Currently, there are several femoral stem designs available for use, but few have an extended track record. We have previously reported on 10- and 15-year outcome studies of total hip arthroplasty (THA) using a cemented normalized and proportionalized femoral stem from a single surgeon series. This is a follow-up study reporting the minimum 20-year outcome of this femoral stem design. The study began with THA performed in a consecutive series of 184 patients; stem fixation was achieved using first-generation cementing techniques. The overall early complication rate was 10%. There were 23 patients (31 hips) who had been followed-up for a minimum 20-year period (average 21.3 years). Mean d'Aubigne and Postel scores improved from 5.9 to 11.3; mean Harris hip scores improved from 43.8 to 92.8. Kaplan-Meier survivorship was 93% at 20 years (95% confidence interval); there were no stem failures. The use of a cemented normalized and proportionalized femoral stem in primary THA provides satisfactory long-term clinical and radiological outcomes in patients.