Operative vs. nonoperative management of acute complete distal biceps tendon ruptures: a systematic review

Background Acute complete distal biceps tendon ruptures are usually repaired, but conservative treatment remains an option in selected patients and comparative outcomes are incompletely defined. Hypothesis We hypothesized superior strength but higher complication rates after surgery, with comparable pain, range of motion (ROM), and patient satisfaction. Study design Systematic review. Methods PubMed/MEDLINE, Embase, and the Cochrane Library were searched from inception to September 2026 according to PRISMA for studies of conservative or surgical treatment of acute complete ruptures. Acuity was defined a priori at cohort level (mean or median injury-to-treatment interval 3 weeks or less). Given heterogeneity, data were synthesized descriptively in accordance with the Synthesis Without Meta-analysis (SWiM) guidelines; proportions are reported with exact 95% confidence intervals (CIs). Results In total, 11 studies (Level III–IV, 425 patients, 432 ruptures) were analyzed; 387 ruptures were treated operatively and 45 nonoperatively. Pain, patient-reported outcomes, and ROM were comparable and favorable in both groups. Pooled mean strength deficits after repair were 3.2% (flexion) and 5.7% (supination) versus 14.0% and 23.3% nonoperatively (three cohorts, 39 patients). Complications occurred in 91 of 387 operative ruptures (23.5%; 95% CI: 19.4–28.1), predominantly transient nerve injuries, and in none of 45 nonoperative ruptures (0%; 0–7.9). Groups were markedly unbalanced and nonrandomized; all comparisons are therefore descriptive. Conclusion Based on this low-certainty retrospective evidence, both treatments yielded acceptable outcomes in terms of pain, ROM, and patient-reported function, whereas supination strength was more consistently restored after repair and complications occurred almost exclusively after surgery. Given the small number of nonoperative ruptures ( n = 45), these findings are hypothesis-generating, and treatment should be individualized through shared decision-making.