Sixty patients with extra-articular tibial shaft fractures were randomized to suprapatellar nailing (n=30) or infrapatellar nailing (n=30). The primary outcomes were clinical (knee pain VAS; knee ROM), functional (Knee Society Score, Lysholm, KOOS-PF), and radiological union (mRUST/alignment). Secondary outcomes included operative time, intra-operative blood loss, radiation exposure, and number of C-arm shots. Outcomes were assessed repeatedly to 24 months. Overall, the results of the study revealed no between-group differences in pain, ROM, functional scores, union, or alignment, but suprapatellar nailing had a shorter operative time and lower blood loss. These findings suggest the suprapatellar approach can streamline surgery without compromising medium-term clinical or radiographic results.