Although functional outcomes of hip joint reconstruction may be superior to those of internal fixation, differences in mortality between the 2 procedures are poorly defined. We conducted a retrospective study of patients 50 years and older with femoral neck fracture treated with joint reconstruction or internal fixation, performing adjusted logistic regressions to compare the odds of inpatient and 30-day mortality among patients according to surgery type. Of 12,867 patients with femoral neck fracture, 9001 had joint reconstruction and 3866 had internal fixation. After adjustment for patient factors alone, the odds of inpatient mortality were higher with reconstruction (OR, 1.62; 95% CI, 1.18-2.23; P=.003); however, the difference in the odds of 30-day mortality did not achieve statistical significance (OR, 1.18; 95% CI, 1.00-1.41; P=.053). Controlling for patient and hospital factors, we found higher odds of both inpatient mortality (OR, 1.65; 95% CI, 1.19-2.28; P=.003) and 30-day mortality (OR, 1.22; 95% CI, 1.02-1.46; P=.026) with reconstruction. Joint reconstruction is associated with a 60% increase in the odds of inpatient mortality after femoral neck fracture.