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Purpose: Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice. Methods: A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand). Results: For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries. Conclusions: Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved. [ABSTRACT FROM AUTHOR]