Good morning, and welcome to today's Orthofix Medical Inc. fourth quarter 2021 earnings conference call. My name is Candice, and I will be your moderator for today's call. All lines will be muted during the presentation portion of the call, with an opportunity for question and answer at the end. If you would like to ask a question, please press star followed by one on your telephone keypad. I would now like to pass the conference call over to our host, Alexa Huerta, Senior Director of Investor Relations. Please go ahead.
Thank you, operator, and good morning, everyone. Welcome to the Orthofix fourth quarter 2021 earnings call. Joining me on the call today are our President and Chief Executive Officer, Jon Serbousek, and Chief Financial Officer, Doug Rice. I'll start with a safe harbor statement and then pass it over to Jon. During the call, we will be making forward-looking statements that involve risks and uncertainties. All statements other than those historical facts are forward-looking statements, including any earnings guidance we provide and any statements about our plans, beliefs, strategies, expectations, goals, or objectives. Investors are cautioned not to place undue reliance on such forward-looking statements as there is no assurance that the matter contained in such statements will occur. The forward-looking statements we will make on today's call are based on our beliefs and expectations as of today, February 25, 2022.
We do not undertake any obligation to revise or update such forward-looking statements. Some factors that could cause actual results to be materially different from the forward-looking statements made by us on the call include the risk factors disclosed under the heading Risk Factors in our Form 10-K for the year ended December 31, 2021, filed this morning, February 25, 2022, as well as additional SEC filings we make in the future. If you need copies of these documents, please contact my office at Orthofix in Lewisville, Texas. In addition, on today's call, we will refer to various non-GAAP financial measures. We believe that in order to properly understand our short-term and long-term financial trends, investors may wish to review these matters as a supplement to the financial measures determined in accordance with U.S. GAAP.
Please refer to today's press release announcing our fourth quarter 2021 results for reconciliations of these non-GAAP financial measures to our U.S. GAAP financial results. At this point, I will turn the call over to Jon Serbousek.
Thank you, Alexa. Welcome, everyone, and thank you for joining our fourth quarter and full year 2021 results conference call. On today's call, I'll provide an update of our fourth quarter performance and review progress against our strategic initiatives before handing the call over to Doug, who will provide our financial update. I'll close with our perspective on the business in 2022 before opening lines for questions. Turning to our fourth quarter performance, we're very pleased with what we were able to accomplish and the momentum we will continue to build despite the prevailing macro landscape. In the quarter, we delivered a total revenue of $125 million, an increase of 6% on a reported basis and 7% on a constant currency basis compared to the prior year quarter. This growth was seen across both franchises.
Starting with the global spine business unit, the spinal implants team executed another outstanding quarter with strong U.S. motion preservation performance and market share capture overall. In our global orthopedics business unit, we executed double-digit growth, year-over-year growth predominantly coming from our recovery among our international markets and share capture with Fitbone. On a sequential basis, we drove double-digit growth across all product categories compared to our third quarter of 2021. Now, shifting to the performance within each of our product categories, starting with our bone growth therapies or BGT, sales for the quarter were $50 million, down 2% versus prior year due to the negative impact of COVID, including nursing shortages on complex spine procedures within the fourth quarter, partially offset by continued market share capture with PhysioStim.
We are happy to announce that in the fourth quarter, we reached the 1 millionth patient treated with our BGT portfolio. This major milestone demonstrates our committed leadership position in the bone growth stimulation, one that we look to continue to build upon in the future. Thank you to our BGT sales and corporate teams for your leadership and efforts in obtaining this remarkable patient-focused achievement. Moving to spinal implants, we are excited to report that global revenue was up 12%, representing the fourth quarter in a row of double-digit year-over-year growth. As a reminder, this category is made up of our spine fixation and motion preservation products, with the majority of which are used in procedures that are typically considered elective.
The primary drivers of growth were increasing U.S. market share capture with 12% growth in the revenue from both new distributors and over 20% increase in total surgeon users and a rebound in international market procedure volumes. Turning to our biologics portfolio, revenue was down 1% compared to the fourth quarter of 2020 due primarily to the negative impact of COVID on procedures and nursing shortages in the fourth quarter, offset somewhat by sales growth from our fiberFUSE allografts, which continue to gain momentum with our fiberFUSE strip introduction this past fiscal year. Lastly, moving to our global orthopedics business, which is primarily focused on limb reconstruction and deformity correction. Sales in the fourth quarter were up 21% over 2020. This increase is primarily a result of recovery of our international markets and share capture driven by the Fitbone intramedullary limb lengthening system.
During the fourth quarter, Fitbone generated over $2 million in sales, mainly in the European markets, bringing the full year revenue contribution from Fitbone to over $7 million. Thank you to our orthopedics team for their leadership and market success with Fitbone in its first full year of commercialization. Before discussing our key initiatives, I want to share how excited we are that Thomas West joined our board of directors in December. He brings over 30 years of global experience in the medical device industry to Orthofix. Tom is currently the President, CEO, and Director of Intersect ENT, where he's led the transformation of that business, resulting in a definitive agreement to be acquired by Medtronic. Prior to Intersect ENT, Tom served as a Division President of the Diagnostic Solutions at Hologic after spending over 20 years at Johnson & Johnson.
Tom's varied global experience will be an asset as we continue to scale the company, and we look forward to working with him on our board. Now, I would like to provide an overview of our progress we have made in the past year on key initiatives around product innovation, commercial channel, and operational execution. Starting with product innovation differentiation. During 2021, we made solid progress developing and acquiring products and procedural solutions to address unmet needs in the marketplace and strengthen our product portfolio. We introduced key products in our spinal implant portfolio with the launch of CONSTRUX Mini and FORZA 3D-printed titanium interbodies. While we are happy with the progress we made in the year, we anticipate further growth acceleration of these products as they gain traction in the marketplace.
We continue to also provide additional investments in the portfolio in both organic and inorganic technologies. Keeping the pipeline of new technology introductions is key to our strategy and will fuel future revenue growth. Within biologics, our goal is to have a comprehensive offering of products and solutions for surgeons to use in our spine and orthopedic procedures. We significantly expanded our portfolio during the year with introductions of AlloQuent structural allograft Q-Pack, fiberFUSE Strips, and Opus MG Set. We also recently extended our exclusive partnership agreement with MTF Biologics for Trinity cellular-based allograft lines through 2032. Orthofix and MTF Biologics have a long history of bringing advanced biologic solutions to the market with over 350,000 patients treated, and that number is growing. We anticipate this more robust portfolio will continue to help drive incremental pull-through of our spine and orthopedics hardware products.
Finally, within Orthopedics, we focused on investments in limb reconstruction and pediatric deformity, which included upgrades to our existing products as well as new products with the incremental indications to increase our addressable markets. The strong performance of Fitbone throughout the year following its global introduction in early 2021 is an example of the success we have been able to bring to this highly innovative technology to the market to address unmet needs. Turning to our second initiative, commercial channel development. For this initiative, we are focused on our U.S. channels for Biologics, Spinal Implants, Orthopedics, and working to make these channels as dedicated and predictable as our current BGT channel.
In Q4, our U.S. strategic channel partners, which we define as distributor partners that carry multiple Orthofix product categories like hardware and biologics, generated over 1/3 of our spinal implants, biologics, and orthopedics U.S. revenue, and has grown 5% when compared to the prior year quarter and 15% compared to the fourth quarter of 2019. We will continue to invest in the development and optimization of these channels to support our growth initiatives moving forward. Moving on to our third and final initiative, operational execution. Throughout 2021, we have managed through several supply chain challenges, including the microchip shortage, without missing a beat. We are very proud of how our team has managed through all of the macro challenges during the year and believe that we are well-positioned to continue to execute all aspects of our global supply chain.
I am very proud of what our organization has been able to accomplish during 2021, which was, without a doubt, a challenging year. The momentum we were able to generate was a direct result of a successful execution of our strategy, and we look forward to continuing that momentum into 2022 and beyond. With that, I'll turn the call over to Doug to review our financial performance. Doug?
Thanks, Jon, and good morning, everyone. I will provide some additional details into our net sales and earnings results and then discuss some of our other financial measures. Because many of the financial measures covered in today's call are on a non-GAAP basis, please refer to today's earnings release for further information regarding our non-GAAP reconciliations and disclosures. Starting with revenue, as Jon mentioned, total net sales in the quarter were $125 million, up 6% on a reported basis and 7% on a constant currency basis when compared to the fourth quarter of 2020.
In the U.S., total net sales of $97 million or 78% of our global total revenue for the fourth quarter were up 2% over the fourth quarter of 2020, mainly due to U.S. M6-C growth, offset by the reduction in complex procedures seen early in the fourth quarter. International total net sales of $28 million were up 23% as reported over the fourth quarter of 2020, reflecting the growth from our Fitbone limb lengthening system, as well as international market recovery. Gross margin in the fourth quarter of 2021 was 73% compared to 75% in the prior year period.
The decrease was primarily due to changes in our sales mix from the timing of international orders, as well as a short-term increase in electronic procurement costs due to the global microchip shortage, offset somewhat by decreased non-cash inventory reserve charges versus 2020. For the full year 2021, gross margins were 75% of total net sales. For the full year 2022, we expect gross margin to be similar to 2021 or approximately 76%, which reflects the continued impact of the changes in our sales mix, as well as the expected short-term increase in microchip costs in the first half of the year. Sales and marketing expenses in the fourth quarter of 2021 were 46% of net sales, flat to the fourth quarter of 2020.
Although we saw travel expenses and investments in our commercial channels increasing in the fourth quarter of 2021, these expenses were offset by the one-time $2.5 million expense reduction related to a decrease in our Italian medical device tax liability that resulted from a recent law change by the Italian government that provides limited COVID-related relief to certain suppliers of their public hospitals. This non-recurring credit is adjusted out of our non-GAAP earnings. In 2022, we expect sales and marketing expenses to be in the range of 49%-50% of net sales due to further investment in our US BGT and global orthopedics direct distribution channels early in the year to support expected revenue growth, including our launch of AccelStim, as well as an increased travel and in-person events in anticipation of regional COVID restrictions easing throughout the year.
GAAP G&A expenses in the fourth quarter of 2021 were flat on an absolute dollar basis and 15% of net sales on a relative basis, down from 16% in the prior year period. Although we had increased spending on strategic investments in the fourth quarter of 2021 and certain employee benefits that had been suspended in 2020, these spend increases were offset by the completion of the GAAP charges related to the 2019 CEO transition, as well as decreased expenses related to COVID disruption. GAAP R&D expenses for the fourth quarter increased to 11% of net sales, up from 9% in the prior year period. This increase reflects our planned spending to support new product development, clinical studies, as well as costs associated with our EU MDR compliance efforts.
We will continue to ramp up our efforts to drive organic innovation and differentiation through investment in clinical trials, such as the rotator cuff repair study within BGT and our M6-C two-level indication study, and continued spend to build a robust product pipeline in both spine and orthopedics. These investments will continue to cause our R&D spending growth to outpace revenue growth in the near term. We expect 2022 GAAP R&D expense to be approximately 12% of net sales, including an impact of about 200 basis points related directly to our EU MDR implementation efforts, for which we adjust within our non-GAAP financial metrics. R&D spend will be somewhat front-loaded this year based on the timing of certain product launches, clinical site enrollment, and milestone payments. We expect our spending related to the 2024 EU MDR implementation requirements to taper somewhat after 2022.
Adjusted EBITDA in the fourth quarter decreased to $17 million or 14% of sales compared to $22 million in the fourth quarter of 2020, driven by the investments we have made in R&D related to product development and clinical trials, as well as investments in building our commercial channel to accelerate future revenue growth. Our cost of sales expenses have also increased with the changes in our sales mix, as well as increased procurement costs related to supply chain disruption. Adjusted EBITDA for the full year 2021 was 13% of total net sales compared to 12% in the prior year. A quick note that based on our Orthopedics reporting unit goodwill analysis, we incurred a non-cash GAAP write-off of $12 million in the fourth quarter, which is reflected in the acquisition expense line item in our P&L.
The write-off reflects our current and planned investments in our growth, including our EU MDR implementation and Fitbone integration spend. Now turning to tax. We had GAAP income tax expense for the quarter of $23 million or -240% of loss before income taxes as compared to GAAP income tax expense of $15 million or 270% of income before income taxes in the same period of 2020. In addition to the timing of earnings during the year, this quarter's tax provision was significantly impacted by a $25 million non-cash charge to increase the reserves against our U.S. deferred tax assets due to the accounting recognition rules involving historical and forecasted GAAP earnings, which is a non-cash charge in the quarter.
We continue to expect to fully realize our NOL carryforwards and tax assets over time as the company grows and our profitability increases. For our non-GAAP results, we utilized a 27% long-term adjusted effective tax rate in the fourth quarter. However, we will prospectively utilize a 28% long-term adjusted effective tax rate in order to recognize the current and expected general increases in international statutory income tax rates, as well as our expected adjusted earnings and the elimination of certain non-cash tax impacts.
For the fourth quarter of 2021, we reported GAAP loss of $1.65 per share as compared to GAAP loss of $0.48 per share in the fourth quarter of 2020. After adjusting for certain items and when normalizing for tax using our non-GAAP long-term effective tax rate, adjusted earnings for the fourth quarter of 2021 was $0.27 per share compared to an adjusted EPS of $0.44 per share in the fourth quarter of 2020. This decrease was primarily driven by COVID impacted lower spending in 2020 as well as increased 2021 short-term expenses due to the global microchip shortage, increased R&D spend to drive organic innovation and differentiation, and increased spend to build out our commercial channel.
Regarding cash, we continue to maintain a strong liquidity position with $88 million at the end of the fourth quarter of 2021 compared to $83 million at the end of the third quarter of 2021. We currently have no borrowings outstanding under our $300 million senior secured revolving credit facility. We commenced repayment of the $14 million 2021 Medicare advance in the second quarter of 2021. The balance of the remaining advance as of December 31, 2021 was approximately $5 million. We still expect the repayment to be complete by early Q2 of 2022.
Net cash provided by operating activities was an inflow of $12 million in the quarter, down $10 million compared to an inflow of $22 million in the fourth quarter of last year, primarily due to the recoupment of the 2020 Medicare advance in 2021, the change in accounts receivable due to an increase in net sales in 2021 over the prior year, and the 2020 cost reduction initiatives such as the 401(k) match suspension, travel freezes, and conferences being held virtually. Capital expenditures were approximately $7 million in the quarter compared to just over $4 million in the prior year period due primarily to the timing of spend for instruments in U.S. Spine to support our strategy to bring in additional strategic distribution and future accelerated growth plans. CapEx for the full year, 2021, was $20 million.
We expect capital expenditures in 2022 to be in the $25 million-$27 million range. This increase over the prior year is due to the investments in instrument sets to support distribution growth for our new product launches, investments in our technology abilities, as well as investments in our facilities and operations. Consistent with our decreased operating cash flow, our free cash flow, which we define as cash flow from operations minus capital expenditures, was a $5 million inflow during the quarter, which was down from $18 million of inflow in the fourth quarter of 2020.
As anticipated, our free cash flow decreased significantly in 2021 compared to 2020 due to several items that we mentioned at the beginning of 2021, including the partial repayment of the Medicare advance, investments in our sales channels and product innovation to support future sales growth, the Spinal Kinetics milestone payment, and increased spending on EU MDR implementation efforts. For 2022, we expect cash flow from operations to increase modestly due to the timing of the 2021 Spinal Kinetics milestone payment and the payback of the Medicare advance payment ending early in the second quarter of 2022. Now shifting to guidance. For the full year of 2022, we expect revenue to be in the range of $475 million-$490 million, which represents mid-single-digit growth at constant currency.
We are currently anticipating about a 1% headwind to our top line at reported rates due to the strength in the U.S. dollar compared to 2021 FX rates. Similar to the experience of other companies in the medical device industry, in January and into February of this year, we saw a significant increase in elective procedure restrictions as a result of the increase in hospitalizations related to the Omicron variant. From a macro perspective, we continue to expect a COVID overhang during the first half of the year, with a revenue acceleration in the back half of the year as key products continue to gain momentum and COVID subsides throughout the year, as well as delayed or deferred procedures are being made up. We expect Q1 to be slightly down to flat to 2021 on a reported basis.
We expect Q2 to be flat on a reported basis, and Q3 likely to show strong growth versus 2021. In both cases, due to the COVID impact felt during the prior year's quarters. Due to the inability to predict the impact or trend of the global pandemic, our guidance does not assume any additional surges in COVID variants at this point in time. For the full year 2022, we expect our adjusted EBITDA to be in a range of $56 million-$61 million, or approximately 12% of revenue, and our adjusted EPS is expected to be between $0.58-$0.73 using a non-GAAP long-term tax rate of 28%. These ranges reflect our continued investment in delivering a robust pipeline of differentiated product, expanding our distribution channel to accelerate our growth trajectory. I'll now turn the call back over to Jon.
Thanks, Doug. Looking ahead, we view 2022 as an inflection point for our business. In recent years, we have been a low single-digit top line growth company. As you just heard, our guidance for this year represents mid single-digit growth, which is largely a result of the investments we've made over the last two years across the organization. In particular, those investments into our talent leadership, product portfolio, and commercial channels. As we move into 2023 and beyond, we expect to further accelerate our trajectory to become a mid to high single digit growth company while still delivering a positive adjusted EBITDA. To achieve that growth, we are focused on two areas. First, continued product innovation and differentiation.
This includes delivering near-term growth through the increased adoption of recently launched products, as well as accelerating our organic and inorganic investments in new products, new indications, and new solutions that build on our core strengths as an organization. Second, the ongoing development of our commercial channels to drive our products into the hands of surgeons and physicians worldwide. Beginning with product innovation and differentiation. In a continuation of last year, the primary drivers of growth in 2022 will be our M6-C cervical disc, our Fitbone limb lengthening system, and our recently bolstered technology-leading interbody portfolio. We also expect additional top-line growth to benefit from the over 20 new products we launched since 2020 and the products we will launch in 2022.
As we work to drive accelerated growth in future years, we plan to increase the investments during 2022 in the key areas of strength within our product portfolio. While we have a relatively broad product portfolio today, which is required to enable the type of distribution needed to compete in this market, we by no means want to be everything to everyone. There are several areas of our business where we have clearly differentiated ourselves, and we're going to put capital to work in areas that leverage our expertise and current market position to accelerate our growth. These key areas of strength and opportunities are, first, regenerative technologies, a category that includes bone and soft tissue stimulation and biologics. Second, spinal technologies, which includes innovative implants and cervical solutions. Third, limb reconstruction and pediatric deformity. Fourth, enabling technologies.
Lastly, alternative surgical site development and single-use sterile packed product technologies. Starting with regenerative technologies, one of the fundamental aspects of our business that differentiates us from others in the spine and orthopedic space is our industry-leading regenerative portfolios. We offer a bone growth stimulation portfolio, which provides postoperative and adjunctive healing solutions, and a biologic portfolio which provides surgical procedure-based healing solutions. We are highly focused on investing in the development of both of these regenerative product portfolios. As previously noted, we recently submitted a PMA application to the FDA for the approval of AccelStim bone healing therapy, a low-intensity pulse ultrasound product for the healing of both fresh fracture and nonunion fracture. Upon approval, this will expand our bone growth therapies portfolio and complement our current PEMF technologies that focus on nonunion fractures and spinal treatments.
We continue to expect the initial market release during the second half of 2022. We will also continue to invest in our ongoing rotator cuff IDE trial, which, if successful, will be our initial entry into the soft tissue regeneration market. As a first of its kind therapy to enhance patient care for those undergoing rotator cuff reconstruction, we would have a first mover advantage to tap into the over 650,000 patients who receive rotator cuff repair surgery in the U.S. every year. We're making meaningful investments in our biologics regenerative portfolio, as recently announced with our launch of our Opus synthetic products and the extension through 2032 of our exclusive partnership with MTF Biologics for the flagship cellular allograft technologies.
As part of this partnership, we will also look forward to launching two additional biologics products mid-year, one of which we believe will be an important differentiated solution in the market. We are striving to provide a full portfolio of biologic solutions to surgeons, so that for any surgery procedure, there is an Orthofix solution that meets the specific needs of the surgeon and the patient. In spinal implants, we currently offer an extensive portfolio of products and technologies, including a comprehensive cervical offering and a differentiated artificial cervical disc. Additionally, we've been evaluating our portfolio to bring in additional innovative and differentiated products and procedures. In the first half of 2021, we initiated five key spine R&D projects.
These projects are developing spine product innovations and solutions for anterior column support, a lumbar minimally invasive spinal platform, a posterior cervical system, and a deformity correction system, and the FITSPINE deformity technology platform. These organic innovation programs have engaged key surgeons throughout the world to create innovations and clinical solutions which will assist Orthofix to stand out in the market and create long-term top-line growth. We anticipate these developments to be introduced late this year and throughout 2023. Turning to limb reconstruction and pediatric deformity, another key area of differentiation for our business is our narrow and dedicated focus within orthopedics market. Many of our peers have exposure to highly competitive or crowded markets such as hip and knee replacements.
However, we are squarely focused on a small segment of orthopedics where we have expertise and a long-standing track record of leadership and innovation in limb reconstruction and deformity correction. While we have a number of projects ongoing in this space, I want to highlight two. We plan to expand our TrueLok ring fixation system portfolio to become radiolucent. This system was developed at Texas Scottish Rite Hospital for Children in Dallas, Texas, and allows precise alignment of fixation segments without compromised stability and also enhancing imaging characteristics. We will also continue to invest in our cutting-edge German-engineered Fitbone technology with the development of new products in response to the input from leading U.S. pediatric orthopedic surgeons and identified need within the U.S. pediatric market.
We believe that with the extensions of the Fitbone system in early 2023, we'll be able to drive the same type of adoption and growth in the U.S. that we currently see in the European market. These two new projects, along with our JUNIORTHO plating system, which is a complete plating system designed to address the specific demands and advanced deformity and trauma reconstructions of the lower extremities, will give Orthofix the broadest deformity care system in pediatrics. Turning to enabling technologies, Orthofix is focused on the future of digital preoperative planning of limb reconstruction and deformity corrections for clinicians across the world. OrthoNext, our organically developed planning software, will soon be connected to most of the major products within the orthopedics business. Our goal is to provide preoperative planning and surgical assistance to surgeons throughout our intuitive pre-planning software in both pediatric and adult patients.
In January, we also announced a partnership and investment agreement to jointly develop and co-market the innovative nView systems with cervical spine and pediatric limb deformity correction procedural solutions. The nView S1 imaging and surgical guidance system features a unique ability to instantaneously capture 3D images with very low dose radiation, making the 3D images available throughout the surgery and enabling real-time visualization. This technology complements our preoperative and postoperative software platforms, and we are excited to collaborate with nView to broaden the use of this technology in cervical spine surgeries and pediatric procedures. Finally, under product differentiation innovation, we're looking to continue to develop procedures for our alternative surgical sites of care as more procedures continue to be moved out of the hospitals and into ASCs. Through our Neo partnership, we're developing single-use sterile pack instrument technologies.
We'll focus on the continued expansion of our already robust cervical offering with an outpatient setting emphasis. Turning to the optimization of the commercial channel, we will invest further in the expansion of our distribution channel with the addition of targeted direct reps in our U.S. limb reconstruction and deformity business to increase focus on pediatrics in geographies where direct employees make sense. With the anticipated 2022 launch of AccelStim, we are making investments in our BGT channel to drive growth in long bone for non-union and fresh fracture care. We are also continuing to focus our efforts on driving synergies within our channels to increase the number of strategic channel partners carrying multiple Orthofix product lines, which improves our product pull-through and provides for more predictable and reliable sales channel. In summary, we are very excited about the future at Orthofix.
We've generated tremendous momentum over the last two years, and we're moving into an inflection period in our growth trajectory. We will continue to invest to accelerate growth in future years, and importantly, do so while remaining sustainably profitable. With that, I would like to open the line for questions. Operator?
Our first question comes from Matthew Blackman of Stifel. Your line is now open. Please-
Good morning, everybody. Can you hear me okay?
Yes, we can, Matt. Morning, Matt.
Great. Maybe just to start with a housekeeping question for Doug on the 2022 guidance. The 1-point top line currency headwind, is there any way to quantify that drop through impact to EBITDA and/or EPS? Then I have a couple of follow-ups.
It's a good question. You're right about 1% on the top line. It's mostly reporting translation risk, obviously, at the revenue level as well as the cost level. We're fairly naturally hedged in most of the geos where we have exposure primarily to the euro dollar rate, and some to the Brazilian real. I would look at it as a lot less or fairly immaterial at the EBITDA and EPS level in terms of FX impact.
Got it. Great. Jon, a couple for you. Just, sort of thinking about the longer term expectation for upper single-digit growth, what's the bridge to get there from mid single-digit growth? Is it another step up in spinal implant growth that gets you there? Does it contemplate rotator cuff and bone stim? Essentially, I'm just asking whether the acceleration would be balanced across the business or if it'd be disproportionately weighted to any particular segment or a new product launch. One more follow-up after that.
Yeah. Matt, thanks for the question. I think there's a general maturation of our strategies going forward. It's a combination between new product innovation and launch as well as differentiating the marketplace, which attracts new surgeons to your organization, as well as building the commercial channel. Those two go hand in hand. We continue to focus on commercial channel, both direct and indirect. We track better talent when we have better portfolios. They tie together back and forth across one another. As far as where it's gonna occur, we've seen growth and we've been focused on both the orthopedics limb reconstruction and deformity sectors, as well as the spine areas. You saw the performance in Europe with the limb reconstruction deformity.
That's a combination of both our TL-HEX, our Fitbone, and then also our JuniOrtho plating systems have a very comprehensive line to partner with OrthoNext from a planning standpoint. For spine, you saw that we also had good performance in Europe and the other regions, but we'll continue to invest in that area as part of our investment strategy, as well as in the U.S., and we continue to execute those plans not only in spine fixation, but also in BGT. With BGT, we look forward to a new product innovation, which has not occurred in many, many years within BGT with the AccelStim, and we look forward to launching that in the second half of the year.
Great. Thank you. The last question, and I'm not asking for more explicit long-term guidance. I appreciate what you gave this morning. As we think about where EBITDA margins could go beyond 2022, is there anything structurally that prevents you from getting to upper teens or even 20%? I'm really just trying to frame what the profitability profile could be with a higher single digit top line growth trajectory. Thanks.
Yeah. Thanks, Matt. We've stated consistently that as we build or rebuild the organization, that we know where we're spending our dollars. As we basically get those product portfolios refreshed and sales channels put in place, that we believe there'll be EBITDA leverage in the out years. That is by plan and design. From that standpoint, we do expect to have EBITDA leverage in the out years. We should be able to operate at a cost comparable to any other company of our size and style and increase our profitability over the near term and the far and the midterm.
Got it. Thank you so much.
Thank you, Matt.
Thank you. Our next question comes from Jeffrey Cohen of Ladenburg Thalmann. Your line is now open. Please go ahead.
Good morning, and thank you for taking our questions.
Good morning, Jeff.
A few from Aaron. Firstly, is there any update on the M6 two-level study?
Yeah, Jeff, we continue to add enrollment sites. We continue to see enrollment within those sites we've already established, and we are just on plan as far as the M6 two-level study.
Got it. Okay. Could you talk a little bit about the AccelStim technology and how that falls into the BGT platform? On a commercial standpoint, it sounds like late this year or so back half of 2022, you'll be commercial on that. Those channels will be largely the same, and they'll kind of bolt on to your current platform.
Yes, Jeff. On the AccelStim, as a reminder, that's a technology that we licensed from IGEA, an Italian partner in that area. We had submitted that PMA last fall, and we expect to have a PMA approval in this first half this year. The indication will be for fresh fracture and non-union, and we've been building our PhysioStim channel within our BGT commercial channel to basically be prepared for that. Also we have a very strong non-union approval within our PEMF technology that we've been executing with. We see the combination with our existing technology in PEMF partnered with the new technology from AccelStim to be even a better momentum driver as we build that channel.
We're investing in reps in that physio channel, and we have been over the last 12 months.
Would you expect the AccelStim technology to, as well as BGT to be, largely focused domestically here?
Yes. We've contemplated looking outside the U.S., but really this is a U.S. position for our product. It has been for BGT for many years, and it'll be. We'll remain focused on the U.S.
Okay. Got it. A couple for Doug. I guess firstly, the $23.3 income tax expense. I know you've been carrying that for a number of years and it was $23 last quarter. That heads to zero. Looks like your actual was $1.77 on the balance, so we should expect that to remain at that very low level going forward. Is that a safe assumption?
Jeff, if I understand the question correctly, you're asking about the volatility in our income tax rate?
Yeah. No, not the rate. The income tax expense that the $22.2 million Q4 income tax expense. Was there something that-
I see. Yeah.
That caused that to come toggled off? Because we were a bit unexpected that that would come through now.
Right. We're still normalizing to a long-term rate. In the script, I mentioned that we're moving from 27% for an adjusted long-term rate to 28% to reflect changes in the world, international tax rates starting to inch up in jurisdictions.
Where we do business. What you're seeing in Q4 was the GAAP charge. It was a non-cash charge of the expense related to a valuation allowance on our U.S. deferred tax assets. Because of our historical GAAP losses over the last couple years, you're seeing pressure on our ability to record full value around our DTAs. We were in a position in the U.S. similar to Italy last year to reserve our tax rate. That put about $25 million of tax expense additional in the fourth quarter. I would simply look to the longer-term rates for more normalized.
We do continue to expect to fully realize all of our net operating loss carryforwards and tax assets, as our earnings improve over time.
Okay. Related to the acquisition-related amortization remeasurement of $12.56 for the fourth quarter, what should we expect or what should we model for, 2022 and going forward on that line item?
For the Spinal Kinetics final milestone, I would expect that in 2022 to accrete up a lot closer to the ultimate payment amount of $30 million. It'll happen semi-ratably over each quarter. You'll also notice in our balance sheet that the final milestone liability payment flipped from long-term to current. That'll give you an idea of the speed of the accretion.
Okay. It is the 12.5 part of the 30, or should we expect 30 during 2022?
The current liability is simply an accounting fair value that's discounted to today's dollars. We go through a lot of simulations with a third party to value that payment, the ultimate payment. That's the liability at the end of the fourth quarter was roughly $17 million. The $12 is just a part of the $30.
Okay. Got it. Lastly for us, any specific commentary on labor issues that you've been seeing or you expect to see going forward into 2022, both domestically as well as internationally?
Jeff, this is an ongoing issue. It's gonna be an ongoing issue for all companies. I was just recently with three institutions, East, Mid., and West Coast, very large institutions, and they see labor going out in 12-18 months plus as far as just with the dynamics that are going on in their institution. The good news is that I think the positive side of that is that those institutions as well as the surgeons are out there ready and motivated to care for those patients that come to them, and we'll be there right with them as far as ready to do that.
Yep. Okay. Thanks for taking our questions.
Thank you, Jeff.
Thank you.
Thank you. As a reminder, to ask a question, it is star followed by one on your telephone keypad. Our next question comes from Jim Sidoti from Sidoti & Company. Your line is now open. Please go ahead.
Good morning, and thanks for taking the questions. It's nice to hear somebody asking questions about the non-GAAP adjustments other than me for a change. Can you repeat what your guidance was for gross margin for 2022?
Gross margin for 2022, we expect to be at 76% approximately. It reflects sales mix. We've got some pressure in the first half of the year for the chip shortage that we experienced late last year. Those are the primary items at 76%.
Okay. All right. I wanted to focus in on the capital spending because I think you said, you know, you're gonna be, you know, roughly $25 million-$27 million for CapEx, which is about $10 million more than you did this year. I assume that's more mostly instrument sets. Is that primarily for the spine business? Is that a function of the new products or the new distributors or a combination of both?
It's a little bit of both. It's about a $7 million increase over our $20 million CapEx level in 2021. I would characterize it in just big buckets of about two-thirds of that spend is related to instruments. The majority of that is just increased distribution, right? It just takes more cash to support the increased distribution for our products like M6 and AccelStim rolling out. Those are the primary drivers. We've also got some investments in our operations and some of our facilities as well.
Okay. Last one for me, and this is a strictly long-term question. I mean, if you look at the new products you have coming out for spine and you have the M6, you have the increased distribution. I mean, do you think at some point that this becomes a double-digit grower? Because I mean, there just seems to be a lot of levers here that you can push. I know that's not gonna happen right away, but it just feels like growth could go beyond that mid-single digit target at some point.
Jim, thanks for the question. We basically stated where our trajectory is at right now. The new product activity does not include any M&A. We have that on the organic side. We see as markets grow and as we basically improve our portfolio, improve our channel, that we see a good future for Orthofix. I can't really say right now as far as where we're gonna be at as far as in the ultimate high singles, doubles, and all the rest of that. I don't think that's fair to do that right now. We are very confident where we're at and with the guidance we've provided.
Okay. I just wanted to be clear on one thing. It's spending for CE approvals in Europe, sounds like that's starting to taper off a little bit. I mean, does that mean there's a light at the end of the tunnel with regard to getting all those products registered?
Jim, I know your question is related to MDR and maintaining our CE marks in Europe. If your question is about spending levels, we weren't getting each word you were saying there, but if I'm anticipating the question-
Oh, okay.
Correctly. Yep. Yeah, we spent about $8 million.
Is there a light at the end of the tunnel to that process?
Yeah. From a spending perspective, we are on track. We spent about $8 million in 2021. We'll spend as we called out, about 200 basis points or about $10 million this year. We expect it to start tapering as everything comes together in advance of the spring of 2024 deadline for MDR.
Okay. All right. Thank you.
Thank you.
Thank you. There are no additional questions waiting at this time, so I'll pass the conference over to management team for closing remarks.
Thank you to everyone who joined the call today. We look forward to a very positive year in 2022 and beyond. We'll be talking to you throughout the year. Have a wonderful day.
This concludes today's conference call. You may now disconnect your line.