Smith & Nephew PLC

LSE:SN

Earnings Call Analysis

Smith & Nephew Reports Strong Growth in 2023

Smith & Nephew concluded 2023 on a high note, surpassing its already raised revenue growth guidance, with Sports Medicine and ENT experiencing double-digit expansion and Advanced Wound Management sustaining momentum. While Orthopedics improvement is ongoing, their 12-Point Plan fosters advancement, as highlighted by accelerated growth across all business units and a solidified portfolio. The company met its 17.5% target margin, despite inflation and slow market activity in China, and achieved a 7.2% underlying revenue growth, totaling $5.5 billion. Reported growth was slightly lower at 6.4%, due to currency effects. Trading profit saw a 7.6% uptick to $970 million, and a notable $200 million betterment in working capital outflow brought trading cash flow to $635 million. Adjusted earnings per share increased modestly by 1.3% to $0.828. The dividend remained steady at $0.375 for the year. Entering 2024, Smith & Nephew anticipates further growth and margin improvement, even in light of the anticipated headwinds from China's Volume-Based Procurement (VBP).

Smith & Nephew Finishes Strong in 2023, Embarking on 2024 with Confidence

Smith & Nephew's Q4 and full-year 2023 earnings call was a bittersweet occasion marked by the farewell of CFO Anne-Francoise Nesmes and the introduction of incoming CFO John Rogers, indicating a transition in the company's financial stewardship. CEO Deepak Nath presented a narrative of resilience and strength, highlighting the company's higher-than-predicted underlying revenue growth and consistent performance across all business units. While the Orthopedics sector is undergoing revitalization with a 12-Point Plan, it has shown encouraging signs of accelerated growth.

Solid Financial Framework and Margin Performance

Smith & Nephew's financial performance showcased robustness, with full-year revenues climbing to $5.5 billion, representing a 7.2% growth on an underlying basis, and a 6.4% increase on a reported basis. Importantly, the organization accomplished its targeted trading margin of 17.5% in the face of inflationary pressure and foreign exchange headwinds, underlining its resilience and efficient cost management strategies. This efficiency is slated to continue with a projected trading margin expansion to at least 18% for the next year.

Promising Business Unit Showcases Across Geographies

The company's global strategy paid off, with an evenly distributed performance uplift across all regions. The U.S. market saw a rise of 6.2%, established markets grew by 6.1%, and emerging markets topped the growth chart at 7.6%. While the Sports Medicine segment and ENT (Ear, Nose, Throat) delivered standout results with double-digit growth, the Advanced Wound Management division followed suit with an impressive 7.8% growth. These figures were supported by recent product launches and better availability, which bode well for future market performance.

Advanced Wound Management as a Beacon of Growth

One particular spotlight is on Advanced Wound Management (AWM), a segment where Smith & Nephew expects to dial up its growth rate in the forthcoming years. The AWM revenue upsurge of 6.4%, powered by the mid to high single-digit growth of its foam dressing and infection management portfolio, demonstrates the company’s solid positioning in an underpenetrated yet high-growth market. The outlook here is bullish, with leadership aspirations in negative pressure biologics and digital clinical solutions.

Net Debt and Future Financials

From a financial stability perspective, Smith & Nephew's net debt concluded at $2.8 billion, a manageable increase considering their robust adjusted EBITDA. The company's financial fortitude is further evidenced by its proactive approach to refinancing its substantial revolving credit facility, which is set to mature in 2028. All these indicators position the company well within its leverage ratio range of 2 to 2.5 times adjusted EBITDA, affirming a strong foundation for future investments.

A Look Ahead: 2024 Outlook

CEO Deepak Nath laid out the roadmap for 2024 exuding optimism. Smith & Nephew is targeting an underlying revenue growth of 5% to 6%, with a balanced contribution expected from key areas such as Orthopedics, Sports Medicine outside of China, and Advanced Wound Management despite looming headwinds from China's Volume-Based Procurement (VBP). This guidance sets a positive tone for the company's strategic focus and anticipated growth trajectory in the year ahead.

Earnings Call Transcript 2023-Q4

[Deepak Nath, executive]

Good morning, and welcome to the Smith & Nephew Q4 and Full Year '23 Results Presentation. I'm Deepak Nath, Chief Executive Officer. And joining me is Chief Financial Officer, Anne-Francoise Nesmes.

As you know, this will be Anne-Francoise's last set of results for Smith & Nephew. It has been an absolute pleasure working with her. I'd like to thank her personally for all that she has done in her time as CFO.

I'd also like to take this opportunity to welcome our incoming CFO, John Rogers, who's here today in the audience. He brings a wealth of experience to the company, and I very much look forward to working together. John will be up here with me going through the numbers at our Q1 trading update in May.

I'm pleased to report a good finish to 2023 with underlying revenue growth ahead of the guidance that we already raised during the year. And all 3 of our business units grew by over 5% for the full year, which is a clear demonstration of the strength of our portfolio.

Sports Medicine and ENT had a very good year, accelerating to double-digit growth despite a slow China market. And Advanced Wound Management has also maintained its momentum. Fixing Orthopedics is still a work in progress, but I'm encouraged by the 12-Point Plan progress and the higher overall growth that we've delivered.

I'm also very pleased that we've achieved our target margin of 17.5% for the year despite macro headwinds from inflation, transactional FX, and a slow China market. That included a significant year-on-year step-up in the second half, and the organization showed what can be done with growth, focus and cost discipline.

The company is well positioned going into 2024. We continue to transform the way we operate Smith & Nephew through our 12-Point Plan, which aims to drive better execution in a more focused and accountable business unit structure. Our progress against the plan has laid the groundwork for improvement in U.S. recon with better product availability and improving set deployments by the end of the year. Our innovation strategy is delivering a strong pipeline of new products to drive consistent high growth over the coming years. And our productivity is visibly improving.

For 2024, we expect another year of good growth and margin expansion even against the headwind of China VBP, and I'll come to the detail in the outlook section. So the improvements we've made to how we do business have already translated into stronger financial performance in 2023. Revenue was $5.5 billion, which is 7.2% growth on an underlying basis and 6.4% on a reported basis, after an 80 basis points headwind from foreign exchange. Trading profit increased by 7.6% to $970 million, with a 17.5% trading margin, which as I've just highlighted was in line with our guidance for the year.

A nearly $200 million improvement in working capital outflow resulted in trading cash flow of $635 million. At 65% conversion, this is a good improvement in 2022, but there is, of course, still more to come. Adjusted earnings per share grew 1.3% to $0.828. And we're proposing an unchanged dividend of $0.375 for 2023.

I'll now pass you to Anne-Francoise to go into the detail of today's results before I come back to discuss our outlook and the strategic progress. Anne-Francoise?

[Anne-Francoise Nesmes, executive]

Thank you, Deepak. Good morning, everyone. As Deepak said, this is my last set of results, and I'm pleased to be presenting to you a good set of improving financial results. So I'll start by covering the fourth quarter numbers that Deepak referred to.

Revenue was $1.5 billion with a 6.4% underlying growth and a 6.8% reported growth after 40 basis points benefit from exchange rate. The growth, as you can see, was across all of our regions and businesses. And factors behind the strong finish included the contribution of recent launches, better product availability, and the rebound in Bioactives following the successful transfer of SANTYL manufacturing to Fort Worth, which we completed in Q3.

Looking at the performance by geography. Growth in the quarter was broad-based with the U.S. growing by 6.2%, established markets rising by 6.1%, and emerging markets growing by 7.6%. Growth in emerging markets includes, of course, the headwinds ahead of Sports Medicine VBP implementation in China.

I'll now move to the details by business units as we traditionally do, starting with Orthopaedics, which grew 4.9% in the quarter. Global Hips and Knees grew by 3.6%, with strong out-of-U.S. growth, reflecting improved product supply and commercial execution. U.S. Recon was a little slower, and this was due to a combination of factors, which we're continuing to address through the 12-Point Plan. There were still some areas where product availability impacted key U.S. SKUs during the quarter, before improving by year-end. We also made further progress in set deployments although, again, there is a lag before this reflects into the sales.

Slow asset deployments earlier in the year were still costing us growth in a stronger market. And together with some anticipated rep turnover, this limited our ability to win new business and offset the usual revenue churn. So overall, our U.S. performance is not yet where we wanted to be, and this remains a priority.

Other Reconstruction delivered revenue growth of 19%, rounding out a good year with a record number of CORI placements in the quarter. Full year installations came in a little behind our target, mainly from a delayed ramp-up in the slower China capital environment, but the broad adoption picture is very positive and running ahead of our Recon share position.

Utilization hit a new high in the quarter, building on the over 25% of U.S. knees being placed with robotics at the end of Q3. We're bringing CORI to the full range of surgical settings from ASCs to teaching institutions. And we see customers committing in scale with around 1/3 of our new installations in the U.S. coming as part of multimillion unit deals.

And that's all underpinned by CORI being the most versatile system on the market, supporting a range of surgeon preferences and a broad suite of procedures. And if you remember, in '23, we added a new solution -- the sole solution to give surgeons a choice between milling and cutting for the first time with robotics. We added unique functionality with the digital tensioner, enabling them to measure soft tissue tension before cutting the bone.

And we added revision indication, which is not available on any other major robotics platform. And of course, there's more coming in 2024, including supporting both image-free and image-based planning as options. And it's clear that CORI has a strong runway of growth ahead.

And Trauma and Extremities continues to play an important part in the Orthopaedics growth story. Revenue grew by 5.8% in Q4 with double-digit growth in the U.S., reflecting the continued ramp-up of the EVOS plating system following improved capital product availability and capital deployments earlier in the year. EVOS can be a multiyear growth opportunity and we're adding a further driver in extremities with the full U.S. commercial launch of the AETOS shoulder system announced earlier in the month.

As you know, Sports Medicine is a very attractive area of our portfolio. The steady flow of innovation and improving product availability have generated consistently high level of growth for many years. The business delivered underlying revenue growth of 7.1% in the quarter. Excluding China, where we faced a headwind ahead of VBP, Sports Medicine and ENT grew 8.7%. Within Sports Medicine, Joint Repair grew 8.8% in the quarter. And if we strip out China, growth would have been 12%.

Our REGENETEN Bioinductive Implant was the largest growth driver across the sports portfolio, and will remain a key focus in 2024 with increasing market penetration and the development of new applications.

We also added a new growth opportunity with the acquisition of CartiHeal, which brings the AGILI-C cartilage repair implant into Smith & Nephew. This is a novel treatment for osteochondral lesions that promotes natural regeneration of the cartilage and restoration of the underlying bone. It has a broad indication, including the previously unaddressed population with lesions in knees with mild to moderate arthritis, as well as the approximately 700,000 patients that receive cartilage repair annually in the U.S.

And importantly, the product is backed by outstanding clinical evidence and is a great fit for our portfolio. China VBP will be a headwind in 2024. The tender process is now complete, and we expect implementation in the second quarter of 2024. For the year as a whole, we expect around a 5 percentage point headwind to growth in Sports Medicine joint repair.

Arthroscopic enabling technologies revenue grew 3.7% underlying, with good growth from COBLATION resection range and patient positioning portfolio, and the China volumes returning to a more normal level after a slow Q3. As we expected, demand growth in ENT continued to moderate in Q4 as we lap some of the COVID recovery -- post-COVID recovery, shall I say. As a result, ENT revenue grew 10.7% led by our tonsil and adrenal business, which represents a return to more normalized procedure volumes.

And finally, Advanced Wound Management delivered underlying revenue growth of 7.8% in the quarter. Advanced Wound Care revenue grew 1.4%, primarily driven by our foam dressing and infection management portfolio, both of which grew mid to high single digit.

Bioactives growth of 12.5% was due to a very strong quarter for SANTYL following the temporary delays to shipments we saw in the third quarter after the manufacturing transfer to Fort Worth. The rebound in Q4 included some stocking above normal levels, so you should expect Bioactive will see significantly lower growth rates in Q4 2024 as the effect unwinds.

Finally, the ongoing implementation of our Advanced Wound Devices Acceleration Plan is reflected in the underlying revenue growth of 14.9%, with double-digit growth from both our traditional platform, RENASYS, and our single-use PICO.

The outlook for our wound business is strong. We have a good position in what is an underpenetrated market and a high-growth market, with the broadest portfolio of products and #1 or 2 positions in each segment and geography. We believe we're positioned to move the growth rate higher in the coming years, including through gaining share in negative pressure on biologics, digital solutions to support clinicians in product selection, and demonstrating the value of our existing platform by using our broad commercial reach to build awareness of our clinical evidence.

Now I'll move to the full year financials. And to bring all of these together, for the full year, revenue was $5.5 billion, up 7.2% versus 2022 on an underlying basis, which was ahead of our guidance, and up 6.4% on a reported basis. Performance was broad-based with all 3 reporting segments delivering growth above our midterm target for the whole group.

As you can see in the chart, Orthopedics grew 5.7% for the year. Sports Medicine and ENT grew 10.9%. And AWM grew 6.4%.

Now I'll move to the summary P&L, where I'll expand on some of the comments in the next few slides -- on key elements in the next few slides. The underlying gross profit was $3.9 billion with a gross margin of 70.7%, which is a decrease of 30 basis points. Raw materials inflation was clearly a key headwind with offsets from price increases across the portfolio and productivity measures in manufacturing and procurement.

Trading profit was $970 million, an increase of $69 million, with positive leverage across operating expenses resulting in 20 basis points of trading margin expansion to 17.5% for the full year, again, in line with our guidance. While R&D was down on a reported basis, investment in constant currency continued to grow.

On Slide 13 shows a more detailed bridge explaining the components of the trading margin expansion. As you can see, we absorbed some major macroeconomic headwinds in the year. I already mentioned continued high input cost inflation, which cost us around 130 basis points of margin. In addition, we had significant transactional FX headwinds of 120 basis points. And that arose from the fact we have a higher share of our COGS in U.S. dollar than in our revenue. And so the U.S. dollar strength in 2022 resulted in a P&L headwind that was delayed into 2023 by our hedging program.

But we were able to offset around 160 basis points with our productivity savings, including those coming through the 12-Point Plan. And a number of moving parts add up to the remaining 110 basis points shown on the revenue leverage and other, with volume leverage and price increases more than offsetting higher labor costs.

I'd also like to highlight the progress we made as 2023 progressed. The second half trading margin of 19.6% represented 200 basis points of expansion over the prior, with leverage on all expense lines in the P&L. And I'm encouraged by that close to the year, which shows that we can drive significant expansion through gross leverage, better productivity and cost discipline.

Now on Slide 14, looking further down the P&L. Adjusted earnings per share grew by 1.3% to $0.828. That's below the growth in trading profit due to increased financial expense, reflecting both higher interest rates and the negative associates contribution in the year, while the trading tax rate was broadly unchanged from 2022 at 16.2%. Basic earnings per share grew 18% to $0.302.

And moving to the cash flow statement. We generated trading cash flow of $635 million in the full year, with trading cash conversion of 65%. The increase over 2022 was primarily driven by significantly reduced working capital outflow. And this was mainly as a result of improving inventory trends as the year progressed, and I'll come back to that in a moment.

There was a partial offset from higher CapEx as we accelerated instrument set deployments, both for established products and to support our launches. And we expect CapEx to remain at a level of around 8% sales in 2024. We're committed to further improve trading cash flow going forward, so it was encouraging to see a return to more normal level of cash conversion in the second half of '23.

And on the free cash flow, restructuring, acquisition, legal and other outflows largely relate to restructuring under the 12-Point Plan and the EU MDR compliance cost. And as you'll see in the technical guidance, we expect both of those items to be significantly lower in 2024, with the MDR project coming to an end in the first half.

Now I'll cover the inventory. And as you can see that the long-term upward trends has now stabilized and started to come down later in the year. Whilst there was still a cash outflow from inventory for the full year, inventory fell slightly in absolute dollars in the second half and DSI also fell to finish broadly flat compared to the start of the year after several years of increase.

The second half improvement came across every business unit. Orthopedics is where inventory build has been a longer-term challenge, as you know, both from supply and demand being disconnected, and also we're be building launch capital in Trauma. And addressing this has been a specific focus of the 12-Point Plan, particularly with moving manufacturing volume and mix back into line. For 2023, we were able to bring Orthopedics DSI down by 5% for the year as a whole, even as we continued to invest behind the rollout of EVOS and AETOS.

Pulling all of that together, we are increasingly confident that inventory days across the organization have now turned and we expect ongoing improvements in the coming years.

And to conclude on the financials, I'll cover net debt. Net debt ended the year at $2.8 billion, which is an increase of $241 million. The leverage ratio finished at 2.1x adjusted EBITDA, which is broadly stable and comfortably within our range of 2 to 2.5x.

In 2023, we refinanced our $1 billion revolving credit facility, which now matures in 2028, maintaining our strong funding position. And in 2024, we have just over $400 million of private placement debt maturing with the majority in November.

And with that, I'll hand back to Deepak.

[Deepak Nath, executive]

Great. Thank you, Anne-Francoise. So I'll now cover our outlook for 2024. So we're guiding for underlying revenue growth of 5% to 6%. So within that, you should expect further progress in Orthopedics driven by improvements in supply and execution improvement, especially in U.S. Recon, and the continued rollout of our key growth products. We also expect to continue our strong performance in sports outside of China and in Advanced Wound Management. VBP for some sports medicine products will be the main headwind with close to 2% of our Group sales that are within scope, and the implementation, as Anne-Francoise mentioned, expected in the second quarter.

Overall, this amounts to another strong year expected for the portfolio as a whole with revenue growth continuing above historical levels even after the effects of Sports VBP. There's also phasing to consider through the year, with a number of factors driving slower growth in the first quarter. These include a strong U.S. comparator from higher-than-normal surgery volumes than the start of 2023 and a slower first quarter for Bioactives as the strong SANTYL sales at the end of 2023 unwinds.

In addition, trading days will initially be a headwind before benefiting growth later in the year. There'll be one fewer trading day in Q1, then one additional day in Q2, and 2 additional days in Q4, for a total of 2 extra days for the full year.

We also expect meaningful trading profit -- trading margin expansion to reach at least 18% for the year. There are a lot of moving parts behind that, and the chart on Slide 19 shows the major components of the bridge. Macro headwinds should be lower than in 2023, but have not gone away. Input cost inflation will continue to be a headwind, much as it was in 2023, although the transactional FX will be a substantially smaller effect at around 30 basis points. China Sports Medicine VBP will be an additional factor this year, and we expect around 70 basis points of headwind from lower pricing before any cost and revenue offsets.

However, we expect to more than offset all of those headwinds, and that will come from the combination of productivity improvements under the 12-Point Plan, including the restructuring program we had presented a year ago, and positive operating leverage from our continued higher revenue growth than in the past.

As in prior years, we expect the trading margin to be higher in the second half than in the first half, although with a less marked step-up than in 2023. Our midterm margin target of at least 20% in 2025 is unchanged. And the progress we expect for 2024 will keep us on track.

There's clearly still a further step-up to come. And as we've said before, 2025 is the biggest margin improvement year of our plan. There are more headwinds than when we set this goal 18 months ago, particularly China VBP, transactional FX and input cost inflation that has stayed higher for longer.

However, we're also a much stronger and determined organization than we were as a result of the 12-Point Plan. There are a number of offsetting positives to consider.

First, the incremental impact of input cost increases should reduce. At the same time, the operating leverage from a higher level of growth than the past should continue. So the net of operating leverage, OpEx savings and input cost inflation should be similar to the pre-VBP and pre-FX effects that we benefit from in 2024.

On top of that, one of the major headwinds for 2024 will fall away and will be replaced by an additional tailwind. Sports Medicine VBP will largely annualized, and so not to be a meaningful incremental effect in 2025. And then in 2025, we should instead see the largest block of our cost savings as the bulk of the manufacturing savings flow through into our P&L. The work on our footprint that underpins those savings is well advanced.

Putting all of that together, the pre-VBP, pre-FX margin expansion in 2024 can broadly repeat in 2025, with the additional manufacturing savings further lifting the trading margin and continuing beyond 2025.

As you know, the 12-Point Plan is central to how we're improving our overall performance. We'll reach the 2 years duration in the second half of this year. So while we've made a lot of progress, there is still more to come. What I'd like to do is take a step back and look at the overall picture since the plan's inception. On a plan of this many initiatives, there'll always be elements moving at different speeds. Some work streams just take longer by nature and others will meet their milestones a little faster or slower than envisaged at the outset. Taken as a whole, though, we're clearly on track for what we set out to do.

There are now multiple positive trends in Orthopedics. On the operations side, implant availability has dramatically improved since the start of the plan and has now closed more than 95% of the gap between the trough level and our goal. We're also more effectively deploying and turning capital, with set turns at year-end more than 20% higher than at the start of the plan.

Commercially, Trauma and Extremities has accelerated to become an important growth driver for the whole business unit. CORI placements and utilization have inflected upwards. And our OUS Recon business has now accelerated to be ahead of the market.

There's more to do in U.S. Recon, and I'll come back to that in a moment, but we're also making good progress in productivity. Inventory days and cash conversion improved through 2023. And as Anne-Francoise set out, we turned the corner and we're on a positive trajectory by year-end with Orthopaedics DSI down 5% year-on-year after a period of several years of increases.

Pricing excellence is another success area with positive realized pricing across the business units since the second half of 2022. And we've been doing the hard work on manufacturing optimization, the planned facility closures in Tuttlingen, Beijing and Lyon now underway.

The third pillar of the 12-Point Plan is building on the performance of our Sports Medicine and Advanced Wound Management business units. These are also developing well. We've seen early acceleration in the focus area of negative pressure wound therapy and we've more than tripled the pace of cross-unit business deals in ASCs. There is a new headwind with Sports Medicine VBP, which we did not expect at the start of the plan, and we'll need to work through that in 2024.

Improving execution in orthopedics is still an important part of the story. As I set out, there is good progress in much of the business, and other areas where there is more work to do. In total, subsegments representing around 60% of Orthopaedics sales are now growing at or above the peer average based on the second half of the year. Much of that is attributable to the 12-Point Plan.

We're starting to recover the share that we had lost in EMEA recon, supported by better implant availability. And we have a dedicated initiative to drive CORI that is producing growth ahead of what we can see from peers.

Trauma and Extremities performance reflects much improved consumables and capital availability and has become a new growth story in our portfolio, driven by the EVOS plating system and more recently, AETOS shoulder.

U.S. recon robotics is growing as a whole and has returned to its 2019 sales level. Even so, we're still not satisfied with our U.S. recon growth, particularly in knees. That remains a key focus in 2024 as we continue through the final year of the 12-Point Plan.

A positive sign is that operational KPIs continue to develop favorably. By quarter-end, overall implant availability was almost at our goal of being in line with industry standards, including in some previously softer categories such as OXINIUM with increasingly limited areas still trailing.

On the capital side, hip set availability has now reached our target level for the first time in the life of the plan. Knee sets are improving, but still have further to go with our KPI of instrument orders filled now at the level where it was for hips back in May of 2023. The focus now is to convert that operational improvement into revenue growth, and 3 of our priorities for doing that are listed on the slide.

Firstly, we need to complete the improvement of knee set deployment up to our target level, and drive greater utilization of both knee and hip sets that are out there. There is a process we've already followed successfully in trauma and OUS recon. Set availability is getting better, so from here, it's a matter of executing our growth plans while maintaining the discipline around capital efficiency.

Secondly, we need to drive consistent commercial excellence. Part of that is continuing to advance our product milestones through the 12-Point Plan. But the cultural and structural changes we've implemented in the last year are also critical. We expected some initial sales rep turnover after the incentive changes, and that did play out in some areas as the year progressed. We prepared for that with a recruitment pipeline already in place and expect the new growth-oriented structures should increase in benefit as they become a settled way of doing business.

Finally, we need to continue to drive our long-term differentiators at the same time, particularly CORI. We now have the most versatile platform on the market, and as we continue to build our installed base and utilization that will both reinforce our relationships with existing customers and help us with new business.

More broadly, I'm pleased with what Smith & Nephew is already delivering in terms of growth. 7.2% revenue growth in 2023 is well above our historical average, even taking into account the stronger recon market. This achievement is in line with our aim to be a consistently higher growth company.

When I look at what's behind the acceleration, it's from sustainable drivers and is aligned with our strategy. We talked at our November Meet the Management event about the central role of innovation. Through internal R&D and M&A, we're delivering successive waves of technology, including new legs for growth, for products already in the market, and further launches at the beginning of their life cycles.

In 2023, the innovation benefit was clearly visible again. Almost 3.5 points or close to half of our growth came from products launched in the last 5 years. That absolute contribution is on its own enough to take us to above that for previous average even before the contributions of our existing portfolio or M&A. It's important that we maintain that momentum of innovation.

It's not all about the dollar spend, but where they're spent and how the technology is supported with clinical data. We've continued to develop our key growth opportunities in recent months, including new evidence and launches on our existing products and bringing forward the next wave of devices.

Firstly, we added new evidence for REGENETEN, publishing the final results of a randomized controlled trial that confirmed the promising interim signal from 2022. The study found that, at 1 year, medium and large full thickness rotator cuff tears treated with REGENETEN had a statistically significant 3-fold reduction in retail rate compared to the control arm, with no difference in the number of serious or minor complications.

This remains a multiyear growth opportunity for Smith & Nephew with only single-digit penetration of rotator cuff procedures today. Bringing compelling clinical evidence like this is a key element of our plans to drive market access and increase that penetration globally.

CORI is another platform where we can keep adding further growth drivers, and we showcase additional functionality in AAOS in '24, it's version 2 of the RI Knee robotic software. This provides AI-powered reference values to guide planning alongside surgeons' preferences.

As I said, our innovation delivery is about successive waves of technology. We've also advanced 2 key devices from our next wave, acquiring CartiHeal's AGILI-C and announcing the full commercial availability of the AETOS total shoulder at AAOS. These add important growth drivers to Sports Medicine, Joint Repair and to Extremities. And both enable us to access significant new markets while leveraging our existing commercial organizations.

And importantly, the contribution of innovation will come across our portfolio. This is a slide we've shown before, and how the key projects from our current generations of innovation align with our reporting segments. We've highlighted 5 areas where we expect to grow above historical levels in the coming years with the innovation as a key driver. Those are Trauma and Extremities, Other Recon, ENT and Sports Medicine, excluding the headwind as we move through VBP, and of course, Advanced Wound Management. Taken as a whole, around 50% of Group revenue in these areas -- is in these areas with an outlook for higher growth.

Overall, I'm pleased with our progress in 2023. The portfolio as a whole is performing well with all 3 business units growing very nicely compared to history. And the team is working hard to implement -- to drive improvement in the remaining areas of weakness.

Meeting our financial commitments for the year was important to us. The organization had a heavy lift to deliver in the second half of the year, but we demonstrated what can be done when we put together operating leverage at higher growth, productivity measures and rigorous cost discipline.

We have gained momentum and made clear progress in strengthening, accelerating and transforming Smith & Nephew. In 2024, our opportunity will be to build on this, embed and expand execution discipline we've gained through the 12-Point Plan, leverage our commercial model to better meet the needs of customers, and challenge ourselves to achieve greater levels of efficiency and excellence.

So with that, we'll be happy to take your questions.

[Veronika Dubajova, analyst]

Veronika from Citi. Can you guys hear me?

[Deepak Nath, executive]

I can hear you, Veronika.

[Veronika Dubajova, analyst]

Okay. Fine. Perfect. Three questions for me. The first one is just on the Knees performance. Obviously, in the fourth quarter, it seems like things went a little bit backwards relative to your peers. So just would love to understand exactly what went wrong in Q4 and what you guys are doing about it as you move into 2024. So that's my first question.

My second question is just on the manufacturing initiatives, and I think you promised, Deepak, that you would give us more this quarter in terms of what exactly is happening and what the expected cost savings are. So if you could elaborate on that just to give us a little bit more insight into what you're shutting down, where you're moving manufacturing to, and how much money that is going to save.

And then my last question, and thank you for your comment on the phasing of growth in 2024, I'm going to ask a follow-up, as you expect, which is the phasing of margins and how you guys are thinking about the margin improvement first half versus the second half. Obviously, bearing in mind the easy comp from H1 last year, but also appreciating that you have the VBP headwinds probably more H1 weighted than 2H weighted.

[Deepak Nath, executive]

U.S. Knees, we'll start with product availability against the backdrop of overall improved -- improving and actually to near target levels overall in terms of life or for the portfolio. U.S. Knees specific SKUs were slow to come, particularly OXINIUM related and the benefits didn't start to flow through until really September -- late September-ish. So that impacted not only replenishment, but also sets.

So set delivery, which we had targeted early in the year, didn't come through into -- really well into Q4. So that impacted our ability to drive new growth. And typically, when you put a set, takes anywhere from 45 to 90 days before those sets start to turn to target levels.

We had expected churn as we implemented performance management -- tighter performance management and incentives. I talked about that in previous forums. It was a bit later in the year than we expected because the first half of the year was -- the market was quite frothy. And so the expected kind of turnover didn't materialize into the second half of the year.

So what ended up happening was we had turnover. It came later in the year. Set and replenishment availability was impacted in U.S. Knees. And there's, of course, commercial performance that layered on top. So the combination of all of those effects led to a weaker-than-expected performance in U.S. Knees.

But when I look to the fundamentals of how we work our way out of it, first and foremost, the sets are flowing now. They came later in the year than we expected, but they are flowing. I think we -- the chart that we had showed relatively speaking, where hips are versus knees, right? Hips are pretty much at target levels. We're getting there on knees. Roughly speaking, knees are where hips were kind of May of last year when the hip performance started to turn.

So as we go into 2024, we expect the sets that we've got out there. And we've got a much tighter process now in terms of where we allocate those sets. So part of the operational improvements that we've been making right over the last 1.5 years is much tighter discipline around sets, around where we deploy capital. And we're starting to see the benefit of that, right? So where we place sets, those are starting to turn, and we'll expect that to continue into -- as we turn this after.

So improved product availability, the rep churn that we'd expected, as we indicated, there's a pipeline. So we're okay in terms of hiring the reps to offset that turnover. And on the back of those factors coming together in '24, I expect to see improved knee performance. So that's your first question.

Your second question around manufacturing optimization. So we'd always said 2025 was the big year for the benefits of our efforts to bring capacity in line with demand would start to pay off. The steps to get there are optimizing our footprint. I called out Tuttlingen, I called out Lyon, I called out Beijing, are the 3 big factories we announced the closure. They're at various stages of actually being closed and volumes from those being shifted into either Memphis or into Malaysia. So all of these are Orthopedics-related plants, which is where our issue actually is around capacity.

So as those volumes get shifted into those sites, the benefit from a P&L standpoint will start to flow through into 2025. And there's also a balance between Memphis and Malaysia in terms of what gets manufactured there. So there, it's about cost and, of course, resiliency in terms of how we determine which SKUs get manufactured there.

The combination of those should yield significant margin benefit. I don't think we've called out exactly the number, but we've -- there's a little block there, you can bring out your rulers and maybe kind of dimensionalize it. But what I want to call out is that is the one big factor that you didn't see in '23, you didn't see in 2024. And we've been pretty consistent in our messaging around that.

So the third question is around phasing, margin phasing, I'll start off and maybe you can chime in, Anne-Francoise. As you say, easy comps from a margin standpoint for 2023. A lot went into making sure that we overcame that in the second half of 2023. We said we would. I don't think many people believed it. But we've got the results to show for it, right? So we came in bang-on where we said we were going to come in.

That said, I would expect '24 to be more of a normalized year in terms of first half margin. To state the obvious, we see -- we will see growth H1 to H1, so '24 to '23. And the step-up between H1 to H2 will be more normalized. So you can kind of go through the history in terms of where the averages are around that. So we expect more of a normalized kind of performance.

We called out particular factors. Last year, a lot of it had to do with incentives and commissions that we paid. Some of it, we had calibrated our quota to a certain market assumption. The market was significantly higher than we calibrated to. So that resulted in a commissions delta. We had some one-off investments last year around commercial, that we don't expect to repeat in this year. And of course, all the productivity measures and our measures around cost discipline, we started last year, it's now matured a year forward. So all of those will start to flow through to what we expect to be a normalized year.

The one thing around growth, the top line, you didn't -- you asked about margin phasing, Veronika, but the top line, so we expect the comps there are not easy, right? Particularly, on Recon, because we had a very strong market, as you know, particularly in Q1. So that will impact a little bit growth in Q1. And also for SANTYL, where as we transfer production over into Q4 -- into Fort Worth, there was an unusual ordering pattern in Q4 for SANTYL. And as a result of that stocking that happened in Q4, we'll expect, compared to Q4, Q1 will be softer. Those 2 effects to call out in Q1 relative to growth.

Anything you want to add to that, Anne-Francoise?

[Anne-Francoise Nesmes, executive]

Actually on margin, if I may come back to manufacturing, because you focus very much on the network optimization. So that's aligning capacity with volume. There are other elements and a significant amount of work around the cost base. So if you look at the 12-Point Plan, working with our suppliers to get better raw material cost, being smarter, more disciplined. So that's one. The other is around lean and looking at our overheads and how can we reduce.

So if you take -- you've aligned your volumes, you're reducing your cost base, that's what takes time, but delivers from '25 and '26 onwards.

[David Adlington, analyst]

David Adlington, JPMorgan. Two questions, please. Just wondered if you could quantify your pricing expectations for '24, what you're sort of coming out with there. And it's taking slightly longer term, so I know you're not quite levied on '25 margins yet, but beyond '25, is a setup here for further annualization of the cost savings on the manufacturing side, but also ongoing operating leverage so we get some further margin expansion beyond '25?

[Deepak Nath, executive]

Sure. '24, there's 2 things. One is inflation-related pricing. So we expect that to start to come down, in terms of our ability to pass through. So it will be -- we expect a lower impact of that in '24 compared to '23. Layered on top is our efforts around strategic pricing, which is really the substance of the pricing component of the 12-Point Plan where we've not been, as an organization, as mature relative to best-in-class around our strategic pricing efforts.

We've made tremendous progress over the last year. We just had a review of that not too long ago, very pleased with the capabilities we have built up as an organization to take ourselves to the next level. And the benefits of that will start to flow into our P&L starting in 2024. So you put those 2 effects, net a little bit less than in 2023, but we expect to see pricing benefit as we move forward.

As to how we think about the world after '24, obviously, we're not giving specific guidance beyond 2025. We have reaffirmed 20-plus in 2025. The world doesn't end then. So we expect to continue to realize the benefits that we'll start to accrue in 2025 as we move forward beyond. So continued improvement from 2025 onwards. But we're not guiding specifically to those numbers.

[Samuel England, analyst]

Sam England from Berenberg. Firstly, just a follow-up on pricing. Does the commentary around positive pricing across the portfolio, I mean that all 3 segments are positive or just positive in aggregate across the Group? And then can you dig into some of the drivers of the stronger growth in Wound Devices and negative pressure specifically? And on the 12-Point Plan initiatives, what's being sort of most impactful in driving the levels of growth that you're seeing there?

[Deepak Nath, executive]

Yes. So pricing, as we indicated, it's not in the aggregate. In fact, each of our businesses contributed to the positive. And it's actually quite refreshing to see, it was not only was it across each of the businesses, but also across geographies. The levels vary, right? Depending on the geography, but it was quite broad-based. So that's the short answer to that question.

Secondly, in terms of negative pressure and the 12-Point Plan, we are launching RENASYS, RENASYS EDGE, and it's new product driven growth. We're still in the very early stages of that. So we expect that to be a multiyear platform for growth. And so, expect to see continued traction. But it's new product launch -- launch driven.

Yes. Jack next. You waited for you to be called upon and now you've got 2 microphones.

[Jack Reynolds-Clark, analyst]

I was too keen. Thanks for taking the questions, I had 3, please. First, on VBP. So you mentioned that, that 70 basis point headwind is without any kind of mitigations. Could you just remind us what mitigation you may be able to implement and kind of the magnitude of those?

Second, on CORI. As you mentioned, the placements in the year was slightly below your target. I'm just wondering if you're expecting a rebound in 2024, if you had a rebound already, and whether you can kind of give us some color on your target for this year.

And then my third question is on demand. So there's been a bit of kind of debate around market level, whether we're still having some COVID rebound, whether it's kind of secular drivers there. I was wondering if you could give us your -- kind of how you see that progressing through 2024.

[Deepak Nath, executive]

Yes. So regarding mitigating effects for VBP, it's restructuring around the organization, how we go to market in response to VBP, the types of actions that you expect us to take when you -- when you're faced with that kind of an impact. We've been through that in Orthopedics. We're able to offset some of the margin impact from price. Not all of it, of course. But there's things that you do commercially in terms of your channel and how you go to market, and those are the steps we expect to take.

I do want to remind the group that, in Sports, what's impacted is joint repair and certain components joint repair capital is not impacted. We're also launching REGENETEN in China. So there's a bunch of factors that are going into it. And so we will -- having experienced this with Orthopedics, we kind of have a way to adapt our commercial model in response to this, right? So that's the first question.

The second question is around CORI. I think that was the second one. So CORI, we fell short. I'd said, sitting here where I'm sitting, about 300, last year, we came in at 240. The primary delta there is China. We had expected a more robust market for CORI. And largely because of the anticorruption drive in China, there was a significant impact to the uptake of robotics. It's not us, it's just the market. That's the biggest source of the delta.

As Anne-Francoise called out, our CORI placements were above our relative share with it. So I'm actually genuinely pleased with the traction we've gotten. We saw a step-up actually in Q4, to your question about what -- what does the momentum look like? The momentum in Q4 was great, U.S., OUS.

What I'm particularly pleased about is it's not just placements, right? We're not running a strategy of place first. We're actually being much more thoughtful about placing it where there is actual demand. And one of the proxies that I look at or we look at is utilization. So we're at 25%, which is a build on when we last reported on that number. So even as our fleet is growing, our utilization is growing with it, right? And so that's what you want to see, the CORI that we're placing are, in fact, getting used.

The other thing that I like is where we're seeing CORI is being placed, and Anne-Francoise has called that out too. This has got broad appeal across a range of settings. You've heard us talk about ASCs and the resonance that it has. But it's not just there, but it's also in other places like academic medical centers. We've said that historically have not necessarily had the strongest position in AMC. What I'm particularly pleased about is the kind of traction we're getting in the academic medical centers with CORI. So that's a good thing.

And then -- and we also called out multi-unit deals. So one of the value propositions of CORI is that, given its price point, you can put multiple of these things as you outfit an entire institution. And as Anne-Francoise said, 1/3 of our deals are multiunit deals. So very encouraged by the type of traction that we're getting. We're up to nearly 800 units, robotic placements, for us, which is pretty good. But we're still in the early stages of our commercialization there. So that's the story around CORI.

And in terms of the market, obviously, last year was quite robust in recon. We fully participated in that and then some OUS markets. You see the gap narrowing relative to our competitors. In the U.S., it was more mixed in terms of our ability to participate in the market. I believe '24 will be continued strong market.

But for us, in terms of what's going to be driving growth, it's our own improvement in performance. That's far and away going to be the biggest driver of growth for us. So -- and our plans are based on normalized kind of market. So I think I answered your questions.

[Sebastien Jantet, analyst]

It's Seb Jantet with Liberum. Two questions, if I could. One, just on the revenue guidance for the year. I'm just wondering what type of headwind from a revenue perspective you baked in for VBP in Sports Medicine.

And the second one is just picking up on Advanced Wound Care. Quite a slow kind of quarter and certainly a slowdown if you look over long term in the growth rates in Advanced Wound Care. I wonder if you can comment a little bit on that and what you're doing to try and stimulate the growth there.

[Deepak Nath, executive]

Yes, sure. So on the VBP, we had said about 2% impact on Group sales is how VBP -- is what translates. In terms of Wound Care, your question was overall wound or -- Wound Care -- yes.

[Anne-Francoise Nesmes, executive]

What we've said in the presentation as well, that you should expect Joint Repair growth to be a -- impacted by about 5 percentage points. So for the full year.

[Deepak Nath, executive]

2% Group, 5% Joint Repair. For AWC, there's 2 factors. One, we're impacted by supply historically. There were periods of time when we just didn't have regular supply. And we put -- our teams were commercially on the back foot relative to that. We've had now a couple of quarters of more steady supply in Wound Care. So we are in a more front-footed posture relative to that. It takes time for us to recover some of the share we've lost there, but that is one factor.

The second is, from a product standpoint, we've made investments where there is a gap between us and competitive offerings. That will start to come through in about 18 months' time where there'll be new product offerings to make us even more competitive from a product lineup standpoint. That will continue to drive better performance.

Right now, the focus is on commercial. We're coming off of a period of interrupted supply. And so the way these things ladder up will be going forward, you should see improved AWC growth numbers.

[Richard Felton, analyst]

Richard Felton from Goldman Sachs. Two questions, please. The first one is on the medium-term margin targets and the implied step-up in '25. So thank you for the color you gave us in the presentation. One of the building blocks to better margin in 2025 was easing of inflationary pressures. So my question is, what level of visibility or confidence do you have either through hedges or your discussions with suppliers that inflationary pressures can actually ease in 2025?

And then also point of clarification on your 2025 margin expectations. Is there any FX assumption embedded in that guidance?

Then second question on free cash flow. It's obviously better performance this year. You both alluded to more to come, particularly on inventory. So as you benchmark your business either against peers, your own history, how big is that opportunity to drive better inventory performance from here?

[Deepak Nath, executive]

So the first one around inflation. Sorry, I need to reground myself. Around inflation. What I remind this group is there's about a year lag as inflation flows through our P&L -- flows through inventory and impacts our P&L. So we've got visibility now in terms of the type of contracts we're doing as part of the procurement efforts. It's one of the elements of the 12-Point Plan. We see the benefits that we're seeing through the negotiations that Anne-Francoise mentioned. So we've got some visibility to how that's coming down.

Now we've called out the impact in '24 relative to '23, which is really at comparable levels. The double-click within that is, within Orthopedics, the particular raw materials that we see, there hasn't been a lot of change from '23 to '24, right? So that part of it is going to be slower to unwind. But when you look across the portfolio, we have a reasonable sense as to how this will start to flow into our P&L 2025. So in other words, a year removed, we've got some visibility.

The second thing, around the working capital and inventory. As we've said, we have turned the corner in 2023. Our biggest challenge on inventory is in Orthopedics. So there's 2 pieces, right? There's Recon and there's Trauma. On the Recon side -- actually, this comment applies to both. Our ability to connect commercial and operations were historically not very good. We've made tremendous progress over the last 18 months in doing that. Our new S&OP process has led to a significantly better ways to connect supply and demand down at a SKU level, right? Not just in the product family or a category level. And that has been the key underpin for us to start to bring DSI down, right? And that's both Trauma and Recon.

Specifically in Trauma, a big chunk of the inventory buildup has been fueling our launch of EVOS, right? As you know, Trauma is a capital-intensive business, a particularly capital-intensive business within Orthopedics, and we're in a launch phase. Towards the latter part of the year or the second half of the year, there was AETOS as well that fueled that launch, but the bigger driver actually is in Trauma.

So we're in the big bolus of investment there, but it will continue into 2024. But our ability to kind of match demand and supply at a SKU level is a key unlock that leads to DSI. The second is our production planning itself. Where we had been previously running our factories for absorption, we're now running our factories for mixed attainment, right? And that's led us producing exactly what's needed rather than too much of the stuff we don't need and not enough of the stuff that we do need, right? So that's another key part of it. And that was great progress actually 2023 that we made.

So these factors will lead to this modest improvement, 5% improvement in DSI and Orthopedics start to gather steam and deliver as we go on, right? So we feel very good about how we're positioned in being able to drive that down as we go into '24 and '25.

[Richard Felton, analyst]

And is there any embedded assumption for FX.

[Anne-Francoise Nesmes, executive]

For FX. I was hoping you don't go back there. I don't have a crystal ball, so certainly, as you know, we hedge some of our FX. So we're guiding to a lower transactional FX impact in '24 of 30 basis points versus the 120 we've seen in '23. In '25, we assume normalize on that. That's a variable. That's part of the pluses and minuses you face when you forecast. But if I get FX right, then I'll be rich next time I talk to you.

There's some questions on the phone.

[Operator]

Our first question from the phone line is from Julien Dormois from Jefferies.

[Julien Dormois, analyst]

Thanks for taking my questions, I have 3. But before, I would just like to say [Foreign Language] while wishing John a warm welcome.

So my 3 questions related to products. The first one is on CartiHeal AGILI-C. I was just curious whether there is a timeline for the full product rollout? What is the total addressable market and whether we shall see an early contribution to Sports Medicine sales already in 2024?

The second question is you guys are -- seem to place great emphasis on the AETOS shoulder system. Is there any plan on that side of making it available with CORI? Because I think one of your competitors has just received approval for the first time robotic application on that side. So wondering whether you have similar plans on the agenda.

And my last question coming back to the knee business. I'm just curious whether you have set some sort of internal KPI for 2024 of maybe growing the knee business at or above the market growth in the U.S. specifically.

[Deepak Nath, executive]

Sure. So I'll take those. So CartiHeal is more of a midterm driver for growth. It's not -- there'll be some impact in '24, but it won't be material to the Group. Where we are right now is we're in the process of training up our organization. So we featured it in our booth in AAOS. We're putting through our reps through CartiHeal through AGILI-C training. And as we roll through the year, we expect to see traction. But in terms of a material growth driver for the Group, it's more of a midterm thing, so it's not '24.

AETOS, we're scratched -- we've just now entered shoulder on the arthroplasty side, right? AETOS is our foray into it. As we announced in AAOS, we have plans to build out a full offering into shoulder.

You've heard me comment about my level of excitement for CORI in shoulder. Its form factor is ideally suited for shoulder given its anatomy. We have a program for shoulder -- on CORI. It's roughly 2 years out before we bring it to market. It will line up with our implant portfolio coming to line. So those things will come together. So it doesn't make sense to have CORI when we don't have an implant portfolio to go with it.

So we've got a holistic program that brings up the full shoulder portfolio and take advantage of the unique applicability of CORI to that anatomy. So we're really excited about it and look for more progress as we continue.

In terms of Knee, what am I looking for in terms of market performance? What I hope to see in Knee is a trajectory that we've seen in Trauma, where about this time last year, we would have lamented our limitations on supply. In fact, the main story about this time last year was how we're exiting certain markets. Fast-forward a year, we're talking about growth in the U.S. and a key unlock on the basis of availability.

I'm expecting something like that in knee. It won't be quite as dramatic because the dynamic in knee is a bit different than trauma. But on the back of supply availability and all the other commercial things that we're doing, right? An incentive scheme aimed at growth, tighter performance management, very crystal clear set of plays that we're executing and holding our teams accountable to, and more disciplined around capital deployment, all of these things to come together to get better performance.

As to whether that will be above market in the first half of the year or not, that's for us to work out. I don't want to get into that level of detail here. But what I'm trying to give you is a sense of the building blocks that I'm looking for.

In terms of KPIs, yes, obviously, at the end of the day, we are looking for growth and growth compared to competitors as the ultimate KPI. But what I'm looking at is set turns, both for the sets that are out there, but also newly placed sets and how they're performing. I am looking at quota adherence in terms of how our reps are performing and the distribution around that. I am looking at CORI, where we're placing CORI, how CORI is being utilized, and kind of win rates and how we're doing in terms of competitive situations versus defensive or retention type of situations.

So these are some things, they're not the full set of KPIs, but gives you a feel for the types of things we're looking at for a turnaround in knee performance. I hope those answer your questions, Julien.

[Operator]

Our next question is from Lisa Clive from Bernstein.

[Lisa Clive, analyst]

Just 2 questions for me. First of all, given all the movements in VBP in China, can you just remind us of what your exposure is in Wound in case it goes in that direction? I know at least for 2022 China was 6% of your total sales. If you could just let us know for wound whether that's sort of a higher proportion or not. And also, if you could comment on what proportion of sales in China wound are into hospitals, or whether you have a sort of self-pay segment in the community as well.

And then next question is, given all the changes in your sales force in the U.S., can you just give us an overarching view of how it is set up today? Is sports medicine totally separate from Ortho? Within Ortho, is Recon separate from Trauma? How do Extremities fit in? And then also, I guess, in terms of the structure of those reps, are they direct employees? I know some companies do it differently. I'm just trying to understand sort of what it looks like. I know Smith & Nephew has tried a bunch of different structures in the past. So just trying to figure out why the new setup should be the sort of winning formula.

[Deepak Nath, executive]

Sure. Lisa, so VBP and Wound, our position in Wound is relatively small in China. Certainly, from a Group standpoint, it would not be hugely material. In contrast to Sports, where we were the market leader, in Ortho, we were the market leader, so VBP implementation had significant impact not only to their businesses, but also to a Group level. In Wound, we're not positioned in that way. Good news, bad news story.

In terms of our sales, I'll need to get back to you in detail, we'll do that. But I believe the majority of our sales are to hospitals versus self-pay. But let me confirm that with you, Lisa, post...

[Anne-Francoise Nesmes, executive]

We have a smaller portion of retail.

[Deepak Nath, executive]

Right. In terms of sales force, we do have distinct sales forces for Trauma and Recon. And we have distinct sales forces for Sports and Recon. Now there's, of course, some geographies somewhere where there is some overlap. So there are certain parts, if you will, in the U.S., where there's Trauma and Recon go together. There are certain distributors that we have that carry both Trauma and Recon. So there are those exceptions. By and large, they are distinct sales forces, both -- I think you asked -- the question was around the U.S. It's certainly true in the U.S.

In terms of direct versus 1099s or agents, our Sports is primarily direct. Our Orthopedics is a mix. I don't know that I certainly want to give you that mix, but it's a mix between direct and distributors. Obviously, as you know, you can make any model work, but that is a difference between our Sports versus our Ortho.

And then in terms of Extremities, that is combined with our Trauma sales force. In other words, we don't have a shoulder specific sales force, at least not at the moment. So that's, I think, the rough answer to your question. If I missed anything, let me know, Lisa.

[Lisa Clive, analyst]

No, that's super helpful. And leading from that, given this gradual shift for recon procedures in ASCs, could you talk about what that looks like? Are these surgeons who may be doing 70% of their procedures in a hospital, but then may do 30% in an outpatient setting? Is it -- how -- I'm just trying to understand sort of which reps are servicing that growing area. And also given your comments around potential sort of cross-selling opportunities, Sports Medicine and Recon are distinct. I know some surgeons will do sort of a little bit of each. But just trying to understand sort of how you're capitalizing on that potential new opportunities.

[Deepak Nath, executive]

So we've got a ton of experience in ASCs. About 40% of our sports business flows through the ASCs already. So we've got quite a bit of experience in that channel. And as you note, there's more and more joint replacements that are moving into that channel. And recognizing that, we've called that out as one of the elements of the 12-Point Plan.

We noted the progress -- we start off at a good place in '22. We've built upon that in '23 where we -- I think we tripled the number of deals that we did. Now it sounds great, but it's still a fairly modest thing in the universe of all deals that could be done. But we're pleased with the progress and the traction we're getting.

We're also the only ortho company to have a significant sports business that's well represented in the ASC. So we know the channel well and there are cross-selling opportunities. But having said that, there are distinct surgeon groups that do them. There's, of course, there's always surgeons that do both procedures, but by and large, the distinct surgeons that do replacements versus Sports cases.

So we're particularly excited about the prospects there. CORI, as we've called out in previous forums like this, has resonance across the board, but in particular, in ASCs given its price point, given its form factor, it -- there's a very compelling value proposition for CORI. So as we start to capitalize on the trend of procedures moving into the ASC, we've got in CORI great vehicle or catalyst to start to be competitive in that segment.

What we're seeing as we look at our business in the ASC channel versus our hospital channel, we're seeing a relatively higher performance in ASC relative to our overall average share position. So it's early days yet, but I'm kind of pleased with the traction that we're getting there.

But we do need to keep a focus. There's a lot going on. It's a highly dynamic market. I like the way we're positioned. But we, of course, have to execute commercially to take advantage of the opportunity. But the building blocks for us to do that are there. CORI and Recon, a strong presence already in that channel through our Sports position and a fundamental value proposition that seeks to tie those things together where it makes sense.

[Operator]

Our last question we have time for today is from Sezgi Ozener from HSBC.

[Sezgi Oezener, analyst]

Just 2, please. First of all, on China in CORI. You said there is, of course, an impact from the Integra. How is it -- have the sales completely come to in halt? Or are you selling at a much slower pace? And also going forward, what's your target in terms of out of U.S. CORI placements? That was my first question.

And the second one, on sales incentives, you said that had an impact on the churn, and you're trying to replace that through equipment. Have you more observed the sales force going to competition? And would you be reacting in terms of changing the incentive structure to that? Or would you be reacting by completely hiring new force that adjusts to the current systems -- incentive systems?

[Deepak Nath, executive]

Yes. So China, CORI, it's primarily a market effect. So when we look at how many quarries we did place relative to the number of robotic placements that happened in China, we were doing very, very well relative to our share. These are small numbers. So it isn't necessarily a value proposition question for CORI in China, but rather an overall adoption of robotics in the orthopedic space. So that's by far and away the effect in China.

OUS versus U.S., we're already the #1 robotic -- CORI is the #1 robotic system in EMEA already. That was the case in '23, we built upon that -- in '22 that was -- we built upon that position in '23. So we're looking to capitalize on the opportunities there.

We have targets internally, of course, but not something that I'd want to kind of put out there in a public sphere. But suffice it to say that the value proposition of CORI is quite strong in a range of settings within the U.S., but also in a range of health care systems.

In terms of incentives, it's incentives and also tighter performance management that led to the churn. We expected that. It just came kind of later in the year than we thought would happen.

In terms of how we respond to it, the solution is not a structural change. We went through a structure change in terms of going to a more business unit first model compared to a matrix model that we had run, primarily impacted the OUS geographies. We're not looking to make further changes from a structure standpoint. We've got a structure that, at least, that I'm happy with. And it's more about trying to have the best organization that we possibly can.

In terms of where our reps are going, there's a range of things. Some going to competitors, some going into other fields. And in terms of our response to that, I don't know that I want to necessarily spell that out other than we've got a great recruitment pipeline, and I expect that we'll have a great -- we have a great team already we're looking to add to that team as we move forward.

[Sezgi Oezener, analyst]

That's very helpful. Thank you.

[Deepak Nath, executive]

You're welcome. Okay. That's a wrap. Thank you very much. Appreciate the attention and engagement.