BACKGROUND The outcomes of using a ceramic-on-ceramic (CoC) vs ceramic-on-polyethylene (CoP) bearing surface for primary total hip arthroplasty (THA) are much debated. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) to compare and evaluate the outcomes of these 2 bearing surfaces. METHODS Electronic databases (PubMed/Medline, CENTRAL, Embase and Web of Science) were systematically searched for RCTs investigating the association between bearing surfaces and outcomes following primary THA. Two investigators independently reviewed studies for eligibility, assessed the risk of bias, extracted and analysed the data. RESULTS In total, 13 RCTs including a total of 2,488 THAs were identified. The Harris Hip Score appeared to be similar between CoC and CoP THAs. The acetabular liner wear rate was lower in CoC than CoP THA, but the meta-analysis showed that the incidence of component-related noise and overall ceramic fracture in CoC group were 14.73 times and 6.02 times higher than CoP THA, respectively. There were no statistically significant differences in rates of radiolucent line formation (>1 mm), osteolysis, loosening, revision with follow-up ≥ 5 years, intraoperative femoral fracture, dislocation, deep infection, deep venous thrombosis and leg length discrepancy between CoC and CoP THAs. CONCLUSIONS There appears to be no clear evidence favouring the use of either a CoC or CoP bearing surfaces in primary THA, further studies with high-quality and longer term follow-up to provide more evidence on this topic are still required.