245 patients with OTA type 42 and 43A fractures were randomized to receive either infrapatellar (n=117) or suprapatellar intramedullary nailing (n=128). The primary outcome of interest was Visual Analog Scale (VAS) kneeling scores. Secondary outcomes of interest included patient-blinded Aberdeen Kneeling (AKT), Aberdeen Standing (AST), weight distribution, Lysholm scores, Photographic Knee Pain Map (PKPM), EuroQoL 5 Dimensions (EQ-5D), knee range of motion (ROM), Work Productivity and Activity Impairment Questionnaire (WPAI), fracture reduction, tibial alignment, and union rates. Suprapatellar nailing showed significantly better VAS kneeling scores up to one year compared to infrapatellar nailing. Suprapatellar nailing also showed significantly more weight distribution and anatomic fracture reduction. All other outcomes were similar between the 2 groups.