AIM: This study aims to evaluate the utility, feasibility, time, and cost-effectiveness of awake ultrasound-guided percutaneous biopsies (AUPBs) in children with suspected musculoskeletal tumours, when compared with more conventional biopsies under general anaesthesia (BGAs). MATERIALS AND METHODS: A retrospective analysis of paediatric biopsies performed in a UK tertiary musculoskeletal centre between March 2016 and March 2023 was undertaken. Eighty-six paediatric patients were included in the study, 53 undergoing BGA and 33 undergoing AUPB. RESULTS: The mean age of patients undergoing AUPB was more than that of patients undergoing BGA at 13.2 years (range: 5-16 years) and 8.5 years (range: 3 months-15 years), respectively. AUPB significantly reduced the time to biopsy, with a mean of 4.7 days (median: 3 days, interquartile range [IQR]: 2-7 days), compared with 11.1 days (median: 5 days, IQR: 2-18 days) for BGAs (P = 0.037). AUPB conferred a one-third reduction in financial cost at £1177 vs £1824 for BGA. Fifty-eight percent patients undergoing AUPB had their biopsy on the same day as their initial assessment in clinic, whilst none of the BGA cases had their biopsy on the same day as their initial assessment in clinic. No complications or procedural abandonment were reported in the AUPB group. CONCLUSION: Awake ultrasound-guided biopsy in paediatric musculoskeletal tumours is safe, well tolerated, and cost-effective. It reduces the time to obtain a histological diagnosis compared to BGA. Collaboration between clinicians, radiologists, and play specialists in identifying suitable patients for AUPB can facilitate efficient one-stop clinics and timely diagnosis and reduce costs incurred in paediatric oncological services. LEVEL OF EVIDENCE: Level IV-Diagnostic.