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. 2023 Jan 28;37:9–14. doi: 10.1016/j.jor.2023.01.011

Corona Mortise- anatomical variants and implications in pelvic-acetabular surgery: An evidence based review

Abhay Elhence 1, Akshat Gupta 1,∗
PMCID: PMC10039118  PMID: 36974088

Abstract

Background

Corona Mortise is the name given to the anastomotic vessels forming a communication between external and internal iliac vascular systems. These channels have a high tendency to cause uncontrollable bleeding if injured and are particularly at risk during the anterior approach to acetabulum. While previous studies have described them as arterial or venous connections or both, there is still a lack of consensus regarding exact nature and location of these vessels, which make their timely identification all the more challenging.

Objective

The present review is aimed at performing a comprehensive review of existing literature and discuss the anatomy and implications of correct identification of Corona Mortise in pelvic-acetabular surgery.

Conclusion

Corona Mortise is more commonly venous than arterial. This not only makes haemorrhage control more challenging but also precludes the use of pre-operative angiography. However, most authors do not recommend a change in surgical approach for fear of damaging these vessels.

Keywords: Corona mortise, Anatomical variants, Haemorrhage, Pelvic-acetabular surgery

1. Introduction

The pelvis is a highly complex anatomical structure housing a host of important visceral organs as well as neuro-vascular bundles. Amongst the latter, the internal iliac blood vessels are of significant importance as they not only supply and drain blood from the lateral pelvic walls but also numerous visceral organs, external genitalia and proximal aspect of the lower limbs.1 The obturator artery (OA) is one such branch which arises from the anterior division of the internal iliac artery (IIA), leaving the pelvis via the obturator canal. Traumatic injury to this artery can result in potentially life-threatening haemorrhage. Additionally, a host of anastomotic channels exist between the external and internal iliac systems, which have the propensity to cause excessive bleeding if injured accidently. These vessels constitute what is better known as the Corona Mortise (CMOR). The latter can be defined as a vascular connection between the obturator and external iliac or inferior epigastric arteries and/or veins (EIA/EIV/IEA/IEV) located behind the superior pubic ramus (SPR) in the retropubic space, at a variable distance from the pubic symphysis.2, 3, 4, 5 The term comprises of two Latin words: “corona” (which means crown) and “mortis” (which is derived from “mors” meaning death).2,4,6,7 The name itself is a grim reminder why surgeons all over the world attach so much importance to the correct identification as well as protection of this anatomical variant. These vessels are quite susceptible to iatrogenic trauma during acetabular fracture surgery, laparoscopic hernia repairs and a host of other urological as well as gynaecological procedures.8,9

Classically, textbooks of anatomy describe CMOR to be an arterial connection, but in reality, the nature of the anastomoses is more venous than arterial.2,4,5,7,8,10,11 Moreover, the CMOR is located at a variable distance from the pubic symphysis. Owing to this variation in the anastomotic circulation, a detailed knowledge always comes in handy so as to prevent iatrogenic injuries associated with surgical procedures. The purpose of this review was, therefore, to shed more light on the gross anatomy of CMOR as described in the literature and talk about its relevance in orthopaedic surgical practice.

2. Anatomy

2.1. Embryological basis

According to several authors who have studied the vascular development of the lower limb in great detail, arterial pattern anomalies usually result from an unusual selection of blood vessels from the primary capillary plexus. While the most appropriate channels enlarge, others gradually regress in size and finally disappear. In 1993, based upon Senior's embryological description of the various arterial anomalies of the pelvis and thigh (1919,1925),12 Sañ udo et al.,13 proposed a new ontogenetic theory. According to them, sometimes before the OA can arise as an independent blood vessel from the rete femorale and rete pelvicum, blood flow destined for its territory arises from the IEA. This theory not only accounts for the various anomalies surrounding the origin of the OA but also explains its concomitant association with accessory/aberrant obturator vessels in selected cases.13

2.2. Gross anatomical description

2.2.1. What exactly constitutes the CMOR?

There are several communicating vessels which navigate the SPR. They are variously referred to as ‘aberrant’, ‘anomalous’ or ‘pubic branches’ of the obturator or IE vessels. However, not all connect the OA to the EIA/IEA and hence, not all constitute CMOR. However, some authors have used terms such as ‘aberrant’, ‘anomalous’ or ‘accessory’ while referring to the CMOR.10,14 This has led to a lot of confusion and is one of the primary reasons why consensus has yet to be reached with respect to the exact definition of the CMOR. However, going by the original description found in the 34th edition of Gray's Anatomy (Davies and Coupland, 1967) and that given by Letournel and Judet (1993), CMOR can be defined as an anastomotic communication between the obturator and the external iliac/inferior epigastric arteries/veins.2

Further light was shed by Rusu et al.,3 who stated that any major vessel, regardless of its origin, that entered the obturator canal constituted the OA. The authors also added that if there were more than one artery entering the upper border of the obturator foramen, the larger vessel would be considered as OA while the other would be taken as the accessory vessel. Furthermore, in the absence of any other OA, the only existing one must be considered as the OA. Thus, an accessory OA would be a supplemental artery with a normal course in the presence of a normal OA. An aberrant or accessory aberrant OA, on the other hand, would be a supplemental artery with OA present, but with an aberrant course through the obturator foramen. Darmaris et al.,2 observed that the latter usually involved a course more oblique and more posterior towards the SPR vis-à-vis standard anastomotic connections.

2.2.2. Arterial and venous CMOR

Rusu et al.,3 classified CMOR on the basis of their respective vascular composition into three major types:

Type 1: Pure arterial CMOR.

Type 2: Pure venous CMOR.

Type 3: Combination of arterial as well as venous CMOR.

Arterial and venous anastomoses are further divided into four and three subtypes respectively (Fig. 1):

Fig. 1.

Fig. 1

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Classification of Corona Mortise into arterial and venous subtypes.

EIA- External Iliac artery; EIV- External Iliac vein; IEA- Inferior Epigastric artery; IEV- Inferior Epigastric vein; CMOR – Corona Mortise.

I.1.Obturator artery (OA) arising from the external iliac artery (EIA).

I.2.OA leaving the inferior epigastric artery (IEA).

I.3.Anastomosis of the OA and IEA.

I.4.pubic branch(es) from the OA, un-anastomosed to the external iliac system but traversing over the superior pubic branch.

II.1. Obturator vein (OV) draining into the external iliac vein (EIV).

II.2. OV draining into the inferior epigastric vein (IEV).

II.3. Venous anastomosis of the OV and IEV.

The incidence of arterial CMOR reported in literature varies from 8% to as high as 65%.1,3,7,8 Okcu et al.4 reported 29 arterial anastomoses in 150 hemipelvis specimens (19%). Darmanis et al.,2 on the other hand, observed an incidence rate of 36% in their study involving 80 cadaveric halves. Arterial CMOR channels were seen in 11 out of 50 cases (22%) by Mahato et al.10 Findings of the two most recent research papers1,8 peg the overall incidence of arterial CMOR to be somewhere between 8.2 and 8.3% (similar to that reported by Pellegrino et al.7). Interestingly, both studies have been performed on different sections of the Indian population, Nayak et al.1 on south Indian subjects and Kashyap et al.8 on north Indian patients.

Reported incidence rates of venous CMOR have varied from 40% to 96%.5,10 In one of the earliest cadaveric studies, Tornetta11 reported that venous connections accounted for up to 70% of their anastomotic channels. Venous CMOR have been noted by Pellegrino et al.7 in 48% cases, Okcu et al.4 in 52% cases, Rusu et al.3 in 55% cases and most recently, by Kashyap et al.8 in 58.5% cases.

As most of the earlier studies were based upon Computerized tomography angiography (CTA) findings, the classical description of CMOR is akin to that of an arterial connection.5,6 However, as more and more studies were performed subsequently (particularly on cadaveric specimens), it became clear that the percentage of venous CMOR was much higher than originally anticipated.2,4,7,8,10,11 Evidence from a recent review, in fact, suggests that the incidence of venous anomalous channels is higher than those of arterial origin, with the overall incidence ranging from 63 ± 20% (irrespective of the type of blood vessel).15 From a surgeon's perspective, although arterial CMOR is more dangerous in terms of haemorrhage and hemodynamic instability, the identification of an active venous source of bleeding is much more challenging as angiography cannot be used for this purpose.16 A brief summary of the overall incidence of arterial as well as venous CMOR, as reported by various authors is given in Table 1.

Table 1.

Pattern of arterial and venous CMOR seen in prior studies.

SNO. AUTHOR (YEAR) TYPE OF STUDY SAMPE SIZE MEAN AGE (YEARS) SEX RATIO (M: F) ARTERIAL CMOR VENOUS CMOR MISCELLANEOUS
1. Tornetta(3rd) et al. (1996)11 Cadaveric 50 – – 17/50 (34%) 35/50 (70%)
  • -

    Both arterial and venous connections were seen in 10/50 cases (20%).
2. Berberoglu et al. (2001)5 Cadaveric/Operative 50: – – Cadaveric: Cadaveric: In two cadaveric halves, instead of an arterial CMOR:
  • -

    Cadaveric halves = 14

 12/14 (85.7%) 14/14 (100%)
  • 1)

    OA originated from the EIA.
  • -

    Hernia surgeries = 36(28 patients)

 Operative: Operative:
  • 2)

    Accessory OA originated from the IEA.
31/36 (86.1%) 34/36 (94.4%)
3. Karakurt et al. (2002)6 Radiological 98 55 59:39 28/98 (28.5%) – –
4. Okcu et al. (2004)4 Cadaveric 150 40 58:17 29/150 (19%) 78/150 (52%)
  • -

    Both arterial and venous connections were seen:
1 Artery + 1 vein = 13/150 (9%)
1 Artery + 2 veins = 3/150 (2%)
[Pure Arterial = 13/150 (9%)]
[Pure venous = 62/150 (43.3%)]
5. Darmanis et al. (2007)2 Cadaveric 80 58 27:13 29/80 (36%) 48/80 (60%)
  • -

    Aberrant OA arising from the EIA = 1/80 (1.25%)
  • -

    Aberrant OV arising from the EIV = 3/80 (3.75%)

  • -

    Both arterial and venous connection = 22/80 (27.5%)

6. Mahato (2009)10 Cadaveric 50 – 22:3 – 20/50 (40%)
  • -

    Both abnormal OA and OV = 11/50 (22%)
  • -

    Abnormal OA originating from EIA = 5/50 (10%)

  • -

    Abnormal OA originating from IEA = 4/50 (8%)

  • -

    Abnormal OA originating from EIA/IEA common trunk = 1/50 (2%)

7. Rusu et al. (2009)3 Cadaveric 40 – 12:8 26/40 (65%) 22/40 (55%) –
8. Pellegrino et al. (2014)7 Operative 25 laparo-scopic procedures (50 hemi -pelvises) 59.5 0:25 2/26 (8%) 12/25 (48%)
  • -

    Both arterial and venous connections were seen in 6/26 (23%) patients:
1 Artery + 1 vein = 5/6 (83%)
1 Artery + 2 veins = 1/6 (17%)
  • -

    One venous connection = 10/12 (83%)

  • -

    Multiple venous connection = 2/12 (17%)

  • -

    Patients with arterial CMOR had a SINGLE arterial connection only.

9. Leite et al. (2017)9 Cadaveric 60 – 25:5 27/60 (45%) – –
10. Perandini et al. (2018)17 Radiological 300 73 112:38 90/300 (30%) – –
11. Selcuk et al. (2018)18 Operative 96 – 0:96 2/96 (2.01%) 4/96 (4.1%) –
12. Kashyap et al. (2019)8 Cadaveric 24 68 11:1 2/24 (8.3%) 14/24 (58.3%)

  • −11/14 cases had a single venous connection.
  • -

    One arterial CMOR connected the OA to the EIA near the origin of the IEA. In the other case, the OA originated from the IEA itself.
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CMOR- Corona Mortise; OA- Obturator Artery; OV- Obturator Vein; EIA- External Iliac Artery; EIV- External Iliac Vein.

IEA- Inferior Epigastric Artery.

2.2.3. Laterality

CMOR not only differs comprehensively in terms of whether it is an arterial or venous connection but also with respect to its laterality and side most commonly involved. Some cadaveric studies have noted the anastomotic vessels to be more prevalent on the right side1,7 whereas others have observed the opposite.8,9 Nayak et al.1 reported bilateral CMOR in three out of 69 cases (4.3%). The incidence reported in other studies was notably higher.7,8 Okcu dissected 150 cadaveric hemipelvis specimens and noted 21 bilateral vascular connections. However, only nine had bilaterally symmetrical findings (12%).4 Darmanis et al.,2 on the other hand, had observed bilateral vascular anomalies in 34 out of 40 cases with bilaterally symmetrical distribution seen in two specimens. Data from the systematic review of Cardoso et al.15 has shown that:

  • -

    incidence of bilateral CMOR is lower than that of unilateral CMOR.

  • -

    there is no significant difference in the occurrence of unilateral CMOR on the right vis-à-vis the left.

2.2.4. Distance from the pubic symphysis and calibre

The CMOR is located at a variable distance from the pubic symphysis and different values have been described in different studies. The same rationale applies to the vessel diameter. These values have been summarized in Table 2.

Table 2.

A brief depiction of the variability in laterality as well as calibre of CMOR anastomoses.

SNO. AUTHOR (YEAR) MEAN CALIBRE (mm) AVERAGE DISTANCE FROM THE PUBIC SYMPHYSIS (mm)
1. Tornetta(3rd) et al. (1996)11 – 62
2. Berberoglu et al. (2001)5 Cadaveric: 40.4
  • -

    Arterial = 0.98

  • -

    Venous = 3.3

  • -

    OA = 2.4

  • -

    Accessory OA = 2.2

Operative:
Arterial/venous <1
3. Karakurt et al. (2002)6 – 33.4
4. Okcu et al. (2004)4 – Arterial = 64
Venous = 56
5. Hong et al. (2004)19 2.6 52
6. Pungpapong et al. (2005)20 – 52.8
7. Darmanis et al. (2007)2 2.6 Arterial = 71
Venous = 65
8. Leite et al. (2017)9 2.7 49.6
9. Perandini et al. (2018)17 1.7 50
10. Kashyap et al. (2019)8 All 19 CMOR had diameter >1 mm (Four specimens had diameter > 4 mm; One specimen had diameter >10 mm) Arterial = 51
Venous = 41
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CMOR- Corona Mortise; OA- Obturator Artery.

Cardoso et al.15 have pegged the average calibre of the CMOR vessels at 2.8 mm.

3. Imaging modalities

In a study evaluating the extent of blood loss in pelvic-acetabular osteotomies, Hu et al.21 were able to identify CMOR vessels in 21 out of 28 (75%) cases using Magnetic resonance imaging (MRI). Magnetic resonance venography (MRV) has shown to be superior to contrast venography for detecting deep vein thrombosis in pelvic veins in patients with acetabular fractures and is a promising modality for imaging veinous CMOR connections.22 It is non-invasive and does not require the use of contrast medium, thereby preempting any systemic reaction associated with the latter.22

4. Clinical relevance in pelvic-acetabular surgery

It has been observed that the actual incidence of haemorrhage arising due to traumatic injury to the CMOR blood vessels is far lower than what one would expect, going by the results of the various cadaveric studies. Three reasons have been proposed for this discrepancy.2 The first theory states that any direct/indirect injury to the CMOR following fracture of the pelvis would cause these vascular channels to go into spasm. This would automatically make their identification much more difficult at the time of surgery.4,23 According to another theory, demographic and ethnic differences between sections of different study populations maybe one reason for the discrepancy observed in the clinical setting. A systematic review performed to detect the prevalence as well as characteristics of the CMOR variant of obturator artery concluded that the latter has a higher frequency in the European population vis-à-vis the Asian community.24 The last theory states that many a times the EIA or the OA maybe occluded secondary to atherosclerosis or deep vein thrombosis in the geriatric population. This would then stimulate the development of collateral vascular channels and aberrant obturator blood vessels in these people.25,26

Scenarios in which CMOR can be injured:

  • 1.

    Fracture of the upper part of the obturator foramen, including SPR fractures, low anterior column fractures etc.27

  • 2.

    Iatrogenic injury during exposure to the anterior acetabulum (Ilioinguinal as well as modified Stoppa approach).2,19

  • 3.

    Coil embolization of the IIA and its various branches performed following excessive bleeding associated with pelvic injuries.28

  • 4.

    Acetabular dysplasia surgeries and pelvic osteotomies making use of the medial approach.29

According to Darmanis et al.,2 surgeons carrying out any kind of exposure to the anterior acetabulum must be careful while dissecting about the SPR, as there is a high chance that they might encounter a leash of vessels about 4–9 (average 6) cm lateral to the pubic symphysis. The latter may obstruct the field of surgery, making placement of implant a tedious and difficult task (Fig. 2), especially for fractures involving the quadrilateral plate.30 Although small vascular channels are inadvertently thrombosed due to the fracture and do not pose any significant risk, any tear or laceration of the larger aberrant obturator vessels may have disastrous consequences.8 However, most authors, while advising caution, recommend against altering the surgical approach for fear of damaging the CMOR.2,8

Fig. 2.

Fig. 2

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Schematic representation of the Corona Mortise blood vessels and the difficulty encountered during acetabular plate application.

B/V- Blood Vessels; CIA/V- Common Iliac Artery/Vein; EIA/V- External Iliac Artery/Vein; A-IIA/V- Anterior Division Internal Iliac Artery/Vein; P-IIA/V- Posterior Division Internal Iliac Artery/Vein; CMOR B/V- Corona Mortise Blood Vessels.

There has been a lot of debate surrounding the utility of pre-operative angiography for mapping the vasculature around the operative site (thereby helping in decision making). Jensen et al.31 argued that such studies were actually not needed if a careful and gentle dissection was performed during surgery. The authors further stated that it was highly unlikely that CMOR could be the only source of bleeding in an unstable pelvic injury and under such circumstances, it would be wiser to first externally stabilize the pelvis. In the absence of clear-cut guidelines, the need of pre-operative angiography needs to be further studied in detail.8

In conclusion, it stands to reason that CMOR is more often a venous anastomotic channel between the external and internal iliac systems contrary to the earlier understanding on the subject. This clarifies that preoperative CT angiography may not have a significant role as a guide to an anticipated pelvic dissection in an acetabular fracture patient. Another significant feature is that a venous anastomotic connection is more difficult to manage in case of an inadvertent injury at the time of surgery. This anatomical fact has a direct bearing on the timing of the surgical intervention in approaches which are aimed to deal with fractures and comminution in the region of the quadrilateral plate. A fresh injury allows easier dissection of the anastomotic connections in the region of the quadrilateral plate. Surgical delays often lead to gumming up of the vascular channels and formation of fibrous tissue and callus in the area making surgical dissection even more difficult and fraught with possibility of vessel injury during surgery.

Moreover, the anastomotic connections whether arterial or venous or both, may be more than one, which again has a bearing for the pelvi-acetabular surgeon at the time of surgery, as merely identifying one anastomotic channel should not divert the attention of the surgeon and the surgical team towards the possibility of further anastomotic connections between the external and internal iliac vascular systems. The knowledge of vascular anatomy of the CMOR and other communicating channels, irrespective of what they may be called, is important for all surgeons/surgical teams as the number, location, size and obliquity are all important guides to the origin of these vascular channels and would advise extra caution by surgical teams to avoid major or catastrophic complications.

The size and position of the vascular anastomotic channels is another factor which has an important bearing on outcomes as often a large communicating channel or as Rusu et al.3 have described, an aberrant connection emanating directly from either the EIA or the EIV, may join the obturator vascular channel directly. In such circumstances, it would be a significant sized vascular connection more vertical and posteriorly located on the SPR at the level of the EIA or the EIV, causing often uncontrollable bleeding if accidently injured.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Funding statement

We did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for conducting this research; in study design; collection, analysis and interpretation of data; writing of this manuscript or decision to submit the article for publication.

Author statement

Abhay Elhence: Writing-review and editing; conceptualization and supervision. Akshat Gupta: Writing and preparing diagrams.

Declaration of competing interest

None.

Acknowledgement

None.

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