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Mechanical stress, as a core physical trigger, directly damages chondrocytes and the extracellular matrix, leading to the release of damage-associated molecular patterns (DAMPs, such as high-mobility group box 1 (HMGB1) and fibronectin fragments)

Melanin pigment may, at times, be identified in these epithelioid cells at the periphery of the islands

While heterogeneity was high (I 2 =96.86%), the direction of effect consistently favored ALC across robustness checks