Immunohistochemical analysis of the ligamentum mucosum is the key to understand its clinical usefulness

Background: Ligamentum Mucosum(LM) is a ligamentous structure within the synovial layer of the knee joint capsule. For a long time LM was perceived as the vestigial remnant from the embryological development of the knee. Being treated as an irrelevant structure LM is often the first victim of shaver during arthroscopy. However, last years have shown increased interest in this structure due to its potentially significant clinical role. Our aim is to classify LM based on its morphological characteristics and examine its microanatomy to reveal the potential clinical value for surgeons. Hypothesis/Purpose: Our purpose was to reveal the clinical significance of LM based on immunohistochemical analysis. Methods: : Sixteen fresh frozen lower limbs, 6 females (mean age 83.1 ± 3.4 years) and 10 males (mean age 84.2 ± 6.8 years) were examined. Classical histological H+E stain was routinely conducted. Subsequently, CD31 antibody (DAKO, Monoclonal Mouse Anti-Human, Clone JC70A) was used to mark vascular epithelium. Monoclonal Mouse Anti-Human Neurofilament Protein (NFP) antibody (DAKO, Clone 2F11) was used to expose the nerves. Results: : The dissection process has revealed that LM was present only in 75% of cases. Histological examination confirmed the presence of longitudinal collagen fiber bundles in all samples. Tiny nerves were confirmed by NFP, along the subsynovial layer in all samples. CD-31 immunostain revealed the presence of many vascular vessels along the entire ligament, especially well developed at its distal end. Conclusion: Our study has revealed that LM contains rich vascular network. Thus, it may be a donor for the revascularization process after ACL tear or reconstruction which may improve the recovery. Another great advantage of the LM is the presence of nerves along the subsynovial layer, hopefully they may serve as the source of reinnervation and hence better clinical outcome Clinical Relevance: Based on our results we believe that seemingly irrelevant LM may be very useful during surgical procedures in the knee region. Suturing LM to the ACL may not only prevent the infrapatellar fat pad from subluxation but also improve the blood flow and reinnervation of the injured ACL.