Five hundred eighteen patients undergoing primary total knee arthroplasty were randomized to receive highly cross-linked polyethylene (HXLPE) tibial inserts (n=264) or conventional ultra-high-molecular-weight polyethylene (UHMWPE) tibial inserts (n=254). The primary outcome of interest was implant survivorship free from revision or reoperation. Secondary outcomes included revision indications, radiographic results, and clinical outcomes. Outcomes were assessed over a mean follow-up period of 11 years. Overall, the results revealed no significant differences between groups in revision or reoperation rates, with 10-year survivorships of 96% (HXLPE) and 94% (UHMWPE). Notably, no wear-related failures or fractures occurred in the HXLPE group, while one case of osteolysis occurred in the UHMWPE group. These findings suggest equivalent long-term performance of HXLPE and UHMWPE in primary TKAs, with potentially lower wear-related risks for HXLPE.