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We previously reported the seven and fifteen-year results of the use of a porous-coated acetabular metal shell inserted without cement in a consecutive series of 204 primary total hip arthroplasties. In the present study, we evaluated the longer-term outcomes of these arthroplasties at a minimum follow-up time of twenty years. One hundred and fourteen (92%) of the 124 hips available for study had retained the original acetabular metal shell. A total of five acetabular components had been revised for aseptic loosening or had radiographic evidence of definite loosening. Fourteen hips with well-fixed acetabular shells required a change of the modular acetabular liner because of excessive wear and/or for the treatment of osteolysis, and liner changes have been recommended for another eight hips. The twenty-year rate of survival of the metal shell, with failure defined as revision because of loosening or radiographic evidence of loosening, was 96% (95% confidence interval, 94% to 98%). Cementless acetabular reconstruction continues to provide durable fixation at twenty years postoperatively. Wear-related complications continue to be the major mode of failure.Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.