Three hundred thirty-one patients (n=165 FNS, n=166 CS with medial plate), aged 18–65 with femoral neck fractures, were randomized to receive either femoral neck system (FNS) or cannulated screws (CS) combined with a medial plate. The primary outcomes were bone union rate and Harris Hip Score (HHS). Secondary outcomes included Garden’s alignment index, surgical data, Barthel index, visual analogue scale (VAS) for pain, gait analysis, and complication rates. Follow-up assessments occurred up to 24 months postoperatively. Overall, the study found no significant differences in bone union rates or long-term hip function between groups. However, the FNS group showed faster functional recovery at 3 months and less pain at 1 month, while the CS with medial plate group had fewer cases of coxa vara. These findings suggest that both methods are effective, but each has distinct short-term benefits.