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The biological problems related to wear debris after total hip arthroplasty have stimulated renewed interest in alternatives to metal-on-polyethylene bearing surfaces.We retrospectively evaluated the clinical and radiographic results of 100 patients who had undergone a total of 109 primary total hip arthroplasties with a cementless alumina ceramic-on-ceramic prosthesis between January 1985 and December 1989. The mean age of the patients at the time of the index arthroplasty was forty-six years. Clinical evaluation was performed with use of the Charnley modification of the Merle d'Aubigné-Postel scale. Seventy-eight patients who had had a total of eighty-five arthroplasties were available for follow-up evaluation at an average of 20.8 years. The patients’ average age at the time of the latest follow-up was 66.8 years.Six hips (six acetabular cups and one femoral stem) in six patients underwent revision. Aseptic loosening of the cup combined with focal osteolysis was the cause of all six revisions. In one patient, the stem was also revised because of aseptic loosening. At the time of final follow-up, the result was excellent (according to the Merle d'Aubigné-Postel scale) in 68% of the hips, good in 19%, fair in 9%, and poor in 4%. The mean Merle d'Aubigné-Postel score improved from 7.9 points preoperatively to 16.9 points postoperatively (p < 0.001). The cumulative rate of survival of the prostheses was 84.4% at 20.8 years.The results of these cementless ceramic-on-ceramic total hip arthroplasties continued to be satisfactory at a minimum of twenty years postoperatively. The improved design of contemporary prostheses and the new generation of ceramic-on-ceramic bearing surfaces may lead to even better long-term results.Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.