Abstract: Abstract: Background Femoral neck fractures exhibit a high incidence rate and are associated with a significant risk of avascular necrosis of the femoral head. However, the confined space available for closed reduction and minimally invasive screw fixation poses considerable technical challenges. The complexity of the procedure increases the likelihood of screw cut-out into the joint capsule, potentially resulting in severe complications. Consequently, the precise placement of screws through closed minimally invasive techniques remains a critical clinical challenge.Objective To compare the efficacy of remote interactive surgery with freehand percutaneous nailing for the treatment of femoral neck fractures.Methods Clinical data about patients with femoral neck fracture admitted to the Department of Trauma Orthopaedics, Department of Orthopaedic Medicine, Chinese PLA General Hospital from January 2023 to June 2024 were retrospectively analyzed. According to the methods, patients were divided into tele-surgery group (treated by telesurgery) and freehand nailing group (freehand nailing). The operation time, intraoperative bleeding, number of intraoperative guide pin adjustments, number of intraoperative fluoroscopy, fracture healing time, Harris score of hip function and postoperative complications were compared between the two groups. Results A total of 30 patients were included, including 15 patients in the telesurgery group, 10 males and 5 females, aged (48.20±14.09) years old; 15 patients in the freehand nailing group, 9 males and 6 females, aged (47.33±16.44) years old, and the differences in age and gender between the two groups were not statistically significant (P＞0.05). The operation duration (1.70±0.24 h vs 2.19±0.63 h, P=0.008) and intraoperative haemorrhage (23.67±9.35 mL vs 55.00±36.29 mL, P=0.004) in the telesurgery group were lower than that in the freehand pinning group. The differences in the number of guide pin adjustments (1.93±0.88 vs 6.33±2.77) and the number of intraoperative fluoroscopies (5.13±1.35 vs 11.67±4.04) between the two groups were statistically significant (both P<0.01). Both groups were followed up, and the postoperative fracture healing time in the telesurgery group was lower than that in the unarmed nailing group (17.00±2.33 weeks vs  25.00±2.85 weeks), and the Harris score was higher than that in the unarmed nailing group (82.73±6.31 vs 72.27±12.52), with statistically significant differences (both P<0.01). In postoperative complications, 3 cases of partial screw cut-out were observed in the freehand screw placement group, resulting in mechanical instability at the fracture site and subsequent delayed union, whereas all