162 patients scheduled for intramedullary nail fixation following a tibial shaft fracture were randomized to nail insertion via a suprapatellar approach (SPA) or an infrapatellar approach (IFA). Clinical scores and radiological assessment of union, patellofemoral cartilage changes and any incident of articular injury were assessed over a 24-month follow-up. From 6 to 24 months, the SPA group demonstrated significantly lower pain scores compared to the IFA group. Also from 6 to 24 months, functional outcome via either the Lysholm score or the SF-36 Physical component score was significantly higher in the SPA group compared to the IFA group.