Abstract:[Objective] To compare the long-term clinical outcomes of femoral neck system (FNS) versus four cannulate compression screws (CS) for femoral neck fracture. [Methods] From September 2018 to June 2021, a total of 45 patients with femoral neck fracture were included in this study. According to doctor-patient communication, 22 patients received FNS internal fixation, while the remaining 23 pa- tients underwent CS internal fixation. The perioperative, follow-up and imaging data were compared between the two groups. [Results] All the patients in both groups had corresponding surgical procedures performed successfully. The FNS group was significantly less than the CS group in terms of operative time [(54.6±18.0)min vs (84.3±33.3)min, P=0.001] and intraoperative fluoroscopy times [(17.3±4.2)times vs (24.3±6.3)times, P＜0.001], whereas the former was significantly greater than the latter in terms of incision length [(5.4±0.6)cm vs (4.6±0.7) cm, P＜0.001] and intraoperative blood loss [(132.4±50.9)ml vs (47.0±15.7)ml, P＜0.001]. All patients were followed up for 15~46 months, with a mean of (29.5±15.2)months. The FNS group returned to full weight-bearing activity significantly earlier than the CS group [(5.5±1.2) months vs (7.7±4.2)months, P=0.029]. The Harris score, hip extension-flexion ROM and hip internal-rotation ROM were significantly in- creased in both groups over time (P＜0.05). By the latest follow-up, the FNS group had significantly lower incidence of late adverse events, including internal fixation displacement, femoral neck shortening, fracture nonunion, and femoral head necrosis, than the CS group [7/22 (31.8%) vs 15/23 (65.2%), P=0.027]. The former had low rate of total hip replacement revision than the latter, despite of that the difference was not statistically significant [4/22 (18.2%) vs 8/23 (34.8%), P=0.563]. In terms of imaging, Garden index was significantly improved in both groups at the last follow-up compared with the preoperative period (P＜0.05). At the last follow-up, the FNS group got significantly low- er incidence of adverse imaging changes than the CS group (P＜0.05). The Tonnis grade of hip degeneration tended to increase over time in both groups, but the difference was not statistically significant (P＞0.05). [Conclusion] The FNS used as internal fixation for femoral neck fracture in young and middle-aged does considerably be superior to the CS regarding fracture healing and late adverse events.