In the late 1970s, we started the clinical use of total knee prostheses (TKPs) composed of alumina ceramic. In this study, we investigated the long-term clinical performance of ceramic TKPs. First-generation ceramic TKPs were used between 1981 and 1985; second-generation TKPs, between 1990 and 1996 and third-generation TKPs, between 1993 and 1998. We examined the findings of clinical radiographic observation. A total of 137 first-generation ceramic TKPs were followed up for 20–23 years after implantation. All the rates of loosening, sinking and revision were higher with cementless fixation than with cemented fixation. In the second- and third-generation TKPs, all the components were implanted using bone cement. In 249 joints that were followed up for 6–14 years, neither loosening nor sinking was observed. No osteolysis was observed in any case. We compared the wear of metal TKPs and ceramic TKPs that were retrieved after long-term use. Metal TKPs exhibited a higher wear rate than ceramic TKPs, and they also exhibited scratched surface damages. The lower wear rate and considerably less surface damage observed in our previous study suggest the long-term durability and performance of ceramic TKPs.