A retrospective study compared hemiarthroplasty (HA) and internal fixation (IF) in the treatment of femoral neck fractures in elderly patients. The study analyzed data from 192 patients, with 117 undergoing IF and 75 HA. The HA group had a lower incidence of postoperative complications and mortality. One year after surgery, the HA group showed better functional results and overall survival. Operative method, ASA score, number of comorbidities, and blood transfusion were identified as factors influencing postoperative mortality. IF, high ASA score and comorbidities were independent risk factors for postoperative death. The study suggests that HA may be associated with a better postoperative prognosis compared to IF.