My name is Caitlin Cronin, and I am on the MedTech team here at Canaccord Genuity. I am joined today by Vericel, a publicly traded medical device company focusing on treatments in sports medicine and severe burn care. With me today is Nick Colangelo, CEO. Before we begin, I want to remind everyone of any relevant disclosures which can be found on our conference and our firm website. And with that, I'll turn it over to management. Nick?
Thanks, Caitlin.
Okay, well, good morning, everyone, and thanks again, Caitlin. We're happy to be here for the Canaccord Conference. Before I begin, I'd like to just remind everyone that this presentation contains forward-looking statements, so you should refer to our documents on file with the SEC for further information. Vericel's a leading provider of advanced therapies for the sports medicine and the severe burn care market. We combine innovations in biology with medical technologies to create a portfolio of highly innovative advanced cell therapies and specialty biologics that are used to treat tissue injuries and restore function and lives for our patients. Our leading product is MACI, which is a product that uses a patient's own cells to repair cartilage defects in the knee and restore function.
It's a product that we launched back in 2017, again, for the treatment of cartilage defects in the knee, and it's become the leading restorative cartilage repair product by far and the only FDA-approved product in its class. In the severe burn care market, we focus on hospitalized patients with severe burns. And for these patients, the treatment pathway entails first removing the burned tissue or eschar and then grafting the wound to allow that wound to close. And so we have two products, one that addresses each aspect of that pathway. The first is NexoBrid, which we recently launched in the U.S. This is an enzymatic eschar removal product that is indicated for the treatment of adult patients with severe burns. Our second product is Epicel, which is a skin graft product that uses a patient's own cells to cover the wound once the eschar has been removed.
We believe that with the leading products or a leading product in each aspect of the treatment pathway that we have the premier severe burn care portfolio in the industry. I think one of the defining features of our portfolio is that we have sort of a unique set of competitive barriers to entry. As I mentioned earlier, each of MACI, Epicel, and NexoBrid are the only approved products by the FDA in their class. Epicel and MACI are regulated by the FDA as combination device biologic products. Obviously, the use of a patient's own cells is the biologic component, and there's a device component to each of the products as well. That provides great barriers to entry for us because there's no established generic pathway, no 510(k) pathway, etc. Really hard for other market entrants to come into our markets.
There's really no like products on the horizon, so we have a really long runway for those products. NexoBrid was approved as an orphan biologic in the U.S. It's got orphan market exclusivity for seven years, biologics data exclusivity for 12 years, and then patent protection beyond that. A really unique portfolio that we think provides a great foundation for us to continue strong revenue and profit growth. We think we're well positioned to deliver on that growth, and it starts with our financial profile. In addition to sustained high revenue growth that we'll talk about in a moment, we've also delivered positive Adjusted EBITDA and operating cash flow each quarter for the last three and a half years. We ended the year 2023 with about $150 million in cash and no debt. A really strong profile for the company moving forward.
As we look forward, we're really focused on reinforcing our position as a premier sports medicine company and, again, the leading cartilage repair business in the industry by focusing on MACI and maximizing growth in the core indication for cartilage defects in the knee. Advancing our pipeline, which in addition to a pediatric indication for NexoBrid, includes MACI Lifecycle Management Initiative so that arthroscopic delivery of MACI, which we hope to launch later this year, and then additional indications including the use of MACI for ankle cartilage defects that we'll talk about in a moment as well. And then secondly, creating a second high-growth franchise in the burn care space with the launch of NexoBrid and continued increased utilization of Epicel. So we entered 2024 with a lot of momentum after delivering outstanding results across the business in 2023. So we pre-announced our revenues at J.P. Morgan last month.
Company revenue, total company revenue growth grew 20% to $197.5 million. MACI revenue for the year was really strong, so up 25% to close to $165 million, and had a really strong fourth quarter. Had record revenue in the fourth quarter of $65 million. MACI growth was up 20-some%, so it was the sixth straight quarter of 20-plus% growth for MACI, a 50% step up from the third quarter. It was really driven by very strong underlying business fundamentals. We had the highest number of implants for MACI, implanting surgeons, biopsies, and biopsying surgeons. Really strong momentum with MACI. The burn care franchise had a great quarter as well. It was up 31% versus the prior year.
So great revenue growth that we think will carry into 2024 and also delivered strong profit growth, which I think sets our company apart from other companies of our size or in our space. So for the year, we had gross margins in the high 60% range. It'll be north of 70% in the fourth quarter, which is our highest revenue quarter. In terms of adjusted earnings, we pre-announced that that would be at least 30% in the fourth quarter and mid-teens for the year. So again, that sustained profitability that we think makes our company unique. And so as we look into 2024, based on the momentum of our core business plus the potential launch of arthroscopic MACI, having NexoBrid for our first full year, we expect company revenue growth to be even higher this year in the 20%+ range. And then profitability will continue to expand.
It's really we have a lot of leverage in our business as revenue goes up, strong pull-through to the gross margin and adjusted earnings line. We're actually on target to reach GAAP profitability for the full year as well, in addition to the fourth quarter, which we usually do because that's our highest revenue quarter. We certainly are playing in large underserved markets that support this growth. Just with our core portfolio of MACI and Epicel, it's a $3 billion-plus addressable market that we'll talk about in a moment with the addition of NexoBrid, MACI arthroscopic, and then MACI for the ankle over the course of the rest of this decade. It increases our addressable market by half again to over $4.5 million. Lots of room for us to grow.
Our core portfolio of MACI and Epicel has really proven to be a durable growth platform. So even through COVID, over the past seven years, we've had a 20+% compounded annual revenue growth rate. And that's, again, driven by the fact that these are very highly unique products, no competition for the products. And so it's really allowed us to grow very strongly over the past couple of years and again, or few years. And as we move into 2024 and 2025, for the reasons I mentioned, the momentum of the core portfolio, arthroscopic MACI, NexoBrid for a full year, we expect higher growth in 2024 and in 2025 as well. And that, of course, as I mentioned, will translate into strong profitability for the company.
So we expect margins, which really were kind of in the gross margins in the 50%-ish range back in 2017 when we launched MACI, will be in the high 60% this year. We mentioned we expect 70% gross margin for 2024 and then moving into the 70+% range as we continue to move in 2025 and beyond. From an adjusted earnings perspective, again, mid-teens in 2023, about 20% adjusted earnings margin in 2024. And that's a good proxy for our operating cash flow. So you can do the math and say if you're at close to $200 million, you're growing 20%, and you have a 20% earnings margin. It's a pretty substantial earnings and operating cash flow profile for the company. And really, even if you look at the fourth quarter, 20+% top-line growth, 30% adjusted earnings growth. So a really strong profile for the company.
Moving into sort of our products and pipeline, I'll start with the cartilage repair market as, again, MACI is our leading product. Cartilage injuries represent a significant unmet need. Cartilage defects are found on about 60% of arthroscopic procedures, and they're caused, as I'm sure most of you know, by either acute injuries, repetitive injuries, or degenerative conditions. It's essentially a pothole on the surface of the knee. Really, the issue with cartilage injuries is that there's no intrinsic healing properties with cartilage. So there's no blood vessels to bring repair cells. There's no lymphatics to clear away the debris. There's no nerves. So if you have one of these defects, it basically is going to get bigger. It causes pain, dysfunction, osteoarthritis, and ultimately partial and full knee repairs.
And that's why our approach of using a patient's own chondrocytes, which are the cells that are responsible for producing cartilage, has been so clinically effective and, again, has positioned MACI as the leading product in the market. It's a very large market given the incidence of these cartilage defects. There's about 750,000 cartilage repair procedures that are done each year. We believe that about 60,000 of those patients, based on the MACI label, how surgeons typically treat patients with cartilage injuries and so on, about 60,000 of those patients each year make up the MACI addressable market. And our revenue is a little north of 50,000 per implant, leads to about a $3 billion-plus market opportunity, which certainly supports the growth that we've seen over the past several years. The product itself is basically made up of a resorbable collagen membrane.
That's the device component seeded with a patient's own cells at a density of about 500,000-1,000,000 cells per square centimeter. We obtain the cells when a surgeon is typically doing sort of a chondroplasty or an investigational arthroscopy. They take a small Tic Tac-size biopsy of the cartilage, send it to our facility in Boston. We isolate the chondrocytes, expand them, cryopreserve them until a patient and surgeon are ready to move forward, thaw the cells, further expand them, seed them onto the collagen membrane, ship it out to the surgery center where the surgeon simply cleans up the defect, cuts the membrane to the size of the defect, glues it in with fibrin glue, and they're done. The chondrocytes then migrate down to the subchondral bone.
They begin to expand and basically repair the cartilage tissue, fill that defect, and allow the patients to resume their active lifestyle. So we think there's a number of attributes with just sort of the core MACI product that have really driven its growth. As I mentioned earlier, MACI has a very broad label indicated for the treatment of defects anywhere in the knee, no limitation on size, number of defects, whether there's bony involvement or not. And it's got unsurpassed clinical data and now long-term data out to 10 and 20 years. So once you repair the cartilage, it can last a lifetime for the patients. So that obviously brings in a larger number of patients that are eligible for treatment.
From a surgeon perspective, MACI basically took what was a very highly invasive, technically demanding, difficult procedure where in a prior version of the product, we had the patient's cells. It was in a cell suspension, so very tough to surgically administer, basically a liquid, filled with cells. So it was used by the top cartilage repair specialists in the country and world because it's effective. But again, it was a very difficult procedure and very sort of specialized. Number of surgeons that used the product with MACI, again, it made it a much simpler, less invasive procedure, much faster. And it's really grown the surgeon bases we'll talk about in a moment. From a patient perspective, obviously, without having to open up the whole knee, MACI is administered by a mini-arthrotomy. It's faster rehab for the patients, and that's demonstrated in published rehab protocols.
Very importantly, MACI's got great reimbursement coverage. Every major plan in the country has a medical policy that covers MACI, and over 90% of the submissions for prior approval are approved. Great coverage for MACI, which again has really helped with its uptake since we launched. As I mentioned earlier, the growth of MACI has been really driven in part by sort of a dramatic expansion of the surgeon base. When we launched MACI back in 2017, we had about 3,000 targets. By 2019, we had biopsies coming from about half of those surgeons on an annual basis, cumulatively more than that. We expanded our sales force to 76 territories, increased our targets of high-volume cartilage repair surgeons by a like amount, up to about 5,000.
After another double-digit growth in biopsying surgeons last year, we're approaching that 50% penetration again on our larger surgeon target base. As we expect to launch arthroscopic MACI later this year, there's another 2,000 surgeons that do high volumes of cartilage repair but principally or exclusively arthroscopic procedures. We'll continue to increase our surgeon base, and we would expect to kind of get to the same penetration levels over time. Of the growth drivers for MACI, which are expanding the surgeon base, increasing the number of biopsies per surgeon, which is a measure of the depth of penetration, how those biopsies convert to implants, and then price, surgeon base expansion will remain a strong growth driver for the next several years for us.
So when we turn to our pipeline, as I mentioned earlier, in addition to a pediatric label expansion for NexoBrid, which we hope to obtain this year, we're really focused on the approval for the arthroscopic MACI delivery. So we submitted a package to the FDA in the fall. We expect the approval in the third quarter of this year and commercially launch MACI arthroscopic. And this is really just a continuation of the journey, as many of you know, in the medtech industry. As you go from highly invasive procedures to minimally invasive procedures, you expand that customer base and the patients that are treated. And that's what we expect to happen with the arthroscopic delivery of MACI. Lots of market research, as you'd expect, indicates that current MACI users would expect to do more procedures. Surgeons who haven't yet adopted MACI would expect to shift procedures to arthroscopic.
Importantly, as opposed to other procedures, MACI would be the only arthroscopic procedure for restorative cartilage repair products like osteochondral allografts. So it's really moving into the mainstream of how these patients are treated generally. Of those 750,000 patients, 500,000 of those are chondroplasties, which are done arthroscopically. Another 200,000 are microfractures, which are done arthroscopically. It's really MACI osteochondral allografts. And if there's a concomitant procedure that's done, when you really have to open up the patient's knee. So we think, again, this takes MACI right into sort of the mainstream of how cartilage repair is done in the country. And importantly, the whole instrument system is designed around 2-4 square centimeter defects on the femoral condyles. So MACI is a go-to product for patella cartilage injuries or the back of the kneecap or the patellofemoral joint or larger defects.
We have a lot of business in smaller femoral condyles but a different share. So about 20,000 of those 60,000 patients each year have these 2-4 square centimeter defects on the femoral condyles. Our share of patella defects is double digits. And if we had the same share in the femoral condyle defects, we'd double our business over the next couple of years. So it's a really important entry for us, and we look forward to hopefully launching it in the third quarter of this year. So in addition to procedural advances, which is what MACI arthroscopic represents, we've also been looking at other joints. Obviously, there's cartilage on the end of the bones in every joint. The knee is the largest market opportunity by far. It's the greatest weight-bearing joint in the body, but behind that is the ankle.
So there's a large number of ankle resurfacing procedures that are done each year, about 165,000. We think about 20,000 of those, based on quantitative market research, would be eligible for treatment with MACI. So that, again, at our price point, would be another billion-dollar opportunity for us and combined about a $4 billion addressable market for MACI in the ankle and knee. So excited about those opportunities. And again, with no like competition coming down the pike and if ever, certainly the foreseeable future, we think we have a really long runway of high growth for MACI moving forward. So quickly turning to the burn care franchise. So the treatment pathway for these severe burn patients that are hospitalized basically is determined by the size and the depth of the burn.
So if you have a full-thickness burn of any size, and that means that the burn goes down to basically the muscle, the fat, or bone, you're going to be admitted to one of the 140 specialty burn centers in the country. Or if you have a partial-thickness burn, which means there's some dermal components left that's greater than 10% total body surface area, you'll be admitted to one of those hospitals as well. And those are catastrophic burns. 1% TBSA is about the size of your palm. So even a 10% burn is a very large burn. And again, the treatment pathway for these patients is first to get rid of the eschar or the dead tissue. That's a source of further burn progression because your body has an inflammatory response to the injury, obviously infections, and so on.
So it's really important to get the eschar off the patient and then figure out how you're going to cover the wound or graft the wound to promote healing. Again, large opportunity with concentrated call points, obviously, around these burn centers. So there's about 500,000 burns in the U.S. each year. About 40,000 patients are hospitalized. We think about three-quarters of those or about 30,000 patients a year typically have some sort of eschar removal. That's where NexoBrid comes into play. And at our price point, it's about a $300 million market opportunity for us. And then for the more severe catastrophic burn patients, where Epicel is used - and this is for patients that have 30% body surface area burns or above and we're typically treating 60%, 70%, 80% burns - it's a much smaller population.
But again, given the number of grafts they need, etc., it's almost like an orphan drug for us where it's $200,000 per order. So it's a big market opportunity even though it's a smaller patient base for us. So combined, we're really happy to have this sort of synergistic play of an eschar removal product, the only FDA-approved permanent skin replacement for full-thickness burns. And it makes for a really nice opportunity for us. The products themselves, so NexoBrid is really what we believe is a significant advancement in care for these patients right now. As I mentioned, getting rid of the eschar quickly is very important to the treatment of these patients. Right now, the standard of care is surgical. So they basically take the patients into the OR. They take a knife and basically cut away the dead tissue.
Obviously, burns are a variable depth, so you have a lot of healthy tissue and blood loss, so very traumatic for the patient. There are some nonsurgical products out there that are sort of well-known not to have great efficacy or limited efficacy. There's really a need for kind of a selective and effective eschar removal product, and we think that's NexoBrid. NexoBrid is a mixture of proteolytic enzymes derived from pineapple stems, so bromelain-based. Basically, these enzymes can recognize collagen proteins in the skin that are denatured by thermal burns. It's an amazing technology. If it doesn't work on electric burns, it's just how the proteins are denatured in thermal burns. Essentially, instead of going into the operating room and again going through surgery to remove it, you just topically apply it. Over the course of four hours, it dissolves the dead tissue.
You wipe it away, and then you're ready to cover that wound. So we think it'll change the standard of care for these patients over time, which we're really excited about. And then again, Epicel is a product that uses a patient's own cells. Just like with MACI, we take a small postage stamp biopsy or the surgeon does. They send it to our facility in Boston. We isolate the keratinocytes, which are the predominant cell in the epidermal layer of the skin. We culture them, and it forms a skin sheet that you can see here. Put a petroleum gauze on the back of it, which is the device component. Ship those grafts out to the surgeons and surgical centers, and they apply them to the patients. And it's a very important product.
For these catastrophic burn patients, they typically don't have a lot of healthy skin because skin is highly immunogenic. You can't do a transplant with somebody else's skin. The body will just slough it off. So you either have to do autografts where they'll take a layer of skin off, run it through a mesher, and try to cover the wound, or you use a product like Epicel for these patients. And so there's great patient survival data that's been published around Epicel and a really important product for us. So just to wrap it up, in addition to our core portfolio and all the great things we have going on in terms of new product launches, we're obviously out there looking for other products as well, typically in the sports medicine, severe burn care.
There aren't many companies that actually have approved cell therapy products that are successfully commercialized in the U.S. So we do look at other products like that. They aren't quite as common. And so from our perspective, we're always on the lookout. We built the company. We purchased the core business from Sanofi. It was part of Genzyme Biosurgery. We licensed in NexoBrid. So we do a lot of BD transactions. But we're also pretty selective in what we look at. We have a very innovative portfolio. We have a great financial profile. And anything we do needs to fit within that. So we tend to be pretty selective about it. But we're certainly spending time looking at that. So Caitlin, I'll wrap it up here just saying we're pretty excited about kind of how the company's position going forward and happy to take any questions.
Do you have a bit more time left? So do you have any questions? Just a follow-up quick question.
Oh, we're out of time. Oh, okay. That happens pretty often. Sorry about that. So okay, thanks, everyone.