Orthofix Medical Inc

NASDAQ:OFIX

Earnings Call Analysis

Earnings Call Transcript 2023-Q3

[Operator]

Hello. Good afternoon, and welcome to the Orthofix Third Quarter Earnings Conference Call. [Operator Instructions] As a reminder, this call is being recorded for replay purposes.

I would now like to turn the call over to Louisa Smith from the Gilmartin Group for a few introductory comments.

[Louisa Smith]

Thank you, operator, and good afternoon, everyone. Welcome to the Orthofix Third Quarter 2023 Earnings Call. Joining me on the call today are Board of Directors Chair and Interim Chief Executive Officer, Catherine Burzik; and Interim Chief Financial Officer, Geoff Gillespie.

During this call, we will make forward-looking statements that involve risks and uncertainties. All statements other than those of historical facts are forward-looking statements including any earnings guidance we provide and any statements about our plans, beliefs, strategies, expectations, goals or objectives. Investors are cautioned not to place undue reliance on such forward-looking statements as there is no assurance that the matter contained in such statements will occur.

The forward-looking statements we will make on today's call are based on our beliefs and expectations as of today, November 8, 2023. We do not undertake any obligation to revise or update such forward-looking statements. Some factors that could cause actual results to materially differ from the forward-looking statements made by us on the call include risk factors disclosed under the heading Risk Factors in our Form 10-K for the year ended December 31, 2022, and Form 10-Q filed this afternoon, November 8, 2023, as well as additional SEC filings we make in the future.

In addition, on today's call, we will refer to various non-GAAP financial measures. We believe that in order to properly understand our short-term and long-term financial trends, Investors may wish to review these matters as a supplement to the financial measures determined in accordance with U.S. GAAP. Please refer to today's news release announcing our third quarter 2023 results for reconciliations of these non-GAAP financial measures to our U.S. GAAP financial results.

At this point, I will turn the call over to Cathy.

[Catherine Burzik, executive]

Thank you, Louisa, and thank you, everyone, for joining us this afternoon. On today's call, I will review the highlights of the third quarter results, followed by a more detailed look at the performance of our business units, and then finish with some operational comments. Geoff Gillespie will review our financial results, and we will conclude with a question-and-answer session.

Let me begin by saying that we're very pleased that our business has operated smoothly since the management transition announcement in September. I am extraordinarily proud of the commitment of our employees and grateful for the support of our distributors and surgeons. Our company is continuing to build on the momentum we have fostered since the business combination was finalized in January. And simply put, we have not taken our foot off the gas throughout the period of transition.

Our leadership team is highly capable and I have the utmost confidence in our ability to capture market share, deliver value and execute on a long-term vision of the company. The search for a permanent CEO is underway led by the well-regarded executive search firm, Heidrick & Struggles, and we anticipate announcing our permanent CEO by the end of the year. Let me reiterate that the fundamentals of our business, the merger thesis and the long-term growth strategy remain intact.

Turning now to highlights of the third quarter results. Orthofix performed well. We saw unprecedented growth in BGT and double-digit growth in U.S. Orthopedics. Revenue for the third quarter 2023 was $184 million, representing a growth of 61% on a reported basis and 1.2% on a pro forma basis, normalizing for a onetime stocking order that occurred in the third quarter of 2022, revenue on a pro forma basis grew 8.4%. We are proud of our strong adjusted EBITDA performance for the quarter, delivering $13.5 million and representing 36% improvement sequentially over the second quarter.

We executed our key commercial initiatives and strategic decisions made in prior periods, including cross-selling opportunities and meaningful expansion of our commercial reach with added distributors. Beginning with Bone Growth Therapy, or BGT, revenue for the third quarter 2023 was a record-breaking $53.4 million, an increase of 15% year-over-year, marking the third consecutive period of double-digit BGT growth. We are increasingly pleased with the performance of our BGT business and are encouraged by the effective cross-selling of our sales teams, particularly the Legacy C-spine sales channel.

The quarter's impressive growth in BGT came from success on all product lines across the spine and fracture channel and most significantly, [indiscernible] where we are taking market share from our competitors. In 2022, Orthofix management made a decision to invest more meaningfully in the fracture channel, which included adding sales representatives and building out area managers to establish a more focused sales organization. We are now reaping the benefits of that decision. Additionally, we continue to see great traction from [indiscernible] as demonstrated by further accelerating our sequential growth rate for this product to over 25% relative to the prior quarter an increase from the 23% sequential growth we reported in the second quarter.

Moving on Spinal Implants, Biologics and Enabling Technologies. We were pleased with the strong performance in the U.S. during the third quarter. The U.S. reported 6.6% year-over-year growth on a pro forma basis, approximately 2x above estimated market rate. The performance was driven in large part by more exclusive distributor partnerships, cross contract access and an increased focus on adding Legacy C-spine products to Legacy Orthofix distributor offering and vice versa. Our emphasis on larger and more exclusive partners resulted in year-over-year growth in the high teens from our top 20 distributors. We are pleased we have been able to maintain existing and build new relationships with our key distributor partners.

Global revenue for this segment in the third quarter of 2023 totaled $101 million representing a decrease of 6% on a pro forma basis compared to the third quarter of 2022. It's important, however, to note that the prior year period included a large stocking order of $12 million associated with C-spine [indiscernible] exit from Europe due to the high cost of MDR compliance. Normalizing for the effect of this stocking order, our global revenue growth was 5.8% year-over-year.

From a Spinal Implant perspective, year-to-date, we have had 7 new product launches and line extensions all of which have been very well received in the market, and we remain committed to innovation across our portfolio. We are particularly proud of new products in cervical, our fastest-growing franchise led by Waveform C, our unique cervical interbody and NorthStar, our posterior cervical system. Within our [indiscernible] franchise, we continue to see great momentum with our recently launched [indiscernible] Lateral Retractor, which is driving greater than 50% growth across our lateral platform.

Surgeons indicate our improved lateral portfolio has optimized each procedural element from access to [indiscernible] in order to more effectively treat bearing spinal conditions. We have successfully worked within our supply chain to build additional inventory of spinal implant sets for a significant growth initiative with new channel partners. Many of these steps are coming online this quarter, allowing us to treat even more patients with our new and existing commercial reach.

With respect to our M6 motion preservation franchise, we are pleased to share that a detailed manuscript of the 5-year results of our FDA investigational device exemption, IDE, clinical trial of M6-C artificial cervical disc has been accepted for publication in the Spine Journal. We have previously shared the very positive results of this IDE study in abstracts and other presentations but this marks the first publication. Results of this trial showed that at the 5-year end point, the M6-C disc demonstrated one of the lowest subsequent surgical interventions, SSI rate at 3.1% when compared to other FDA approved our official cervical discs.

We expect to achieve another major milestone in the M6 franchise. The M6 artificial disc was commercialized outside the United States in 2006 and have an established robust clinical history. We expect to complete our 100,000 M6 disc implantation during the fourth quarter. Congratulations to this franchise.

Within Biologics, in mid-October, we announced [ 510(k) ] clearance and the full commercial launch of OsteoCove, an Advanced Bioactive synthetic collagen graft. This product indicated for use in posteriolateral infusion, filled a gap in our bone substitute portfolio. Orthofix has historically been a leader in the DBM and cellular allograft market. An OsteoCove will strengthen the Biologics portfolio with synthetics to offer the entire spectrum of options in a surgeon preference driven market.

Turning now to the Enabling Technology franchise. We placed [ 10, 70 units ]in the third quarter, with 3 of those via an earn-out arrangement. This brings the total number of 70 units placed via earnouts to 11 with an annual revenue commitment of $6.6 million. We are very pleased with the increasing market adoption of our 70 systems and the role our guided navigation technology plays and leveraging growth across all product lines. We believe that 70 with its unique flash capabilities that reduced exposure to radiation is well positioned to capitalize on the high growth expected in the enabling technology market in both the hospital and [ ASP ] environment.

In the Global Orthopedics segment, revenue totaled $29.7 million, which represents approximately 7% year-over-year growth on a reported basis and approximately 1% on a constant currency basis. We are exceptionally pleased with our 14% growth in the U.S. The double-digit growth momentum is driven by investments in U.S. sales and marketing, best-in-class surgeon education programs and continued product innovation and launches like TrueLok EVO and FITBONE.

Internationally, we saw a 3% contraction on a constant currency basis, primarily driven by a difficult year-over-year comp as there were significant international stocking orders in the third quarter of 2022. Our commitment to innovation is central to our market share expansion and we were excited to recently announce the launch of our single-use sterile pack galaxy ankle kit developed specifically for the U.S. market. We continue to expand our already brought offerings of single-use sterile pack kits across all Orthopedics product lines.

More broadly, beyond our individual businesses, we are fully committed to Orthofix' mission and we believe the growth and value opportunities ahead of us are significant. The integration of Orthofix C-spine is progressing as originally contemplated without meaningful disruption and we will continue to drive profitable growth for the company as evidenced by EBITDA margin improvement, as Geoff will explain.

We are seeing the benefits of cross-selling initiatives, a strengthening of our commercial channels and the capturing of market share. We are updating our 2023 revenue range to be between $739 million and $744 million, representing 5.4% to 6.2% pro forma growth over the prior year. This revised guidance is primarily due to changes in the competitive environment, resulting in near-term market disruption. While we are not going to give guidance for 2024, I am confident in Orthofix ability to leverage our momentum going forward.

We are focused on maintaining strong relationships with our distributor and surgeon partners. We have a robust pipeline of new distributors. We believe we have sufficient inventory to meet the expectations of existing and new distributors and surgeons, and we are executing well on commercializing our newly launched products. And we have a strong pipeline of new products under development that will launch in 2024. Going forward, we are laser-focused on driving profitable growth. We will continuously improve EBITDA and expect to be cash flow positive in late 2024.

I'm very excited for what's to incoming to Orthofix. With that, I'll turn the call over to Geoff for further details on our third quarter financial results. Geoff?

[Geoffrey Gillespie, executive]

Thanks, Cathy, and good afternoon, everyone. As Cathy noted earlier, total revenue for the third quarter of 2023 was $184 million, representing growth of 61% on a reported basis and 1% on a pro forma constant currency basis over the prior year period, normalizing for onetime stocking order that occurred in the third quarter of 2022. Revenue on a pro forma basis grew 8.4% in the third quarter of 2023 over the prior year period.

Revenue growth was led by BGT, which grew 15% year-over-year to $53.4 million, the third quarter marks 3 consecutive periods of double-digit growth for the BGT franchise, led by the recently launched [indiscernible] product, which experienced over 25% sequential growth from Q2 2023. Global Orthopedics reported total revenue of $29.7 million for the third quarter, an increase of 7% over the prior year period. In the U.S., Orthopedics revenue continued to show strong growth with a 14% increase over the prior year period and a 4% sequential increase over the second quarter of 2023.

GAAP gross margins for the third quarter of 2023 was 65% compared to 73% for the third quarter of 2022. Adjusted gross margin was 71% for the third quarter of 2023 compared to 74% for the prior year period for Legacy Orthofix.

In the third quarter of 2023, merger-related charges continue to temporarily [ depress ] GAAP gross margin, primarily driven by the following: $7.9 million in amortization of noncash purchase accounting adjustments related to acquired SeaSpine inventory. These noncash charges are standard in business combination as companies must step up the basis and acquired inventory to ensure that future margins are recognized only on value-added activities subsequent to the merger date; $1.4 million of excess and obsolete inventory charges recorded in connection with product rationalization decisions made as a result of the merger and the dilutive impact of the acquired legacy SeaSpine business on legacy Orthofix overall gross margin.

On a pro forma basis, including the financial results of SeaSpine for the third quarter of 2022 revised to conform to the Orthofix presentation, we estimate that adjusted gross margin increased by 350 basis points to 71% year-over-year. The pro forma gross margin improvement is primarily driven by product mix and a large low-margin stocking [indiscernible] in Q3 2022 that did not reoccur in the current quarter. We expect adjusted gross margins to increase over time as we recognize efficiencies, final implant set utilization and product rationalization as well as other efficiencies that we expect to generate as a result of the merger.

Net sales and marketing expenses in the third quarter of 2023 were 52% of net sales, up from 49% in the third quarter of 2022. [indiscernible] Adjusted sales and marketing expenses were 49% of net sales for the third quarter, up from 48% in the prior year period. The increase in GAAP sales and marketing expense is primarily driven by integration-related severance, retention costs, stock-based compensation associated with the merger and [indiscernible] adjusted EBITDA to continue to increase in the fourth quarter of 2023 as planned operating expense synergies continue to materialize.

Adjusted gross margin and adjusted EBITDA are non-GAAP financial measures that provide valuable information on our operating results, making it easier to compare our core operating performance between periods and against other companies in our industry. A reconciliation of GAAP to adjusted gross margin and adjusted EBITDA is presented in the financial tables of the news release we issued this afternoon. A reconciliation of pro forma adjusted gross margin and pro forma adjusted EBITDA is included in the back of our updated investor presentation that was included in the current report on Form 8-K that we filed today.

Cash and cash equivalents on September 30, 2023, totaled $34 million. And as of September 30th, we had $70 million of outstanding borrowings under our $175 million credit facility. During the fourth quarter of 2023, the company entered into a 4-year financing arrangement with [ Blue Torch Capital ]. The financing arrangement provides for $100 million senior secured term loan which was fully funded on the effective date, a $25 million senior secured delayed draw term loan and a $25 million senior secured revolving credit facility. In connection with entering in the financing agreement, the company repaid in full amounts outstanding and terminated all commitments under the company's prior $175 million senior secured revolving credit facility.

Our free cash flow, which includes operating cash flows and cap expenditures was an outflow of $21.9 million for the third quarter of 2023, which is a sequential increase from $18.3 million reported in the second quarter of 2023. The increase is primarily attributed to continued investments in inventory and capital instruments as we continue to take advantage of channel displacements driven by market disruption. Free cash flow for the first, second and third quarters of 2023 included an estimated $15.5 million, $5.8 million and $4.4 million, respectively, of spend on merger-related items.

Turning to updated guidance for the full year of 2023. As Cathy mentioned, we are revising our full year revenue guidance. We now anticipate revenue for the full year 2023 to be in the range of $739 million to $744 million, representing a 5.4% to a 6.2% year-over-year growth on a pro forma basis. For adjusted gross margin, we are maintaining previously issued estimates to range between 71% and 72% for the full year of 2023. We remain focused on overall profitability and positive free cash flow going forward and are reaffirming our full year adjusted EBITDA guidance to range between $42 million to $46 million. We continue to expect that free cash flow will be approximately $100 million outflow for the full year '23 as we continue to gain operating leverage and realize continued operating expense synergies, we expect to be cash flow positive in 2024.

Finally, in our second quarter earnings call, we raised our estimates of annualized [ COGs ] and OpEx expense synergies from $40 million to $50 million by 2025. We are maintaining that guidance and are pleased to be tracking ahead of our estimates and we'll have realized over $30 million of those synergies on an annualized run rate as we exit 2023. The cost to achieve the higher synergy target is expected to be approximately $45 million with more than $30 million of those dollars being spent in 2023.

At this point, I would like to turn the call over to Cathy to provide closing comments.

[Catherine Burzik, executive]

I'll close by reiterating that our entire team remains highly encouraged by the stability of our business, the prospect of creating and delivering long-term value and the incredible momentum we are carrying into 2024. I again want to thank all of our employees for their dedication to the company and their commitment to our mission to collaborate, innovate and improve the lives of patients.

At this point, operator, please open the line for questions. Thank you.

[Operator]

[Operator Instructions] Our first question comes from the line of Mathew Blackman from Stifel.

[Mathew Blackman, analyst]

Can you hear me okay?

[Catherine Burzik, executive]

Yes, we can you hear you, Matt.

[Mathew Blackman, analyst]

Great. I've got a few questions. Maybe just to start, I was hoping you could walk us through the implied 4Q guide. A little bit more detail on what you're seeing that's driving that? Is this sales dislocation you're seeing or you're trying to be prudent with uncertainty or some combination of both? And then the follow-up to that, I think if I do the math on the EBITDA contribution margin for the lower revenues, I would have expected a bigger hit to EBITDA. First of all, is that right? And if so, is that a function of additional cost cutting? Or are we seeing perhaps the lift from cost synergies mitigated in a higher drop to? And then a couple of follow-ups, if I may.

[Catherine Burzik, executive]

So let me start Matt, and then I'll turn it over to Geoff to talk about the EBITDA question. Thanks for the question. And your commentary about being prudent, it's really bright answer here. As we look at the overall market at this point, others have talked about this too, the competitive environment is complicated right now. I mean there's a lot of market turbulence that we all are facing.

That said, I think we should be very proud. I'm proud of the whole organization here that we have not lost any distributors. We have not lost any Orthofix employees to competition at all during the course of the last several months. So the company is very stable.

What we see happening in the marketplace, however, is a slowdown in decision making just as a result of the market turbulence. Our pipeline, our distributor pipeline is very strong. We have a very good funnel that we review regularly of opportunities. We have gained a number of distributors already as a result of the activity in the market in the last few months. As I said, the adjustment is really just being prudent going forward. I would say that just to give you a little color here, the quarter started off very well in the month of October. So we'll see how the rest of the quarter turns out.

And I'll turn it to Geoff -- for yes, your observation on EBITDA is spot on, and we're pretty proud of our ability to execute on the EBITDA line.

[Geoffrey Gillespie, executive]

Yes, I think that's right. As we continue to optimize our company footprint as we go through the integration, that has been top of mind, obviously, and we're starting to see those dollars flow through to the bottom line. And that's really the story here as we continue to gain synergies and optimization in our business, we're going to continue to see more dollars fall to the bottom line.

[Mathew Blackman, analyst]

Okay. That was both of those answers really, really -- and [indiscernible], you gave us, I think, a very encouraging update on the stability of the sales force. I think that was your word as well. I guess the question really is how much risk is there from here, I guess, in particular, with some of the larger distributors you've onboarded over the last couple of years, where your conversations are with the selling footprint? Are we through the worst of it potentially? Obviously, we're still at risk here. But just your thoughts on how far along you are in the process of sort of locking in the selling footprint to the extent that you can? And how much more risk is there from here over the next couple of quarters?

[Catherine Burzik, executive]

So I'd say I meet regularly now with the sales leaders, trying to understand the funnel, trying to understand any distributor relationships that are up for renewal. I think it's fair to say it's an all hands-on process at this point. I think you know we have very strong leadership at the top of the sales organization that are dealing with distributors, both new distributors and past distributors. And as I said, right now, we're confident in moving forward with the pipeline that we have and the distributors that we have. We obviously built additional inventory. We've talked about that in past calls. Our spinal steps are in the process of rolling out now, so we can definitely get inventory into the hands of our new distributors as well as updated inventory and sets to our existing distributors as we renew them going forward. So I guess the short answer is I see things being very stable at this point in time. And as I mentioned, what we see right now is just a short term, we think it's a relatively near-term slowdown in decision-making.

[Mathew Blackman, analyst]

Okay. And Cathy, just a follow up to that last point, this is my last question, I swear. And you, I think, mentioned it to some extent, but obviously, you've got more instrument sets available obviously going to your new distributors. But what's your expectation or hope -- your ability to use some of those sets to potentially onboard new distributors? Is that a possibility here even in the midst of this uncertainty?

[Catherine Burzik, executive]

Yes. We're already onboarding numerous new distributors. I hear about this weekly at our meeting. So yes, we are onboarding many new distributors. We're providing our sets to the distributors so that entire process is rolling forward as planned.

[Operator]

All right. Actually, that looks like our last question. We had somebody on the line, but they dropped off. Okay. I would now like to turn the call back over to Cathy Burzik for closing comments.

[Catherine Burzik, executive]

All right. Well, thank you very much. We're really pleased that all of you could join us this afternoon for the conference call, and have a good rest of the day. Thank you very much. Take care.

[Operator]

This concludes today's call. Have a pleasant day.