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Stabilization of rare unstable pelvic fractures in the case of sacral fractures and iliosacral joint dislocations can be tricky. 3D reconstruction and reverse engineering templates may be used to increase the accuracy of screw placement.Computed tomography (CT) images were used to design the template for 16 consecutive patients with unstable pelvic ring fractures, which were used to guide the screw placement. Another 10 patients received screw placement under conventional fluoroscopy. The screw position, radiation exposure, and surgery time were compared between the two groups.Personalized image-based templates had better correct screw positions (P < 0.05), reduced radiation exposure (P < 0.01), and shorter surgery time (P < 0.05) compared with the conventional group.Personalized image-based templates for iliosacral screw insertions can increase the sacral lag screw placement accuracy, reduce radiation exposure, and shorten surgery time compared with traditional fluoroscopic methods. Copyright © 2012 John Wiley & Sons, Ltd.