Selection of biopsy technique for musculoskeletal lesions is complex. Fine-needle aspiration (FNA) is uncommonly used due to concerns regarding accuracy. We compared diagnostic accuracy of FNA, core, and open biopsy in a series of musculoskeletal lesions. Records of the University of Utah were searched for biopsy and resection specimens of musculoskeletal lesions. Results of corresponding imaging studies were obtained. Biopsy and FNA diagnoses were correlated with resection diagnoses. For each technique, diagnostic accuracy, utility, and frequency of subsequent biopsy were calculated. Open biopsy had the highest diagnostic accuracy (89%) followed by FNA (82%) and core biopsy (78%). Clinically significant errors occurred with all methods. The likelihood of an open biopsy being performed was affected by prior performance of an FNA or core biopsy and by diagnostic imaging and FNA results. Diagn. Cytopathol. 2014;42:476–486. © 2014 Wiley Periodicals, Inc.