Welcome to the first quarter 2022 Stryker's earnings conference call. My name is Brica, and I'll be your operator for today. At this time, all participants are in a listen-only mode. Following the conference, we will conduct a question-and-answer session. This conference call is being recorded for replay purposes. Before we begin, I would like to remind you that the discussions during this conference call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also, the discussions will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release. That is an exhibit to Stryker's current report on Form 8-K filed today with the SEC. I will now turn the call over to Mr. Kevin Lobo, Chair and Chief Executive Officer.
You may proceed, sir.
Thank you. Welcome to Stryker's first quarter earnings call. Joining me today are Glenn Boehnlein, Stryker CFO, and Preston , Vice President of Investor Relations. For today's call, I will provide opening comments, followed by Preston Wells with an update on the trends we saw during the quarter, as well as recent acquisitions. Glenn will then provide additional details regarding our quarterly results before opening the call to Q&A. For the quarter, organic sales growth exceeded 9% with double-digit growth from our MedSurg and Neurotechnology businesses led by endoscopy, instruments, and neuro and cranial. Our orthopedics and spine businesses delivered high single-digit growth, highlighting procedural recovery throughout the quarter. Internationally, we posted mid-single digit organic growth, highlighted by double-digit organic growth in Europe and emerging markets. During the quarter, we continued to have robust demand for our capital products.
However, we had meaningful shipment delays as a result of ongoing product supply challenges, mostly affecting our large capital businesses. For the quarter, we delivered adjusted EPS of $1.97, reflecting growth compared to the first quarter of 2021, despite the ongoing impacts from inflationary pressures and significant premiums on inventory spot buys. We expect these supply chain pressures to persist throughout the year, although they will moderate with less reliance on spot buys in the second half of the year. In addition, we continue to invest in R&D at a healthy rate of 7.2% of sales, demonstrating our continued focus on our new product pipelines.
Despite the ongoing supply chain pressures and the continued COVID volatility in certain regions of the world, we remain confident in the outlook of our business, and we expect to continue to deliver sales growth at the high end of med tech. However, as previously mentioned, despite continued discipline with our spending, the pressure on our supply chain will impact our ability to deliver earnings leverage in 2022. With one quarter behind us, a very strong order book, and these macroeconomic dynamics, we now expect full year organic sales growth towards the high end of our guidance range of 6%-8% and expect adjusted earnings per share at the lower end of our guidance range of $9.60-$10 a share.
During the quarter, we also closed the acquisition of Vocera, and I'm excited about the highly complementary and innovative portfolio that Vocera brings to our medical division. We believe that this deal will drive strong value creation in the years ahead. Finally, I am pleased about our ongoing commitment to our talent and culture, which is reflected in the recognition of Stryker for the 12th year in a row as one of Fortune's 100 Best Companies to Work For. Over this time, our employee base has moved from 20,000 to 46,000, and I would like to thank our leaders for maintaining our positive culture as we have grown.
In addition, we also published our second annual comprehensive report during the quarter, which captures our environmental, social, and governance strategy and details our commitments and disclosures on our three pillars of corporate responsibility, stronger people, healthier planet, and good business. Overall, I am pleased with our start to the year despite the challenging macroeconomic environment and believe we are well positioned for the future. I will now turn the call over to Preston.
Thanks, Kevin. My comments today will focus on providing an update on the current environment, including the procedural and geographic trends during the quarter. In addition, I will provide an update on the continued integration of Wright Medical and the initial integration progress of the Vocera business. After being impacted in January by the Omicron variant, procedural volumes recovered sequentially throughout the quarter as COVID-related delays and restrictions eased. While we're seeing volumes recover towards more normal levels, there continues to be some overhang from hospital staffing shortages, which is causing scheduling disruptions around the world. This improvement in procedural volumes is primarily impacting our implant-related businesses, including hips, knees, spine, and extremities. In addition to the procedural recovery, our double-digit growth in knees continues to benefit from the growing Mako install base.
We also grew high single digits in foot and ankle, upper extremities, and hips, driven by continued new product penetration. Within our hips business, the launch of the new Insignia hip stem, along with the Mako Total Hip 4.1 software, which also incorporates Insignia into the Mako robotic platform, continues to proceed well and should be a tailwind to our hip business throughout the year. Geographically, procedures recovered during the quarter in the United States, Europe, and Latin America, which resulted in strong double-digit growth in those regions. Procedural trends in Asia have been more volatile due to the ongoing COVID-related impacts, with Japan and Australia beginning to see improvements towards the end of the quarter, while other parts of the region saw COVID rates peak in March.
In China, COVID related impacts were more widely seen beginning in March, and we expect to see negative impacts on procedural volumes in China during the second quarter as a result of strict lockdown restrictions across major cities in the country. Demand for our capital products remained strong in the quarter, including double-digit growth in orders, which bolstered the strong order book for capital products that we carried over from 2021. As a reminder, our capital business makes up less than 25% of our total sales, with under 10% coming from large capital items like beds, robotics, booms and lights, and the remainder coming from small capital products like power tools and cameras, which facilitate surgical procedures. The strong demand in the quarter is occurring across our portfolio, including our small capital products within Instruments, Endoscopy, and neuro and cranial that support the recovery of procedural volumes.
While we experienced solid growth from our capital businesses in the quarter, the growth was limited as a result of ongoing headwinds, including raw material shortages, primarily related to electronic components and installation delays because of hospital staffing challenges. The raw material shortages have had the largest impact in our medical business, both within our acute care and emergency care business units. These macro challenges will continue to be pronounced in the second quarter. We continue to partner closely with our customers to ensure we are meeting their more immediate and longer term capital requirements. Turning to our key integration activities. The integration of Vocera is in its early stages, and we are pleased with how the teams are working together to maximize the opportunity. On a pro forma basis, the Vocera business continued its strong double-digit momentum during the quarter.
Finally, the Wright Medical integration continues to progress well across all regions, which is reflected in the double-digit growth of our U.S. trauma and extremities business during the quarter, which was led by excellent performances in both U.S. foot and ankle and U.S. upper extremities. In summary, while the macro environment remains volatile, procedural volumes are improving and the underlying demand for our products remains strong, which gives us confidence in our ability to continue to drive market leading growth. With that, I will turn the call over to Glenn.
Thanks, Preston. Today, I will focus my comments on our first quarter financial results and the related drivers. Similar to last quarter, sales comments will be provided based on our new reporting structure. Our detailed financial results have been provided in today's press release. Our organic sales growth was 9.2% in the quarter. The first quarter's average selling days were in line with Q1 2021. The impact from pricing in the quarter was unfavorable 1%. Foreign currency had an unfavorable 1.8% impact on sales. During the quarter, we saw a recovery of surgical procedures and accelerated sales momentum as the impact of the COVID-19 pandemic has eased in the U.S. and Europe. However, our sales growth has been constrained by continuing supply chain challenges and electronic component shortages, especially impacting the capital products in our MedSurg businesses and primarily our medical business.
Our capital order book has continued to be very robust as demand from our customers has continued to be strong. For the quarter, U.S. organic sales increased by 10.5%, reflecting strong double-digit growth in many of our businesses. International organic sales showed growth of 6%, impacted by positive sales momentum in Europe and emerging markets, somewhat offset by lingering COVID impacts in Australia, Canada and China. Our adjusted quarterly EPS of $1.97 increased 2.1%, reflecting sales growth, partially offset by a higher tax rate and gross margin inflationary pressures. Our first quarter EPS was negatively impacted from foreign currency by $0.02 versus 2021. Now I will provide some highlights around our segment performance.
In the quarter, MedSurg and Neurotechnology had constant currency sales growth of 12.1%, with organic sales growth of 10.8%, which included 12.2% of U.S. organic growth. Instruments had U.S. organic sales growth of 16.3%, led by strong growth in their orthopedic instruments and surgical technologies businesses, highlighted by growth in SurgiCount, waste management, smoke evacuation and Steri-Shield products. Endoscopy had U.S. organic sales growth of 17.7%, reflecting strong performances across their portfolio, including video products and double-digit growth of their communications and sports medicine businesses. The medical business, which includes our recently acquired Vocera business, which closed in February, had U.S. organic sales growth of 6.2%, reflecting solid performances in their Sage and acute care businesses, somewhat offset by the aforementioned supply chain challenges, primarily impacting our emergency care products.
During the quarter, we also saw significant growth in orders for our acute care and emergency care businesses, driven by very strong demand. Assuming normalization of the customer environment and certain reduction of certain supply constraints, we expect these orders to contribute to another strong year for medical in 2022. Our U.S. neurovascular business posted an organic decline of 1.4% versus a very strong comparable growth of approximately 20% in 2021. The U.S. neurocranial business posted organic sales growth of 16.6%, which included solid growth in our MaxFace, NSC drills, and bio-reabsorbable products. Internationally, MedSurg and Neurotechnology had organic sales growth of 7%, reflecting double-digit growth in the endoscopy and neurovascular businesses. Geographically, this included strong performances in China and Australia.
Orthopedics and Spine had constant currency and organic sales growth of 7.2%, which included 8.2% of organic growth in the U.S.. This reflects the impact of the ramp-up in surgical procedures during the quarter. Our hips business grew 8.5% organically in the U.S., reflecting strong primary hip growth fueled by the launch of our Insignia hip stem and improved underlying market dynamics. Our knee business grew 17.5% organically in the U.S., reflecting the previously mentioned strong recovery of procedures and our market-leading position in robotic knee procedures. Our U.S. trauma and extremities business grew 10.6% organically, reflecting double-digit growth in foot and ankle, upper extremities, and biologics. Our US spine business grew 3.7% organically, led by the performance of our enabling technology products.
Other ortho declined organically in the U.S. as the impact of hospital operational staffing challenges and lengthening purchasing cycles limited our ability to place Mako's during the quarter. Comparatively, in Q1 2021, other ortho had growth of 49%. Assuming normalization of the customer environment, we expect another strong year for Mako in 2022. Internationally, orthopedics and spine grew 4.8% organically, which reflects the strong momentum in Europe as surgical procedures ramped up, as well as a strong performance in hips and knees in Japan, somewhat offset by lingering COVID challenges in Australia, Canada, and China. Now I will focus on operating highlights in the first quarter. Our adjusted gross margin of 64.1% was unfavorable approximately 130 basis points from the first quarter of 2021.
Compared to prior year, our gross margin was adversely impacted by purchases of electronic components at premium prices on the spot market and other inflationary pressures primarily related to labor, electronic components, steel, and transportation costs, as well as operational inefficiencies due to our aforementioned raw material shortages. We expect these adverse impacts to continue throughout 2022, and to be more pronounced in the first half of this year. Adjusted R&D spending was 7.2% of sales, which represents a 35 basis points increase versus first quarter of 2021, and this reflects our continued commitment to innovation funding and the related future growth it will provide. Our SG&A was 35.1% of sales, which was 5 basis points lower compared to the first quarter of 2021.
This reflects continued cost discipline and fixed cost leverage, offset by the ramping of certain expenses and hiring to support future growth. In summary, for the quarter, our adjusted operating margin was 21.8% of sales, which is approximately 160 basis points unfavorable to the first quarter of 2021. This performance is primarily driven by inflationary impacts resulting in gross margin challenges and other continued investments in innovation, somewhat offset by our sales momentum and cost discipline. Other income and expense decreased as compared to the first quarter in 2021, primarily resulting from an equity investment gain as well as lower interest expense. Our first quarter had an adjusted effective tax rate of 13.9%, reflecting the impact of geographic mix and certain discrete tax items.
For the full year, we continue to expect an adjusted effective tax rate of 15%-16%. Focusing on the balance sheet, we ended the first quarter with $1.5 billion of cash and marketable securities and total debt of $13.9 billion, which includes the additional $1.5 billion of debt raised to fund the Vocera acquisition. During the quarter, our long-term credit rating at S&P was downgraded from A- to BBB+, and our long-term rating at Moody's was reaffirmed at Baa1. Turning to cash flow, our Q1 cash from operations was $203 million.
This performance reflects the results of net earnings and continued focus on working capital management, partially offset by the impact of pre-buying certain electronic component inventory and approximately $130 million of charges related to the stock compensation payments for the Vocera acquisition that are accounted for in operating cash flow. Given the dynamic supply chain pressures, COVID uncertainty, strong order book for capital equipment, and considering our first quarter results, we now expect full year 2022 organic sales growth towards the high end of our previously guided range of 6%-8%. This performance assumes that the recovery environment experienced in Q1 continues to improve throughout the rest of the year with a normal procedure environment returning during the second half of the year.
If foreign currency exchange rates hold near current levels, we expect net sales in the full year to be adversely impacted by approximately 1.2%. Adjusted net earnings per diluted share to be adversely impacted by approximately $0.10-$0.15 in the full year, and this is included in our guidance range. Based on our performance in the first quarter and including consideration of the continued supply chain challenges, the inflationary environment, and the anticipated impact related to foreign currency
We expect adjusted net earnings, adjusted earnings per share towards the lower end of our previous guidance range of $9.60-$10 per share. The low end of the guidance range assumes the continued macro environmental volatility persists, including inflationary pressures that could impact costs, particularly our cost of sales, and includes more transient spot buying and longer-term supply chain challenges. We will continue to evaluate the changing environment and will provide updates to our guidance as necessary. Now I will open the call up for Q&A.
Thank you. We will now begin the question and answer session. To ask a question, you may press star, then one on your telephone keypad. If you are using a speakerphone, please pick up your handset before pressing the keys. If any time your question has been addressed and you would like to withdraw your question, please press star then two. Please note we will limit analyst questions to one at a time. If you can, please rejoin the queue. At this time, please pause while we begin the Q&A session. The first question we have comes from Vijay Kumar of Evercore ISI. Sir, your line is open.
Hey, guys. Thanks for taking my question. Congrats on the strong print here. Maybe one on the capital environment, Kevin. There's been a lot of questions on the hospital capital budget cycle. Maybe talk about your order book, how it's perhaps different. I couldn't help but observe the other line item, which includes Mako, it was down year-over-year. I understand it's a tough comp. Was it just comps or anything to do with the capital cycle here?
Yeah, sure, Vijay. First, I'd tell you that hospital liquidity is still very strong. As a result, our orders have actually grown in the quarter. We had a strong order book coming into the year, and we added to that very significantly with strong double-digit growth in orders in the first quarter. As we mentioned in our opening remarks, large capital has been disrupted partially because of shortages of primarily electronics, but also hospitals' ability to actually receive the capital, either because of short staffing or because some of their construction projects were delayed. I'm not concerned about the shortage in other ortho for the first quarter. Our order book for Mako is very, very strong. We had a lot of delays in actual installations, and they're going to have a strong year overall.
Certainly, we did have a big comp from the prior year. The order book for Mako is very strong. The order book for all of our capital is very strong. You saw the actual sales results in instruments, endoscopy, neurocranial. The small capital, in fact, we're able to largely meet those orders that we're growing. Our challenge is meeting the orders of larger capital, primarily medical, but also, to a lesser degree to Mako. Overall, no concerns, strong demand for Mako. You saw the results in the hip and knee business that really benefits from the strong performance we had in Mako throughout the pandemic.
That's helpful, Kevin. Maybe one on guidance here. Q1 off to a really strong start here, 9% organic. The guide, you know, 6%-8% now looks like you guys are pointing towards the high end. Is there perhaps some conservatism baked in when you look at the back half? Certainly your comps are, you know, 7% average for the back half. If the recovery trends do persist, perhaps it seems like the top line is a little conservative, maybe walk us through the assumptions for the back half.
Well, you know, we're not going to give guidance by quarter, Vijay, but what I would tell you is the second quarter we have very difficult comps. If you remember, the second quarter of last year was extremely strong. Yes, you're right that Q3 and Q4, the comps do get a lot easier. I would say that we are still a little bit nervous about our ability to meet the demand for these orders in capital because of the supply chain pressures. There is a little bit of conservatism baked into that, just because the environment is pretty uncertain. We do assume an improvement, a continued improvement in procedural volumes. If that continues to play out well, and certainly there is the potential for us to do even better than what we've guided.
based on what we know today, that we feel pretty good about sales at the high end of the original range, given the strong start to the year and the strong order book.
Thank you. We now have the next question from Matt Miksic from Credit Suisse. Please go ahead. Your line is open.
Hey, thanks so much. Congrats on a really strong quarter. Kevin, I'll ask the question because I'm sure folks are wondering, and then I have one quick follow-up, if that's all right. Just follow up on Vijay's question about the robot trends. You know, would you say these are challenges that, you know, all competitors across large capital robots, and otherwise are having putting systems into hospitals at the moment or, you know, in other words, would you expect that these aren't things that are gonna put you at a disadvantage competitively over the next several quarters? I just one quick follow-up.
Hey, Matt, it's Preston. You're right. It's something that we're seeing across the board. As Kevin said, it's really more the macro elements around the ability for hospitals to be able to put the equipment in and get it installed that's driving it. That's something that everybody is facing. We've heard that from several folks as well. It's not something that puts us at a disadvantage at all. As Kevin mentioned, we feel very strong about where we're heading for Mako and what we're expecting to deliver for Mako this year.
Great. A follow-up on hips, just to give us some perspective, you know, it was a really nice bump up here, on the back of these launches that you described. I'm just wondering if you could give us some sense of how confident we should be about, you know, that going forward, or is there some trialing or there's a couple of quarters here that we should sort of need to digest, the interest in the hips, or do you really feel like you've turned a corner? Thanks.
Yeah, I would say that we certainly are very pleased with the initial launch of Insignia as we recently just launched it at AAOS. It's certainly an indication as we think about going forward and what we expect to drive from our hips. We're happy with the initial phases of the launch. We expect Insignia will continue to provide a tailwind along with Mako, along with the recovery of procedural volumes.
Thank you. We now have a question from Robbie Marcus at J.P. Morgan. Robbie, you may proceed.
Hi. Great. Thanks for taking the question. Congrats on a nice quarter. I wanted to ask on down the P&L, and you mentioned cost headwinds a couple times during the presentation, and you were able to still hold the guidance range, albeit at the lower end. I was just hoping maybe you could walk us through sizing some of these impacts and the cadence as it flows, you know, into and out of the P&L as we start thinking about building second, third, and fourth quarter. Thanks a lot.
Yeah. Robbie, I would tell you that when we gave guidance back in January, we discussed, you know, pressure of 50-100 basis points on our gross margin. I would tell you that that is looking like it is trending to the upper end for the whole year. If I think about where we're gonna feel most of that pronounced increase, it's probably Q1 and Q2 here with some easing in Q3 and Q4. If you think about the types of costs, obviously there are these spot buys where we're paying pretty exorbitant prices for chips and the related electronic components, but there are also increases in labor or supplier labor, warehouse and distribution costs are going up.
Then related to that, just because of supply shortages, we're also feeling a little bit of the inefficiencies that that might be driving in our own manufacturing facilities. So all of those are obviously putting pressure on our gross margin. You know, and then the last thing I'll mention, and I know this has probably come up in other calls, is just freight is another place where we're seeing real increases. And a lot of that is just because of the tight supply chain and even the tightness of our ability to deliver products to our customers. You know, we're seeing a lot of overnight deliveries. We're seeing a lot more air freight when normally we would use a more economical mode for freight.
All of that is kinda compounding in terms of what we're implying as inflationary pressures. I do see some of that easing up, but I would tell you for the longer term, these labor costs, these transportation costs are probably a little more permanent than some of the other costs as we think about it. Moving down the P&L, if you think about what we're spending in R&D, we're not backing off of that innovation spend. We really honestly think it's very important to keep that product pipeline going and keep it robust. Launches like our Insignia Hip, we're gonna be able to fuel growth as long as we continue to fund that R&D. On the
Further down in SG&A, you know, we have tried to moderate some of the more discretionary SG&A costs, but the single biggest cost there is sales commissions. As long as our sales force are out there selling, we're gonna continue to pay them and pay them well because it's important to us. You know, beyond that, you know, we have some moderation in other income and expense, and I gave you the guidance on tax, so I think we're trending pretty much in line with all of that.
Great. Appreciate that. If I could sneak one, quick follow-up in. We heard from Baxter this morning, they have a growing order book like you and, they're hoping to be able to, you know, shorten it and sell through throughout 2022. Is that your expectation as well, that the chip supply should, you know, improve and you'll be able to clear a lot of the order book within 2022? Thanks.
Yeah. Robbie, I think that you know, we certainly believe that we're gonna work through that backlog. You know, it's still early days as we're you know, confronted with the supply challenges, and we're certainly working actively with those chip suppliers and trying to get through. As Kevin mentioned, you know, certainly second quarter will be a little bit more disrupted than we think about the later part of the year. We'll work through it throughout the year. You know, as we think about our overall guidance and certainly getting to that upper end or exceeding that upper end would mean working you know, all the way through the entirety of that backlog.
Right now what we're doing is really focused on just getting the supply and working through it, for the remainder of the year.
We now have Larry Biegelsen of Wells Fargo. You may proceed, Larry.
Good afternoon. Thanks for taking the question. I wanted to start with the inflation and pricing. Just how are you guys kind of managing the rising cost, and what's your ability to offset it, and where are you guys able to take price? It looks like price got a little better if I'm looking at Q1 versus Q4, if I'm looking at that correctly. I have one follow-up.
Yeah. Larry, thanks for the question. We're looking at a few different ways. Obviously, we continue to focus on some of the internal projects that we had going with CTG 2.0 that are really looking at how we change our cost structure. Beyond that, we are looking at areas around price. Just as a reminder, we do have some businesses that historically we've been able to gain some price in, particularly on our MedSurg and Neurotechnology businesses. As we look at all of our businesses in the future, as we have contracts that are coming up on our orthopedic side, we will be looking at whatever price actions that are appropriate at that point in time. Along the MedSurg business, again, same thing.
We'll be looking at price actions as appropriate, going forward. We are looking at that as a way to continue to help with the rise in inflation.
Thanks. That's helpful. Then I know China is small for you guys, but a little more color on what you're seeing on the ground there from the lockdowns and your expectations for the VBP for recon, which it seems like is delayed to the second quarter, and then, you know, trauma and neurovascular, if there's anything on the horizon there. Thanks so much for taking the question.
Larry, on China, as you mentioned, it is small. It's about 2% of our total business. Those products that are being currently impacted by VBP, so think about joint replacement, trauma, and extremities, are less than half of that. We have that factored into our guidance. We've talked about that before. We're expecting that to really play out this year, from a trauma and joint replacement standpoint. You know, neurovascular is early days. There are some activities happening at a province level, so we're still early in that process and don't really expect any major impacts there, for 2022. In terms of what we're seeing on the ground with regards to the COVID impacts, we're seeing the same thing that everybody else is hearing.
The strict lockdown policy is certainly having an impact on procedural volumes. We expect that to continue to play out in second quarter. Where it goes from there, I think is still to be determined, but we would expect probably easing as they go through this latest wave, look probably towards the back half in terms of procedural volumes.
Thank you. The next question is from Joanne Wuensch from Citi. Please go ahead, Joanne.
Thank you very much for taking the question. I wanna spend a little bit of time talking about the Vocera, the closing of it and your expectations for growth and revenue in this fiscal year.
Yeah. Joanne, thanks for the question on Vocera. I mean, as I mentioned in my prepared remarks, it's very early. I mean, we just closed the deal in February. When we announced the deal, we talked about our general expectations in this marketplace, where the market and the sales are growing in the teens. We would expect that to continue initially, but as we get it integrated into our businesses, that we're gonna be able to accelerate the growth of Vocera by being able to put it into more hands and more hospitals. We do expect that we'll be accelerating throughout the year, but again, we're early days in terms of the integration.
Yeah. The only thing I'd add, Joanne, is so far so good in terms of retention. We were able to retain a lot of the employees that we had identified. Frankly, all of the key employees have been retained and the integration efforts, even though it's early, we had a very good month of March. No disruption whatsoever in the sales cycle. So while it is early, so far so good, and we're very bullish on the prospects of Vocera having a very good year this year and obviously continuing into the future.
To put a little finer point on that, what is your expected impact on revenue and EPS? 'Cause we have organic revenue, and we have an EPS range, and I would assume this is incorporated in your updated guidance.
It is incorporated in our updated guidance. As we said from the beginning, we expect them to continue in turn, and you'll see it in the organic numbers every quarter. You'll see where Vocera shows up. You will see very strong double-digit growth on the top line. What we've said on the bottom line is that it certainly there's a modest impact on the bottom line. Really nothing really more to add there. We're gonna fuel the growth. It'll be a good year this year, and it'll be accretive starting next year.
Thank you. We now have Pito Chickering of Deutsche Bank. Please go ahead when you're ready.
Good afternoon, guys. Thanks for taking my questions. One more question on the inflationary pressures. Can you provide some color on what percent of the pressures came from freight versus raw materials versus labor? I'm trying to understand how much of this pressure is sort of permanent like labor will stick around into 2023. You said that the pressures are trending to the high end of 100 basis points you talked about last quarter. You know, what are you seeing that ends up in the fourth quarter?
Yeah. Pito, we aren't gonna provide that breakout in terms of the various parts of the business. I mean, it does continue to fluctuate around depending on where some of the shortages are. Like Glenn said, if we have supply shortages, we are seeing increases in freight that's more mixed based on air freight and things like that. We're not gonna provide that breakout. Certainly, we do expect, as Glenn mentioned, there are gonna be some portions of this that will be more permanent in nature and some that'll be more transient as we go through. Where it lands, I think we're still early.
Certainly as we think about our guidance that we laid out, we do expect it to have impacts as we continue throughout the year, but certainly within the range of the guidance that we provided.
Okay. Talking to a bunch of hospitals, you know, recently, they're talking about, you know, a lot of supply inflation that they're seeing. Just, you know, back to the pricing question, do you guys think that you have the ability to pass on some pricing to offset some of these inflationary pressures? Kind of how should, you know, we think about prices or, you know, for different divisions or different geographies? Thanks so much.
Yeah. I think the answer is yes. I mean, we are evaluating that. We're looking at pricing actions across our businesses, and it will be different. It'll be different based on the different types of businesses that we're in, the contracts that are in place, and in different geographies for sure. It's not gonna be a one-size-fits-all as we think about this. It'll be a very deliberate approach across our different business units and across our different geographies.
Let me just try to quantify that. If, you know, we had -1% price sort of in the first quarter, do you think we can end the year sort of flat or kind of how much price do you think we can get during the year?
Yeah, not something that we're guiding on.
Thank you, Pito. We now have a question from Ryan Zimmerman of BTIG. Please go ahead when you're ready.
Yeah, thanks for taking the questions. I wanna follow up on a couple things. Glenn, on your comments on EPS guidance, you said that, you know, you continue to expect more transient spot buying and long-term supply challenges. I think that was pretty clear in your messaging. You know, as I think about, you know, companies like Hologic last night who saw, you know, incremental headwinds on some of these electronic components more than they initially thought, I mean, how de-risked have you? I mean, at the low end of that $9.60, how comfortable are you that if this market gets worse for electronics, that we wouldn't have to go lower? I mean, how, you know, how much have you incorporated there, I guess?
Yeah, that's a tough question. I mean, I think, you know, I don't have a crystal ball. What I do have is I can see what we have pre-bought in our inventory. I do have the inputs from our suppliers in how they are looking at that sort of chip availability. And I also see, you know, the amount of activity that we have currently ongoing in terms of buying in that spot market. I would tell you that, you know, Q2 is probably gonna look pretty similar to Q1 in terms of that kind of pressure. But I am building up inventories, and I'm building up component inventories, and so I expect it to ease a little bit as I look at Q3 and Q4.
I think right now, that's the best I can do in terms of sort of eyeballing in where I think the impact of that will be in the P&L and also in terms of where our guidance is coming in. I think, you know, we didn't lower our guidance from January because, you know, we still saw a pathway to get within this guidance based on the activity we're seeing now.
Okay. I appreciate the color there. Kevin, you know, I appreciate the comments about neurovascular having a tough comp. But as we think about that market, particularly in the U.S. and, you know, the product profile today, how do you think about the long-term growth rate in the neurovascular segment given kind of where we're at, and the performance we saw this quarter, and what gets you back to kind of that sustained long-term growth rate?
Yeah, look, I still think this is a fabulous market long term. There's just no question it's a great market. We had a tough comp. There also was a bit of competitive activity in the U.S. in the ischemic side of the business. We see this from time to time, from quarter to quarter, so we certainly weren't expecting double-digit growth in the U.S. It was a little lower than we expected because of the competitive activity, but nothing too alarming. We will have a very strong year. We're gonna have a double-digit growth year in neurovascular globally, and the U.S. will pick up, in Q2, Q3, and Q4. It's still a great market. We're only treating a small fraction of the patients that have stroke today.
For that reason, with the pipeline and the great leadership team that we have over there at Neurovascular, I know that this is gonna be a very good long-term business.
Thank you. You now have David Saxon of Needham & Company. Your line is open.
Good afternoon, and thanks for taking the questions. Just wanted to get a sense on if you're seeing backlog procedures come back and if so, kind of where you're seeing you know those concentrated you know whether it's hips or knees or spine?
Yeah. Thanks for the question. In terms of the backlog, as we've said in previous calls, you know, the backlog has built up over really the last 24 months as many patients hadn't had procedures done. Certainly, we saw the uptick with procedures being done this past quarter. It's hard to say what portion of that was backlog versus new patients entering into the funnel. There has to be some piece of that backlog that's been worked down. Really, for the full backlog to be worked through, it's gonna take a sustained recovery. We're thinking about many quarters of recovery and being back to normal that's gonna get that backlog all the way down.
In terms of where it's coming from, it's really gonna be across all of those products that are more deferrable, so hips, knees, spine, some of the extremities products that we would expect to see that coming from. As we said previously, really it's gonna take several quarters of sustained normal that will work that full backlog down.
Okay. Great. Thanks. Just on the US spine 3.7% growth, just wondering, you know, how you think you did from a market share perspective and, you know, what's driving your growth. Thanks so much for taking the questions.
Yep. It's early in terms of the overall market growth assessment, but just like we look at hips and knees, we're pleased with the quarter. We're pleased with procedures recovering, certainly having an impact on spine. We're happy with our product portfolio. We do expect that spine will continue to benefit as procedures come back to more normal levels throughout the rest of the year.
Thank you. The next question's from Matt O'Brien of Piper Sandler. Matt, please go ahead.
Hi guys. This is Drew in for Matt. Thanks for taking the question. I just wanna follow up on Vocera with maybe a little bit more of a high level question. You know, we're obviously transitioning from a pandemic to a post-pandemic environment, which will presumably result in changes in how hospital environments have operated compared to the last couple of years. Is that changing how your customers are thinking about the value proposition or use case for Vocera at all?
I think the pressure that that's been put on the healthcare system and particularly nurses was obviously very acute during the pandemic. With the shortages that are out there right now, hospitals are looking for solutions that are gonna help keep their nurses engaged, help ensure that their errors aren't being made in the hospital, improve the workflow. I think our timing is perfect and that Vocera should be able. That this is a tailwind that's not over. I think this tailwind will continue to last for the next couple of years because it does provide really a reduced cognitive load for nurses. It makes their jobs easier. They're much happier when we have Vocera in their hospitals. We're really excited. We think our timing is really ideal and this is a multi-year tailwind.
That's all for me. Thank you.
Thank you. We now have Jason Wittes of Loop Capital. Please go ahead when you're ready, Jason.
Hi. Hi. Thanks for taking the questions. Just on cash flows, obviously you're having some P&L impact from inflationary expenses. How is that impacting your cash flows? Generally speaking, what sort of cash flow generation should we anticipate for this year? I guess related to that, when do you think you get back to a point where we could see another Vocera-like sized acquisition from Stryker?
Yeah. I'll tell you what, I'll take the cash flow one, and I'll have Preston talk about the M&A one. On cash flows, you know, a couple places. We're feeling the inflationary pressures that flow through with earnings first and foremost. And we'll see that all year long as those flow through all the way to cash flow. I think the other thing that you can see is that because we're in a position where we're pre-buying inventories and raw material inventories to make sure we have enough supply, we'll see increases in inventory that may be under normal conditions we wouldn't necessarily have. In terms of where I think cash flows will land, you know, I still think we're seeing really good performance in working capital.
We're performing relative to guidance in terms of CapEx spending, and those fundamentals are still in place. I would still expect us to deliver sort of a 70%-80% free cash flow conversion, excluding the Vocera impact related to that acquisition, the $130 million that related to a payout related to the employees' acceleration of options in their stock. Aside from that, we'll still be in that 70%-80% range.
Thanks. Appreciate it.
Oh, sorry. In terms of acquisition activities as we move forward, as we've said previously, following the Vocera deal, our first focus is gonna be on pay down of the debt. We'll certainly continue to evaluate tuck-in opportunities along the way as well. As we think about larger type deals like Vocera, it really is gonna depend on a couple of things. I think number one, the cash flow performance, as Glenn mentioned before. The second is really gonna be about the opportunities. I mean, we're not gonna just do larger sized deals just to do them. Certainly it's gonna be the right opportunities. I think overall just thinking about it, we still have the bandwidth to continue to operate in that space and complete those type tuck-ins and eventually get back to a Vocera type sized deal.
Thank you. I appreciate that detail. If I could just maybe a clarification on Mako. Did I hear you earlier specify that there were still some staffing issues sort of impacting installations there? Or, did I mishear that? Just curious about the dynamics right now for installing Mako systems.
No, no, that's correct. I think a lot of times when we talk about staffing, we immediately think about just the nursing staffing component, but staffing has been an impact at all different types of areas across the hospital. With a lot of our larger capital items, we've seen some delays in installations or even just in construction projects that have led to some of those delays, and Mako was impacted by that during the quarter as well.
Thank you. Our next question comes from Drew Ranieri from Morgan Stanley. Please go ahead.
Hi. Thanks for taking the question. Just more of a product question than I had a follow up. You guys highlighted Q Guidance and System 9 power tools, kind of that AAOS, and I know that they were more limited launches here in 2022. Just given the macro factors here, supply chain disruptions, I mean, does that
Realistically, what we could expect these products to deliver in 2023 with your spine growth or any pull-through there with enabling technologies or pricing benefits on the power tools?
Yeah. No, I mean, right, at this point, I would say we're obviously not giving guidance on 2023, but in terms of those products, still early. Q Guidance, still, it's still in the approval process, so we still have a ways to go there. In terms of the next power tools, also similar, we're still early in terms of getting that out from a launch standpoint next year. At this point, no update in terms of major impacts or expectations to what it might have on our numbers for next year.
Okay. Thank you. Just with Insignia, I think it was also highlighted that the instrument tray, it's more attuned for ASC usage. Is there anything that you're seeing with the recent launch that really shows that ASCs are being receptive, or is just the general environment maybe masking any uptake there of the new platform at ASCs? Thanks.
Yeah. What I'd say is the Insignia long, long product is ideal for direct anterior, which of course is very popular in the ASCs, but not just in the ASCs, also in the hospital. Even though we only launched it very recently, the feedback has been incredibly positive. We have a great design for the product. Surgeons are finding it terrific, the broaching, the offsets, the sizes, the fit, that it's really delivering on what we thought. We couldn't be happier with the launch, at least this initial phase of the launch. This will be a tailwind for our hip business, and it'll actually pick up as more and more sets are deployed in the field. You'll see it actually accelerate through Q3, Q4, and into next year.
Thank you. We now have Joshua Jennings of Cowen. Please go ahead. I've opened your line, Joshua.
Thank you, and I appreciate taking the questions. Just two, one on just the natural margin tailwind, Glenn, that you talked about earlier in the year, potentially driving some operating margin expansion and at least by the fourth quarter. Can you just help maybe frame that up a little bit better? Just thinking about how you're not guiding to upside to the six to eight percent range. We're getting to the top, but you know, getting through that top end of the revenue guidance range and just how impactful that natural margin tailwind from increased volume could be. Any quantification? I know it's hard, probably hard, but would be helpful even directionally. Then, just was curious, Kevin and Preston on just the strong recovery in knees and hips versus spine.
I mean, spine is recovering but not as quickly. Any thoughts on just why spine market recovery or volume recovery is a little bit slower than knees and hips so far in 2022? Thanks for taking the questions.
Yeah. Josh, I think I heard your question right, is what kind of op margin lift could we get out of sales performance that's above the 10%. You know, a couple things. Anything that we delivered above the 10% would still have that kinda gross margin and inflation overhang. We would feel that pressure. But you are correct that there's a natural operating expense leverage that incurs, that we incur when we sort of pierce through some of those larger double-digit growth items. I expect that you would see delivery at the op margin level in excess of where you're seeing us now, the 22% roughly. It would be accretive to that for sure.
Yeah. On your second question around the spine market versus hip and knee market, even if you go back to pre-pandemic, you know, the hip and knee market was growing, on a dollar basis, was growing faster than the spine market. The spine market did have some elements of the more acute procedures that were less deferrable. They, you know, it didn't decline nearly as much as the hip and knee business did. Not as much of a decline, and then therefore not as much of a pickup in a market that frankly hasn't been historically growing quite as fast as hips and knees. Those are the dynamics I think that you're seeing play out here. We're delighted with our performance, certainly in our, if you look at our knee business and hips, just this quarter.
We were leading the market in knees for a long time. Mako has been an enormous driver. Our cementless procedures are roughly one out of every two knees in the United States are going in cementless. We have a real competitive advantage that you're seeing play out with our knee number. Excited that our hip number's now moving up as well. I'm not surprised to see those growing faster than the spine business. We'll have to see how, when everyone else reports how the market's played out. To me, it's not that surprising.
Okay, Kevin. Appreciate it.
We now have a question from Danielle Antalfy from SVB Leerink. Please go ahead when you're ready, Danielle.
Good afternoon, everyone. Thanks so much for taking the questions. Just a quick question on, I'm not gonna ask about inflationary pressures per se, but what I am going to ask is the supply constraints that you saw, if there's any way, I know there's a lot of balls in the air as far as trying to nail down, you know, the different impacts to the top line on the quarter between COVID and supply constraints, things like that. Whether you can quantify even just directionally the impact from the supply constraints that you did see in the quarter, and then I have one follow-up on the backlog.
Yeah, no, nothing that we're gonna specifically quantify with regard to that. I mean, we still had pretty strong growth in our MedSurg businesses, which are where primarily our capital businesses are. Just know that there was impact in that those sales as a result. As we mentioned from an electronic component standpoint, primarily in the MedSurg business, as opposed to some of the others. Not something that we're gonna quantify.
Okay. I appreciate that. Then just a commentary on the backlog. The question I have there is if there's still backlog being worked down in such a meaningful way, is this impacting the referral chain at all? I guess what I'm getting at is how this impacts sort of midterm growth, sort of once we're through the acute COVID period. You know, I'm trying to think about hospital staffing issues and how all of this reconciles and what this means for really midterm growth, less near term. Thanks so much.
Yeah. No, no. I think if I understand your question correctly, I mean, I think the way we have to think about this is we've had 24 months of irregular activity with regard to these procedures. Throughout that time period, we've seen that backlog, quite frankly, just grow. I mean, the number of people that haven't had procedures done, as a result, whether they're currently in the funnel, whether they've been deferred from the funnel. Then as we keep going forward, the part of what we're gonna continue to see is we're gonna see new patients entering that funnel. I don't think there's gonna be a slowdown at all. That's why we're saying with this backlog, it's not something you're gonna see pronounced in any one particular quarter or month.
It's gonna be something that's gonna be a longer term work down that we're gonna see from people kind of funneling through the whole process. I think you're gonna just see that growth rate continues to just be pretty steady and growing.
Okay. Thank you.
Thank you, Danielle. We now have the final question on the line from Richard Newitter of Truist. Please go ahead when you're ready, Richard.
Hi, guys. Thanks for squeezing me in here. Just the first one, going back to some of the pricing commentary. I was wondering if you might be willing to comment a bit by care setting. The reason I ask, I was trying to think through some areas perhaps where Stryker's better positioned to take price even than other med tech companies, and your potential or your competitive advantage in the ASCs immediately came to mind. I'm just wondering if that's one of the areas where, you know, potentially there might be a possibility of renegotiated contracts in particular are gonna offer some opportunity there.
Yes. Look, given the inflationary environments we're in, as Preston Wells mentioned earlier, we are obviously gonna look at pricing actions across our portfolio. In some places, it's gonna be easier than other places, given the nature of our contracts. For competitive reasons, we're really not gonna disclose the tactics, the strategies, which products. Every quarter you see, we do report our pricing, so you'll get to see the overall impact. It's not something we're really gonna get into on this call.
Okay. Fair enough. Just maybe one last one. I think you said that you know, you're steering towards the lower end of earnings guidance for earnings per share. And you said that this assumes that at the low end at least supply chain pressures persist throughout the remainder of the year. You also said that you expect some improvement as you move into 3Q and 4Q. I just wanna make sure I'm reconciling those two comments appropriately.
Yeah, I think you're conceptualizing them right. I think what we're trying to communicate is, you know, in the short term, how we saw inflation impacting us in Q1, we'll feel similar inflation in Q2. We expect the environment to improve, which also means that we expect to start delivering more of the capital that's been in our order book in Q3 and Q4. We'll feel the impact of a lesser comparable from Q1 on the top line, and we'll also feel the impact of that sort of procedural backlog starting to free up, which from a mix standpoint also helps the bottom line.
Thank you.
Thank you. There are no further questions, and I would like to hand the call back over to Kevin for some final remarks.
Thank you all for joining our call. We look forward to sharing our second quarter results with you in July. Thank you.
Thank you. This does conclude today's conference call. You may now disconnect your lines.