The ideal bearing surface for total hip arthroplasty still is being sought. This bearing would be durable, cost-effective, easy to implant, inert, and produce minimal wear debris. Ceramic-on-ceramic bearings have continued to evolve and have enjoyed success in many European centers throughout the past 3 decades. A limited number of early reports from the United States discouraged widespread acceptance and use of ceramic-on-ceramic total hip arthroplasty. Once critically analyzed most of the failures from the early reports are attributable to design and material specific flaws. Vast improvements have been made in ceramic manufacturing leading to even more superior wear characteristics and higher burst strengths. The case for alumina-on-alumina ceramic bearings is becoming stronger as data accumulate clinically and in vitro. In a multicenter, prospective and randomized study, an alumina-on-alumina ceramic bearing is compared with a cobalt chrome-on-polyethylene bearing. After as many as 48 months there has been no significant difference in clinical performance between the two study groups. No ceramic head fracture or ceramic bearing failure has occurred. Therefore, this new alumina-on-alumina ceramic bearing is a safe option for total hip arthroplasty and may provide a more durable prosthesis especially in young and active patients.