Direct arthrography extends the diagnostic capabilities of conventional imaging by far. It is the method of choice in patients with suspected partial tear of the rotator cuff, for the diagnosis of meniscal tears in the postoperative knee, and for assessment of the labrum in the hip. In the other indications, it increases the sensitivity and specificity of MR imaging, and enables surveying ligaments and cartilage in CT. In the hands of an experienced radiologist, complications are extremely rare. However, it turns a noninvasive examination into a mildly invasive procedure. Accordingly, the indication for direct arthrography has to be critically reviewed in each patient. In general, MR arthrography should be preferred if MR is available and contraindications for MR imaging are not present, in order to limit radiation exposure. Joint puncture with cross-sectional image guidance, particularly MR guidance allows for a safe direct puncture of the joint and helps to reduce paravasation that might mimic pathology. Moreover, this technique permits online monitoring of intra-articular contrast injection, providing additional information on the joint.