Globus Medical Inc

NYSE:GMED

Earnings Call Analysis

Globus Medical Reports Strong Q3 2024 Results Driven by Innovation and Integration

In Q3 2024, Globus Medical saw revenues reach $625.7 million, a 63.1% increase fueled by the NuVasive merger. Non-GAAP EPS grew 45% to $0.83 with record free cash flow of $161.7 million. The U.S. Spine segment grew 55%, showcasing strong product demand and increased sales efficiency. Globus anticipates full-year sales between $2.49 billion and $2.5 billion, representing a 3.9% to 4.3% rise over the previous year. They expect gross profit margins to improve to mid-70s in the near future as integration synergies materialize. Excitingly, 2025 is forecasted as a pivotal growth year as they enhance product portfolios and expand market reach.

Strong Third Quarter Results Amid Integration

Globus Medical made notable strides in its third quarter, reporting revenue of $625.7 million, a substantial growth of 63.1% compared to the same period last year. This includes a day-adjusted sales growth of 60.8%, aided by an additional selling day in the U.S. Additionally, the company achieved a net income of $51.8 million, translating to a fully diluted earnings per share of $0.38, significantly higher than the $0.01 EPS from the previous year.

Impact of the NuVasive Merger

The merger with NuVasive played a crucial role in driving growth, particularly in the Musculoskeletal segment, which reported $587.4 million in revenue—a 65% increase year-over-year. On a pro forma basis, if NuVasive's results were included in last year's figures, growth would still show at a solid 5.4%. This integration is ongoing, with expectations of increased synergy benefits moving forward.

Record Free Cash Flow and Profitability

Globus Medical's financial discipline is reflected in its record free cash flow, reaching $161.7 million in Q3, which is on par with their entire cash flow for the fiscal year 2023. The adjusted EBITDA margin was reported at 31%, highlighting the company's focus on delivering strong profitability while navigating the complexities of integration.

Guidance and Future Expectations

Looking ahead, Globus has revised its full-year net sales guidance to a range of $2.49 billion to $2.5 billion, which equates to a growth of approximately 3.9% to 4.3% over 2023. Additionally, they forecast non-GAAP EPS of between $2.90 and $3.00 after accounting for changes in non-GAAP reporting methods that impacted prior guidance. This reflects confidence in operational improvements even as they acknowledge the challenges associated with the merger.

Innovation Driving Future Growth

In Q3, Globus launched four new products and has reported a total of thirteen product launches year-to-date. Innovations such as the Excelsius Navigation hub and the ACTIFY 3D Total Knee System are set to streamline surgical processes and improve outcomes, potentially driving additional revenue streams. The continued investment in R&D, which constituted 5.7% of revenue, will support future growth trajectories.

Expansion of Market Share

The company noted significant international growth, with revenue from international operations growing 74.8% to $129.9 million. U.S. revenue also showed a robust performance with a 60.3% increase. This progress indicates that Globus is not only capitalizing on the U.S. market but is also expanding its footprint globally, particularly in Europe and Asia.

Cost Management and Efficiency

The integration has come with cost efficiencies, with SG&A expenses as a percentage of sales decreasing from 40.7% to 38.5%. Despite the increased costs tied to the merger, the reduction in percentages indicates a focus on leveraging scale and improving operational efficiencies.

Strategic Positioning for 2025

Looking towards 2025, the executives expressed their optimism about sustaining mid to high single-digit growth, driven by the company's strategies to enhance product offerings and optimize their sales force. With an eye on competitive recruiting and cross-selling opportunities between the musculoskeletal and enabling technology segments, the groundwork is being laid to secure a stronger market presence.

Conclusion: A Transformational Year Ahead

With a stellar performance in Q3, a strategic merger integration in progress, and a solid pipeline of innovative products, Globus Medical is positioned for both immediate and long-term growth. Investors can expect continued focus on profitability and expansion as the company works to realize the full potential of its merger and ongoing product innovations.

Earnings Call Transcript 2024-Q3

[Operator]

Welcome to Globus Medical's Third Quarter 2024 Earnings Call. [Operator Instructions].

I will now turn the call over to Brian Kearns, Senior Vice President of Business Development and Investor Relations. Mr. Kearns, please go ahead.

[Brian Kearns, executive]

Thank you, Victor, and thank you, everyone, for being with us today. Joining today's call from Globus Medical will be Dan Scavilla, President and CEO; and Keith Pfeil, Chief Operating Officer and Chief Financial Officer. This review is being made available via webcast, accessible through the Investor Relations section of the Globus Medical website at www.globusmedical.com.

Before we begin, let me remind you that some of the statements made during this review are or may be considered forward-looking statements. Our Form 10-K for the 2023 fiscal year and our subsequent filings with the Securities and Exchange Commission identify certain factors that could cause our actual results to differ materially from those projected in any forward-looking statements made today. Our SEC filings, including the 10-K, are available on our website. We do not undertake to update any forward-looking statements as a result of new information or future events or developments.

Our discussion today will also include certain financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We believe these non-GAAP financial measures provide additional information pertinent to our business performance. These non-GAAP financial measures should not be considered replacements for and should be read together with the most directly comparable GAAP financial measures. Reconciliations to the most directly comparable GAAP measures are available in the schedules accompanying the press release and on the Investor Relations section of the Globus Medical website.

With that, I will now turn the call over to Dan Scavilla, our President and CEO.

[Daniel Scavilla, executive]

Thanks, Brian, and good afternoon, everyone. September 1 marked the 1-year anniversary of the Globus NuVasive merger, making this quarter the fourth consecutive combined earnings release with sales growth strong financial performance and best-in-class innovative product launches.

Globus delivered an exceptional third quarter with sales of $626 million, growing 63% or $242 million. Non-GAAP EPS was a record $0.83, increasing 45% even with the 20% increase in diluted shares versus prior year. We also had a record free cash flow of $162 million in Q3. This amount is equivalent to our 2023 full year free cash flow. These results reflect our continued drive in market penetration, synergy acceleration and sustained profitable growth through financial discipline.

Based on our results so far, I would like to compliment the entire Globus team for their speed and effort in completing the most successful spine merger in history. There's still a great deal of work ahead of us, but I look forward to building from this base and accelerating growth as we move into the future.

In addition to our great financial performance, Globus launched 4 new products in Q3 across our businesses, reaching 13 product launches year-to-date and more to come this year. These results are a testament to our incredible team working tirelessly around the clock to drive integration, overcome challenges and create scalable solutions so that we can reach steady state quickly and shape the markets in which we compete, while delivering innovation to our surgeons.

Focusing on the performance of our business, U.S. Spine grew 55% in Q3 with significant gains across our product portfolio in expandables, MIS screws, biologics, lateral and cervical offerings. The growth is driven by several factors, including a high retention rate at all levels of our field sales team, successful distributor to direct conversions, the strength of our combined product offering, increasing product cross-selling, implant pull-through from robotic procedures and contributions from prior period competitive rep recruiting.

Competitive rep recruiting remained strong in Q3 and the pipeline is solid as we enter Q4. 2024 is positioned to be 1 of the strongest competitive recruiting years as we continue to attract the most successful and tenured competitive professional reps who see the power and future we can offer them as a destination of choice for innovation and growth.

As mentioned earlier, we continue to flex our innovation muscle, launching 4 new products from our prolific R&D pipeline in Q3. I want to share these meaningful launches with you. The Excelsius Navigation hub pairs navigational accuracy with innovative patient safety features such as patient array shift tracking and navigation of DuraPro oscillating instruments. The Hub seamlessly integrates with Globus products and procedures, offering enhanced navigation of best-in-class instruments and implants for a complete procedural solution from the cervical spine to the sacrum.

It is the only freehand navigation system on the market to offer the versatility of 3 distinct imaging workflows. The first is with Excelsius 3D imaging with automatic registration for optimized flexibility and efficiency. The second is preoperative CT fluoroscopy emerging, and the third is interoperative 2D fluoroscopy.

Excelsius health navigated instruments are an expansive and comprehensive suite of navigated instruments that enable the navigation of a wide variety of open and minimally invasive spine procedures, including XLIF, TLIF, posterior cervical fusion, thoracolumbar fusion and SI joint fusion. They are designed for optimal camera tracking throughout the procedure and are compatible with innovative angle navigation arrays that reduce the need for interoperative camera adjustments, streamlining all workflows while maintaining backward compatibility with existing Excelsius GPS navigated instruments.

ACTIFY 3D Total Knee System is a contemporary total knee solution that pairs cementless reconstruction with operative efficiency and anatomic fit. Compatible with manual robotic-assisted workflows, ACTIFY 3D is engineered to combine implant endurance and a poor lattice interface for cementless fixation, addressing surgeon preferences and varying patient anatomies. ACTIFY 3D complements the Excelsius Flex robot with the TKA total knee arthroplasty application that received FDA clearance in late Q2.

E-Flex enables consistent accurate anatomic cuts while maintaining surgeon flexibility in tactile feel. It accommodates varying surgeon preferences by offering imageless and CT-based workflows, ergonomic and unrestricted jigless resections and restore surgeon control while active tracking is engaged. The system features advanced registration and planning algorithms to enable streamlined and efficient procedures. The system is slated for launch in Q4.

For trauma, the captivate solar headless compression screw system provides a fast and efficient solution for fracture repair, bone reconstruction, joint fusion, osteotomy and arthrodesis. This headless screw is capable of accommodating a wide range of patient anatomies, the intuitive graphic case design, aids efficiency and reduces space in the OR. In addition to driving growth from the 13 products we've launched so far this year, I look forward to sharing future impactful launches as we go through the rest of 2024.

This is a year of record launches for us, and this innovation is key to building long-term growth while working through near-term merger integration. We are investing significantly in comprehensive product development training to harmonize our product development processes between Autobahn, San Diego and the Filan. And this is expected to further expand our significant lead over the competition in IP generation and new product development.

Enabling Technology sales were $38 million, an increase of 39% versus prior year. Q3 was the highest number of unit placements since launch, growing 50% over prior Q3, including the acceleration of our rental program, where, unlike unit sales, we recognize revenue over the rental contract life. Robotic procedures continued to accelerate, growing 34% versus prior year and exceeding 84,000 robotic procedures performed since launch.

As mentioned earlier, the Excelsius Hub launch in Q3 is going well. as we enter the freehand navigation market, opening the largest market segment of navigation for Globus innovation and growth. The combination of the E3D imaging system with the iHub navigation platform, gives Globus the most comprehensive and sophisticated navigation offering available. We also plan to advance navigation further in the near future with our XR augmented reality headset designed to work with the Excelsius Hub. We expect to gain FDA clearance of the headset in Q4.

The DuraPro and Vocera Power Tool systems launched in Q1, continue to differentiate our power tool offerings and pair seamlessly with our enabling tech portfolio. The unique ability of DuraPro Oscillating Drill to add extra safety around soft tissue structures, including neurovascular anatomy while allowing for easy removal of bone, help surgeons work safely and efficiently.

Market interest remains high for our state-of-the-art Excelsius 3D imaging system with most surgeons immediately recognizing and appreciating the stark differentiation over existing systems and seeing the value of combining E3D with the Excelsius GPS or hub. We're delivering on our promise to create a launch our enabling tech ecosystem, an ecosystem that is designed and built from the ground up to communicate together seamlessly. Investment in this area remains strong as we enhance our ecosystem offering and bring about more functionality in our imaging, navigation and robotic current and future portfolio.

Our international spinal implant business delivered record sales in Q3, growing 86% on a constant currency basis compared to prior year with high double-digit growth in most markets and strong dollar contribution driven by Japan, Germany, the U.K., Italy, Brazil and Colombia. We have yet to fully harness the power of the combined Globus NuVasive product offerings internationally and feel this will be a significant tailwind moving forward in 2025 and beyond.

The combined trauma and NSO business delivered 99% growth for Q3, driven by the continued powerful performance and market penetration of our base trauma business, combined with the fast uptake of the NuVasive specialty orthopedic growth now. The combination of these 2 businesses is one of the strengths of our merger, offering a broad range of products and market-changing innovation. Integration is progressing well as we continue to cross-train our field, implement common global systems, expand our investment in sets and bring new products to market.

There's been a great deal of progress [indiscernible] to have such strong leaders throughout the world. You can see from this quarter's financials, synergies have been identified and actions have begun to realize benefits, focusing on out-of-pocket spending and prioritizing investments to match future growth plans. In-house organizational structures have been implemented, and working towards reaching steady state by year-end.

[indiscernible] the potential for Globus has never been greater. It's up to us to harness our resources and shape the future of our markets. We have at our fingertips, everything we need to realize this. I want to thank the worldwide Globus team for your dedication and support, delivering an incredible quarter and furthering the pathway to becoming the preeminent musculoskeletal technology company in the world.

I will now turn the call over to Keith.

[Keith Pfeil, executive]

Thanks, Dan, and good afternoon, everyone. During our third quarter, we passed the 1-year mark since the closing of the NuVasive merger. Much work has been done thus far in becoming the most successful spine integration at the 1-year mark. Much work remains, we are hard at work to continue in this vein. I'm extremely pleased with the outstanding results of our third quarter. As I look at sales performance, profitability, the balance sheet cash flow and cash generation, I see Q3 as a fundamentally complete quarter. All facets of the business performed and the outcomes are clearly visible in our third quarter results.

Revenue for the third quarter was $625.7 million, growing 63.1% as reported. Day adjusted sales growth was 60.8%, with 1 more selling day in the U.S. versus Q3 of 2023. Our Q3 GAAP net income was $51.8 million, resulting in $0.38 of fully diluted earnings per share. This compares to GAAP net income of $1 million and $0.01 of fully diluted earnings per share in the prior year quarter. Q3 '24 non-GAAP net income was $114 million, growing 73.9% versus the prior year quarter resulting in $0.83 of fully diluted earnings per share. Third quarter non-GAAP earnings per share grew 45% despite a 20% increase in diluted shares as a result of the merger. Our third quarter adjusted EBITDA was 31% and free cash flow was a record $161.7 million.

Musculoskeletal revenue in the third quarter was $587.4 million, growing 65% as compared to the prior year quarter, driven mainly by the contributions from the NuVasive merger. On a pro forma basis, assuming NuVasive was in our prior period results, musculoskeletal revenue grew 5.4% compared to Q3 of 2023. Growth was again led this quarter by U.S. Spine and our International Spine businesses.

Our Q3 enabling technologies revenue was $38.3 million, growing 38.5% versus the prior year quarter. Growth was driven by increased sales within the U.S. market across our EGPS and E3D products. In addition, we also sold and shipped our first EHub units during the quarter. Overall, the third quarter represented a record for total Excelsius units placed in a quarter. Looking ahead to our fourth quarter, the capital market remains healthy, and we are well positioned with a strong pipeline and seek to close the year strong.

U.S. revenue in the third quarter was $495.8 million, growing 60.3% as reported compared to the prior year quarter. Looking at the quarter on a pro forma basis, U.S. revenue grew 7.3%, driven predominantly by U.S. Spine and Enabling Technologies. Looking back on the past year since the merger closed, I call attention to the fact that our U.S. business has grown on a pro forma basis in each of the 4 quarters, led predominantly by our U.S. Spine and Enabling Technologies businesses. International revenue during the third quarter was $129.9 million, growing 74.8% as reported compared to the prior year quarter. On a pro forma basis, international revenue grew 5.1%, driven by strong implant growth primarily in our EMEA countries, partially offset by lower capital sales.

Q3 GAAP gross profit was 53% compared to 62.2% in the prior year quarter, which is inclusive of product-related intangible amortization for both periods presented. The decline in GAAP gross profit is primarily the result of step-up amortization from the NuVasive merger, which will end during our fiscal fourth quarter. Excluding the impacts of step-up amortization, non-GAAP gross profit was 66.5% compared to 69.7% in the prior year quarter. The decline in gross profit rate was driven primarily by the inclusion of NuVasive in our consolidated results as well as a higher mix of capital sales in the quarter.

We expect the full year adjusted gross profit rate to be in the range of 67% to 68% for the full year 2024. Looking ahead, we expect to work back towards the goal of a mid-70s adjusted gross profit margin as we complete the integration and realize all the synergies across manufacturing, operations and vendor management.

Research and development expenses in the third quarter were $35.4 million or 5.7% of sales compared to $29.3 million or 7.6% of sales in the prior year quarter. The increase in spending is the inclusion of NuVasive in our consolidated results, partially offset by synergy actions taken. Consistent with our previous expectations, we still expect R&D expenses to be in the range of 6.5% to 7% for the full year 2024. SG&A expenses for the third quarter were $240.7 million or 38.5% of sales compared to $156.2 million or 40.7% of sales in the third quarter of the prior year. Consistent with prior quarters, the increase in total SG&A dollars is directly the result of the NuVasive merger, partially offset by cost actions taken and fixed cost leverage on spending. Consistent with our comments last quarter, we still expect full year SG&A expenses to improve 1 to 2 percentage points over the full year 2023 SG&A expense as a percentage of sales.

Net interest expense in the third quarter of 2024 was $0.8 million compared to net interest income of $7.8 million in the prior year quarter. The resulting $8.6 million pretax unfavorable impact is driven by the use of cash to fund the NuVasive line of credit pay down at merger close b, fund share repurchases related to our buyback plan and c, interest expense from the senior convertible note, which is assumed from NuVasive at merger close.

The GAAP tax rate for the third quarter was 9.1% and compared to 60.7% in the prior year quarter. The prior year rate was impacted by the low level of GAAP pretax income in the prior year quarter as well as a nonrecurring benefit in the current year quarter related to a reserve reversal, which favorably impacted the rate by approximately 11%. Our non-GAAP tax rate for the quarter was 29.1% and does not include this nonrecurring benefit. We expect our full year non-GAAP tax rate to be in the range of 24% to 25% for the full year 2024.

Shifting to cash flow. Our third quarter results were stellar, with both record operating cash and free cash flow. Operating cash flow was $203.7 million and free cash flow was $161.7 million. As Dan mentioned earlier, our Q3 '24 free cash flow was essentially our entire cash flow for fiscal 2023 and which is $165.2 million. The drivers of the improved cash flow are twofold. One, we are seeing the cash benefit of synergy capture roll through our P&L as our cash earnings continue to improve; and two, we are unwinding the impacts of the system go-live to accounts receivable, which I commented on during our first quarter call. Specifically, our U.S. systems go live in Q1 temporarily impacted accounts receivable, which resulted in a higher working capital investment. As expected, we are seeing this issue improve and expected to drive working capital improvements through the fourth quarter and into early 2025.

Our record free cash flow was also achieved in a quarter where capital expenditures were approximately 6.7% of sales, showing evidence of our investment in the business, namely spine sets during the quarter. Our expectation is that full year 2024 CapEx will be in the range of 4.5% to 5.5% of sales.

I began my remarks today commenting that I viewed our third quarter results as a fundamentally complete quarter. A key driver of that statement was based on our cash flow for the quarter. To further highlight now that we have a full 4 quarters behind us since the merger, we are starting to see the financial vision we envisioned for the merged Globus company become more of a reality. In these trailing 4 quarters, operating cash flow was $415 million and free cash flow was $293.8 million. Our capital allocation priorities remain unchanged. Our long-term vision is to maintain strong financial discipline with little to no debt, invest in organic and inorganic opportunities while providing a return to shareholders through share repurchases.

Share repurchases have and will remain an integral part of our approach moving forward. I remind everyone that since the merger closed, we spent a total of $310.3 million on share repurchases. Shifting over to debt and looking ahead to early 2025, it is our intent to use existing cash reserves to repay the $450 million senior convertible notes, which are due to mature in March of 2025.

Now I'd like to spend a few minutes discussing our integration progress and synergy capture. Looking back on the decisions made and actions taken thus far in 2024, we are heavily focused on our U.S. operations, namely territory realignments, [ remuneration ] of cost redundancies, facility consolidations, system integrations and contract renegotiations. Year 2 efforts will focus on further refinement of our international systems and its footprint the implementation of additional warehouse efficiencies and, most importantly, product insourcing efforts. We've begun ordering the machinery and equipment that will drive our in-sourcing initiatives that will encompass both of our manufacturing facilities in Pennsylvania and Ohio. As we execute this, we will seek to expand our manufacturing know-how with new and expanded capabilities, all while fostering a sense of teamwork and collaboration as we bring together the knowledge and approaches of both legacy organizations.

As it relates to synergy capture, we previously communicated our expectation of $170 million of synergies over 3 years with the ability to realize 40% or $68 million in year 1, 40% or an incremental $6 million in year 2 and 20% or an incremental $34 million in year 3. While we expect and remain committed to achieving the $170 million in savings over 3 years, we are updating the time phasing of these savings. We now expect to realize 55% or approximately $94 million in year 1, 30% or $51 million in year 2 and 15% or $25 million by the end of the third year. This timing improvement in savings ties back to our Globus culture of moving with a sense of urgency as our employees are relentlessly changing patients' lives. We'll provide additional updates to our projections when necessary as we move ahead.

Based upon our Q3 performance and outlook for the remainder of the year, we are again increasing our previously provided guidance. We now expect 2024 net sales to be in the range of $2.49 billion to $2.5 billion. Our revised net sales guidance implies 3.9% to 4.3% growth over 2023 pro forma revenues of $2.396 billion. We are delivering sales growth in a year of extensive integration.

Before I provide a revised fully diluted non-GAAP EPS guidance, I'd like to call attention to a change we made during the quarter related to our non-GAAP reporting where we will no longer adjust for the impact of the acquisition of in-process research and development. This change in reporting will unfavorably impact our previously provided 2024 non-GAAP EPS guidance by $0.09 as a result of our Q1 '24 IP R&D acquisition. Given this change, as well as our expectations on business performance. Our revised fully diluted non-GAAP EPS is now expected to be in the range of $2.90 to $3 per fully diluted share.

Our revised guidance range assumes a $0.19 increase to operational performance, partially offset by the $0.09 impact due to no longer adjusting for the acquisition of IP R&D as previously stated. Overall, this change reflects our views of enhanced profitability driven by improving business performance while more closely aligning our non-GAAP reporting with the most comparable GAAP measure. Our Q3 performance reflected the underlying strength of our business. We achieved meaningful sales growth, drove enhanced profitability and generated record free cash flow, all while still investing in our business. I'm extremely pleased with our results and remain excited for what's to come.

Closing out on my comments, I'd like to once again thank our employees for their commitment and dedication. In the state of change, we've continued to deliver innovation and new products to our partners based on our culture of maintaining operational excellence and a focused, disciplined approach to cost, thus ensuring we have the right product at the right price and on time.

We will now open the call for questions.

[Operator]

[Operator Instructions] And our first question from the line of Matt Miksic from Barclays.

[Matthew Miksic, analyst]

So one quick sort of question on margins and then a follow-up on robots, if I could. So margins, obviously, EBITDA margins popped up nicely. You mentioned some of the things that were driving that sort of acceleration into the low 30s. Could you maybe highlight the large moving pieces that sort of -- that got you there faster, certainly faster than we were expecting and the Street was expecting? And then I mentioned I have one quick follow-up.

[Keith Pfeil, executive]

Sure. So Matt, I'll take the first part of that question -- actually, I'll take the first part of what you stated. Really, when you look back on the year, we aggressively went after eliminating cost redundancies as well as facility consolidation like I commented on in the quarter. As we got into the year, we identified more and more places where we felt that there was opportunity for savings and really as we really looked at the year come together, the key focus for us is driving cash savings. I'm not super interested in driving or finding ways to generate noncash savings we really took a look at 4-wall spending and said, what do we need to do to really drive improved profitability. It's really about it.

[Matthew Miksic, analyst]

Okay. Well, I'm sure there'll be follow-ups on that. But on robots, one of the things I think we've asked about since the beginning and since the merger was announced is behind this mission of doubling the field force and selling your robot across the broader field force. What has the progress been like on the NuVasive side? reps getting into -- getting you into accounts and kind of what's the look forward on that?

[Daniel Scavilla, executive]

Matt, I'll take that one. So it's been progressing well. It's really been several fold. The first one is we have been training our reps on the system itself. So we've been bringing our team in, making them experts, getting them comfortable with that so that they understand how to perform this. And I've seen dozens and dozens of teams from the former NuVasive team in our labs running through that. At the same time, our product development team has been working to take the great NuVasive products like Reline or Modulus and get those on to the software that's been done.

We're actually working now to -- and we're waiting for approvals of that to come through to go. It's really the combination of those 2 that will allow us to make that more functional. In addition to that, we've already been obviously seeding through conversations with surgeons bringing them in for VIPs, having conversations with that. I'll tell you I'm pleased where it is the real thing we need to do is get the approvals to use those NUVA products out on our system. But I think that's really what 2025 is going to be for us.

[Operator]

And our next question comes from the line of Vik Chopra from Wells Fargo.

[Unknown Analyst]

This is Dino on for Vik. I just wanted to ask about if you have an update on the FDA warning letter that recently came out. what update can you provide on it? And what are the next steps? Do you expect it to be resolved soon? And what, if any, is the commercial impact?

[Daniel Scavilla, executive]

Thanks, Dino. I'll take that as well. So just again, to remind everybody, that warning letter was really about our internal processes of how we handle complaints. It was not directed towards the actual robot nor did it imply any issues with a robot or with patient safety. It was about how we handle complaints. And it was really about the array of criteria we selected when we're analyzing plates. The FDA would like us to do more, in which case we did. We went back to the very first complaint and went through every single one of them, realized that our outcome would not change with all the additional criteria. We've agreed to put that going forward.

We've submitted that out to the FDA. We've had a few back and forth for clarification. And now we're in the phase of just proving it out as an effective approach. And we're willing, and we're excited to actually have them come back in for reinspection to get this behind us. Morning letters in the past from other companies tend to last in the year or excess of a year. So we're seeing if we can close that down and do that faster than that normal curve. As far as sales, there's no doubt there's probably been a few customers that were worried about this. We've gone out, had direct conversations with them. We've assured them in several different ways that it's not a product-related issue. And while there's some impact, I wouldn't quantify it, and I don't feel that it's been significant to date.

[Unknown Analyst]

Got it. That's helpful. And then one follow-up on the capital equipment environment. Just what's your view on the capital equipment environment heading into Q4? And how are you feeling about 2025 after 2 of your competitors recently received FDA approval for their spine robots.

[Keith Pfeil, executive]

This is Keith. I'll take that. I think about going into Q4, we feel good about where the capital environment is. Our pipeline remains strong. There's a lot of inbound interest. There's lots of quotes getting turned around. As I think about going into 2025, competition is coming. We knew competition would be coming at some point. And at this point, we're leaning in and we're really focusing on selling our robot, which we still feel is best-in-class technology.

[Daniel Scavilla, executive]

And if you remember, one of the premises of the merger was to actually double our total available market and introduce this to more surgeons through the NuVasive side. that is and will remain our focus. We will willingly compete head-to-head with any competition in any account, but our main focus is going to be taking advantage of the surgeons we're active with to place those units through next year.

[Operator]

Our next question comes from the line of Matt Taylor from Jefferies.

[Young Li, analyst]

This is Young Li in for Matt. I guess to start, one on reps, spending a little bit more than a year since the deal closed. Can you level set us on how many reps might have guarantees that are expiring? Is it a material number or revenue impacted? It sounds like you're seeing [indiscernible]. I guess, are you also maybe seeing some competitive responses from the other companies on your reps?

[Daniel Scavilla, executive]

Thanks, Young Li. I'll take that as well. There was a word in the street falsely spread that the majority of our people are on contracts. I'm not sure why someone would come up with that. it's simply untrue. It shows that people are disconnected with the industry. We have historically had a few people who are on contracts and to date, even combined as one that still remains very low for us. It is not a significant impact by any stretch with that. And like regular business, we aggressively go after competitive recruits and our competition goes after competitive recruits. We're not seeing anything unusual with that related to this merger at that point.

But I do want to stress the word on the street is simply incorrect. We do not have the majority of folks own guarantees at all it's a very manageable number. It has been managed that way. We expect our people to perform with the best-in-class portfolio. And unlike other companies, we don't have to guarantee them to do that. The products and the innovation allow them to self-sustain.

[Young Li, analyst]

All right. Great. I guess one to follow up on really strong growth OUS, you increased investments in the useful U.S. business. I wanted to hear a little bit about your thoughts on the international spine business profitability. There's a lot of opportunities and tailwinds on the revenue side, but I can U.S. EBITDA back up versus the U.S.

[Keith Pfeil, executive]

This is Keith. I'll take that question. I mean, absolutely. I mean international profitability is going to vary country to country. But couple of things you got to think about is we're operating in places where pricing may be favorable and you're driving volume growth of the same products that we're making here in the U.S. So as you incrementally add more product internationally, can drop more variable profit to the bottom line just by the nature of what you're selling. So absolutely, there's an ability to create more of an enhanced profitability internationally as we move forward, which can have a compounding effect on the larger business.

[Operator]

Our next question comes from the line of Shagun Singh from RBC Capital Markets.

[Shagun Singh Chadha, analyst]

Congratulations on a really strong quarter. I guess just 2 for me. The first on the recon robotic launch, you did call out what the features are going to be. Can you maybe elaborate on what do you think is going to be most differentiated? What's your commercial strategy and how we should think about the impact in 2025. And then I guess for my second question, on capital allocation, you had previously called out a focus on complementary M&A. It seems like you still have more work to do on NuVasive, but the big chunk is behind you. So can you just elaborate on your appetite and preference for deal size, et cetera?

[Daniel Scavilla, executive]

Thanks, Shagun. I'll take the first part of it. I think what we're excited about with the robot is it's obviously newly designed, built from scratch. I feel like the movement of its arm itself is really a benefit of what we do. I think the accuracy of what we can come up with using all latest technology is really good as well. I think ultimately, it can be many different things where we want to get into. The big thing I like about this is the multiple workflows, whether you want to do CT or image lists with that. The fact that it can instantly go, you don't need to send something away for planning of it to get it organized. So there's a lot of flow and efficiency. There's a lot of flexibility that I think put in the hands of the surgeon coupled with the newness and latest technology built from the ground up, I think, can be meaningful and impactful.

[Keith Pfeil, executive]

And Shagun, this is Keith. I'll take the second part. As it relates to capital allocation and driving M&A, really go back to our mission. We're a musculoskeletal company looking to improve the lives of patients with musculoskeletal disorders. So as you think about that in our products, we want to fill out the bag of what is not in our product portfolio yet. And as I think about kind of what we would look at, you could look at shoulders, you can look at enhancing our joint portfolio. There's lots of places to look, but it's also looking at complementary pieces of technology that could really help develop something or bring something in the market quicker.

I wouldn't comment on a specific size or scale at this point. as we work through the integration and NuVasive acquisition, we want to make sure we get all of this right, there's still more work to do. I think that as time passes, we'll see what opportunities are out there. And really move based on what we see as a fit for us as we move forward.

[Operator]

Our next question come from the line of Matthew O'Brien from Piper Sandler.

[Unknown Analyst]

This is Joe on for Matt. Congrats on the great quarter. I really wanted to ask about the guidance update. You've seen in Q3, and I hate to ask if this bluntly, but you beat the Street by a bit over $20 million raised by $15 million. I think it implies Q4 revenue is growing in the 2% to 3% range. Is that the right way to think about things? And any color on how that's broken out between musculoskeletal and enabling technologies.

[Keith Pfeil, executive]

Sure. So this is Keith. I'll take the question. I mean, really, when we provide guidance, we're providing guidance on the full year Obviously, we had a strong quarter, but we're still maintaining appropriate conservatism going into Q4 in saying that though, we remain extremely positive about the progress it's made and where it's going. We don't provide breakouts between enabling tech and musculoskeletal. I would really just fall back on the comments that I had on the call. our musculoskeletal business really has grown this year led by U.S. Spine and International Spine and our enabling tech business looking into Q4, the pipeline remains strong and we remain positive about it.

[Unknown Analyst]

That's helpful. And in that context and then relatedly, I know you've described the new and improved Globus is at a high single, low double grower into the future. Just curious to get your take, and I understand it will probably be light, but any color on next year? I think the Street says 7%. But just any way to help or adjust between this year and next.

[Keith Pfeil, executive]

Thanks for that second part or the second question. I mean, at this point, we're not looking too much into 2025 or providing color at this point. We're coming out of this year. We've managed to work through bringing the businesses together. And we remain positive. And really, we stick by what we said. We still think Globus could be a mid- to high digit -- a mid- to high single-digit grower.

[Daniel Scavilla, executive]

I think one of the indications for that as well is as we keep talking about our strong competitive recruiting activity and our strong product launches that we're putting out to build the platform for future growth.

[Operator]

Our next question will come from line of David Saxon from Needham & Company.

[David Saxon, analyst]

I wanted to follow up on the guidance question. It is kind of low single digits sequential growth. I think in a normal year, we're closer to high single digits. So I mean I heard you say kind of appropriate conservatism that's baked into the guide. But I just want to be clear, are you seeing anything in the market that kind of would be a risk in your view?

And then, I guess, second to that is I thought guidance assumed around $150 million of dissynergies this year. Is that still the case in any way to kind of gauge where we are with dissynergies? And then I'll have a quick follow-up.

[Keith Pfeil, executive]

Sure, sure. So as it relates to guidance, as I think about the year, we're extremely positive with where we are and how we finished. The $150 million dis-synergy, you'll note that I did not reference it in my prepared remarks. I think that as time passes, we feel more and more confident is there the risk of having synergies in the future? Sure, there could be risks. But at the same time, at what point does it become part of just running your business. We remain appropriately conservative, like I said earlier.

But going into Q4 and into 2025 will remain positive. If I think about anything specifically that we looked at, we did see a little bit of an impact related to some of the hurricanes and some shortages related to IV bags. That's really the only main thing that I would call out as I go into my Q4 and get into it deeper.

[David Saxon, analyst]

Okay. Super helpful. And then just on the trauma portfolio, I heard the combined NSO in Trauma was like 99%. I think trauma historically has kind of been in the 40% to 50%. Is that still the case? And any way you can give us a sense for the size of that portfolio in terms of revenue contribution?

[Daniel Scavilla, executive]

Yes, we don't actually break that out right now with where that is. Both have great uptake. They're both growing well, super high double digits with it. But we're really not in a position to split them out or actually lay out what the dollar impact is right now.

[Operator]

Our next question comes from the line of Steve Lichtman from Oppenheimer.

[Steven Lichtman, analyst]

Dan, one of the drivers you mentioned up top for this quarter was a successful distributor to direct conversions. Can you talk about what the impact is of those conversions and where you are in that process?

[Daniel Scavilla, executive]

Yes, Steve, glad to. So we started out with Globus years ago. doing those conversions and coming into a more direct exclusive sales force. We obviously did the same with several of the former NUVA distributors bringing them in. And what that is, it just allows us to invest better in those markets, hire people, push through, get the right amount of reps, share that risk with the former distributor so we can get more rapid growth out of that type of approach, that's really the benefit. There is some more out there that have not converted or chose not to convert, which is fine. But where we do have that opportunity, we're taking advantage, again, more to use the power and cash of Globus to create further growth and faster impacts into those areas.

[Steven Lichtman, analyst]

So would you say, Dan, that you're kind of toward the end of that process, is that right?

[Daniel Scavilla, executive]

I don't know if I'd say towards the end of that process. We're year-end. We've done several. I would say there's probably several more. I don't want to reveal numbers or locations yet. And I think it's really several things. We want to make sure that people get comfortable with us, we get through the startups. We'll continue to work with it. We're not going to mandate it but it's clear for anyone who has gone through that. And it's a very big benefit to them when we start using these approaches. And I think the goal, Steve, is to remain focused on that. Just for the sake of controlling our sales force in a better way and really accelerating how we can invest in there.

[Steven Lichtman, analyst]

Okay. Got it. And then on Orthopedics, your focus initially is in total primary as where, of course, is most synergistic with robotics. As you approach accounts, whether hospital or ASC, how are you looking to overcome, not having as full a bag as the major players? Do you see a need to sort of rapidly advance products like [ Uni ] or others. How are you thinking about that?

[Daniel Scavilla, executive]

Yes. No, great question. Everything that we need is in progress. Nothing is ever fast enough for me, just the nature of what it is. But the [ Uni's ] developed and honestly, ready to go, we're really far down the path is what I think is a fabulous revision knee. Everything related to hip is really either approved or in play and we're moving the robot further along in the hip development itself. Like anything, it's a journey. I would tell you we're going to be in a stronger spot this time next year. But I think when surgeons understand that and see where we're investing in how they're willing to come along with us.

And so again, I think the real start of this is going to be in 2025. And like spine, it will be a slow journey as we go and make inroads unlike what we do with robots, which was a big bang. I think this is going to be one of those steady climbs that we get out there. But I really do think '25 will become the meaningful year of impact there.

[Operator]

Our next question comes from the line of Matthew Blackman from Stifel.

[Mathew Blackman, analyst]

Just one. And look, I appreciate you're not going to want to talk too much about 2025. But can you maybe just help us to think through maybe in the broadest sense, the most important puts and takes on the top and bottom line next year. Anything you'd call out tonight as we think through our 2025 numbers.

And I'm just reflecting on this quarter's performance, you're back to market levels of growth, you posted 31% plus EBITDA margins, and there's still incremental cost synergies next year. And then I look at consensus at something like [ $333 million ] or something in that neighborhood. Just given this quarter's results, that number feels low, but would love to hear what you guys think. And at the least, the thought process I just laid out is sound and I'm not missing anything.

[Keith Pfeil, executive]

So thanks for the question. I think qualitatively, stepping back and looking at the business, year 2, what do you think or what do you expect could happen? You would expect more cross-selling to occur as the team further integrates in the U.S. and international. You would expect to see greater cross-selling of the robots. There was a question earlier that I believe Dan commented on, that there's a lot of inbound interest from legacy NuVasive customers related to EPS we're continuing to come out with more and more technology products. So that all points to a positive when you think about the top line.

As you move to the bottom line, you're going to annualize some of the synergy capture that you generated this year. plus you're going to drive some slight improvements, I think, early on operationally. But really, as I think about the synergy capture from in-sourcing. That benefit is really the back half of '25 and into 2026. Again, when you get into year 2, the focus really is again on managing your 4-wall spending. So what is 4-wall spending? It's looking at things like consulting spend and outside spend. How do you identify ways either reduce that spend or find ways to bring it in-house, that's really going back to the strategy of Globus, and we're going to continue to focus on that in year 2.

[Operator]

Our next question will come from the line of Ryan Zimmerman from BTIG.

[Ryan Zimmerman, analyst]

I'll echo everyone's sentiment. We came out of NAS in probably what I would argue as one of the best spine markets we've seen in years, just judging by some of the feedback and commentary from management teams. And I'm wondering, Dan, if you can give your thoughts about just the durability of that, what you see as kind of the spine market and what's driving that? And also maybe kind of your thoughts on how it can continue.

[Daniel Scavilla, executive]

Thanks, Ryan. It does seem to be a strong year this year. And I would tell you that it seems to be above historical growth, the normal growth. I don't think any of us could ever say it's pent-up demand from COVID or anything like that, like we went through in the past. That said, I think when you run your historics on this kind of data, the market does tend to be about a 3% to 3.5% growth. And I think I'll still set my sights there to say probably over the long term, this will be somewhere between a 3% to 4% growth.

While I think changing demographics can be some of the lift, I think some of the incumbent people having jobs therefore, having insurance to do it can be part of a lift. I don't know if we're looking towards a future where you've got 5% to 7% growth in the spine market. I think it's going to just get back down to my guess, and it is an absolute guess just based on history. Somewhere between the 3 to 4 a normalized state and just progress that way.

[Ryan Zimmerman, analyst]

That's fair. And then if I could ask Keith A couple of conceptual questions as I think about the future for year 2 of the merger, Keith, you talked about just some of those in-house manufacturing dynamics. It doesn't sound like you want to put numbers out there. I imagine you have some ideas, but maybe you could help give us some guardrails around some of that in-house manufacturing initiatives for next year as it relates to kind of what you could or couldn't do from a margin perspective?

And the second part of my question is more on the R&D side, which is you're moving into these markets like [indiscernible] recon, you talked about R&D at 6.5% to 7%. But I would imagine you have to maybe step up conceptually R&D to develop more products as we think about 2025 and beyond. And so am I thinking about that correctly as well? Any color on those 2 would be appreciated.

[Daniel Scavilla, executive]

Ryan, let me jump in, we'll kind of start with the back part of that first. Keep in mind that we always spend I consider heavily in R&D. And so everything that we need is currently in the margins we have and then the percents we have. There's nothing we're waiting to do. And it's not like we're at a milestone before we start. And so just keep in mind that the R&D spending you have encompasses everything that we're putting out a thing that we want to do and we talk about I don't think it's a step up. We'll take the opportunity to discover new things and go in new areas, and we'll certainly increase spending there.

I think as Keith has always said, maybe looking around 7% of sales will be a great target to go to but I don't feel like we have a portfolio that's been untouched, I feel like everything is moving. So I just want to answer that one first and I'll kind of turn over the first part of your question, Keith.

[Keith Pfeil, executive]

Yes. So if you think about in-sourcing and what's planned, I mean, obviously, we've got to get all the machinery and equipment into each of the locations and get the machines program to run. But at the end of the day, the goal is really to really drive a lower cost per unit. And as you drive a lower cost per unit for what you're in-sourcing you're also going to get fixed cost leverages across both locations. As we do this also, the goal here is to cross-pollinate both of the manufacturing facilities that they can make both Globus and legacy NuVasive product. That helps lower our risk, but it also allows us to become more efficient with how we plan both existing products and then new product development. Over time, that creates a flywheel effect to drive some of your fixed cost savings.

[Daniel Scavilla, executive]

I would also say, Ryan, you've got to burn through the existing inventory that's on the shelf and then go work that through. And so we'll look to see what that impact is next year. but recognize it's more of a long-term play than a splash.

[Keith Pfeil, executive]

And that really ties back, Ryan, to what I said earlier on a previous question, is that any gross profit improvement really is going to be smaller in 2025, but it's in the back half of the year. As we get into the year, I would expect to see that benefit first coming through in cash because your working capital investment is going to change because of your in-sourcing the inventory.

[Operator]

[Operator Instructions] Our next question come from the line of Craig Bijou from Bank of America Securities.

[Craig Bijou, analyst]

And congrats on the quarter. I wanted to start when you did the NUVA deal, you looked at it on -- really, with the synergies on a 3-year period. And just taking your Q4 guidance, that 2% to 3% and then your aspirational goal to get to the mid- to high single digits. So I guess I kind of wanted to ask you if you need -- like if it's a 3-year period to get to that aspirational goal or with some of the cross-selling synergies that you expect to come through soon. can that happen faster? I think investors are just trying to get a sense for where -- what can that acceleration look like? Or when can we see you guys reach that mid- to high single-digit growth?

[Keith Pfeil, executive]

Thanks, Craig, for the question. This is Keith. I mean as I think about going into next year, we should start to be able to see the growth rates accelerating. I don't want to give too much color yet on 2025, but it is our expectation that as we get into next year, it really ties back to some of the things I had said earlier that you would expect more cross-selling to occur, both across musculoskeletal enabling tech, you should start to realize that next year.

[Daniel Scavilla, executive]

Yes. And Craig, one of the things I'd add to that, and that's what we're pulling out in our commentary is we're putting in place all of the pieces to achieve that, whether it's the manufacturing and expanding the investment in sets everything that we've been calling out the launching of products, the retention of the sales force, the competitive recruiting. We're really putting all the building blocks in place here to deliver that.

We're not in a position to commit yet because just to be honest, we haven't run through 2025 yet. We haven't had a chance to get it approved internally. It's -- as you know, something we'll release as we get into January as normal. But we feel confident with everything that we're doing, and we feel like we're in a really strong spot to deliver what we've committed to here. And of course, like anything, we'll strive to beat that and accelerate where we can.

[Craig Bijou, analyst]

Got it. Okay. That's helpful. And if I could just ask on the power tools I know just launched this year, it's probably not a huge dollar revenue contribution. But I did want to see if there's -- if you'd be willing to provide anything on kind of the size or the ramp for growth of the power tools specifically? And then one just clarification of where you book those revenues.

[Daniel Scavilla, executive]

I'll handle that first part. We're really pleased with the launch. We think that the potential and the interest that we see with the surgeons, whether it be through the feedback we're getting when they are being used in the operating room is very positive. The pull-through that we're seeing of disposables and its usage is, again, a very good leading indicator that these things are being well adapted. Keep in mind that this is one part of a procedural solution. And so while we look to them as a stand-alone, not truly, it's really about how well they can go freehand with our navigation of or how they work with the Excelsius robot, et cetera, right? So it's all part of the entire program that goes. The application that we see longer term within trauma and joints as well very promising.

So you're right. We're not going to really call it out, but I would tell you that what we see is this can be a significant growth driver as we thought it would be in the upcoming years, and it's doing well for this year. And it is a component of musculoskeletal.

[Operator]

Our next question comes from the line of Caitlin Cronin from Canaccord.

[Caitlin Cronin, analyst]

Just starting with the ortho robot, maybe a reminder of what the value prop here over competitor systems, i.e., the price point, footprint, et cetera?

[Daniel Scavilla, executive]

Thanks. I'll take that. I would say that footprint is certainly one of them to be considered, especially as you work in ASCs. We've looked at this, and we're really pleased with how we've designed it to go in there. One of the things Caitlin, I had mentioned earlier is I think that just the fact that it's a newer robot that we've really built within the last year or 2 using some of the newest componentry, the ability to have smooth and articulating movements that I think are really good.

The fact that you can do a registration with or without CT, how you want to operate this. We don't need preplanning to be sent away. It's something that a surgeon can decide to do either the day before or right in the OR. So we'll build more on that and get through that. We're still working how to put that out with our Q4 launch. But all in all, I think the main components of that I've just laid out, we just probably have a lot more polish than what I just laid out for you.

[Caitlin Cronin, analyst]

Awesome. And then just with the free hand NAV, who has been the early customers? And where do you see uptake of this technology over time? Is it more in a hospital, outpatient or ASCs.

[Daniel Scavilla, executive]

Yes, it's a great question. I'm going to say the answer is all of the above with that. Really pleased with the ones we've put together so far. The procedures that have occurred have really been strong. There's a lot of excitement out in the field and also with our surgeon and with these given that it is currently the largest section of navigation entering into that actually opens a brand-new field for us. While we think the long-term play will be robotics, we obviously recognize there's always going to be multiple avenues for surgeons to treat patients. And so we want to just offer that as best we can, whether it be robotic or free hand.

But I would tell you, again, with the activity we've seen so far late in the third quarter, I think that this can be meaningful for us as we set our eyes on what to do and grow and achieve some of our goals in 2025 and beyond.

[Operator]

[Operator Instructions]. The next question comes from the line of Richard Newitter from Truist Securities.

[Richard Newitter, analyst]

The first question I had, Dan, I think you had said that you expect meaningful contribution from the ortho robotic initiatives in 2025 or something to that tune I thought you had kind of suggested that would probably be a little bit more of a gradual ramp into the out years. I guess is that a change in expectation, did I hear that right?

[Daniel Scavilla, executive]

Yes. No, you heard the right words, Rich, and I'll articulate. Thanks for calling it out. Given the fact that it has not been contributing much to us at all, this is one of the pathways for to become a growth engine. So keep in mind that obviously, the ortho market has doubled that of the spine, one would say $20 million versus $10 million with that and us piecing together all of the implants and getting them designed and ready to go now with the robot at our fingertips, I'm thinking that it can add to our dollars.

I don't think it will become the growth driver of Globus as we come out with next year's forecast. But I'm saying that it can actually get out from the R&D side or lower contribution into something that will mean a bit more for us in the company and set the stage for '25, '26 and onward. But again, not a main growth driver of '25, but I would want to see the change in its revenue contribution to the company. really starting in 2025 with all of those components in play.

[Richard Newitter, analyst]

Okay. That's helpful clarification. And this question is kind of another angle to 2025. So directionally, if I think about the -- if you were going to deliver overage relative to kind of where the Street is sitting, it's about 7% pro forma growth for '25 on the top line, about 31% or about 100 basis point margin improvement, where do you think you -- or already to have more confidence that you could -- you have more cushion or more ability to achieve overage relative to those estimates. I'm just trying to get a sense, is it on the top line? Or is it maybe some of the visibility you have on the cost savings? I would love to just hear your kind of thoughts on that.

[Keith Pfeil, executive]

Rich, this is Keith. I'll take that question. As I think about it, the place that I would look really would be COGS, cost of goods sold, do you have the ability to take out more spending or turn the inventory quicker in-house to drive greater profitability in the '25. That would be the place. I think that -- I think we continue to look at spending outside of COGS or outside of the gross profit caption. But I think if it was going to accelerate anywhere to drive more profitability, it would be in the core product cost.

[Operator]

And with no further questions in the queue, that concludes the Globus Medical earnings call. Thank you for participating. You may now disconnect. Everyone, have a great day.