Kimberley Provincial Hospital provides the sole public sector orthopaedic surgical service to the entire Northern Cape Province of South Africa (SA). Ankle fractures form part of the trauma burden and pose a challenge owing to high numbers and limited resources. The incidence of ankle fracture is reported to be 169.7/100 000/year. [1] Currently there are no statistics on the incidence in the Northern Cape. An alternative surgical method of treatment was explored in the form of a prospective cohort series, to increase turnaround time of patients needing surgery and thus improve service delivery. Data collection while conducting this prospective trial highlighted loss to follow-up in ankle fracture patients, which prompted this report. Numerous studies have highlighted the challenges in terms of loss to follow-up when conducting trials in musculoskeletal injuries. [2-5] The main factors contributing to this loss to follow-up are reported to be socioeconomic, and include level of education, poverty, male gender, smoking and alcohol abuse. [6] Young individuals as well as the very elderly are prone to be lost to follow-up. Potential reasons for this vary, but are hypothesised to include an increased frequency of substance abuse in younger populations and lack of mobility in older populations. [2,7] In addition, smokers are reported to have an 80% higher risk of loss to follow-up compared with non-smokers. The reason for this is not clear, but it has been postulated that individuals with substance use may lack motivation to change their behaviour for health-related purposes. [2] Several other studies also report smokers to be at risk of not attending for follow-up as expected. [4,5,8] This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.