Twenty-four randomized controlled trials including 2,082 patients undergoing primary total hip arthroplasty were included in this systematic review and meta-analysis comparing hydroxyapatite-coated femoral stems vs. non-hydroxyapatite-coated femoral stems. Pooled outcomes of interest included Harris Hip Score, endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, thigh pain, and heterotopic ossification. The pooled results showed significantly fewer revisions for aseptic loosening and decreased postoperative thigh pain for patients with hydroxyapatite-coated stems. There were no significant differences in other outcomes. The findings suggest that hydroxyapatite-coated femoral stems may be preferred for reducing aseptic loosening and thigh pain in primary total hip arthroplasty.