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Stryker Corp
Earnings Call Analysis
Q4-2023 Analysis
Stryker Corp
The company reported remarkable sales growth of over 11% in Q4 and for the full year, continuing a trend of significant growth despite strong prior year comparatives. Notably, there was double-digit organic growth across various segments including Instruments, Endoscopy, Medical, Trauma and Extremities, with robust performances both in the U.S. and international markets.
The adjusted earnings per share (EPS) for Q4 and the full year increased by 15% and 13% respectively. This rise was attributed to robust sales as well as continuous recovery in operating margins. Plans to further drive growth include a blend of organic innovation and strategic mergers and acquisitions.
Looking ahead, the company expects to maintain its high growth trajectory for 2024. They have issued guidance predicting organic sales growth between 7.5% and 9%, demonstrating confidence in their ability to sustain their position at the forefront of the med tech industry.
With a constant currency and organic sales growth of 10.7% in Orthopaedics and Spine, the company underscored its market leadership, particularly in robotic-assisted knee procedures. Their commitment to operating margin improvement is unwavering, with a clear plan to reach pre-2019 operating margins by the end of 2025. This improvement is expected to arise from opportunities in both operating expenses and gross margins.
The company's innovation pipeline is stronger than ever and is expected to support high-end growth for years to come. Upcoming product launches and a continuous strategy of innovation and mergers and acquisitions will reinforce the company’s growth and market leadership, especially in areas like robotic-assisted surgery and trauma and extremities.
The company perceives the operating environment as normalized, with orthopaedic procedure capacity issues largely resolved. With the increasing construction of Ambulatory Surgery Centers (ASCs), there's optimism for continued robust growth, particularly due to orthopaedics being a lucrative area for hospitals.
The balance sheet reflects a solid financial position with $3 billion in cash and marketable securities against a total debt of $13 billion. As part of its capital management strategy, the company repaid outstanding debt associated with a major acquisition and refinanced upcoming maturities. However, there are no immediate plans for share buybacks.
The company strategically balances investments and margin expansion. Their adjusted operating margin saw an increase for both Q4 and the full year, supported by easing cost pressures and positive impact from pricing actions. R&D and SG&A investments increased marginally, reflecting the company’s commitment to fueling future growth while carefully managing expenses.
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Welcome to the Fourth Quarter and Full Year 2023 Stryker Earnings Call. My name is Luke, and I'll be your operator for today's call. [Operator Instructions] This conference call is being recorded for replay purposes.
Before we begin, I'd like to remind you that discussions during this conference call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also, the discussions will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release that is an exhibit to Stryker's current report on Form 8-K filed today with the SEC. I would now like to turn the call over to Mr. Kevin Lobo, Chair and Chief Executive Officer. You may proceed, sir.
Welcome to Stryker's fourth quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO; and Jason Beach, Vice President of Investor Relations. For today's call, I'll provide opening comments, followed by Jason with the trends we saw during the quarter, Mako performance insights, and updates on recent acquisitions. Glenn will then provide additional details regarding our quarterly results and 2024 guidance before opening the call to Q&A.
First, I want to recognize and celebrate our achievement of surpassing $20 billion in sales. We continue to be a high-growth company with a focus on our mission to deliver for our patients and customers. As we begin 2024, I am very excited about our future. We are in a strong position with robust demand across both procedures and capital, easing macro constraints and a strong pipeline of innovation. I want to thank our over 50,000 employees for their unrelenting determination, agility and performance.
We've delivered terrific sales growth of over 11% in Q4 and the full year despite strong comparatives from the prior year. Our commercial execution, including many successful product introductions, was excellent across our businesses and regions. Globally, for both Q4 and the full year, we had double-digit organic sales growth in Instruments, Endoscopy, Medical, Neuro Cranial, Hips, Knees and Trauma and Extremities. For the full year, we also had double-digit organic sales growth both in the U.S. and internationally. Spine and Neurovascular also demonstrated good performances while making notable advancements in future innovations and acquisitions. It was a comprehensive performance across our businesses, and we have built significant momentum entering 2024.
For the sixth straight year, our international sales growth, excluding China VBP, outpaced our strong U.S. business. Canada, Australia and most emerging markets had double-digit growth, while Europe and Japan grew in high single digits. International continues to be a large growth opportunity for us.
Next, we delivered quarterly and full year adjusted EPS of $3.46 and $10.60, respectively, which represents 15% growth for Q4 and 13% growth compared to the full year of 2022. This was driven by our strong sales but also demonstrates our continued operating margin recovery. We remain focused on driving high growth now and in the future through investments in organic innovation and M&A. We expect to continue to deliver sales growth at the high end of med tech, which is reflected in our full year 2024 guidance of organic sales growth of 7.5% to 9%. This growth, combined with an accelerated margin expansion plan, translates to adjusted EPS of $11.70 to $12 per share. I will now turn the call over to Jason.
Thanks, Kevin. My comments today will focus on providing an update on the current environment as well as Mako, Vocera and our recently announced agreement to acquire SERF. During the quarter, we saw strong procedural demand. We continue to expect the ortho markets will remain strong in 2024, driven by continued adoption in robotic-assisted surgery, demographics, a more favorable pricing environment, and healthy patient activity levels with surgeons. While supply constraints continue in pockets around the globe, our supply is stable overall and gradually improving.
Additionally, demand for our capital products remained very robust in the quarter, with double-digit organic growth in Medical, Instruments and Endoscopy. Hospital CapEx budgets remain healthy, and our capital order book remains elevated as we enter 2024.
Next, specific to Mako, we had a record quarter of installations globally. The progress of our Mako offense, including our recent direct-to-consumer campaign, has resulted in strong growth of our installed base alongside continued increases in utilization. In the U.S., we saw 60% of Knees and 34% of Hips performed using Mako as we exited the year. Globally, we exited the year with just over 40% of Knees and nearing 20% of Hips performed using Mako. We have momentum, and a significant opportunity remains as Mako adoption increases.
We are nearing the 2-year anniversary of our Vocera acquisition and remain very excited about the acquired assets, as it provides a platform for us to be at the intersection of medical devices, software and clinical support. With integration activities now complete, which included a migration towards the cloud as well as the commercial reorganization, we are pleased with the accelerating double-digit sales and order growth achieved as we exited the year. In 2023, we saw many cross-sell wins, including new bed business leveraging Vocera.
Also, we completed the seamless experience created between the Vocera platform and both ProCuity and our new wireless structure. This year and beyond will bring even more integrations and enhancements with a focus on scalability, user experience, automated workflow and documentation. We expect strong double-digit annual sales growth to continue for years to come, and we are excited to have Vocera as part of the Stryker family.
Lastly, we are progressing with our recently announced agreement to acquire SERF, and we expect the deal will close this quarter. With that, I will now turn the call over to Glenn.
Thanks, Jason. Today, I will focus my comments on our fourth quarter financial results and the related drivers. Our detailed financial results have been provided in today's press release. Our organic sales growth was 11.4% in the quarter, compared to 13.2% organic growth in the fourth quarter of 2022. The fourth quarter of 2023 has the same number of selling days as 2022. The impact from pricing in the quarter was favorable by 0.7%. We continue to see a positive trend from our pricing initiatives, particularly in our MedSurg and Neurotech businesses, all of which contributed positive pricing for the quarter.
Foreign currency had a 0.3% favorable impact on sales in the quarter. In the quarter, U.S. organic sales growth was 12.7%. International organic sales growth was 7.7%, against a very strong comparable of over 18% in 2022. This performance included positive sales momentum across most of our international markets, particularly Australia, Canada, Japan and most emerging markets. For the year, organic sales growth was 11.5%, with U.S. organic sales growth of 11.7% and international organic sales growth of 10.9%. Excluding the impact of China VBP, international growth was 12.8%.
The impact for pricing in the year was favorable 0.6%. Foreign currency had a 0.5% unfavorable impact, and 2023 has the same number of selling days as 2022. Our adjusted EPS of $3.46 in the quarter was up 15.3% from 2022, driven by higher sales and operating margin expansion as well as lower other income and expenses. Foreign currency exchange translation had a favorable impact of $0.02. Our full year adjusted EPS was $10.60, which represents growth of 13.5% from full year 2022, reflecting the favorable impact of sales growth and operating margin expansion, partially offset by the unfavorable impact of foreign currency exchange translation of $0.10.
Now I will provide some highlights around our quarterly segment performance. In the quarter, MedSurg and Neurotechnology had constant currency sales growth of 12% and organic sales growth of 11.8%, which included 13.8% of U.S. organic growth and 5.7% of international growth. Instruments had U.S. organic sales growth of 11.5%, with strong double-digit growth across its Surgical Technologies and Orthopaedic Instruments businesses. From a product perspective, sales growth was led by power tools, Steri-Shield, smoke evacuation and SurgiCount. Endoscopy had U.S. organic sales growth of 17.9%, with double-digit growth in its communications, endo BU and Sports Medicine businesses. From a product perspective, this includes strong growth in booms, lights and video. During the quarter, the Endoscopy business continued to see very strong momentum of the 1788 camera system, which had its full launch in September.
Medical had U.S. organic sales growth of 12.9%, led by performances in its Vocera, Acute Care and Sage businesses. This included strong growth in Vocera badges, beds, structures and Prevalon repositioning products. All of this was against a very strong comparable growth of over 20% in 2022. Neurovascular had U.S. organic sales growth of 7.6%, reflecting solid performance in our hemorrhagic business. Neuro Cranial had U.S. organic sales growth of 14%, which included double-digit growth in the Neurosurgical and ENT businesses, with strong growth in high-speed drill and balloon dilation products.
Internationally, MedSurg and Neurotechnology had organic sales growth of 5.7%, reflecting double-digit growth in our Instruments and Neuro Cranial businesses. Geographically, this included strong performances in Australia, Canada and Japan.
Orthopaedics and Spine had constant currency and organic sales growth of 10.7%, which included organic growth of 10.9% in the U.S. and 10.1% internationally. Our U.S. knee business grew 12.9% organically, which reflects our market-leading position in robotic-assisted knee procedures. Our U.S. hip business also grew 12.9% organically, reflecting solid primary hip growth fueled by our Insignia Hip Stem.
Our U.S. Trauma and Extremities business grew 12.1% organically with strong performances across all of its businesses, including upper extremities, biologics, core trauma, and foot and ankle. Our U.S. spine business grew 6%, led by the performance in our enabling technology and Interventional Spine businesses. Internationally, Orthopaedics and Spine grew 10.1% organically, including strong performances in Canada and most emerging markets, particularly driven by Mako and strong knee performance across most geographies.
Now I will focus on operating highlights in the fourth quarter. Our adjusted gross margin of 63.9% was favorably -- was favorable approximately 120 basis points from the fourth quarter of 2022. This improvement was primarily driven by the continued easing of certain cost pressures, including the elimination of spot buy purchases that we experienced in 2022 and the continued benefit of pricing initiatives. Adjusted R&D spending was 5.6% of sales, which was 10 basis points higher than the fourth quarter of 2022. Our adjusted SG&A was 31% of sales, which was 40 basis points higher than the fourth quarter of 2022 due to continued investments, including sales growth incentives and a more normalized cadence of travel and meetings.
In summary, for the fourth quarter, our adjusted operating margin was 27.2% of sales, which was approximately 60 basis points favorable to the fourth quarter of 2022. For the full year, our adjusted operating margin was 24.2% of sales, a 40 basis point increase over 2022. This performance is mainly driven by the easing of certain gross margin cost pressures throughout the second half of the year as well as the positive impact of our pricing actions.
Adjusted other income and expense of $31 million for the quarter was $23 million lower than 2022, mainly driven by higher interest income and other favorable discrete items. For 2024, we expect our full year other income and expense to be approximately $250 million. Our fourth quarter and full year had an adjusted effective tax rate of 14.6% and 14.1%, respectively, reflecting the impact of geographic mix and certain discrete tax items. For 2024, we expect our full year effective tax rate to be in the range of 14% to 15%.
Focusing on the balance sheet. We ended the year with $3 billion of cash and marketable securities and total debt of $13 billion. During the year, we paid down the remaining $850 million outstanding on the $1.5 billion term loan associated with the Vocera acquisition and achieved our de-leveraging commitments. In Q4, we also refinanced certain debt maturities, including prefunding of $600 million that is due in May 2024.
Turning to cash flow. Our year-to-date cash from operations was $3.7 billion. This performance reflects the results of net earnings and higher accounts receivable collections. For 2024, we anticipate that capital spending will be $650 million to $700 million. We do not anticipate any share buybacks.
And now I will provide 2024 full year sales and earnings guidance. Based on our momentum from 2023, strong procedural volumes, healthy demand for capital products and a stabilizing macro and economic environment, we expect organic sales growth to be in the range of 7.5% to 9% for 2024. There is 1 additional selling day in 2024 compared to 2023, with 1 less day in Q1 and 1 more day in both Q3 and Q4. Based on the steady progress of our pricing actions, we would expect the full year impact of price to be roughly flat.
If foreign exchange rates hold near current levels, we anticipate sales will be modestly unfavorably impacted for the full year, being more negative in the first half of the year. EPS will be negatively impacted $0.05 to $0.10. This is included in our guidance.
Finally, for the full year 2024, we expect adjusted net earnings per diluted share to be in the range of $11.70 to $12, representing our commitment to accelerated operating margin expansion in 2024 as well as the stabilizing operating environment. While we do not provide quarterly guidance, we do expect seasonality for sales and related earnings to be similar to 2023, but adjusted for the quarterly differences in 2024 selling days. And now I will open up the call for Q&A.
[Operator Instructions] Our first question comes from Robbie Marcus with JPMorgan.
Congrats on another fantastic quarter. Kevin, maybe to start, I feel like it's a bit of deja vu where we were sitting here at exactly this time last year and investors were starting to worry after a good year in 2022 and how good can 2023 be. And now people are wondering about '24. So I was hoping you could give a little color behind the 7.5% to 9% organic sales growth. How much of that is transitory? How much of that is durable pricing? And any key drivers you could point us to?
It certainly was a terrific year in 2023. We had 9.7% organic the year before and over 11% organic in '23. And frankly, we feel very good going into '24. At some point, you think the comps will start to catch up too a little bit, and so we think 7.5% to 9% is a strong guide. I can tell you, coming off all of the domestic sales meetings, there is tremendous energy and excitement among our teams.
Procedure volumes are strong. The capital markets are very strong. Hospitals are spending. We have exited the year with more backlog than we began the year, which means, obviously, our orders are continuing to be strong for capital equipment. So we have a number of new launches, again, planned in 2024. Obviously, 2023 was a great year of capitalizing on product launches, whether it's System 9, whether it was Neptune S, whether it was the 1788. We have other launches coming again, so our pipeline of innovation is very strong. And so I expect us to continue to grow at the high end of med tech in a med tech market that is quite healthy.
Great. Maybe, Glenn, a follow-up for you. And I appreciate you don't guide quarterly, but there's a lot you could do to help us get models in the right spot based on what you can say. And I guess really, the question is my math is implying 50 to 100 basis points of operating margin expansion. You talked about the top line should look like 2023. And I imagine that looks like a normal comparable quarter in first quarter and maybe some sharper seasonality, then historically down 3Q, up 4Q. Also, anything down the P&L operating margin that we should be considering in that seasonality?
I think, Robbie -- and I tried to sort of lay this out at the end of my guidance there. But I think a good place to start would be to look at sort of the cadence of sales and earnings in 2023 and really just adjust out for 1 selling day in Q1 and then adding 2 on the back end. And so as you look at, hey, Stryker, how are you going to deliver op margin expansion throughout the year? It's probably a little more back half-loaded just based on the cadence that we'll see through the year for sales and related op income.
Our next question will come from Lawrence Biegelsen with Wells Fargo.
I'll echo Robbie's congratulations on a really strong year and finish to the year. Kevin, I'd love to hear your updated thoughts on M&A headed into 2024. Your focus has been on paying down debt in 2023. Is your focus in '24 on smaller deals? Are you open to considering something larger? And are the target areas the same as the ones you shared at the orthopaedic meeting last year? And I have one follow-up.
I would say that we're back on M&A offense now, what I'll call our normal M&A offense. And as you've seen in the past with Stryker, that would typically mean larger volume of tuck-in deals. And those can be large, and they can also be small. But during the pause, while we paid down debt, all of our BD teams worked very actively. Believe me, they have a long list of targets. And we are going to be active now that we've gotten our leverage back to where we'd like to be. So let's say we're back to the normal Stryker offense. Expect us to be doing deals. We are open to larger deals. But our history would tell you that the vast majority of our deals are going to be the smaller tuck-ins, but we can do many deals versus being very limited last year.
Glenn, to follow up on Robbie's question on the margins. First, is it coming -- the margin expansion coming, how much is coming from gross margin versus operating margin? And are you committed still to the 200 basis points, getting back to the pre-COVID margin by 2025? I mean, it actually -- I don't know if the math -- not to get too much into it, but it looks like -- I thought it looked like over 100 basis points implied in the guidance this year. So I assume we can all figure that out off-line, but just any color on gross versus operating margin and the 200 basis points for the 2-year sprinting back to pre-COVID margins would be helpful.
Larry, I think, first of all, we're not backing off of our sprint to 2019 op margin at all. And we have clearly a plan to get there by the end of 2025. As I said in the Analyst Day, we have good opportunities in operating expenses and in gross margin. I think if you look at our delivery in 2023, we got about 80 basis points out of gross margin. And we invested in some operating expenses that we had indicated would get back to sort of normalized spend.
So my thoughts on 2024 is that expansion will generally be led by operating expenses, but there continues to be really good opportunities in gross margins that we continue to work on. And if you think about some of these things, price isn't going away from us. We're still going to continue to work on that. Viju elaborated on the benefit we have of low-cost manufacturing sites, and we'll continue to see expansion there. We have opportunities in purchasing and procurement, supplier consolidation.
On the OpEx side, we'll continue to expand into shared services in some of these low-cost areas where we have those. And then honestly, from OpEx, we have a lot of natural leverage. It just comes when you're growing at the rate that we're growing.
Our next question will come from Ryan Zimmerman with BTIG.
So I want to ask about orthopaedics. It's just been stellar performance, and we've heard from you and one of your peers. And Kevin, I just would appreciate if you can kind of characterize the confidence that this continues to persist for '24. And how are you improving or what are you doing to improve potentially productivity on the Mako unit to capture the demand that's continuing to be so strong?
We're delighted with the progress that we've made. 60% of U.S. knees being done on the robot is pretty remarkable, given how long ago we launched the total knee application and seeing hips starting to really climb since we launched the 4.0 software has been terrific. Cementless continues to climb as well. And that tends to index much higher with the use of Mako. And as you know, we are clearly the leader in not just in robotic-assisted surgery, but clearly the leader in cementless as well.
So a lot of good things going on with a market that is obviously a little better than it has been historically. But Mako continues to be the engine of growth, and that's true in the hospital. That's true in the ASCs as well. And we're seeing continued growth in ASC, where our Stryker offense is really winning at pretty spectacular rates as it relates to new builds and big renovations. So we have a lot of momentum across all of those dimensions, which translates to terrific performance as you saw with Hips and Knees.
But the other part of our story is Trauma and Extremities. So the Wright Medical acquisition has been a complete home run of a deal, and you're seeing that. And not only has it been great for our Extremities business but enabled us to focus a lot more on our core Trauma business. And we really had all of our businesses in Trauma and Extremities humming as we exited the year and some great product launches towards the end of the year and some more to come in 2024.
Okay. And then maybe turning to Medical because it is now, I think, the biggest unit inside the company. And the comps are increasingly tougher in the first half of this year. It's been exemplary growth through late '22 and then in the first half of '23. Inside of that, you talked about Vocera continuing to be a double-digit grower. But if you can level set us on the entire portfolio, how do you think about the ability of that business to continue to be accretive to overall growth? And maybe what the appropriate expectations are around the Medical segment given how much is in that segment?
Look, we love our Medical business. And frankly, it's become a big and very fast-growing business. We continue to expect it to grow above Stryker's average growth rate. That is going to be true for the next 5 years. From quarter-to-quarter, it does bounce around a little bit because, of course, there's capital. A lot of large capital within Medical, but you also have increasingly more stable revenue with Sage, which is doing [ attack ] as well. Then you've got obviously the AED demand, which has exploded, and we have a terrific AED business. Tremendous innovation. We launched the Xpedition stair chair in the early part of the year, the first powered stair chair, which the firehouses absolutely love. And then you've got a lot of new demand for the wireless connection, wireless stretchers.
So just tremendous innovation, tremendous leadership position, and now a much more diverse set of businesses than we had historically. So I think Medical is the business in Stryker that's the most underestimated because AEDs are high growth, our power costs are high growth.
And now our bed business is doing really well behind ProCuity, and then you have Vocera in addition to that. So really, I would expect high growth from all of those different businesses, Sage, Vocera, beds, stretchers, AEDs because of innovation that we're constantly innovating. And we have a couple of big launches in Medical coming this year as well, so it's an exciting time to be at Medical.
And we also have an outstanding leadership team. They've really focused on talent for years and years and years. And so I'm very bullish on Medical. And I think, again, whatever people have in their models, we've tended to beat in Medical if you go back for the last [ 6 ] years.
Our next question will come from Joanne Wuensch with Citi.
Very nice end to the year. I'm curious about where you are in your super cycle. And not to use sports analogy, but are you halfway through? Half time? Or you have a couple more innings to go? I know I'm mixing my metaphors there. And also, sort of similarly, AAOS, what should we be expecting for that?
I'll take the first part, and then Jason can talk about AAOS. Look, I would say that our pipeline of innovation is incredibly strong. When I mentioned the term super cycle, that really was referring to, let's call them, big platform launches. But the reality is we're driving tremendous growth even in some of the divisions that don't have big platform growth launches, if you think about upper extremities, you think about foot and ankle.
But I would say the big ones coming up, we have this Pangea launch within our core trauma business, which is a big platform launch. We have a new defibrillator that's coming, of course, pending FDA approval. It's a PMA device, but we're very excited. That's what I would call a big platform launch. We have Mako spine coming in the third quarter of this year. That's another big platform launch towards the end of the year. We have the Mako shoulder, and we have this product that we call CoPilot, which is a very exciting product that's going to be used by spine surgeons as well as neurosurgeons, which is within the same ecosystem as Mako and our Q navigation system.
So those are the ones I'd point out to, but what I'd tell you is every business has launches planned. And as some of them accumulate a number of small launches, then you end up driving pretty terrific growth. But I would say maybe we're kind of midway through the large platforms.
But I would tell you, everyone is reloading. So we launched 1788, and they're reloading and already working on 1888. So I think we've just hit a sort of a cadence of innovation that's as good as it's ever been in my time at Stryker. And so I don't expect that we're going to sort of come off this super cycle and suddenly have some kind of a dip. We're just reloading and reloading, and getting back on M&A offense also will help to continue to fuel that. So I'm very, very bullish really for the next couple of years that this innovation pipeline across our company will continue to fuel high-end growth for Stryker. And second part, Jason?
Joanne, it's Jason. Happy to follow up after the call as well. But AAOS will be exciting. Some of the products that Kevin just referred to, we will be demoing at AAOS. Starting with Blueprint, followed by Pangea, 1788 camera will also be demoed as well. So it will be action-packed, so we plan on seeing you out there.
Our next question will come from Vijay Kumar with Evercore ISI.
Congrats on a really strong print here. I had 2 questions. Maybe first one on the guidance here. 7.5% to 9% for the fiscal '24, what is being assumed for China VBP? Any backlog contribution? And I'm looking at Q1, that's the toughest comp of the year. Should Q1 still be within that annual guidance range of 7.5% to 9%?
Vijay, yes, as we look at -- I don't want to guide quarterly, but I would tell you that the cadence of what we're going to deliver from the midpoint will play out similar to 2023. But keep in mind, you got to back out 1 selling day in Q1 is what I would say. And then on VBP, I'll let Jason...
Yes, I mean -- it's Jason. On VBP, I think we don't disclose in terms of the impact there, so we won't. But in terms of a follow-up to your capital question, as we think about the capital environment, really the tone has not changed there. We feel really good. Orders are very healthy. I mentioned that we came into the year with an elevated level, so we feel good. And just as a reminder, right, if you think about our capital sales, so our smaller capital being, call it, 15% of our sales needs to continue to be refreshed as you think about kind of the procedural volume. And then large capital being 10% of our sales, again, very healthy from both a order and backlog perspective. So we feel good about that in 2024.
Understood. And Kevin, maybe one for you on that. I saw that you mentioned direct-to-consumer campaign on Mako is very successful. Could you just elaborate on that? And I'm curious, do you think like on the Spine side, we could perhaps see adoption rates similar to Knee, where 50%, 60% of spine procedures could be done in Mako at some point in the future?
Well, first, the direct-to-consumer has been terrific. I mean obviously, we have such a lead in robotic-assisted surgery. We want to make sure that we're differentiating our product among the rest of products, and the searches and the impressions that we have kind of exceeded our expectations. So we're really pleased, we're going to continue that program for a good portion of this year. And so that certainly helped create a tremendous interest among consumers as well as hospitals, who actually watch the same ads as consumers, so we're very excited about that.
Spine, we couldn't be more happy because certainly, that's been a gap in our portfolio relative to others. And this has got terrific workflow. And look, I think robotic adoption tends to really grow no matter what procedure you're doing. If you have a good solution, it will, over time, become the majority and eventually standard of care. And we've obviously seen this in the general surgery world, as it relates to prostate, and starting to happen in other cases. And I think it's going to happen in orthopaedics. And so Spine might take a little longer, but I absolutely do believe it's going to be key for us in the future.
We're extremely excited. We've been showing surgeons the Mako spine, getting terrific feedback on the workflow and the speed and the efficiency. And again, that's within the same ecosystem as the Q Guidance. So we've been selling a lot of Q Guidance software, which is used to navigate those procedures. And that same camera, which is the fastest camera in the market, will be compatible with Mako when we launch it. So I do believe it will become, for pedicles replacement at least, the vast majority of the procedures in the future.
Our next question will come from Shagun Singh with RBC.
Kevin, I was hoping to get your thoughts on utilization. It's been a key topic this last week across some health care sectors. What trends are you seeing in health care utilization across different care settings? What is driving it? And how do you think about the sustainability of it? Is it being driven by the aging demographics? Is it innovation? Is it just low market penetration? And I think you did indicate that there is still a backlog and it is contributing. But is it a meaningful contributor to growth on a year-over-year basis? And then I have a follow-up.
Okay. Well, I think if you look at the hospitals and what they're saying, that's kind of one of the indicators we look at, they're busy, right? The hospitals are busy. Patients are -- definitely, aging demographics plays for Stryker's portfolio. That definitely plays to our advantage. And every day, 10,000 more people are turning 65. The activity levels are also increasing, right? The advent of pickle ball has been a terrific thing for our business. More active people who are elderly tend to want to stay active, and activity levels are kind of the biggest predictor of needing joint replacements and Sports Medicine procedures. And so we're seeing very good activity levels.
And so I don't really want to talk about backlog. I just think what we're seeing is patients presenting -- frankly, some patients who are just wanting to be more active, losing weight, and then wanting to be more active and then being eligible for surgery. So we do see really good -- a waiting list for surgeries, for surgeons in the orthopaedic space. Hospitals ordering capital, whether it's small capital or large capital, building more ASCs. The ASC trend has actually really helped because patients love it. They go, they get home the same day. They have a terrific experience, and they tell all their friends. And that word of mouth is spreading for hip and knees. Absolutely, for hip-and-knee surgeries, that is happening. And our percent of procedures in ASCs continues to climb.
So I think those are -- there's a number of factors I just outlined, all of them pointing to this, at least for this year, continued good demand. And I'm not -- I don't know that it's -- I don't know how temporary it is. This could be continuing, frankly, for a period of time because I think demographics and activity levels are the 2 drivers that we're seeing, at least for our portfolio of businesses.
That's really helpful. And then just on guidance, you guys delivered a pretty -- or you put up a pretty strong initial guide out of the gates. Does it give you room for upside as you move through the year? And I guess more specifically, what areas could we potentially look to drive that upside?
Great question. First of all, we have a history that we generally like to follow. And I would tell you that it's early days. We're here in January looking at 2024. We feel very confident about where we're going to perform on sales and driving op margin expansion. At this point, I'm not going to comment on the potential to go beyond that. But we feel very good about the guidance that we put out.
Our next question will come from Pito Chickering with Deutsche Bank.
Congrats on an amazing year. On the gross margins, can you help bridge the third quarter to fourth quarter gross margins? How much of the impact was mix? And then you have the good guys and bad guys, if you can help us understand that sequential change?
Yes. Sure, Pito. Without going into too much detail, I would say the single biggest item was really mix in terms of what was growing much faster in Q4 versus Q3, relative to sort of some of the other items. We also had really solid price performance in Q4, which contributed to that. And then lastly, in sort of in typical Stryker fashion, we hit a little bit of a hockey stick here in Q4 too. And so that actually benefits on the gross margin line.
Okay. Great. And then on pricing, back in third quarter, I think it was about 30 basis points favorable. It's 70 basis points favorable this quarter. Guidance assumes flat pricing for '24. I guess, shouldn't there be some positive pricing in '24 just as the fourth quarter comps out? And after you've gotten accelerating pricing throughout the year, I guess, why is your 2024 pricing flattened out?
Keep in mind, flat is the average for the whole company. And the way that, that pricing guide is calculated is legacy product over legacy product. So a lot of our pricing increases carry over into 2024. They're just comparing to the new higher price. I would also say too that flat is the average of some up and some down, and so we absolutely will see price increases across some of our businesses. And that will be balanced with some of the challenges we have in, say, spine or some of our other orthopaedic businesses. So I do think we haven't backed off our pricing strategy one bit, and we fully expect to sort of maximize the benefit we're going to get out of pricing.
Our next question will come from Travis Steed with Bank of America.
Glenn, maybe just a finer point on some of the op margin guide. It looks like the 200 basis points, more than half of that is in 2024. Can you just confirm that? There's a little bit of kind of math going around. I just want to make sure we got the math in '24 correct. And then with such a big ramp in '24 on the guidance, just can you give a little more confidence on what you're doing to kind of achieve that 100 basis points plus in 2024 from what you're seeing on the cost input side? Just to kind of drive confidence that that's achievable in '24?
Yes, I think you can do the math as well as I can, especially given all the areas that I've guided in the full year. So I definitely think you're in the ZIP code for what we think will happen in 2024. And honestly, if we look at sort of what we've laid out and planned for the year, first of all, the natural leverage we get from growth versus fixed cost and operating expenses certainly will provide us some benefit. We also won't stand still in a lot of the gross margin initiatives that I mentioned, and those will move forward and also provide some benefit that we'll see in 2024. And so I would tell you that we haven't walked lightly on this. I would say that across the globe, Stryker is very focused on these op margin expansion projects and sustainable op margin expansion for 2024 and 2025. And so we feel very confident that we'll be able to deliver that.
Great. And then maybe one quick question on Mako shoulder just to make sure that's still expected to come in 2024. And anything else you want to say on that at this point?
Yes. Listen, as we've said from the beginning, Mako shoulder will launch at the end of '24. So don't expect to have much at all of a revenue impact. That said, [ it's ] something like our shoulder business needs, Mako shoulder to be growing at strong double digits. They have terrific products within upper extremities, with Shoulder iD, with a number of really pyrocarbon humeral. We have a fracture stem for Perform, which is incredible, a reverse Perform stemless. So we have 4 terrific launches in upper extremity, so they're going to be fine even before Mako. But Mako will be the end of the year. The feedback from surgeons have been terrific, but that will have much more of an impact in '25, not so much in '24.
Our next question will come from Matthew O'Brien with Piper Sandler.
Just on Mako, this question might be for Jason. Just the domestic number this quarter was a little bit soft, and we're hearing about one of your competitors just giving their system away, so it's not all that great. Can you talk about the dynamics that you're seeing in the market, especially domestically for Mako in terms of placing systems, selling systems, and then just having to get really aggressive on the pricing side, just given the environment that you're in? And then conversely, the OUS number looks phenomenal again. Just where are we at in terms of growing that business over the next several years? And I do have one follow-up.
Matt, I'll start this and Kevin, feel free, obviously, to weigh in. But as we think about the Mako offense, and I think we've said this previously as well, when we think about the various options to bring Mako to market, we've been flexible, right, whether it's leasing, rental, et cetera. So I think we're very competitive from that standpoint. And to your comment on kind of where we are, I would still say whether it's U.S. or internationally, early innings here. We've got a lot of runway relative to Mako. But as we think about the financing options, it's not going to be an impediment for us to expand the Mako footprint.
Yes. The only thing I would add to Jason's comments are that every ASC Mako that's installed is financed. Every one. And that's becoming a bigger percentage of the Mako installations. So what you're seeing is more financed rentals and financed versus outright capital purchases. So that, obviously, the revenue number and the revenue growth of 3% in the U.S. is not installation growth. Installation growth is higher than what you're seeing. And over time, that will start to normalize and then you'll start to see the growth rate to be more reflective of the installation rate. But we're going through this kind of transition phase right now.
And we aren't giving them away. So we charge for it. We have different pricing models, obviously. And we want the customers to have skin in the game. So that -- if we just give it away, they have no incentive to use it. And what we don't want are a bunch of robots collecting dust. So we care a lot and we monitor utilization of the robots very, very significantly.
And then, of course, OUS, we're seeing terrific pickup and a lot more purchases than finance. We do offer financing around the world. But so far, in international, we're seeing a lot more purchases than we are financing, which is why you see the revenue spike. But again, international has a huge potential. It's kind of where we were in the U.S. about 5 years ago.
Understood. And then sticking with Mako. Kevin, you mentioned shoulder. You don't really need the application as much because you're crushing it on the shoulder side. In spine, you're doing better in the last couple of quarters. I haven't really heard why that is. I don't know if it's just on the dislocation or not. But I think it's probably a bigger opportunity on the spine side of the business going forward. These centers that already have Mako and use them for hips and knees, can you quickly transfer the system to the spine part of those institutions or facilities and start to pick up share fairly quickly? Or is this something that's going to take many, many quarters? We're talking '25, '26 before it really starts to impact the Spine business?
What I'd say is, first of all, the Mako brand is extremely well known. That's a very, very big positive. And I think what you're going to see is a much faster uptake than you would have seen had we not had already had Mako on hips and knees. Will it take a little bit of time? Sure. Well, let's find a surgeon who want to share the robot with hips-and-knees surgeons. Not sure yet. Obviously, that's something we're going to see play out, whether they're going to want their own robot or they're going to be willing to operate on the days that hip-and-knee people aren't operating. So that's a whole dynamic, I think, that will vary account by account.
So we're already working on our commercialization plans. I think part of the reason for our success is success of the Q Guidance, which is 1/2 of the system. So you have the Q Guidance and as well Mako, they know it's coming now. Customers have gone to Leesburg, Virginia, our spine headquarters, to see Mako spine. And many of them have stopped their purchases of other robots, knowing that this is coming. So I think that's what's helping to contribute to our, let's call it, somewhat improved performance. But we still would like to grow at a higher rate than we are right now. And we know we need not just Mako but also the CoPilot product, so we're going to go from being behind to being ahead. And CoPilot should launch in a similar time frame, slightly ahead of Mako spine, so you're now going to have the CoPilot product plus the Mako spine, where our subpar competitors will just have their robot. The ones that have robot will just have a robot, without CoPilot with haptic feedback that can do the laminectomy and discectomy portions of the procedure, which complements the pedicle screw placement.
So we're really going to be in a great position by the time third quarter comes around. Robots do take time, so the scaling will take time. But I think it will be certainly much faster than the initial people who came in with robotics. And they know they benefit from it, and they know they can trust the Mako brand.
Our next question will come from the line of Josh Jennings with TD Cowen.
I wanted to, hopefully, Kevin, ask about just get a temperature check on the health care delivery systems capacity for orthopaedic procedure growth. I think heading into '23 after experiencing 2022, there were concerns around staffing shortages, et cetera, and potentially creating a bottleneck for procedure volume growth. That clearly didn't play out in 2023. It doesn't sound like from your comments, it's going to play out. You expect it to play out in 2024. But are there any capacity constraint issues in the U.S. health care delivery system for orthopaedic procedure volume growth as we go forward in '24 and '25? Or is that fully in the rearview mirror?
Yes, I think it's largely in the rearview mirror. There's still niggling things here and there, but it's gotten very quiet. You saw that in Q4. It's just a boomer of a Q4. And the kind of the normal seasonality, I think we now have finally a normalized year for you to compare against, of course, adjusted for selling days. But there is a normalized year finally. And yes, they've gotten their staffing issues solved largely, and they do prioritize orthopaedics because orthopaedics is a money maker for hospitals, right? Cardiovascular and orthopaedic procedures are the 2 money makers.
And so if they are short staffed, they are going to prioritize staffing for orthopaedics. I would say the only area that still has a lot of room to run is ASCs. So every hospital is constructing ASCs, and that's going to continue to be an engine of future growth. But I'd say we're in a very normalized environment. They have the capacity. They can operate additional days, which we saw some of that in Q4 again, which we hadn't seen for a couple of years. So I think the hospitals are absolutely ready now, and a lot of that is behind us.
Excellent. Just one follow-up on Mako. Just another record system placement quarter. Was hoping to just get some details on where -- what you're seeing in terms of second or even third system purchases by hospitals, hospital systems. Any kind of percentage of total systems? Or how big of an opportunity do you see kind of getting that second, third, maybe even fourth system into hospitals?
Josh, it's Jason. First, I would say there are many hospital systems across the U.S. that are second, third system. For competitive reasons, we don't disclose kind of number of units installed. But you certainly see numerous systems with multiple Makos. I think as you fast forward to a shoulder and spine application, you're going to see more and more of that when you think about utilization and the need for future systems. So that's kind of how we think about that.
Yes. Frankly, I would say it's rare to have one Mako in a hospital now. There are some that have 5, 6, 7 Makos. I think 60% of our knees are going to Mako. That's got to be a lot of Makos to be able to drive that kind of volume. So the days of people saying, well, this is my first Mako, those days in the U.S. are kind of fading. That phenomenon still exists outside the U.S.
Our next question will come from Chris Pasquale with Nephron.
Just quickly on the SERF acquisition. Are there any particular portfolio gaps you closed with that deal? Or is it more about expanding your distribution footprint internationally?
Chris, it's Jason. And we'll talk about this more after the close. But it really is -- it helps from a hip portfolio perspective. But beyond that, we haven't said much at this point. And like I said in my prepared remarks, we're set to close this quarter, and then we'll certainly talk more to that.
And then I'm curious how you're thinking about the outlook for Neurovascular in '24. '23 was a better year for that segment in the U.S., but it kind of got offset by international. And along with Spine, it was really one of only 2 segments not to grow high single digits or better. So what's the game plan to drive better growth in that business? And do you have what you need internally? Or do you need to look for supplements to that?
Look, we continue to like the neurovascular market, as there's still a large number of patients that aren't being treated. It's an attractive market growing high single digits. And we do expect to grow in line, at least in line with the market. We are obviously very hard hit by China this year with the VBP. We had a very big neurovascular business in China, so that hurt. I don't know that we completely lapped it, but it's going to -- we're going to get to the bottom of China pretty soon, and then that will be behind us.
We also have the SERF acquisition, which is off to a very good start outside the United States. We are seeking U.S. approval. I believe that will be some time in 2025, maybe beginning of '26. So we still have a bit of time to wait for that, but that is a fabulous product for intrasaccular technology.
We are looking at an area like liquid embolics. We don't have that product, if you want to think about one that we are going to be looking into. Every business has something they'd like to add. But we do have a good pipeline. We don't talk about Neurovascular pipeline too much because they get subject to regulatory approval through a PMA process. So -- but the team does have some very good products that are lining up. And I do believe we're going to be back to kind of much closer market growth, slightly above market growth in the years ahead. But as the market continue to [ like ], it obviously has gotten much more competitive on the ischemic side, and we continue to have a very strong business on the hemorrhagic side. We launched a couple of products last year, the Vecta 46 catheter, the Tetra coil, and that kind of fueled some very good U.S. growth as you saw in the back half of the year.
So we like the business. Yes, it's not as fast growing as it was historically, but it's still a very good business. We're committed to it and do expect that, that will pick up as we put VBP in the rearview mirror.
Our next question will come from Danielle Antalffy with UBS.
I'll echo everyone's congrats on a really strong end to the year and strong start to 2024. Just a quick question on the orthopaedics market in general. One of the things I've been trying to get a handle on is what's really happening in underlying market growth. Obviously, 2023 benefited from some semblance of a backlog work-down. But it seems like yourselves and your competitors -- not that you gave guidance specifically for ortho, but seemed to be signaling higher than sort of normal, call it, pre-COVID market growth.
And I'm curious, beyond pricing, what's really changed here? Has capacity increased? We talked about ASCs. What's changed fundamentally in the orthopaedic -- large-joint orthopaedics market that might be driving higher -- sustainably higher growth versus pre-COVID levels?
Danielle, it's Jason. I think a couple of things, right? And Kevin even alluded to this, I think, earlier as well. But I think there's a variety of things around demographics. Kevin touched on activity levels. Certainly, that plays a part here. We talked about a more favorable pricing environment. Certainly, it plays a role. And then if you think just from an adoption standpoint with robotic-assisted surgery, I think there's a variety of dynamics at play here that have come into play in terms of elevated market levels. And if you saw what we published coming out of Investor Day, we've said over the next 2 to 3 years, we expect this to be in kind of that mid-single-digit range. So we're certainly confident in 2024 and beyond as we think about the ortho markets.
And I guess just a follow-up on that. How much of that is Stryker-specific though? Because given the innovation on Stryker's side, the success of Mako and pull-through there, how much is market broadly versus Stryker-specific, if you can even remotely quantify that?
Danielle, look, we've always talked about outgrowing the market. Let's call it, round numbers, 300 basis points ahead of the market. And in the past, there was a time when hips weren't quite growing that fast until we launched [ it ]. But if you go back over the last decade, we have been growing roughly 300 basis points faster than market. So if the market moves up, then our numbers move up as well. And I think you've seen that all year this year, as you've seen in the last couple of years. So that's kind of the way I'd look at it is whatever the market grows, we should be roughly 300 basis points faster because we have this huge lead in robotic-assisted surgery as well as cementless. And we just have a team that's firing on all cylinders.
Our next question will come from Matt Miksic with Barclays.
So maybe a couple of follow-ups on some of the things that have come up, and I'd love to try to get some additional color on M&A. You talked about sort of being back on offense, which is awesome. And just maybe if you could talk a little bit about what that means, large versus small, sort of new platform versus maybe something that strengthens one of your existing businesses like, I don't know, Neurotech or ENT or Neuromod has come up in the past. Anything to add, you can talk about that. That would be great. And then I have one follow-up.
Matt, look, I can't get too specific. You know the nature of M&A. M&A is fluid, and the deals have to make sense financially after the buyer that's ready to sell when you want to acquire. I think because of the pent-up demand in the businesses, we have a lot of mouths to feed and they're hungry. And so I would think in the, let's say, at least the first half of the year, there'll probably be more of tucking things in that -- because we've been staying close to these companies, and we have a bunch of deals that are teed up. But then once you get through the first half of the year, I think it becomes open field. And then open field means maybe more tuck-ins, but it means maybe more things that are in the adjacency categories. We're always open to those. But a lot of things have to -- stars have to align in order to be able to do those deals.
But we're back on the normal Stryker offense. And again, what does that mean? It means most of the deals, by number, are going to be those tuck-in deals. But things like a Vocera and Neurovascular and those types that do Physio-Control, those kinds of deals are going to pop up that are more in the adjacent categories. But I can't predict this, honestly, because I don't know what's going to happen. But we are out hunting, and we are excited to get back to a more regular M&A. It's been a huge part of our offense. We know how to do this. We've gotten really good acumen around valuations and around integrations, which -- early in my tenure, we weren't so good at integrations. And if I look at Wright Medical, it was just like -- it's just been a role model for how to integrate a complex business, and the results have been stunning.
That's great. And then just a follow-up on ASCs. This has always been kind of sort of a hot topic, I guess, for the last few years, particularly coming out of the pandemic. So just maybe some thoughts, if you could, on where you are in terms of the build-out of that opportunity? Maybe where -- like the percentage of hips and knees that are now, you think, being done through that channel? And then sort of back to the M&A side of it, is there -- are there other businesses that have some synergy there? You've obviously got [ all the ] equipment with Mako, with your OR equipment and implant pull-through for these -- to these ASCs. But anything else makes sense to kind of bridge and lever that success you've had there?
Okay. I could spend a long time on this, but I'll just sort of cut to the chase and say that, look, things are continuing to progress in the ASC. We're now running between 12% to 15% of our hips and knees in the ASC. That's higher certainly than it was last year. So it continues to climb at a gradual rate because the great limiting factor is capacity and the build-outs of these ASCs. But it is definitely continuing a steady climb. We have everything we need for orthopaedic ASCs. And when I say everything, I mean booms, lights, power tools, Steri-Shield, Neptune, waste management, operating table, every implant from foot and ankle to shoulder to hips to knees to spine. And I'm going to include spine in that because we just most recently did a really terrific ASC deal in spine, a lot of spine procedures moving to the ASC. We did this in Duluth, Minnesota, which is a really exciting deal, and we were able to leverage spine in addition to a lot of other capital equipment in the ASC.
And some of those new builds and big renovations, we are absolutely beautifully positioned. What we're now looking at, now that we're a little bit in the GI space with Neptune and the POM acquisition that we have, is what else can we do in that space and other things we could add in that space. Now it's not -- I'm not saying that specifically about ASC. It's about we are -- we like to be really busy in the call point. And now that we're in the GI call point, with every call point we go into, we say, what else can we bring to that call point? What other value can we bring? I'm not predicting that we'll do something in that space, but that's kind of how we look at it. But as it relates to these orthopaedic ASCs, we are in an incredibly good position to be able to win in the ASC world.
Our next question will come from Caitlin Cronin with Canaccord Genuity.
Congrats on a great quarter. Just jumping up on Matt's question earlier. Momentum in spine really seems to be strong. Do you have any more clarity on how much you've been able to capitalize on the disruption in the space or expect to kind of capitalize from the disruption?
Yes. I tell you, listen, our performance thus far has really nothing to do with the disruption of the consolidation. I mean it's just starting. We've just started to hear some disruption in Texas as an example and a couple other little spots. So I would say, very early days of disruption, and that's not the reason why we're doing better. We kind of really improved our offense in spine, especially as it relates to enabling tech. I think the Q Guidance was big shot in the arm for the Spine business. They've done a terrific job selling that and then, of course, leveraging that for implants. That's been more of a factor than disruption. I think we're going to see the disruption starting this year. And hopefully, we'll be able to pick up on that. But thus far, there really hasn't been much in the way of disruption. And we're going to see that play out over the course of this year.
Got it. And then just a quick one on Mako shoulder. You noted great feedback from docs. What's kind of going to be the use case for the docs? Is it going to be outcomes, time savings, et cetera?
Just -- look, there's a whole series of outcomes. Just to simplify it, it makes a very hard procedure very easy to do. That's the way I would simplify it. Why was the partial knee so widely successful? It was a hard procedure to do, and the robot made it easy. And the shoulder is harder to do than a partial knee, and it's going to make a very hard procedure very easy to do. It takes stress off the surgeon and have very predictable results. That's been the value prop. There are surgeons I talk to now that, due to high volume of knees, that tell me at the end of the day, I'm not tired anymore. This robot is taking away my stress. It's just making life easier for me, and you can multiply that by 10 for shoulder replacements.
Our next question will come from Steven Lichtman with Oppenheimer.
First on price, how are you thinking about the relative pricing outlook in '24 as you look at the major segments of MedSurg Neuro versus Ortho Spine? Anything meaningfully different than what we saw in '23 directionally? And I know we touched on this at Investor Day, but what gives you the confidence in the sustainability of this firmer pricing environment? And then I have a quick follow-up.
It's Glenn. So as we look at price, first of all, we've really honed in a strategy and a group that solely focuses on pricing for the whole company. If we think about sort of those segments, I don't think you'll see a lot of different performance in what we see out of our segments in general. MedSurg and Neurotech has more of an ability to gain pricing, and we see price increases in those businesses. And honestly, even before the pandemic, we would see price increases coming out of the MedSurg businesses.
I would say on the Ortho side, the trend has really been that it's just been less negative. Also, if you think about those ortho contracts, they're generally 3-year contracts. So we haven't really even cycled through all those contracts yet. We have real discussions around inflation in our business with our customers. They know it, they experience it themselves. And so we're just -- I'm not expecting to see positives come out of the Ortho side, but we'll probably continue to see less negative.
Got it. And then Glenn, just on PILLAR II, is there an impact in '24 that you're offsetting? And how are you thinking about sort of the potential impact in 2025 based on what you know today?
Good question. As we think about 2024, there is an impact for us. I think that through our tax planning and other strategies, we feel like we have fully offset that impact, and that's included in our effective tax rate guidance. For 2025, it's just -- it's too early to comment at this point, to be honest. It's something we're just starting to look at, and we'll have more on that probably a year from now.
Our next question will come from Mike Matson with Needham & Company Inc.
It sounds like you're looking at doing some more M&A here. I was just curious if you could remind us where your leverage ratio is. And if you have a target, just how high you'd be willing to go there?
We generally try to maintain a leverage ratio of 2.5 to 3. And I think if you do the calc on 2023, where we're sitting at year-end, we're squarely on the lower end of that range. So we do feel like there is some room, if needed, depending on sort of what we see in the acquisition landscape. But I fully expect that sort of given the normal cadence of acquisitions and that product tuck-ins are generally what we sort of normally go after, we likely won't be out borrowing to do those types of acquisitions.
Yes. And keep in mind that 3 is not necessarily an upper limit, right? So that's a normal landing zone for us, this 2.5 to 3. For the right deal at the right price, could we go higher than 3? Sure, we would. And we have -- obviously have to commit to paying down the debt. But we don't really look at us as sort of being constrained that way. So for the right asset, if it's going to be value-creating for Stryker, we are not afraid to push beyond the 3. But that's kind of the land we like to live in as a landing zone.
Yes, I understand. And then just wanted to ask one about Sports Medicine. I didn't really hear much there. Do you feel like that business is kind of where you want it in terms of the product offering and the scale?
I am so glad you asked about sports. It's absolutely a rocket ship of growth for us for the past 5, 6, 7 years. They have a number of shoulder launches coming out this year, I believe, 4 different shoulder launches. They call it internally, the shoulder [ speech ], which is quite motivating. But we've done a terrific job with hip. We've had a terrific job with knee, but shoulder has been kind of the area that we've needed to have new products.
But they've been just an amazing business. It was a start-up 12 years ago, and it just become a big, fast-growing business. It's really helped us win ASC deals. Frankly, having a really -- every ASC deal -- orthopaedic ASC deal involves sports. And because we have such a strong portfolio, we are able to win those deals. But historically, we wouldn't have been able to. And it's an incredibly exciting year of new product launches, particularly in shoulder.
And I think some of those hopefully might be shown in AAOS. I'll have to get back to you on that. But I'm very bullish. We have a fabulous leader who's been leading the Sports Medicine business since the start-up when we had just a camera and not really much in the way of implants. And we are now formidable in sport medicine. Certainly in the U.S., certainly in Europe, we still have work to do in the emerging markets in Asia Pacific, but really a fabulous business. And it's been part of the growth engine within Endoscopy. And you've seen Endoscopy post pretty impressive results, certainly last year and this year.
Our next question will come from Drew Ranieri with Morgan Stanley.
I'll put both of mine together. But Kevin, you were so early on in the orthopaedic robotics landscape just with soft tissue robotics. What are your kind of current thoughts on supporting that ecosystem today versus entering soft tissue robotics? Is it something that's concerning you? Or just how are you thinking about that opportunity? And then second, just -- could you talk about the PROstep launch from earlier in the fourth quarter or late third quarter? Just any metrics you can kind of share there on the foot business.
Yes, sure. So as it relates to soft tissue robotics, listen, it's a very interesting space. As you know, there's a very large and very successful company that kind of dominates the space. We certainly don't have a problem selling endoscopy if you look at our numbers. Certainly, for our 1788 and our cameras, we're doing extremely well. We still have huge room for growth outside of being in soft tissue robotics. It's an area that we're certainly interested in, but very respectful of the large incumbent. And I'm not sure that we'd want to try to take them head on. Just like anybody trying to come and take us head on in our space, wouldn't be so easy.
But it is an area that we like. There are loads and loads of companies, start-ups in the space, and we're looking at them. And it's not inconceivable that we would make a move at some point. But again, not expecting to come out and launch something that would go head-to-head with the Goliath and try to take them down. So -- but it is a space we're pursuing. We're interested. We're looking at companies, and it's not impossible that we would make a move at some point in the future. It's just not an easy space. As you know, robots are hard. And we're going to be very thoughtful and very careful. But we don't see this kind of -- at this point anyways, as a major threat to our Endoscopy business at all.
Our next question will come from Matt Taylor with Jefferies.
I wanted to ask one about the sprint of margins here and ask you, if you do produce some upside on the top line and the margins over the course of this year and next year, how do you think about delivering that to the bottom line versus reinvesting it above that goal to get back to your pre-COVID margins?
I mean, first of all, it's heavily dependent on sort of the mix that we get if we over-deliver on sales in terms of how much margin we can get to. I would say that 200 basis points expansion is the absolute goal, and that will be the target. And if we get there a little sooner, so be it. But we won't take our eye off of making sure that we're doing what's right in the business so that we can deliver that 200 basis points.
And that -- I wanted to ask another one on Vocera. You talked a lot about it on this call, and it's obviously doing well. Can you talk a little bit about how that's expanding its tentacles kind of throughout your organization? And anything else we should expect from it in the future as it connects some of the different technologies and provide you some cross-selling opportunities?
Yes. Great. Listen, I -- integrations are challenging. In this one, we had some challenges with the cloud. We had to restructure the sales force. We are already seeing terrific integration with both beds and now more recently with our wireless stretcher. We had a list before we bought the company, and we've expanded that list of connecting products. And those products that we're going to connect to the ecosystem are not just Stryker products, so there are third-party companies that are coming to us and asking to be connected to our ecosystem.
So we want to be a vital resource within hospitals. We're even looking at emergency departments that don't have really well-automated workflow that actually do the documentation that take cognitive load off of nurses. So the potential every day, it just keeps expanding and expanding, and so it's wildly exciting. And the team now -- the new sales team is really starting to hum. Our order growth is starting to really, really pick up in a big way.
And so we're super excited. We're not ready to talk about which products we'll be integrating. We'd rather do the integration and tell you about it. And we'd like to sort of give you a full year update. So a year from now, expect we'll give you kind of a wholesome update and include more of those products that will be attached to the ecosystem. But we are really, really excited about this acquisition, and it's a platform.
So I'd say after Mako, this is the second platform acquisition that I've done during my tenure. The other deals we've done, none of them have been platforms. And that means it has wild upside potential over time. Now it's not going to happen overnight. It's going to take time. But this is -- for us, it's -- it will be very sticky in hospitals. It will just be a renewal, a recurring revenue. And then as you add more and more to the ecosystem, it becomes something that hospitals can't live without. So that's our dream, and we're pretty optimistic given where we are right now, given the momentum that we have, given the interest that we have, both from parts of Stryker as well as third-party companies wanting to integrate to the system.
Our final question will come from Richard Newitter with Truist Securities.
I'll just ask one here. And by the way, congrats again on a fantastic quarter. Solid end to the year. So just -- clearly, you guys -- since your Analyst Day, in particular, you've been conveying how committed you are to margin expansion. You're kind of putting a stake in the ground, really strong guidance here for '24. I guess I'm just going to ask, how should we think about that margin guidance relative to the potential and willingness to take on margin dilution as you get more aggressive on the M&A front? Should we think of that as something that already had contemplated the potential -- the need to absorb some dilution? Is there -- are you more focused on top line accretion and more sensitive to kind of margin accretion faster than historically? I would just love your thoughts there on how we should think about kind of this margin trajectory and sprinting back to pre-COVID with respect to deals and how that will fit in the P&L.
Thanks, Rich. Thanks for the question. Look, think back to '17, '18, '19. We were expanding margins before some dilution. We have around 80 basis points. And we were not growing at this kind of growth rate, right? We were growing in the 6s and 7s organically, not double-digit growth organically or high single-digit growth organically.
So with that higher growth, this is not a crazy level of margin expansion that we think we could do. But doing small deals and if they're small tuck-in varieties, there's some dilution that will come with that. We expect we're going to eat that and be able to deliver the 200 basis points. If a deal came along, let's say, something like a Mako, which as you know occurs once a decade maybe, it's not an everyday occurrence, that had dilution but we felt was just so great for the company that we had to do it, we would go ahead and do it. And then we would look at our numbers and say, is this something we can absorb? Or isn't it?
Our going-in assumption is that that's not a likely occurrence. It's not impossible though. And I never want to rule anything out when it comes to M&A. If something really delicious appears and we think that this is going to be great for our future, we're going to go ahead and do it. And then we'll do our math and figure out, can we get there with the 200 basis points? But in the normal cadence of operations of Stryker, and that means doing a number of deals that have a little bit of dilution here or there, we're going to eat it and we'll deliver our 200 basis points. If something bigger happens like a Mako that, as you know, was very dilutive but has proven to be a pretty terrific asset for our company, we're not going to say, well, we're going to wait 2 years and then we'll do it later. We're going to go ahead and do it.
But again, I don't see that on the horizon. It's not obvious to me. But I'd never want to rule that out. It would be foolish, frankly, to be beholden to a certain financial target and pass up what could be very value creating for our company. But again, it's not our current frame of mind, not our current thought process. But I don't want to rule out that, that could be a possibility.
I will now turn the call back over to Mr. Kevin Lobo for closing remarks.
Thank you all for joining our call. As you can see, we have terrific momentum as we finish the year. We're excited about 2024, and we look forward to sharing our first quarter results with you in April. Thank you.