or redness of the calves  
  • Swelling of the thighs, calves, ankles, or feet

Warning signs of a blood clot moving to the lungs:

  • Accelerated or interrupted breathing rhythm  
  • Chest pain, especially when inhaling  

Again if you experience any of the warning signals above, immediately contact your doctor for assistance.

Infection prevention

The most common cause of infections after the hip replacement surgery is from bacteria which enter the blood stream during dental procedures, bacteria from urinary tract infections, or skin infections. These bacteria can invade the tissues around your artificial hip implant.

After your intervention, is may be required to take antibiotics before any oral procedures such as dental treatments, especially teeth cleanings or any surgical procedures during which bacteria can enter your blood stream. For the majority of people whom underwent a hip replacement antibiotics are recommended as a preventative measure before having any dental work done.

Warning signs of possible infections of artificial hip joint implants:

  • Prolonged and elevated body temperature  
  • Chills  
  • Increased redness, tenderness, and/or soreness of the operation wound  
  • Secretion from the operation wound  
  • Increasing hip pain during movement and at rest

If you experience any of the warning signals above, immediately contact your doctor for assistance.

Avoiding falls

Falling during the first several weeks can damage the new joint and cause the need for a repeat operation. In particular stairs are a challenge to be careful with while your hip joint is recovering its mobility and stability. During this recovery period, we strongly recommend that using a cane, crutches, walkers, or handrails or any other walking aids until you regain your balance, flexibility and stamina.

Your orthopedist and/or your physical therapist can help you decide which walking aids will be most helpful after your surgery, and how long you must use them.

Other precautions

To ensure your proper recovery and to prevent any implant dislocations, you should follow several guidelines during the first several months after your procedure:

  • Do not cross your legs  
  • Do not bend your hip joint more that 90 degrees
  • Do not rotate your leg excessively in an inwards or outwards direction  
  • Place a pillow in between your thighs at night when you sleep, until your orthopedist tells you can stop using the pillow

Your orthopedist or physical therapist will give you more instructions specific to your case before you are discharged from our hospital. 

What differences to expect with a new hip joint?

After your procedure, you may have skin numbness around the surgical incision and may feel a noticeable stiffness upon deep hip joint bending. These sensations commonly decrease with time and most patients report that they are insignificant in comparison to the hip pain and limited function before the hip replacement surgery.   

You new hip joint may activate metal detectors used in airports and some buildings. To avoid issues, inform security personnel that you have an artificial implant which may activate metal detectors.  You can also ask your orthopedist to provide you with a card to confirm that you have a artificial hip implant.

After your hip replacement surgery we recommend that you do the following:

  • Follow a regular light exercise program designed to restore, strengthen, and increase mobility of your new hip joint
  • Take all necessary precautions to avoid accidents such as falls and injury
  • Inform your dentist that you have a recently implanted artificial hip joint, and that you must take antibiotics before any dental treatments
  • Regularly visit your orthopedist for routine examinations and x-rays to monitor your hip joint even if your hip joint feels great

Your should regularly visit your orthopedist to solve current health problems or prevent future health problems, and be assured that your orthopedist has vast experience covering diagnostics, non-surgical and surgical treatments of muscular-skeletal system diseases and trauma affecting the bones, joints, ligaments, muscles and nerves.  


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Hospital location

51B "Nikola I. Vaptsarov" blvd. (if you drive, the entrance is from "At. Dukov" str.), "Hladilnika" distr., 1407 "Lozenets".

The hospital has a parking lot. The first 30 min. are free of charge, then a fee of 3 bgn/hours applies.

Public transport:
Buses: №88, 120
Shuttle bus: 32

Subway: Getting off at "James Bourchier" station, after that walking through "Lozenets" distr., or tram №10, taking off at "Nikola I. Vaptsarov" stop. or a bus №88, taking ff at "Tokuda Hospital" stop.


From the Central Railway Station

Bus line №305 getting off at "Romanian embassy" stop
From "Romanian embassy" stop – Bus line №120 getting off at "Tokuda Hospital" stop.
(after the traffic lights at "Atanas Dukov" str.

With a subway, from "Central Railway Station" station, getting off at "James Bourchier" station, after that walking through "Lozenets" distr., or tram №10, taking off at "Nikola I. Vaptsarov" stop. or a bus №88, taking ff at "Tokuda Hospital" stop.