Good morning, ladies and gentlemen, welcome to this video webcast on the Medartis 2021 first half-year results. We will use the presentation slide deck, which was published this morning on our website, together with the press release and our half-year report. In particular, I would like to draw your attention to the disclaimer on page number two, which also applies to the forward-looking statements during this webcast. On the following slide, you can see today's agenda, which will then be followed by an answer and question session. Today, I would like to welcome our new Chief Financial Officer, Dirk Kirsten, who has started at Medartis in his role at the beginning of March of this year. I'm also joined by Fabian Hildbrand, our new Head of Corporate Communications. Let's go on the half-year highlights.
I'm very pleased to report that the acceleration of our growth momentum has continued into the first half of 2021. We have achieved a growth in revenue of CHF 73.6 million, which is a revenue growth of 29.2% in constant exchange rates versus prior year, and 20.6% versus 2019. I'm also very pleased to see that all the regions and all the key markets have contributed strongly to the strong growth, with the U.S. market leading at 46% versus prior year, and 31% versus 2019. The strong growth in top line has also delivered on a record in EBITDA of CHF 14 million, which in addition to efficiency gains, we report an EBITDA margin of 19.2%. The headcount has slightly increased to 649, which is an increase of 5% versus prior year.
We have mainly added new jobs and new employees in the area of sales, R&D, and quality and regulatory to comply with the MDR requirements. We have been very pleased with the strong growth in all the regions, in all the markets across all the segments, especially leading in the key markets, the U.S. at 46%, where we have seen the investments that we have started in the second half of last year are paying off now, not only in the U.S. market, but also in the other key markets. During the first half year, we have seen also an easing of the pandemic restrictions, but we still notice some uncertainties, and the caseload is still not at 100%. The uncertainty, especially in relation to the Delta variant, remains also during the second half of this year. The profitability has increased strongly on all levels.
The product and also the KeriMedical portfolio continues to receive very positive feedback from our surgeons. In relation to the distribution of the KeriMedical that has started during the course of the second quarter in Austria, Germany, and U.K., we can note that still on a low level, we are ahead of plan. The completion of our product portfolio continues. We have added new projects for global and also for the U.S. market, and are building R&D capabilities in the U.S. to further strengthen our innovation pipeline. We have also gone live with an EU supply chain hub in Germany successfully, not only to comply with MDR regulations, but also to mitigate the risk as a result of the cancellation of the framework agreement between Switzerland and the European Union.
The strong first half-year performance allows us to look more positively into the second half-year, and is the reason why we raised our full year sales growth guidance to at least 20% in constant exchange rates. The growth momentum we have gained in the second half of 2020 has continued to accelerate as a result of market investments, and is driven by surgeon conversions, new product introduction, and also a higher surgical activities in the elective surgery field. With those comments, I would like to hand it over to Dirk Kirsten to give you a financial and business review.
Thank you, Christoph, and good morning, everybody, also from my side. Let me start my presentation with giving you an overview on our regional business development. As you can see, Medartis has grown 29% versus prior year. The U.S. grew 46%, APAC did grow 35%, Europe, our largest region, grew 22%, and even LATAM, which was heavily affected by COVID, grew 32%. In this chart, you also see the growth rates versus 2019, as last year was strongly affected by COVID in H1. The figures show you that with the exception of LATAM, all of the regions also grew materially against 2019.
If we go more in detail into the regions in H1, Europe was still affected somewhat by COVID, especially in April and May, when the third wave came through, many hospitals delayed elective procedures wherever possible in order to raise capacities for COVID cases. In the U.K., the NHS was at case levels of only 70% towards the end of H1. This led to lower than expected growth. On the flip side, some other countries, for example, in the DACH region, in the German-speaking countries region, grew strongly even within the remaining COVID uncertainties. France was a country with specifically strong growth in H1. Also, our distributors in the region generated good growth, and the introduction of our new KeriMedical products was very successful. In the U.S., we've grown 46% year-over-year and 31% versus 2019.
Our highly motivated team has become stronger and faster, and successfully converted many hospitals to work with Medartis. We feel that the momentum has increased, and we receive a lot of positive feedback from the market. We will now, as COVID allows it, also visibly increase our activities in training and education, enforce our U.S. IBRA chapter, and also intensify our work with the regional fellowship programs. This goes along with the further buildup of our sales force, as well as investments into infrastructure such as supply chain, automatization of processes, and similar. Overall, we are very confident to grow significantly in this key market over the next periods to come. Also in Australia, we've seen significant growth beyond 35% in the first half of the year.
As in the U.S., we have a highly motivated team there, are winning new accounts on a daily basis, and we're increasing the business with existing customers as well. Japan was behind plan, which was due to the COVID situation in the country. The activity level was still limited as COVID restrictions were very tough. We believe that we are about one quarter behind plan. In China, we have further established our footprint, won a couple of tenders, and selected additional distributors. We expect that sales would increase in the coming months as well. Through the entire APAC region, we've seen distributors still holding back larger orders and remaining cautious on inventory buildup. Also here, we would expect that the situation in H2 will improve, always assuming no further turbulences from COVID to occur.
Leads me to LATAM, a region with enormous growth potential, but also a region which has suffered even stronger from COVID. Especially in Brazil, our largest country, the COVID situation was very severe during Q1. Many public hospitals didn't do any selective business or procedures anymore. Our teams navigated carefully through this situation and impressively kept the team morale high within this very difficult time. Due to the low comparison basis from 2019, Brazil still strongly grew, as did Mexico on a smaller basis. Selected distributors in the region put in also larger orders toward the end of Q2, thus also stabilized the trend going into the second half. Let me also give you a quick split of our overall growth into business segments as you can see here. The lower extremity business grew almost 40%, whereas the much larger upper extremity business grew 30%.
The strong growth in lower extremities comes mainly from Australia and the U.S. This is strategic for us, we will also try to accelerate this growth with products who are designed even more specifically for the needs of these two countries. In upper extremities, we've seen strong growth from the extended TCS portfolio. In countries such as Germany, Austria, and also the U.K., where we introduced the new KeriMedical products, we've seen also strong demand and promising initial sales. Training and education will be a very important growth driver going forward. This will allow us better to present our new products in physical meetings to our customers, which unfortunately wasn't possible so far due to COVID. CMF, which is mainly elective business, also grew nicely at almost 30% here.
We have continuously replaced the former MODUS I with the new MODUS II system, which was introduced last year. We have supported the growth with our customer-specific solutions and digital planning for surgeons, which we call the so-called CMX platform. Within this context, let me make the overall statement that we believe our product portfolio is one of the most comprehensive and innovative in the market. We will use this competitive advantage to systematically gain customers and talent who want to work with Medartis in setting quality benchmarks in the industry. With that, let me quickly move to the P&L on page 12. Gross margin has improved 160 basis points to now 83.6%. This is due to regional mix effects from countries with higher ASPs, but also from increasing production efficiency. We are running our business at higher capacity utilization than one year ago.
We did have a couple of non-recurring elements in last year's P&L which had diluted the margin. I would say that the margin is now at sustainable levels of around 84%. Slide 13 shows the operating leverage of our business. When top line picks up, you see an immediate improvement of our OpEx ratios as the majority of the operating expenses is from FTEs or other fixed costs. As you can see here, we have increased the level of spending in absolute terms again after last year's special situation in Corona. We will even increase further these spendings for meetings with our customers, doing training, education, and similar, all directly to the market. We are committed to research and development in order to drive further innovation. With respect to general and administration, we remain cautious.
Of course, also we need to strengthen the group infrastructure further, serve an increasing number of countries, and also work on processes which are impacted, for example, by regulatory or similar. As Christoph has mentioned before, we have established a new European supply hub in H1 in order to fulfill with the new MDR requirements. This has added complexity and also caused some increase of G&A expenses. The important aspect is, however, that the higher absolute expenses still lead to a lower, what I call, OpEx to sales ratio. It was 80% in H1 2019. Due to corona, it increased to 85% in 2020. Now, in the first half of 2021, it only stood at 75%. It's our ambition to sequentially improve that ratio without forgetting the necessary investments into our group, especially on the market side. Slide 14 puts everything together. Better gross margin, better OpEx ratio.
Both combined leads to 10% higher EBITDA margin than in 2020. We had guided for at least 16% for this year. In the first half of the year, the underlying margin was clearly better. Assuming less restrictions from COVID, we will now spend slightly more money in H2 for customer activities. Directly outside, we are confident to accrete this margin readily towards the 20% level and beyond, which is in line with top-line growth in the further periods to come. Two technical comments. A, currencies didn't play a big role in 2021 in the first half of the year. B, also, we received a small income from KeriMedical, of whom we took a stake, remember, in the 25% towards the end of last year. With that, let me summarize the net profit development.
Operating profit was also supported by an improvement from the financial result, which had been more challenging in the first half of last year. We have recently started to de-risk CapEx as much as possible, and installed a program there. Taxes are slightly higher than last year. This reflects also that we're back in a profit-making situation, and also we've grown 30% versus the prior year. As a result of that, the net profit margin was almost 10% for the first half of the year. Our absolute net profit has increased from CHF -6 million to CHF +7 million year-on-year. To finish my presentation, we can also report an increase of cash versus end of last year.
Our group has sufficient cash reserves to support further growth, be it on the working capital side, for example, with consignment inventories for our customers, or be it for CapEx, which also includes the set investments for our customers, and of course, R&D. We do also have sufficient cash to drive small to mid-size M&A projects if and when such should occur. Thus, we believe we are well prepared to grow faster and stronger also in the future. With that one, let me hand back to Christoph. Thanks very much.
Thank you, Dirk. Let me give you an update on our strategy and business. Our strategy for the long-term growth remains the same. We will continue to play in a very attractive market, which demographics will continue to be the key driver. We also expect the global extremities market, also post-COVID, to continue to grow at an attractive mid-single-digit growth rates. Our priorities also remain: enhancing sales focus, continue to target investments in key markets such as the U.S. as a first priority, and then also accelerate the time to market post-MDR certification to continue to deliver fast and differentiated solutions to the market. This should help us to establish Medartis as an innovation leader in global extremities. As we execute on our strategy, we have also initiated a culture journey. Let me explain how we move forward on our culture journey.
We have undergone significant changes in the organization. We have made changes over the past 12- 18 months in our Executive Leadership Team, but also on regional teams. The pandemic has changed the way we interact, the way we collaborate internally, but also collaborate and engage our surgeons, may it be in R&D projects, in professional education, but also in our sales process, how we introduce new products to the market. That digitalization will remain as we go forward, as we hopefully now return to what we call the normality. We're going to reconnect our employees, but also want to reconnect with our surgeons as we start with face-to-face professional education events during the course of the second quarter.
With all those changes and the complexity, and to cope and adopt to those, we believe that a learning culture becomes even more important to position Medartis as a responsive, flexible, agile organization where people are valued. We have started with a culture journey and the first workshops, and engaged the top management, and we will also roll out concepts and workshops to engage the entire organization in the course of the second half year. Let me comment and give you a little bit of an order of magnitude of the changes that we have seen by going more towards digital content. The virtual training and education offerings at Medartis and IBRA has tripled on a year-on-year comparison in 2021. Also, the webinars, trainings, and live surgeries have increased by almost 50%, with very positive surgeon responses, especially in the far-reaching countries in Latin America and Asia Pacific.
Online formats have also established themselves in the engagement of surgeons as part of our sales process, where new offerings to existing customers, new products, also the engagement in R&D project has changed. We have also seen an increase of 50% of our IBRA membership, which is the biggest increase of its foundation over the past 17 years. As we believe those digital platforms and content will remain, we are now also going to reactivate the face-to-face education and marketing activities in the course of the second half year. The U.S. remains our key priority. We have made clear progress in the sales network, investments also in infrastructure and product development, and also investments in training and education. Let me go through in more detail.
As communicated in the full year 2020 results in March, we have and continue the reallocation of sales territories to increase the distributor network and made changes in our direct sales organization. The investments of surgical set continues, especially as we launch new product, and we have gone live now with the new compensation plan in the U.S. sales force. We are now in the hiring phase of building up R&D capabilities in the U.S. to support a regional innovation pipeline for the U.S. market. We also need to continue to invest in supporting infrastructure, in back office, and logistics to accommodate anticipated growth. The regional chapter for IBRA is up and running, and we are continuing to onboard key opinion leaders to expand our training and education offering, but also engaging KOLs in the future development of our portfolio.
In the second half year, we anticipate or plan for the following launches. In August, we are all about to launch a new minimally invasive distal radius plate with the first patient-specific application in the wrist osteotomy, which is a 3D-printed drilling guide and cutting guide. Also in September, we will go into the full launch now of the Ankle Trauma System, which is currently in the limited release, followed by a new edition of the KeriMedical portfolio, KeriFuse, which is an intramedullary arthrodesis device for the finger joints. We will conclude the year with the launches of a patient-specific application for orthognathic indications in November, as well with an addition in our hand portfolio with the CMC-I Fusion Plate. That will conclude the launches of Medartis in the second half of this year.
The start with the distribution of the KeriMedical portfolio in Austria, Germany, and the U.K. is off to a good start. The sales level are still on a low level, but we are already ahead of plan as we have experienced some delays in the distribution in the U.K. We are now on the way of the registration of the KeriMedical portfolio for the U.S. market, followed for the Australian market. The MDR has been a multi-year journey or project, however you want to look at it. We are now in the final steps to conclude, hopefully. We are scheduled now for the second audit on the MDR regulation in September, and we anticipate the registration of the self-certification on the CE mark under the MDR in the first half of 2022.
I would also like to draw your attention to the proposal of the board for new board members. Ciro Roemer and Nadia Tarolli Schmidt have been proposed for the election at the AGM in 2022. Ciro Roemer has more than 30 years of experience in the medical device industry. He has held leading executive positions at Synthes and then in J&J, and has been a former board member of the AO Foundation and Eucomed. Mrs. Tarolli Schmidt is a registered Swiss attorney at law, tax expert, and has extensive experience in business law with specific skills in the areas of taxation and social security. This leads me now to our outlook for the full year 2021.
As I have mentioned, based on the strong performance in the half year one, and despite the more challenging baseline in the second half year, we expect a full year sales growth in constant exchange rate of at least 20%. This also assumes a further improvement of the corona pandemic environment, which should especially lead to more elective surgeries. We also confirm, as Dirk has presented this morning, our assumption of a stable EBITDA margin as we continue to invest in our sales force, product pipeline, and assume a gradual pickup of the training and marketing activities in the remainder of this year. With this, we conclude our presentation, and I suggest now we open up the Q&A session.
Our first question comes from the line of Dylan van Haaften from Bryan, Garnier & Co. Please go ahead.
Good morning, sorry. Congrats on a very strong H1, Dirk and Christoph. Just a few questions from my side. Maybe first for you, Dirk. Could you quantify in very broad terms the COVID impact you have seen in terms of surgical capacity? Perhaps if the distributor markets are back to 2019 levels in stocking and absolute sales figures? My second question would be on the exit rate trends you're seeing in June, and if there's any reason to think that the second half would be softer, excluding the slightly tougher comparison base.
Good morning, Brian. Thank you very much. I hand it over to Dirk for the questions.
Good morning also from my side. I think the first question was also the run rates, especially the COVID impact, and whether we can quantify that a little bit. The answer is, it depends from country to country. We say that on overall, probably we are at capacities which is slightly ahead of 90%. Of course, it depends on the countries. If you look at the U.K., it's probably slightly lower, 70%. You go to other countries, such as in Brazil, we're lower. On the flip side, we have the U.S., where the momentum currently is very nice. In Germany, I think the situation picked up, and it's a little bit volatile. We've seen that through the second to the third wave. Hopefully, there's no fourth wave to come, that's very important.
Where do we see the second half of the year in terms of much will it be softer? We are confident that we can further grow. We see also from the months after the half year closing, we see that the momentum is increasing or it's going on a similar level. We're confident also to close the second half of the year in similar levels. As Christoph and myself have presented to you, we are focusing very much on the U.S. There's a terrific momentum in the market, and we're sure we can also capture further market share here. We are confident on the second half of the year. That's also the reason why we increased the guidance on a top-line basis for the second half of the year and for the full year.
Excellent. Thank you very much. Then maybe just two more on my side. One would be on, have you seen any market share gains so far? Or is this still largely penetration growth, new product growth? My final question would be on the TOUCH prosthesis, if there's any regulatory interaction with the FDA you could tell us about so far.
Mm-hmm. Okay. Thank you. If you look at our growth, yes, we have converted surgeons. We have certainly gained market share across all the segments in all our key markets. In relation to the TOUCH prosthesis, KeriMedical actually is in the submission and presentation of the documentation. We have had some conversations as to how we want to approach the registration. We are using the European data that we have and submit the documentation to the FDA. We are still in that submission process, so we have not heard yet any feedback on the registration documentation from the FDA.
Excellent. Thank you very much. I will pop back in the queue.
Dirk has a follow-up on.
I just wanted to build on the market share gains. One of our friendly competitors came up with an estimation that the extremity market grows somewhere between 6%-10%, which is a huge range, depends on the region. If that is the case, we clearly have won market share, for example, in the U.S., but also in Australia or some of the European countries. Yes, we do believe that we have made some progress also in relative terms.
Excellent. Thank you very much for that clarification. Have a nice day, guys.
Thank you, Brian. You too.
Thank you.
The next question comes from the line of Daniel Buchta with Zürcher Kantonalbank. Please go ahead.
Yeah, thank you very much. Maybe three questions from my side. The first one on the new compensation system in the U.S. that you mentioned. You mentioned before as well that you're hiring a couple of people there now again. In the past, it was a risk that you lost good sales reps again due to competitors paying better than you. How can you avoid that issue now in the future? How is your new compensation system in that regard designed? Maybe a question on Dirk. You mentioned this FX de-risking. What does that mean a bit more specifically, and how can we see that then in the future in terms of margin influence and things like that? Maybe the last one on sales and marketing.
You have kindly shown how sales and marketing relative to sales have developed, and last year first half and also the prior year first half was roughly 52%. Now it was around about 45%. Into the second half and especially into 2022, is it expected to go back to this 52% level? Or because of the material efficiency gains from virtual trainings and education, is that going to be lower than that? How can we expect that to develop? That's it from my side.
Good morning, Mr. Buchta. Thank you for your questions. Let me start with the first one and then hand it over to Dirk for the other two questions. The compensation scheme in the U.S. that we have changed is mainly targeted towards growth. What we have seen in the past, and that's also what you're alluding towards, why we did lose sales rep. They not only left the company at the very beginning because of competitors paying more. The main reason is always when you start with a sales rep, if you have not a complete portfolio that supports a full year income of a sales rep, then you need to overpay him in the fixed salary. Especially for a rep, not having a full portfolio, over time it's frustrating.
That's probably the key reason why reps are leaving, because they're not competitive in the office, in the search, and in the OR, with a full range of portfolio. In the meantime, especially in the upper extremities where we have a competitive and also complete portfolio, that has changed, first of all. Second of all, we are now coming from less fixed towards more compensation towards variable pay, especially in the U.S. where we have increased the variable pay, reduced the fixed, with giving a higher target. That means the sales rep are more incentivized with the stronger growth. An uncapped commission on growth with a higher target, that allows them to make more money if they achieve the objective versus just maintain the business.
That drives the behavior change of our sales organization in the market to get more focused, driving more and more aggressive growth. That was the back, and that's the intent of the entire change in our incentive scheme. For the other two questions, I would hand it over to Dirk.
Yes. Good morning also from my side. FX de-risking. What we haven't done is started into any complex hedging programs at this point of time. We think that's just not the situation we should do right now. What we do, we're a little bit more cautious in what currencies are we holding our cash. Can we sell it back into Swissies? That has been successful also for the first half of the year. When I'm talking about a program, I'm looking deeper into the organization, and I'm also looking at the supply chain. As you probably know, our supply chain is quite complicated. Sending the sets forth and back to customers. We have a lot of inventory, also on a consignment basis with our customers, which we're tuning, where we're trying to grow, and where we put that inventory and also the sets into the countries.
What that means is that there's a lot of implied FX risk. Managing FX risk for me means also to simplify the supply chain and take out risk which is more related to the processes, and that's what we continuously doing also going forward, number one. Number two, on the ratio with the sales and marketing and the 45%, look, the important figure here on page 13, I believe is the CHF 33 million in absolute terms. We're back on the level where we were in 2019. Having said that, it comes down as a margin because the top line has increased. What do we plan for the second half of the year?
We have established a program which is called Medartis Reconnect, which is, especially after Corona, important that we do get close contacts to our customers again on a social level, but also when presenting the new products, introducing the new features we have, and getting very close to those customers back. Yes, that will increase costs again in the second half of the year. This is not a guidance, maybe in the range of CHF 2 million-CHF 3 million for the second half of the year. That means that the 45% is probably at the lower level. I would more assume it to go back to 47%-50%. Don't take this as an absolute number. We're still in a COVID environment, nobody knows what's happening just one month afterwards as we speak.
This is just to give you an idea what we plan to do, and hopefully we can spend the money.
Yeah, hopefully. In the long term, it's obviously beneficial for your investment case. Maybe one quick follow-up afterwards. You mentioned how the market dynamics, for example, in the U.S. and in Germany are. That mean, at the moment, based on the rising incidents in the various countries like Germany, also like the U.S., you see no bigger impact yet on non-urgent or elective procedures? Nothing yet.
It depends. Nothing major. Honestly. Yes, absolutely. I think it's also what we see that the countries and the hospitals are dealing with the different waves in different matters. We went into the lockdown, in spring 2020, most of the countries went in a complete shutdown of elective surgeries and reserved the capacities for the treatment of Corona patients that at the end then didn't come. Now with the second, third, or whatever, fifth wave in the meantime, the hospitals are still trying to mitigate COVID patients, trauma, and elective surgeries. This is also why the overall caseload has appreciated again, and is in the range as we estimate, as Dirk has mentioned, at the 90% level.
Now with the Delta variant that came up and started to come up a few months ago, we have seen local shutdowns in Australia, for example, that has been open and has seen a very low caseload. All of a sudden, now Australia has started to slow down and shut down. Australia has closed elective procedures. They continue to do trauma. Other countries like Germany and also Switzerland are more pragmatic. We don't see a significant impact now for Delta, but it remains a Damocles sword basically for the second half of the year.
Okay. That's very interesting. Thank you very much.
You're welcome.
The next question comes from the telephone and it is from the line of Christoph Gretler with Credit Suisse. Please go ahead.
Thank you, operator. Good morning, Christoph, Dirk, Fabian.
Good morning, Christoph.
Good morning. I still have another three questions. Maybe starting off on IBRA. Could you maybe disclose how many followers do we have here? What percent of those now are in the U.S.?
I don't have transparency to members, the actual numbers, but I can follow up and let you know how many memberships that we have. In the U.S., of course, it's a new organization. We have established the IBRA chapter now in the U.S. in the course of the year, and now we are also gaining not only new members, but also onboarding KOLs to add to our faculty. I can follow up separately and let you know what the total numbers of members are.
Mm-hmm. Okay. Just to put, again, the 50% increase somewhat into perspective.
Interesting. Yeah.
I appreciate it. On headcount, it was, I think, 5% up. It's about 30 persons or 30, 35 kind of employees. Could you maybe disclose in what area those are, like R&D, manufacturing, sales or so on? I'm obviously particularly interested in the sales force.
Mm-hmm. In absolute numbers, 5% seems to be low. Do not forget, we have many changes. We have shifted also headcounts from one department to another department. Mainly what we have built is sales management, sales force on a global level. We have also added, and are still in the hiring of R&D engineers, also project managers, for our innovation projects. Also quality and regulatory. Quality and regulatory, as you can imagine, as the activities are ramping up or have ramped up now for the MDR audit now in September, that's a crucial function to be compliant and also maintain the compliance then on the MDR regulations.
Okay. The last topic maybe on M&A now. Somehow, I missed that in your presentation. Maybe could you give an update on your current pipeline of projects and how you see the environment right now for you?
We continue to look at, again, technologies, to add, to complement our lower extremities portfolio. We're looking at technologies which are in an adjacent segment, to our plates and screws. Mainly in the U.S., but we're open actually for any technologies that is scalable in the extremities. Technology that we can not only use in the lower extremity, but also scale it, for example, in the upper extremities. We still continue to evaluate technologies, but we are not in a position to comment any more specifics at this point in time.
Okay, let me step back. Thanks for answering.
Thank you.
The next question comes from the line of Daniel Jelovcan with Mirabaud. Please go ahead.
Yeah. Good morning, gentlemen as well.
Good morning.
Just a question on the U.K. and China. In China, I guess it's still relatively small within the Asia Pacific region. You mentioned that you won several hospital tenders. I guess the margin there is also pretty low. Is that a correct assumption? That's the first question to China. The second question in the U.K., I'm a bit puzzled by your comments. In the slide you say that U.K. growth is lower. In the press release, you say that it has recovered nicely. Is that because of the strong distributors or in general, if you can add a bit more color on the U.K. business. How important is it within Medartis? I guess it's not the biggest country, of course. Why is NHS still at the 70% caseload? I guess it's just because it's the NHS.
Yeah
The vaccination is good. The country should be good. It's just Yeah.
Yeah. Let me start with China. Yes, China is still on a very low level. We have won tenders, that's correct. We continue to win tenders. Once you win, and I think it's important to understand the sales process in China, and that's also a learning curve for us. Once we have won a tender, we start working with the distributor who supports and serves the hospital at the end. At the end, it's not a guaranteed volume that we can get once we have won a tender. Tender is basically a license to sell in the hospital for the portfolio that we have won the tender. Now we have equipped the distributors, mainly in the Shanghai area where we have won the first tenders. Those distributors are now starting to sell in the hospitals.
This is why it is a slow pickup even following a tender that we have won. We expect now to win more tenders as we go forward, and as a result of that, over time, that we also start the appreciation of the sales, but still on a low level for this year. Concerning the U.K., first of all, let me explain the regimen that NHS has put in place as a part of the COVID mitigation. The NHS has started to change the regimen in the OR. That means the patient, which is normally prepared outside of the OR, moved in for the surgery, and then moved out to get ready for the station. All that procedure remains now within the OR. That means that the turnaround and the OR time is extended, and the OR capacity is reduced.
As an example, a 45-minute surgery may easily now turn into an hour and a half and two hours until the next patient may come in. That reduces the capacity of NHS, extends the waiting list, especially for the elective surgeries. With that regimen has not changed, despite the fact that the pandemic, the coronavirus situation, is normalizing in the U.K., the regimen in the OR remains. Our comments are related to the strong decrease as a result of the NHS regimen, as a result of the cancellation of elective surgeries, and the lockdown also resulted in less trauma cases with the first lockdown in 2020. The U.K. remained on a much lower level compared to Germany, France, or Switzerland, and that regimen remains.
Now what we have seen is with the easement of the lockdown measures, with more activity and mobility, the trauma cases are coming back up. We're now estimating that the U.K. caseload, compared to pre-COVID, is around in the high mid-70%s, getting hopefully closer to the 80%. This is why our comment is we have seen now, especially in the second quarter. Yeah, we just want to apologize for the technical difficulties, but we can hear you now clear and loud. I would suggest we go back to the next question.
There are no more questions from the telephone. We'll now go to the webcast question. We have a question coming from Frans Jurgens with Juno Investment Partners. In your three business segments, how would you rate the completeness of the variety of your product offering, completeness of the portfolio, and how do you see the number of products offered grow in the coming one or two years?
Let me rate the completeness. We certainly are complete in the CMF portfolio. We are very competitive and complete in the upper extremities, mainly in the hand, wrist, and elbow. We have certainly gaps in the proximal humerus. The least complete is the lower extremities portfolio, where we now launched foot and ankle and osteotomy sets in the next weeks and months, which will give us a significant completeness in terms of the plates and screws for the lower extremities. Going forward, looking at technologies, we have certainly gaps in the lower extremities. That means technologies like small joint replacement, maybe intramedullary devices or total ankle replacements. Also, soft tissue management and staplers are gaps that we still have in our lower extremities portfolio.
In the hand and wrist, we will continue to add the KeriMedical portfolio, which is in the soft tissue, which is anchor systems and also small joint replacements. I think we will also continue to advance. We will come out with a new hand system, which will give us an improved instrumentation and also adding new plates for these particular fractures in the hand and in the wrist. We will also continue in the elbow and proximal humerus. There will be an overdesign of existing portfolio in combination with new technologies and with line extensions on our current plates and screw systems. As an innovation company, we will continue to launch new products, which also help us not only to extend the indication, but also give more options to the same surgeons to treat the same indication.
That's how we want to position Medartis as a specialist, as an innovative company in the hands and for the hand and lower extremity surgeons. Does that answer your question?
Thank you. There are no more questions from the webcast, and no questions from the phone. I'll now hand back over to you, Mr. Brönnimann, for any closing remarks.
Okay. Thank you very much. Thank you for the questions and your interest in Medartis. Before we terminate the webcast, I would like to draw your attention to our upcoming investor events, which are listed on page 30. You will also find the updated contact details on the same slide. Our full year results conference will be March 8th, 2022, and we hope we will be able to meet you again, hopefully then also in person. I am also pleased to be able to introduce to you a new and familiar face. After two years in the consumer industry, Fabian Hildbrand is back in the medical device industry, and we will be able to benefit from his relationships and experience.
At the same time, I would like to thank Patrick Christ, our former Head Corporate Services, for his valuable work, not only during the IPO, but also in the years after the IPO. Patrick will assume a new role within the organization, and I wish him for his future a lot of success and continued satisfaction in his new role. For now, I wish you all a pleasant day, a good rest of the week. Hope to see you soon. Goodbye. Thank you, everyone.