Objectives: This study aims to evaluate whether adding internal fixation to grafting could improve radiological and functional outcomes compared to grafting alone in patients with aneurysmal bone cysts (ABCs) of the proximal femur and to investigate whether there was a significant difference between these two treatment methods in terms of the need for a second surgery. Patients and methods: Between January 2012 and January 2022, a total of 30 patients (21 males, 9 females; mean age: 13.7±5.1 years; range, 5 to 23 years) with proximal femur ABCs who underwent surgical treatment were retrospectively analyzed. Twelve of them were treated by grafting alone (Group GA), while the remaining 18 were treated by grafting along with fixation using plates and screws (Group GF). The demographic data of these patients, the need for secondary surgery, radiological and functional scores were recorded. The modified Neer Classification was used for radiological evaluations, while the Musculoskeletal Tumor Society (MSTS) scores were utilized for functional assessments. Results: Overall, the mean preoperative MSTS scores were lower than the postoperative MSTS scores in both GF and GA groups (p<0.001 and p=0.002). The postoperative radiological scores of the GF group were superior to the GA group (p=0.012). However, no significant difference was found in the postoperative MSTS scores between the groups (p=0.185). Secondary surgeries were performed in six patients in the GF group due to implant removal and in three patients in the GA group due to recurrence. No significant difference was observed between the GF group and the GA group in terms of secondary surgery (p=0.626). Comparisons of final radiological (p=0.325) and final MSTS (p=0.346) scores after secondary surgeries revealed no significant differences. Conclusion: In proximal femoral ABCs, grafting with fixation may provide more favorable radiological outcomes with lower recurrence rates. While grafting with fixation seems to increase the risk for a secondary surgery due to implant removal, our study shows that recurrence in high-risk regions can also necessitate secondary surgeries with grafting alone. Notably, both approaches can achieve successful outcomes, even with recurrent surgeries.