A new concept and classification of corona mortis and its clinical significance.

PURPOSE: The obturator artery and its accessory (aberrant) arising from different origins and crossing the pubic rami are vascular variations. The internal iliac artery usually provides the obturator artery which may communicates with the external iliac artery through either the accessory obturator or inferior epigastric artery. A collateral circulation between the external and internal iliac system is known as corona mortis. The aim of current study is to provide sufficient data of vascular variability crossing the pubic rami for clinical field. METHODS: Present study includes 208 hemipelvises dissected in the Institution of Anatomy, Medical University of Graz. During dissection, the obturator artery and its accessory crossing the superior rami of pubic bone were found to have different origins. RESULTS: The obturator artery arising from the external iliac artery and from the femoral artery accounts for 9.8% and 1.1% respectively. Therefore, it passes over the superior pubic rami in 10.9%. Further, the accessory (aberrant) artery arises only from the femoral artery in 1.1%. In present study, the vascular variation crossing the superior pubic rami with or without collateral circulation between external and internal iliac system referred as corona mortis is addressed. This study includes new classification of obturator and accessory obturator arteries as well as the corona mortis. It includes a comparison of corona mortis incidence in Austria population and other populations. The corona mortis found to be in 12% of Austrian population. CONCLUSION: A great attention of clinicians, radiologists, surgeons, orthopedic surgeons, obstetricians and gynecologists has to be considered before pubic surgical procedures such as internal fixation of pubic fracture, an inguinal hernia repair. Further, traumatic pubic rami fracture may lead to massive hemor- rhage due to laceration of the obturator artery.

Corona mortis: anatomical data and clinical considerations.

BACKGROUND: Minimally invasive procedures, such as the TVT-Secur™, have been linked to injury to the corona mortis. Injury during the insertion of the TVT-Secur™ happens due to the vessel's position close to the place of the margin (25-30 mm from the symphysis pubis). AIMS: Systematic description of the aberrant vessel anatomy so as to help gynaecologists determine the risk of peri- and postoperative complications during the TVT-Secur™ and related procedures. METHODS: In a cadaver study, the lesser pelvis of ten female cadavers with venous or arterial coronae mortis was dissected. The origin, diameter and course of the aberrant vessels, as well as the distance from the symphysis pubis, were documented. RESULTS: Arterial coronae mortis were found in eight hemipelvises. All vessels originated from the ipsilateral inferior epigastric artery and all crossed over the superior pubic rami. Average distance from the symphysis pubis was 52.4 mm. Average vessel diameter was 3 mm. Venous coronae mortis were identified in ten hemipelvises. Eight drained into the external iliac and four into the inferior epigastric artery. Nine vessels crossed over the superior pubic rami. Average distance from the symphysis pubis was 46.7 mm. Average vessel diameter was 3.13 mm. CONCLUSION: Although individual variation makes direct contact with the vessel possible, in most cases there is a window of eight millimetres at least between the margin of the TVT-Secur™ and most aberrant veins. Possible aberrant arteries seem to lie even further.

The adult human pubic symphysis: a systematic review.

The pubic symphysis is a unique joint consisting of a fibrocartilaginous disc sandwiched between the articular surfaces of the pubic bones. It resists tensile, shearing and compressive forces and is capable of a small amount of movement under physiological conditions in most adults (up to 2 mm shift and 1° rotation). During pregnancy, circulating hormones such as relaxin induce resorption of the symphyseal margins and structural changes in the fibrocartilaginous disc, increasing symphyseal width and mobility. This systematic review of the English, German and French literature focuses on the normal anatomy of the adult human pubic symphysis. Although scientific studies of the joint have yielded useful descriptive data, comparison of results is hampered by imprecise methodology and/or poorly controlled studies. Several aspects of the anatomy of the pubic symphysis remain unknown or unclear: the precise attachments of surrounding ligaments and muscles; the arrangement of connective tissue fibres within the interpubic disc and the origin, structure and function of its associated interpubic cleft; the biomechanical consequences of sexual dimorphism; potential ethnic variations in morphology; and its precise innervation and blood supply. These deficiencies hinder our understanding of the normal form and function of the joint, which is particularly relevant when attempting to understand the mechanisms underlying pregnancy-related pubic symphyseal pain, a neglected and relatively common cause of pubic pain. A better understanding of the normal anatomy of the human pubic symphysis should improve our understanding of such problems and contribute to better treatments for patients suffering from symphyseal pain and dysfunction.

A South Indian cadaveric study on obturator neurovascular bundle with a special emphasis on high prevalence of 'venous corona mortis'.

Surgical procedures in the pelvic region are very challenging because of the complex anatomy of this region. "Corona mortis" is a term used to describe retro-pubic anastomosis between the obturator and external iliac vessels. It is considered as a key structure as significant haemorrhage may occur if the vessels are cut accidentally during pelvic surgeries. Earlier studies have documented a high frequency of venous anastomosis compared to its arterial counterpart. The objective of our study was to document the prevalence of venous corona mortis in South Indian human adult cadaveric pelvises. We conducted this study on 73 cadaveric pelvic halves. Out of the 73 hemi pelvises, 36 were normal without any variations of the obturator vessels while 37 hemi pelvises (51%) showed the presence of abnormal obturator vessels which proves to be a very high incidence in terms of variations. Out of the 37 hemi pelvises, 25 (68%) showed the presence of 2 obturator veins, out of which 1 was normal and the other was an abnormal obturator vein. 8 hemi pelvises (22%) had only abnormal obturator vein. Most of the abnormal obturator veins drained into the external iliac vein, while two veins drained into inferior epigastric veins. Venous corona mortis is said to be frequently encountered during surgery and is considered to be as important as arterial corona mortis in its clinical implications. Individual evaluation of this risky anatomical structure should be done prior to any surgical interventions.

Vascular anatomy over the superior pubic rami in female cadavers.

OBJECTIVE: The objective of the study was to characterize the vascular anatomy over the superior pubic ramus. STUDY DESIGN: Detailed dissections of the retropubic space were performed in 15 fresh female cadavers. Vessels crossing the superior pubic rami were inspected for width, course, communications, and relationship to the midline of the pubic symphysis and the obturator canal. RESULTS: Vessels 1 mm or greater in width connecting the obturator vessels and inferior epigastric or external iliac vessels were noted in 10 of 15 (66.7%) cadavers: 9 (60%) had veins, 5 (33.3 %) had arteries, and 4 (26.7%) had both. In all specimens, the vessels crossed over the superior pubic rami lateral to or at the level of the obturator canal, which was on average 5.4 cm from the midline of the pubic symphysis. CONCLUSION: Communicating vessels crossing the superior pubic rami were present in the majority of specimens. Understanding this anatomy should aid the surgeon in avoiding vascular complications.

Guinea-pig interpubic joint (symphysis pubica) relaxation at parturition: underlying cellular processes that resemble an inflammatory response.

BACKGROUND: At term, cervical ripening in coordination with uterine contractions becomes a prerequisite for a normal vaginal delivery. Currently, cervical ripening is considered to occur independently from uterine contractions. Many evidences suggest that cervical ripening resembles an inflammatory process. Comparatively little attention has been paid to the increased flexibility of the pelvic symphysis that occurs in many species to enable safe delivery. The aim of this study was to investigate whether the guinea-pig interpubic joint relaxation process observed during late pregnancy and parturition resembles an inflammatory process. METHODS: Samples of pubic symphysis were taken from pregnant guinea-pigs sacrificed along gestation, parturition and postpartum. Serial sections of paraffin-embedded tissues were used to measure the interpubic distance on digitalized images, stained with Giemsa to quantify leukocyte infiltration and to describe the vascular area changes, or studied by the picrosirius-polarization method to evaluate collagen remodeling. P4 and E2 serum levels were measured by a sequential immunometric assay. RESULTS: Data showed that the pubic relaxation is associated with an increase in collagen remodeling. In addition, a positive correlation between E2 serum levels and the increase in the interpubic distance was found. On the other hand, a leukocyte infiltration in the interpubic tissue around parturition was described, with the presence of almost all inflammatory cells types. At the same time, histological images show an increase in vascular area (angiogenesis). Eosinophils reached their highest level immediately before parturition; whereas for the neutrophilic and mononuclear infiltration higher values were recorded one day after parturition. Correlation analysis showed that eosinophils and mononuclear cells were positively correlated with E2 levels, but only eosinophilic infiltration was associated with collagen remodeling. Additionally, we observed typical histological images of dissolution of the connective tissue matrix around eosinophils. CONCLUSION: The present study shows that a timely regulated influx of infiltrating leukocytes is associated with an extensive collagen remodeling process that allows the pubic separation for a normal delivery in guinea-pig. Thus, the findings in this study support the hypothesis that the guinea-pig pubic symphyseal relaxation at parturition resembles an inflammatory process.

Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report.

Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure.

An anatomical study of corona mortis and its clinical significance.

OBJECTIVE: To provide detailed information of corona mortis for ilioinguinal approach as an anterior approach to the acetabulum and pelvis. METHODS: The course, branches and distribution of the vascular connection between the obturator system and the external iliac or inferior epigastric systems located over the superior pubic ramus were observed on 50 hemipelvises with intact soft tissues. RESULTS: During the dissections, 72% of the cadaveric sides had at least one communicating vessel between the obturator system and the external iliac or inferior epigastric systems on the superior pubic ramus. The average diameter of the connecting vessel was 2.6 mm (range, 2.0-4.2 mm). It coursed over the superior pubic ramus or iliopubic eminence vertically to enter the obturator foramen and exit the pelvis. The average distance from pubic symphysis to the vascular connections between the obturator and external iliac systems was 52 mm (range, 38-68 mm). CONCLUSIONS: Vascular connections between the obturator system and the external iliac or inferior epigastric systems were found over the superior pubic ramus with a high incidence. They are prone to damage during the ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Thus, corona mortis located over the superior pubic ramus deserves great attention during the ilioinguinal approach.

[A preliminary anatomical study on design of cannulated screw channels for fixation of symphysis pubis diastasis in small samples].

OBJECTIVE: To design the channels of parallel screws and cross screws for fixation of symphysis pubis diastasis through a small sample anatomic study on pubic symphysis and its neighbor structures so as to provide anatomical basis for minimally invasive fixation of symphysis pubis diastasis. METHODS: Eight cadaveric pelvic specimens (6 men and 2 women) were transected along L5 and the proximal 1/3 of bilateral thighs, with intact lumbar spines. The spermatic cord, womb round ligament, and corona mortis were dissected; the distance to the i psilateral pubic tubercle was measured and subsequently the distance between pubic tubercles, the height of pubic symphysis, the diameter of outer edge of pubic tubercle, the thickness of pubic symphysis and 2 cm outside the pubic symphysis (upper, central, and lower 1/3 thickness of pubic symphysis) were measured to provide anatomical basis for the design of channels of parallel screws and cross screws. RESULTS: Parallel screw fixation: the entry point of first screw was on the outer edge of pubic tubercle, and its exit point was on the outer edge of contralateral pubic tubercle; a cannulated screw with a diameter of 4.5 mm or 6.5 mm can be suitable for this channel. The entry point of second screw was 20 mm outside the pubic symphysis and 23 mm beneath the pubic symphysis, and its exit point was symmetrical with entry point; a cannulated screw with a diameter of 4.5 mm can be appropriate for the second channel. The direction of two screws was perpendicular to the pubic symphysis. Cross screw fixation: the entry point of cross screws was on one side of the pubic tubercle, and its exit point was 20 mm outside the contralateral pubic symphysis and 23 mm beneath the contralateral pubic symphysis; two cannulated screws with a diameter of 4.5 mm can be chosen for cross screws channels. The direction of two cross screws was intersected with the horizontal line of two pubic tubercles at an angle of 25 degrees respectively; besides, two cross screws formed an anteversion angle and retroversion angle of 5-10 degrees with pubic body plane, respectively. CONCLUSION: The channels of parallel screws and cross screws are feasible for fixation of symphysis pubis diastasis by analyzing the anatomical data of the pubic symphysis and its neighbor structures, but further biomechanical research is need to confirm the stability of two fixation methods.

Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum.

The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises) through the ilioinguinal approach. A vascular anastomosis was found in 83% of specimens. Of these, 60% had a large diameter (>3 mm) channel along the posterior aspect of the superior pubic ramus. In clinical practice, however, 492 anterior approaches (to the best of our knowledge the largest series described) have been carried out over the last 15 years by the senior author (MB) and only five of these problematic vessels were discovered, and in only two cases was there troublesome bleeding. This study confirms a paradox: in anatomical dissections a large vessel was identified behind the superior pubic ramus, whereas in clinical practice this vessel does not seem to be as great a threat as initially perceived. Orthopedic surgeons planning an anterior approach to the acetabulum, such as the ilioinguinal or the intrapelvic approach (modified Stoppa), have to be cautious when dissecting near the superior pubic ramus. Despite the high prevalence of these large retropubic vessels in the dissecting room, surgeons should exercise caution but not alter their surgical approach for fear of excessive hemorrhage.

Anatomical consequences of "open-book" pelvic ring disruption: a cadaver experimental study.

UNLABELLED: "Open-book" pelvic fractures associate a diastasis and/or a fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint. These uni or bilateral lesions are potentially lethal mainly due to associated injuries and massive pelvic hemorrhage. The most frequently injured arteries are parietal branch of the commune, internal or external arteries because of their proximity to the bone, the sacro-iliac joint and the inferior ligaments of the pelvis. The pelvic bone dislocation and the increase of pelvic volume facilitate blood effusion. The aim of this study was to determine, on a cadaver fracture model, the direct anatomical consequences of "open-book" pelvic fracture on the ilio-lumbar pedicle and the pelvic cavity volume. MATERIALS AND METHODS: Bilateral open-book pelvic ring injuries were created in ten non-embalmed cadaver specimens by directly disrupting the pubic symphysis, the right and the left sacro-iliac joints. Pelvic volume was determined after total pelvic exenteration. Consequences of this fracture on vascular parietal network, nervous pelvic trunk and pelvic cavity volume were studied. RESULTS: The mean volume of the pelvic cavity after complete visceral exenteration was 872.5 cm(3) (extremes 580-756 cm(3)). The average increase of pelvic volume was 20.8% after 5 cm of pubic diastasis. In all cases, because of a transversal disposition of the ilio-lumbar pedicle with regard to the sacro-iliac joint, reproduction of the open-book fracture caused a venous dilaceration of the ilio-lumbar vein in 12 cases after 5 cm of pubic diastasis (12/20=60%). No arterial dilaceration was observed on the ilio-lumbar artery, but this artery was put in tension. CONCLUSION: Open-book fractures create an increase of pelvic volume that facilitates blood diffusion from parietal pelvic vascular network. Ilio-lumbar pedicle seems to be very vulnerable in this type of fracture because of its relations to the sacro-iliac joint and its transversal disposition with regard to this joint.

[Drainage of the erectile organs in the rat]. / Le drainage des corps érectiles chez le rat.

The retro-pubic veinous circle of the male rat was investigated on the both sides: anatomic and functional aspect. The dorsal vein of penis in the male rat run into a retro-pubic veinous circle. This circle receive the anterior vesical veins too. The internal pudendal vein and the anastomotic vein begin in this circle, and go together to the iliac vein. From the retro-pubic veinous circle, there is a triangular circulation between the internal pudendal vein, the anastomotic vein and the iliac vein. Angiographies performed on rats in vivo, indicates that the anastomotic vein is effical for the drainage of the retro-pubic circle only if the flow of the penis dorsal vein is sufficient. These conclusions are proved by experimentation on dead rats.

Nutrition pathways to the symphysis pubis.

The blood supply of the symphysis pubis is still the subject of some debate. Classic anatomy books state that this joint is avascular, whereas some published works have shown blood vessels in young specimens. As several articular discs such as the knee menisci are known to have blood vessels in their peripheries, we decided to investigate the possible nutrition pathways to the interpubic disc and ligaments. We used 60 Wistar rats, male and female, aged between 28 and 32 days, or between 90 and 100 days. Samples were processed using a variety of techniques: regular histology, immunohistochemestry, India ink injection and corrosion casting. The interpubic disc consisted of an inner bearing portion and an outer fibrous rim. The interpubic ligaments and the fibrous rim were well vascularized in all groups. Marrow contacts between the interpubic disc and the subchondral bone were also observed. Blood vessels formed an authentic arterial circle embracing the joint, from which blood vessels branched into capillary loops facing the avascular inner bearing portion of the disc. These results confirm the need for future studies on the human symphysis pubis, to provide more details on its structure, which would enable clinicians such as physiotherapists to improve prognosis and treatment design. Future studies may also explain the pathways down which the hormone relaxin reaches its targets within this joint.

[Sexual complications from superficial venous surgery]. / Les complications sexuelles de la chirurgie veineuse superficielle.

Post-surgical erectile dysfunctions of superficial veins of the lower limbs are seldom reported. It seems to be due to the fact that they are ignored. In most cases, one has to find their origins in an abnormality of arterious distribution towards sexual parts: one or several of these latters come from common femoral veins and their colaterals (the external pudendal arteries) and not from hypogastrics (and internal sexual arteries). Therefore, it is necessary to take care of external sexual arteries during Scarpa's dissections in male patients in order to avoid the possible occurrence of a partial secondary or total impotency.