A retrospective study compared early hip arthroplasty (≤48 hours after injury) in 77 patients older than 65 years with a Garden-IV femoral neck fracture versus delayed (>48 hours) in 91 patients in 2023–2024. Early surgery significantly reduced the 30-day composite complication rate (χ²=15.670, p<0.001, ARR=30.5%, 95% CI: 16.2–44.9%), especially hypoalbuminemia (3.9% vs. 24.2%, χ²=13.5302, p<0.001) and joint pain (1.3% vs. 24.2%). 11.0%, χ²=6.401, p=0.012). It shortened the length of stay by 4.6 days (t=-9.969, p<0.001) and reduced the postoperative drop in hemoglobin (115.43±15.03 vs. 98.04±18.48 g/l, t=6.609, p<0.001). At 1 month, the early group had a higher HHS score by 10.9 points (79.12±4.37 vs. 68.24±8.06, t=11.090, p<0.001) and FJS by 13.3 points (68.74±7.10 vs. 55.44±9.65, t=10.308, p<0.001), an advantage persisted after 3 months but disappeared after 6 months. GDS-15 scores were lower by 2.2–2.7 points at 1, 3, and 6 months (eg, 1 month: 5.40±3.77 vs. 7.62±2.49, t=-4.546, p<0.001) and IADL higher at all follow-ups (eg, 1 month: 26.29±11.39 vs. 34.37±3.75, t=-5.962, p<0.001). There were no differences in intraoperative blood loss, operative time, 90-day readmission, or 1-year mortality