One hundred and sixteen patients (140 hips) scheduled for a primary total hip arthroplasty (THA) were randomized to receive a ceramic-on-ceramic (alumina) bearing (n=71 hips) or a metal-on-conventional polyethylene bearing (n=69 hips). The outcomes of interest included implant survivorship, measured by the aseptic revision rate and Kaplan Meier survivorship estimator, the mean time to aseptic revision, the incidence of osteolytic signs, the incidence of adverse events, Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index scores, and Joint Perception scores. Outcomes were assessed at 20 years post-operation. Results revealed statistically significantly favourable aseptic revision rates (3% vs 25%, p<0.001), Kaplan Meier survivorship (96.9% vs 73.6%, p<0.001), and WOMAC scores (11.0 vs 19.4, p=0.048) in the ceramic bearing group compared to the metal bearing group. Moreover, the incidence of periarticular osteolytic signs was statistically significantly lower in the ceramic bearing group compared to the metal bearing group (6.1% vs 60.9%, p<0.001). Finally, the mean time to aseptic revision was 12.9 years in the metal bearing group and 11.5 years in the ceramic bearing group. In addition, 3 cases of dislocation were observed in the metal bearing group.