Purpose: Bone biopsy is the only technique capable of comprehensively assessing all bone parameters, including turnover, microarchitecture, and mineralization, yet its clinical utility is debated. This study evaluates its role in routine diagnostic and therapeutic applications. Methods: A retrospective analysis was conducted on 22 horizontal transiliac bone biopsies from 20 patients referred for rheumatology consultation between August 2016 and May 2022. Diagnoses included osteoporosis, adynamic bone disease, hyperparathyroidism-related bone disease, and osteomalacia. Results: Histopathological findings led to therapeutic strategies differing from standard anti-osteoporotic treatment in over one-third of cases. In certain cases, bone biopsy provided critical diagnostic insights that guided therapeutic decisions. Conclusion: Although advancements in non-invasive diagnostics exist, bone biopsy remains indispensable for a subset of patients, offering essential diagnostic and therapeutic insights that significantly influence clinical management.