Iliac fixation is indicated to provide spinopelvic stabilization in select cases of long segment thoracolumbar spine fusion, spinal osteotomy/realignment, trauma, and instability caused by tumor or infection. Traditional iliac fixation with iliac screws or S2 alar/iliac (S2AI) screws may provide inadequate fixation in select clinical scenarios, such as severely compromised bone quality or spinopelvic dissociation. The purpose of this article is to describe the perpendicular iliac screw technique with ipsilateral iliac crest screw plus S2AI fixation. The technique may be applied for select individuals in cases of 3-column osteotomy in the lower lumbar spine, spinopelvic dissociation (caused by trauma, neoplasm, or Charcot arthropathy), and failure of previous iliac fixation and when anatomic constraints limit standard iliac screw or S2AI screw placement. [Orthopedics. 2016; 39(6):e1209-e1212.].