Objective: To explore the influence of artificial total hip arthroplasty via direct anterior approach (DAA) in lateral position on perioperative blood loss, imaging improvement and gait in elderly patients with femoral neck fractures. Methods: 116 elderly patients with femoral neck fractures admitted to the hospital from January 2023 to June 2025 were randomly classified into traditional group (total hip arthroplasty via direct lateral approach) and observation group (total hip arthroplasty via DAA) by random number table method, with 58 cases in each group. The surgical indexes of the two groups were recorded, and the imaging indexes ( ratio of acetabular cup in the safe area and length difference of both lower limbs) at 1 week and 1 month after surgery and gait (step speed, step frequency, step length difference, step length and step width) at 1 month after surgery were compared between the two groups of patients, and the incidence of complications within 3 months after operation was recorded. Results: Compared with traditional group, the intraoperative blood loss, surgical time and postoperative hospital stay in observation group were less or shorter (P<0.05), and the step speed, step frequency and step length at 1 month after surgery were higher (P<0.05) while the step length difference and step width were lower (P<0.05). At 1 week and 1 month after surgery, the ratio of acetabular cup in the safe area in observation group was higher (P<0.05) while the length difference of both lower limbs was lower (P<0.05), and the incidence of complications was lower at 3 months after operation (P<0.05). Conclusion: Total hip arthroplasty via DAA can reduce the trauma of elderly patients with femoral neck fractures, simplify the surgery, help to increase the ratio of acetabular cup in the safe area and reduce the length difference of both lower limbs, and accelerate the recovery of gait after surgery.