Zimmer Biomet Holdings Inc

NYSE:ZBH

Earnings Call Analysis

Revenue Forecast and Restructuring Drive Optimism

The company closed the year on a high note, with Q4 GAAP diluted earnings per share at $2.01, a notable rise from the previous year's loss of $0.62. This was underscored by a 17% year-over-year growth in adjusted EPS to $2.20, buoyed by higher revenues, improved gross margins, and operational efficiencies. SCT category growth stood at 3.8% for the year, while 'other' categories surged by 15.9% in the quarter, thanks to strong Global ROSA sales. Looking ahead, 2024 promises constant currency revenue growth between 5% to 6%, translating to 4.5%-5.5% reported growth considering forex impact. The EPS is projected to grow 6%-8%, reflecting confidence in market health, new product launches, and supply improvements. The firm also anticipates a robust free cash flow of $1.05 billion to $1.1 billion, facilitated by cost-saving initiatives from a 2023-launched global restructuring program.

Strong Annual and Quarterly Growth with Substantial Free Cash Flow

Zimmer Biomet ended its fiscal year with robust growth, highlighting a 7.5% increase in constant currency revenue and an impressive 9.5% rise in adjusted earnings. The company also reported nearly $1 billion in free cash flow, exemplifying solid financial health and operational efficiency.

Segment Performance and Operating Margin Expansion

The company's growth was broad-based across various segments, with over 10% growth in Global Knees, a 5% uptick in Hips, and nearly 4% in the SET category, comprising sports, extremities, and trauma. Notably, the adjusted operating margin expanded by approximately 100 basis points, marking a second consecutive year of such expansion - a positive signal of improving profitability.

Forward-Looking Expectations

Looking ahead, the company anticipates sustaining mid-single-digit revenue growth and proportional levered earnings increases. The fourth quarter showed a 6.3% reported net sales growth, reaching $1.94 billion, and a similar 6.1% bump on a constant currency basis - setting a forward-looking tone for continued financial growth.

Category-Wise Growth Indicators

The fourth quarter further saw Global Knees grow by 5.6%, with both the U.S. and international markets contributing to this rise. Global Hips and the SET category followed suit, posting increases of 3.6% and 6.4% respectively, signaling steady performance across the board.

Reaffirming Commitment to Growth and Execution

Zimmer Biomet is committed to propelling itself further in growth and market leadership, with a minimum target of 5% growth in 2024. The company assures that earnings per share will climb faster than revenue, and in turn, free cash flow will outpace EPS growth - an ambitious multiyear commitment to elevate financial metrics and create shareholder value.

Earnings Call Transcript 2023-Q4

[Operator]

Good morning, ladies and gentleman, and welcome to the Zimmer Biomet Fourth Quarter 2023 Earning's Conference Call.

[Operator Instructions]

As a reminder, this conference is being recorded today, February 8, 2024. Following today's presentation, there will be a question-and-answer session. [Operator Instructions]

I would now like to turn the conference over to Keri Mattox, Chief communications and Administration officer, please go ahead.

[Keri Mattox, executive]

Thank you operator and good morning everyone. Welcome to Zimmer Biomet Fourth Quarter 2023 Earning's Conference Call. Joining me today are Ivan Tornos, our president and CEO and CFO and EVP Finance, Operations and supply chain, Suky Upadhyay. Before we get started I would like to remind you that our comments during this call will include forward-looking statements. Acutal results may differ

materially from those indicated by the forward-looking statements due to a variety of risks and uncertainties. Please note, we assume no obligation to update these looking statements even if the actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties in addition to the inherent limitations of such forward-looking statements.

Additionally, the distances on this call will include certain non-GAAP financial measures, some of which are forward-looking non-GAAP financial measures. Reconciliation of these measures to the most directly comparable GAAP financial measures and an explanation of our basis for calculating these measures is included within our Q4 earnings release, which can be found on our website, zimmerbiomet.com. With that, I'll turn the call over to Ivan. Ivan?

[Ivan Tornos, executive]

Thank you, Kerri, and thanks, everyone, for joining the call here this morning. I'd like to start the way that I typically do, taking a moment to recognize to show my gratitude to the almost 20,000 Zimmer Biomet team members for their dedication, for their commitment, for their strong resilience and for their super performance in 2023. Simply put, 2023 was just a great year for our company. And I want to say thank you.

In 2023, we impacted the lives of almost 4 million patients. And along the way, we deliver best-in-class financial performance, growing our constant currency revenue by 7.5%, while adjusted EPS earnings per share grew almost 9.5% in the year. as 200 basis points of leverage between the 7.5% revenue growth and the 9.5% growth in EPS. In the year, we generated almost $1 billion in free cash flow. And that's with some turbulence around inventory management and whatnot.

So again, strong performance, top to bottom, and I'm just very, very proud of the execution in the year. It's worth noting that this level of execution and performance came in a year in which we still have to deal with fairly complex macro issues, whether it's inflation, FX, geopolitical challenges. I don't think I need to talk much about that and also some macro challenges in the year. We did struggle with some supply challenges throughout some of the periods. I'm happy that's behind, but it was a headwind in many periods in 2023.

But again, delivering 7.5% in 2023 against some tough comparables, having grown constant currency revenue in 2022, the year before, by 6.6%. So clearly, a great trend in the making, clearly strong performance, and I'm just so grateful and so proud of all of you, the Zimmer Biomet team. At the same time, beyond grateful I'm truly excited as I note that this is just the very beginning when it comes to the level of performance that we can realize here at be Zimmer Biomet. and multiple drivers of why I'm confident that this is just the very beginning.

But I'll start with highlighting the bold pipeline that we have in place. The size of our pipeline is twice what it used to be in 2018. We got great new product launches that are happening here early in 2024. We have a stable supply. We've created a stable supply environment. And we've got great commercial execution. We're developing flawless commercial execution as evidenced by these growth rates that I just highlighted. To compound or believe behind this level of excitement ahead is the fact that we have seen and we continue to see a substantial improvement in our end markets. This is not the same market growth profile that we used to have. Patient demand is strong. Procedure volume is very strong given a variety of reasons.

And as the market leader in both knees and hips, being in better markets is just very exciting as we enter 2024. Back 5 years ago, when I joined the company, wish to think go for WAMGR weighted average market growth rates as being somewhere in the 3% range. And today, we pick our WAMGR has been very near if not at 4%. And again, that's a meaningful increase we believe, is sustainable. So we're not going back to the 3% days when it comes to market growth rates. So again, internal and external dynamics gives me gives us confidence that the best is truly ahead.

When you add to all of these variables, the fact that we have the strongest balance sheet in the history of the company, that is no doubt then that we can claim that our future is nothing short of truly right. So again, very pleased, very proud and very confident. I'd like to thank our investors as well for the support in 2023 and for their confidence in 2024 and beyond. We continue to take biggest strides forward. So we're being a company with a very different growth profile from top to bottom, committing to an expectation to grow at least 100 to 200 basis points above market in revenue with our EPS, with our earnings per share growing faster than revenue and our free cash flow dollars growing faster than EPS. The guidance that we are providing today for 2024 already reflect such a commitment to this type of financial discipline.

And I'm very much looking forward to our Analyst Day on May 29 in when we will provide additional details in terms of our long-range plan, which will illustrate that this is not a 1-year wonder. This is a multiyear commitment. And you will see then that Zimmer Biomet has truly entered our growth stage here, and we're no longer in turnaround mode. We're ready to deliver by being laser focus on the 3 strategic imperatives that I highlighted during my very first earnings call as [indiscernible] the strategic imperatives that I continue to repeat over and over at every Zimmer Biomet meeting. And frankly, I will continue to repeat because those are the 3 drivers that we know are going to drive our performance. Those being: number one, people and culture; number two, operational excellence; and number three, innovation and diversification.

So let's talk about our 2024 commitments. -- how different initiatives across these 3 strategic imperatives will drive our growth forward. First, in the area of people and culture, -- and again, I've explained this in the past, what it means, it's about having the right people in the right roles within the right culture. We must make sure that we support team members to act as owners and operators of the business. This means decentralizing decision-making, driving agility and empowering team members at every level across every function around the world. We must become leaner, and we got to be closer to the customer.

Equally important, we must truly live an environment of pay for performance. And this is something that has already kicked off in a very meaningful way in the fiscal year -- in this fiscal 2024. An example of that is the fact that we're incentivizing free cash flow dollar generation or growth in a much more disciplined way across the enterprise knowing that revenue is also the most durable driver of free cash flow performance. incentives are also set for revenue growth to meaningfully drive compensation across our firm at every level.

So again, we changed the way we pay people, in terms of growing revenue above market. And we changed the way that we pay people, giving a larger percentage of compensation in adherence to the fact that we, as a company, need to grow free cash flow dollars at double-digit rates in the second area of operational excellence. And again, this is about how we think about growing the business top to bottom. You can see already in today's update in the press release that we mean it. It is tough to restructure a company. It's certainly something that we don't take lightly, and you read the press release, we had to do it. It's a tough choice once again that we needed to make operational changes to simplify our structure to deliver greater efficiency and to ensure that we're enhancing investments in the right areas of the business, again, closer to the customer.

So again, not an easy thing to do, but something that we had to do and something that we have done. Beyond the restructuring, other initiatives in the area of operational excellence that are already in full motion, are the new programs that we got in place kicking out how to drastically reduce inventory levels at Zimmer Biomet. This will drive substantial improvement in our free cash flow dollar growth while also reducing our days on hand DOH by 50 days or more and will reduce our excess and obsolescence exposure, which is something that, frankly, we've not done that well in previous years.

Second thing we're doing is the rollout of a global initiative to drive new product launch excellence across the key new product introductions that we have in the year 2024. In simple terms, the 7 or 8 most meaningful product launches, let's make sure we have a cadence of operating mechanisms with proper governance to ensure that we're maximizing these product launches across each key geography. And then the first thing we're doing in operational excellence beyond the restructuring is the integration of the pricing organization under the financial structure, reporting directly to Suketu, our CFO, to ensure maximum governance and accountability across the enterprise.

While we are pleased with the reduction in price erosion over the last 2 to 3 years, we believe there is a much greater opportunity to drive even better and more durable pricing dynamics. So again, in the area of operational excellence beyond the restructuring is about drastically reducing inventory levels to generate improved free cash, flow dollar growth. It's about governance beyond or behind the new product launches. And then thirdly, is around doing better in the area of pricing dynamics.

In the third strategic imperative of innovation and diversification, we're going to continue to invest in innovative R&D in customer-centric R&D. We're going to continue to fuel our pipeline with meaningful product launches. We're going to continue to drive our vitality index, which has already expanded very meaningfully over the last 3 years. We're going to make sure that as we continue to launch new products, we also see margin expansion coming from these new products. I'm excited about where we are today. Our pipeline -- the dollar value associated with our pipeline is twice what it was at the end of 2019.

And as we enter 2024, we have very meaningful product launches, particularly in the hip area in where we lost market share in the last 2 years, given the lack of products in key categories like surgical impactors, triple taper stems or hip navigation. So again, 2024 is the year in where through very meaningful product launches, we will regain the momentum that we lost. Beyond Hips, I'm excited about where we are in shoulder, Identity continues to generate great excitement. We will enter 2024 in full launch mode when it comes to identity. We're excited about stemless shoulders entering the market, and yes, very excited about being first to market in the category of shoulder robotics with a very highly differentiated offering in robotics for shoulders that will apply for both anatomic and reverse surgeries.

In the area of knees within the early days of our cementless knee launch, In 2024, we seek to increase our penetration rates drastically. Here in the U.S., our penetration rate in cementless is not even in the 20% range and we are committing to drive the penetration rate into the 50% to 60% range at a very rapid pace. Again, more details to those plans at our Analyst Day, but rest assured that our knee penetration rate in the cementless category is not going to stay in the teens or even the low 20s for long.

Beyond cementless, we're excited about next-generation robotics in knee. We are excited about partial cementless knees. We're excited about the fact that in 2024, we're going to be entering the full launch for Persona iQ, the only smart knee in the world that fully integrates data technology and best-in-class implants in a way that nobody else is doing. In the category of [indiscernible], which is 6 different businesses, sports, foot and ankle, restorative therapies, trauma extremities and CMFT, cranio-maxillofacial thoracic, we are seeing great growth already exited in 2023. The second semester of 2023, we grew set by mid-single digit or above and as we entered 2024 and beyond, the expectation is that said, we will continue to grow mid-single digit or above. And this is something that, as a company, we've not realized ever since the merger in [indiscernible] with exclusion of the POSCO year given comps.

So really excited about the return on the multiple investments we made in [indiscernible], particularly in the areas of innovation and commercial execution. There is a great cadence of product launches in SEP. I already mentioned some of those and more to come when we do our Analyst Day in -- later in the spring. So excited about [indiscernible], innovation as a whole. Our new product development pipeline is strong. We're going to be launching over 40 different new products in the next 24 months or so. Most of them are going to enable category leadership, establishing Zimmer Biomet as the leader or the second position in the category.

And virtually, virtually all of them are going to be in market spaces that are growing 4% plus or above. So I like the quantity, a like the quality, and like the market growth profile in terms of whether innovation is going. I'm also particularly excited about the innovation plans that we have for the here in the ASC here in the U.S., ASC side of care. We've made meaningful investments in innovation during all stages of the episode of care. What happens before surgery, what happens during surgery and what happens after surgery.

And relative to the ASC in the intra-op stage of the ASC, we are best-in-class when it comes to solving problems and delivering efficiency, best-in-class outcomes and safety. So again, really excited about our ASC strategy where we're going relative to this side of care. Diversification of Zimmer Biomet's end markets will happen not just by innovation internally, but will happen through smart M&A, which will remain the #1 category when it comes to capital allocation. With the best-in-class level ratio, and with deep confidence in our free cash flow generating plans over the next few years, our strategy is to make a smart M&A, the top recipient of our capital.

But at the same time, I just love the fact that we have the optionality to continue to do share buybacks as we announced this morning and perhaps at a more meaningful level. So the combination of smart M&A and buybacks can coexist, given the strong free cash flow dollar generation that we are seeing come in [indiscernible] this regard. I'm energized by the very detailed and focused plans that the team has put in place, which I know that upon their execution will position Zimmer Biomet to deliver on the growth profile that we keep recommitting and that is to grow above 100 to 200 basis points.

So as a minimum point of entry commitment of 5% in the year 2024, with earnings per share always growing faster than revenue, and free cash flow always growing faster than EPS. This is not a 1-year commitment. This is a multiyear commitment. And again, I know based on the very detailed plans we will get there. In closing, we are very excited about where we're at the track record over the last 2 years. And most importantly, we're deeply excited in terms of where we're going to go in 2024 and beyond. The team is ready, we are establishing the right trend, and we're going to continue to drive flawless execution, delivering our commitments.

Along the way, we're going to help patients, we're going to create shareholder value, and we will leave our mission of [indiscernible] pain and improving the quality of life for people around the world. With that, I'll turn the call over to Suketu.

[Suketu Upadhyay, executive]

Thanks, and good morning, everyone. As Ivan mentioned, our fourth quarter results ended a successful year for Zimmer Biomet with full year constant currency revenue growing 7.5% and adjusted earnings growing more than 9.5% on a reported basis, while generating just under $1 billion in free cash flow. Inside of that, our business segments performed well for the year. With Global knees constant currency growth of over 10%, Hips growth of 5% and SET growth of almost 4% and all while also expanding adjusted operating margin by almost 100 basis points, the second consecutive year of operating margin expansion in a challenging environment.

Also, as previously guided, we closed the second half of 2023 with mid-single-digit revenue growth and levered earnings growth, a profile we expect to continue moving forward. Let's dive into the fourth quarter results. Unless otherwise noted, my statements will be about the fourth quarter of 2023 and how it compares to the same period in 2022, and my commentary will be on a constant currency and adjusted operating basis. Net sales in the fourth quarter were $1.94 billion, an increase of 6.3% on a reported basis and an increase of 6.1% on a constant currency basis.

We had a selling day tailwind of about 100 basis points in the quarter. U.S. growth was 4.4% and international growth was 8.7%. As expected, we saw a robust sequential step-up versus the third quarter across all regions. Global Knees grew 5.6% in the quarter with the U.S. growing 5.4% and international growing 5.8%. The knee business continues to be driven by our Persona product portfolio, combined with our ROSA robotics platform, and we remain excited about the positive feedback around our recently launched cementless form factor for Persona, OsseoTi. For the full year, Global Knees grew 10.2%. Global hips grew 3.6% in the quarter, with the U.S. growing 4% and international growing 3.2%.

We are eager to accelerate performance of this segment with the addition of multiple new product offerings in 2024. For the full year, Global hips grew 5.1%. Next, the SET category grew 6.4% in the quarter, with our key focus areas of sports, CMFT and upper extremities, all growing in the mid-single digit to low double-digit range. The strong growth in these focus areas was partially offset by other subsegments within the category.

For the full year, SCT grew 3.8%, including a step-up to mid-single-digit growth in the second half of the year. Finally, our other category grew 15.9% in the quarter, driven by another strong quarter of Global ROSA sales. Now moving to the P&L. In Q4, we reported GAAP diluted earnings per share of $2.01, compared to GAAP diluted loss per share of $0.62 in the prior year. The increase in GAAP results was driven by higher revenue, a goodwill impairment charge in 2022 that did not repeat favorable onetime tax benefits in 2023 and a lower share count.

The details around our financial performance can be found in today's press release. On an adjusted basis, we reported diluted earnings per share of $2.20 compared to $1.88 in the prior year, representing year-over-year reported growth of 17%. The step-up is driven by revenue growth, better gross margins, lower OpEx margin in tandem with a lower tax rate. Our adjusted gross margin was 72.5%, up 80 basis points from the prior year, driven by favorable mix higher volumes and lower royalties. And for the full year, we came in slightly above expectations, representing 90 basis points of year-over-year expansion. Adjusted operating margin was 30.3%, up 200 basis points from the prior year. The year-over-year operating margin step-up was primarily driven by revenue leverage, better gross margin and realized efficiencies across SG&A.

For the full year, operating margin was slightly ahead of expectations at 28.2%, up 90 basis points year-over-year. Net interest and other adjusted nonoperating expenses were $43 million in the quarter and $194 million for the full year. And our adjusted tax rate was 15.8%, the slightly more favorable tax rate was driven by discrete onetime items in the quarter, bringing our full year tax rate to 16.3% and in line with overall expectations.

Turning to cash and liquidity. We generated operating cash flows of $588 million and free cash flow totaled $447 million, and we ended the year with cash and cash equivalents totaling $416 million. As Ivan mentioned earlier, we completed a $500 million share buyback program in early 2024, which is more than required to offset annual dilution. For the full year, we generated operating cash flow of just under $1.6 billion and free cash flow of $979 million. Our balance sheet remains strong, leaving us continued financial flexibility and strategic optionality as we move forward.

Now moving on to our financial outlook for 2024, our outlook takes into account certain key assumptions, including pricing, which is expected to be about 100 to 150 basis points of erosion, but it's a continued step change improvement from historical trends. We expect to see continued strength in our end markets in tandem with new product introductions and continued improvement in product supply. Against that backdrop, we expect 2024 constant currency revenue growth of 5% to 6%, including a foreign currency exchange headwind of approximately 50 basis points, translating to reported growth of 4.5% to 5.5%. Adjusted diluted earnings per share in the range of $8 to $8.15, representing reported growth of 6% to 8%.

And currency is expected to have about an $0.08 headwind on EPS based on recent rates and the implementation of Pillar 2 has an $0.18 or about a 250 basis point headwind on earnings per share growth for the year. This implies operating margin expansion of greater than 50 basis points at the EPS guidance midpoint when compared to 2023. We expect slightly lower year-over-year gross margins to be more than offset by efficiency and restructuring programs that were initiated in 2023.

Net interest and other nonoperating expenses are expected to be about $205 million. And as previously discussed, our effective tax rate is expected to step up to 18% in conjunction with the implementation of Pillar 2. We expect to end the year with about 207 million shares outstanding, lower than 2023 due to the $500 million share buyback plan that I referenced earlier.

Finally, we expect our free cash flow to be in the range of $1.05 billion to $1.1 billion or growth of about 10% at the midpoint. As Ivan mentioned, we initiated a global restructuring program along with other cost savings initiatives in late 2023. These programs further streamline our organizational structure, shift select reporting lines, prioritize how we spend across the organization and further above our operational footprint in order to simplify and maximize efficiency.

This program is expected to result in total cash charges of about $125 million to $150 million over the next 2 years and deliver up to $200 million in run rate savings as we exit 2025, enabling us to invest in priority areas while driving margin expansion and earnings leverage despite a meaningful step-up in tax rate. In terms of cadence through the year, we expect constant currency revenue growth for the first half of the year to be at the lower end of the mid-single digits while the second half will be at the higher end of mid-single digits.

Also, quarterly results are expected to be choppy due to billing day impacts. Q1 will be about 150 to 200 basis point headwind and Q2 and Q3 will be a 150 basis point tailwind in each quarter, and Q4 will be a 50 basis point tailwind. Full year impact will be immaterial or less than 50 basis point tailwind. 2024 gross margin is expected to step down slightly versus 2023 due to lower FX hedge gains and the realization of capitalized third-party manufacturing cost increases observed in the second half of 2023.

From a cadence standpoint, gross margin will be higher in the first half of the year. Additionally, because of the timing of the restructuring program, we expect operating margin will be higher in the second half than in the first half with Q4 being our high watermark, followed by Q2. In summary, 2023 was another strong year for the company, and we expect to maintain that momentum into 2024 and beyond.

With that, I'll turn the call back over to Karrie for the Q&A.

[Keri Mattox, executive]

A session, just a quick reminder to please limit yourself to a single question and 1 brief follow-up so that we can get through as many questions as possible during the call. [indiscernible]

[Operator]

[indiscernible]

We'll go first to Larry Biegelsen with Wells Fargo.

[Larry Biegelsen, analyst]

Yvon, -- congratulations on a nice first year here as CEO, I I'd love to ask about the 2024 guidance. Just talk about the key assumptions for the 5% to 6% constant currency growth in '24. What you're assuming for the recon market. And Yvon talked about your guidance philosophy -- have you incorporated any conservatism in the guidance? What would get you to the high end of the range? And just quickly, Suky, on the buyback, the $500 million -- does that imply that it's hard to find good M&A targets? How should we interpret that? .

[Ivan Tornos, executive]

Thank you, Larry. Always great to hear from you. So I'll take the first 2 parts and then Suky can talk about the rest. So embedded in the guidance for 2024, which we're very confident on the 5% to 6% is macro and micro reasons. So from a macro perspective, by now you heard from most of our peers, the markets are very healthy. We believe the -- beyond the backlog, the markets are going to continue to be healthy. You got better patient demographics, younger patients, you got the dynamic of cases moving into an ASC. You got more days of surgery in the U.S. where not just 2 days, it's in 3 days. you've seen shorter, better, rehabilitation processes. I can go on, but the markets are very healthy.

And then from a micro perspective, we got a cadence of new product launches. Most of them are going to be very meaningful as you hit the second semester of the year. We got 3 new product launches in hips early in 2024, which again will be more material later in the year. We're launching [indiscernible] shoulder. We got a cadence of new product introductions in set, and we're going to continue to increase our penetration in cementless and ROSA.

So again, the combination of new product launches, great commercial execution amplified by the healthier market dynamics gives us confidence on a minimum 5% and the range of 5% to 6%. Relative to my philosophy when it comes to guidance, it's very basic. We make commitments and we don't miss them. So we study the different dynamics, we study what we had. We know that operationally, we're in a better place. We don't have the headwinds that we had in 2023 around supply and whatnot.

So my guidance represents nor exemplifies my philosophy of making commitments and driven on those commitments. I'm not going to comment today on whether there is opportunities to bid and raise through the year. just live at philosophies to make commitments and deliver commitments, and these are very well-stated commitments. So with that, I'll pass it on to Suky your second question.

[Suketu Upadhyay, executive]

Yes. Larry, thanks for the question. I'd say, first of all, the $500 million share buyback, I think, demonstrates our confidence in our outlook in the business. And the short answer to your question, does this imply some deterioration in M&A targets. And I would say absolutely not. I think based on where the company is from a firepower perspective, we feel that we've got the balance sheet strength and power as well as the forward-looking results to really do both. We still will prioritize smart M&A, as Ivan has talked about. We still favor tuck-in acquisitions to midsized acquisitions. .

But even in the backdrop of doing a heightened level of share buyback, we still see very significant M&A firepower to execute that strategy as well. So short answer, again, is no, we don't see this as any type of deterioration in the target.

[Operator]

Yes. We'll go next to Matthew O'Brien with Piper Sandler.

[Matthew O'Brien, analyst]

Just maybe start a little bit, Evan or Suky, on the knee performance in the quarter. It was a little bit below what we were expecting, still better than 1 of your competitors, but below another one. on a 2-year stack basis, it's not quite 50% of sales, but close to it. So I would anticipate that that's going to need to see very good performance here in '24 in order to hit the guidance range, which I think is maybe being questioned a little bit this morning.

So what is it there specifically between cementless, between robotic between Persona IQ that gives you the confidence in the knee franchise outside of the macro environment here in '24? And then I do have a quick follow-up.

[Ivan Tornos, executive]

Thanks, Matt. So performance relative to the quarter, we're very pleased with the quarter. We performed in line with our expectations for knees and frankly, for entire business. And for the year, it was a solid year with [indiscernible] growing double digit, and the entire business growing 7.5% with no EPS expansion. We really don't pay acute attention to what happens to 1 quarter. I know that is your job to do that, but we just don't the 60 to 62 working days in a quarter, there is all kinds of volatility, then you got comps.

So when it comes to performance, we look to 8 to 12 quarters. And if you do run the analysis, 8 to 12 quarters, you're talking about knees, but take a look at hips and whatnot, the performance is there. Speaking of volatility in Q4 for knees, we did see in the U.S., we did see some timing of orders. that impacted some of our largest IBMs here. We also had, let's remember, some tougher comps versus Q4 of 2022, particularly in the U.S. where we were at 500 basis points ahead of our strongest competitors in knees.

And then again, when you look at Q3, that's the quarter where both in its and hips, we outperform our competitors in the U.S. So again, given all this volatility, all these ups and downs, we just don't pay any attention to 1 particular quarter. We look acutely at the trends. And the trends do show that 2, 3 years later, we continue to be the #1 player in news, and we continue to gain market share.

Relative to the second part of your question around 2024, what gives us confidence around the guidance is the fact that we continue to see increases in cementless penetration. We continue to see increases in ROSA penetration, we have solved the backorder challenge that we had in knees, which was a headwind for many periods in 2023. And we'veee seen this great commercial execution in the ASC. So we're very confident about where we are in is, and we are very confident around the acceleration in knees going into 2024.

[Matthew O'Brien, analyst]

Appreciate that. Follow-up is just on -- there's a lot of good things coming this year as far as new products, et cetera. But you're trying to lower inventory levels significantly 50 days of ton in this space. And then the restructuring as well, are those -- how have you factored in those potential headwinds in '24 and even into '25 in terms of potentially some lost revenues or dislocation you may suffer as a result.

[Ivan Tornos, executive]

Well, let me just begin with the simple answer. Anything and everything we do in restructuring wise and inventory management wise is embedded in the guidance we've given. So that's part of that. In terms of inventory management or inventory reductions, we're going to be bold, but not reckless. So we're not reducing inventories in the key categories. We actually are making sure that inventory is where it needs to be for those key brands. whether it's Persona, whether it's the key components in hips, whether it's is the key components is SET. This is a lot of the leftover from the integration that we did do.

So the inventory reduction is going to be in noncritical areas, frankly, in noncritical countries, -- so again, we're doing this thoughtfully. In terms of the restructuring, the reductions that we announced this morning, these are happening in back office. I will tell you, virtually all reductions are noncustomer-facing and again, the changes we make in inventory and people are embedded in the guidance that we've given.

[Keri Mattox, executive]

Thanks, Matt.

[Operator]

We'll go next to Robbie Marcus with JPMorgan. .

[Robert Marcus, analyst]

Great. I wanted to ask on SET and other. Those were the 2 line items that beat versus -- the Street. I was just hoping you could break out some of the trends there. What did well, what might have underperformed, if anything? And how we think about those different line items as part of the guide in 2024? And how much of the strong growth is coming from that versus hips and knees?

[Ivan Tornos, executive]

Thank you, Robbie. So solid quarter for set, frankly, solid last semester of 2023 for growing around mid-single digits, around 5% and committing to grow in mid-single digit above in 2024. The key drivers are the use of suspects. We continue to do really well with upper extremities, growing upper single digit, double digit in most geographies that's new product launches that's focusing the ASC, that's stable supply, just great commercial execution.

Our CMFT business, Craniomaxillofacial thoracic continues to do really well. I recall that we did 2, 3 acquisitions over the last 3 years and those continue to do really well. And again, CMFT is a business where we see upper single digit, double digit. We finally stabilized our Restorative Therapies business here in the U.S. Recall that we had some reimbursement challenges there. And those are behind. So you've seen the biologics restorative therapy business growing at a nice clip now. And then sports med, we've done some acquisitions. We have had some challenges, but that continues to perform in line with expectations. So I will tell you, Robbie, out of the 6 businesses within the category, 4 are going really well. Trauma, foot and ankle, we got some work to do. We got some decisions, some strategic considerations to make. As we enter 2024, mid-single digit is the point of entry. This has to be the year where we see sales growing mid-single digit. Frankly, in some geographies, I think it's going to be higher than that. We got the innovation, we got the investments in terms of dedicated infrastructure and specialization. Heavy emphasis here in the U.S. in the ASC environment. So again, full confidence in the growth profile that we're going to see moving forward.

[Robert Marcus, analyst]

Great. Maybe just a quick follow-up for Suky on the guidance and a clarification. The lower end of mid-single digit in the first half and then higher in second half. Is that inclusive or exclusive of the selling day benefit .

[Suketu Upadhyay, executive]

That is inclusive of the selling day benefit, Robbie.

[Robert Marcus, analyst]

Yes. .

[Keri Mattox, executive]

Can we go the next question.

[Operator]

We'll go next to Joanne Wuensch with Citi.

[Joanne Wuensch, analyst]

I'm curious why gross margins are expected to be somewhat down year-over-year, but the dynamics are for that? And then my second question has to do with smiles -- can you walk us through the math of what you think moving to 50% to 60% of our needs being cemented or cementless, excuse me, 50%, what the benefit is of that?

[Suketu Upadhyay, executive]

Yes. Joanne, it's Suky. I'll start with the gross margin 1 and then pass it over to Ivan on cementless. Overall, we got a really good year on gross margin in 2023, up 90 basis points year-over-year. drivers of that are really around, we had some FX hedge gains, which we had talked about at length throughout 2023 as well as improved mix and better pricing, still pricing erosive year-over-year, but better than we expected. Overall, generated a pretty nice profile for -- we had previously communicated that we had thought that gross margins might get down slightly into '24, primarily driven by the loss of those FX hedge gains. They won't repeat at the same level, in '24 as they did in '23.

But also, we're seeing in the capitalization of some increased costs in the back end of '23 around third-party manufacturing, which will feather into the P&L towards the back end of 2024. Despite those 2 headwinds, we're able to offset a large component of that. But overall, we do expect to see gross margins down just slightly versus '23 in the backdrop of those headwinds. Now having said that, if you take the midpoint of our EPS guidance, I think that would back you into an implied operating margin of about 29%, which represents about an 80 basis point increase year-over-year.

And so while gross margin may step down slightly, you are seeing operating margins increase as we drive better efficiency and revenue growth through the company. So again, there are a lot of puts and calls throughout the P&L. The great thing is we've got optionality where we see headwinds in 1 area. We can make that up with efficiency and tailwinds in other areas. I think you've seen that now once we deliver '24 or 3 years in a row, which, in a challenging environment in all 3 years, we're able to continue to grow operating margin and levered earnings. So thanks for the question.

[Ivan Tornos, executive]

And Joanne, relative to your question on cementless, I'll give you as much as again. So starting with the basic pricing dynamics, we see with cementless Persona [indiscernible], we see an ASP uplift of around 10% to 15%, frankly, closer to the 15% than the 10%, around 40% to 50% of the time we combo the cementless knee with robotics with ROSA, and that drives additional uplift in revenue in the form of disposals or not. So that's a great dynamic we see in particular in the ASC. Our penetration today on cementless we'll exit in 2023, somewhat near 18% to 20%, with both expectations get into the 50% to 60% range.

And I'm not going to give you a commitment today. But at our Analyst Day, you will see the long-range plans and some of the trending when it comes to getting to 60%. We believe that there's going to be a fairly quick uplift, given the fact that the market is already being developed by some of the work that our peers have done. So again, you should not expect that getting to 50% to 60% is going to be a long journey. All of these dynamics are in the U.S., we're launching in 2024 in other markets outside of the U.S., and I will disclose the pricing dynamics when the time is right, but excited about the launch in Japan in 2024 another key market. So those are the dynamics here when it comes to cementless.

[Keri Mattox, executive]

Katie, can we go the next question in the queue?

[Operator]

We'll go next to Ryan Zimmerman with BTIG.

[Ryan Zimmerman, analyst]

Following up maybe on Larry's question about guidance. You talked about the WAMGR being at 4%. And clearly, we're in a stronger market environment. And so as I think about the components of guidance, with pricing as a headwind of 100, 150 basis points it suggests product mix is going to contribute 200 to 300 basis points. I just want to see, one, if that's how you're thinking about it? Or if you're thinking about the market contribution to guidance at a higher rate in 2024, and maybe potentially the product mix contribution lower. Maybe just help us flesh a little that out. .

[Ivan Tornos, executive]

Yes. I'll try to simplify it and Suky, I don't mean to elaborate, but we believe the market is around 4%. -- all in. And again, we model this in different ways, but let's call it 4%. I'm not going to quantify the new product contribution, but it's significant. We got 40 new products getting launched in the next 2 years, and these are meaningful products. I mentioned we got 3 large hip products that are going to be launched early in 2024. We got Rosa Shoulder, which we believe is going to be meaningful in the year 2024, giving the fact that it's not a late year launch. We got a lot of products in the same category. So again, you should think of new product introductions has a very meaningful contributor to the guidance.

Add to that the fact that we don't have the headwinds that we had in 2023 when it comes to supply, I would say between #1, #2, we got confidence on where we're going. Beyond that, we don't see a headwind when it comes to the shift to the ASC. We actually see that as a tailwind, we're excited about some of the dynamics we hear about when it comes to the movement of holders into ASC. That's going to be a contributor. And as I mentioned to Joanne, the uplift that we see on cementless and Rosa which are products that we launched 2 years ago but not going to get accelerator are the main contributors to the confidence in the guidance.

I don't know, Suky you have anything else here.

[Suketu Upadhyay, executive]

I think that's well said. One of the key points in Iron is a set that pricing erosion is assumed in that land.

[Ryan Zimmerman, analyst]

Right. Okay. That's helpful from both of you. And then just to kind of dovetail on Joanne's question around margins. You talked about gross margin, Suky, clearly, operating margins are doing more heavy lifting this year. And so how much from the restructuring program is benefit, is driving some of that operating margin expansion how much are you assuming for top line leverage in that 80 basis points or so of expansion? And yes, that's about it.

[Suketu Upadhyay, executive]

Yes. So the key driver with gross margin being sort of flat to down slightly, it really is coming from revenue leverage and operating margin you could expect overall OpEx as a percentage of sales to drop by about 100 basis points, give or take. And that's even with R&D increasing year-over-year. So the efficiency in the restructuring programs in the near term are really focused on SG&A. However, inside of that full program, we are working on things inside of COGS, to help maintain and keep gross margin stable over time.

Those are going to be a little bit more midterm in nature and how they get realized, things like SKU rationalization, site optimization, inventory reductions and and corresponding E&O reductions. Those are all things that have a little bit longer lead time. Naturally, as you can expect, as you're moving your supply chain around and not wanting to disrupt the ability to supply demand, but they are definitely going to take more of a prominence as we move forward beyond 2024. But for '24, the way you characterize is right. It's primarily revenue-driven and SG&A.

[Keri Mattox, executive]

Katie, can we go to the next question in the queue?

[Operator]

We'll go next to Travis Steed with Bank of America.

[Travis Steed, analyst]

I wanted to ask about the $200 million in cost savings that you guys called out this year. Curious if the plan is for that to kind of drop through to the bottom line? Or are you going to reinvest that -- and what does that mean for kind of margins beyond this year and longer term?

[Suketu Upadhyay, executive]

Yes. So the way we characterize it was that it would be $200 million run rate as we exit 2025. And in year for 2024, we expect that to be about $100 million or about half of the run rate savings that we're predicting over a 2-year period. we're dropping a lot of that to the bottom line. As you can see with our implied guidance at the midpoint would suggest about an 80 basis point increase in operating margins. .

And so we're actually taking a good portion of that dropping it to the bottom, but we're also reinvesting a pretty significant portion back into our priority areas, ensuring that we've got the appropriate amount of sets and instruments for cementless uptake as well as Persona uptake through [indiscernible], ensuring that we've got the right level of commercialization and execution in our new ROSA shoulder launch, ensuring and ramping up commercialization efforts in our hip franchise around the the product launches that we have for hip.

So it really is a combination of both, and that's the great thing about this efficiency program. It enables us to reinvest back into our priority areas while dropping pretty significant substantial margin expansion now for the third year in a row.

[Travis Steed, analyst]

Helpful. And on the new comp plan that you called out, curious if that's going to have an impact on margins or just not material enough to impact margins? And then on M&A. Just curious if there's been any change on the 2 years of EPS solution from M&A?

[Suketu Upadhyay, executive]

Yes. On the comp plan, it's not really going to have any material impact, and it's embedded in our guidance. I think it's more about a mix shift of how that comp plan is designed, right? Whereas previously, it was more focused and biased towards revenue growth. I think now what we're trying to do is get a greater balance between top and bottom line all the way through cash flow.

So it's really a mix shift in how we think about comp versus an increase in comp. And again, all of that is embedded into our guidance for '24. Relative to the dilution, we still think about 2 years from a dilution standpoint is reasonable. Of course, we'd like it to be inside of that. But just given where valuations are today as well as the cost of debt, which hopefully is going to come down over time, that's kind of where we see one of our guardrails. .

[Keri Mattox, executive]

Kate, can we go to next question in the queue?

[Operator]

We'll go next to Jeff Johnson with Baird

[Jeffrey Johnson, analyst]

Congratulations Ivan, maybe you mentioned in passing that shoulder for ROSA is not going to be a late year '24 launch. Just could you dial on that timing anymore. And I'd be interested in hearing about kind of your view on the uptake of ROSA shoulder, obviously, shoulder surgeries replacements. -- technically more challenging. I think some questions about what role robots can initially play in those procedures. So just how does that help the uptake of ROSA I don't think I heard a ROSA placement number. I think sometimes you give it on kind of an annualized basis. Any updates on kind of exiting 23 where ROSA placements were .

[Ivan Tornos, executive]

Jeff. So I got to be careful what I say about time lines for Rosa Shoulder. I'll just say that I'm very confident that this is not a late 2024 launch. And as I mentioned, I think it's going to be -- I think it's going to be very meaningful. So beyond being first to market, it's a high-quality product. It's going to be applicable for both reverse and anatomic surgeries, is going to simplify a very complex procedure. It is going to be fully integrated with the rest of the shoulder CVH ecosystem. I believe he's going to get great traction in an ASC environment where speed and accuracy matters.

And we're going to hopefully demo this next week at the academy meeting. whether it's ready or not, it would be demo there at the academy medium. Relative to your second question on the ROSA placements and the numbers, you should expect us to do around 300 installations per year. You should expect us to drive penetration rates of minimum 5% to 7% at least per year. You should expect that 1/3 of the Ross -- overall Rosa installations are going to go into an ASC environment. And as I mentioned earlier to [indiscernible], you shall expect that in a large percentage of cases, these ROSA installations are going to pull cementless. So again, great momentum with ROSA and I'm very excited about where we are welder.

[Jeffrey Johnson, analyst]

And maybe as a follow-up, just as I think about the 5% to 6% constant currency guidance in the 100 to 200 basis points above market, it seems like market is settling in at a good rate. If I think about gross margin, obviously, some of the hedge settlements should normalize as you get into 2025, E&L coming down, pricing getting less bad. So it sounds like gross margin, at least not a big day headwind going forward. .

And then, of course, you've got cost savings initiatives here on the SG&A side. If I roll all that together, including the improving balance sheet and cash flow and a commitment to some share buyback, it feels like 10%, 10.5% EPS growth, which is kind of the midpoint of your guidance this year if it were for tax rate and FX headwinds. And that sounds like it could be a sustainable kind of target. I'm sure you don't want to lay out an LRP here out of your Analyst Day. But is there anything in my facing there that would say 10%-ish plus or minus is not a reasonable kind of longer-term EPS growth rate to be thinking about?

[Suketu Upadhyay, executive]

Jeff, I think that was actually a really good articulation and summarization of what we're trying to get across. In fact, if you look at our guidance today on reported EPS, it would suggest 6% to 8% at both ends of the range. That's after overcoming about 400 basis points of headwind between nonoperational things like interest expense, FX and tax rate, right? .

So again, that's about a 400 basis point drag that's embedded in that 6% to 8%. So the way you're thinking about it, could we be in that low double-digit ZIP code on EPS in a sustainable durable way. I think, yes.

[Keri Mattox, executive]

Katie, do you have another question in the queue.

[Operator]

We'll go next to Richard Newitter with Truist Securities. .

[Richard Newitter, analyst]

Just with AAOS next week, I was wondering, anything that we should be on the lookout for with respect to Canary or to rather and data presentations. I think you had also mentioned on the prior call, you were expecting a GLP-1 kind of data analysis, possibly at AAOS. And then I have a follow-up. .

[Ivan Tornos, executive]

So the answer is yes to both, Richard. So we will have some data points on Persona IQ, and we'll have some data on GLP-1. On Personal IQ, we moved from a limited market release in 23 to a full market release in '24. We got the value proposition finalized. We got over 2 billion data points. We understand there is a product that is going to enable clinicians to intervene when needed. We've got data points on how this product will reduce overall complexity in the episode of care, how we can, by intervening soon, reduce costs, especially post surgery when it can be pretty taxing. We done with reimbursement. We spoke about the NTAP new technology add-on payment, which we got back in October. So that's in full launch mode.

We will submit -- very always ask me this question, we will submit for a [indiscernible] coming at some point in the spring summer. And we're going to bring some data around some of the experiences that we've seen with Persona IQ at the Cleveland Clinic, HSS and other facilities. So excited in terms of what we have with Persona IQ , more to come by the Academy. And then for GLP-1s, yes, we're going to be sharing some of the data we've done in conjunction with the Academy. And what I will tell you is that so far, everything we've seen with GLP-1 is that it remains a tailwind we're actually tracking the number of patients that are using a GLP-1 presurgery, and that number is in the 20% to 30%.

So by all means this is not a headwind. And I'm glad that, that conversation is being muted.

[Richard Newitter, analyst]

Great. And then just piggybacking off to Jeff's question, even with potential earnings dilution if you're potentially going to be -- or have the potential to be in a low double digit or 10% plus earnings growth range and given your commitment to growing earnings faster than the top line where it sounds like 5% is kind of a sustainable floor, given your end market and your WAMGR. It sounds like no matter what, even with dilution over a 1.5, 2-year period, you feel confident or we should feel confident in a high single-digit earnings growth rate at worst. Is that also a reasonable assumption based on all the different commitments and the commentary that you provided?

[Suketu Upadhyay, executive]

Well, I think what you're asking is, can you still sustain that in a world where you do a sizable M&A transaction if I've gotten that correct? That's really difficult to tell, right? Because no 2 deals are created equal. It's very situational. And so I don't want to get out there front footed to kind of hypothesize theoretically what could happen to EPS inside of sort of Maple Leaf deal.

So I think that what you should take away is that from an underlying perspective at 5% to 6% organic growth with the levers that we have operationally, but also with the strength of our balance sheet organically that we can deliver that attractive earnings per share profile.

[Keri Mattox, executive]

Katie, I think we have time for 1 more question if there's 1 in the queue. .

[Operator]

We'll go next to Jayson Bedford with Raymond James.

[Jayson Bedford, analyst]

Yes. Sorry about that. I'll be quick. On the supply challenges that you incurred in '23, can you just remind me what was the impact of these challenges on the P&L last year, meaning is there a way to quantify the impact on revenue? .

[Jeffrey Johnson, analyst]

Yes. Jayson, Suky. It's a bit of more is to try and say exactly how days on back order really impact sales. Because one, obviously, you have an impact on actual cases. But the more meaningful impact is the ability for our sales reps to go out there and actually hunt for new business, right? They're going to be a little bit hesitant to go shift and make conversions if they don't feel like they can supply. So that's actually probably the bigger impact but trying to frame that in in percentage points is very difficult to do. The way I look at it is as a tailwind from last year. We believe it's part of the -- sorry, it was a headwind for last year. We believe it's part of the tailwind that's going to help give us confidence in delivering that 5% to 6% organic growth for this year.

[Ivan Tornos, executive]

We have some internal data points that we don't share. What I will tell you, Jayson, is that new product launches, we had to do limited market releases instead of full market releases Persona Osiatis, an example. Conversions, as Suky mentioned, we had to prioritize our friends and family customers versus converting accounts. And then the third headwind of supply from a revenue perspective, we couldn't embark on global expansion of these new product launches.

So the example that I used earlier around Japan, second largest market in the world, we could have done things differently. We could have been in other markets. So it is sizable, and it is behind us.

[Jayson Bedford, analyst]

Okay. That's helpful. Maybe just along a similar vein, I think you talked about a 50 basis point impact to revenue growth in the second half from Russia. Is Russia a net tailwind as we look to '24?

[Suketu Upadhyay, executive]

It is. It is. I would say it's less than 50 basis points, but given that we now have all the licenses secured we need to operate, that will be a tailwind, probably most pronounced in the third quarter because that's when we saw the biggest impact in '23.

[Keri Mattox, executive]

Thanks for the question, Jayson. I think we're wrapped up with the queue and just hitting 9:30. So I'll turn it over to Ivan for some closing remarks. .

[Ivan Tornos, executive]

Sure. Thanks, Kerri. I'll keep it short. We got to get going here. So a minute or less. I want to start -- I want to end the way that I started the call by thanking the team members, the almost 20,000 team members here at Zimmer Biomet, we're doing a remarkable job in executing the plans that we lay forward. So grew 7.5% constant currency in '23 with a nice EPS expansion of 200 basis points, that's after growing 6.6% in 2022.

And now we're committing to at least 5% revenue growth, 5.5% midpoint with nice EPS expansion and double-digit growth in free cash flow. So very proud of the work that team members are doing. But we're very excited about 2024. We are moving from remediation to -- we have moved from remediation to innovation. I'm excited about the pipeline of products. I'm excited about the financial profile that we're committed to growing EPS faster than revenue and free cash flow faster than EPS.

And so far during the year, everything that we're seeing is as confident or confidence that is going to be a very solid year for Zimmer Biomet Biomed. So thank you for your attention this morning, and thank you, team members at Zimmer Biomet.

[Operator]

Thank you for participating in today's conference call. You may now disconnect.