Objective To investigate the clinical effect of total hip arthroplasty（THA）versus hemiarthro⁃ plasty（HA）through the direct anterior approach（DAA）for femoral neck fractures in elderly patients. Methods A total of 86 elderly patients with femoral neck fractures in our hospital from June 2019 to October 2020 were enrolled and assigned to total hip arthroplasty group（n = 41，THA group）and hemiarthroplasty group（n = 45， HA group）. The operation duration，intraoperative blood loss，time of first postoperative walking，duration of post⁃ operative hospitalization，central fixation of femoral prosthesis，limb length discrepancy，Harris hip score in 3 months，6 months and 12 months after the operation，and complications were compared between the two groups. Results Compared with the THA group，HA group had shorter operation duration，less intraoperative blood loss and higher ratio of limb length discrepancy shortened than 5mm，and the differences were statistically significant between the two groups（P < 0.05）. The Harris score in 12 months after the operation in the THA group were signif⁃ icantly higher than that of the HA group，and the difference was statistically significant（P < 0.05）. No significant difference was noted in time of first postoperative walking，duration of postoperative hospitalization，central fixation of femoral prosthesis，the ratio of limb length discrepancy shortened than 10mm，the Harris score in 3 months and 6 months after the operation，and the incidence of complications between the two groups（P > 0.05）. Conclusion Both THA and HA via DAA could achieve excellent short⁃term efficacy in the treatment of femoral neck fractures in elderly patients. But the long⁃term outcomes of THA were better than HA，the latter was featured by shorter opera⁃ tion time，less intraoperative blood loss and accurate limb length reconstruction.