Objective <p>Femoral neck fracture (FNF) is a common type of hip fracture, for which cannulated screw fixation is a primary internal fixation method. The optimal configuration for cannulated screw fixation remains controversial, with debate primarily focused on two approaches: parallel fixation configuration (PFC) versus non-parallel fixation configuration (NFC). The objective of this study was to compare the efficacy and safety of two configurations in the treatment of femoral neck fractures.</p> Methods <p>Following PRISMA guidelines, we systematically searched PubMed, Embase, the Cochrane Library, and CNKI for studies comparing PFC and NFC in FNF fixation. Study quality was assessed using the Cochrane risk-of-bias tool and MINORS scale. Outcomes included femoral head necrosis, nonunion, femoral neck shortening, and fixation failure. Meta-analysis was conducted in RevMan 5.3, employing a fixed-effects model unless heterogeneity (I² &gt; 50%) warranted an alternative approach.</p> Results <p>A total of 20 studies involving 1,508 patients were included in the meta-analysis. The meta-analysis showed that the NFC group had significantly better outcomes, including lower rates of femoral head necrosis (OR 0.50, 95% CI 0.34–0.74, <i>P</i> = 0.0005), nonunion (OR 0.41, 95% CI 0.26–0.65, <i>P</i> = 0.0001), femoral neck shortening (OR 0.40, 95% CI 0.28–0.57, <i>P</i> &lt; 0.00001), and internal fixation failure (OR 0.34, 95% CI 0.22–0.52, <i>P</i> &lt; 0.00001).</p> Conclusions <p>Our findings indicate that NFC is more effective than traditional PFC for internal fixation of FNFs.</p> <p><?qj left?><?noindent??><i>Level of evidence</i> Level III.</p>