CONMED Corporation

Thank you for standing by. Before the conference call begins, let me remind you that during this call, management will be making comments and statements regarding its financial outlook, its plans, and objectives. These statements represent the forward-looking statements that involve risks and uncertainties as those terms are defined under the federal securities laws. Investors are cautioned that any such forward-looking statements are not guarantees of future events, performance, or results. The company's actual results may differ materially from its current expectations. Please refer to the risks and other uncertainties disclosed under the forward-looking information in today's press release as well as the company's SEC filings for more details on the risks and uncertainties that may cause actual results to differ materially. The company disclaims any obligation to update any forward-looking statements that may be discussed during this call except as may be required by applicable law. You will also hear management refer to non-GAAP or adjusted measurements during this discussion. While these figures are not a substitute for GAAP measurements, management uses these figures to aid in monitoring the company's ongoing financial performance from quarter to quarter and year to year on a regular basis and for benchmarking against other medical technology companies. Adjusted net income and adjusted earnings per share measures the income of the company, excluding credits or charges that are considered by the company to be special or outside of its normal ongoing operations. These adjustment items are specified in the reconciliation supporting the company's earnings releases posted online. on the company's website. With these required announcements completed, I will now turn the call over to Curt Hartman, ConMed's Chair of the Board, President, and Chief Executive Officer for opening remarks. Mr. Hartman?

Thank you, Jonathan. Good afternoon and thank you for joining us for ConMed's fourth quarter and full year 2023 earnings call. With me on the call is Todd Garner, Executive Vice President and Chief Financial Officer. Today, I'll provide a brief overview of the financial and operating performance for the fourth quarter and the full year. Todd will then provide a more detailed analysis of our financial performance and discuss our 2024 financial guidance. After that, we'll open the call to your questions. Overall, I'm pleased with our fourth quarter results, which delivered record revenue for ConMed. Total sales for the fourth quarter were $327 million. representing a year-over-year increase of 30% as reported and an increase of 32% in constant currency. These growth rates are obviously aided by the fourth quarter 2022 warehouse disruption, which impacted each part of our business differently in the fourth quarter of 2022. Fourth quarter earnings delivered gap net income of $33.1 million, an increase of 24% over net income of $26.6 million, in the fourth quarter of 2022. Excluding special items that affected comparability, our adjusted net income was $33.2 million and our adjusted diluted net earnings per share was $1.06. For the full year, sales reached a new record of $1.245 billion, representing a year-over-year increase of 19% as reported and 21% in constant currency. 2023 was a year of balanced growth when you look at the full-year growth rates across domestic and international, general surgery and orthopedics, and single-use and capital. My perspective is that this speaks to the underlying strength of the entire product portfolio that has been built strategically over time. 2023 gap net income totaled $64.5 million compared to a net loss of $80.6 million in 2022. Excluding special items that affected comparability, our adjusted net income of $108.3 million increased 27% year-over-year, and our adjusted diluted net earnings per share of $3.45 increased 30% year-over-year. Looking back at 2023, I'm very proud of both the top and bottom line performance, which exceeded and finished at the top end of the original respective 2023 guidance. Early in the year, we quickly remediated the warehouse issues from late 2022, and I can confidently say our global distribution strategy has never been clearer. Our 2022 acquisitions performed well within the bones, now ConMed foot and ankle, delivering double-digit growth for the full year while absorbing the growing pains of supplier integration and leadership transitions so common in private acquisitions. BioBrace platform is a game changer and exceeded our expectations and as important, has a great trajectory as we expand the market reach through sales channel expansion and geographic registrations. Overall, the entire portfolio is strong and in 2024, we expect the introduction of several new products across each of our businesses. And while I usually reserve the financial detail analysis for Todd, I'm proud of the team for driving our leverage ratio down to 4.1 times as our increased focus on working capital and overall asset management continues to improve. In summary, 2023 was a great year for ConMed. Looking forward, I could not be more confident in our prospects to continue delivering top-line growth and leveraged earnings growth driven by clinically differentiated solutions across our business. This stems from my confidence that we have a talented global team armed with an innovative high-growth portfolio which was built through a disciplined combination of organic and inorganic development across both our general surgery and orthopedics categories. The strategic outlook for ConMed remains strong, and this will benefit patients, customers, employees, and shareholders in the quarters and years ahead. With that, I'll turn the call over to Todd, who will provide a more detailed analysis of our financial performance and discuss our 2024 financial guidance. Todd? Thank you, Curt.

All sales growth numbers I referenced today will be given in constant currency. The reconciliation to GAAP numbers is included in our press release. As usual, we have included an investor deck on our website that summarizes the results of the quarter of the year and our updated guidance. For the fourth quarter of 2023, our total sales increased 31.5%. As a reminder, during the fourth quarter of 22, we were dealing with our warehouse software implementation that affected our ability to ship product. For Q4, our sales in the US increased 33.3% versus the prior year quarter, and our international sales grew 29.0%. Worldwide orthopedics revenue grew 19.4% in the fourth quarter. In the US, orthopedic sales grew 6.0%, and internationally, orthopedic sales increased 29.8%. As we talked about last quarter, supply constraints in our domestic orthopedic business, including our MTF allograft tissue, kept us from being on offense as much as we would like. The MTF supply returned to normal during the fourth quarter, and we expect to be able to move more fully to offense on the rest of the orthopedics portfolio by the end of Q1 2024. BioBrace again delivered strong growth in the fourth quarter and has good momentum going into 2024. What we've previously referred to as interbones, we will refer to as foot and ankle going forward. As Kurt said, we are currently dealing with normal growing pains in this business, which caused Q4 to be below trend, only growing in the high single digits. So still above market, but below what we're used to and what we expect. We continue to expect this business to outgrow the market and be a double-digit grower for us in 2024. Total worldwide general surgery revenue increased 41.7% in the quarter. U.S. general surgery revenue grew 47.6%, while internationally general surgery revenue increased 27.8%. Obviously, these elevated growth rates are aided by easy comps from the prior year, but we continue to see the same trend of strong growth from our leading products on this side of the business. For the full year of 2023, our total sales increased 20.9%, which represents 18.4% growth on an organic basis. For the full year, our U.S. and international sales both grew 20.9% versus the prior year, which is amazing from a balance perspective. Worldwide orthopedics revenue increased 17.7% for the full year of 2023. In the U.S., orthopedic sales grew 15.2%, and internationally, orthopedic sales increased 19.2%. Total worldwide general surgery revenue increased 23.4% for the full year 2023. U.S. general surgery revenue grew 23.4%, while internationally, general surgery revenue increased 23.5%. Now let's move to the expense side of the income statement. We will discuss expenses and profitability in the fourth quarter and the year, excluding special items, which include charges for acquisitions and contingent consideration, termination of distributor agreements, legal matters, debt refinancing costs, restructuring of software implementation costs, amortization of intangible assets, and amortization of deferred financing fees net of tax. Adjusted gross margin for the fourth quarter was 56.4%, which is a 50 basis point sequential improvement over Q3 and an increase of 220 basis points from the prior year quarter. So the product mix tailwind we're counting on is real and working. The challenges we had in Q4 in the US orthopedic business affected gross margin. We also made some process improvements in one of our plants that drove some period costs that we recognized in the quarter. For the full year, adjusted gross margin was 55.2%, a decrease of 10 basis points from 2022. While margin improved sequentially throughout the year, inflation experienced throughout 2022 was cycling through the P&O in the first half of 2023, offsetting the underlying favorable mixed impact of the product portfolio. Research and development expense for the fourth quarter was 4.3% of sales, 60 basis points lower than the prior year quarter. For the full year, 2023, R&D expense was 4.2% of sales, 30 basis points lower than 2022. For the fourth quarter, adjusted SG&A expenses were 36.7% of sales. Leverage gained on the higher sales drove the 300 basis point improvement over the prior year quarter. So despite the gross margin headwinds, we delivered 15.8% adjusted operating margin in Q4. For the full year, adjusted SG&A expenses were 37.4% of sales, 140 basis points lower than in 2022. On an adjusted basis, interest expense was $8.0 million in the fourth quarter and $33.7 million for the full year. The adjusted effective tax rate in Q4 was 24.2%. For the full year, our adjusted effective tax rate was 23.0%. Fourth quarter gap net income was $33.1 million. This compares to gap net income of $26.6 million in Q4 of 2022. Gap earnings per diluted share were $1.05 this quarter compared to 86 cents a year ago. For the full year, gap net income was $64.5 million compared to gap net loss of $80.6 million in 2022. Gap earnings per diluted share were $2.04 in 2023 compared to gap net loss per diluted share of $2.68 in 2022. Excluding the impact of special items discussed earlier, in the fourth quarter we reported adjusted net income of $33.2 million, an increase of 156.5% compared to the fourth quarter of 2022. Our Q4 adjusted diluted earnings per share were $1.06, an increase of 152.4% compared to the prior year quarter. For the full year of 2023, we reported adjusted net income of $108.3 million, an increase of 27.4% compared to 2022. Our full year adjusted diluted net earnings per share were $3.45, an increase of 30.2% compared to the prior year. Turning to the balance sheet, our cash balance at the end of the year was $24.3 million compared to $30.5 million as of September 30th. Accounts receivable days as of December 31st were 67 days compared to 68 at the end of Q3. Inventory days at year end were 198 compared to 215 at September 30th. Long-term debt at the end of the year was $903.1 million versus $942.2 million as of September 30th. Our leverage ratio on December 31st was 4.1 times. Cash flow provided from operations in the quarter was $56.4 million compared to cash flow used for operations of $11.6 million in the fourth quarter of 2022. Cash flow provided from operations for the full year 2023 was $125.3 million compared to $33.4 million in 2022. Both Q4 and the full year are all-time records for this metric. Capital expenditures in the fourth quarter were $4.9 million compared to $5.7 million a year ago. For the full year, capital expenditures were $19.0 million compared to $21.8 million in 2022. Now let's turn to financial guidance. For the full year 2024, we expect revenue in the range of $1.34 billion and $1.365 billion, representing year-over-year growth of approximately 8 to 10 percent. Q1 2023 had the benefit of the backlog catch-up from our 2022 warehouse issue. so the Q1 2024 growth rate we estimate between 3% and 5%. Q1 also has one less selling day than the prior year. Q3 and Q4 both have one extra day, so the full year has one extra day over 2023. We believe the growth rate should accelerate as we move through the year. Q2 may be more like mid to high single digits as the ortho business ramps back up, And then Q3 and Q4 performance should get us to that 8% to 10% for the full year. Based on current rates, we expect currency to have an immaterial impact to 2024 growth rates on the top and bottom line. For the past seven months, we have attempted to allay concerns regarding a potential insufflator integrated with a new surgical robot, beginning with a very detailed discussion of the clinical benefits and patent protection around our technology as part of our second quarter 2023 earnings call. To be clear, we continue to believe the impact on AirSeal will be minimal, but we don't think it is wise to have company guidance that ignores such a pervasive theoretical market overhang. So we have elected to include in our guidance what we believe to be a worst-case estimate of what that impact could be. While we aren't going to share the specifics of our model, I will tell you that our guidance allows for a conversion rate associated with placements of the new robot that is roughly half of what we have seen historically. As a reminder, AirSeal has successfully treated millions of patients and has significant data showing 50% reduction in length of stay and other significant benefits. We believe surgeons value the clinical outcomes and associated data and will want to see similar or better results from any new technology before making a change. Finally, to mitigate a theoretical slowdown in conversions, we would accelerate the shift of our resources and energy in favor of general laparoscopic cases. Turning to adjusted gross margin, the improving mix of the portfolio remains strong. which we think should drive between 100 and 150 basis points of margin expansion in 2024. That's gross margin expansion. This is a little slower than we envisioned for 2024 when we talked about it a year ago. The expected slow start in orthopedics and some improvements we still need to make in our manufacturing processes are contributing to that headwind. Having said that, it is still a very good gross margin story, and it should build throughout the year. We expect Q1 to be about 100 basis points better than the prior year. And by Q4, we expect to be providing about 150 basis points of improvement over the prior year. So where does that put us on our quest to 60% gross margins by the end of 2025? If Q4 2024 is around 58% and the mix and improvements should be accelerating, we believe it is still possible to be around 60% by the end of 2025. If not, we would expect to be on a strong trend and hit that milestone comfortably in 2026. As a percentage of sales, we expect adjusted SG&A to improve between 60 and 80 basis points in 2024 for the full year. Q1 will likely be at a similar rate to the prior year Q1, given our typical sales-forth expansions to start the year, but we expect to gain leverage as we move through the year. We expect full-year R&D expense in 2024 to be between 4% and 4.5% of sales. We expect Q1 in the mid-fours. We expect adjusted interest expense to be between $33 and $34 million in 2024. Keep in mind that we have $70 million of the 2.625% converts that mature this week. Those will be funded by a revolver, so expect interest expense for the first two quarters of 2024 to be between $8.5 million and $9.0 million per quarter. We expect the adjusted effective tax rate to be around 24.5% in 2024. We expect adjusted EPS in 2024 to be between $4.30 and $4.40 representing growth between 25% and 28%. Because gross margin is expected to build throughout the year and interest expense will be higher in the first half, we expect adjusted EPS in Q1 to be between $0.72 and $0.75, and we expect the first half to be between $1.65 and $1.71. We expect full-year operating cash flow in 2024 to be between $145 and $155 million, with capital expenditures in the $20 to $25 million range, putting free cash flow between $120 million and $135 million. We project adjusted EBITDA between $270 million and $280 million for 2024. Given the heavier cash requirements in the beginning of the year, we expect our leverage ratio to stay relatively flat for the next six months and then drop into the low threes by the end of 2024. As Kurt said, we are pleased with our record-setting 2023 performance and are focused on delivering a strong 2024. We remain confident in our ability to deliver innovation to our customers while driving above-market growth and profitability over the long term. And with that, we'd like to open the call to your questions, and I'll hand it back to Jonathan. Certainly.

Ladies and gentlemen, if you do have a question at this time, please press star 1-1 on your telephone. To remove yourself from the queue, simply press star 1-1 again. We ask that you please limit yourself to one question and one follow-up. Our first question comes from the line of Rick Wise from Stifel.

Your question, please. Good afternoon. Sorry about that.

Let's start off with maybe one big picture question. My thoughts will be something specific. I appreciate, and you've laid it out extremely clearly, some of the moving pieces and the timing. What do you think, Todd, how should we think about fourth quarter growth, let's say on a normalized basis? let's say, adding back if allografts had been normal, what kind of growth might we have seen? And maybe you can talk about your confidence in the timing of getting that back on track. And what I'm really trying to get at here is we've heard from some other larger companies how the environment's improving, procedures rebounding, a lot of strengths Do you feel like you're seeing that X some of these moving pieces?

Yeah, so let me take that first part, and maybe Kurt can chime in on that second part. It's really impossible, Rick, to try and normalize what Q4 would be, really not because of the allograft issue. That's a That's a smaller issue, right? It affects margins because that's a 100% margin product, as we've talked about before. What's hard about getting to a normalized growth rate for Q4 is that Q4 22 had that major disruption of our warehouse software implementation. And so it's just impossible to know what a normal quarter would have been a year ago And so it's impossible to get to kind of what this Q4 is normalized because it's impossible to know. So we feel very good about all the growth drivers of our business. As we talked about, the ortho business has had lingering supply issues that are getting better every quarter. They get a little better. We're just not out of the woods yet. And we think we're a few months still from getting out of the woods there where we can move back to offense the way we want to be on that side of the business. But that's the beauty of diversification and balance that we talked about. And so the total business remains healthy and headed in the right direction. And when we can get all cylinders pumping like we'd like, it'll be even better.

And Rick, on the last part about the markets, You know, we just came a week or so ago from our global sales meeting, leadership meetings, and I would tell you our teams are pretty optimistic about the markets broadly. That's across our categories of orthopedics and general surgeries, but also across our geographies. We have a higher concentration outside the U.S. in most med tech companies, and having folks from the various markets in attendance and talking about what they're seeing and what they're experiencing, we feel like healthcare, generally speaking, is pretty pretty solid right now.

Yeah, that's great. And just as a follow-up, I mean, it sounds like BioBrace is in great shape. Talk to us a little more about the challenges or the near-term issues affecting interbones or foot and ankle that drove high single digits. So what happened? And help us understand what you've dialed into the 24 guide and why does it get better and when? Thank you very much.

Yeah, I think the first part of that question I'll take and I'll let Todd talk about guidance. You know, you buy a private company, you go through the integration steps, putting them into your systems, your process, that includes supply chain. We're working hard on international registration. There's far more demand on the supply of the product out of the gates and working with that new supplier base and trying to get them integrated into our systems and our processes. As is typically the case in smaller private companies, there's some evolution, transition, and disruption. And really, those are the things that slowed us down. And we think, to Todd's earlier comment, we think those things clear up here as we get through the first quarter and we get back on full stride as we get into second quarter. So it's I don't think it's anything systemic. I think it's all about integration and taking a private company, put it into a public company's framework, and trying to let those processes work the way they should.

Yeah, and as far as guidance, Rick, we definitely have included in our guidance the assumption that that business grows double digits in 2024. As Kurt said, we think this hiccup is temporary. It doesn't magically go away with the turning of the calendar, but we do think it's a short-term hiccup that we will get through and get this business back to double digits, and we do think it will be double digits for the full year.

Great. Thank you.

Thank you. One moment for our next question. And our next question comes from the line of Robbie Marcus from TV.

PM. Your question, please.

Yeah, thanks for taking the question. I wanted to follow up on Rick's, and I guess I'll ask it this way. You know, fourth quarter missed and margins were weak, and 2024 is all predicated on improvement over the course of the year, although recognizing it includes a potential headwind for something that hasn't even happened yet with AirSeal. So I guess a lot of it is predicated on trust that the business will improve. And I was just wondering if you could give us any more concrete reasons to believe that growth could be in the essentially double digits towards the end of the year to get to the guidance range and what the building blocks are that you have visibility to today versus just a bit of hope.

Yeah, thanks, Robbie. Yeah, I think if we just raise our view a little bit other than just Q4, right? In Q2 and Q3, the last two quarters we reported on, the business was growing in the low double digits organically. So this is not an aspiration or a hope to us. We know this portfolio can do it. We've identified the causes for this kind of slower Q4 than we expected. We do believe those are temporary. We think we're doing all the right things. Really, the aberration is the hiccup. The business is built to grow as we've guided, and I think we feel very comfortable with the guidance we've provided today.

Got it. And as you think about just the M&A you've done and where the leverage is right now, how do you feel about your ability to continue to do M&A and your thoughts on the need for additional assets in the P&L? Thanks a lot.

You know, we finished leverage ratio at 4.1, which was better than we had expected based on some fine work on asset management through the second half of the year. We've said publicly we didn't give our business development teams time off. If a great asset came along, we would take a very hard look at it, and we candidly continue to look at items. The bar is obviously much higher, and with a little bit higher end market interest rates, the bar becomes just that much higher. I'm not sitting here today feeling we need to do anything. I really like the portfolio, as I said in my scripted comments, both on general surgery and orthopedics. There's some new products coming that are additive to the overall effort, and I think our teams on a global basis have plenty to say grace over in terms of talking to their customers about clinically differentiated offerings. But again, MedTech 101, if a great asset came on the market and we thought it was a great fit and going to contribute to the long-term growth story, we'd take a really hard look at it. But not sitting here saying we need to do it, not sitting here saying we have to do anything to change our outlook and change or do something to deliver on the guidance. The guidance we put out, we feel very good about, and that's based on the portfolio that we have with us today.

Great. Thanks for taking the questions.

Thank you. One moment for our next question. And our next question comes from the line of Matthew O'Brien from Piper Sandler.

Your question, please.

Good afternoon. Thanks so much for taking the questions. You know, Todd, when you were at our conference at the end of last year, you were talking about a double-digit grower at ConMed in 24. You're backing off that a little bit here today. for a product that I don't think it's supposed to be out until the end of the year. Most likely will come earlier than that. But is the lowering of 100 basis points maybe 150 versus what you were expecting entirely because of this hypothetical launch? Or are there other things in there specifically? It looked like your capital business was a little bit slower than we were kind of anticipating down sequentially versus in normal years being up. Is there something else going on too that's impacting the business just beyond your conservatism on AirSeal?

No, I mean, there's a few moving pieces here, but let me just clarify the record. You're right, you know, like we said, Q2 and Q3, which were the quarters we reported on going into your conference, we had delivered between 11% and 12% organic growth in both of those quarters. And those quarters had no odd comp. Those were not easy comps. Those were kind of normal comps. And so that was very representative of what the engine is doing. We still obviously were guiding 8 to 10 with, as you put, some conservative assumptions behind that. We feel very good about the strength of this portfolio. Success here has always been defined as grow faster than your markets, right? So double digits is kind of a milestone that we'd all, you know, be very happy about. But as we're growing faster than our markets, we're winning. And I think eight to 10 is clearly faster than our markets, even with those kind of assumptions, which I think you've got them right. There's nothing more than what we've said, Matt, and I think you captured them. The The ortho business is in a little bit of a slow point. We've got to get that back to normal. And so that's affecting the start of the year. And we've been very generous. I think we've tried to lean into this narrative that's out there on our company and the valuation. And we've tried to make this really a worst-case scenario in relation to this competitive launch that the market is worked up about. So we... You're saying end of the year. Our assumptions are that it comes way before that. And I think, again, I'm not sharing the details of our model, but we've been as generous as we could to be conservative in those assumptions and to build that in. So having said all that, I don't think any of that is inconsistent. We were growing double digits. Q4 was disappointing for the reasons we told you.

and uh but the rest of the portfolio continues to be strong we're going to strengthen up that ortho side of the business and uh and get all cylinders humming okay and then on the margin side of things you know again backing off here a little bit too for the full year it's just you know the q1 number is well below what i was expecting from a gross margin perspective so Maybe just talk about line of sight on improving that metric so dramatically throughout the course of this year. And then I know you said approaching 60% next year, but that 250 number was a kind of vivid number for me in my head. Is it another situation where it could be more like, hey, it's 200 to 250 next year? And I guess why not just go ahead and back off that number now? What is it that you see in the business that we can't see that gets you there? Thank you.

Yeah, I mean, I think we've been very transparent with all of those assumptions. So there's always seasonality, right? I mean, we'd all love for Q1, we'd love for Q4 of the prior year to be the jumping off point and everything always be up and to the right, but that's not how seasonality and margins work. So if you compare Q1 to Q1, we're guiding today to 100 basis points of improvement. I don't know how many companies are guiding that. But you are correct that it is lower than we thought 12 months ago. 12 months ago, we said 150 should be the expectation for 2024. This morning, we're saying 100 to 150, or I'm sorry, this afternoon. And it builds throughout the year because of these challenges we have on the ortho business. And I'll just remind you, the ortho business is accretive to the company margins, especially the foot and ankle side of that business. It's in the 80s. And we have to make some, we hoped that our operations and manufacturing would make more progress in 23 than we did. So there's still more work to do there. So it is slower and backing off a little bit of how we thought 2024 would look 12 months ago. But we're still in the ballpark. And as I said, You know, if Q4 is going to be 150 bps better, then that puts you at 58. And so, you know, maybe we don't get all the way to 60 by the end of 2025, but we should be very close and easily get there, you know, in the following quarters. So you are accurate that it is a back off a little bit of what we said, but not much is how I would frame it.

Understood. Thank you.

Thank you. One moment for our next question.

And our next question comes from the line of Kristen Stewart from CL King. Your question, please.

Hi. Thanks for taking the question. I just wanted to go back to AirSeal, not to beat a dead horse, but just to get a little bit better understanding of the exposure there to the business. How much of your AirSeal business today is tied to Intuitive Surgical? And what was the conversion rate that I guess you were tracking at today? And what gives you confidence that you're modeling a worst-case scenario going forward?

Yeah, thank you, Kristen. AirSeal is definitely not a dead horse. And unfortunately, the narrative of this competitive thread is not a dead horse. I can tell you, we have disclosed in the past that about, we estimate that about 60% of our air seal revenue is currently associated with intuitive surgical procedures. So we're at about 60% today. To be clear, that doesn't mean we're assuming 30%. That's not the 50% cut. What we're talking about is our historical trend of attachment of new conversions to the robot. That's what we're cutting in half. We're not sharing that rate with you today, but we shared the 50% reduction to try and demonstrate that we've taken this seriously. We haven't been dismissive of it. Frankly, I think we've been very, I think it's highly conservative. I think it's unlikely that there's that much disruption in those new systems. But the market is clearly very concerned about it. And we did not think it was wise or helpful to provide guidance that ignored it. And so we've tried to be as generous as we thought was rational and kind of build that allowance in. But that's as much as I'm going to share with you about the details of that model.

Okay. And I guess getting back to the gross margin of going close to 60% for 2025, is that also under the assumption of a worst case scenario of a 50% reduction as well? Or do you think if that, okay, so you still think that you can get there with a 50%?

Yeah, we're not guiding to 2025 today, obviously, but that margin improvement story is very strong and is bigger than this issue. I would tell you, I'll give you a little more color into that model. Like I said, we've assumed that that's pretty disruptive to us out of the gates. If that all plays out, how the narrative is on the street. We also know that if that were to materialize, that non-robotic procedures are 10 times the robotic procedures, right? So we would adjust energy resources away from robotic procedures and to non-robotic procedures if that theory were to materialize. That takes time, obviously. It's a longer sales cycle. So I would tell you the disruption assumed in the model is bigger early than it is late. Because the longer we have to adjust and kind of change our sales focus, the less disruptive to the overall business it is. And so the out years, I'm less worried about than the early years from that perspective.

Okay, that's helpful. Thanks very much.

Thank you. One moment for our next question. And our next question comes from the line of Vic Chopra from Wells Fargo.

Your question, please.

Hey, good afternoon, and thanks for taking the question. So thanks for providing all the color on the guidance. I'm just wondering if you can share what's assumed in your guidance for the rest of the higher growth businesses, and then I had a follow-up, please.

Yeah, no change. Vic, we continue to expect... all of our high-growth businesses to perform as they have been. So, again, just to make everybody feel comfortable, that's over 20% for AirSeal and Buffalo, twice the market for foot and ankle side of the business, and obviously Biores is a geometric type of growth engine. So no change to how we view those growth drivers.

Yeah, and I would just, adding on to that, point to the – conference at the beginning of the year where we put up slides that talked about the percentage of portfolio that was growing double digit, growing single digits, or declining. And if you just look at that mix, it's a pretty healthy portfolio. So that in and of itself underlies history of the business and our portfolio is only getting stronger with new product introductions. So I feel really good about our portfolio, not only the ones we've identified as high growth, but the rest of the portfolio and our outlook.

Thanks. And then just to follow up, I had on Biobrace, maybe just talk about your view on how quickly the product can grow in 2024 and any thoughts you can share with respect to your approach to the market and competitive strategy. Thank you.

Well, I mean, it's still... early days for BioBrace in the marketplace and for ConMed. And, you know, we had said this year it would be high single digits and we exceeded that and we feel very good. And part of my script was talking about sales channel expansion. And that means geographic expansion as registrations and approvals come through, which we've been working on since day one. But it also means leveraging our foot and ankle sales force. We have a sales force that we didn't have really until, you know, right before we acquired BioBrace, and there's a clinical need in foot and ankle for a product like BioBrace, and that sales team is being ramped up, educated, trained, and we feel very optimistic that that is a great channel for that product as well. So there's a lot of growth drivers here, and our core... Sports Medicine Channel for knee and shoulder and candidly other applications come by the booth on Wednesday at Academy and you'll see a lot of surgeon presentations related to BioBrace. Our outlook on this is really exciting because it's clinically differentiated. It is second generation technology. It is game changing for patients and clinicians and I've said many times it's the single most contacted product that I have surgeons reaching out to me expressing their pleasure with the product and how it's changed patient outcomes. So we're very optimistic about BioBrace.

Thank you. One moment for our next question. And our next question.

comes from the line of Mike Mattson from Needham & Company. Your question, please.

Yeah, thanks. So just in the orthopedics business, I guess I want to better understand, you know, what's happening or what happened with the tissue situation. So, you know, obviously there's some kind of direct impact there from the shortage. Maybe, I don't know if you've disclosed before how big a part of the orthopedic sales come directly from sales of that, but then I was also wondering, was there some kind of spillover effect where by not having those products that you maybe lose procedures or lose other products that would have gotten sold for those cases?

Yeah, Mike, I think, and I'd go back to what we said last quarter, but also what I think Todd had in his commentary, the supply disruption in the MTF portfolio as a smaller part of our business, had a bigger impact on margins because of the margin profile. What we highlighted in Q3 and what got better but not as much as we had hoped was just a general supplier challenge that was impacting a larger portion of our sports medicine and our foot and ankle business. Foot and ankle a little bit different because that's more supplier integration, whereas the standard sports medicine business was more just supplier delays and disruptions that candidly caught up to us. We thought we had been doing a pretty good job, but as things were moving forward, we had some disruptions. And as you know, in that business, if you don't have the product for the case, you can try substitute or they find an alternative from a competitor. So we just missed cases. And that was the bigger impact in the quarter. That is improving as we exited the year. It's improving in the first quarter, and we'll be back fully on offense as we get to Q2, broadly speaking, in orthopedics. So I wouldn't get hung up on the MTF portion of that. That, as Todd said, was more about the margin hit. The revenue hit was more in the general sports medicine side because of lost cases, because of supply disruption.

Okay, got it. Sorry, I guess when I heard supply issues, I was confusing that with the MTF thing, but okay. And then, um, just, you know, you're sure that there's no other, you know, competitive issues in that business. I mean, strikers launched a new camera and power tools and they seem to be doing really well. Um, I mean, I know that's capital, but, um, or, you know, any other, you know, product launches from competitors that are, that are hurting you.

Well, I mean, obviously sports medicine is one of the most competitive markets out there and it is a game of new product innovation. Um, And I look at our portfolio, and we've got new products in the knee, the shoulder. We've got BioBrace that is a platform technology that just candidly makes everything else look better in the portfolio. So our team is on offense with new product introduction as much as anybody, and that's just been part of our plan and approach. So I think the supply disruption is our bigger issue right now because when you have supply disruption – It keeps you from being on offense. You've got to take care of your existing customers, let alone go after new customers. Yeah, okay, got it. Thank you.

Thank you. One moment for our next question. And our next question comes from the line of Young Lee from Jefferies.

Your question, please.

All right, great. Thanks for taking questions. I guess, you know, appreciate you taking a more conservative approach to guidance ahead of the potential competitive launch. I guess, you know, if you were to pivot the U.S. reps selling focus, wondering, you know, how long would that process take? What would the reps be doing differently?

Yeah, it's a theoretical question, Young, but I I think the really short answer is if I'm a sales professional and I'm used to selling air seal behind the wake of an intuitive surgical robot, and for whatever reason I don't get that opportunity, I still have a quota. I still have a quota that dictates how much I'm paid and how much I make. And if I know the opportunity means I've got to turn down the other hall and go in the general laparoscopic room and work I'm converting more customers. It's going to be a longer sales cycle. They get there really quick because it hits them in their paycheck. So they get there really fast. Trust that ConMed has been messaging this opportunity for a long time, and you see that being successful outside the U.S. where there's less robots. It's just the U.S. market has a lot more robots on it, and it's a quick pathway that our team – has learned, and it's where Surgiquest started back in 2008. I want to be very fair to that sales team. We have a great selling organization in advanced surgical. That business had a record year. It'll probably have another record year this year. It's selling the entirety of the portfolio. It's selling Buffalo Filter. It's selling AirSeal. It's selling anchor tissue retrieval bags. It's selling manual instruments. It's selling energy and argon platforms. all to the core customer in general surgery. And we put the conservative guidance in. I stood in front of our sales force and asked them this specifically question. How are you feeling about your position with AirSeal relative to any other competitive entrants in the marketplace? And not one of them is backing down. So we're being conservative in our guidance to you. Inside the business, the team is full charge, full speed, and my expectations are very high for that business.

All right. I appreciate that. Maybe just one more. Just on Smoky Vac legislation headwinds in 24, what are the key states coming online and what are the key ones for 2025 that we should be focusing on also?

Yeah, I can't. I can't break out like that young, right? I mean, we're we know who's has things in the works. For example, we thought Texas might be the next state to sign something. They did not get that done before their legislative session adjourned, so that'll be hopefully taken up in their next session. The other states that we show that have something in the works that could be close. are Massachusetts, Pennsylvania, West Virginia, Virginia, North Carolina, and Florida. So some pretty sizable states in there. But I can't tell you by quarter or who's going to be first. But we would not be surprised if those that I just named off announced something in 2024. We also wouldn't be shocked if some of that drug out into 2025 as we've as we've experienced with others. So still really good activity. We've got, if I have, you know, there really hasn't been, there wasn't any states that announced since our last call. California was the last one that announced. But the states that have announced something represent 44% of the U.S. population. And so, you know, there's still good momentum and a lot of states, you know, on deck. but I can't predict timing. All right, thank you.

Thank you. One moment for our next question.

And our next question comes from the line of Travis D from Bank of America. Your question, please.

Hey, thanks for taking the question. Just curious as Intuit has started talking to their customers, if you guys have learned anything new on the design or if it's still low-pressure, And just curious if you're still sticking with it being standard installation and if that's the key thing here.

I've never heard them talk to their customers about it. I haven't heard them talk about it on their earnings call. We have a lot of similar shared key opinion leaders. And so I think we have a pretty good view of what they're bringing to market, which we very specifically highlighted at the end of the second quarter earnings call. We know they talked to their sales team about it at their sales meeting, as was publicly reported by many, but we work very closely with Intuitive, with AirSeal and their training programs, and I do not believe there's anything in the marketplace or anything coming to the marketplace that is even in the same zip code as AirSeal, and I'll end there. Can I not end there, Kurt?

I just want to be clear for those that are listening. When Kurt says that we know they talked about it to their sales force, they talked about their new robot to the sales force. If you listen to what they said publicly, what they're focused on, what solutions this new product is supposed to address, There was no mention from Intuitive about Insufflation. So this is not a new Insufflation robot. They're solving many other problems that are focused on. I think it is safe to say that Insufflation is not on their top 10 list of features of this robot. The shorts on ConMed have made it about an Insufflation robot. Intuitive has never framed it that way. And Travis, I want to correct something you said so that the audience is not confused. You said, is it still low pressure? It has never been low pressure. There's zero evidence anywhere that it's low pressure. That is an imagination. So there is no evidence that it's a low pressure device. All the evidence would suggest that if they do integrate insufflation, it would indeed be what is referred to as standard insufflation, like everything that exists on the market today. That's what all the evidence points to. There is zero evidence to suggest that this product will compete clinically with AirSeal.

And the electronic world of people sending around images of two insufflators hooked up and that's how they're going to get to low, I got news for you folks, that stuff's been around for a long time. There's nothing in the market that's anywhere near AirSeal and has the volume of patients and the clinical studies behind it that AirSeal has. So there's no one more anxious for the robotic company to get this device in the market so we can demonstrate once and for all there is no risk here to the AirSeal franchise.

Great. Thanks for that thorough answer. And sorry, Todd, I may have misspoken in the question and got it backwards. But the follow-up question I wanted to ask was on the capital revenue in the quarter. It was a little light versus street expectations. And I think the businesses you talked about, the weaknesses, and in Q4, are more recurring revenue and not capital. And was capital light in your mind in Q4? Just curious if there's any one-time things in the capital thing to talk about this quarter.

Sitting in my chair, I did not think capital was light in the quarter. I looked at our business in detail.

I mean, capital grew 44%, 43.8% in the quarter. Single-use products grew 29.2%. Now it is, I will, the ortho business that is having the challenges right now is a higher percentage capital business than the general surgery business. It's a kind of 30% typically capital business. But overall, our capital growth was faster than our disposable growth.

Okay, so some of the challenges in Q4 were in the capital side of the business in terms of the ortho side.

Yeah, there is impact.

Okay, that's a helpful clarification. Thank you.

Thank you. This does conclude the question and answer session of today's program. I'd like to hand the program back to Kirk Hartman for any further remarks.

Thank you, Jonathan. And I just want to say thank you to everybody today for your time, and we look forward to speaking with you during our next earnings call. Thank you.

Thank you, ladies and gentlemen, for your participation at today's conference. This does conclude the program.

You may now disconnect. Good day. you Thank you. Thank you. Thank you.

Thank you. music music Thank you.

Thank you for standing by.

Before the conference call begins, let me remind you that during this call, management will be making comments and statements regarding its financial outlook, its plans, and objectives. These statements represent the forward-looking statements that involve risks and uncertainties as those terms are defined under the federal securities laws. Investors are cautioned that any such forward-looking statements are not guarantees of future events, performance, or results. The company's actual results may differ materially from its current expectations. Please refer to the risks and other uncertainties disclosed under the forward-looking information in today's press release as well as the company's SEC filings for more details on the risks and uncertainties that may cause actual results to differ materially. The company disclaims any obligation to update any forward-looking statements that may be discussed during this call except as may be required by applicable law. You will also hear management refer to non-GAAP or adjusted measurements during this discussion. While these figures are not a substitute for GAAP measurements, management uses these figures to aid in monitoring the company's ongoing financial performance from quarter to quarter and year to year on a regular basis and for benchmarking against other medical technology companies. Adjusted net income and adjusted earnings per share measures the income of the company, excluding credits or charges that are considered by the company to be special or outside of its normal ongoing operations. These adjustment items are specified in the reconciliation supporting the company's earnings releases posted on on the company's website. With these required announcements completed, I will now turn the call over to Curt Hartman, ConMed's Chair of the Board, President, and Chief Executive Officer for opening remarks.

Mr. Hartman? Thank you, Jonathan. Good afternoon and thank you for joining us for ConMed's fourth quarter and full year 2023 earnings call. With me on the call is Todd Garner, Executive Vice President and Chief Financial Officer. Today, I'll provide a brief overview of the financial and operating performance for the fourth quarter and the full year. Todd will then provide a more detailed analysis of our financial performance and discuss our 2024 financial guidance. After that, we'll open the call to your questions. Overall, I'm pleased with our fourth quarter results, which delivered record revenue for ConMed. Total sales for the fourth quarter were $327 million. representing a year-over-year increase of 30% as reported and an increase of 32% in constant currency. These growth rates are obviously aided by the fourth quarter 2022 warehouse disruption, which impacted each part of our business differently in the fourth quarter of 2022. Fourth quarter earnings delivered gap net income of $33.1 million, an increase of 24% over net income of $26.6 million, in the fourth quarter of 2022. Excluding special items that affected comparability, our adjusted net income was $33.2 million and our adjusted diluted net earnings per share was $1.06. For the full year, sales reached a new record of $1.245 billion, representing a year-over-year increase of 19% as reported and 21% in constant currency. 2023 was a year of balanced growth when you look at the full year growth rates across domestic and international, general surgery and orthopedics, and single use and capital. My perspective is that this speaks to the underlying strength of the entire product portfolio that has been built strategically over time. 2023 gap net income totaled $64.5 million compared to a net loss of $80.6 million in 2022. Excluding special items that affected comparability, our adjusted net income of $108.3 million increased 27% year-over-year, and our adjusted diluted net earnings per share of $3.45 increased 30% year-over-year. Looking back at 2023, I'm very proud of both the top and bottom line performance, which exceeded and finished at the top end of the original respective 2023 guidance. Early in the year, we quickly remediated the warehouse issues from late 2022, and I can confidently say our global distribution strategy has never been clearer. Our 2022 acquisitions performed well within the bones, now ConMed foot and ankle, delivering double-digit growth for the full year while absorbing the growing pains of supplier integration and leadership transitions so common in private acquisitions. BioBrace platform is a game changer and exceeded our expectations and as important, has a great trajectory as we expand the market reach through sales channel expansion and geographic registrations. Overall, the entire portfolio is strong and in 2024, we expect the introduction of several new products across each of our businesses. And while I usually reserve the financial detail analysis for Todd, I'm proud of the team for driving our leverage ratio down to 4.1 times as our increased focus on working capital and overall asset management continues to improve. In summary, 2023 was a great year for ConMed. Looking forward, I could not be more confident in our prospects to continue delivering top-line growth and leveraged earnings growth driven by clinically differentiated solutions across our business. This stems from my confidence that we have a talented global team armed with an innovative high-growth portfolio which was built through a disciplined combination of organic and inorganic development across both our general surgery and orthopedics categories. The strategic outlook for ConMed remains strong, and this will benefit patients, customers, employees, and shareholders in the quarters and years ahead. With that, I'll turn the call over to Todd, who will provide a more detailed analysis of our financial performance and discuss our 2024 financial guidance. Todd? Thank you, Curt.

All sales growth numbers I referenced today will be given in constant currency. The reconciliation to GAAP numbers is included in our press release. As usual, we have included an investor deck on our website that summarizes the results of the quarter of the year and our updated guidance. For the fourth quarter of 2023, our total sales increased 31.5%. As a reminder, during the fourth quarter of 22, we were dealing with our warehouse software implementation that affected our ability to ship product. For Q4, our sales in the US increased 33.3% versus the prior year quarter, and our international sales grew 29.0%. Worldwide orthopedics revenue grew 19.4% in the fourth quarter. In the US, orthopedic sales grew 6.0%, and internationally, orthopedic sales increased 29.8%. As we talked about last quarter, supply constraints in our domestic orthopedic business, including our MTF allograft tissue, kept us from being on offense as much as we would like. The MTF supply returned to normal during the fourth quarter, and we expect to be able to move more fully to offense on the rest of the orthopedics portfolio by the end of Q1 2024. BioBrace again delivered strong growth in the fourth quarter and has good momentum going into 2024. What we've previously referred to as interbones, we will refer to as foot and ankle going forward. As Kurt said, we are currently dealing with normal growing pains in this business, which caused Q4 to be below trend, only growing in the high single digits. So still above market, but below what we're used to and what we expect. We continue to expect this business to outgrow the market and be a double-digit grower for us in 2024. Total worldwide general surgery revenue increased 41.7% in the quarter. US general surgery revenue grew 47.6%, while internationally general surgery revenue increased 27.8%. Obviously, these elevated growth rates are aided by easy comps from the prior year, but we continue to see the same trend of strong growth from our leading products on this side of the business. For the full year of 2023, our total sales increased 20.9%, which represents 18.4% growth on an organic basis. For the full year, our US and international sales both grew 20.9% versus the prior year, which is amazing from a balance perspective. Worldwide orthopedics revenue increased 17.7% for the full year of 2023. In the U.S., orthopedic sales grew 15.2%, and internationally, orthopedic sales increased 19.2%. Total worldwide general surgery revenue increased 23.4% for the full year 2023. U.S. general surgery revenue grew 23.4%, while internationally, general surgery revenue increased 23.5%. Now let's move to the expense side of the income statement. We will discuss expenses and profitability in the fourth quarter and the year, excluding special items, which include charges for acquisitions and contingent consideration, termination of distributor agreements, legal matters, debt refinancing costs, restructuring of software implementation costs, amortization of intangible assets, and amortization of deferred financing fees net of tax. Adjusted gross margin for the fourth quarter was 56.4%, which is a 50 basis point sequential improvement over Q3 and an increase of 220 basis points from the prior year quarter. So the product mix tailwind we're counting on is real and working. The challenges we had in Q4 in the US orthopedic business affected gross margin. We also made some process improvements in one of our plants that drove some period costs that we recognized in the quarter. For the full year, adjusted gross margin was 55.2%, a decrease of 10 basis points from 2022. While margin improved sequentially throughout the year, inflation experience throughout 2022 was cycling through the P&O in the first half of 2023, offsetting the underlying favorable mixed impact of the product portfolio. Research and development expense for the fourth quarter was 4.3% of sales, 60 basis points lower than the prior year quarter. For the full year, 2023, R&D expense was 4.2% of sales, 30 basis points lower than 2022. For the fourth quarter, adjusted SG&A expenses were 36.7% of sales. Leverage gained on the higher sales drove the 300 basis point improvement over the prior year quarter. So despite the gross margin headwinds, we delivered 15.8% adjusted operating margin in Q4. For the full year, adjusted SG&A expenses were 37.4% of sales, 140 basis points lower than in 2022. On an adjusted basis, interest expense was $8.0 million in the fourth quarter and $33.7 million for the full year. The adjusted effective tax rate in Q4 was 24.2%. For the full year, our adjusted effective tax rate was 23.0%. Fourth quarter gap net income was $33.1 million. This compares to gap net income of $26.6 million in Q4 of 2022. Gap earnings per diluted share were $1.05 this quarter compared to 86 cents a year ago. For the full year, gap net income was $64.5 million compared to gap net loss of $80.6 million in 2022. Gap earnings per diluted share were $2.04 in 2023 compared to gap net loss per diluted share of $2.68 in 2022. Excluding the impact of special items discussed earlier, in the fourth quarter we reported adjusted net income of $33.2 million, an increase of 156.5% compared to the fourth quarter of 2022. Our Q4 adjusted diluted earnings per share were $1.06, an increase of 152.4% compared to the prior year quarter. For the full year of 2023, we reported adjusted net income of $108.3 million, an increase of 27.4% compared to 2022. Our full year adjusted diluted net earnings per share were $3.45, an increase of 30.2% compared to the prior year. Turning to the balance sheet, our cash balance at the end of the year was $24.3 million compared to $30.5 million as of September 30th. Accounts receivable days as of December 31st were 67 days compared to 68 at the end of Q3. Inventory days at year end were 198 compared to 215 at September 30th. Long-term debt at the end of the year was $903.1 million versus $942.2 million as of September 30th. Our leverage ratio on December 31st was 4.1 times. Cash flow provided from operations in the quarter was $56.4 million compared to cash flow used for operations of $11.6 million in the fourth quarter of 2022. Cash flow provided from operations for the full year 2023 was $125.3 million compared to $33.4 million in 2022. Both Q4 and the full year are all-time records for this metric. Capital expenditures in the fourth quarter were $4.9 million compared to $5.7 million a year ago. For the full year, capital expenditures were $19.0 million compared to $21.8 million in 2022. Now let's turn to financial guidance. For the full year 2024, we expect revenue in the range of $1.34 billion and $1.365 billion, representing year-over-year growth of approximately 8% to 10%. Q1 2023 had the benefit of the backlog catch-up from our 2022 warehouse issue. so the Q1 2024 growth rate we estimate between 3% and 5%. Q1 also has one less selling day than the prior year. Q3 and Q4 both have one extra day, so the full year has one extra day over 2023. We believe the growth rate should accelerate as we move through the year. Q2 may be more like mid to high single digits as the ortho business ramps back up, And then Q3 and Q4 performance should get us to that 8% to 10% for the full year. Based on current rates, we expect currency to have an immaterial impact to 2024 growth rates on the top and bottom line. For the past seven months, we have attempted to allay concerns regarding a potential insufflator integrated with a new surgical robot, beginning with a very detailed discussion of the clinical benefits and patent protection around our technology as part of our second quarter 2023 earnings call. To be clear, we continue to believe the impact on AirSeal will be minimal, but we don't think it is wise to have company guidance that ignores such a pervasive theoretical market overhang. So we have elected to include in our guidance what we believe to be a worst-case estimate of what that impact could be. While we aren't going to share the specifics of our model, I will tell you that our guidance allows for a conversion rate associated with placements of the new robot that is roughly half of what we have seen historically. As a reminder, AirSeal has successfully treated millions of patients and has significant data showing 50% reduction in length of stay and other significant benefits. We believe surgeons value the clinical outcomes and associated data and will want to see similar or better results from any new technology before making a change. Finally, to mitigate a theoretical slowdown in conversions, we would accelerate the shift of our resources and energy in favor of general laparoscopic cases. Turning to adjusted gross margin, the improving mix of the portfolio remains strong. which we think should drive between 100 and 150 basis points of margin expansion in 2024. That's gross margin expansion. This is a little slower than we envisioned for 2024 when we talked about it a year ago. The expected slow start in orthopedics and some improvements we still need to make in our manufacturing processes are contributing to that headwind. Having said that, it is still a very good gross margin story, and it should build throughout the year. We expect Q1 to be about 100 basis points better than the prior year. And by Q4, we expect to be providing about 150 basis points of improvement over the prior year. So where does that put us on our quest to 60% gross margins by the end of 2025? If Q4 2024 is around 58% and the mix and improvements should be accelerating, we believe it is still possible to be around 60% by the end of 2025. If not, we would expect to be on a strong trend and hit that milestone comfortably in 2026. As a percentage of sales, we expect adjusted SG&A to improve between 60 and 80 basis points in 2024 for the full year. Q1 will likely be at a similar rate to the prior year Q1, given our typical sales fourth expansions to start the year. But we expect to gain leverage as we move through the year. We expect full-year R&D expense in 2024 to be between 4% and 4.5% of sales. We expect Q1 in the mid-fours. We expect adjusted interest expense to be between $33 and $34 million in 2024. Keep in mind that we have $70 million of the 2.625% converts that mature this week. Those will be funded by a revolver, so expect interest expense for the first two quarters of 2024 to be between $8.5 million and $9.0 million per quarter. We expect the adjusted effective tax rate to be around 24.5% in 2024. We expect adjusted EPS in 2024 to be between $4.30 and $4.40 representing growth between 25% and 28%. Because gross margin is expected to build throughout the year and interest expense will be higher in the first half, we expect adjusted EPS in Q1 to be between $0.72 and $0.75, and we expect the first half to be between $1.65 and $1.71. We expect full-year operating cash flow in 2024 to be between $145 and $155 million, with capital expenditures in the $20 to $25 million range, putting free cash flow between $120 million and $135 million. We project adjusted EBITDA between $270 million and $280 million for 2024. Given the heavier cash requirements in the beginning of the year, we expect our leverage ratio to stay relatively flat for the next six months and then drop into the low threes by the end of 2024. As Kurt said, we are pleased with our record-setting 2023 performance and are focused on delivering a strong 2024. We remain confident in our ability to deliver innovation to our customers while driving above-market growth and profitability over the long term. And with that, we'd like to open the call to your questions, and I'll hand it back to Jonathan.

Certainly. Ladies and gentlemen, if you do have a question at this time, please press star 1-1 on your telephone. To remove yourself from the queue, simply press star 1-1 again. We ask that you please limit yourself to one question and one follow-up. Our first question comes from the line of Rick Wise from Stifel.

Your question, please. Good afternoon. Sorry about that.

Let's start off with maybe one big picture question. My thought will be something specific. I appreciate, and you've laid it out extremely clearly, some of the moving pieces and the timing. What do you think, Todd, how should we think about fourth quarter growth, let's say on a normalized basis? let's say, adding back if allografts had been normal, what kind of growth might we have seen? And maybe you can talk about your confidence in the timing of getting that back on track. And what I'm really trying to get at here is we've heard from some other larger companies how the environment's improving, procedures rebounding, a lot of strength Do you feel like you're seeing that X some of these moving pieces?

Yeah, so let me take that first part, and maybe Kurt can chime in on that second part. It's really impossible, Rick, to try and normalize what Q4 would be, really not because of the Allocraft issue. That's a That's a smaller issue, right? It affects margins because that's a 100% margin product, as we've talked about before. What's hard about getting to a normalized growth rate for Q4 is that Q4 22 had that major disruption of our warehouse software implementation. And so it's just impossible to know what a normal quarter would have been a year ago And so it's impossible to get to kind of what this Q4 is normalized because it's impossible to know. So, you know, we feel very good about all the growth drivers of our business. As we talked about, the ortho business has had lingering supply issues that are getting better every quarter. They get a little better. We're just not out of the woods yet. And we think we're a few months still from getting out of the woods there where we can move back to offense the way we want to be on that side of the business. But that's the beauty of diversification and balance that we talked about. And so the total business remains healthy and headed in the right direction. And when we can get all cylinders pumping like we'd like, it'll be even better.

And Rick, on the last part about the markets, You know, we just came a week or so ago from our global sales meeting, leadership meetings, and I would tell you our teams are pretty optimistic about the markets broadly. That's across our categories of orthopedics and general surgeries, but also across our geographies. We have a higher concentration outside the U.S. in most med tech companies, and having folks from the various markets in attendance and talking about what they're seeing and what they're experiencing, we feel like healthcare, generally speaking, is pretty pretty solid right now.

Yeah, that's great. And just as a follow-up, I mean, it sounds like BioBrace is in great shape. Talk to us a little more about the challenges or the near-term issues affecting interbones or foot and ankle that drove high single digits. So what happened? And help us understand what you've dialed into the 24 guide and why does it get better and when? Thank you very much.

Yeah, I think the first part of that question I'll take and I'll let Todd talk about guidance. You know, you buy a private company, you go through the integration steps, putting them into your systems, your process, that includes supply chain. We're working hard on international registration. There's far more demand on the supply of the product out of the gates and working with that new supplier base and trying to get them integrated into our systems and our processes. As is typically the case in smaller private companies, there's some evolution, transition, and disruption. And really, those are the things that slowed us down. And we think, to Todd's earlier comment, we think those things clear up here as we get through the first quarter and we get back on full stride as we get into second quarter. So it's I don't think it's anything systemic. I think it's all about integration and taking a private company, put it into a public company's framework, and trying to let those processes work the way they should.

Yeah, and as far as guidance, Rick, we definitely have included in our guidance the assumption that that business grows double digits in 2024. As Kurt said, we think this hiccup is temporary. It doesn't magically go away with the turning of the calendar, but we do think it's a short-term hiccup that we will get through and get this business back to double digits, and we do think it will be double digits for the full year.

Great.

Thank you.

Thank you. One moment for our next question. And our next question comes from the line of Robbie Marcus from JVC.

PM. Your question, please.

Yeah, thanks for taking the question. I wanted to follow up on Rick's, and I guess I'll ask it this way. You know, fourth quarter missed and margins were weak, and 2024 is all predicated on improvement over the course of the year, although recognizing it includes a potential headwind for something that hasn't even happened yet with AirSeal. So I guess, you know, a lot of it is predicated on trust that the business will improve. And I was just wondering if you could give us, you know, any more concrete reasons to believe that, you know, growth could be in the, you know, essentially double digits towards the end of the year to get to the guidance range and why that's, you know, what the building blocks are that you have visibility to today versus just a bit of hope.

Yeah, thanks, Robbie. Yeah, I think if we just raise our view a little bit other than just Q4, right, in Q2 and Q3, the last two quarters we reported on, the business was growing in the low double digits organically. So this is not an aspiration or a hope to us. We know this portfolio can do it. We've identified the causes for this kind of slower Q4 than we expected. We do believe those are temporary. We think we're doing all the right things. Really, the aberration is the hiccup. The business is built to grow as we've guided, and I think we feel very comfortable with the guidance we've provided today.

Got it. And as you think about just the M&A you've done and where the leverage is right now, how do you feel about your ability to continue to do M&A and your thoughts on the need for additional assets in the P&L? Thanks a lot.

You know, we finished leverage ratio at 4.1, which was better than we had expected based on some fine work on asset management through the second half of the year. We've said publicly we didn't give our business development teams time off. If a great asset came along, we would take a very hard look at it, and we candidly continue to look at items. The bar is obviously much higher, and with a little bit higher end market interest rates, the bar becomes just that much higher. I'm not sitting here today feeling we need to do anything. I really like the portfolio, as I said in my scripted comments, both on general surgery and orthopedics. There's some new products coming that are additive to the overall effort, and I think our teams on a global basis have plenty to say grace over in terms of talking to their customers about clinically differentiated offerings. But again, MedTech 101, if a great asset came on the market and we thought it was a great fit and going to contribute to the long-term growth story, we'd take a really hard look at it. But not sitting here saying we need to do it, not sitting here saying we have to do anything to change our outlook and change or do something to deliver on the guidance. The guidance we put out, we feel very good about, and that's based on the portfolio that we have with us today.

Great. Thanks for taking the questions.

Thank you. One moment for our next question. And our next question comes from the line of Matthew O'Brien from Piper Sandler.

Your question, please.

Good afternoon. Thanks so much for taking the questions. You know, Todd, when you were at our conference at the end of last year, you were talking about a double-digit grower at ConMed in 24. You're backing off that a little bit here today. for a product that I don't think is supposed to be out until the end of the year, most likely will come earlier than that. But is the lowering of 100 basis points maybe 150 versus what you were expecting entirely because of this hypothetical launch? Or are there other things in there specifically? It looked like your capital business was a little bit slower than we were kind of anticipating down sequentially versus in normal years being up. Is there something else going on too that's impacting the business just beyond your conservatism on AirSeal?

No, I mean, there's a few moving pieces here, but let me just clarify the record. You're right, you know, like we said, Q2 and Q3, which were the quarters we reported on going into your conference, we had delivered between 11% and 12% organic growth in both of those quarters. And those quarters had no odd comp. Those were not easy comps. Those were kind of normal comps. And so that was very representative of what the engine is doing. We still obviously were guiding 8 to 10 with, as you put, some conservative assumptions behind that. We feel very good about the strength of this portfolio. Success here has always been defined as grow faster than your markets, right? So double digits is kind of a milestone that we'd all, you know, be very happy about. But as we're growing faster than our markets, we're winning. And I think eight to 10 is clearly faster than our markets, even with those kind of assumptions, which I think you've got them right. There's nothing more than what we've said, Matt, and I think you captured them. The The ortho business is in a little bit of a slow point. We've got to get that back to normal. And so that's affecting the start of the year. And we've been very generous. I think we've tried to lean into this narrative that's out there on our company and the valuation. And we've tried to make this really a worst-case scenario in relation to this competitive launch that the market is worked up about. So we... You're saying end of the year. Our assumptions are that it comes way before that. And I think, again, I'm not sharing the details of our model, but we've been as generous as we could to be conservative in those assumptions and to build that in. So having said all that, I don't think any of that is inconsistent. We were growing double digits. Q4 was disappointing for the reasons we told you.

and uh but the rest of the portfolio continues to be strong we're going to strengthen up that ortho side of the business and uh and get all cylinders humming okay and then on the margin side of things you know again backing off here a little bit too for the full year it's just you know the q1 number is well below what i was expecting from a gross margin perspective so Maybe just talk about line of sight on improving that metric so dramatically throughout the course of this year. And then I know you said approaching 60% next year, but that 250 number was a kind of vivid number for me in my head. Is it another situation where it could be more like, hey, it's 200 to 250 next year? And I guess why not just go ahead and back off that number now? What is it that you see in the business that we can't see that gets you there? Thank you.

Yeah, I mean, I think we've been very transparent with all of those assumptions. So there's always seasonality, right? I mean, we'd all love for Q1, we'd love for Q4 of the prior year to be the jumping off point and everything always be up and to the right, but that's not how seasonality and margins work. So if you compare Q1 to Q1, we're guiding today to 100 basis points of improvement. I don't know how many companies are guiding that. But you are correct that it is lower than we thought 12 months ago. 12 months ago, we said 150 should be the expectation for 2024. This morning, we're saying 100 to 150, or I'm sorry, this afternoon. And it builds throughout the year because of these challenges we have on the ortho business. And I'll just remind you, the ortho business is accretive to the company margins, especially the foot and ankle side of that business. It's in the 80s. And we have to make some, we hoped that our operations and manufacturing would make more progress in 23 than we did. So there's still more work to do there. So it is slower and backing off a little bit of how we thought 2024 would look 12 months ago. But we're still in the ballpark. And as I said, You know, if Q4 is going to be 150 bps better, then that puts you at 58. And so, you know, maybe we don't get all the way to 60 by the end of 2025, but we should be very close and easily get there, you know, in the following quarters. So you are accurate that it is a back off a little bit of what we said, but not much is how I would frame it.

Understood. Thank you.

Thank you. One moment for our next question.

And our next question comes from the line of Kristen Stewart from CL King. Your question, please.

Hi. Thanks for taking the question. I just wanted to go back to AirSeal, not to beat a dead horse, but just to get a little bit better understanding of the exposure there to the business. How much of your AirSeal business today is tied to Intuitive Surgical, and what was the conversion rate that I guess you were tracking at today, and what gives you confidence that you're modeling a worst-case scenario going forward?

Yeah, thank you, Kristen. AirSeal is definitely not a dead horse, and unfortunately, the narrative of this competitive thread is not a dead horse. I can tell you, we have disclosed in the past that we estimate that about 60% of our air seal revenue is currently associated with intuitive surgical procedures. So we're at about 60% today. To be clear, that doesn't mean we're assuming 30%. That's not the 50% cut. What we're talking about is our historical trend of attachment of new conversions to the robot. That's what we're cutting in half. We're not sharing that rate with you today, but we shared the 50% reduction to try and demonstrate that we've taken this seriously. We haven't been dismissive of it. Frankly, I think we've been very, I think it's highly conservative. I think it's unlikely that there's that much disruption in those new systems. But the market is clearly very concerned about it. And we did not think it was wise or helpful to provide guidance that ignored it. And so we've tried to be as generous as we thought was rational and kind of build that allowance in. But that's as much as I'm going to share with you about the details of that model.

Okay. And I guess getting back to the gross margin of going close to 60% for 2025, is that also under the assumption of a worst case scenario of a 50% reduction as well? Or do you think if that, okay, so you still think that you can get there with a 50%?

Yeah, we're not guiding to 2025 today, obviously, but that margin improvement story is very strong and is bigger than this issue. I would tell you, I'll give you a little more color into that model. Like I said, we've assumed that that's pretty disruptive to us out of the gates, if that all plays out how the narrative is on the street. We also know that if that were to materialize, non-robotic procedures are 10 times the robotic procedures, right? So we would adjust energy resources away from robotic procedures and to non-robotic procedures if that theory were to materialize. That takes time, obviously. It's a longer sales cycle. So I would tell you the disruption assumed in the model is bigger early than it is late. Because the longer we have to adjust and kind of change our sales focus, the less disruptive to the overall business it is. And so the out years, I'm less worried about than the early years from that perspective.

Okay, that's helpful. Thanks very much.

Thank you. One moment for our next question. And our next question comes from the line of Vic Chopra from Wells Fargo.

Your question, please.

Hey, good afternoon, and thanks for taking the question. So thanks for providing all the color on the guidance. I'm just wondering if you can share what's assumed in your guidance for the rest of the higher growth businesses, and then I had a follow-up, please.

Yeah, no change. Vic, we continue to expect... all of our high-growth businesses to perform as they have been. So, again, just to make everybody feel comfortable, that's over 20% for AirSeal and Buffalo, twice the market for foot and ankle side of the business, and obviously Biores is a geometric type of growth engine. So no change to how we view those growth drivers.

Yeah, and I would just, adding on to that, point to the – conference at the beginning of the year where we put up slides that talked about the percentage of portfolio that was growing double digit, growing single digits, or declining. And if you just look at that mix, it's a pretty healthy portfolio. So that, in and of itself, underlies history of the business, and our portfolio is only getting stronger with new product introductions. So I feel really good about our portfolio. Not only... the ones we've identified as high growth, but the rest of the portfolio and our outlook.

Thanks. And then just a follow-up I had on BioGrace. Maybe just talk about your view on how quickly the product can grow in 2024 and any thoughts you can share with respect to your approach to the market and competitive strategy. Thank you.

Well, I mean, it's still – early days for BioBrace in the marketplace and for ConMed. And, you know, we had said this year it would be high single digits and we exceeded that and we feel very good. And part of my script was talking about sales channel expansion. And that means geographic expansion as registrations and approvals come through, which we've been working on since day one. But it also means leveraging our foot and ankle sales force. We have a sales force that we didn't have really until, you know, right before we acquired BioBrace. And there's a clinical need in foot and ankle for a product like BioBrace. And that sales team is being ramped up, educated, trained. And we feel very optimistic that that is a great channel for that product as well. So there's a lot of growth drivers here. And our core sports medicine channel for knee and shoulder and candidly other applications come by the booth on Wednesday at Academy and you'll see a lot of surgeon presentations related to BioBrace. Our outlook on this is really exciting because it's clinically differentiated. It is second generation technology. It is game changing for patients and clinicians and I've said many times it's the single most contacted product that I have surgeons reaching out to me expressing their pleasure with the product and how it's changed patient outcomes. So we're very optimistic about BioBrace.

Thank you. One moment for our next question.

And our next question. comes from the line of Mike Matson from Needham and Company. Your question, please.

Yeah, thanks. So just in the orthopedics business, I guess I want to better understand what's happening or what happened with the tissue situation. So obviously there's some kind of direct impact there from the shortage. Maybe, I don't know if you've disclosed before how big a part of the orthopedic sales come directly from sales of that, but then I was also wondering, was there some kind of spillover effect where by not having those products that you maybe lose procedures or lose other products that would have gotten sold for those cases?

Yeah, Mike, I think, and I'd go back to what we said last quarter, but also what I think Todd had in his commentary, the supply disruption in the MTF portfolio as a smaller part of our business, had a bigger impact on margins because of the margin profile. What we highlighted in Q3 and what got better but not as much as we had hoped was just a general supplier challenge that was impacting a larger portion of our sports medicine and our foot and ankle business. Foot and ankle a little bit different because that's more supplier integration, whereas the standard sports medicine business was more just supplier delays and disruptions that candidly caught up to us. We thought we had been doing a pretty good job, but as things were moving forward, we had some disruptions. And as you know, in that business, if you don't have the product for the case, you can try substitute or they find an alternative from a competitor. So we just missed cases. And that was the bigger impact in the quarter. That is improving as we exited the year. It's improving in the first quarter, and we'll be back fully on offense as we get to Q2, broadly speaking, in orthopedics. So I wouldn't get hung up on the MTF portion of that. That, as Todd said, was more about the margin hit. The revenue hit was more in the general sports medicine side because of lost cases, because of supply disruption.

Okay, got it. Sorry, I guess when I heard supply issues, I was confusing that with the MTF thing, but okay. And then, um, just, you know, you're sure that there's no other, you know, competitive issues in that business. I mean, strikers launching new camera and power tools and they seem to be doing really well. Um, I mean, I know that's capital, but, um, or, you know, any other, you know, product launches from competitors that are, that are hurting you.

Well, I mean, obviously sports medicine is one of the most competitive markets out there and it is a game of new product innovation. Um, And I look at our portfolio, and we've got new products in the knee, the shoulder. We've got BioBrace that is a platform technology that just candidly makes everything else look better in the portfolio. So our team is on offense with new product introduction as much as anybody, and that's just been part of our plan and approach. So I think the supply disruption is our bigger issue right now because when you have supply disruption – It keeps you from being on offense. You've got to take care of your existing customers, let alone go after new customers. Yeah, okay, got it. Thank you.

Thank you. One moment for our next question. And our next question comes from the line of Young Lee from Jefferies.

Your question, please.

All right, great. Thanks for taking questions. I guess, you know, appreciate you taking a more conservative approach to guidance ahead of the potential competitive launch. I guess, you know, if you were to pivot the U.S. reps selling focus, wondering, you know, how long would that process take? What would the reps be doing differently?

Yeah, it's a theoretical question, Young, but I I think the really short answer is if I'm a sales professional and I'm used to selling air seal behind the wake of an intuitive surgical robot, and for whatever reason I don't get that opportunity, I still have a quota. I still have a quota that dictates how much I'm paid and how much I make. And if I know the opportunity means I've got to turn down the other hall and go in the general laparoscopic room and work I'm converting more customers. It's going to be a longer sales cycle. They get there really quick because it hits them in their paycheck. So they get there really fast. Trust that ConMed has been messaging this opportunity for a long time, and you see that being successful outside the U.S. where there's less robots. It's just the U.S. market has a lot more robots on it, and it's a quick pathway that our team – has learned, and it's where Surgiquest started back in 2008. I want to be very fair to that sales team. We have a great selling organization in advanced surgical. That business had a record year. It'll probably have another record year this year. It's selling the entirety of the portfolio. It's selling Buffalo Filter. It's selling AirSeal. It's selling anchor tissue retrieval bags. It's selling manual instruments. It's selling energy and argon platforms. all to the core customer in general surgery. And we put the conservative guidance in. I stood in front of our sales force and asked them this specifically question. How are you feeling about your position with AirSeal relative to any other competitive entrants in the marketplace? And not one of them is backing down. So we're being conservative in our guidance to you. Inside the business, the team is full charge, full speed, and my expectations are very high for that business.

All right. I appreciate that. Maybe just one more. Just on Smokey Vac legislation, Headwinds in 24, what are the key states coming online and what are the key ones for 2025 that we should be focusing on also?

Yeah, I can't. I can't break out like that young, right? I mean, we're we know who's has things in the works. For example, we thought Texas might be the next state to sign something. They did not get that done before their legislative session adjourned, so that'll be hopefully taken up in their next session. The other states that we show that have something in the works that could be close. are Massachusetts, Pennsylvania, West Virginia, Virginia, North Carolina, and Florida. So some pretty sizable states in there. But I can't tell you by quarter or who's going to be first. But we would not be surprised if those that I just named off announced something in 2024. We also wouldn't be shocked if some of that drug out into 2025, as we've as we've experienced with others. So still really good activity. We've got, if I have, you know, there really hasn't been, there wasn't any states that announced since our last call. California was the last one that announced. But the states that have announced something represent 44% of the U.S. population. And so, you know, there's still good momentum and a lot of states, you know, on deck. but I can't predict timing. All right, thank you. Thank you.

One moment for our next question.

And our next question comes from the line of Travis D. from Bank of America. Your question, please.

Hey, thanks for taking the question. Just curious as Intuit has started talking to their customers, if you guys have learned anything new on the design or if it's still low pressure, And just curious if you're still sticking with it being standard installation and if that's the key thing here.

I've never heard them talk to their customers about it. I haven't heard them talk about it on their earnings call. We talk to, we have a lot of similar shared key opinion leaders. And so I think we have a pretty good view of what they're bringing to market, which we very specifically highlighted at the end of the second quarter earnings call. We know they talked to their sales team about it at their sales meeting, as was publicly reported by many, but we work very closely with Intuitive, with AirSeal and their training programs, and I do not believe there's anything in the marketplace or anything coming to the marketplace that is even in the same zip code as AirSeal, and I'll end there.

Can I not end there, Kurt? I just want to be clear for those that are listening. When Kurt says that we know they talked about it to their sales force, they talked about their new robot to the sales force. If you listen to what they said publicly, what they're focused on, what solutions this new product is supposed to address, There was no mention from Intuitive about Insufflation. So this is not a new Insufflation robot. They're solving many other problems that are focused on. I think it is safe to say that Insufflation is not on their top 10 list of features of this robot. The shorts on ConMed have made it about an Insufflation robot. Intuitive has never framed it that way. And Travis, I want to correct something you said so that the audience is not confused. You said, is it still low pressure? It has never been low pressure. There's zero evidence anywhere that it's low pressure. That is an imagination. So there is no evidence that it's a low pressure device. All the evidence would suggest that if they do integrate insufflation, it would indeed be what is referred to as standard insufflation, like everything that exists on the market today. That's what all the evidence points to. There is zero evidence to suggest that this product will compete clinically with AirSeal.

And the electronic world of people sending around images of two insufflators hooked up and that's how they're going to get to low, I got news for you folks, that stuff's been around for a long time. There's nothing in the market that's anywhere near AirSeal and has the volume of patients and the clinical studies behind it that AirSeal has. So there's no one more anxious for the robotic company to get this device in the market so we can demonstrate once and for all there is no risk here to the AirSeal franchise.

Great, thanks for that thorough answer. And sorry, Todd, I may have misspoken in the question and got it backwards. But the follow-up question I wanted to ask was on the capital revenue in the quarter. It was a little light versus street expectations. And I think the businesses you talked about, the weaknesses, and in Q4, are more recurring revenue and not capital. And was capital light in your mind in Q4? Just curious if there's any one-time things in the capital thing to talk about this quarter.

Sitting in my chair, I did not think capital was light in the quarter. I looked at our business in detail.

I mean, capital grew 44%, 43.8% in the quarter. Single-use products grew 29.2%. Now it is, I will, the ortho business that is having the challenges right now is a higher capital business than the general surgery business. It's a kind of 30% typically capital business. But overall, our capital growth was faster than our disposable growth.

Okay, so some of the challenges in Q4 were in the capital side of the business in terms of the ortho side. Yeah, it's impacted by... Okay, that's a helpful clarification. Thank you.

Thank you. This does conclude the question and answer session of today's program. I'd like to hand the program back to Kirk Hartman for any further remarks.

Thank you, Jonathan. And I just want to say thank you to everybody today for your time, and we look forward to speaking with you during our next earnings call. Thank you.

Thank you, ladies and gentlemen, for your participation at today's conference. This does conclude the program. You may now disconnect. Good day.