Welcome to BONESUPPORT Q3 Report 2024. For the first part of the conference call, the participants will be in listen-only mode. During the questions and answers session, participants are able to ask questions by dialing pound key five on their telephone keypad. Now, I will hand the conference over to CEO Emil Billbäck and CFO Håkan Johansson, please.
Thank you, operator, and welcome everyone to BONESUPPORT's Quarter Three 2024 results call. My name is Emil Billbäck, and I'm making this broadcast, as always, together with Håkan Johansson, our CFO, by my side. So we will use the next 25 minutes to guide you through the presentation of the third quarter results, and then we will open up the line for question and answers. But before going through the presentations, we would like to draw your attention to the disclaimers covering any forward-looking statements that we will be making today. So let's start the presentation and go to slide three. I would like to start the entire presentation with some condensed highlights from the report that we released this morning.
So overall, quarter three results, sales were at SEK 238 million , which corresponds to a reported growth of over 50% YoY . In constant exchange rate, the growth was 54%. The strong sales resulted in a record operating results. Before incentive provisions, the operating results was SEK 48 million . The reported EBIT was at SEK 41 million . The positive development resulted in a strong organic cash boost of SEK 39 million-SEK 153 million . Now, before moving into the details of the report, let me quickly cover the highlights of the quarter. The SOLARIO study has been running for more than four years, and hearing the positive outcome at a packed auditorium at the European Bone and Joint Infection Society's annual meeting was a personal milestone highlight.
Several leading representatives for the EBJIS proclaimed that this is a game-changing study that will lead to modified treatment protocols. I will come back to SOLARIO later in the presentation. We're making good progress in our preparation for the spinal fusion market entry, and we will provide a short update and status in today's call. Finally, I would like to highlight that CERAMENT G in the U.S. is taking significant market shares, reaching sales of SEK 134 million in the quarter. We continue to see that existing customers continuously increase their use, and in addition, new users are constantly being added. So let's go into the presentation now and go to the next slide, where we will look at sales development.
This chart shows last twelve months sales in Swedish currency every quarter since early 2017, in stacked bars per region and product category. In this slide, the strong launch momentum for CERAMENT G in the U.S. is becoming very graphically visible. CERAMENT G in the U.S. grew 114% YoY in the quarter, and the sales value of CERAMENT G in the U.S. is actually now making up 50% of the total sales in the quarter. As we are broadcasting this, we are at the North American Orthopaedic Trauma Association meeting in Montreal, which is also coinciding with our launch conference for the open trauma indication. As CERAMENT G has only been market authorized for open trauma in the U.S. since March of this year, we have not had close interactions with orthopedic trauma surgeons before.
There are between 9,000 and 10,000 orthopedic trauma surgeons in the U.S., and we expect to establish many new relationships at this congress. For those interested in listening to some early experiences from CERAMENT G in trauma, I would recommend the podcast on BONESUPPORT's LinkedIn with three very prominent traumatologists sharing firsthand experiences of CERAMENT G. All in all, our top line is advancing with a solid and steep trajectory, as CERAMENT is rapidly taking market shares from other treatment options and seemingly is even expanding the market. It is mainly the antibiotic-eluting CERAMENT that is driving the development, with in total 81% sales growth across the two regions in quarter three, 2024 versus quarter three, 2023. Let's now go to North America on the next slide.
Sales of SEK 192 million in the quarter corresponds to a reported growth of 59% YoY and 63% at constant exchange rate. Now, there were many highlights in the quarter. In September, the NTAP reimbursement request for CERAMENT G in open trauma was submitted to the CMS. The combination of easy handling, ability to do a one-stage procedure, ability to mimic natural bone healing, and the elution of local gentamicin over more than 30 days appeals strongly to the US surgeons and the orthopedic clinics. These key points are the main reasons for the fast and strong sales ramp up. In addition, though, the avoidance of bone infection and the avoidance of amputations are also incentivized through the regular US reimbursement system, which penalizes failed procedures, or so-called Modifier 78. That's the code for a failed procedure.
The number of surgeons and nurses being trained on and using CERAMENT G is constantly increasing. We are progressing well with hospital system approvals, with a total of 145 listings for CERAMENT G at the end of quarter three. The focus right now is actually to strike a balance between adding hospital system approvals and training the surgeons and nurses in the hospitals where a listing has been accomplished. We have to train surgeon by surgeon and nurse by nurse ahead of using the product. A positive dynamic, though, is that surgeons that used CERAMENT G in 2023 and early 2024 have followed up on their patients and are sharing positive feedback and testimonials that they see the same positive outcome as have previously been displayed in many published clinical studies on CERAMENT G.
This gives a very positive endorsement, and we are receiving an increasing amount of surgeon-to-surgeon referrals for CERAMENT G. So while we have been busy training surgeons for the last 23 months on CERAMENT G, we have only scratched the surface of the full opportunity. As an example, we have just surpassed 1,000 surgeons trained on CERAMENT G, and there are over 20,000 orthopedic surgeons in the U.S. Another interesting market dynamic that we would like to share with you is that approximately 10%-15% of the surgeons that have started to use CERAMENT G in the last 12 months have previously not used any local antibiotics in their bone graft surgeries for extremities, as historically, there were no FDA-approved alternatives. This is an early-stage observation, but an interesting one, pointing towards CERAMENT G as a driver also of market expansion.
Several market investigations have shown that the use of local antibiotics in Europe is estimated at almost 10 percentage points higher than in the US, but possibly, we see some first tendencies of the US moving in the European direction. Finally, a few mentions on our preparations for the future entry in the spinal fusion segment. In preparing for the market entry into the spinal fusion, we have conducted several different activities to further map the market dynamics and determining factors for surgeons' choice of technique and material. Overall, what we see from the market insight is that a large part of the surgeons have concerns for infection among and after spinal fusion. 57% of the surgeons regard infection following the fusion surgery as a significant clinical problem.
The use of local antibiotics has become an unregulated and off-label standard of care, used in 35%-40% of all the spinal fusion procedures. We are making good progress in running several preclinical studies to build applications, instructions, and handling manuals for the various different techniques in spinal fusion. We hope to share some first data from these at the quarter four report in February next year. Now let's turn to Europe and the rest of the world. For the quarter, we saw sales of SEK 46 million , corresponding to a reported growth of 22% YoY and 21% at constant exchange rate. We are seeing good progress in Europe, where CERAMENT is capturing market shares in more or less all markets we're present.
However, there was a higher-than-expected negative seasonality impact in quarter three, which was exacerbated by healthcare staffing disruptions in many areas. This resulted in fewer surgeries in general compared to the previous quarter, as well as slightly challenging market access for our sales representatives. Looking at this quarter's highlight, CERAMENT V was approved for market introduction in Canada, and CERAMENT BVF and CERAMENT G are already being sold in Canada through distributors, and the business is developing well. With the addition next year of CERAMENT V, we believe that the market potential will increase further, and we have therefore decided to mirror the successful implementation in Spain and Italy. We are now recruiting to also make Canada into a hybrid market with both distributor reps and own staff on the ground.
The largest highlight is, of course, that SOLARIO study met its primary endpoint, showing that bone substitutes with local antibiotics enables reduced systemic antibiotic treatment. Let's go a bit more in detail into the SOLARIO study. So being able to reduce systemic antibiotic by using CERAMENT G or V could have a profound effect on the fight against antibiotic resistance, as well as significantly reduce the challenging side effects associated with systemic antibiotic treatment. This is why this study is so important. Only top-line results from SOLARIO has been released so far, so we should expect the full-length article to publish sometime during next year, upon which we will have more data and details about adverse events and the full cost analysis. However, based on what we've learned from the top-line results, these results are indeed spectacular.
The standard protocol around the world in a patient with bone infection is to administer more than four weeks of systemic antibiotic, and in many cases, this treatment will last and continue for six to eight weeks. The healthcare practitioners are well aware of the difficult side effects and the high cost of this treatment, but it has been seen as a necessary evil to manage the bone infection. The SOLARIO study challenges the existing protocols, as it shows that antibiotic-eluting bone fillers enables a systemic antibiotic treatment for less than a week without any increase in reinfection rate. This has significant and material effect on the side effect, as visible on the graph to the right. It should be mentioned that these adverse events and side effects are in no way trivial. They're causing a large amount of patient suffering and cost for society.
Severe adverse events in the study were classified as life-threatening, or requiring hospitalization, or resulting in persistent or significant disability. To further understand the seriousness of the adverse events, to treat an episode of nephrotoxicity, which is influencing between 5%-20% of patients on a long-term vancomycin treatment, could easily cost up to $15,000. We know also from protocol and available data that one week of intravenous antibiotic combination treatment cost up to $3,500 in the U.S., and around GBP 1,600 in the U.K. If we take a U.S. reimbursement perspective on treatment failures and adverse events, so if this happens within 30 days after the index surgery, they are categorized as failures, which is also called Modifier 78.
The reimbursement for the follow-on treatment of the patient then drops with 20%-30%. The antimicrobial resistance is one of the greatest public health and development threats. The misuse and overuse of antimicrobials in humans, animals, and agriculture are the main contributors to the rise of drug-resistant pathogens. According to the Antimicrobial Resistance Review report, in 2050, as many as 10 people could die each year due to antimicrobial resistance, and the World Bank has estimated that enormous cost will be associated with the antimicrobial resistance. So on that rather apocalyptic and dramatic note, I would like to hand over to Håkan.
Thank you, Emil. Let's move to slide number 9. Net sales improved from SEK 158.2 million- SEK 237.5 million, equaling a growth of 50%, or 54% in constant exchange rates. Emil has already spoken about the strong performance and the major drivers behind the sales acceleration. The contribution from the North America segment improved with SEK 32.8 million and amounted to SEK 79.3 million. The improved contribution relates to increased sales after the effect from increased costs. Sales and marketing expenses during the quarter amounted to SEK 102 million, compared with SEK 67.6 million previous year, of which sales commissions to distributors and fees amounted to SEK 65 million, compared with SEK 42.2 million the same quarter last year.
From the lower graph showing net sales as bars and gross margin as the orange marker, it can be noted that the gross margin remains strong and amounted to 94.7%. The drop from the second quarter this year, all in all, relates to a weaker U.S. dollar. In Europe and the rest of the world, a contribution of SEK 15.6 million was reported, to be compared with SEK 9.3 million previous year. Sales and marketing expenses increased by 3 million, dropping compared with the second quarter this year and following seasonality. From the lower graph in orange marker, you can see the gross margin remaining stable. The increase in selling expenses reflects investments in the organization, but also investments in systems to improve customer handling and inventory management to stay ahead of the increasing demand.
The slight reduction compared with the second quarter this year follows normal seasonality. As presented at our capital markets day in November, R&D is focused on the execution of strategic initiatives, such as spinal fusion and a planned market authorization submission for CERAMENT V in the U.S. These initiatives have been progressing well during the quarter, which also explains an increasing spend. And administration expenses, excluding the effect from the long-term incentive programs, remain on a stable level. However, impacted in the period by temporary resources. To sum up then, the financials, the reported operating profit amounted to SEK 41 million , an improvement of SEK 26.1 million compared with the same quarter previous year. This follows a strong sales performance, despite unfavorable currency effects in the period and despite the investments made in our commercial platform and in innovation.
The difference between Adjusted EBIT and reported EBIT operating result are costs regarding our long-term incentive programs, amounting to an expense of SEK 7.3 million in the quarter, compared with SEK 9.7 million previous year. As you could see from the previous slide. Of the total cost of SEK 7.3 million in the period, only SEK 1.9 million was cash flow impact. With strong momentum in our sales, increase in our safety stock of raw materials and semi-finished products were made during the first half of this year. As we have now reached satisfactory levels of inventories, we see a strong cash flow returning, improving cash balance with SEK 39 million during the quarter. So with this, I hand back to Emil.
Yeah, thank you very much, Håkan, and we're going to wrap this presentation up. We're, of course, very pleased with the quarterly performance and the continuous solid trend. All three quarters in 2024 have shown sales growth well above 50%, and we see solid and robust sales trending over the past 24 months. The current market penetration is strong and we anticipate further future sales enablers to play out with a milestone scenario study, the entry of CERAMENT G in open trauma, and the future entry into the spinal fusion segment. Thanks to its clinical superiority over standard of care, CERAMENT is constantly increasing its user base and enabling surgeons to achieve a better patient outcome. With that, we close our presentation, and we'd like to open the line for questions.
If you wish to ask a question, please dial pound key five on your telephone keypad to enter the queue. If you wish to withdraw your question, please dial pound key six on your telephone keypad. The next question comes from Mattias Vadsten from SEB. Please go ahead.
Yes, hi, Emil and Håkan. Thank you for taking my questions. I have some questions here relating to SOLARIO to begin with. I think there are all reasons there is to lower the use of systemic antibiotics and instead use the CERAMENT G and V. We also know changes are slow out there, especially in Europe, and I think you talked about treatment protocol changes here in the presentation, Emil, but what can you share in terms of speed at which behaviors will change? And maybe also comment on some of the dynamics in the U.S. for a bit as well. That's the first one.
Thank you. Thank you, Mattias, and thanks for joining us today. Yes, unfortunately, I'm probably not well positioned to speak about speed, as when I joined BONESUPPORT and I discovered this great technology, I thought the success would come even faster. But eventually, results came, and it's difficult to predict how long time will it take this time to actually change old behaviors at a rather conservative customer group. You mentioned also U.S., and possibly there's a difference between U.S. and Europe. I think that this change will be facilitated over the fact that the study is not our study. It is the study of the European Bone and Joint Infection Society, who has members all across Europe and also some in the U.S.
The second point, I think there's a general trend, which is, communicated also as an unwanted direction by the United Nations, WHO, to have a more balanced use of antibiotics, the current path is unsustainable, so a change is demanded. And lastly, what we see, Mattias, many times in the U.S., is that they're slightly faster to jump on topics with strong clinical and scientific evidence if it also has financial impact on the healthcare system. So they're more of course, they care most about the patient, but they also have a more monetary consciousness. And I believe that there's not a single orthopedic surgeon that have not experienced the patient suffering, and also the financial impact of a patient coming back with nephrotoxicity, or hearing loss, or Red Man syndrome, which has also costed large amounts to treat these adverse events.
No one has taken really the strong initiative to reduce the systemic antibiotics before, because there was no data, and no one wanted to be first to do it and have the risk of setbacks. Now, there is data in one of the biggest published studies in this domain. So hopefully, these are levers that will be justifying a faster change of protocols than what we have seen historically, because historically, it's been a bit discouraging on how quickly, or rather, how slow it is to change these protocols.
Thanks so much for that. I appreciate. It's a difficult question, but good flavor. And I think secondly, then, to this topic as well, local antibiotics use, let's just say 38% of extremity surgery with bone graft in the U.S., or 47% in Europe, according to this analysis. An even tougher question then, what share in your world, you know, should use local antibiotics, let's say, long term?
I think the number is gonna rise both in Europe and in the US. We see that there's constantly a trend away from autograft, allograft to more to synthetic grafts. And given the overwhelming evidence available now, including SOLARIO, I wouldn't be surprised if the use of local antibiotics as a first step will go up to 60% of the procedures, but could potentially continue after that.
Thanks so much. I will limit myself to one more before jumping back to the queue. It would be great to hear you talk a bit about the performance of early adopters and the initial customers in the U.S. And if you could give a feel for how sticky the customer base is, it seems very sticky, and how much of stop-and-go you're experiencing right now. And also, maybe the typical question of commenting a little bit on growth that you see coming from previous customers and the share that is coming from incrementally new customers. That's my last one for now.
Yeah. So we are fortunate to work with a fantastic product. We are unfortunate that we are in a dynamic that the surgeon, first of all, when using the product in a surgery, can only assess the handling and the applicability capabilities of the product. It takes three to six months before we get the final verdict, and we get the SMSs, or WhatsApp messages, or emails from the surgeon saying, "Wow, I have achieved great results." So there's a time lag, and we know that if we lose a surgeon that have started to use CERAMENT and they stop using it, it is in the first six months, before they have seen the final results of the bone remodeling, and they've seen that the patient is infection-free for the entire treatment period.
What is also an interesting dynamic here now is that those surgeons that are very meticulous and have followed up their patients and also documented it, they see almost the same results as these very well-controlled studies that have been made both in the U.S. and Europe. So, if the product works, it doesn't only work in the hands of prominent surgeons in university hospitals, it also works with the common orthopedic surgeon struggling with challenging indications day to day. The dynamic also is such that no one will use a new product like this before they have been trained. So even though a lot of people have read now about SOLARIO, SOLARIO is sending some shock waves, I would say, around the world, and people are aware of it.
People are still not going to start using CERAMENT G until they have had the training, so it's a rather tiresome work, and I mentioned in the call that we've trained a bit more than 1,000 surgeons out of 20,000, so it can feel like an endless journey, almost, but we know that the ones that have been trained and are using it, the loyalty to the product and the loyalty to producing better patient outcome is very high, so we feel very confident and energetic on this journey going forward.
Thanks so much.
... The next question comes from Kristofer Liljeberg from Carnegie Investment Bank. Please go ahead.
Thank you, and good morning to you, too, in the US. I have four questions. I'll try to be shorter, but first one, first the SOLARIO. So, of the patients receiving antibiotic, systemic antibiotic treatments, is that typically intravenous, or could it also be oral? Because you mentioned that the cost for treating intravenous. And then on the proportion of patients that receive local antibiotic treatment, antibiotic, was that for extremities overall? Do you know what the figure is for bone infection, specifically? So those two related to SOLARIO. And then, just a question for Håkan. Working capital as a percentage of sales, where you think that will be over time? It has fluctuated a bit here, up and down, early in the launch.
And then I just wonder about the NTAP , or actually, the outpatient segment, how much is that contributing to growth now? Thank you.
Yeah. Thank you very much, Kristofer. So there was a little bit of distortion on the line on the first question. I actually could not hear the full content. I don't know if you heard it, Håkan. Could you help me, or otherwise, I'm going to hear it again.
The first question was on how the antibiotics was distributed to the patients, if it was all intravenous or-
In the SOLARIO study.
In the SOLARIO study.
Yeah. No, we don't know that yet, actually. We have specifically asked the group on how much was intravenous and how much was per oral, and the team doing the study have let us know that this is data that will come in the full-length presentation. So we don't have the data. We know that vancomycin was one of the most used antibiotics, and vancomycin is given almost always intravenously. We also know that there's a higher degree of intravenous treatment in the first couple of weeks in the long arm. And we also know that with the severe side effects and some of those failures, that the patient has been hospitalized and received intravenous. But more than that, we don't know, so this will have to be for further and future analysis.
The next question was regarding the use of antibiotic, local antibiotic in extremities. So I presume here that you refer to slide five in the presentation, the 38% that we-
Sorry, I mean, trauma. Yeah. Sorry. So the question was actually in patients with the bone infection. I guess that figure is higher than for-
Yes
... all extremities.
Yes. Yes. We-
Do you know what that figure is today?
I would say it's close to 100%. It could be-
Oh.
A few percentage points deviating, but almost 100% with patients with bone infection. An active bone infection are receiving local antibiotics today.
Okay, but if that is the case, how will the SOLARIO study then increase use of CERAMENT if all patients are already today receiving local antibiotics?
I think SOLARIO is a great study in that it shows one of the most difficult conditions of bone infection and an antibiotic course, which, if you would believe SOLARIO, is too long, meaning more than four weeks, so the greatest effect of SOLARIO is that the systemic antibiotic can be shortened with the regular use of an antibiotic eluting bone graft, but in many of these patients, I would say specifically in the U.S., what is being used is vancomycin powder sprinkled right into the bone infection. No such patients were included in the SOLARIO. There's also a lot of off-label mixing with very dubious results. None of those were included in the SOLARIO study.
So if you want to make sure that you treat the patient in the best possible way, you want to make sure that you follow the scrutiny of the FDA, and you would like to then have the ability to reduce your systemic antibiotic, then you need to use a product that has been regulatory approved and has been part of the biggest clinical study. So that is how I see that more patients will receive CERAMENT G and V going forward.
Okay, that makes a lot of sense. Thank you.
Just to follow up there, Kristofer, we saw that as an example of all the patients in the US that were local antibiotics was used in bone infections, 40% used PMMA beads, where we know that the reinfection rate is around 13%. With CERAMENT G and V, it's down to 5%. Yeah, it's local antibiotics, but there are big differences in results.
Thank you.
... Your next question, yes, Kristofer, was on the working capital. It's correct. Now, reporting a plus 50% growth and a strong sales momentum, et cetera, it tends to create a certain volatility in working capital ratios to sales. We haven't set a firm target long term, but as I'm just looking from the numbers and how it looks all the time, it is reasonable to believe that it should be able to land somewhere between 22% and 24% in relation to annualized sales.
Okay, any further question?
The next question comes from Maria Vara, from Bryan, Garnier & Co. Please go ahead.
Hi, Emil Billbäck. Thank you for the presentation, and congratulations for the great traction in the U.S. with CERAMENT G. I just wanna touch upon a bit the development on spinal fusion and sort of remarks and insights on CERAMENT G is gaining traction in the U.S. because of the need for the same way in spinal fusion. Wouldn't it be, you know, more strategic or actually needed to accelerate antibiotics approval for a spine? Because it's my belief that first you will go to market with BVF, which of course, will be of use for bone graft alone use. But, you know, if you could give a bit of an insight into how you're gonna plan on bringing?
Yeah. Thank you, Maria. Thanks for being with us. So also, again, a little bit of disruption on the line, but we'll try to provide a good answer. Yeah. Of course, when we discuss CERAMENT with spinal surgeons or neurologists, the first question that comes up is, when can we have CERAMENT G? So you picked the dynamics perfectly there, Maria. The data that we have on CERAMENT BVF in this perspective is more extensive. So we will have to start the data development to apply for CERAMENT G to get approved indication for spinal fusion. When that happens, we will announce to the market. We will let the market know when we have made the decision to go forward. The work we're doing now on CERAMENT BVF is putting also the foundation for CERAMENT G in spine.
We are learning valuable insights on how the product should be applied. As an example, the most common procedure on spine is interbody fusion. It represents between 75% and 80% of all the spinal fusions. And for interbody fusion, there are five different techniques that can be used and several different variants. So we are now testing how could CERAMENT, as one of the very few injectable products, be applied with a convincing technique. We're also monitoring and tracking bone remodeling, bone growth, and how is the product reabsorbed in this new indication. So all that data can also be used for our ultimate project, which is, of course, to bring CERAMENT G into spinal fusion. That's all I can say now. We will come back with the timing. We're working hard on it.
That is what I can promise.
All right. Thank you. That's all from my side.
The next question comes from Sten Gustafsson, from ABG Sundal Collier. Please go ahead.
Yes. Hi, good morning. First question, CERAMENT G in the U.S., it's a pretty significant step change in sort of sequential uplift in sales in the third quarter. So my first question is, are you aware of any, you know, some sort of inventory buildup among customers, or are there any any extraordinary sales, you know, reported during the quarter? Or is this, you know, just a change in the trajectory?
Yeah, thank you, Sten. No, we're very pleased, of course, for the strong performance in the quarter, and we have analyzed and gone through the numbers, and I can confirm there are no inventory build, there are no one-off orders, there are no bulking orders that is behind this sales. Well, the extraordinary that I can mention is hard work. And we have had especially strong success in California. We're making great inroads in Florida, both which are notoriously big orthopedic markets. And in regions where we've had lower penetration before, such as New Jersey and New York, sales is taking off very nicely. But I should also be humble, Sten, and say that we have declared that there will be a go stop, go behavior.
It's puzzling that we haven't seen any such disruption so far. The curve has been almost linear for CERAMENT G. We're very happy with that, of course, but we're also old in the game, and we know that one day there will be disruption when a larger hospital chain have the usage stopped by procurement, and which is when we have to rush there with our health economic data, where we also now have SOLARIO, of course, which will be strong, but there will come disruption, but I have to conclude also that so far, there's not a single hospital system or hospital that have paused CERAMENT G that have not continued to use it after we have discussed the data.
So there could be temporary disruptions, back and forth, but the long-term trend, I think you should all feel very confident with.
Yeah, I know. Thank you. Thanks for that. And I mean, in theory, you could almost argue that the incremental growth in SEK should go up even more now with when you target a broader audience with the trauma surgeons going forward.
Yes.
So my question would be then, do you expect an even higher incremental sales growth going forward, or...?
So, I realized also I got a question before on the TPT and the outpatient setting, if we're seeing sales pick up there. So what we know, Sten, and everyone else here, is that the movements in orthopedics are slow. It's a handheld process. The ramp up takes time. We have started to see some outpatient setting sales in quarter three. We have seen a few orthopedic surgeons come on board using the product for open trauma, but these are rather vectors for the future. So we don't give forecast for the next quarter or the quarter after, but I can tell you that all of you, with the questions you're raising, you have fully understood the dynamic.
The open trauma, the outpatient settings, these are market segments that have opened themselves, where we didn't have any sales before, and these will continue to increase going forward.
Great, and then one question on the spine opportunity here, and you got questions earlier about CERAMENT G and spine. Have you considered going with CERAMENT V in spine? I'm not an expert on this, but someone told me that the kind of infections related to spine could be perhaps more relevant for CERAMENT V. Is that something you have considered?
Yes, we have also CERAMENT V in consideration for spine. There are different pathogens that can infect a wound and that can make it into the bone. Different antibiotics work for different pathogens, but gentamicin is broad spectrum and has very good coverage of the potential microbials that would represent the infestation. CERAMENT V is mainly used when there is methicillin-resistant bacteria. It's a good complement and supplement, and then there are different preferences around the world. Our position is not to try to make a distinction here, but rather say, we will have two products available in the case there are resistant bacteria, and in case there are certain preferences in some direction.
Okay. Yep. Thank you very much. I'll get back to the queue. Thank you.
Thank you, Sten.
The next question comes from Kristofer Liljeberg, from Carnegie Investment Bank. Please go ahead.
Yes, this was actually to remind you about my last question, but you answered that. But another thing I wonder is, now with launching trauma, et cetera, what capability do you have to train a large number of surgeons? Do you continue to add sales reps through your external distributors? And how does that compare with the number of feet on the ground versus a couple of quarters ago?
Yeah. It's definitely a good question. We are increasing the number of distributors. We're increasing the number of salespeople. We have now around 430 sales reps on the ground. Many of the distributor reps that we're working with are very good and have relationships with all the different subspecialties at the orthopedic clinic. So when they come and visit the hospital, they might go to one orthopedic surgeon covering one part of the body, then they go to the next after that, being a traumatologist, and then they, before they leave the hospital, they might even go down to the spine surgeon. So many times it can be covered with the same sales reps on the ground.
But to be more specific, we have also signed up specific distributors that are focused on trauma and have specific trauma hardware in their portfolio, and they've been very pleased to add CERAMENT G to their value proposition.
Great. Thank you.
Thank you, Kristofer.
As a reminder, if you wish to ask a question, please dial pound key five on your telephone keypad.
It doesn't look like there are more questions.
There are no more questions from the phone lines at this time, so I hand the conference back to the speakers for any written questions and closing comments. Please go ahead.
Yeah. You know, I just want to thank everyone for taking the time to listen to our presentation of the quarterly report. Håkan and I will now move out, have a quick breakfast with coffee before we head back into the congress area to spread the word about CERAMENT G with the orthopedic traumatologist. So thank you, everyone, and take care. Bye-bye.