AIM: Elderly patients with displaced femoral neck fractures present significant treatment challenges, with total hip arthroplasty (THA) and hemiarthroplasty (HA) being common surgical options, each with distinct benefits and limitations. This retrospective study aimed to compare the mid- and long-term outcomes of THA and HA in elderly patients using a propensity score–matched analysis. METHODS: Clinical data from 147 patients treated between January 2018 and April 2022 were analyzed, including 46 who underwent THA and 101 who underwent HA. After 1:1 propensity score matching, 46 pairs were compared with respect to operative time, blood loss, postoperative hospital stay, hospitalization costs, nutritional indices, complications, and hip function. RESULTS: The THA group demonstrated significantly longer operative times (80.04 ± 23.85 minutes vs. 59.07 ± 18.01 minutes, p < 0.001), greater blood loss (830.50 ± 127.55 mL vs. 600.44 ± 116.50 mL, p < 0.001), and higher hospitalization costs (32,499.50 ± 9803.48 CNY (≈ 5030.29 ± 1517.56 USD) vs. 25,699.51 ± 7399.50 CNY (≈ 3977.26 ± 1145.52 USD), p < 0.001) compared to the HA group. No significant difference was observed in postoperative hospital stay between the groups (p = 0.488), but the incidence of postoperative pain was significantly higher in the HA group (32.61% vs. 6.52%, p = 0.002). At 6 and 12 months postoperatively, Harris Hip Scores were significantly higher in the THA group (p < 0.001). No significant differences were observed in the overall rate of postoperative complications (p = 0.625). CONCLUSIONS: THA offers superior long-term outcomes compared to HA in elderly patients with displaced femoral neck fractures. However, HA may be more appropriate for patients with poor general health.