AxoGen Inc

NASDAQ:AXGN

Earnings Call Analysis

Company Revenue Jumps 18.7%, Aiming 11-14% Growth

The company announced a revenue of $42.9 million for the quarter, marking an 18.7% increase from the previous year. This boost was due to a 10.5% increase in unit volume, a 4.9% improvement in product mix, and a 3.3% rise in pricing. Growth was particularly strong in scheduled procedures, which surged over 25%, while emergent trauma, accounting for about half the revenue, grew by a mid-single-digit percentage. Gross profit climbed to $33.8 million from $30 million, but gross margin fell from 83% to 78.7%, largely due to new facility costs. Operating expenses rose 3.7% to $37 million as sales and marketing expenses grew 11.6% to $22.2 million. However, sales productivity improved, and R&D costs upped by 7.2% to $7.3 million due to regulatory submission costs. The company concluded the quarter with a net loss of $3.9 million, improved from a prior $5.4 million loss, and presented 2024 revenue guidance anticipating a growth rate of 11% to 14%.

Progressing Towards Regulatory Milestones

The company completed a critical pre-Biologics License Application (BLA) meeting with the FDA, paving the way for a Q3 2024 BLA filing and a mid-2025 product approval expectation, indicative of positive regulatory progression.

Solid Revenue Growth with Diverse Drivers

A year-over-year revenue increase of 18.7% to $42.9 million for the quarter was reported, reflecting balanced growth across multiple categories, including a 10.5% rise in unit volume, 4.9% from product mix improvements, and a 3.3% price increment. This growth comes amidst a backdrop of expanding market segments, with emergent trauma procedures and scheduled procedures each contributing to half of the total revenue.

Anticipating Profitable Horizons

Management provided a full-year guidance for 2024, expecting revenues to be between $177 million and $181 million, translating to an 11% to 14% growth rate, a conservative estimate reflecting the company's commitment to measured growth.

Enhanced Productivity without Team Expansion

Growth strategies include improving the productivity of the existing sales team rather than significantly expanding it. The focus remains on cultivating core accounts, suggesting an emphasis on the quality of relationships rather than quantity.

Navigating Market Dynamics in Trauma and Scheduled Procedures

Projected growth in trauma, a significant market segment, is hampered due to its unscheduled nature and the sporadic schedules of surgeons. Conversely, the scheduled nature of non-trauma procedures allows for faster adoption and planning. As the company balances its portfolio between trauma and scheduled cases, a shift in sales seasonality and cadence is anticipated.

Leveraging Regulatory Approval for Market Penetration

With the BLA's submission and anticipated approval, the focus is also on post-approval commercialization. Regulatory achievements, coupled with clinical data, aim to standardize the company's offerings in treatment algorithms and facilitate negotiations with payers.

Sustained Growth in Early 2024

The company has witnessed a robust expansion across all application areas in the scheduled procedures category and maintains a positive trajectory entering Q1 of 2024.

Expanding the Pool of Potential Core Accounts

A base of 1,006 active accounts, which have made at least six orders in the previous year, sets the stage for a focused effort to transition them into higher revenue-generating core accounts. This underpins a strategic approach of deep market penetration rather than broad-scale expansion.

Diversified Use of Product Portfolio

There is an indication that most core accounts already use more than one of the company’s products. However, there is still an opportunity to increase product penetration across the wide spectrum of trauma types.

Earnings Call Transcript 2023-Q4

[Operator]

Hello, and welcome to the AxoGen, Inc. 2023 Fourth Quarter and Full Year Financial Results Conference Call and Webcast. [Operator Instructions]

As a reminder, this conference is being recorded.

It's now my pleasure to turn the call over to Harold Tamayo, Vice President, Finance and Investor Relations. Harold, you may now begin.

[Harold D. Tamayo, executive]

Thank you, Kevin, and good morning, everyone. Joining me on today's call is Karen Zaderej, AxoGen's Chairman, Chief Executive Officer and President; and Nir Naor, Chief Financial Officer. Karen will discuss the quarter and full year 2023, and Nir will provide an analysis of our financial performance guidance and discuss our outlook for the year, followed by a question-and-answer session.

Today's call is being broadcast live via webcast, which is available on the Investors section of the AxoGen website. Following the end of the live call, a replay will be available in the Investors section of the company's website at www.axogeninc.com.

Before we get started, I'd like to remind you that during this conference call, the company will make projections and forward-looking statements, including our expectations regarding our ability to expand our footprint, expand core accounts, anticipate growth for revenue categories, penetration of core accounts, marketing opportunities with nerve applications associated with emergent trauma, breast, OMF and surgical treatment of pain and new products.

Our expectations regarding the timing of our launch for Avive+, our statement regarding the timing of the complete biologics license application submission for Avance Nerve Graft, as well as statements of the timing of the approved BLA. Our expectation is that assuming approved the BLA Avance Nerve Graft will be designated as the reference product and expected market exclusivity of such designation.

Our belief that our balance sheet will continue to be sufficient to bridge through to cash flow breakeven and longer-term profitability. Our expectation is that we will continue trending towards cash flow breakeven, and our belief that trends towards operating leverage will allow us to maintain a strong balance sheet position and provide ample support as we work towards profitability.

Forward-looking statements are based on current beliefs and assumptions and are not guarantees of future performance and are subject to risks and uncertainties, including not without limitation, the risks and uncertainties reflected in the company's annual and periodic reports such as hospital staffing issues, regulatory processes and approvals, surgeon and product adoption and market awareness of our products.

The forward-looking statements are representative only as of the date they are made and as said as required by applicable law. We assume no responsibility to publicly update or revise any forward-looking statements.

In addition, for a reconciliation of non-GAAP measures, please reference today's press release and our corporate presentation on the Investors section of the company's website.

Now I would like to turn the call over to Karen. Karen?

[Karen Zaderej, executive]

Thank you, Harold. And thank you all for joining us today as we discuss our 2023 Fourth Quarter and Full Year financial results.

2023 was a solid year of key accomplishments, and we entered 2024 with a strong commercialization strategy, fueled by innovation and focused execution by our sales team. Full year 2023 revenue was $159 million, a 14.7% increase compared to 2022. In the back half of 2023, we saw improved commercial execution, and during this period, we estimate that revenue from our emergent trauma procedures grew in the mid-single digits, and revenue from scheduled procedures grew above 25% as compared to the same period in 2022.

As a reminder, these estimates of procedure categories are based on available data received from hospitals and sales reps and assumptions regarding specific surgeon practices and account information, and as such, are subject to the limitations of the data received and our assumptions.

We're pleased with our progress and execution as we drive long-term growth, leveraging innovation clinical data, surgeon education and patient activation. We're appreciative of our ongoing surgeon engagement and feedback as they continue to integrate AxoGuard HA+ into their nerve protection algorithm, finding differentiated applications as compared to AxoGuard classic. We're confident that AxoGuard HA+ will expand the adoption of nerve protection products and will help more patients with nerve injuries.

Additionally, we're continuing to expand our offering for nerve protection with Avive+ Soft Tissue Matrix, which we anticipate will be commercially available in the second quarter of 2024. Avive+ is a resorbable nerve protection product that functions as a barrier, providing temporary protection and tissue separation during the critical phase of healing for nerve injuries. We believe Avive+ will be regulated as a Section 361 tissue product and will further strengthen our position in nerve protection, supporting emergent trauma and the surgical treatment of pain.

In 2023, we also launched our Resensation breast neurotization technique for women who choose an implant-based reconstruction. We believe this innovative technique could apply to an additional 10% to 15% of all breast reconstruction patients. We're pleased with the surgeon engagement, positive feedback from our educational programs, and the early adoption of this new technique. This approach will allow more patients to have the opportunity for sensory restoration, following their mastectomy and reconstruction.

In August, the RECON study was published in the Journal of Hand Surgery. The publication includes the authors' analysis of the results, which found that Avance returned a greater degree of functional recoveries and conduits, and superiority was demonstrated as gap length increased. We believe that this addition of Level 1 evidence supporting the efficacy of Avance Nerve Graft and published literature continues to play an important role in surgeon clinical decision-making, especially with middle adopter surgeons. This study adds to a strong pool of clinical evidence supporting Avance Nerve Graft.

In combination with the recent publications of the meta analysis, the premier all payers cost comparison study and the U.S. cost-effectiveness analysis, these 4 studies provide a package of compelling evidence for both clinicians and payers.

During the year, we completed the validation and transitioned into our new processing facility near Dayton, Ohio. This facility was designed for long-term growth and expansion, providing 3x our previous capacity. This new facility will also support our BLA for Avance Nerve Graft.

Now turning to our fourth quarter results. We're pleased with our performance during the quarter. Revenue from the quarter increased by 18.7% to $42.9 million compared to last year. We estimate that revenue from the emergent trauma represented approximately half of total revenue and grew mid-single digits compared to last year.

As a reminder, emergent trauma generally results from injuries that initially present in an ER. These procedures are typically referred to and completed by a specialist either immediately or within a few days following the initial injury.

We believe scheduled procedures also represented approximately half of total revenue. During the quarter, we estimate that this category grew more than 25% versus the prior year. As a reminder, scheduled procedures are generally characterized as procedures where a patient is seeking relief of a nerve condition caused by a nerve defect or surgical procedure. These include breast reconstruction following a mastectomy, nerve reconstruction following the surgical removal of a painful neuroma, nerve decompression, and oral and maxillofacial procedures such as a mandible reconstruction.

Strength in this category reflects the opportunity to provide improved quality of life outcomes for patients, compelling clinical data, effective surgeon education and implementation of patient activation programs.

As mentioned in today's press release, our growth strategy continues to be focused on going deeper into core accounts where we see significant opportunity to expand our footprint. As a reminder, Core Accounts are defined as those generating more than $100,000 in revenue over the trailing 12 months. Revenues from Core Accounts represent approximately 65% of total revenue. Growth was primarily driven by increased productivity of our direct sales force as they gain deeper surgeon adoption and expanded use cases of our products within these Core Accounts.

We ended the fourth quarter with 116 direct sales representatives, up 1% from a year ago and flat sequentially. We will continue to evaluate and add sales reps as their territories approach targeted levels. Our direct sales force is supplemented by independent sales agencies that represent approximately 10% of our total revenue.

In Q4, growth was broad-based across all applications and products. We were pleased by the contributions from innovation in new products and new applications. We continue to raise awareness of the need for nerve protection and saw expanded use of AxoGuard HA+ across both emergent and scheduled procedures. We also saw strong surgeon and patient interest in neurotization and implant-based breast reconstruction and expanded the number of surgical teams trained in this important new application.

Moving on to updates on our growing body of clinical evidence. Over the years, we've made significant investments to develop quality clinical evidence to demonstrate the safety performance, economics and utility of our nerve repair solutions. Our active clinical programs are progressing as expected. At the end of the quarter, we have 245 peer-reviewed publications, including trauma, breast, OMF and pain. This January, we announced positive top line results from the REPOSE clinical study, comparing the standard of care neurectomy of symptomatic neuroma to neurectomy and protection of the terminated nerve end with AxoGuard Nerve Cap. This post-marketing study met its primary endpoint for reduction of pain as measured by the visual analog scale.

In addition, the study investigators found that over the full 12-month course of follow-up, AxoGuard Nerve Cap demonstrated statistical superiority for reduction in total pain reported by the subjects as compared to the standard of care neurectomy. We believe that these findings will play an important role in surgeon clinical decision making.

Now turning to the BLA for Avance Nerve Graft. We've recently completed our productive pre-BLA meeting with the FDA. We're encouraged by the positive interactions and have aligned with the FDA on a rolling submission process and the content of the modules for submission. We now anticipate the filing to be completed in Q3 of 2024, with potential approval in mid-2025.

As a reminder, a BLA approval will complete the regulatory transition of Avance Nerve Graft from a 361 tissue product to a 351 biological product. Importantly, we believe Avance will be designated as the reference product for potential biosimilars, providing 12 years of market exclusivity. With over 100,000 Avance Nerve Graft implanted since launch, we are well positioned to continue to lead and innovate in the large and developing peripheral nerve repair market. I'm proud of our team, and I look forward to continuing our mission of revolutionizing the science of nerve repair.

Now I'll turn the call over to Nir to provide a review of our financial highlights and guidance. Nir?

[Nir Naor, executive]

Thank you, Karen. I'm very happy to participate in my first call. It's been great 3 months ramping up and meeting people on the team. I'm very excited about the AxoGen story and the potential of the company.

And moving to the financial results. For this quarter, our revenue reached $42.9 million, [indiscernible] 18.7% growth from the fourth quarter of 2022. This growth is attributed to a 10.5% increase in unit volume, added with a 4.9% mix favorability, and a 3.3% increase in price. We estimate that revenue for emergent trauma represented approximately half of total revenue and grew mid-single digits compared to last year. We estimate that revenue from scheduled procedures represented approximately half of total revenue. During the quarter, we estimate that this category grew more than 25% versus the prior year.

Our gross profit for the quarter was $33.8 million, an increase from the $30 million recorded in the fourth quarter of 2022. This represents gross margin of 78.7%, down from 83% in the same period last year. This change is mainly driven by the costs associated with starting tissue processing at our new facility.

Our total operating expenses for the quarter increased by 3.7% to $37 million, up from $35.6 million in Q4 of 2022. Specifically, our sales and marketing expenses for the fourth quarter grew by 11.6% to $22.2 million.

Sales and marketing expenses as a percentage of total revenue decreased to 51.7% from 55% in the fourth quarter of 2022 as we saw improved sales force productivity.

Research and development expenses increased by 7.2% to $7.3 million from $6.8 million in 2022, driven by costs related to the BLA. As a percentage of total revenues, total R&D expenses reduced to 17%, down from 18.8% in the last quarter of the previous year.

General and administrative expenses decreased by 16.3% to $7.5 million in Q4 of 2023 from $8.9 million in Q4 of 2022, driven mainly by stock com forfeitures due to the departure of executives from our company.

The quarter ended with a net loss of $3.9 million or $0.09 per share, compared to a net loss of $5.4 million or $0.13 per share in the fourth quarter of 2022. However, we recorded an adjusted net loss of $2.6 million for the quarter, translating to roughly $0.06 per share, a shift from an adjusted net loss of $1.1 million or $0.03 per share in the same period last year, driven in part by onetime severance costs.

Adjusted fourth quarter EBITDA was $0.6 million compared to an adjusted EBITDA loss of $0.7 million in the prior year. As of December 31, our balance of cash, cash equivalents and investments was $37 million compared to $38.6 million at the end of the third quarter.

Turning now to our guidance. As outlined in today's press release, we are issuing our full year guidance for 2024. We expect revenue to be in the range of $177 million to $181 million, which represents an annual growth rate of approximately 11% to 14%.

Additionally, we anticipate gross margin for the full year to be in the range of 76% to 79%. In the future, we expect our gross margin to benefit from improved capacity utilization of our new processing facility and as sales volume of Avance increases.

And in summary, we're pleased with our fourth quarter performance. We will continue to execute our strategies, investment innovation, improve our productivity and drive towards cash flow breakeven and profitability.

And this time, we'd like to open the line for questions. Kevin?

[Operator]

[Operator Instructions] Our first question today is coming from Chris Pasquale from Nephron.

[Christopher Pasquale, analyst]

Karen, Avive was annualizing at close to $8 million in sales before you pulled it off the market. Is there any reason to think that Avive+ won't ramp to that same level relatively quickly? And how do you think about how much of that is incremental versus cannibalistic to your existing portfolio?

[Karen Zaderej, executive]

Yes. Just to remind people Avive and Avive+, we previously had a product that we launched that was Avive that we withdrew because of changes in regulatory classifications from the FDA, and we've launched Avive+ to help move back into that segment of a temporary protection barrier, which we think is an important tool for surgeons.

I don't think it's going to be an immediate ramp up, so I don't want to overplay that as something that's going to completely pop into this next few quarters. We do have some surgeons who are very anxious to get this product because they used it -- they used the prior Avive product as an important part of their nerve treatment algorithm. So I'd be more cautious than that and just say I think it's going to continue to help complement the protection business that we have and allow us to continue to see growth overall in protection but it won't ramp immediately up into that size of revenue.

There is some cannibalization. Surgeons had to turn to another tool when they no longer had Avive on the market. So there will be some cannibalization where the surgeons were using alternatives of our other products to try and still provide some protection for their nerves. But we do think most of the Avive business will be a new business for us. So it will -- while there will be some cannibalization, it will be predominantly new.

[Christopher Pasquale, analyst]

And then Nir, just a question about the cadence of gross margin during 2024. The guidance is a little bit lower than what we were thinking. I'm assuming that's related to the new facility. Can you give us some sense of what the first half looks like versus the second? And whether you see a pathway back to the 82%, 83% margins the company enjoyed a year ago.

[Nir Naor, executive]

So yes, so indeed, as we mentioned, we fully transitioned to the new processing facility end of last year. It is an important milestone for BLA. It is designed for long-term growth and basically has capacity, which is 3x our previous one, which is very good for long-term potential and the margin, that said, in the short term, it's running at a fraction of its total capacity. And this is one of the drivers for the lower margin.

And we're ramping it up, learning about the various benefits of capacity and other efficiencies. That said, we wanted to give guidance that we feel fully confident with. We expect the margin probably in the later half of the year to be on the lower side versus the first half of the year. Nonetheless, this is our average. And then long term, definitely, we expect the margin to benefit from higher sales, higher production and higher capacity utilization.

[Christopher Pasquale, analyst]

Sorry. So just to confirm, we should expect sequential decreases in gross margin through the year? Not a first half dip and then a second half rebound?

[Nir Naor, executive]

Right. I mean, basically, we're selling an old inventory, which was produced in the prior -- the previous facility. So this is why the second year might be a bit lower. But again, we're learning all of those impacts, as I said, of the new facility. And for the total year, our guidance was -- we said 76% to 79%, with definitely a clear expectation for improvement in the longer term.

[Operator]

Next question is coming from Mike Sarcone from Jefferies.

[Michael Sarcone, analyst]

I guess just to start on the guidance, the 11% to 14%, can you just talk about what's baked in, in terms of scenarios and health care utilization environment at the low and high ends of the range?

[Karen Zaderej, executive]

Yes. So we're looking at continuing to see measured growth through the year, driven predominantly by productivity improvements with our existing sales team. So think of it as about the same number of reps, maybe up or down a few, but in the same side, not a big expansion of sales team, so it's driven by productivity, and a real focus in driving that growth in our Core Accounts.

So that's our strategy. That's how we think we're continuing to build this out. And we drawn that out and have taken what we think is a measured approach in thinking about our overall growth.

[Michael Sarcone, analyst]

Okay. And I guess, can you provide any color on how you're thinking of the growth differential in 2024 between emergent trauma and scheduled nontrauma? Can you break that out for us or help us think about that?

[Karen Zaderej, executive]

Well, as we've talked about before, we think the conversion process in trauma, well, it's a very large market, it's just hampered by the very nature of the fact that it's an unscheduled procedure, and surgeons don't take trauma call every day in a given month. And so we think that the trauma growth will continue to be paced through continued growth but having to reach those surgeons in a longer time frame with a greater number of adoption steps.

In scheduled procedures, by the very nature of the fact that they're scheduled, you can plan to be with the surgeon as they adopt a new technology, work with them in those cases and help change their practice patterns over a more discrete amount of time. So we think the adoption process and scheduled cases can be more rapid than what you see in trauma. So it's a blend of those 2 that is what made up our overall guidance.

[Michael Sarcone, analyst]

And maybe if I could just squeeze one last one in. Can you maybe just elaborate on how you're thinking about seasonality and sales cadence through the year?

[Karen Zaderej, executive]

Yes. Great question. So as we've talked about in the past, trauma is -- has a peak during the time periods where people are more active. And so as our business was originally trauma, you saw a cadence where first quarter to second quarter, there was a big jump up. Second quarter to third quarter, there was another jump up. And then it was basically flat to down in fourth quarter, and then sequentially, again, flat to down into the first quarter of the next year.

Scheduled cases don't follow that cadence. So you're seeing some shifts in our cadence and seasonality, where scheduled cases will be driven, like most other elective scheduled procedures, they tend to be heavy towards the end of the year. A little slight nuance difference for breast reconstruction, where many women prefer not to have their breast reconstruction during that holiday period.

But in most scheduled elective procedures, you'll see a push towards the end of the year and it will be a little bit lighter at the beginning of the year and then more of a steady slope through the -- throughout the year.

So again, we're going to see some shifts over time in the cadence quarter-to-quarter as we balance between trauma and scheduled cases.

[Operator]

Next question today is coming from Mike Kratky from Leerink Partners.

[Michael Kratky, analyst]

Great to see the agency alignment on the Avance BLA. What's the latest you've been hearing from KOLs and physicians on the extent to which having that ultimate BLA approval could really drive higher utilization? And what are the key factors that are driving that?

[Karen Zaderej, executive]

Well, we're really excited about continuing to move forward in getting to the final stage of our submission on the BLA. It's been a long process for us. So we had a very productive meeting with the FDA that we think laid out a clear path for us as we go forward. So yes, we are turning our sights not just to the submission, but to our commercialization post-BLA.

Look, from a surgeon standpoint, the surgeons really care more about the data, and that RECON publication, then they care about the regulatory classification of a particular product. But we do think, it will be helpful to continue to drive standardization, especially with middle adopters and accounts as, again, becoming a premium standard product that they use in their nerve protection algorithm.

We also think that having the BLA, and again, the data will be helpful as we continue to work with payers to make sure that Avance is listed as nonexperimental on payers' algorithms.

So we think that it will continue to be helpful as we continue to grow. But the first step actually -- was actually getting this recent publication of the RECON data, which we're wanting to make sure that surgeons sees so they can make an informed choice in their clinical decision-making.

[Michael Kratky, analyst]

Got it. Yes, that makes sense. And then maybe just one separate one. You saw a great growth in the scheduled procedures in 4Q. Would be curious if you could provide some additional color on which procedures within that category were driving some of that growth? And whether you've seen some of that momentum continue so far in early 2024?

[Karen Zaderej, executive]

Well, all -- I mentioned in the script, all of our application areas grew. So we were really pleased across all of the areas and with all of our products. So it wasn't one hit, it's really for us to continue to develop and grow out this market. And we've seen continued enthusiasm for that growth and expansion in -- as we've entered here into Q1.

[Operator]

Next question is coming from Caitlin Cronin from Canaccord Genuity.

[Caitlin Cronin, analyst]

Congrats on a great quarter. Just to start with 2024 guidance, it seems to imply a deceleration year-over-year at the midpoint, even though it seems like scheduled procedure growth has seemed to tick up. Any kind of reason for that? And where do you think the mix between scheduled and emergent trauma could trend really over time?

[Karen Zaderej, executive]

Well, again, I think we're taking a measured approach. We looked at this not just on them, we had great momentum coming out of the year, but really looking at the total year to take a measured approach and think about our overall guidance. And so that was the thinking behind it. Again, so far, we've been pleased how we saw the beginning of the year, but we're wanting not to get out over our skis on this.

[Caitlin Cronin, analyst]

Okay. Makes sense. And where did Active Accounts end for the year?

[Karen Zaderej, executive]

Can somebody pull up the Active Account number for me. So we generally are focusing and it will be in the deck that we'll get out. But we're generally focusing on the Core Accounts because that's where the majority of our revenue comes from, it's from those Core Accounts. But of course Active Accounts grow into Core Accounts. So it's important to make sure that we have that feeder pool of Active Accounts. But our real focus is on thinking about how can we take these accounts to be $100,000 or bigger so that we can continue to go deeper and become a standard of care in those Core Accounts.

If you remember, an Active Account is a pretty low threshold. It means that we had only 6 orders in the past 12 months. Basically what it says is you're through the back committee, and you've got a surgeon who has started to use the product in some small way, but it may not be a focus or target account for us. So we had 1,006 Active Accounts. So we have a very good pool to continue to build from as we drive those Core Accounts and build a bigger base.

[Operator]

Next question today is coming from Dave Turkaly from Citizens JMP.

[David Turkaly, analyst]

I just wondered if you may provide us a little additional detail. When you look at the 367 Core Accounts, like how many of them are using more than 1 AxoGen product or how many of them -- are there accounts that are doing the trauma procedures as well as the scheduled, and how kind of popular or how common is that?

[Karen Zaderej, executive]

Yes. So it's going to be hard to answer that because it's some of all of those things. Look, most of our Core Accounts use more than 1 product, but they -- most are not fully penetrated that they use all of our products in all of the applications and algorithms. So -- and by that, I mean, in trauma, remember that there's a lot -- we call trauma one thing, but there's a lot of different types of trauma. So a surgeon will adopt initially in sort of short digital nerve injuries and work their way up to complex mixed and motor injuries across a stair step process of adoption. And most of our accounts are at an early stage of penetration. That's why we think we want to continue to focus on that Core Accounts and become a standard of care in those Core Accounts.

There are some Core Accounts that are trauma only. There are some Core Accounts that are scheduled procedures only. And so it is still -- you get a foothold with one surgeon. That's generally what it takes to become a Core Account, is one surgeon who will then be about $100,000 in revenue. And the rep's job is to continue to expand out to other surgeons across all of the applications. And so because the threshold is only $100,000, like I said, there can be a Core Account, there can be one surgeon that takes trauma call, and that could be a Core Account, but we got a lot of opportunity to build it from there.

[David Turkaly, analyst]

And then maybe one for Nir. Congrats on the progress on the bottom line. I guess, as we're looking into next year, I assume probably not adjusted EBITDA positive for the full year, but maybe trending in that direction. I was wondering if you can make any comment on sort of what you think that EBITDA loss might look like or maybe compared to what '23 was directionally? Any help there would be great.

[Nir Naor, executive]

Yes. I mean, we -- yes, those are specific figures. But I would say a couple of things that I would be looking at. Revenue growth and benefit of the operational leverage and the economies of scale, I think this is the most important thing. In addition to that, better and continued focus on resource allocation, sales force productivity. In addition to that, a couple of tailwinds, one of them impacting the EBITDA and the other one, the cash balance, but the royalties on Avance is that we have been paying for the past couple of years grown a bit over $3 million in 2023, they rolled off at the end of 2023.

So those are sort of the high-level levers that I would be looking at when you're looking at the improvement from last year to this year when it comes to bottom line.

[Operator]

[Operator Instructions] Our next question is coming from Ross Osborn from Cantor Fitzgerald.

[Ross Osborn, analyst]

So in your prepared remarks, you mentioned seeing AxoGuard HA+ being used in new types of cases versus classic offering. Could you maybe just walk us through some of those use cases?

[Karen Zaderej, executive]

Sure. One of the things we're really excited about AxoGuard HA+ is the HA layers provide a slippery gliding surface. So when you think about your extremities and where you need to bend or move, that slippery layer helps when a nerve is going around a large joint. So elbows, knees, hips, those are all areas where that gliding surface can be important to make sure that the nerve remains free from attachments and can move smoothly across and through that joint.

And so that's one of the big areas that we see surgeons really seeing a great application for the AxoGuard HA+. So we continue to see be interested in how they're using it, seeing some great applications in those areas where they want to have that gliding surface and getting some very positive feedback about the product.

[Ross Osborn, analyst]

Okay. Great. And then maybe lastly for us, just on OpEx. So it sounds like higher, maybe minimal this year in terms of sales reps. But would you walk us through any new or expanded marketing initiatives? And also remind us puts and takes on the R&D line, please?

[Karen Zaderej, executive]

Yes. We -- think of it as from a sales rep number that we will stay very close to that 116 number maybe up or down a few reps from that, but it will stay very close to the 116 number.

In terms of new things, again, we've already talked about the Avive+, which will be coming up here shortly. So we'll have a new product, continuing to focus in different parts of nerve protection.

We aren't looking at anything here in the short term of a big launch in a new application, but we are doing continued development work in several application areas and see that the opportunity for nerve repair is pretty expansive because nerves run all over the body and are injured in many types of procedures. And so we have a medical affairs team that really focuses on advanced techniques in nerve repair and looking at new expansion areas.

So at this point, I don't have anything that I want to tell you is a confirmed expansion area, but to say that our R&D team continues to work on it and see some promising new areas for us to look into.

[Operator]

Thank you. We've reached the end of our question-and-answer session. I'd like to turn the floor back over to Karen for any further or closing comments.

[Karen Zaderej, executive]

Well, thank you. As we conclude today's earnings call, I want to express my appreciation to our team for their exceptional efforts, and all the participants for your attention and contributions.

The dedication of our staff has been pivotal in achieving the milestones we discussed today, and we look forward to sharing our continued progress with you in the future.

[Operator]

Thank you. That does conclude today's teleconference webcast. You may disconnect your line at this time, and have a wonderful day. We thank you for your participation today.