Treatment of displaced femoral neck fractures with total hip replacement (THR) in appropriately selected patients has become more widely accepted. The use of the posterior approach for THR remains controversial due to concerns regarding dislocation, the cause of which is multi-factorial. This study is a single surgeon series of 45 consecutive active, healthy patients (mean age 78 years) with displaced femoral neck fractures treated with THR through a posterior approach. Large diameter heads (32mm in 47%, ≥36mm in 48% of patients) and an anatomic posterior soft tissue repair were utilised to minimize the risk of dislocation. Outcomes were reported at a mean of 2 and 6 years. The mortality rate was 13% at 2 years and 40% at 6 years. All revision surgery (4.4%) was performed for dislocations which occurred in 6.7% of patients. Good VAS pain, OHS and SF-12 scores were reported both at 2 and 6 years. Patient satisfaction with the results of surgery was high.