OBJECTIVE The purpose of this study was to evaluate the diagnostic performance of magnetic resonance imaging (MRI) guided musculoskeletal biopsy and the value of fine needle aspiration biopsy (FNAB) when combined with histologic biopsy. METHODS A total of 172 biopsies were performed under MRI guidance, 170 were histologic biopsies. In 112 cases, a fine needle aspiration biopsy was also performed. In two cases, a stand-alone FNAB was performed. The diagnostic performance was evaluated retrospectively by comparing the histopathologic and cytologic diagnosis with the current or final diagnosis after at least one year of clinical and imaging follow-up. A 0.23 T open MRI scanner with an interventional stereotactic guidance system was used. RESULTS The overall diagnostic accuracy of MRI guided biopsy was 0.95, sensitivity 0.91, specificity 0.98, positive predictive value (ppv) 0.97 and negative predictive value (npv) 0.93. The diagnostic accuracy of trephine biopsy alone was 0.93, sensitivity 0.89, specificity 0.98, ppv 0.97 and npv 0.91 and accuracy for FNAB alone was 0.85, sensitivity 0.80, specificity 0.90, ppv 0.89 and npv 0.82. CONCLUSIONS MRI guidance is a feasible and accurate tool in percutaneous musculoskeletal biopsies. Fine needle biopsy is a useful low-cost supplement to histologic biopsy.