Background <p>The optimal management of nondisplaced femoral neck fractures in very elderly patients remains controversial. Although hip arthroplasty is frequently advocated, internal fixation with cannulated screws may represent a less invasive alternative in carefully selected patients.</p> Methods <p>A retrospective single-centre cohort study was conducted including patients aged 80 years or older with nondisplaced femoral neck fractures treated with cannulated screw fixation between 2010 and 2019. Primary outcomes were fixation failure and conversion to hip arthroplasty. Secondary outcomes included reoperation rate, radiographic fracture collapse, ambulatory status, weight-bearing protocol, and radiographic measurements related to screw positioning.</p> Results <p>A total of 170 patients were included, with a mean age of 86.9 years. Fixation failure occurred in 17 patients (10%). Reoperation for any cause was required in 15 patients (8.8%), and conversion to hip hemiarthroplasty was performed in 6 patients (3.5%). Radiographic fracture collapse was observed in 46 patients (30%), although only 7 patients (15.2%) required reoperation. Immediate full weight-bearing was not associated with increased fixation failure or fracture collapse and was associated with improved ambulatory status at 6 months. Greater femoral head occupancy on lateral radiographs was associated with fracture collapse, whereas tip–apex distance was not.</p> Conclusions <p>In carefully selected patients older than 80 years with nondisplaced femoral neck fractures, cannulated screw fixation was associated with low rates of fixation failure and conversion to hip arthroplasty. Immediate full weight-bearing did not increase complication rates and was associated with improved early mobility, supporting a less invasive treatment strategy in this super-aged population.</p>