Femoral neck fractures, a type of hip fracture, are a common and disabling injury, particularly given an ageing population in many countries. Throughout the past half-century, multiple different treatments have evolved for the treatment of these fractures, and these include sliding hip screws, cannulated screws, hemiarthroplasty (HA), and total hip arthroplasty (THA). Given that femoral neck fractures have the potential to compromise blood flow to the femoral head, arthroplasty options have gained prominence in recent years. However, it remains unclear which of the two options (THA or HA) is optimal in this population. Thus, in this definitive, landmark randomized controlled trial, which is by far the largest of its kind to date, the investigators randomized 1495 patients 50 years of age older with a displaced femoral neck fracture to undergo HA or THA. The trial was conducted across 80 centres in 10 different countries. Primary outcome was a secondary hip procedure within 24 months. Secondary endpoints included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health. There was no significant difference between the two groups in terms of revision rate, mortality, serious adverse events, revision procedures, EQ-5D, timed up and go test, or Short-Form 12 scores. There was a trend toward higher dislocation rates in THA, though this was not statistically significant. There was a significant difference in favour of THA on the WOMAC total and sub-scores, though this difference fell below the minimal clinically important threshold. Overall, in the absence of a convincing indication for THA, HA is a comparable treatment for femoral neck fracture which does not result in a significant difference in revision rate. There may be a slightly higher rate of serious adverse events with THA, and slightly better function with THA, though these differences may not reach clinical significance.