Good afternoon. This is the Chorus Call conference operator. Welcome, and thank you for joining the Medacta First Half 2026 Results Conference Call. As a reminder, all participants are in listen-only mode. After the presentation, there will be an opportunity to ask questions. At this time, I would like to turn the conference over to Mr. Francesco Siccardi, CEO of Medacta. Please go ahead, sir.
Thank you very much, and good afternoon or good morning. Welcome to Medacta H1 2026 Results Conference Call. The slides of today's presentation can be found on the Medacta investor relations website, along with the media release. I would like to remind all participants that the presentation includes forward-looking statements which are subject to risks and uncertainties. Listeners and readers are therefore encouraged to refer to the disclaimer on slide two of today's presentation. After those housekeeping remarks, I will now turn to slide number four and start with the highlights of today's publication. As already reported, Medacta grew almost 10% in constant currency in H1, reaching EUR 368 million in terms of revenue. We managed to report an adjusted EBITDA margin of 27.8% in constant currency or 26.5% reported, equivalent to adjusted EBITDA of EUR 97 million.
The net profit for the period reached EUR 42 million, or 11.4% of revenue, and we are confirming both our 2026 outlook and our midterm outlook. If we turn to the same page, this is just to remind everybody how Medacta has been able to continue to deliver a significantly above-market growth. Our success relies on differentiating innovation that are really improving patient outcome, and at the same time, they are sustainable under an ecosystem point of view. Those innovations are introduced in the market with a very strong focus on medical education. Training of surgeons all over the world that are able to acquire the knowledge necessary to use these new techniques, new technologies, new products through our medical education.
Then, of course, we needed to constantly expand our sales force globally across all our business lines in order to reach as many customers as possible on a global scale. If we go to slide number six, we have already reported our geo mix sales. We have been able to grow double digits across three out of four regions. In EMEA at 10%, in APAC at 13.1%, in Latin America, 16.4%, while North America, differently from the other periods, grew around 7%. This changed a bit our geo mix, and as you will see, this will have an impact on some of our margins. If we go to slide number seven, we can see the very solid growth across all the portfolio, starting from our hip, that grew around 8%, knees almost 11%, extremities almost 16%, and spine 4.5%.
The product mix, as well, did change a little bit, and as we will hear later, this has an impact as well, mainly on the gross profit. If we go a little bit into the details, our performance in hip continues to be significantly above market, probably around 2x . We continue to focus on our minimally invasive solutions, and we have introduced, in the first half of the year, our enabling technology, NextAR Hip, in the U.S. and Australia, which is in limited market release. While we are in a full market release for our new triple-tapered stem, Infinity, which is starting to gain momentum in the U.S. and more recently in Japan. On slide number nine, we can follow our consistent expansion on the knee portfolio, almost 11% in H1 2026.
This is driven by our focus on Kinematic Alignment and the unique implant we have in the market specifically designed for Kinematic Alignment, the GMK SpheriKA, which is clearly growth and becoming our most important knee product in a relatively short period of time. Here as well, we are more than 2x faster than the market in this segment. In spine, we did grow single digit, 4.5%. We have redesigned a bit our strategy, mainly in the U.S. market, focusing much more on enabling technology, which is now representing around 50% of our spine revenues in the U.S., meaning 50% of our spine products are implanted with the support of enabling technology, and we are going more direct and more with exclusive agents in that segment.
We continue to have a very strong performance in EMEA as well in spine, followed by both Latin America and Asia Pacific, and this remains well above market growth in the first half of 2026. We now move to the extremity segments, almost 16% year-over-year growth for H1. We have introduced here as well additional technology elements, together with our NextAR Shoulder application. We have introduced the revision shoulder arthroplasty, first in the U.S., and now it is going to expand outside of the U.S. And this technology is supported by a new AI-based MyShoulder Planner, which helps surgeons to carefully plan their products, their procedures, and hopefully deliver a better care for their patients.
On the sports med side, which is the other element together with the shoulder arthroplasty part of the extremity segment of Medacta, we launched the Secure-Fix, which is an all-inside meniscal repair system for knee sports medicine, which is very well appreciated by our customers and is a clear driver for our knee sports med portfolio. Here as well, we have a growth rate which is more than 2x the market year-over-year. I would now like to ask our CFO, Corrado Farsetta, to go over line by line of our P&L and comments on the marginalities.
Thank you, Francesco, and good afternoon, everyone. Let me now walk you through our financial performance in the first semester. Let's start with the gross profit slide. In H1, the gross profit was EUR 240 million, increasing from EUR 233 million of the previous year. On sales, the GP margin in the first semester was 65.2% compared to 68.3% of the previous year, representing a reduction of about 3%. This reduction is attributable to three main factors. The first one is an adverse effects impact of 1.3%. The second one is a price erosion of about 0.5%. Those two, coming from the market, totaling 1.8% of this 3% reduction are, as I said, taken from that. There is a third element which is strictly related to the top-line performance in terms of geographic mix and product mix, as just discussed by Francesco, which is affecting our GP of another 1.3%.
This is primarily attributable, as we have seen, to lower sales in the U.S. market, to a higher top line coming from our new business, sports medicine, and also given a lower than expected top line, also to a higher D&A ratio coming primarily from our instruments that are in the market. This is important because those two, the two elements coming from the market are taken. The second one are strictly related to our top line and performance. Moving to the EBITDA margin slide. What you see here is, as always, there are two lines. The yellow line is representing the evolution of our EBITDA margin in reported currency, and the red line is showing the EBITDA margin at constant currency.
You see that net from the 1.3% FX effect, there is a 0.9% reduction from the previous semester, which is primarily coming from the GP erosion that we have just discussed, only partially offset by a limited operating leverage due to volumes and also the ability of the company to keep our costs under control. Moving to the net profit slide. The net profit in the first semester amounted to about EUR 42 million, compared to EUR 60 million of the previous year. In order to comment comparable numbers, we should read last year net profit as EUR 46 million, net from the one-off positive purchase gain, coming from the acquisition of the company last year. So EUR 46 million comparing to EUR 49 million, which is coming from EUR 42 million reported plus about EUR 7 million of negative FX effect.
The net adjusted and comparable is EUR 49 million versus EUR 46 million. Moving to the slide of the operating cash flow. The operating cash flow in this semester was about EUR 56 million, down from EUR 73 million of the previous year, and this is representing, of course, the performance just discussed of our EBITDA, but also a higher net working capital needs that were basically needed to replenish the implant safety inventory after the super strong performance of last year, and the preparation of the necessary inventory level to enter the Indian market in the second half of the year. We will discuss very soon in the next slide the investing activities, EUR 74 million, and this is resulted into a negative free cash flow of EUR 18.6 million. Moving to slide 21. Sorry, CapEx, not 17. Yes. This is the usual pie of our CapEx.
As always, instruments, EUR 42 million, represent the biggest chunk of our investment, but it is important to notice that our tangible now are EUR 22 million, and this is a number which is reflecting the big amount of investments that we have to do in order to expand our production capacity to produce our office and facilities to accommodate, let us say, the future production machines and employees that we have in our pipeline. The rest are more or less in line with the previous year, R&D, EUR 8 million and other, EUR 2 million, for a total of EUR 74 million. Moving to the CapEx for growth, instruments, plus other intangibles. This chart summarizes the evolution of CapEx on sales over the last three semesters. Three lines. The yellow line is representing CapEx for other tangible that are primarily land, buildings, and production capacity.
The light yellow line is representing instruments on sales, and the blue line on top is the total of the two. As you see, the percentage on sales of our instruments is pretty stable, around 10.5%-11.9%. This fluctuation is basically driven by two main factors. The first one is the acceleration of top line, and the second one is also the planning and delivery phase in our business, which basically needs to place orders ahead of time in the order of 9-12 months. It is feasible to adjust, but is not necessarily possible to do it in the first semester or in the same year. This is explaining these fluctuations. The other one is, as we said, representing expansion in our land and buildings and the expansion of production capacity.
So 17.5% is, just to be clear, without the R&D investment that we have seen in the previous map. Moving to the last slide of my presentation. The leverage net debt on adjusted EBITDA was 1.2x , very low, compared to 0.9x of the full year, last year. I think that concludes my part of the presentation, and I will now hand over to Francesco, who will take you through the outlook session and some final remarks. Thank you.
Thank you, Corrado. Yes, so we mentioned, at the beginning, Medacta is confirming its outlook for 2026 with revenue growth in the range of 10%-14%, and an expansion of the adjusted EBITDA margin of around 50 basis points versus prior year in constant currency. At the same time, we confirm our midterm outlook, which brings our revenue compound annual growth rate, in constant currency, between 12% and 15%, with a gradual improvement of the adjusted EBITDA compared, versus 2025, again, in constant currency and subject to unforeseen events. Medacta remains not impacted by the U.S. tariffs, and we will continue to monitor the development. Which are the key messages? The key messages is that Medacta is able to continue to develop and to grow on an above market rate for H1 2026.
This is the result of our differentiating innovation, medical education, and constant expansion of our sales reps and teams. We have been able to continue to deliver a high adjusted EBITDA margin of approximately 28% in constant currency. An accelerating U.S. development and expansion as we have announced, the acquisition of a first, large piece of land in Tennessee where we are going to develop our new U.S. headquarters and manufacturing activity for the U.S. market. Our aim continue to be to outgrow the market in a significant way for the years to come. Thank you very much for your attention, and once again, thanks to all our employees, clients, suppliers, and partners worldwide for the excellent period. Thank you very much.
This is the Chorus Call conference operator. We will now begin the question-and-answer session. Anyone who wishes to ask a question may press star and one on their touch-tone telephone. To remove yourself from the question queue, please press star and two. Please pick up the receiver when asking questions. Anyone who has a question may press star and one at this time. The first question is from Sam England with Berenberg. Please go ahead.
Hi, guys. Thanks for taking the questions. Could you just give us a bit of a sense of what you've seen in the U.S. joint market so far in Q3? I think one of your competitors commented at a conference yesterday that the markets remain quite soft this quarter, so I wondered if that's what you're seeing as well, and to what extent you think you can offset any market weakness with innovation and share gains in the second half. Secondly, your EBITDA margin now implies a bit of a step up in margins in the second half of this year.
Can you just walk through the drivers that you see to get you to hit that level in the second half, and do you expect any of the gross margin pressures that you called out to ease as we move into the second half so you can hit that guidance? Thanks.
Yeah. Thank you, Sam. In the U.S. we have seen, of course, H1 market. Everybody reported the numbers, which is quite a bit lower than the previous years in terms of market growth. We have seen probably a 3% U.S. market growth versus an expected 5%, 5.5%. Q3, we have started to see, at least on our end, some of the Medacta specific factors to be reduced, especially the spine dilution in the U.S. spine segment, which is heading in the right direction. We have seen a good re-acceleration on the hip side, but this was very much linked to our introduction of this triple-tapered stem. We remain very confident on our ability to accelerate quite a bit in the U.S., specifically as well, which was the biggest gap we had and the biggest surprise we had in H1.
It is fair to remind maybe everybody that last year, Medacta U.S.A. did an exceptionally strong H1. We have a different comparable in H2, both in the U.S. and at company level. Definitely we see a better chance to accelerate in the second half, including in the U.S., and that is true outside of the U.S. as well. On the EBITDA margin, I think it is pretty much linked as well to what we just discussed. We were aiming, in terms of growth, a bit higher. We did generate cost in the first half of the year in order to achieve a higher growth rate in terms of people, structure, et cetera. This did not fully materialize in certain region in particular, and we mentioned the U.S. growing single digit, which is a very big surprise for us.
Of course, we have quite a bit of leverages to adjust our cost increase. We did reduce our cost increase to the level of revenues we are seeing at the moment. We are confident that if revenues develop in the way we now see and expect to continue, we are going to be able to basically hit the targets we have in mind. We had a little bit, again, of external factors headwinds, in particular, some fuel surcharge, so hitting our variable transportation cost. This is something we cannot control, and I think the fuel this morning is again at some record heights, so this will not help. Let us say outside of external factors, basically the contribution coming from a strong top-line acceleration, which is what we expect should help us to increase leverage on our cost and therefore expand our marginality.
Great. Thanks.
Thank you.
The next question comes from Michelle Büchler with ZKB. Please go ahead.
Hello, and thank you for taking my question. You noted the notable softening within Medacta existing customers in the U.S. and the general market slowdown. Could you maybe comment on that a bit more? How much was coming from existing customers, and how much was coming from new customers?
Yeah. This was quite an interesting dynamic because we have seen a very successful and continued pickup of new customers. In terms of number of customers, we are almost as strong as the previous year, whereas we discussed before, we had a record year, which means our offering, our products, our ability to attract new customers and to hire new salespeople remains pretty much intact. While we have seen, for different reason, mainly base attrition, so existing customers either doing less than the previous year, moving more business from hospital to ambulatory surgery centers, and this is a more profitable business for them. Therefore, they are happy with potentially a lower volume. Maybe we are present working with them in an ASC and not in the hospital. What else?
We've seen some, of course, reduction on the spine side, which was, again, more a Medacta specific thing linked to our decision to refocus on more profitable spine business and not growing at any cost, refocusing mainly on our specialty products, as we said, technologies, and sales through technology. That is a specific area for the spine.
Okay. Thank you. If I may, follow-up questions. You mentioned in the first half strikes in Europe. Do you still see that for the second half, or is that over?
Yeah. Unfortunately, it's not over. We're talking now specifically about Spain, which is one of our fastest-growing market in Europe, which is still growing despite the fact that the Spanish market in the first half is almost down 20% due to those strikes in the public market. They have announced that those strikes will potentially continue, but it's really unknown. There are some regions which are not taking part of those strikes anymore. As you know, Spain is a federal state, so the regions are very autonomous. We will have to see. It is very challenging for us to forecast Spain. I just actually had a meeting this morning with our Spain general manager, and that's a little bit an unknown situation. Medacta is doing very well despite this very strong headwind and would've been a record year in Spain for us without.
Still, Spain is affected by those strikes, while we did not see any other strike outside of Spain, which was the case in H1 with France, for example. Outside of Spain is more normal.
Perfect. Thank you. Maybe last question from my side. Do you have the approval for the first product in India already?
We did, actually. A few weeks ago, we just got approval for our knees, which is the most strategic product and the most important in terms of market potential in India. We would start to ship finally those goods that have been sitting on our shelf because every week could have been the week of a green light. We should start to see some action already in September.
Perfect. Thank you, Francesco.
Thank you.
The next question comes from Graham Doyle with UBS. Please go ahead.
Afternoon, guys. Thanks for taking the questions. Just two, please. One for Francesco, one for Corrado. Francesco, on the top line, when I look at the midpoint of the guidance, I think it is something like 14% growth in the second half, which is about four percentage points more than H1, which is when I look at my math. In H2, you have an extra trading day. It seems like U.S. demand probably gets a little bit better as insurance normalizes and you get your deductibles. Presumably, there is some pent-up European demand from strikes, and then you have the improving spine piece as well. Is it still reasonable to think of the midpoint or better is actually still possible for the full year, because of these tailwinds, you could do something like a 14% in the second half? Corrado, just a quick one on depreciation.
There is nothing happening. You are not accelerating depreciation on instruments or anything. It is just a case of there is a greater share of instruments out there. Just to double-check how that calculation is. Thank you.
Thank you, Graham. Concerning the top line, there are all the elements you mentioned plus, of course, India. Q4 is only Q4, and that is 100% growth. There are a few other elements. You mentioned spine. There are some price cuts that came into force, for example, in France, which is our most important market in September last year. By September, this price reduction would be not there anymore. It was around 3% in certain products, so it is quite significant. There are still, of course, some variables, like we mentioned Spain and the strike, the spine re-accelerating in the U.S. Is it easy to achieve the mid-portion of the guidance? I would say it is not. But is it possible?
I would say it is possible, but probably is more likely to be slightly below the midline given the fact that we have four months to go. But we remain positive. We always are very ambitious at Medacta. I think to grow even 10%-12% in the current environment is phenomenal, and would probably be close to 3x the market, which is remarkable. But we always target very high numbers, and I always prefer to be slightly disappointed on a very good performance than being happy because we did 6%. That is a little bit on the sales. I hope I addressed your question, otherwise, just let me know, then I ask Corrado to address the other one.
Yes. Hi, Graham. So yes, I confirm we didn't change any accounting treatment of our CapEx. What we have seen the first semester is a pure arithmetical result coming from lower than expected top line, and the same amount of instruments and D&A that are still in the market regardless of the level of top line reached in a certain semester. Just a pure arithmetical calculation, nothing else.
But if I can comment on that, Graham, of course, very often in business, revenues fix a lot of problems. As we can control our new instrument sets that we put in the market, we did put in the market a higher number of instruments based on higher expectation. We can pull back on some incremental instruments in the second half of the year so that we can potentially improve the ratio of CapEx to sales, and therefore you would see a GP improvement in potentially second half, provided, of course, the revenues reach the levels we expect, which is quite likely. But those are all effects linked to an unexpected softening. So you put resources, networking capital, instruments, people, then you're slightly behind. You see this phenomenon in H1. You try to adjust it immediately in H2.
Most of it, you can manage it, some of it you can't, and then you have a little deterioration. But H1 was probably our worst semester in the last five years after COVID. And we were comparing it with the best semester of Medacta history, which was probably H1 2025.
Yeah. That is super clear. Thanks a lot, guys. Maybe a tricky follow-up, which is if you look at some of your big peers like Johnson & Johnson, whether it is their spine or Smith & Nephew kind of reevaluation board, there is clearly a lot of disruption which you would have thought would be quite good for you guys in terms of market share gains and being able to invest and kind of work closer with surgeons. Is there any logic in if an interesting product or facility was to come up as part of that disruption in terms of M&A kind of bolt-on size, does that make sense, or is organic still the best way of thinking about product development or filling in gaps for you guys?
I would say that every time I look at price points paid for M&A, for technology, for products, the return on invested capital when we do it internally is incredibly better.
Okay.
You have seen probably, and all this just announced, the acquisition of Essential Spine for EUR 150+ million . We developed in-house our own technology. We are going to introduce our own robotic pretty soon, and we spent a fraction of that. You see it in our R&D. It did not explode.
Yeah.
That is, I think, always better. Then if there are opportunities, as you have seen with the sports medicine, with the smaller lines, we always look at it. And there are, as you said, from time to time, opportunities, but we tend to develop in-house our own innovative products rather than buy them. That has always been the case and most likely will continue to be the vast majority of our growth strategy.
Perfect. Thank you so much for that. That is really helpful, and it makes total sense.
Thank you very much.
The next question comes from Ed Hall with Stifel. Please go ahead.
Good afternoon. Thanks for taking my questions. The first one would be back on the U.S. and the acceleration that you guys have talked about. So we have seen the last three semesters of relatively flat reported numbers. And I appreciate that you have outlined the headwinds over the last 12 months. So if we think about we are looking at H2, and you have talked about spine getting better and the hip re-acceleration from the taper stem. What else should we expect from the U.S. market? Is it too far to say that we would see a lower attrition rate on the base surgeons in H2? Am I jumping to conclusions there? That would be my first question. Then just second question for Corrado, I guess on the inventory in the rebuild that we have seen there.
How much of this would be for India versus repairing, let's say, safety stocks from the exceptional growth you guys saw in 2025? Thanks.
Let me try to address the U.S. We mentioned a good re-acceleration on the hip side. The knee was already growing pretty well, I would say. We have introduced a new shoulder as well, which we see a good acceleration. It's called the Monoblock Medacta stem, which address an important segment of the market, which is mainly represented by the market leader, which is Stryker shoulder or the former Tornier. That is going to help us a lot. Then you mentioned correctly, the spine, which should reduce the dilution on the overall growth rate of Medacta U.S.A. Then, is the base attrition going to reduce in a significant way? We believe so.
We have analyzed really customer- by- customer, what's going on, and we believe that this phenomenon should significantly reduce and at the same time, we have seen, as we said, a good pipeline of new customers picking up, and that's where the confidence in the second half acceleration of the U.S. market is coming from. The first two months, smaller months, because those are the summer months, are confirming those trends. We remain cautious because those are things out of our hands, but we are quite confident on a good recovery second half of the U.S. Corrado, I'll let you comment on the net working capital.
Sure. Let's say net working capital, I would say that the biggest chunk of our change in inventory is driven by the growth of the top line. Today, we have to serve new customers, and the biggest chunk of this change in inventory per semester is for those new customers in the market. There is a portion of this change in inventory, which is, as we say, needed to cover some tensions on our inventory that we have observed after the super strong growth of the last year. The smallest portion of this change in inventory, EUR 25 million, the smallest portion of it is, say, related to the new market of India. Of course, we will keep this new inventory proportionate to the top line in this semester. I would say that this is the very small part of this change in inventory.
Just an additional comment on that. You are comparing, if you want, a rebuilding of net working capital with a net working capital or a stock level of last year, which was really aggressively deployed because of the very high demand. I think the first semester last year, if I remember well, APAC was above 20%, around 20% in growth. This was quite above our plans. So the stock level you see at the end of H1 2025 was not a physiological level, was already impacted by an above and higher than expected growth. This was the case as well at the end of the year, which is where we were starting to rebuild our stock levels in 2026.
Very clear. Thanks. Maybe just to follow up on India, I appreciate this, I think at the full year call at the start of the year, you mentioned pricing was comparable to Europe with roughly 100 million patients. Is this the sort of market size we should think of, and how should we get to a realistic number for a midterm?
What is very interesting about India is not only the current market of 100 million, but its growth rate. I believe reports talk about 15%+ growth rate of the Indian market able to absorb those kind of procedures. So every year we should talk about this 100 million, because when you have this growth rate, in three, four years, you are close to 200 million and so on and so forth. That is what is appealing about India. They are absorbing quite a lot of innovative products. They are very keen in technologies as well. The pricing, as you said, it's in a range that we feel comfortable to play with. It's a European price, it's a low European price, but it's a European price.
Very clear. Thank you very much, and congrats again.
Thank you, Ed. Thanks a lot.
The next question comes from Sandra Dietschy with Octavian. Please go ahead.
Yes. Good afternoon, and thank you for taking my questions. Last one on the spine margin. The growth in that segment has, as you mentioned, been somewhat soft due to the transition to direct sales force. You also indicated that profitability has been protected. Did also the dilution to the group margin continue to decrease, or where is the spine profitability today relative to the rest of your business? Maybe more importantly, what do you need to achieve in spine so that spine is no longer dilutive to the group margin? Is that anytime soon, or what should we expect there?
Yeah. Hi, Sandra, first of all. It's too long we didn't see each other. Spine, it's quite an interesting beast. First of all, under a GP point of view, it is actually higher than joint. If we talk about the margin starting from the top, the gross profit margin of spine is better than most of our product lines. Then you go down at EBITDA level, and today it is improving. It's not yet at the level of the core business of Medacta hip and knee, and this was mainly driven by very high commission paid in the U.S., which was driving our profitability of that line in the U.S. to negative numbers. Overall, spine is already quite a bit positive, so it's positively contributing to the overall profitability of Medacta.
It is well below the hip and knee EBITDA, mainly driven by volume. I would say it is almost one order of magnitude smaller than our hip and knee portfolio. What needs to happen, we need to change our business model in the U.S. in order for scale to bring marginality, and this is what we have been doing. Then in general overall, continue to scale it up in order for this business to leverage some of the fixed cost and increase marginality. So I would say it is around a third of the marginality we have on the core joint business at the moment. We are already quite happy because only a few years ago, it was barely at breakeven, and if you go two years back, we were losing money. This is trending in the right direction.
The next business line we need to turn around in terms of profitability is sports medicine, which is starting, of course, from a negative. We are investing highly, sales force expansion, et cetera. Those are the two areas we need to grow in order to reduce the dilution at the EBITDA level. That is as well why we believe in our midterm guidance of potentially further expanding our EBITDA over time.
Great. Thank you. That was super helpful. Maybe if I may, a quick follow-up on the profitability. The U.S. impact, as you mentioned, the lower contribution has a negative impact on the gross margin. Can you confirm that on EBITDA level, there is no meaningful difference between the U.S. and the rest of your portfolio? Did I understand it correctly, you would expect that the regional mix will come more supportive in the second half?
Yes, that is correct. So the U.S. pricing is higher than the European pricing. So a geo mix change will impact the GP. It has a much lower impact at EBITDA level because the U.S. market carries quite a lot of additional cost from distribution costs, marketing costs, insurance costs, and so on and so forth. So EBITDA-wise, the profitability of the U.S. market and some of the European markets are similar, very comparable.
Thank you.
Thank you very much, Sandra.
For any further questions, please press Star and One on your telephone. Gentlemen, there are no more questions registered at this time. Excuse me, there is one quick last question from Graham Doyle with UBS. Please go ahead.
Hi. Sorry, thanks for taking the follow-up, but I figured we had a bit more time. One of the comments you made, Francesco, is just that H1 was obviously a bit more challenging on the top line than you had anticipated, and obviously you have talked about the U.S. Do you have any idea what is actually happening in the U.S. as to why that market is a little bit slower?
I would say there are two factors. Number one is it's simply happening what I was expecting since a few years, that the market is going back to a normal growth rate, a pre-COVID growth rate. If you look at the MedTech reports pre-COVID, I think the joint replacement market was in the range of 2.5%, 3%, while we were used now after COVID, 2021, 2022, 2023, at rates of around 5%, 5.5%, which were quite a bit higher. That was abnormal and, if you want, still a recovery of the big gap generated by COVID, and then you remember the shortages of nurses, et cetera. It took quite a bit longer than expected to recover all the patients missing during 2020, 2021. Then, of course, it would normalize. There's no reason why it shouldn't go back to pre-COVID level, and that is one factor.
This is general, I would say. The second one is more Medacta specific. We have, as you know, quite a lot of customers in the ASC segment. I always mention that the surgeons that are working in an ASC are working as well in a hospital. Very often, we work with them, first of all, in an ASC, and then we have to fight with them to go through the hospital purchasing department, and it takes quite a bit of time. It did happen in the first half of the year that quite a significant number of surgeons that was working in an ASC and in a hospital, and we were only serving them in an ASC and only partially in the hospital, they basically dropped their hospital volume. The surgeons picking up those hospital volumes were not Medacta customers, so we have seen some attrition.
This is one of the phenomenon we studied in order to understand why our customer base volume was going down. This has nothing to do with the general market slowdown, and once this phenomenon is finished, that's a temporary situation. We were helping the transition of many customers from hospital to ASC, and when they drop their hospital volume, we lose volume. That is something we have seen unexpectedly in H1. They can drop their hospital volume because they make significantly more money in an ASC setting. Even by doing 80% of the volume they were doing before, they probably make more than what they were doing before in working in a hospital, significantly more. That was an interesting phenomenon we focused on and we did understand.
Awesome. Thank you so much. That's really, really helpful.
Thank you very much. Thank you for the last-minute question.
This was the last question. Back to you for any closing remarks you may have.
No, I would like to thank as well, as always, everybody for participating in this call. And, once again, thank to all our employees, clients, suppliers, and partners worldwide that help us to deliver those performances. So thank you very much, and speak to you all soon.
Ladies and gentlemen, thank you for joining. The conference is now over. You may disconnect your telephones.