***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : Postoperative care for ankle fractures is generally 1 of 2 regimens : 1 ) functional treatment combined with early weightbearing ( EWB ) , or 2 ) immobilization in a cast/orthosis for 6 weeks without weightbearing ( 6WC ) . The objective of this study was 2-fold : 1 ) to follow a prospect i ve group treated with EWB as to long-term subjective and objective outcomes , and 2 ) to compare a subset of this group with a matched group of historic controls treated with 6WC . Design : Prospect i ve , clinical , cohort observation , and retrospective matched pair analysis . Setting : University hospital , level 1 trauma center . Patients : Forty-three patients ( 20 males ; mean age , 49 ± 14 years ) with operated Weber B/C fractures underwent EWB .  For comparison , 23 patients of this group were matched to a same number of historic controls with respect to age , gender , body mass index , and fracture type . Intervention : Open reduction and internal fixation ( ORIF ) using a 1/3-tubular-fibula-plate for the fibula , and malleolar screws for the medial malleolus fracture ( in cases with a bimalleolar ankle fracture ) followed by EWB or 6WC . Main Outcome Measurements : Olerud and Tegner scores at follow-up ( at least 12 months after surgery ) , time to full weightbearing , return to work , pain intensity ( numerical rating scale ( NRS ) ) , and hospital stay . Statistical comparisons were performed by using the Mann-Whitney U test or Fisher exact test ( P < 0.05 ) . Results : Patients with EWB were full weightbearing at 7 ± 3 weeks and returned to work at 8 ± 5 weeks after surgery . At follow-up ( mean , 20 ± 11 months after surgery ) , all EWB patients showed good results in the Olerud score ( 90 ± 13 points ) . Matched-pair analysis in 23 patients in each group revealed differences between EWB and 6WC groups for hospital stay ( mean , 10.8 ± 4.7 vs. 13.6 ± 6 days ; P = 0.12 ) , time to full weightbearing ( mean , 7.7 ± 3.1 vs. 13.5 ± 9.4 weeks ; P = 0.01 ) , and time until return to work ( mean 9.2 ± 5.5 vs. 10.8 ± 7 weeks ; P = 0.63 ) . No differences concerning pain intensities were observed ( EWB vs. 6WC : NRS = 1.9 vs. 1.7 ; P = 0.12 ) . At follow-up , Olerud scores were generally considered good for both groups ; however , mean values in EWB patients were slightly higher ( 87 ± 14 vs. 79 ± 19 points ; P = 0.25 ) . In both groups , the majority of patients reached their preinjury level of activity as demonstrated by Tegner scores . Conclusions : EWB patients tolerated earlier full weightbearing compared with 6WC patients , and there were no disadvantages with EWB compared with 6WC concerning hospital stay , pain intensities , time until return to work , and Olerud/Tegner Scores . Potential c and i date s for EWB are patients with a stable osteo synthesis of their fractured ankles as judged by the responsible surgeon , compliance , and high motivation 40 patients with dislocated bimalleolar and trimalleolar ankle fractures took part in this r and omized study . All ankles were operated on using cerclage , staples and pins . Active ankle movement with weight bearing in an orthosis was compared with active ankle movement without weight bearing using a dorsal splint . Stereophotogrammetric analysis showed small movements in the ankle mortise in both groups but conventional radiography revealed no fracture redislocation . The clinical results did not differ . This study was design ed as the second part of a consecutive project . In the first part , early and late weight bearing in a cast without ankle movements was compared ( Ahl et al. 1987b ) . In comparing the first and the second parts of the study , a small but significant increase in fracture instability was observed in the early motion group . No lasting superior clinical result was achieved by early ankle movement . After operation on dislocated bimalleolar ankle fractures , early postoperative weight bearing in a walking cast is recommended INTRODUCTION Ankle fractures are common and ' stable ' ankle fractures comprise 40 - 75 % of this group . Studies show that these injuries can be managed successfully in a functional brace , with no need for further radiographs and minimal out-patient follow-up . We aim ed to audit current practice and introduce change in order to improve treatment and produce financial savings . PATIENTS AND METHODS A retrospective 6-month audit was carried out to establish practice . Guidelines were then drawn up and widely distributed in the accident and emergency ( A&E ) and orthopaedic departments . These included criteria for diagnosis of stable ankle fractures , a management protocol for treatment of these injuries in a brace and also a follow-up algorithm in the out-patient clinic . A prospect i ve 6-month audit was then carried out to assess the effectiveness of the guidelines . RESULTS Of patients presenting in the second 6-month period , 91 % were managed in a functional brace . The mean number of out-patient follow-up appointments , weeks until discharge and repeat radiographs all decreased significantly ( P < 0.05 ) after the implementation of the guidelines . The cost of treating a patient with a stable ankle fracture  dropped from 310.75 pounds to 129.80 pounds . CONCLUSIONS Previous studies have shown that stable ankle fractures are more effectively treated in a functional brace than a plaster cast , do not displace and , therefore , do not need repeat radiographs . A previous audit demonstrated that 60 % of patients with stable fractures could be treated in a brace . We have shown that , with effective and persistent education of colleagues , the vast majority ( 91 % ) of patients can be managed in this way and this results in a significant cost saving . We have also shown that an evidence -based treatment protocol can produce significant improvements in management for patients and savings for healthcare organisations Fifty-one patients with dislocated lateral malleolar fractures took part in this prospect i ve r and omized study . Active ankle movements with weight bearing in an orthosis were compared with active ankle movements without weight bearing using a dorsal splint . By using cerclage , staples , and pins ( Cedell 1967 ) , an exact reconstruction of the ankle mortise was achieved in 44/51 ankles .  Radiographic and stereophotogrammetric analyses at 3 months showed no redislocation and only small movements in the ankle mortise . Better loaded dorsal flexion capacity at 3 months was found in the orthosis group . This study was design ed as the second part of a consecutive study . In the first part , early or late weight bearing without ankle exercises was compared ( Ahl et al. 1986 ) . The results from the two consecutive parts indicate that active ankle movements in combination with weight bearing facilitate and improve the rehabilitation following operation for an ankle fracture In a prospect i ve , r and omised trial of 81 patients with fractures of the ankle of AO types A , B and C we compared two regimes of postoperative management after internal fixation . The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster . We found a temporary benefit in subjective evaluation only ( 65 v 50 points , Mann-Whitney test , cft , p=0.02 ) for those with a below-knee walking plaster . There were no significant differences between the groups in the loaded dorsal range of movement ( 25 degrees v 23 degrees , Mann-Whitney test , cft , p = 0.16 ) or in the overall clinical result . Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing , wound healing , the type of work and personal preference Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more In a prospect i ve , r and omized study , 30 patients were evaluated after ankle fracture treated by means of open reduction and internal fixation . The patients were r and omized to either postoperative immobilization in a plaster cast for 6 weeks or early mobilization ( 1–2 weeks after surgery ) in an ankle brace . Both regimens allowed weightbearing . Evaluation after 10 weeks and after 12 months included clinical assessment and isokinetic muscle strength measurements . Patients with impaired ankle function , as shown by means of an ankle score at 12 months , were followed for 3 years . At 10 weeks , impaired muscle torque and restricted range of motion was found on the affected side . This impairment was significantly less in the brace group . At 12 months , range of motion of the ankle and subtalar joints was restored , but dorsiflexion was still better in the brace group . Score values from a functional score did not correlate with muscle strength The effect of early mobilization and unrestricted weight bearing on final ankle motion in 51 operatively stabilized ankle fractures was prospect ively investigated . Patients were treated with an ankle-foot orthosis ( AFO ) or a cast . Full weight bearing was unrestricted in both groups . Thirty-two fractures received an AFO and 19 received a cast . The follow-up period ranged from 2.3 to 66 months , with a median of eight months . At the final follow-up examination , the motion in the AFO-treated group was not functionally different from that of the cast-treated group . However , 72 % of the patients treated in an AFO compared with 37 % of patients treated in a cast had ankle dorsiflexion greater than 15 degrees ( p = 0.014 ) . No complications were directly related to the AFO . No loss of reduction occurred in any patient . The results of this series indicate that early motion of a fractured ankle treated operatively does not affect ankle motion . Early motion was not associated with increased morbidity or loss of reduction In a monocenter r and omized controlled trial , 45 patients with isolated malleolar fracture type OTA/AO 44 A1–B2 undergoing ORIF were allocated r and omly to a postoperative treatment either with a vacuum-stabilized orthesis with prescribed full weight bearing after the second week ( 23 patients ) ( orthesis group — OG ) or with functional aftertreatment with partial weight bearing of 15 kg for 6 weeks ( 22 patients ) ( control group — CG ) . Outcomes were compared at 6- and 10-week follow-up examinations . The Olerud and Mol and er ankle ( OMA ) score , ankle swelling , usage of crutches , range of motion , Short Form 12 , patient-reported visual analogue scales ( VAS ) ( pain , comfort , walking confidence ) and time to return to work were evaluated . All patients of OG showed reduced swelling at discharge . The median OMA scores after 6 weeks were 42 and 42.5 ( p = 0.46 ) and after 10 weeks 69 and 72 ( p = 0.55 ) in the OG and CG , respectively . The time to achieve secure walking capacity was reduced by 1 day ( p = 0.03 ) in the OG . After ORIF of simple malleolar fractures , patients with a vacuum-stabilized orthesis can bear full weight 2 weeks postoperatively . This group experienced no adverse events . Postoperative swelling was significantly reduced and of the ability to walk on stairs confidently was shorter as compared to a functional aftertreatment without any external stabilization of the ankle We r and omised prospect ively 60 consecutive patients who were undergoing internal fixation of similar fractures of the ankle into two groups , one of which was treated by immobilisation in a below-knee cast and the other by a functional brace with early movement . All were instructed to avoid weight-bearing on the affected side . They were seen at 6 , 12 , 26 and 52 weeks . The functional rating scale of Mazur et al was used to evaluate the patients at each follow-up and we recorded the time of return to work . After one year the patients completed the SF-36 question naire . By then 55 patients remained in the study , 28 ( mean age 45.5 years ) in group 1 and 27 ( mean age 39.5 years ) in group 2 . Those in group 2 had higher functional scores at each follow-up but only at six weeks was this difference significant ( p = 0.02 ) . They also had higher mean SF-36 scores , but this difference was significant only for two of the eight aspects investigated . For patients gainfully employed , not on workers ' compensation , the mean time from surgery to return to work was 53.3 days for group 2 and 106.5 days for group 1 ; this difference was significant ( p = 0.01 ) . No patient developed a problem with the wound or had loss of fixation . Our findings support the use of a functional brace and early movement after surgery for fractures of the ankle Fifty-three patients with dislocated lateral malleolar fractures were r and omly selected after operation for either active ankle movement and weight bearing in an orthosis or no ankle movement but weight bearing in a walking cast . At follow-up examinations after three , six , and 18 months , no differences were found between the groups except for a better linear analogue scale result at three months for the orthosis group . Active ankle movements 
    Output:
    
INTERPRETATION Results of this meta- analysis show that following  ankle surgery , 1 ) active exercises accelerate return to work and daily activities compared to immobilization , 2 ) early weight-bearing tends to accelerate return to work and daily activities compared to late weight-bearing .
Active exercises in combination with immediate weight-bearing may be a safe option