Despite the tremendous advances in the science and practice of orthopaedic surgery, anesthesia, and perioperative care, repair of displaced fractures of the neck of the femur is still associated with complications in up to one third of patients. The risk of nonunion and osteonecrosis in particular is virtually the same today as in the 1930s. Recent data from well-designed outcome studies now indicate that the most predictable, durable, and cost-effective procedure for an active elderly patient with a displaced femoral neck fracture is total joint arthroplasty; however, not all patients are candidates for this procedure, and the potential complications of arthroplasty, including mortality, may be more difficult to manage and more severe than those associated with internal fixation. The laudable goal of obtaining fracture healing and maintenance of a viable femoral head can be successfully achieved in a number of patients.