Paragon 28 Inc

NYSE:FNA

Earnings Call Analysis

Company Performance and Future Growth Outlook

The company has showcased resilience and adaptability in recent times, achieving a solid gross profit margin of approximately 80%. Their operational strategies led to a 10.5% increase in SG&A and R&D expenses, primarily driven by research and sales and marketing initiatives, signifying the company's commitment to growth and innovation. Despite a $4.4 million adjusted EBITDA loss in the fourth quarter of 2023, there is an overall improvement from the previous year, and optimism surrounds the commitment to positive annual adjusted EBITDA beginning this year.

Revenue and Profitability Projections

Looking forward, the company has set a net revenue target between $249 million and $259 million for the full year 2024, translating to a growth range of 15% to 20%. This is anchored by a robust 25.8% net revenue growth in the first quarter of 2023, which suggests a challenging yet achievable goal given it represents the toughest growth comparison for the upcoming year.

Market Expansion and Growth Comparisons

The company has evidenced strength in its U.S. operations, with a remarkable 23% growth rate, indicative of effective management and market strategies. The momentum is further demonstrated by an accelerated 300 basis points growth from the third quarter, illuminating an upward trend and hinting at sustained, buoyant market performance.

Innovation and Product Development

Innovation is at the heart of the company's strategy, maintaining over 25 active projects under development. This continuous innovation pipeline promises to deliver 5 to 10 new products to the market annually over the next three years, ensuring that the company remains at the technological forefront within its industry.

Sales Force Expansion and Revenue Impact

The company has been expanding its sales force effectively, adding almost 40 new producing representatives, a growth of 14%, last year. This expansion will likely equate to balanced growth moving forward, as new and existing reps contribute to revenue—vital for stability and expansion in the U.S. market.

Fiscal Responsibility and Cash Flow Improvement

Financial prudence is recognized, with anticipation of significant improvements in operating cash flow and free cash flow. This is planned to be driven by two key factors: achieving positive EBITDA and maximizing returns on existing inventory investments. This fiscal responsibility has set the company on a path to avoid the sizeable inventory adjustments experienced in the previous year, paving the way for more robust financial health in 2024.

Earnings Call Transcript 2023-Q4

[Operator]

Good afternoon, and welcome to Paragon 28's Fourth Quarter 2023 Earnings Conference Call. [Operator Instructions] As a reminder, this call is being recorded for replay purposes.

I would now like to hand the conference over to your host today, Mr. Matthew Brinkman, SVP of Strategy and Investor Relations. Mr. Brinkman, please go ahead when you're ready.

[Matt Brinckman, executive]

Good afternoon, and thank you for joining Paragon 28's fourth quarter 2023 financial results and earnings Call. Presenting on today's call are Albert DaCosta, Chairman and Chief Executive Officer; and Steve Deitsch, Chief Financial Officer.

Before we begin, I would like to remind you that management will make statements during this call that include forward-looking statements within the meaning of federal securities laws, which are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Forward-looking statements include statements made as to the company's or management's intentions, hopes, beliefs, expectations or predictions of future events, results or performance. These forward-looking statements are subject to a number of risks, uncertainties, estimates and assumptions that may cause actual results to differ materially from these forward-looking statements.

All forward-looking statements are based upon current available information, and Paragon 28 assumes no obligation, except as required by law, to update those statements. Additional information concerning certain risks and uncertainties that may impact these forward-looking statements is contained from time to time in the company's SEC filings and in the press release that was issued earlier today.

During this presentation, we will refer to the non-GAAP financial measure of adjusted EBITDA and constant currency net revenue growth. A reconciliation to the most comparable GAAP financial measure, net income and reported net revenue growth is contained in our press release issued earlier today.

And with that, I will now turn the call over to Albert.

[Albert DaCosta, executive]

Thanks, Matt. Good afternoon, and thank you for joining us for our fourth quarter 2023 earnings call. I will start things off with a review of our recent performance, followed by highlights from the quarter. Then I'll pass it over to Steve to provide further details on our fourth quarter and full year financial results and an overview of our 2024 revenue guidance.

Before diving into the results, I want to acknowledge our team's amazing work throughout 2023. This was a transformative year for Paragon 28, and we made significant progress in our transition into a more scalable organization for our next phase of growth. I want to thank this team for their unwavering resilience and teamwork to get us where we are today and for advancing our mission to improve foot and ankle patient outcomes.

Now turning to results. Global revenue for the full year 2023 was $216.4 million, representing 19.3% reported growth and 19.7% constant currency growth, in line with the top end of our preliminary revenue results provided on January 8. Once again, we saw balanced growth across all the 5 foot and ankle sub--segments, growing the entire business at nearly 3x our overall market growth rate of 7%.

Fourth quarter '23 global revenue was $60.6 million, representing 17.6% reported growth and 17.3% constant currency growth compared to the fourth quarter of '22. We saw a nice 14.7% step-up compared to the third quarter of '23, reflective of the normalized seasonality we expected this year. This compares favorably to the 11% third to fourth quarter net revenue step-up we saw in '22 and reflects the improving supply chain environment.

Looking at the U.S. business performance, I am pleased to say that our growth accelerated nicely compared to the third quarter. We have a lot to be positive about beyond the fourth quarter top line performance. In the fourth quarter of '23, we increased our U.S. producing sales roster by almost 14%, 266 reps compared to the fourth quarter of '22 and grew our surgeon customer base by 9% to a record 2,215 surgeons. Both our rep roster and surgeon base are larger than ever, and these metrics are strongly indicative of our future growth potential as we expect to continue driving productivity increases on legacy products and new product launches.

We've done a lot to bolster our medical education program, including the launch of a second mobile lab late in '23, specifically designed for more metro markets. With this new mobile app, we're able to cover more ground in the U.S., meeting our surgeons and reps at their respective sites of care for highly focused and efficient training.

Our international business continues to do very well. We've invested heavily in our core markets and have established a direct or directly managed commercial model in 13 of our 22 international markets. We still have positive runway for P28 internationally as we continue to drive regional investments in our teams and infrastructure as well as regulatory initiatives like EU MDR to clear and launch more new products. In short, we continue to build momentum, and I'm excited for what the future holds for FNA and the surgeon community internationally.

Now I want to shine a light on our innovation, which is critical to our growth and our mission to improve foot and ankle outcomes. In the fourth quarter of '23, we launched 2 new solutions with the JAWS Great White Nitinol Staple System and the BEAST Cortical Fiber Bone Graft, which were both great additions to our portfolio. And now we are off to the races to start '24 with 5 meaningful product launches and one limited market release announced already in the first quarter. It's important to note that these products launched so far in '24 are in high-growth foot and ankle segments like bunion, soft tissue and minimally invasive surgery.

In soft tissue, we have launched 3 solutions with the Grappler Knotless Anchor, Bridgeline Tape, and Mister Tendon Harvester, all of which will typically be used in conjunction with other procedures and are highly complementary to our existing plating and screw systems. Another solution is our FJ2000 Power Console and Burr System, designed specifically for the extremities and optimized for MIS surgery. This system features disposable handpieces and instruments that help streamline workflow and minimize the need for sterilization between cases, which allows surgeons to turn more cases in a day.

Lastly, we launched the PRECISION MIS Bunion System and have our new Lapidus clamp, the Bun-Yo-Matic on limited market release. With these 2 solutions, P28 boasts a substantial range of offerings for treating bunions. Ultimately, our goal as a leader in foot and ankle and a real partner to our surgeons is to give surgeons multiple options to treat each patient's unique condition.

We expect that these early 2024 product launches will generally start having a nice impact on top line in the second half of the year and substantially contribute in 2025. I am so proud of the design teams and engineers that brought these truly innovative solutions to life, and we are excited to see them all hit the market. Of course, it's only February, and we have a lot more to look forward to in 2024 on the product front with over 25 active projects, including our first reveal of the Smart28 platform expected midyear. The Smart28 software has already been incredibly beneficial for our internal development, and we are excited to share it once ready. Our balanced and innovative portfolio galvanizes P28 as a strong partner to the surgeon community and an ideal home for the most passionate foot and ankle sales people.

In closing, I am pleased with the progress we made in 2023, but even more excited about 2024 and beyond. We made significant investments in '23 to enhance our infrastructure, teams and processes to enable P28 to realize its full potential. We also fortified our balance sheet and combined with our focus on profitability and cash flow improvements, we have plenty of liquidity to get us to cash flow breakeven. Underlying demand in foot and ankle continues to be very strong, and we are in a great position to execute on our mission to improve foot and ankle patient outcomes across the globe.

With that, I will now turn it over to Steve.

[Stephen Deitsch, executive]

Thank you, Albert. Paragon 28's fourth quarter 2023 revenue was $60.6 million, representing 17.6% and 17.3% reported in constant currency year-over-year growth, respectively. Our U.S. revenue was $51.7 million, representing 14.1% growth over the prior year quarter. Our international revenue was $8.9 million, representing 43.1% and 40.7% reported in constant currency year-over-year growth. Importantly, we continue to see solid balanced growth from each of our foot and ankle segments.

Supply chain headwinds continued into the fourth quarter, but were in line with our expectations and were far less significant than the impact we experienced during the second and third quarters of 2023. Importantly, our supply chain environment continues to improve.

Gross profit margin for the quarter was 74.5% compared to 81.5% in the fourth quarter of '22. For the full year '23, gross profit margin was 79.9% compared to 82.1% for the full year '22. Related to the recent inventory stockpiling, the company recorded noncash inventory write-downs totaling $4 million during the fourth quarter of '23, which reduced fourth quarter and full year '23 gross profit margins by 6.6 and 1.8 percentage points, respectively. This adjustment had no impact on our operations during the fourth quarter, and we expect our annual gross profit margin to continue to be approximately 80% going forward.

We've also continued to drive significant operating leverage. Fourth quarter 2023 SG&A and R&D expenses combined were $56.4 million, a 10.5% increase compared to the fourth quarter of '22. And importantly, the increase from the prior year was driven by increases in R&D and sales and marketing initiatives.

Adjusted EBITDA for the fourth quarter of 2023 was a $4.4 million loss compared to a $1.5 million loss in the prior year period. For the full year 2023, adjusted EBITDA was a $9.7 million loss, an improvement of $1 million compared to the prior year period. Both fourth quarter and full year 2023 adjusted EBITDA included the $4 million inventory write-down. We expect operating leverage to continue to improve in 2024, and we are committed to driving positive adjusted EBITDA on an annual basis beginning this year.

Now turning to cash flow and liquidity. Our operating cash used for '22 and '23 combined totaled approximately $113 million compared to approximately breakeven operating cash flow in both '20 and '21. On our last earnings call, we noted 3 specific items contributing to most of the operating cash use during '22 and '23, including inventory stockpiling, a nonrecurring legal settlement and negative adjusted EBITDA. We believe the cash flow headwinds associated with each of these items will become a tailwind throughout 2024 and beyond.

We have approximately $125 million of total liquidity, consisting of $75 million of cash on the balance sheet and $50 million available through our credit facility. As we continue to lever our growth investments made in '22 and '23 and continue to execute on our plans to improve inventory efficiency, we expect our liquidity will allow us to reach cash flow breakeven.

Now turning to our 2024 revenue guidance. We feel great about our start to '24 and the first quarter in developing in line with our expectations. Among other things, our revenue guidance takes into consideration the improving supply chain environment and an expanded sales channel armed with several exciting and high-impact new product launches. Further, it assumes the foot and ankle market continues to outpace broader orthopedic market growth, which is consistent with the demand we have seen to start the year. And of course, our view is also balanced with respect to what we can control, including the macroeconomic environment.

For the full year of 2024, we estimate net revenue to be between $249 million and $259 million, representing a range of 15% to 20% growth. P28 grew net revenue 25.8% reported and 27.1% constant currency in the first quarter of 2023, making the first quarter of '24 our toughest growth comparison of the year. Additionally, we have 1 less billing day in the first quarter of '24, which creates a 100 to 200 basis point headwind.

Beyond the first quarter, we anticipate seasonality will continue to be more normal. We also expect quarterly growth rates for the rest of the year are likely to be higher than in the first quarter of '24, given dynamics of the year-over-year growth rate comparisons and the timing of our new product launches. Lastly, our net revenue guidance also assumes foreign currency translation rates remain consistent with current translation rates.

That is the end of our prepared remarks.

[Operator]

Our first question today is from the line of Matthew O'Brien of Piper Sandler.

[Matthew O'Brien, analyst]

Maybe just talk a little bit about, for starters, Q4 and especially domestically, I know it was a nice step up sequentially from Q3, but we have been kind of flat-lining a little bit in terms of 2-year stack growth. So what are you seeing in the marketplace domestically? How big of a headwind was the supply chain issue still in Q4? And is that behind you now at this point as we head into 2024?

[Stephen Deitsch, executive]

Matt, it's Steve. Thanks for the question. And we continue to see our U.S. business strengthen. And importantly, we continue to see the supply chain headwinds lessen. And as we begin the year, we're largely through the headwinds, and we're really pleased to see that. We still have a few select SKUs, but by and large, we are in really good shape. And really pleased to see that U.S. business improved so much sequentially compared to the third quarter. And it was, I think, a record sequential improvement into the fourth quarter for us at 14%. So really happy about that. And also our supply chain team has done a really nice job of rectifying the challenges that really impacted us heavily in the second and third quarters of last year.

[Matthew O'Brien, analyst]

Got it. And then on the guidance side, nice to see that the high end of the range still touch in '20 off of a pretty difficult comparison here. So maybe just talk a little bit about the range there that we're seeing low end to high end, what's embedded in there as far as market growth. And then Steve, I didn't hear you talk about adjusted EBITDA this year. I thought we were expecting breakeven this year. Is that right?

[Stephen Deitsch, executive]

Yes. Happy to answer both of those. So I would start with, and then Albert will come in here on our guide for this year. We're incredibly confident in this business. We've really gotten off to a strong start this year. And we've consistently said this is a 20% or better top line growth business. So the top end of our guidance reflects that. And what drives that, the tip of the spear, as we've said before, is our innovative and broad product portfolio. And we also have some really exciting new launches to add to that broad portfolio that we've just put in place and are just getting going.

So the products and then also our growth is enabled by our incredible commercial team, which grows in size and quality every quarter. So it's exciting to have this terrific portfolio and an expanding portfolio, and that gets us to the high end of the range, which is consistent with what we've talked about in the past. When you think about the low end, we've typically said we can't control certain things like the macroeconomic environment. So consistent with the way we've done this before, the 15% takes into account certain things that are outside of our control. So 15% to 20%, it's 2 to 3x the market growth rate of 7%. So pretty pleased with that kind of a guide going into this year as we start the year.

And then Albert, I know I had some comments on the tech.

[Albert DaCosta, executive]

Yes. No, absolutely. It's interesting, just coming off a conference season. We got to showcase some of the new products there and the energy was pretty amazing surrounding that. I think it's just kicking this year off with a wonderful push. We launched several new products in the bunion space. We had a couple of soft tissue introductions, a couple of things on beta launch. But while we had a really, really good reception on that. The products are kind of jazzing up our internal teams as well. So we've got a lot of positivity and good momentum going into the year.

[Stephen Deitsch, executive]

And I didn't answer your second question, Matt. So positive EBITDA, absolutely. We will have positive EBITDA on an annual basis this year.

[Operator]

Our next question today is from the line of Craig Bijou of Bank of America.

[Craig Bijou, analyst]

Maybe to follow up on some of the products, Albert or Steve. And how to think about the contribution from -- especially the bunion products, you guys mentioned how well that market is growing. And then you also mentioned Smart28. So we've been hearing a lot about it. I think there's a lot of excitement around it. Would love to understand kind of how you're monetizing that and what exactly you are going to bring to the market this year.

[Albert DaCosta, executive]

You got it. Craig, good to hear from you. It's great to see a lot of you at the AAOS conference as well. I know I talked a lot of your ears off just getting into some of the technology that we're so excited about. On the bunion space, there's -- I think I'll start off by saying we've always been a company that respects that there's easily 4, maybe 5 different pathologies that relate to bunions. And each one of those pathologies really have different considerations for surgeons.

And so we've been the company that's trying to give surgeons meaningful opportunities to address the unique aspects of each of those different pathologies. And you could see that with some of the products we launched during this conference season, right? We -- the Bun-Yo-Matic to start, is addressing more severe type cases where we tend to go further back into the toe to correct it. The guide gives surgeons a sense of comfort that even though the patient is not in a weight bearing position, we can replicate some of those important aspects so that our correction is giving surgeons the correction that is really important when the patient is going to bear weight.

So that system, the ability for surgeons to create such reproducibility with that has been pretty exciting. And I think when surgeons get their hands on it, they immediately understand that aspect, and they're pretty excited.

The other part, we just introduced minimally invasive surgery for bunions, the PRECISION MIS Bunion product. That product is pretty exciting as well. In Europe, they really started doing this probably 10-plus years ago. So the U.S. is a little bit late to the game there. But it did give us a chance to really learn about the complexities of that procedure, the benefits, how to perfectly address it. And so we've got the PRECISION MIS system that has a really unique guide that gives surgeons the ability to kind of dial in the correction in every single plane. That's really nice when you're going through a small incision and you don't have the visibility that you're used to in the operating room. This guide can give you a good sense of comfort and the single surgeon could do that by him or herself.

The other thing, the drawback to some of these MIS surgeries is we tend to use burs and not saw blades. And so we've launched the first ever completely disposable hand piece that has the perfect combination of torque and speed to allow surgeons to comfortably bur the joint and prepare that for -- and not the joint -- sorry, their osteotomy and prepare that for a fusion with the comfort that we're not overdoing it on the speed, and we're not going to burn and chart the bone, which compromise some of the healing characteristics there. So just a really amazing complement.

We also launched the product, and I won't go too deep on the rest of these, but you know this is my sweet spot. We also launched a first of its kind. It's a Tendon Harvester for flat foot reconstruction or PCFD. That product is really, really unique. It allows the surgeons to not have to do such a dramatic incision and to access the real bottom side of the foot to get that Tendon Harvested. It really is the first of its kind. I'll tell you every surgeon that's put their hands on that product so far has been pretty excited to use it.

So we're optimistic about all of that, and I'll leave the soft tissue stuff maybe for another conversation, but we've got some really exciting things on the soft tissue side as well. So thank you for the question. Really excited about that. You did ask a question about Smart28.

We still expect to launch our first module of Smart28, near about the mid-mark of the year. That product, you know how excited I am about that. Our general theme around a lot of these procedures is how important the millimeters of correction are. And we're really working on systems that are going to give surgeons the sense of confidence that they're going to have those millimeters addressed in every single procedure they do.

So when we see that system, that module, I think it's going to create an aha moment for a lot of the market there that might not totally understand what Smart28 means. But when we introduced that, we're pretty excited that it's going to make a lot of sense to you all. And that's coming about the mid mark. We've got a bunch of products slated for the end of the year. I will tell you this year in particular, has a lot of big key product launches that makes this a pretty exciting time for us.

[Craig Bijou, analyst]

And maybe to follow up on one of Matt's questions earlier. On U.S. and OUS and really how to think about those growth rates going forward. And if you had your 20% growth target or would you guys consider your revenue growth longer term or just how to think about the growth of the company. What's the split in the U.S. and OUS? And in '23, we saw it a little bit lower in the U.S. So should we assume that the U.S. growth is slightly below that 20% level or would be less than the overall company? Just maybe a little bit of color on how to think about that in '24 and maybe not?

[Albert DaCosta, executive]

Yes. Happy to help with that. I think it's clear to us that our 23% growth rate in the U.S. was impacted by the supply chain issues that we have managed largely through at this point. And we posted a 16% growth rate. In the fourth quarter, we accelerated 300 basis points from the third quarter. So we were pleased to see that. We expect this business in the U.S. to be a 20% grower. And we talk about the overall business is 20% or greater. But this U.S. business is that type of performance. And it's a very, very large market. We still have a very large -- or small market share. And we think we have the most innovative portfolio in the marketplace and an expanding portfolio.

So we're going to continue to grow these things at multiples of markets, and we're excited to get the supply chain challenges behind us.

[Operator]

Our next question today is from the line of George Sellers of Stephens Inc.

[George Sellers, analyst]

Maybe looking at the international piece of the business. I am just curious if you could help parse out a little bit some of the growth drivers there. How much of that growth is related to increasing your direct sales exposure versus adding new surgeons or getting your existing surgeons to use more of your device portfolio. What are some of the puts and takes that are really driving that 40% plus growth that we've seen?

[Stephen Deitsch, executive]

Hey George, it's Steve. I'll start and Albert will talk about this. This has been a really exciting year in time for our international business, and we expect that momentum to continue. A 44% constant currency growth rate in '23 is on a pretty good size number as that business is scaled. We've invested there, George. So we've invested in teams, systems, medical education, lot of areas post IPO to really give us some firepower there to take advantage of the market.

We talk about our U.S. market share being small, but it's even smaller internationally. So this is an area of focus for us. And specifically where the growth came from in '23 was a lot of different places. Our big 3 markets of the U.K., Australia and South Africa had amazing years. And maybe specifically, I'll call out the U.K., they were awarded our Country of the Year at the recent international sales meeting, and they've just done an amazing job. It's a big market. We've got a big business developing there. We've got great leadership, and a great sales team. So a lot of good things going on there.

And then we also have markets that aren't new to us, but markets that we've invested more in and we put new teams in place and more folks on the ground, places like Germany, Italy, new relationships in Spain, Canada. We're looking at later in this year in Japan, maybe early '25. So a lot of exciting things on cap outside the U.S.

[Albert DaCosta, executive]

And one thing in -- hey, by the way, great to hear from you, George. But one other thing I'll add to that is there's a regulatory delay that we sort of experienced in the international market. So it's a little bit different than what we have here in the U.S. So what you tend to see is that when we launch a product here, it could take one to years plus before we might have access to some of those products internationally. So it really is a combination.

One, we're very selective when we look at new countries and opportunities there. We want to make sure we're a very clinically oriented organization. Our product development strategy is typically very clinically oriented. And we want to make sure we find partners and territories that match that, very academic type countries. And so we're very selective about where we go. But so far, the reception everywhere we have gone has been overwhelmingly positive.

The second piece of that is, like I mentioned, you tend to see some of the legacy products go into these territories and then you see a staggered introduction of subsequent products. And so that, for us, is pretty exciting because we continue to have opportunities to grow even those more established territories that we've been in really since 2017, 2018, which was when we started focusing on some of the international opportunities. So just a really good combination of all of those things together. And like Steve mentioned, the investments that we're making there are really paying off. We are getting quality people representing our product, the best way that we would envision and it's a real partnership.

And then the last piece that I always tell our team is if we're going to be in a country, we want to be there. We don't want to just sell products into these countries. We really want to participate. We want to meet the key opinion leaders. We want to hear what they're saying on the podium when they're having discussions about technology and approaches to different procedures, we want to actually be present there. And so that means a lot to us that we're having the successes we're having in this international market because we can't be a meaningful change to the foot and ankle market unless we're a global company. And this is our chance to do it.

[George Sellers, analyst]

And then on the product side of things, obviously, some exciting things here that have been talked about in the first quarter so far. As we think about the remainder of the year, how are you all -- how should we think about the sort of -- what percent, I guess, of the new devices or how significant of the new devices you're expecting throughout the remainder of the year will be more of the sort of single-use type devices like the Mister Tendon Harvester versus the CapEx spend type devices.

[Albert DaCosta, executive]

Yes. That's a great question, George. And we've got a few products throughout the year. By the way, this year, one of the things that's most exciting is, I think it's really less line extensions type introductions this year and some real new introductions in areas we haven't really participated in yet, absent some of the bunion areas, but a lot of really exciting areas, and it's balanced across all the sub-segments of foot and ankle. So you're going to see some things in the trauma arena. You're going to see some things in the Charcot arena. You're going to see some things scattered throughout all the 5 sub-segments, which has always been our strategy.

I will highlight that we still have 25-plus projects still being developed. And we anticipate, at least for the next 3 years, a cadence of 5 to 10 new products hitting the market. I'd probably say that when we think about some of the soft tissue products, those tend to be more of the sterile pack type products that you're asking about. We have a few pretty big launches later this year that are going to be hardware. But maybe not as dramatic on the CapEx side, as you would expect from like a large joint, like an ankle replacement or some of our counterparts in orthopedics.

So modest CapEx associated with those products. But generally speaking, I think we've got really good products hit in the market this year, which is going to drive a lot of momentum even starting the year, but ending the year as well. We expect to start to see a real contribution to the growth of this company, second half of the year and even into '25 from some of the products we're launching now and even launched in Q4 of last year. So a lot of good stuff there.

[Operator]

Our next question today is from the line of Dave Turkaly of Citizens Bank.

[David Turkaly, analyst]

Maybe Albert, I was wondering if you might share with us sort of embedded in your guidance, sort of what kind of rep adds do you think you might have this year and maybe for like a target docs turning into something, anything like that, you would like share with us in terms of how you get into those numbers, that would be helpful, if you could.

[Albert DaCosta, executive]

You got it. Maybe I'll start this question by the way, great to hear from you, Dave. Maybe I'll start this question and then I'll turn it over to Steve for some metrics there as well. But you know our balanced approach to growth. One of the nice things about the products that we're introducing to the market, it does generate a lot of interest on the sales side of things. So we get a lot of activity either from surgeons or from sales reps who are really looking at these products and wanting to be a part of this mission to improve foot and ankle outcome. So it's always an exciting time for us. I feel like right now, the visibility as a public company with some of these big launches that could be really meaningful to surgeons are generating a lot more interest than even in the past.

And so I continue to expect to see a lot more rep type improvements. But we're also really careful. We want to make sure that the sales folks that come on board with us have the same culture and feel about wanting to be a true service to our surgeon partners. And that means that they want to learn everything they can about foot and ankle surgery. They want to really sympathize with what's going on in the operating room, so they can be the best service.

So we're in a wonderful place now. We've got an amazing portfolio. It's pretty comprehensive. It's not one of the most comprehensive and still growing the way it's growing, I think we could take our choices here and really find the right partners and continue to expand our sales representation. Anything to add to that, Steve?

[Stephen Deitsch, executive]

Yes, I would just tell you, Turk that the -- we had an outsized contribution from the growth in the number of producing reps during '23 in the U.S. I mean, we added almost 40 producing reps or 14% growth. We expected that to be more balanced in terms of the numbers being added as well as the productivity dollars per. We expect a lot of revenue from these producing reps that recently have joined us and are just getting going. So some really exciting adds to the team, both last year and in the first part of this year, even some really exciting ads. And so we expect some more balance though, in terms of the overall math on what's driving the U.S. business, the split between numbers of reps and actual dollars per rep.

[David Turkaly, analyst]

And you had mentioned last quarter you had a step-up in inventory that you expected and obviously closing out around $100 million. I think that's kind of what you anticipated. I want to make sure that's sort of in line and then also that you think the write-downs are essentially over at this point?

[Stephen Deitsch, executive]

Yes. No, I think that's a great question. Our inventory levels ended up exactly where we had anticipated they would. And as we go into this year, as we've said, we expect significant improvements in operating cash flow and free cash flow, and we believe that, and we have great visibility to that. And it's going to be driven by positive EBITDA. It's going to be driven by leveraging the existing inventory investments we've made. And so we don't expect and are planning for -- and we will not have the kind of inventory increases that we saw last year. So that's all going to bode very well from a cash flow perspective improvement in '24.

And to your point, the adjustment that we made in the fourth quarter was a noncash charge increasing the level of reserves on just a much higher level of inventory. So we don't expect adjustments of that order of magnitude at any time in the future. It's -- those kinds of adjustments, you always have inventory adjustments, but not to the size and scale we saw in the fourth quarter.

[Albert DaCosta, executive]

One comment just to add to that is we still respond to my mom. As one of the first investors, it's really important that we keep good records and account -- everybody is accountable for what we spend and how we invest those dollars, and that's not changed since we've become public. So we take a lot of pride in building an amazing business there.

[Operator]

[Operator Instructions] And our next question today is from the line of Mike Matson of Needham & Company.

[Michael Matson, analyst]

Yes. So I appreciate the detail on the funded products you provided and getting to see them at AUS. But I guess I wanted to ask one just about kind of the market opportunity there in bunions, can you just remind us, I don't know if you have numbers in terms of the number of bunion procedures. But -- and then to what degree do you think these products will drive market share gains, conversions from competitive products versus just expanding the overall market?

[Albert DaCosta, executive]

Yes. Maybe I'll start here. The first part of your question, the bunion market today, there's about 400 -- according to our estimates, I'll preface it by saying that. But there's about 450,000 bunions done annually in the United States. We do think that, that's growing pretty nicely. There's a lot of patients waiting for better technology to get their bunions treated. We've had and continue to have a really strong presence there. We've got some of the best technology in our opinions to treat bunions. Again, addressing a pretty wide optionality there to make sure that we can address specific considerations for each patient. We're definitely not a one-size-fits-all organization there, and we've got some amazing products to treat that.

That being said, I think these products are going to be really complementary and put a spotlight on some of the technology that we have and expand our presence or continue to expand our presence in the bunion space, which is -- it's a fast-growing large part of the foot and ankle market as a whole. It is a wonderful balance for us. So it's -- I would say it's more important than fracture fixation or ankle or Charcot or forefoot or any of the other procedures, but it is exciting for us to continue to build a really good balanced portfolio, create reproducibility with every surgery that we can and impact patients in a positive way.

[Michael Matson, analyst]

Okay. And then given the credit facility increase, we haven't seen to do a lot of M&A or just wanted to take your temperature there in terms of the outlook that's something you're still looking at? Or do you feel like you've certainly got quite the engine there internally for developing your own products, but?

[Albert DaCosta, executive]

Yes. Maybe I'll hit this one. I'll tell you, we are 100% committed to creating an environment for foot and ankle surgery that improves outcomes. I can't think of a better way to say it. And we're also very -- I think we are very passionate and excited about what we can build in foot and ankle. We're aware of areas where maybe we don't have the expertise in the technology in-house to do things that are dramatically going to improve those outcomes. So we're always looking for that. And we're very careful about what we consider and how we consider it. But technology that influences better outcomes for foot and ankle patients is always going to be top of mind for us as we're on this mission, right? And this mission is pretty exciting. It's very few times in life that you get a chance to do something so powerful in a market and influence the market the way we hope to.

And so that for us, we're going to keep an open mind to it. I wouldn't say that there's things right now on the burner, but we are always looking for opportunities to continue to expand that technology.

[Operator]

Our next question today is from the line of Caitlin Cronin of Canaccord Genuity.

[Caitlin Cronin, analyst]

Just to start off, thoughts on Stryker's new footprint technology and if Smart28 is eventually going to compete with this product.

[Albert DaCosta, executive]

Yes. Thanks for the question, Caitlin. I'll hit it. I believe the footprint product is surrounding the total ankle piece. I think any kind of preoperative planning is a great way for us to be thinking about the future of foot and ankle surgery. I think it connects a lot to what our aspirations are around Smart28. I think we need to do and have better tools to help diagnose, to help plan and predict what the output of that is going to be. And so to the extent that, that it can influence better outcomes for foot for the ankle replacement, I think it's a positive move for the market.

[Caitlin Cronin, analyst]

Okay. And any color on adjusted EBITDA cadence through 2024 as you hit breakeven on an annual basis?

[Stephen Deitsch, executive]

Yes. Hey Caitlin, it's Steve. I think you can think about it sort of scaling with the revenue build. And we did see, I think, the best leverage of our operating expenses that we've seen as a public company during the fourth quarter with 10% growth on a much higher top line growth. So as we go into this year, you can expect that our operating expenses are going to continue to scale at a much less lower rate than overall revenue growth and that our EBITDA will trend in line as the revenue builds and grows. So that's maybe the simplest way to think about it, but it's the way we're running the business. And we don't get in front of ourselves in terms of investments and really anywhere up and down the P&L.

[Operator]

Our next question today is from the line of Justin Lin of William Blair.

[Justin Lin, analyst]

I guess to start off kind of high level. Can you talk about the strength of the end markets kind of going into 2024? What's kind of the state of the patient backlog, which maybe is less important for your business now, but just curious how are all these dynamics trending?

[Stephen Deitsch, executive]

Yes. Maybe I'll start, and then Albert will talk a little bit about what he's hearing from surgeons every day. I'd tell you that we were very, very busy to begin the year through today. We've had a strong start to the year. End markets are buoyant, and we're participating well in those buoyant markets. The fourth quarter was strong. I would tell you that the fourth quarter was stronger for us at the first half and then December was good, but not quite as good as the earlier months. And then we saw a really strong February. So it feels like we've got buoyant markets and setting us up nicely going into this year and to take advantage of our commercial team's capabilities and this product portfolio and our new products. So we're excited about the setup for '24.

[Albert DaCosta, executive]

I'll maybe just add one comment to that, Justin. I've mentioned before, I don't think we see too much of a backlog bolus type thing for the foot and ankle space. I think we capture OR time where we can. I think maybe some of our counterparts in orthopedics see a little bit more of the bolus stuff. I kind of like that because that, for us, having a pent-up energy just it spreads that over a longer period of time. It's a more predictable business piece, right? But all that to say, I don't think we're seeing as much of a backlog bolus type thing as we are just seeing pent-up demand for foot and ankle surgery, more on the elective side, obviously.

[Stephen Deitsch, executive]

Maybe I'll just add one more thing. This is maybe somewhat anecdotal, but I think it's important. The hips and knees, I know that they really did have more of a bolus impact in '23. And the commentary that I've read is that, that bolus isn't as strong going into '24. That bodes well for foot and ankle surgeons because there's more operating room availability because of that. So I don't know if that will develop into a potential tailwind for these markets that we're in. But I know that when there's less large joint orthopedic procedures taking place, it allows our smaller joint folks time to get in there and take advantage of the OR space.

[Justin Lin, analyst]

Got it. Super helpful color here. Just next question kind of on your commercial strategy. When you hire new reps, are you kind of going after new territories or are they kind of going deeper into accounts? And also kind of the second part of that question is like what are the main geographies you're not in today that you'd like to kind of expand into? I know you guys talked about the U.K., Australia and the South Africa a lot but just curious.

[Stephen Deitsch, executive]

Yes. So look, the international market is about 45% of the global foot and ankle market, so very, very large. And we've got low single digits market share outside the U.S. And we have better than that market share and there's 3 big markets, but well below the rate that we expect to be in the next 3 to 5 years. So our more established markets, we expect to continue to aggregate market share there. And then, some of the other large markets that we're really not participating in meaningfully today, like Germany, Italy, Canada, Spain, we'll continue to grow in those markets.

We've got -- in Spain -- in Italy and Germany, for example, we've got teams on the ground and facilities and systems in place to take advantage and get our products going there in a more meaningful way. And then we're going to be doing the same in Japan, which is the second largest overall orthopedic market. We're going to get in there early '25 perhaps a little bit late this year, but probably more so into '25. So there's a lot of opportunity. And then you look at South America and there's some select opportunities we're looking at there in a very disciplined way. But we want to -- like Albert said, if we're going to go into a market, we want to go into it in a meaningful way and get focused and not be too spread thin across a lot of different locations. We want to win in the markets we're in.

[Operator]

And this will conclude today's question-and-answer session. So I'd like to hand back to the Paragon 28 team for closing remarks.

[Albert DaCosta, executive]

All right. Thank you again for your time today. If you have any further questions, please reach out. Otherwise, we look forward to seeing many of you at our future investor and industry conferences. This concludes our call. Have a great day.

[Operator]

This concludes today's conference call. Thank you all for joining. You may now disconnect your lines.