Before the conference call begins, let me remind you that during this call, management will be making comments and statements regarding its financial outlook, its plans, and objectives. These statements represent the forward-looking statements that involve risks and uncertainties as those terms are defined under the federal securities laws. Investors are cautioned that any such forward-looking statements are not guarantees of future events, performance, or results. The company's actual results may differ materially from its current expectations. Please refer to the risks and other uncertainties disclosed under the forward-looking information in today's press release, as well as the company's SEC filings for more detail on the risks and uncertainties that may cause actual results to differ materially. The company disclaims any obligation to update any forward-looking statements that may be discussed during this call, except as may be required by applicable law.
You will also hear management refer to non-GAAP or adjusted measurements during this discussion. While these figures are not suitable, substitute for GAAP measurements, management uses these figures to aid in monitoring the company's ongoing financial performance from quarter to quarter and year to year on a regular basis, and for benchmarking against other medical technology companies. Adjusted net income and adjusted earnings per share measure the income of the company, excluding credit or charges that are considered by the company to be special or outside of its normal ongoing operation. These adjusting items are specified in the reconciliation supporting the company's earnings releases, post to the company's website. With these required announcements completed, I will now turn the call over to Curt Hartman, CONMED's Chair of the Board, President, and Chief Executive Officer, for opening remarks. Mr. Hartman?
Thank you, Jonathan. Good afternoon, and thank you for joining us for CONMED's second quarter 2023 earnings call. With me on the call is Todd Garner, Executive Vice President and Chief Financial Officer. Our plan is to share with you our second quarter results and then open the call to your questions. I will start by saying we are incredibly pleased with our team's performance in the second quarter. After setting a new quarterly sales record in Q1, we handily beat that with our Q2 performance. Total sales for the quarter were $317.7 million, representing a year-over-year increase of 14.6% as reported, and an increase of 16.6% in constant currency. On an organic constant currency basis, sales growth finished at 12.6%.
Our commercial teams were outstanding in the first half. The results in orthopedics and general surgery indicate we delivered balanced growth across our product offering on a global basis. I'd remind everyone that in mid-June, the In2Bones business reached its one-year anniversary. We remain pleased with this business. Look forward to continued growth in this exciting market as part of our organic base. Additionally, the BioBrace offering continues to build momentum through growing market acceptance, which is being driven by positive clinical experiences. From an earnings perspective during the second quarter, our GAAP net income totaled $13.7 million. This compares to a net loss of $168.3 million in the second quarter of 2022, due primarily to the extinguishment of most of the 2024 convertible notes.
Excluding special items that affected comparability, our adjusted net income of $26.1 million increased 5.3% year-over-year, and our adjusted diluted net earnings per share of $0.83 increased 9.2% year-over-year. At a macro level, and consistent with my first quarter comments, the underlying surgical markets that we serve are healthy and healthcare staffing levels continue to improve. Conversely, inflationary pressure on the material side has been slower to dissipate, and supply chains are not yet fully recovered. Overall, we see all these dynamics as stable to improving in the second half of 2023. In summary, I'm very pleased with the focus and results delivered in the quarter, and I'm confident we will build on our success in the second half.
Before I turn the call over to Todd, I'd like to provide important context about the standard insufflation market and our competitive position with AirSeal. Let me start by saying that AirSeal is an only-in-class technology. From day one, it has been replacing standard insufflation from all marketplace competitors in both robotic and laparoscopic procedures, given its unmatched clinical benefit delivered through low pressure. The introduction of another standard insufflation device into the market will not change our clinical or sales algorithm, whether it is at a standalone device or attached to a robot. The only parties that will feel the pressure from the introduction of another standard insufflation device are the existing standard insufflation companies that we have been replacing for the past seven years.
I will again remind you that none of these companies can deliver consistent pneumo at low pressure, nor the related clinical benefits, which are significant and are included in the investor presentation that we posted this afternoon. Our position has always been that AirSeal delivers better patient outcomes than competitive devices, driven principally through lower pressure. To support that position, we have 33 peer-reviewed studies with over 6,000 enrolled patients across five surgical specialties that demonstrate reduced postoperative pain, reduced length of stay, reduced 30-day visits, reduced ER visits, and improved ventilation metrics.... standard insufflation has zero clinical studies that demonstrate any of these important clinical benefits. In fact, I think I can make a compelling argument that we are, through our clinical capabilities, growing the number of available surgeries that can be done laparoscopically in certain patient populations to include elevated risk and high body mass index patients.
Competitively, since 2018, six new insufflation devices have been introduced to the market. AirSeal continues to win surgeons globally. While the concept of integration of a device with a robot may enhance ease of use, it will do nothing to change the clinical paradigm on which we have been taking market share and will continue to take market share. I will also remind you that in 2018, two strong competitors introduced their AirSeal equivalents. I think our results would suggest we navigated that period just fine. From a technology and sustainability standpoint, we own 187 issued patents and have another 124 pending. They extend our patent position through the end of the 2030s. We continue to add to this position.
Our AirSeal IP crosses the system and is integrated in such a way that it is not one seminal patent that protects us, but rather the integration of the patents across all aspects of the system to include the iFS box, tube set, and access ports. This is what makes AirSeal function in a manner that delivers clinical benefit. Each of these components is manufactured separately in a unique facility, with the critical parts being insourced here at CONMED. We're not currently aware of any patent work that will allow another device to function in a low-pressure mode. Based on the June 2023 Best Hospitals in the U.S. teaching hospital category, AirSeal is present in 92% of the top 25 teaching institutions, with MIS procedural utilization rates ranging from just getting started to over 75%.
This is a statistically significant fact, given that physicians utilize what they are trained on when they depart to surgical practice. We will never be dismissive of competitive entrants, but I think it's misinformed to assume that the same old technology, created by the same partner to the rest of the insufflation market, will somehow materially impact our results. Never mind that the market knows minimal details about this device. From my chair, if it's not obvious that it can provide consistent pneumoperitoneum at low pressure, as proven through clinical studies like AirSeal has shown, it is just another standard insufflation device. The only in-class AirSeal technology, supported by extensive clinical benefits derived through low pressure, has clearly been moving the market to embrace our solution.
We do not see anything in a standard insufflation offering that would slow that progression. We remain extremely optimistic about our future with AirSeal. More importantly, if you really digest the quarter we just delivered, the overall prospects for CONMED, given the surgical diversity of and balanced growth our portfolio is demonstrating, look the best they have ever looked in my tenure. I'll now turn the call over to Todd, who will provide further details on our financial performance and discuss our updated outlook. Todd?
Thank you, Curt. All sales growth numbers I reference today will be given in constant currency. The reconciliation to GAAP numbers is included in our press release. As usual, we've included an investor deck on our website that summarizes the results of the quarter and our updated guidance, and this time it includes some supplemental information on the moat around our AirSeal product line, consistent with Curt's comments. For the second quarter of 2023, our total sales increased 16.6%. On an organic basis, revenue grew 12.6%. We anniversaried the In2Bones acquisition on June 13th, and Biorez will turn organic on August 9th. For Q2, our sales in the U.S. increased 17.1% versus the prior year quarter, and our international sales grew 16.0%. Worldwide orthopedics revenue grew 19.8% in the second quarter.
In the U.S., orthopedic sales grew 29.4%. Internationally, orthopedic sales increased 14.8%. Total worldwide general surgery revenue increased 14.1% in the quarter. U.S. general surgery revenue grew 12.5%, while internationally, general surgery revenue increased 17.9%. Let's move to the expense side of the income statement. We will discuss expenses and profitability in the second quarter, excluding special items, which include charges for acquisitions and contingent consideration, termination of distributor agreements, legal matters, debt refinancing costs, restructuring and software implementation costs, amortization of intangible assets, and amortization of deferred financing fees net of tax. Adjusted gross margin for the second quarter was 54.4%, a decrease of 50 basis points from the prior-year quarter. This was consistent with our guidance of mid fifty-fours for Q2.
Similar to Q1, we saw exceptionally strong growth in some of our lower-margin geographies, which has skewed the margin to the lower end of our guidance so far. We remain excited about the improving margins ahead. For Q3, we expect gross margins to improve sequentially over Q2 by approximately 150 basis points. Then again, sequential improvement from Q3 to Q4 between 100 and 150 basis points. Research and development expense for the second quarter was 4.3% of sales, 20 basis points higher than the prior-year quarter. Second quarter adjusted SG&A expenses were 37.4% of sales. Leverage gained on the higher sales drove the 70 basis points improvement over the prior-year quarter. On an adjusted basis, interest expense was $8.5 million in the second quarter.
We expect a similar level of interest expense in Q3, and that does incorporate the rise from today. The adjusted effective tax rate in Q2 was 21.9%. Taxes came in lower than expected, principally due to the excess tax benefit from stock plans. This is difficult to predict, but we don't expect the same benefit in future quarters. We still expect the tax rate to be around 25% going forward. Second quarter GAAP net income was $13.7 million. This compares to GAAP net loss of $168.3 million in Q2 of 2022. GAAP earnings per diluted share were $0.43 this quarter, compared to a loss of $5.65 per share a year ago.
Excluding the impact of special items discussed earlier, in the second quarter, we reported adjusted net income of $26.1 million, an increase of 5.3% compared to the second quarter of 2022. Our Q2 adjusted diluted net earnings per share were $0.83, an increase of 9.2% compared to the prior year quarter. Turning to the balance sheet. Our cash balance at the end of the quarter was $27.8 million, compared to $26.5 million as of March 31st. Accounts receivable days as of June 30th were 65 days, flat compared to the end of Q1. Inventory days at quarter end were 200, compared to 215 at March 31.
Long-term debt at the end of the quarter was $971.5 million, versus $995.3 million as of March 31. Our leverage ratio on June 30, 2023, was 5.1 times. We continue to expect our leverage ratio to be below 4.25 times by the end of the year. Cash flow provided from operations in the quarter was $26.7 million, compared to cash flow from operations of $18.7 million in the second quarter of 2022. Capital expenditures in the second quarter were $4.5 million, compared to $5.7 million a year ago. Let's turn to financial guidance.
We now expect reported revenue for the full year to be between $1.230 billion and $1.260 billion, compared to our previous guidance range of between $1.205 billion and $1.250 billion, with no material change to the expected currency impact on the year. We now expect full year adjusted EPS in 2023 to be between $3.40 and $3.55, compared to our previous range of $3.30 and $3.50. As discussed previously, the full year 2023 will have one less selling day compared to 2022. The way our calendar falls, Q1 had one extra day, and Q3 will have two fewer sales days.
As we look at the third quarter, we expect reported revenue between $295 million and $305 million. That includes approximately 100 basis points of FX headwind. We expect adjusted EPS in Q3 to be between $0.80 and $0.85. As Curt said, we are pleased with the Q2 performance and are focused on executing and continuing to build on our strong first half as we move through the rest of 2023. We remain confident in our ability to deliver innovation to our customers while driving above-market growth and profitability over the long term. With that, we'd like to open the call up to your questions, and I'll turn it back to Jonathan.
Certainly. Ladies and gentlemen, if you have a question at this time, please press star one one on your telephone. If your question has been answered and you'd like to remove yourself from the queue, simply press star one one again. We ask that you please limit yourselves to one question and one follow-up. Our first question comes from the line of Robbie Marcus from JP Morgan. Your question, please.
Hi, thanks for taking the question. Congrats on a good quarter.
Thanks, Robbie.
Two questions. Maybe first, I could start out with underlying trends. It looks like you're participating in a lot of the strong ortho and surgery trends we're hearing from other peers. Would love to get a sense. I know you touched on it a bit in the script, but would love to get a sense of, you know, specifically, U.S. and how the revamped sales force is doing in ortho and, you know, how surgery ex air filtration and smoke evacuation did in the quarter.
I would just say overall, we're very excited about the performance, broadly speaking. Our U.S. orthopedics business has been undergoing a bit of a renovation. You know, Patrick Beyer, that was tucked in under him in October of 2020. He's brought in a new leadership team. We're really starting to see the fruits of that labor. The second quarter was our best U.S. orthopedics organic performance that we've had in a number of quarters, and I think that bodes well for the second half. That is supported by better sales, better marketing, better overall support, but also the underlying markets, to the point of the question, are seeing higher procedure levels. You put all that together, and it helps for delivering good results.
On the general surgery side, absent AirSeal and Buffalo Filter, we delivered growth. I mean, people on this call probably don't understand the amount of business that we have in our Advanced Endoscopic Technologies category, and that was just shy of a double-digit grower in the quarter. We don't usually talk about that, but it was a great performance by that business on a global basis. Then if I take a different angle on it and look globally, we had really strong global performance leading market except one that had some unique challenges in that market with our portfolio. Really a strong performance across the core of the company and in each of our business categories.
Great. I know you talked a lot about it in the script, so, not to, pound on it too much. You know, there's a lot of, newfound worry in the market that, AirSeal is a, great product and delivers a lot of incremental growth for you. That, you know, a lot of the, placements and use are in conjunction with intuitive surgical robotic procedures, and, you know, reports that a, third-party OEM might be making an insufflator to, integrate with it.
Again, I know you talked in the script, but I think it'd be helpful, maybe just to review, you know, what percentage of AirSeal is from robotic procedures, what's currently in the market today beyond AirSeal, and maybe some of the reasons, you know, that even if the robotic platform comes with an insufflator, that AirSeal will still be used and still be used in a good amount of procedures and forward growth. Thanks a lot.
Thanks, Robbie. I mean, look, the power of AirSeal is in the clinical differentiation that it brings, and we'd shared some of those studies and data that Curt shared verbally, that's in the deck. It's in the back of the deck that we provided today. You can see, you know, this is proven over millions of patients and over many years. As Curt said, many times in the last several years, our competition has said, "Okay, we finally found the answer to AirSeal. You're gonna like this just as much as you like AirSeal." Everything has been found wanting so far because it does not do all three things at once, right? To put gas into the abdomen, remove smoke, and measure.
AirSeal, because of our key feature with no valves and because everything is done simultaneously, it doesn't turn on and off. Everything is simultaneous, that we're allowed to operate at much lower pressures consistently over a myriad of procedures and lots and lots of patients. Doing that in practice is very difficult, and in our opinion, nothing that comes with valves or turns on and off, you know, if I'm now I'm removing smoke, now I'm not. Now I'm inserting gas, now I'm not. Now I'm measuring, now I'm not. Anything that starts and stops with those functions and has valve that is constantly trying to fight the escape of gas, is not gonna be capable of operating anywhere close to the clinical outcomes that you see AirSeal do.
That is why everything that has entered the market so far, even with all the promotions about saying they figured out how to match AirSeal, nothing has come close. As you can... You know, we're coming up on seven and a half years post-acquisition. This product line is growing north of 20% every quarter, because of how differentiated it is in the space. People, doctors are not gonna go backwards in clinical outcomes because another company sells it, that they really like something else that company sells. That's just not how our space works.
To specifically answer your question about the attachment to the robotic procedures, it is high in the U.S. because that business was built in the wake of robotic procedures, and it sells very nicely, and all of the features of the product are relevant to all MIS procedures, but especially robotic procedures, where there's the added risk of the working space collapsing on the arms. There's that added risk and then the added time of having to reset if that were to happen. There's a high attachment in the U.S. There's a low attachment to robotic procedures outside the U.S. because, frankly, there weren't as many robotic procedures outside the U.S. years ago. Our sales force outside the U.S. sells it very effectively into non-robotic MIS procedures.
Our U.S. sales force has not been forced to develop those muscles, and so they've lived a very good life in the wake of robotic procedures, but they're still enormous. If for any reason, that opportunity behind robotic procedures were to someday slow, the AirSeal could still grow just as fast as we have been by shifting focus into the non-robotic. We feel very strong about our competitive position, about the differentiation. We see nothing in the market, nothing in any filings, nothing in any discussions that would challenge that. It's, it's been a terrific product, now almost eight years post-acquisition, and we expect we don't see anything slowing it down.
Robbie, from a competitive standpoint, any company in the marketplace who provides a video platform for MIS surgery is going to have an insufflation device, and the insufflation category has traditionally been provided by an OEM. Suspect it's the same OEM that's providing this device. That is considered standard insufflation technology. When you look at attachment to a robot, it's like a video stack. You're putting the platform on there. There may be some integrated ease-of-use features, but again, consistent pressure, stable pneumoperitoneum at low pressure that can handle the removal of smoke without movement in the working space, that can handle doing that at low pressure. That's the clinical benefit and differentiation that the technology and the intellectual property across the three elements provide.
Hopefully, that helps people understand a little bit different, the clinical aspects and value that AirSeal brings to the marketplace, the clinical marketplace.
Thank you. One moment for our next question. Our next question comes from the line of Rick Wise from Stifel. Your question, please.
Good afternoon, Curt. Hi, Todd. Curt, the warehouse-related issues and customer recapture, maybe you can help us understand or get a little more color on where things stand. Obviously, if the software implementation was done and completed, and you were last quarter back up and running, I think, if I'm remembering correctly, you said that greater than 50% of customers who had been disrupted or in some way had returned. Where are you now? How much benefit did we see in the quarter? When do we get back to where you were or where you would aspire to be?
I think we're on the path that we've talked about, really, probably going back to fourth quarter. We had good return in the first quarter, supported by an uptick in overall procedure volumes, generally speaking, and feel like we're pretty far back to recovery on the majority of our customers. There will always be some stragglers, may have signed up with a competitive entrant and had to make some commitments. I think the best way I can frame it, Rick, we're not walking around worried about how soon are these people gonna come back. We feel like we've done a good job recapturing any customers that may have departed us for some period of time.
I think the underlying strength in the markets and our overall innovation and portfolio and sales teams have done a really nice job reassuring those customers that we're back and we're in front of it again. You know, we said on the last call, we're still working on all the opportunity that the warehouse implementation software brings us, and we'll continue to work on that. Anytime you have a state-of-the-art software platform, you're gonna try to optimize it day in, day out, month in, month out, and that journey will continue.
Okay. and I know how important innovation is in your mind and to the CONMED strategy. Can you give us any color, about, what we might see or any way to characterize the kind of impact that new product launches are having or about to have in a broader portfolio sense? maybe roll into that, just a little more detailed update on In2Bones and Biorez. It seems like they're doing well. maybe just help us understand, you know, where they are in terms of, growth and acceptance, and how we think about the contribution, just those two alone might make to two or four second half top line growth. Thanks so much.
We're encouraged by the contribution from new product introductions, and I would probably say leading that right now across the company is our orthopedics business. If you were at Academy, you saw a lot of products at orthopedics, not just Biorez, that was a focus, obviously, but we had a lot of new products. When I look at our new product revenue in the quarter, based on the way we measure it, globally, our orthopedics business new product contribution has been very helpful. Again, that's credit to the revamp, the new team leadership, and how they're approaching innovation with the commercial team and integrating that with our manufacturing group.
You know, I think I mentioned on the last call, in our interventional endoscopy business, we introduced a product called Beamer AVEO, which we think is an only in class product, and market reception on that has been very favorable. Obviously, it's a capital component, so it's going through a little longer purchasing cycles, boy, the marketplace feedback has been really strong. We continue to push on new product innovation. It's part of what we brought to the company, and it will always be part of our fabric, and our teams are doing a really nice job of it right now. Biorez and In2Bones, as I commented, we feel very good about both of those.
In2Bones, comprehensive business, comprehensive portfolio, rolling out PCR plating, kind of a next iteration on the ankle, doing really good work. You know, we sunsetted the one-year mark. It's part of the organic business now, we'll look forward to that contribution in the second half and going forward, Biorez becomes organic in August. Boy, we're super excited by the market reaction. It's good clinical outcomes drive this, and good surgeon experiences drive this, and we're seeing that. It's about educating surgeons so they understand the technology and how we approach it, how they approach it, the market enthusiasm is very strong. Again, we feel very good about that acquisition.
I don't think we've commented about specific contribution in the second half, so I'm probably not gonna break that out here.
Thank you. One moment for our next question. Our next question comes from the line of Matthew O'Brien from Piper Sandler. Your question, please.
Good afternoon. Thanks for taking my question. Todd, can you just flesh out a little bit more on the smoke side? I think you said AirSeal has been growing 20. I want to make sure, did it grow 20% this quarter? Is Buffalo growing 20 as well? What I'm getting at is, if those two still grow about 20%, it looks like the rest of the general surgery business was a little bit lighter than maybe I would have expected, especially with the comp being a little bit easier here in Q2 versus Q1. Are you just not getting all that halo effect yet from, you know, from those two differentiated products, or is there something else going on there? Thanks.
Yeah, they definitely did grow north of 20% in the second quarter. You know, I don't know that I'd grant your easy comp comment on Q2, but, you know, look, we're pleased with how the business is going. We grew 12.6% organic across the company. We've got these new acquisitions, which are just turning... They're just anniversarying. They're obviously growing nicely, strong. We feel very good about the organic growth profile of the company. That's incorporated in the guidance we just gave. I will remind you that Q3, you know, our range does include the double-digit organic growth, despite having two fewer sales days, right? Remember that as you judge the Q3 number. Look, the business is going well. Obviously, there's some legacy products that grow slower. We all know that.
We have many parts of the business growing really well right now.
Okay, appreciate that. Then, I don't want specifics on BioBrace or In2Bones, but are those two still largely on deal plan as far as what you were expecting or ahead of expectations? Then, you know, this volume growth that we're seeing, everybody's seeing, and I am in no way, Todd, asking you about 2024 numbers, but do you think this is something on the volume side that can continue through not only the back half of this year, which it sounds like it already is, but even into next year as well, just the strength in volumes? Everybody in this space is going to have a tough comp next year as a result of the strength this year. Thanks.
Thanks, Matt. On the deals, they're both performing at least to plan. We talked about on the Q1 call that Biorez, we kind of raised the expectations from mid-single-digit millions to high single-digit millions for 2023. That obviously was out of the gates a little better than we thought. Look, I think halfway through 2023, I don't think we would be alone in saying, you know, the environment feels good. It feels like pre-pandemic, you know, where med tech is back and procedures are back, and the growth rates in our spaces are getting back to where they used to be. You know, you're right.
It's too early to talk about 2024, but it does, you know, barring, you know, I'm knocking on wood here, it does feel like maybe we've finally gotten through all the pandemic disruptions, and that, we probably do have some tailwind from, you know, people that didn't get care when they should have, and there's some pent-up demand, maybe. I think it's really tough to quantify, but I think that probably is a tailwind out there for all of us. Yeah, I think we're feeling good about the future as we sit here today.
Thank you. One moment for our next question. Our next question comes from the line of Vik Chopra from Wells Fargo. Your question, please.
Hey, good afternoon. Thanks for taking the question, and congrats on a great quarter. Two questions for me. Maybe the first one is on your international business. You put up pretty strong numbers on tough year-over-year comps. I'm just wondering what trends you're seeing in your various geographies. Then on my follow-up question, you know, your guidance, you've sort of raised the top line by about $100 billion at the midpoint. Maybe just talk about what gets you towards the low end versus the high end of your guidance. Thank you.
I'll take the easy one, Vik Chopra, and I'll leave Todd Garner the second one. You know, our international business has been a very steady performer, and this year is no exception. They're doing really a nice job across both orthopedics and general surgery. I think Todd Garner commented, some of our export markets have had really strong performance with the Asian markets, Japan, China, Asia, broadly speaking, really probably growing a little faster than we had even assumed. Europe is doing a nice job. Latin American market's doing a very nice job. It's been a very balanced international performance across both general surgery and orthopedics.
That's a testament to the infrastructure, the stability of the leadership team and the evolution of the channel and the country market focus that they've put in place over a number of years. Hopefully, that answers your question on international, and I'll let Todd take the guidance question.
Yeah, just to make sure we're all level set, our current revenue guidance is $1.23 billion-$1.26 billion. Originally, when we started the year, we guided, $1.17 billion-$1.22 billion. It's been a $60 billion increase.
Million.
Sorry, million. I'm doing the same thing. A $60 million increase on the low end from the start of the year, a $40 million increase on the high end from the start of the year. Really, that's just reflected in our performance, right? Things have gone better than we said, and, you know, we always had high expectations for the back half of this year. We continue to have high expectations for the back half of this year. You know, we're executing, and we're gonna continue to focus on executing.
Thank you. One moment for our next question. Our next question comes from the line of Matthew Mishan from KeyBanc. Your question, please.
Hey, good afternoon. Thanks for taking the questions. Last three quarters, you guys have been around the low 54% from a gross margin perspective. It seems like this is the beginning of the ramp you've been expecting over the next, like, two years, closer towards about 60%. Just thinking on what's clicking as you get into the second half that's enabling this change?
Yeah. Thank you, Matt. You're right. We have been waiting to get through the first half of 2023. Things do get better from here. You know, what's really clicking, has been clicking, is the mix of the business, right? These high-growth, highly differentiated product lines, that continue to do well, all also come with elevated gross margins. That mix tailwind, is actually picking up speed. There, it's not waning, it's picking up speed as those things grow faster than the rest of the portfolio. That is finally being allowed to show through because we've had some stability on the cost side, right?
Cost, we still think there's a lot of improvements that we can do on the cost side, but, you know, digesting the increased prices from 2022, which, as you know, takes a while to flow through our inventory and therefore our financials, we knew that that would be a weight on the first half of 2023. As we've seen stabilization in the cost side, now that mix tailwind is starting to show through. We are excited to now start ramping gross margins, as you've pointed out, and we feel very good and confident about the disclosure we made about six months ago when we said we expect gross margins to be to 60% by the end of 2025. We feel very confident that we can get there.
Thanks for noticing, and I hope I answered your question.
Yeah, you did. Thank you. Then I just wanted to switch over to non-robotic U.S. laparoscopic procedures in the U.S. It just seems like such a big opportunity over the long term, that your sales force hasn't really hit on as aggressively, I think, as or built the muscles to hit on as aggressively as probably you would like. You know, when were you planning to kind of. You know, as you kind of think long term, when were you kind of planning to kind of make that shift or incentivize that shift in the sales force? Does it require some, like, an R&D update or a modestly different solution in the U.S.?
Matt, it's a good question, and I'm sure right now our commercial leadership team for that business is squirming in their seat. I think Todd Garner and I are probably being a little harsh. We have several examples of very nice wins on the general laparoscopic side that the team has delivered. One earlier this year, which was a total system-wide swap-out. The single biggest point of resistance is you're asking that extensive surgical volume, which is like a 10-to-one ratio relative to robotics, to move to a much more expensive procedure. In a period, the last couple of years, where volumes have been up and down, and pricing pressure and inflationary pressures, convincing health systems to change and incur additional cost, even though they recognize the clinical benefits, has been more of an uphill climb.
We hope that as the markets are stabilizing, as procedure volumes are coming back, broadly speaking, pricing and everything is normalizing, material costs, et cetera, that customers are more willing to step into that realm. Again, it takes a few big ones to tip over, and we've done that early this year and late last year. We had a couple of really nice wins, that's contagious for a sales force when they see things like that. Todd and I talk to our businesses frequently, they know the story and the journey and the path that they're going on, and part of it is continuing to expand sales forces annually. Part of it is, you know, making sure we've got the right product cost structure for those customers.
We will get there. We're not gonna change incentive plans to force people there that... Been in this industry 30 years, it just doesn't work. It doesn't work the way it's designed. Just keep it simple and let people go sell to the customers that are ready to be buyers, and show them all the clinical value that we have, especially with a product like AirSeal.
Yeah, I think that's an important part that I would just add, Matt. I think that's kind of the wisdom and focus that Curt brings here. It's funny to hear talking about the commercial team squirming. you know, when you whenever you talk about, well, let's drive the compensation plan to make them sell this much of this and this much of that and this much of the third thing, and Curt's always like: Look, let's make it really clear how they make money, and let's let them go make money. Make sure they know they work for the customer. Yes, the check is signed by CONMED, but they work for the customer, and give the customer what they want.
I think it is important, as you ask that question, which is a good question, where some places do try and push behavior that way. Here we say, "Go make your number however you want to make it," right? It serve the customer. Well, if you think about if you're one of those sales reps in that space, you can walk in behind a $2 million robot and say, "Hey, why don't you buy this $30,000 box that makes every procedure safer, faster, better?" That's just an easier starting jumping off point than walking into a place with, you know, without that $2 million block, you know, creating the hole for you there, right? So you're walking in saying: Hey, you know, you should double the expense to get these benefits. That it works.
Doing it in the laparoscopic non-robotic space works. Like Curt said, our U.S. team has proven that it works. Our OUS team, we grow just as fast in AirSeal outside the United States as we do inside the United States, and they don't have the wake of the robot. They have success... We know that we can successfully go into non-robotic procedures and convert those accounts, but we have not micromanaged the sales force to make them go there. They will go there, you know, when they need to go there, they will go there, and that opportunity is still there.
Thank you. One moment for our next question. Our next question comes from the line of Young Li from Jefferies. Your question, please.
All right, great. Thanks for taking our question. Maybe one more on AirSeal. Just to follow up on your earlier comments on the top 25 hospitals that uses it. I think it's 92%, some as high as 75% penetrated. I guess I'm wondering what's the average penetration rate in that cohort, if you have it? Why or how did the top hospital get to 75%? Is it due to their procedure mix or more surgeon champions or, you know, more the longer length of time that AirSeal have been in their hospital?
There, there's a lot to unpack there. Teaching hospitals are notoriously hard to crack into. The surgeon champions are thought leaders. They are very clinically astute. They are absolutely in the prove it to me category. Where we have the higher utilization rates, we've probably found a surgeon champion sooner, and they were able to help proliferate the technology across all the users in that account. Where we have lower utilization rates, it may have been harder to crack into that hospital. They may have had an allegiance to other technology, and they were waiting to see more clinical outcomes. That, that's why you keep chipping away, and to be in 92% of them is really good after seven years.
Because we're in them, we keep showing up, we keep demonstrating the value, we'll get more of those key opinion leaders on board across those facilities. The penetration rate will go up. Off the top of my head, I don't have the exact mean, median, average, but it ranges from just starting to north of 75%, probably everything in between. It is a journey when you're talking about teaching institutions. They don't just turn over overnight. It takes time, our sales teams and our marketing teams spend an awful lot of time to get them on board, and we're proud of that work.
When people leave the teaching institutions, what they were trained on and who they trained by is very important to how they set up practice, and that's why it's such an important statistic for us.
All right, great. That's a very helpful color. I guess, follow-up question. Was wondering, you know, within your general surgery business, can you maybe comment on some of the key categories or indications that's driving growth? You know, we're hearing things like bariatric surgery slowing down. You know, it's a small part of your business, but, you know, are you seeing that as well? Maybe you can highlight some of the categories that's performing a little bit better and some that's a little bit slower.
Yeah, I don't think we would say we've seen any slowdown in bariatric surgery at this point in time. Again, it's a small part of our pie that we participate in. And I also think that patient cohort probably has a broader mortality index that has to be dealt with. When they get to the surgical side of things, sure, there's gastric bypass that is more of a weight reduction that could be impacted by a pharmaceutical solution. But there's just a lot of other bariatric surgery types and indications that are still going to be maintained out there because of the comorbidities of that patient cohort. You know, generally speaking, across our general surgery businesses, we're seeing good procedure volume independent of specialty.
I mean, it's urological, it's general surgery, straight up procedures. It's GYN procedures. There's strength across the board. I don't think I would call out any that are driving the ship, so to speak. I think that as important on the interventional endoscopy side, really good volumes in that market space right now, and our teams are super excited. They've got a very exciting new product there. We feel good generally about that entire category of our business right now.
Thank you. One moment for our next question. Our next question comes from the line of Kristen Stewart from C.L. King. Your question, please.
Hi, good afternoon, and congrats on the results. I was wondering if you could just share a little bit more details on Buffalo Filter, if there's any passage of legislation since we last spoke, and just in general, the competitive environment there, too.
There is. Ohio and Missouri got approved most recently. The cascade continues, and we expect that it will continue to build. You know, it continues to go well. There's a lot of runway there. We have the best device in the market, we believe, and we expect big things out of that business going forward.
Okay, thanks. Maybe you could expand further just on the general capital environment. It looks like capital grew nicely this quarter. Just any additional color there you could share?
Sure. It's interesting. It was solid performance, both in general surgery and in orthopedics. It was interesting, we had one of our better performances on power tools. We had really strong performance on video. On the general surgery side, we have an extensive platform of energy platforms, Argon and just basic energy, and all of those did very well in the quarter. I think the teams feel pretty good about both of those categories as we look into the second half of the year. Obviously, AirSeal capital, Buffalo Filter capital, the boxes fall into that category as well. So those are helpful items as well on the general surgery side.
Thank you. One moment for our next question. Our next question comes from the line of Mike Matson from Needham & Company. Your question, please.
Yeah, thanks for taking my questions. I guess first, just wanted to ask one on, you know, BioBrace. Maybe talk about sort of the early feedback you're hearing there, what type of procedures you're seeing it used in, and, you know, to what degree do you think it's sort of taking share from some of the competing products versus just being picked up by surgeons that hadn't been using that type of product before?
Yeah, it's a great question. We're seeing it deployed in a host of other surgical procedures. We obviously have a product that's specific to rotator cuff. We have a product that's specific to ACL augmentation. The one for rotator cuff is more like a patch construct, so surgeons are modifying that and using it on other indications, whether it's Achilles tendon repair or glute med repair. I think if, trying to remember from the slide at Academy, I think one of the surgeons put up 23 different surgical applications where BioBrace had been used. There's a lot of new users, new to the collagen A market that we're finding.
There are some competitive users from the first generation product in the market who are interested in this product. Because candidly, the strength at time zero is a massive selling feature. That is a super important point when you talk about re-tear. We're seeing some adoption out of that space as well, but it's a growing market. It's new technology for healing, and there's a lot of new adoption. Again, clinical studies are super important in this space, just like they were in the early days of AirSeal, so we're working on clinical studies. The market has some clinical studies from the first generation technology that's out there, but they want to see clinical studies on our technology.
Because there's experience with that first gen product, they probably did some of the market development heavy lifting, that is beneficial to us, and it's probably why we're a little bit ahead of plan.
Okay, thanks. Just with In2Bones now being a year past the actual close, can you just talk about the degree to which you've sort of increased investment there, either, you know, sales force or number of sets, R&D, et cetera?
Yeah, you know, we bought it as a standalone business, Mike, we run it as a standalone business. Obviously, internationally, we're doing more integration because we have the sales channel there, and In2Bones did not have a sales channel. Investment outside the U.S. is about getting regulatory approvals. It's about building more sales channel where there was no lower extremity sales channel. We're able to do that because we have an orthopedics presence under which we can tuck this.
You're not building the management piece, you're building more the direct sales or the distributor agent sales channel. In the U.S., you know, I think everybody in the lower extremity space would say it's a great market and more feet on the street matter, and we're under that same mindset. More feet on the street matter, and a great R&D engine, which came with In2Bones, is essential to us moving forward. As Todd and I have said before, we don't do a top-down, spend this much in R&D. The local marketing team, the local R&D team, the leadership, the general manager, the, you know, this reports, again, into Pat Beyer under Global Orthopedics. They run their business reviews, they take market feedback, they build their R&D portfolio.
They know what the sales channel can consume at once or over a period of years, and they build a R&D engine to support that. I think if we're doing anything on the leverage side, because of our infrastructure on medical education through our straight-up sports medicine business, we're able to do more medical education that In2Bones probably couldn't do on their own as a standalone because we just have scale through our bigger sports medicine business. That occurs both in the U.S. and outside the U.S., and then some of the back office scale that we talked about. You know, we can bring a lot of that back office shared services that they just couldn't scale up.
Okay, great. Thank you.
Thank you. This does conclude the question and answer session of today's program. I'd like to hand the program back to Curt Hartman for any further remarks.
Thank you, Jonathan, and I want to thank everybody today. We went a little longer than normal, but I appreciate your time, and we look forward to speaking with you on our next earnings call. Thank you, and have a good evening.
Thank you, ladies and gentlemen, for your participation in today's conference. This does conclude the program. You may now disconnect. Good day.