Twenty-four patients ranging from 28 to 56 years of age with Garden grade III or IV fractures of the femoral neck are reviewed after treatment by intertrocherantic valgus osteotomy and Richards sliding compression hip screw. The rationale behind this treatment, the operative technique, and the choice of internal fixation device are all discussed. All patients were followed up after more than 2 years so that any late complications could be documented. The results were evaluated using both the Merle d'Aubigné procedure and radiographic examination: 12 (50%) were rated excellent, 5 (20.8%) good, 2 (8.4%) fair, and 5 (20.8%) poor. The unsatisfactory results are analyzed in detail, attributable to non-union in 2 cases (due to technical error), avascular necrosis in 4 cases (2 were limited and well-tolerated by the patients; 2 were early and massive and necessitated prosthetic replacement), and infection in one case. Even though valgus osteotomy and internal fixation fill a gap in the treatment of femoral neck fractures in adults by yielding good results with a conservative method, they are very demanding surgical procedures, requiring anatomical reduction, atraumatic technique, precise calculation of the valgus angle, and precise placement of the internal fixation device.