Okay, good morning again. My name is Rick Wise. I'd like t o welcome CONMED Corporation. To my left, Curt Hartman, President and Chief Executive Officer. And on the end, Nate Miersma, VP and General Manager of US Orthopedics. Thank you both for being here. And as always, I mean, this is a special occasion for me. Curt, you know, I can't believe, you know, you made an announcement recently that a major change is happening in your, it's not retirement. What word should I use here?
I think it's retirement.
Okay, well, go ahead.
Yeah, I'm a believer in three letters, Q-T-R, Quality Time Remaining.
Oh, great.
And I've got a little bit of time remaining, and I'm going to make it high quality with my family. So yeah, it's retirement.
I'm jealous. I started to say, take me with you, but I think maybe your family would be too much for your family, but I said this on the third quarter call. I'm going to say it again. In the early 1970s, when I started as a med tech analyst, I'm sorry, I meant mid-1990s when I first met Curt. It was my first visit to Stryker. Curt showed me around the campus.
You were a GM at one of the divisions, I believe, at the time and I still remember that visit and watching your career evolve to Chief Financial Officer and to the CEO role and now to CONMED. It's just been great knowing you. I have immense respect and admiration for everything you've done, and particularly here at CONMED. I mean, you've transformed this company. We'll get into it. But with all that said out of the way, tell me about 2025 projections. Tell me about the, no, I'm sorry. Okay, enough joking.
You know Todd's listening.
Yes, exactly. He's not here, though, but you know, I'm sure these last couple of years, how all that stuff said, and I really mean from the bottom of my heart everything I said about the things you've done, the last couple of years have been more challenging, I'm sure, than you would have liked and hoped, so let's just start with the big picture. Some of the, I just wanted a high level you to comment, Curt, on some of the key growth drivers, and especially as we, yeah, the setup for next year and beyond, long beyond.
Talk about the portfolio, you know, and both the growth drivers that, what are the, how do you want us to think about the major growth drivers for the next two, four, five years, wherever you want to say, and which ones do you think maybe aren't going to make the journey as optimally? I'll let you set up the question. You see what I'm asking.
No, I understand the essence of the question. And thank you for the comments. I definitely remember the tour. I thought I had arrived. I got to tour some people from Wall Street. Little did I know I was there a lot of times. But I definitely remember the tour, and I remember your associate as well at the time. But to the question of CONMED, the setup for CONMED is along two lines. We break it out publicly as General Surgery and Orthopedics. Within Orthopedics, we have a foot and ankle franchise, and we have a sports medicine franchise. Nate runs the U.S. sports medicine franchise, which also includes all of the R&D for the global sales channel. And that is where the recent 2022 acquisition, BioBrace, resides under Nate's leadership. On the general surgery side, we have two businesses.
We have an Advanced Surgical, think of anything that happens in the abdomen, minimally invasively. And then we have an Advanced Endoscopic Technology business, which is more in the therapeutic GI space. And I think people go, what's common about all that? Number one, they're all driven by a minimally invasive approach, including more and more daily in the foot and ankle market. So minimally invasive approach is really behind what CONMED does, number one. Number two, they're both growth markets. If you look at foot and ankle, we view it as a high single digit market. You look at sports medicine, we view that as a mid to high single digit market. You look at general surgery in our categories, we view that as a kind of 3%-5% growth market. So all healthy, large, robust growth markets.
Specific to the CONMED setup and what you're talking to, 2016, 2019, 2020, 2022, four acquisitions, AirSeal, large platform, Buffalo Filter, smoke evacuation, large platform. And in 2022, we got into foot and ankle and BioBrace. Both we believe will be large platforms in our future. Common theme across all those, great growth and very accretive to the overall gross margin profile. Now, I think one of the disconnects, that's not all that CONMED is.
Right.
That's, you know, do your homework on the last time we disclosed it. That's 25%-30% of our revenue. There's another 70%. It's not just sitting idly by. Nate's team, our other global R&D teams are constantly working to do the D part of that, develop the next generation, make it more efficient for customers, work on gross margin profile. So the portfolio is not sitting static. We are very focused on those four, but we're always looking to advance the overall portfolio and keep the engine fresh.
And that's just kind of med tech 101. You have to do that in med tech because your customers are constantly moving forward. They're constantly looking for new solutions, more efficient ways to do things. They're challenged today more than ever before by reimbursement landscape. So they're working with companies on how do you price this appropriately so we can get the right reimbursement, so there's a lot that goes into this industry that's underneath the cover, so to speak, and CONMED is very aggressively working on all that.
That's great. Let's start, let's work through some of the setbacks and where we are. A bunch of these things really, truly out of your control. Slow to recover orthopedic supply issues, suppliers going bankrupt, worse than anticipated effects, the hurricane. Can you talk us through some of these things and where we are and sort of getting that in the rear window, Curt?
Yeah, I think there's been lots of material written, not just in med tech, but globally, about the rebound of global economies in 2022 and what that did in financial stimulus. And I think everybody in med tech felt some of that back order as demand surged back. I think the large strategics probably got through it a little bit faster than we have gotten through it. In Q3 of 2023, we said we had some back order challenges. We had product from MTF that was on back order. That was an industry-wide reagent issue. We remediated that by the fourth quarter of last year. It's what we said would happen. It's what they told us would happen. We had some back order on our foot and ankle business.
I think that was us overwhelming that supply chain, which was, remember, that was a private small scale startup, and we brought global distribution to that. So I think we overwhelmed that supply chain, not as sophisticated as systems. And then Nate's business had back order on some of the key disposables. And again, a lot of those are suppliers being over capacity, excessive demand, kind of with that economy snapback. And we thought we would get through all of that coming into Q1, Q2 of this year.
And in Q2, we said, listen, it's going to take us a little longer on specifically the US Orthopedics business that Nate runs. We're clear on foot and ankle. We're clear on MTF. It's Nate's business, kind of these core disposables where we're still a little bit hand to mouth. We've made progress, and our goal is to have that remediated by the end of the year. Those are, you know, those are either external or internal inflicted wounds, and we own those, and we just got to work through those.
So, I want to sort of tie a bow on this. So the orthopedic supply chain challenges, I mean, largely done. So as we head into 2025, you're good to go.
That's our stated goal. That's what we said on the last call that we thought as we exited the year. I mean, you never get to perfect. So there may be things that linger into Q1, but our goal is to have our sales teams globally back on offense.
Okay. And the, I think it's Biorez, right?
Biorez was the name of the company. The product is BioBrace. So it's now BioBrace underneath.
Where are we there?
Oh, it's in great shape. There's no supply challenges.
So that's over.
There never was a supply challenge.
But I'm saying for the R&D year, I thought it was. Forget, maybe I'm just misremembering something. And the hurricane impacts on your facility and operators? Everything back up and running?
We are back up. We have, for those who don't know, we have a facility in Largo, Florida, which really dates to the infancy of the sports medicine world. If you're a sports medicine, we had dinner with a doctor last night who remembers Concept, our facilities on Concept Boulevard. So we've been in this industry for a long time. That facility is in Largo, Florida, so kind of central to the peninsula, but very close to the Gulf side where the hurricanes came through, and we have to shut down when the county tells us we shut down. We have a great facility site lead preparedness plan. Facility came through in very good shape, but it was down. First hurricane, it was down for a couple of days. Second hurricane, it was down for four days. You know, no power in the quadrant.
We have onsite generators, but it doesn't matter because people can't get there. The county is not allowing people on the roads, so we were down, call it five, six days, which impacts production, which impacts that recovery. We think we're going to make that up in the quarter. That's certainly the plan we're working towards. Obviously, we still have employees who live in outlying areas that were more directly impacted by the hurricane, and we do what we can to support them both in their personal, both in their professional life, but also in their personal life, and our facility is usually one of the facilities that opens up the soonest. We have electricity, food, services, showers that we open up for the local community. It's just part of where we reside, so to speak.
Yeah. But again, largely you would hope behind you as you enter next year.
Oh, definitely, definitely hope behind, yeah. I mean, we just got to make up those lost production days.
Yeah. Let me turn to AirSeal if I could. Obviously, it's been topic number one, and it's great that we're talking after the third quarter. Gosh, I didn't see much visible impact. Now, more cynically, I cover Intuitive and, you know, they haven't launched it dramatically and widely either. So help us understand where we are. There's been little visible impact. And I was thinking, I would ask it this way, taking two extremes. How am I supposed to think about this over the next couple of years? One, you never see a negative impact because you, CONMED, can pivot the organization, pivot to new customers, prioritize international, whatever the pivots might be or two, as Intuitive inevitably grows and launches and expands in the years ahead, we're going to see there will be more headwind. Which way do we think about it? Help us understand.
I think what Todd and I have been trying to tell people is you need to do the math. And we've seen two models now, I think it's two. And if you look five years out in those models, there's still more Xi robots in the marketplace than there are dV5s. Those are people's models. It's not a CONMED model. I'm not going to comment on how we model it.
There have to be, by the way. It's just no possible way.
Right, exactly. And we have a very big footprint with Xi. And what Intuitive launched was a next generation robot with a standard insufflator, which is what we've been competing against from day one of our investment in ownership of SurgiQuest. And what marketplace data experience is showing us is in those deep gut procedures, those longer procedures, there's only one device that can keep stable pneumoperitoneum, keep the visualization within the abdomen open, and keep that work volume and case efficiency where it needs to be. And when surgeons go through their initiation on the new robot and have those cases, and they get to the end of that period, the request for AirSeal comes back strong to what we've historically seen. Will that be the case forever? I don't know. As you said, it's early in the marketplace. We know what we have.
We know the intellectual property. We know the case volumes. And so we feel very strong, as we have from day one, about our position and continued position in the marketplace. And then you touched on broader laparoscopic procedures. That is a wide open market, and we continue to run after that. We had zero of that market when we acquired the technology in 2016. A year ago, we said 40% of our business is in that market. So we've gone from zero to 40%. Do the math on that, CAGR.
It's pretty powerful. And most of that has been outside the U.S. because there's a smaller robotic footprint. But put it all together, our future with AirSeal is very positive. Is it going to be a specific number? Like every business, it moves up and down, but I feel like it continues to be a growth driver for us and a big part, big important part of our franchise for Advanced Surgical business. But again, we're not standing still. There's other technologies we're working on. There's other products coming into the portfolio. So it's super important.
AirSeal related, Curt, are you saying, or no, just other products?
Just other.
Yeah, right. We'll come back to that. Just one last question on this, or observation first. I talked to actually early dV5 adopter last week, and he said he really liked the convenience of having the, you know, the insufflator inside. But he thinks AirSeal is better. And for certain cases, he's already discriminating between which ones and where he uses it. I didn't hear specifically which one, but sort of validated, I think, the things, your observations.
Yeah, I think that's exactly right. And it's the cases where you're creating a large volume. So I think OB-GYN procedures, hysterectomies. It's a case where there's longer periods of time. Because the longer the patient is under, you want to keep that working volume open and available. And AirSeal is the best technology to do that. You don't want to have delays intraoperatively because the insufflation is cavitating up and down. So things like that are really important to the clinical field. And then you layer all that against all the clinical data we have in the marketplace. Length of stay, length of recovery, length of surgery, all reductions when you use AirSeal. Just makes sense.
Yeah. With Nate here, I felt like I should ask about the US Orthopedic business, the state of the state, the health, and your highlighting innovation. I don't know whether you want to talk about it or you want Nate to address it.
You should ask the questions.
Okay. It's like, so are we fully, you know, is the U.S. market, you were talking about CONMED sort of recovering late, is the U.S. market fully up and running? And maybe talk about the innovative products you're launching or talking about now that are having the biggest impact on customers or new account wins.
When you say the U.S. market, you're talking about CONMED's U.S. business or you're talking about U.S. sports medicine?
I'm happy to hear the bigger picture, but CONMED's business.
Yeah, let me. You can fill in some gaps here. U.S. sports medicine, global sports medicine, a very healthy market. Shoulder and knee, the two biggest categories, but you have a lot of soft tissue repair and healing work that's now starting to be done in the extremities, hand and wrist, foot and ankle, gluteus medius repairs, things of that nature. So the market, we believe, is getting larger and more attractive with time. That's number one. Number two, where does CONMED fit in that? We feel like we have a comprehensive portfolio. We're very focused on the shoulder and the knee.
We're very focused on that largely because that's where our historical presence is. But number two, BioBrace, the 2022 acquisition, which I think that was three, four months into your tenure that Nate was a general manager and led that acquisition. Our portfolio and some of the backorder challenges were impacted. Those are what we're working through. I think we've commented on that plenty. So I think probably I would let Nate talk about BioBrace and how he sees BioBrace and the things that are happening with BioBrace.
Sure. Well, we continue to lean forward with BioBrace. It's clearly the most differentiated biologic augment in the marketplace today. I think you've seen other large strategics take note that this is a hot topic in sports medicine. I think if you go to the industry events, you hear surgeons spending a lot of their time learning a little bit about this. And BioBrace is by far and away the most differentiated technology in that space. And so it's a popular topic with our sales force and with surgeons. And we believe that it's delivering exceptional patient outcomes. So we're continuing to invest in the space. We're continuing to research. We're excited about some of the studies that are ongoing with surgeons.
Touch on the study. The Sean McMillan.
Sure. So I think our first peer-reviewed, I say our, somebody else's first peer-reviewed published journal article on retrospective human data came out in the last 30 days. Sean McMillan from Rothman in Jersey published a study on a cohort of 49 patients. The unique thing here is 49 patients with large or massive rotator cuff tears, which is kind of the worst case scenario, and at least one comorbidity. So on top of that, they were either obese, diabetic, smoker, you know, all of the things that effectively would demonstrate that you're not going to heal well at all.
And the literature today would say that these patients have far less than a 50% chance likelihood that they're going to heal well. And his study showed that 46 of his 49 patients were fully healed at one year out. And one year out is significant because rotator cuff repairs typically fail within the first six months and probably faster within this type of patient population with comorbidities. And so he was a 94% success rate with his patient population and definitely raised some eyebrows in the surgeon community when they saw that.
So that's the type of thing that gets us excited. And people need to be doing those studies. And then CONMED's doing its own randomized control study. But we've modified our approach to get it larger so that we could address international registration requirements, capture more data, and address our global sales channel with this product at some point out in the future. But we have doctors like this doing studies like that and publishing that. And it's anecdotal until you see things like that. But those are super exciting. And then the application for this product, if you understand soft tissue issues, it happens because the underlying tissue is diseased.
And suturing and anchoring it down does nothing to fix the diseased tissue. BioBrace provides healing of the underlying diseased tissue through the collagen A, but you get strength at time zero with the PLLA matrix. So you put that combination together and then you look at. We've had over 40 different surgical applications in the body. And we're trying to focus on just the shoulder and the knee, and we have customers pulling us into these other markets. So very exciting technology for CONMED.
I'm glad you brought the last point up because I wanted to talk about that. You highlighted rotator cuff, but ACL, Achilles tendon, I mean, it's almost, you know, a pipeline and a product, you know, not even almost, it is. How are we going to see that realized? You know, where are we in that process? Or where is CONMED in that process?
Yeah, I think like all things med tech, the sales curve is a very slow drawn-out curve because proof and validation are required. And what you'll do is you'll get a customer interested. They'll go through the approval process. They'll do a case, and then they'll turn around, look at their sales rep and say, "Come back in six weeks. Let's check on the patient." And so we go through that process every time we convert a new doctor. And then they get a few people that follow them and they each do one or two cases. And as we get into these other areas, you know, we're fortunate we acquired a foot and ankle business.
And we did kind of a soft launch at the beginning of this year with our foot and ankle team for applications in Achilles tendon repair and other foot and ankle spaces. We're going through that same exact thing. It's kind of this slow, gradual walk forward. These all bode well for the long-term future and benefit of the company. There's no, this is not consumer demand where the product launches tomorrow and it goes through the roof and then it flattens out and slides. It's more of this long drawn-out sales curve, kind of med tech 101. It's got a great future and we'll continue to innovate around it. That's how we see it.
Once international registration is completed, will we see a big, do you expect sort of a step function in BioBrace sales or adoption or clinical data international expansion? How should we think about that?
I mean, certainly we need the data for the international registrations. And as we turn on new markets, those are important contributors to the growth trajectory of the company, the international business. In the U.S. business, because to Nate's point, there's been a lot of discussion around augments and biologics and healing. I think the market's aware. You have academic centers that are laser-focused on clinical data. So maybe it turns them on a little bit more. I think there's a cohort of surgeons that clearly rely on data because they're not in the busy, prominent centers. Nate, I don't know if you have other comments around that?
I'd say the international markets will benefit from the time in the U.S. market and the additional data being generated and the, you know, the techniques being developed and things over the first few years here in the United States. And just anecdotally, conferences internationally, while BioBrace hasn't even registered in their markets yet, there are surgeons who ask questions and want to learn a little bit about the technology already. So.
No.
Hard to predict.
Yeah, I gotcha. I wanted to touch on Buffalo Filter briefly. This past quarter, I think Todd mentioned that Buffalo Filter sales growth, sales growth rates are improving, but still below normal trends. And I just realized as I reviewed everything, I didn't fully appreciate why. And remind me why that is and where are we now and how quickly do we get back to normal, which I assume is 20%+ kind of growth.
So it goes back to Q2 where we talked about a quality delay in Q2 that was remediated in Q2. And the recovery, the trajectory of the recovery on those customers always takes a little bit longer than you'd want it to. So as we exited Q3, we're on the right trajectory. It's a great market.
As we exited Q3.
As we exited Q3 and Todd spoke, we still weren't back to what we saw as the historical run rates, but we were on the right trajectory.
Gotcha. So again, no reason to be particularly anxious about the setup for 2025 in that sense.
Yeah, I'm going to let Todd and Pat talk about 2025, but it's a great business. The market is robust. We have a leadership position in that marketplace. All the input behind our decision to acquire that business in 2019 remains consistent, and our global footprint continues to expand to further advance that technology in the marketplace.
Curt, we do sort of periodic FDA approval checks and sort of under the radar in August. I haven't heard much about it. CONMED got FDA approval for the PlumeSafe X5 smoke management system. I haven't heard you all talk about it. Is this how big a deal is this? How differentiated? And does this accelerate penetration in some way?
Yeah, it's a little bit where I started. It's the D portion of R&D. It's continuing to develop the portfolio. And sometimes FDA approvals don't always coincide with launches. In this case, we did a soft launch to some of the international markets for the product. So we're very, very early days. But it's advancing the next generation of the technology in the marketplace. I don't think you can read anything into it at this point in time other than us doing exactly what we should be doing in med tech, which is keeping the portfolio moving forward.
We're going to run out of time, but a couple of last questions. One, I'm always very conscious that you made a concerted push several years ago to expand the salesforce, you know, sort of investing ahead of the curve, so to speak. And I keep thinking as volumes recover, there's going to be all things equal, nothing ever is, but all things equal, there could be a lot of leverage in the P&L as volumes grow, as mix heads toward more innovation. Is that, am I again, am I in fantasy land or is that a reasonable way to think about it?
No, I think that's of course reasonable, but that also would be against a static model. We may be adding more things. I think customers would hope we add and broaden our portfolio. Customers would hope we iterate and create the next generation. So there may be other investments required as we do that, but it should be in a leveraged, scaled fashion. Todd and I have always spoken to that. You know, revenue growth, leveraged earnings growth. That's kind of the mantra that we've always believed in while expanding gross margins. Those are kind of the trifecta, if you will. And there's nothing that should change that. The salesforce expansion category is something that med tech generally goes through annually.
Every year as you come into the new year, you're looking at your salesforce saying, "Do I have enough feet on the street to cover the portfolio that we want them to represent to the customers?" Some years you expand more, some years you expand less or gradually, so to speak. And that's a global event that you constantly put into your budget and are thinking through. So you're speaking back to 2021 where we did a mid-year expansion. And we're very happy we did that. It was a little bumpy coming out because of COVID iterations after that, but we're very happy today that we did that back in 2021. Nobody can time these things perfectly, but we feel like today we're in a good spot. But I'm sure as we go into 2021, there'll be more salesforce expansion. It's just the nature of the beast.
Gotcha. Just as we get ready to wrap up, you know, wrap up on a big picture question. To me, it feels like a lot of the headwinds and challenges are going away, lessening, gone as we head into 2025. You do have a number of new products. Markets are stable to improving. And I think back to when I initially launched coverage of CONMED. I remember putting together a chart that I highlighted that said like 16 or 18 of the prior 20 quarters, CONMED had delivered in-line or better than expected performance, top and bottom line. And even after these bumpier than expected years, it feels like CONMED can return, is well positioned to return to being a positive execution story with a great portfolio. And is that a naive dream of mine?
No, I mean, I think every CEO, CFO, board of directors, you want to run a growth company in med tech. Med tech is a growth space. I think our portfolio has greatly enhanced over the last decade. It will be further enhanced over the future decade. You know, there are companies today talking about getting gross margins back to what they were in 2019. We're already ahead of 2019 gross margins. So we've absorbed over 400 basis points of inflationary pressure. And our mix is allowing us to do that. We're not thrilled with this year, but we're going to grow earnings between 15% and 17%. So the story is a good story. We've got to get back to fundamental execution. And that is on us as a company to do and deliver. And that is the focus.
Thank you for being here. Thank you as well. Appreciate it. Good luck. We'll think about you out there on the yacht fishing and, you know, for dinner.
Maybe the horse track.
Okay.