Objective To investigate the clinical efficacy of strong oblique low position cannulated screw combined with sartorius muscle bone flap in the treatment of senile Garden Ⅲ and Ⅳ femoral neck fracture. Methods A total of 86 elderly patients with Garden Ⅲ and Ⅳ femoral neck fractures admitted in our department from June 2016 to August 2017 were recruited and randomly divided into control group (n=43) and study group (n=43). The patients of the control group were treated with conventional parallel compression cannulated screw internal fixation, and those of the study group were treated with strong oblique low tension cannulated screw combined with sartorius muscle bone flap. The intraoperative indices, visual analogue scale (VAS) score, Harris hip function score and incidence of adverse events were compared between the 2 groups. SPSS statistics 22.0 was used for data analysis. Student′s t test or Chi-square test was employed for comparison between groups. Results The control group had significantly shorter operation time [(72.56±10.48) vs (84.17±12.33)min] and less intraoperative bleeding [(125.48±11.52) vs (164.72±14.89)ml] than the study group (P<0.05). The VAS score was significantly lower in the study group than the control group on the 5th day [(4.82±1.02) vs (5.69±1.07)] and 10th day [(3.28±0.85) vs (4.34±0.94)] after operation (P<0.05). The Harris score was obviously higher in the study group than the control group in 1 month [(58.79±4.28) vs (51.25±3.63)], 3 months [(78.46±6.47) vs (70.54±5.89)] and 6 months after surgery [(84.07±6.98) vs (79.22±6.51), P<0.05]. The incidence of adverse events was notably higher in the control group than the study group [48.83%(21/43) vs 20.93%(9/43), χ²=7.371, P=0.007]. [JP+1]Conclusion Strong oblique low position cannulated screw fixation combined with sartorius muscle bone flap can effectively reducepostoperative pain, improve joint function and reduce the incidence of adverse events in the elderly patients with Garden Ⅲ and Ⅳ femoral neck fractures.