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Abbreviations: 3D CT : three-dimensional computed tomography; CREF: closed reduction and external fixation; DPNFCSAF: distally pedicled neurofasciocutaneous sural artery flap; O(C)RIF: open (closed) reduction and internal fixation. Case presentationA 44-year-old obese female (body mass index 37.2 kg/m 2 ) presented with open severely destroyed injuries of her both hindfoots after a suicidal jump from approximately 4 m height out of her private balcony. There was a longstanding history of a psychiatric disorder (schizophrenia) treated by psychopharmaca. The left foot showed an open Gustilo-Anderson II hindfoot injury at the lateral aspect of calcaneus, and three-dimensional computed tomography (3D CT) revealed a highly comminuted hindfoot fracture-dislocation injury involving the calcaneus, the subtalar joint, and the Chopart joint ( Figure 1A). The right foot showed an open Gustilo-Anderson IIIB hindfoot injury at the medial-plantar aspect of calcaneus, and 3D CT revealed a highly comminuted calacaneus fracture ( Figure 1B).Both injuries were initially treated by closed reduction and external fixation (CREF) accompanied with percutaneous pinning, negative-pressure vacuum assisted closure (VAC) therapy, and intravenous application of antibiotics (cefuroxime). Against our strict recommendations not to load her both legs, the patient mobilized herself with full-weight bearing and went away several times from our hospital and so nearly all pins of external and internal fixations were broken. As a consequence, the overall pins for external and internal fixation of both foots had to be removed 4 weeks after primary surgery, resulting in severe posttraumatic flat foot on both sites based on pronounced bony destruction and fragment dislocation and diastases of the calcaneus bones accompanied with re-dislocation in her left Chopart joint (Figures 2A and 3A). After intermittent negativepressure VAC therapy, a secondary wound closure of her left open II injury could be achieved without additional soft tissue coverage 3 weeks after injury. For closure of her right open IIIB injury, wound coverage with the use of a distally pedicled neurofasciocutaneous sural artery flap (DPNFCSAF) was performed 1 week after removal of the pins. For this purpose, the pedicle of the flap was primarily covered by a synthetic skin substitute (Epigard) at its 160° pivot point extending up distally to the flap, and secondarily covered by split-thickness skin grafts 1 week later that was associated with an uneventful wound healing (i.e. flap survival) ( Figures 2B-C).At the left foot, the further course after secondary wound closure of her open II injury without the need of coverage was complicated by development of severe osteomylitis of the hindfoot involving the distal tibia metaphysis presented with marked swelling of the overall foot and an infectious fistula at the lateral aspect of calcaneus (Staphylococcus aureus) ( Figures 3A-B). Hence, the Syme amputation was detected and performed by us that was associated with an uneventful course ( Fi...