Background: Tibial shaft fractures are among the most common long bone fractures encountered in orthopedic practice. The study aimed to compare the suprapatellar and infrapatellar approaches for intramedullary nailing (IMN) in tibial shaft fractures in terms of surgical outcomes, complications, and functional recovery.Material and Methods: This prospective interventional study included 100 patients diagnosed with tibial shaft fractures. Patients were randomly assigned to two groups: Group A (suprapatellar approach, n=50) and Group B (infrapatellar approach, n=50). Surgical parameters such as operative time, fluoroscopy time, and blood loss were recorded. Postoperative assessments included pain using the Visual Analog Scale (VAS), knee range of motion (ROM), time to union, complications, and functional outcomes based on the American Orthopaedic Foot & Ankle Society (AOFAS) score. Results: The suprapatellar approach resulted in significantly reduced operative time (62.5 ± 8.4 minutes vs. 70.3 ± 9.2 minutes, p = 0.03), fluoroscopy time (45.2 ± 6.3 seconds vs. 51.8 ± 7.5 seconds, p = 0.04), and blood loss (190.5 ± 30.2 mL vs. 210.8 ± 35.1 mL, p = 0.05) compared to the infrapatellar approach. Postoperative pain was lower in the suprapatellar group, with VAS scores of 4.2 ± 1.1 on the first day and 2.8 ± 0.9 at one week, compared to 5.1 ± 1.3 and 3.6 ± 1.0 in the infrapatellar group (p < 0.05). Knee ROM at six weeks was significantly better in the suprapatellar group (120 ± 10 degrees vs. 115 ± 12 degrees, p = 0.04). The mean time to union was shorter in the suprapatellar group (15.2 ± 2.3 weeks vs. 16.5 ± 2.6 weeks, p = 0.03). The complication rates were comparable between the two groups. At six months, the AOFAS score was higher in the suprapatellar group (85.2 ± 8.3 vs. 80.5 ± 9.1, p = 0.02), with a higher proportion of excellent outcomes (70% vs. 56%, p = 0.04).Conclusion: The suprapatellar approach for IMN in tibial shaft fractures demonstrated superior surgical efficiency, lower postoperative pain, improved knee ROM, faster fracture healing, and better functional outcomes at six months compared to the infrapatellar approach. Both techniques had similar complication rates, suggesting that the suprapatellar approach is a safe and effective alternative, particularly for proximal tibial fractures.