Good morning, ladies and gentlemen, and welcome to the Zimmer Biomet Q3 2022 earnings conference call. If anyone needs assistance at any time during the conference, please press star followed by zero. As a reminder, this conference is being recorded today, November 2nd, 2022. Following today's presentation, there will be a question-and-answer session. At this time, all participants are in a listen only mode. If you have a question, please press the star followed by the one on your push button phone. I would now like to turn the conference over to Keri Mattox, Senior Vice President, Chief Communications and Administration Officer. Please go ahead.
Thank you, operator, and good morning, everyone. I hope you are all well and safe. Welcome to Zimmer Biomet's Q3 2022 earnings conference call. Joining me today are Bryan Hanson, our Chairman, President, and CEO, EVP and CFO, Suky Upadhyay, and COO, Ivan Tornos. Before we get started, I'd like to remind you that our comments during this call will include forward-looking statements. Actual results may differ materially from those indicated by the forward-looking statements due to a variety of risks and uncertainties. Please note we assume no obligation to update these forward-looking statements, even if actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties, in addition to the inherent limitations of such forward-looking statements. Additionally, the discussions on this call will include certain non-GAAP financial measures.
Reconciliation of these measures to the most directly comparable GAAP financial measures is included within our Q3 earnings release, which can be found on our website, zimmerbiomet.com. With that, I'll turn the call over to Bryan. Bryan?
Thanks, Keri, and thanks for joining us for the call this morning. We've got 3 sections of the call. First, I'm going to briefly talk about our Q3 performance and really the momentum that we saw in Q3 that has allowed us to increase our outlook for the year. In doing so, even in the face of some pretty meaningful macro pressures that we're certainly still facing. I also want to spend time talking about our ZB innovation. This is clearly the driver of our continued strong performance and will be the driver as we go forward. For the second section, Suky will provide more detail on the quarter, but probably more importantly, our 2022 guidance update. Then we'll close things out by addressing any questions you might have.
Before I get started on Q3, I just want to make sure that I take a minute to say thank you. Thank you to the ZB team members that I know are listening. I know a lot of you listen to the call, and I appreciate that. Your continued strong performances, it's just built on day in and day out execution. You're just focused on driving results. I know you're showing up and facing some very, very real macro challenges right now, and I appreciate it. You know, the fact is, I'm just really proud that even in the face of these challenges, you're delivering results for our customers, you're delivering results for our patients and for our shareholders, and you're moving the mission of this company forward every single day. I know it's not easy, but I promise you it is much appreciated.
Okay, turning to the Q3 . You know, although the beginning of the quarter was a bit choppy when it comes to procedure cancellations, we did see very nice improvement throughout the quarter, and we finished strong. That execution and recovery occurred in all of our regions, but especially in our OUS regions, with both EMEA and APAC performing better than our expectations. Inside of this, we saw good momentum in our large joints business, with our knee franchise growing in the high single digits and our hip business growing just above 10%. As you've seen, this was somewhat offset by the telegraphed and expected pressure in our S.E.T. business and our other category. Now, although we did see the strength in the quarter, we continue to face significant challenges across foreign currency, supply, inflation, and staffing.
You know, that said, the team has been able to navigate these challenges and mitigate their impact. You can't completely eliminate them, but they've certainly mitigated their impact, and they've done this through operational and commercial discipline, as well as driving our innovation in the field. As a result, our confidence continues to grow. You see that reflected in our updated financial guidance. In short, our underlying business is clearly strong, and I truly do believe it's getting stronger. Just as an example, when we look at the quarter, we announced a first of its kind 3-year agreement with Hospital for Special Surgery or HSS. You know, the partnership creates HSS Zimmer Biomet Innovation Center for Artificial Intelligence and Robotic Joint Replacement.
We're focused here with HSS to develop new tools that will be powered by AI to provide data-driven recommendations or insights to surgeons for robotic assisted joint surgery. It's really, you know, it's a big deal. We're clearly very excited about it. We really do believe this is a future of medicine opportunity, and we're excited to be involved with HSS. In our Q3, our new product pipeline continued to deliver as well. While it's early, we are definitely excited about the launch of HipInsight. This is the first FDA cleared mixed reality navigation system for total hip replacement. HipInsight is the latest addition to our OptiVu portfolio, and it further expands our ZBEdge suite of solutions. Additionally, we announced the FDA clearance of our Identity Shoulder System.
This is a technology that has proprietary capability of aligning each surgeon's approach to an individual patient's anatomy. All of this with the goal, first and foremost, of alleviating pain, but also optimizing the range of motion for that patient. I got to tell you, our existing product portfolio kept up the momentum as well. Demand continues for ROSA, both in knee and hip. Persona Revision traction in the US remains strong, and our limited launch of Persona IQ is driving positive feedback and interest, and we're focused on aggressive data collection so that we can establish clinical use benefits. We expect to build on this momentum with new product launches in the coming months, including, as we've talked about, our new Persona cementless form factor, additional launches in our S.E.T. category, and a hip product launch that we're excited about in early 2023.
I can tell you that all of these product innovations, coupled with our ongoing efforts to reshape our business and accelerate ZB's transformation, position us very well for future growth. We continue to strive to be a best and preferred place to work for our team members, and we continue to strive to be a top quartile performer for our shareholders. To be a trusted partner to all of our stakeholders, but in particular, our customers and our patients. Just in summary, we're navigating and really managing through some very real macro headwinds that are definitely muting our growth. We're also seeing an offset via COVID recovery, very strong execution from the team, and meaningful innovation in the field. Against that backdrop, our team continues to execute our strategy, and I feel increasingly confident about our future as a company.
With that, I'm gonna turn it to Suky to talk more in-depth about Q3 and give you an outlook for 2022 guidance. Okay, Suky.
Thanks, Bryan, and good morning. Overall, we delivered another good quarter driven by strong execution and continued recovery of elective procedures. While we continue to navigate challenges, our Q3 performance gives us the confidence to raise our full-year financial guidance. With that, I'll turn to our Q3 results. Unless otherwise noted, my statements will be about the Q3 of 2022 and how it compares to the same period in 2021. My commentary will be on a constant currency and adjusted continuing operations basis. Net sales in the Q3 were $1.67 billion, a decrease of 0.9% on a reported basis and an increase of 5% on a constant currency basis. U.S. sales grew 3.2%, driven by strong elective procedure recovery and commercial execution, especially in our knee and hip businesses.
This was partially offset by expected declines in the S.E.T. and other categories. International sales grew 7.3%, driven by strong procedure volumes across most markets in EMEA and APAC, in tandem with lighter comps and continued strong commercial execution. EMEA performed better than expected, driven by recovery in developed markets and continued strength in emerging markets. APAC performed better than expected, with China largely in line with expectations and strength in Japan. Turning to our business category performance. Global knees grew 7.2%, with U.S. knees up 7.3% and international knees up 7%. The strong performance was driven by knee procedure recovery across most regions and easier comps, along with continued global traction of our Persona Knee system, especially with Persona Revision in the U.S., and continued increase in ROSA procedure penetration and pull-through.
Global hips grew 10.5%, with U.S. hips up 5.3% and international hips up 15.5%, driven by strong international procedure recovery and an easier comp outside of the U.S. Continued traction across key hip products, including the G7 Revision System and Avenir Complete Primary Hip, which is focused on the direct anterior surgical approach. Lastly, continued solid ROSA pull-through in the hip category, especially in the U.S. The sports extremities and trauma category declined 2.1% and was impacted by a tough comp in 2021, and the expected pressure around VBP, which is expected to reverse in Q4, and reimbursement headwinds in U.S. restorative therapies that will anniversary in mid-2023. Within the category, we continue to deliver strong performance across our key focus areas of CMFT, sports medicine, and upper extremities.
Finally, our other category declined 0.4%, driven by tough comps and expected lower capital sales related to a higher mix of ROSA placements versus upfront sales. Moving to the P&L. For the quarter, we reported GAAP diluted earnings per share of $0.92 compared to GAAP diluted earnings per share of $0.77 in the Q3 of 2021. The increase was driven by a decline in litigation-related expenses and a tax benefit in the quarter from a favorable tax liability outcome. On an adjusted basis, diluted earnings per share of $1.58 represents a decrease from $1.71 in the Q3 of 2021. Adjusted gross margin was 70.7% in line with expectations. As previously discussed, heightened inflationary pressure will drive full-year gross margins to be slightly down when compared to the prior year.
As previously noted, increasing input costs from this year will pull through into 2023, and we now expect the headwind from inflation in 2023 to be at the upper end of our previously communicated 50-100 basis point range. Our adjusted operating expenses were $742 million, an increase versus the prior year due to inflationary pressures and higher investments into R&D to support future product launches. Our adjusted operating margin for the quarter was 26.3%, a 200 basis point decline from the prior year, and largely driven by increased inflationary pressures and continued investments into the pipeline and product portfolio.
Despite ongoing macro headwinds, we continue to expect our efficiency programs to drive improved H2 operating margins versus the H1 of the year with a step up in the Q4 in tandem with higher revenue. The adjusted tax rate was 16.3% in the quarter, in line with our expectations. Turning to cash and liquidity. Operating cash flows were $451 million, and free cash flow totaled $332 million for the quarter. We reduced our debt by about $160 million in the Q3 , excluding the effects of foreign currency, and ended the quarter with cash and cash equivalents of about $545 million.
On a related note, despite a higher interest rate environment in 2022, interest expense is expected to be broadly in line with our previous expectations for the year. However, we would expect a step up of interest expense into 2023. We have made significant progress in strengthening our balance sheet through improved financial performance and ongoing debt reduction, ultimately providing greater strategic flexibility for the company. Moving on to our updated financial outlook for the year. Constant currency revenue growth is now expected to be 5.5% to 6.5% versus 2021, with an expected foreign currency exchange headwind based on recent spot rates of 550 basis points versus our previous assumption of 500 basis points. This means that reported revenue growth will be in the range of 0% to 1% versus 2021.
Also related to revenue, based on the recent spot rates, we estimate that the strengthening of the dollar through 2022 will create about a 300 basis point headwind to revenue growth in 2023. Additionally, we are tightening our expected adjusted diluted EPS range to $6.80 to $6.90. All other metrics in our 2022 financial guidance remain unchanged from our Q2 update. As a reminder, we expect Q4 revenue growth to be slightly higher than the Q3 , due in part to a tailwind related to Q4 2021 VBP charges that will be partially offset by about a 1-day selling day headwind. In summary, we had another solid quarter underpinned by market recovery and good execution, and we are pleased to again raise our full-year outlook.
While we expect to have to continue to navigate a number of persistent macro headwinds, ongoing market recovery in tandem with strong execution and attractive product pipeline leaves us confident about our future. Lastly, I'm extremely proud of and want to thank our broader ZB team for all that they do. With that, I'll turn the call back over to Keri. Thank you.
Thanks, Suky Upadhyay. Before we start the Q&A session, just a quick reminder to please limit yourself to a single question and 1 follow-up so that we can get through as many questions as possible during the call. With that, operator, may we have the first question, please?
Thank you. We'll take our first question from Shagun Singh with RBC.
Great. Thank you so much for taking the question and congratulations on a strong print here despite a you know pretty challenging environment. Bryan and Suky, I was just wondering if you can elaborate a little bit more on 2023. Just on the top line, how should we think about the durability of growth? I think last quarter you talked about a 4% floor, but it looks like you have stronger momentum going into next year with a 6% exit rate. T hen on margins, given the incremental impact you called out from FX and inflation, do you still believe you can drive operating margin expansion next year, or is that going to be more challenging? I have a follow-up.
Okay. 2 really good questions right out of the gate. M aybe, Suky, I'll start with the revenue side of that equation, and then you could answer on the margin side. Certainly any color you wanna provide that I might miss, feel free to do that. You know, maybe just to make it simple, I'll just start with the end of the story and then I'll get into some of the details around variables that I think are important to consider. But just going to the end of the story, you know, we said that in an undisturbed market we would be disappointed if we couldn't grow 4%. Now, I would tell you that we do not see 2023 as a normal market or a non-disturbed market. There's just too many variables moving.
We still do see a pathway to 4% growth. Okay? That's kind of the end of the story. Now let's take a look at some of the puts and takes that we have to look at that could either benefit or detract from that. On the positive side of the equation, I'm gonna start first with those things that are controllable by our company. There are really 3 major things that I look at that give me confidence and should give you confidence. Number 1, it's around innovation. I'm just gonna call it the innovation flywheel here at ZB is really moving in the right direction, and it's creating a solid pipeline that importantly is translating into moving our vitality index north.
That continues to move north for us, and we expect it to continue to do that on a go-forward basis. Innovation is a really big part of our confidence. The other is just the team is executing, you know, really strong execution right now and hitting a stride, which is important for momentum in a business. The third one is around a continued focus from this organization on moving our weighted average market growth north through very disciplined portfolio decisions. I'm talking about not just active portfolio management, but truly looking at the way we spend in research and development, commercial infrastructure, the way we compensate our people, the way we actively move things out of the portfolio that are not helping our WAMGR and move things into the portfolio that do.
That has allowed us to increase our weighted average market growth, and we're continuing to do so. Those are the positives coming into 2023. From a macro standpoint, we have a couple of positives as well.
I really look at the backlog of patients in orthopedics as being real. I can't put a number to it, but it's hard to size. It's hard to say when it's going to be impacting the markets, the pace that's gonna impact the markets, but at some point, this has got to begin to work its way through the system, and that could provide a tailwind to 2023, and then comps as well in 2023. It's gonna be choppy. You know, we've got choppy comps, so you're gonna see differences in growth rates by quarter. The fact is, when I look at the full year, we should look at comps as a slight positive to 2023. On the negative side, it's the stuff that everybody's talking about, unfortunately.
We do have a very constrained supply challenge situation, and we're managing through it, but it's a tough road and that's gonna continue throughout 2023, we believe. Staffing and OR capacity has continued. It's not as difficult as it was, but that's gonna remain a headwind for us in 2023. We also look at recession risk on elective procedures, particularly if it impacts unemployment. All that to say that 2023 is not a normal year, given all these variables. There's a lot to manage, a lot to think through, and a lot to contemplate in the way that we set up our guidance range.
Based on what I'm seeing today, I expect there to be a 4 handle in that range, which, hey, may or may not sound like a lot to people looking at Medtech, but to us, you know, knowing where we started, that's a pretty significant step up from where we started the journey, and we're proud of it. Again, we're just getting started. That gives you a sense for revenue components and our view on revenue as we come into 2023. Then, Suky, I'll pass it to you on the margin side.
Yep. Thanks, Bryan, and good morning, Shagun. Thanks for the question. On the margin side, you're right. The macro environment has become incrementally more challenging here in the back half than we originally assumed. That's been reflected in our rest of year outlook, and despite those challenges, we've been able to raise the back end of our year. W e're pretty proud of that, and the team's doing a great job. You know, as that rolls into next year, it has become incrementally more challenging, but we still see a path to maintaining or slightly improving our operating margin versus 2022, despite some of these headwinds. You know, and that assumes current market conditions. If things erode or if things improve, we'll revisit that.
Where we are today and assuming some stability on some of those headwinds, that's how we're thinking about 2023. The biggest move for us really has been around FX. As you know, we increased our full year outlook by 50 basis points to 550. That means we're exiting the year at 600 basis points of headwind on revenue. That translates to about 300 basis points of headwind into next year. T hat's got a pretty significant impact on the top line in absolute dollars and, of course, there's a flow-through to margin and to earnings on that. Despite that pretty big drag, again, we believe there is a pathway, and we're committed to maintaining or growing margins into next year. The other major area you touched on was inflation.
Our previous estimate was that we'd have 50 to 100 basis points capitalized out of 2022 into 2023. We're now at the top end of that, but still within our overall purview that we gave earlier this year. The real driver of that increase has been less about supply and raw material costs and less about wage and inflation, which were the bigger areas. It's more about higher freight costs right now trending higher, as well as energy costs, especially in Europe. Again, at least on the bigger components of that, we're starting to see some stabilization. Hopefully that's a positive light towards the end of the tunnel. You know, interest expense, again, just recognizing the higher interest rate environment we're in, we would expect overall interest expense to be modestly higher next year.
Just making sure that folks have that as an update to their model. Look, we're continuing to address our efficiency programs. We're going deeper and faster. I really wanna commend the overall ZB team for embracing these challenges and hitting them head on. They've done a fantastic job. Again, just based on that execution and assuming current market conditions hold into 2023, we think we've got a pathway to maintain or slightly improve.
That's really helpful. Thank you so much for the color. Just as a follow-up, I was just curious to get your thoughts on portfolio management. You know, in the context of shift of procedures to the ASC setting, we are hearing about 60% of recon procedures could be done in the ASC setting by 2028 or let's say even by the end of the decade. You know, any thoughts on that, and are you still under indexed in that setting? Thank you so much for taking the question.
Yeah, thanks. Maybe I'll start off with that, and then, Ivan, if you wanna weigh in, feel free to do so. You know, we clearly still see the ASC as an attractive sub-market of our recon business and also clearly other parts of our set business. It's one of the faster growth sub-markets, and we're clearly increasing our focus and spend in that area. We're doing it in a couple of ways. Number 1, we're putting infrastructure in place. We've got dedicated commercial teams that focus only on the ASC. That's important because you've gotta have contracting prowess in that space, and we've done that over the last couple of years, and we're really getting good traction as a result of it. Additionally, we're making sure that we scale up in the product categories that the ASC is looking for.
You know, we wouldn't have purchased a Booms and Lights company if we didn't wanna have that infrastructure for the ASC. Not to take anything away from Booms and Lights, but it's not an area that we would have waded into if it wouldn't have given us scale in the ASC marketplace. Same thing in sports acquisitions that we've done and in other parts of our business. W e're really doing it 2 ways, commercial infrastructure, product portfolio, so that we have a broad-based contracting opportunity in the ASC. We're seeing traction as a result of that. We do expect the ASC to continue to move north relative to the number of procedures being done in the ASC versus the hospital.
Now, I don't know that I would agree with the numbers you stated, but certainly we believe that it's going to continue to move north, and we want to make sure that we're taking advantage of that. Ivan, I don't know if you had anything else you want to add.
Yes. Good morning. I think you covered pretty much everything, Bryan. But I do think one of the drivers of having a complete portfolio now is that we have best-in-class contracting. There were contracts back in 2020 and 2021 that we're not a part of, Zimmer Biomet was not a part of, and we're a part of today. Indeed, the portfolio gaps have been remediated, the dedicated strategy working. While we don't disclose the specifics in terms of growth, we are growing at double digits in the ASC category here in the U.S. We believe we'll continue to grow at double-digit rates.
Thank you. Thanks, Shagun, for the question. Yeah. Operator, can we go to the next in queue, please?
Thank you. We'll take Steven Lichtman with Oppenheimer & Co. Inc.
Thank you. Good morning. I was wondering if you could talk about the strength you're seeing in the hip side of your business, particularly as it relates to ROSA pull-through. What are you seeing as it relates to surgeon interest on the hip side with ROSA? And would you say you're still in the early days in terms of that being a tailwind?
Yeah. I'll probably pass the. Just that it's product related more than anything. I'll probably pass it to Ivan to speak to the hip performance. Also, Ivan, maybe speak to some of the things that, without too much specificity, that we're predicting in the future to help the hip business as well.
Absolutely. Thank you. Steve, I will just summarize the hip performance so far, when it comes to robotics above expectations. We like the fact that this is the only pinless robotic system in the world. We like the fact that it remains CT scan-less, which is a great advantage for the ASC setting that we're talking about. We've seen versus conventional hip procedures a similar level, if not higher level of accuracy in the procedure. For all the clinical reasons that I'm alluding to, continues to be a best-in-class product launch. It's gonna continue to scale up. We are right now placing, installing about 30% of all robotics, including hips, in ASC settings.
Again, a major advantage in settings where time and efficiency makes sense. Beyond robotics, beyond hip robotics, also excited about other product launches we got going on hips. I think you might have heard from Bryan in the opening remarks. We got a partnership in mixed reality with a company called Surgical Planning Associates that enables Zimmer Biomet to be the only FDA-approved mixed reality platform in hips in the US. What do we solve through mixed reality? We get better visibility in hip surgery. We get better accuracy and overall better efficiency. These are some of the technologies that we're gonna be displaying in Dallas this week, ROSA Hip as well as mixed reality HipInsight. But it's a cadre of other products that continue to have momentum.
Continue to perform strongly, globally with Avenir Complete. We believe that we have the best robotic platform with G7 and Arcos. Again, multiple examples of innovation that are gaining some traction, both here in the U.S. and globally.
Great. Thanks, Ivan. Suky, just a follow-up. Thanks for the color on the 2023 inflationary headwinds. Just wondering if you could talk about offsets. You mentioned some of the internal efficiency programs, but what about on pricing? Are you seeing any progress on pricing initiatives? You know, any color you can provide on that and what potential impact that might have on the offset side?
Yeah. Thanks for the question, Steven. We have so far this year seen an improvement in overall pricing erosion at the company level. You know, our historic pricing erosion was in the 200-300 basis points per year coming into 2022. So far this year, we're tracking about 100-150 basis points. There's been some marked improvement. You know, we've been making investments around data and analytics systems, better governance. We've hired additional capabilities. Ivan talked a little bit about contracting. All of these are contributing strategically and tactically to that improved price. As we move into next year, we do expect there to continue to be pricing erosion.
We would, you know, hope that and expect it to be at the lower end of our historic average, if not better. While we do expect it to be better than where we've been for the last several years, it will still be a headwind year over year. Now, having said that, there are a number of other efficiency programs that we're targeting to help offset some of these headwinds, like our new global business services or shared services operating model that we created through the pandemic. We're taking a much more targeted look at country profitability, the product portfolio, active portfolio management that Bryan spoke about, looking at products that have lower margin, lower growth opportunities, and thinking differently about those investment profiles.
These are all things that are gonna help contribute to offset those headwinds.
Got it. Thanks, Suky.
Steve, thanks so much. Yeah. Operator, can we go to the next slide in the queue, please?
We'll take our next caller from Vijay Kumar with Evercore ISI.
Hey, guys. Thanks for taking my question. Bryan, maybe my first one on your 4% for fiscal 2023 as a starting point. I'm curious, what is that 4 assuming? It looks like there is no backlog. You know, pricing still continues to be a headwind. It looked like you sounded pretty bullish on new products. I'm assuming that 4 is assuming minimal contribution from new products. Could you just go through the assumptions, please?
Yeah, I think, you know, you've kind of laid them out already. You know, when I think about the forward-looking revenue growth, you're gonna have puts and takes. The things that we know are gonna be positive for our business will absolutely be innovation. When I think about the calculus on revenue growth going forward, there's no question that we've included innovation. You know, we're spending a lot of money and a lot of focus in research and development. We're bringing great products to the market, and we absolutely expect that to buoy our revenue growth. That's part of the reason why we came from a 0% growth business in 2017, 2018, and now we're predicting we can get to 4%. That's been a big part of that movement.
The execution of our team is another part of it. There's no question. I know that it's hard to put a dollar amount on momentum in an organization, but momentum does matter, and we have it right now. The other big one is that weighted average market growth. We have moved our weighted average market growth north during the last 5 years. As we get closer for our weighted average market growth to that 4%, it gives us more confidence that without share taking, we can deliver the 4% in a consistent way. Now, certainly we wouldn't stop there. You know, active portfolio management is phase III of this organization, and we're gonna have more financial flexibility going forward. We're gonna continue to change that weighted average market growth rate up.
You know, getting to the 4% to start is a good thing. The negatives against that, because you're saying, "Okay, if you got all these positive why isn't it more than that?" We still have real challenges around supply, and that is a distractor for growing your business. We're gonna have to manage through that as we get through 2023. We believe at least through the middle of 2023, potentially beyond. Even though staffing, you know, our capacity isn't as acute as it was before, it's no question that this is gonna be a headwind for us going forward. Of course, we have to calculate some potential risk associated with the recession if that does occur.
I think it's all those things combined in concert with this concept of having some backlog that we're hoping we can count on in 2023, but as of yet, we haven't seen it. Even Q3, which was a great quarter, we still don't believe backlog was consumed. We certainly might have had some backlog in certain areas consumed, but it was offset by some of these negative headwinds, and we actually think backlog built in Q3. Those are the, you know, the variables that we're looking at as we think about 2023 and beyond.
That's helpful, Bryan. Suky, 1 for you on your free cash flows year to date. It's really been impressive up year-over-year. Free cash conversion north of 80%. You're probably one of the few med tech companies to have free cash flows up. Is that a timing impact or anything else going on the free cash flow line item?
Yeah, Vijay, we have posted a really good 9 months here. I would say there is some timing benefit in the Q3 that will reverse in the Q4 . It has to do with some payments around VBP as well as some tax payments that normally would fall in the Q3 , but now will land in the Q4 . All in all, I think you nailed it. We're having a pretty good year in cash, and we feel confident in our overall range for this year.
Understood. Thanks, guys.
Yep, thank you.
Thanks, Vijay.
Thanks, Vijay.
Operator, can we go to the next question?
We'll take our next question from Travis Steed with Bank of America.
Hey, good morning, everybody. I wanted to follow up a little bit more on the 2023 comments. I think before you had said EPS to grow faster than revenue growth. Now that was with op margins up, now op margins are kind of flat to slightly improving. Just curious how we should think about EPS growth now versus the 4% constant currency growth if EPS is still up, but probably less than 4%. I did wanna clarify on the interest expense. You said higher interest expense, but I think you have no floating debt. Just kind of curious what's driving the higher interest expense.
Sure. Bryan, I'll go ahead and take those. 1 thing to remember on the EPS line is, you know, I talked about 300 basis points of headwind on revenue into next year. As Bryan talks about, you know, that 4% on an ex-FX basis, you need to take into consideration the foreign currency headwind that materializes into next year. Having said that, you know, with the margins kind of being relatively in line, maybe slightly up, and with interest expense up year-over-year, which I'll talk about in a moment, you know, you would expect on a reported basis to see EPS kinda travel in line with overall reported revenue. Hopefully that gives you a little bit more color. Again, that's our best view right now.
Things can obviously change between now and when we finally give guidance for 2023 in the Q1 of next year. On your question related to interest expense, you're right. We are on face value in fixed debt, but we also do and have done some previous strategies to swap out our fixed to floating. It's really the interest burden on those swaps that create that higher interest expense.
Okay. No, that's helpful color. Bryan, I wanted to ask on M&A. Like, you kind of always talked about getting more aggressive with M&A once the market stabilized, which it seems like 2023 is a year where we're in a much more, quote, "almost a normal market." I guess willingness to do something on M&A that can maybe move the needle a bit more and, you know, more adjacent to the portfolio versus some of the things you've been doing historically, which are more smaller private stuff and such.
Yes. You know, first of all, I wanna be careful what I say because it's a pretty competitive space right now, and we don't wanna telegraph too much what we wanna do. You know, clearly, we as an organization are squarely in the phase III of our transformation. You know, we, Travis, we've been very clear that phase III is all around active portfolio management to transform the portfolio, shifting toward more WAMGR accretive markets and diversifying our business. That's kind of broad-based way of looking at what phase III is all about for our company. We've already made some changes here. I know you're saying there's been smaller acquisitions that we've done, but we haven't had as much firepower, obviously, but we have spun businesses out as well that have helped in this strategy.
That said, COVID is getting behind us, there's no question. As a result, just exactly the way you're saying, we would expect to have more strategic flexibility going forward. What I'll probably be willing to say, and maybe not give any more detail, is that we're gonna look at vetting assets across a few metrics, outside of the typical financial metrics. We look at mission centricity. We've got to make sure that we're acquiring something that can move the mission. We want absolutely something can drive WAMGR accretion for our organization, and it's got to translate into revenue growth that's accretive, because just 'cause you're in a fast growth market, if you don't have a good asset, you don't necessarily get the growth rate out of it. It's got to accelerate our EPS growth over time. Okay. That's kind of the vetting.
Then the categories that we're gonna look at would be, first and foremost, probably closest to the best, would be fast growth subcategories of recon. That would be things like data, robotics, or building more scale in the ASC setting like we were talking about just a minute ago. It would be faster growth areas outside of recon, but still in orthopedics, and that would be mainly in our S.E.T. category. That diversifies our business away from just recon in those faster growth subcategories of orthopedics. To your point, you know, attractive white spaces that are completely out of orthopedics, less elective in nature, and provide more diversification, again, out of orthopedics.
I don't wanna say which of those we're gonna prioritize, but just know that all of those vectors are on the table, and we're looking at a number of assets in each of those categories.
Great. Thanks for the color.
Absolutely.
Thanks. Operator, I think we can go on to the next question in the queue.
We'll take our next question from Robbie Marcus with JP Morgan.
Oh, great. Thanks for taking the questions and congrats on a good quarter. Maybe to start, Bryan, I'd love to hear a little bit more about what you're seeing on the capital equipment environment. I know it's a smaller overall component for Zimmer Biomet, but you talked about lower capital sales in the quarter. It sounded like it was a bit more placement versus upfront sales, but any color on ROSA, what you're seeing, if it's different U.S. versus OUS, and how you expect that to trend going forward over the next 12 to 18 months?
Yeah. I'll make some comments and then Ivan can correct anything I say incorrectly. You know, clearly, capital is not as big a component for us, so I almost don't like talking about the capital market because I don't wanna say anything that's gonna hurt those businesses that depend more on the capital market. From our perspective, where we do focus on it hasn't been a major barrier for us. You know, again, we really focus on, from a ROSA perspective, trying to place through agreements that allow for payment for the ROSA system through commitments in increased business. You know, consider it a leasing arrangement, but the leasing payment is actually a commitment of business. That is what we focus on, and we did more of those in the quarter, and that's a good thing for our business.
We do have opportunities to continue to sell, and we do not feel at this point anyway, serious constraints in the capital market when it comes to ROSA. Maybe, Ivan, if you've got any further color to provide around that, you can help as well.
Absolutely, Bryan, good morning, Robbie. I'm pretty sure that correcting my boss publicly is a bad career move, so I'm not gonna correct you. I simply think your answer is right in line. The other thing of that is that it is really a global performance. 50% of the installations are here in the U.S., 50% are OUS. As I referenced earlier, around 30% of our robots are going to the ASC, and that segment is growing. We've seen exciting momentum with the hip software. I would say all in all, our robotic installations placement sales are in line. They continue to move in the right direction. As we enter Q4, we're very excited about where we are now from a ROSA standpoint.
Great. Thanks. Maybe as a follow-up. I think, Bryan, you said last quarter, extremities grew double digits. You know, this a little less visibility in this line item. You know, anything you could give us on extremities? I know sports medicine has the, HA, reimbursement changes so that there's some pressure there. But any color on what we're seeing extremities versus, trauma and sports and how that might shake out US, APAC, EMEA? Thanks.
Yeah, no problem. Maybe just as a quick reminder for everybody, when we think about our S.E.T. businesses, and there's really no proxy for S.E.T. in other businesses because we have different categories in it than others would probably consider. We have the upper extremities business inside of S.E.T., trauma, CMFT, which is our cranial maxillofacial and thoracic business, sports. Separate from sports would be restorative therapies and then foot and ankle. Those are the categories that we manage across the S.E.T. categories. The pressure that you were talking about in restorative therapies would be separate from sports, but it's still in the S.E.T. category. On the areas that we really focus and invest in our growth drivers would be upper extremities, CMFT, and sports. Doesn't mean the other businesses aren't important.
They just don't get the same level of resourcing at this point. Those 3 that we do concentrate on did have another good quarter. If I look at all 3 of them without giving specifics, I would say they ranged anywhere from mid-single digits to double-digit growth again this quarter. In the areas where we're concentrating, there's no question that we're getting the performance in the field.
A lot of that has to do with commercial infrastructure and then the incremental support that we're giving in research and development to those areas, and of course, the acquisitions that we've been tucking in to drive a more fulsome portfolio. What you're seeing relative to pressure in the quarter for the global S.E.T. business, it really has more to do with what Suky said in the prepared remarks around Asia-Pacific pressure and trauma, mainly associated with VBP, which will reverse next quarter, and then that restorative therapies pressure from a reimbursement change in Gel-One. Unfortunately, that will carry through to the middle of 2023 or so.
Appreciate it. Thank you.
Sure.
Thanks, Robbie. Operator, can we go to the next question in the queue, please?
We'll go next to Joanne Wuensch with Citibank.
Good morning, and thank you so much for taking the question. I wonder if you can step back a little bit and talk about the orthopedics markets, what you're viewing as maybe changes or not changes in the competitive landscape, maybe something in physician practices, pricing, or generally what you think of as sort of the state of the union. Thanks.
That's a great question. It's an interesting question. I think, you know, what I'll probably do is, again, maybe start off on some of the things that I'm seeing that I think are interesting. Then Ivan, Suky, you know, Keri, anybody who wants to add anything because I think it's a really interesting question that makes a good one. My view and probably the thing that I like the most that I'm seeing, kind of state of the union, as you're saying, is just the rapid adoption and open arms that I'm seeing from an orthopedics customer perspective to technology. You know, there was a lot of question marks in my mind coming over to orthopedics on whether or not that transition could truly occur.
We saw it with Mako, obviously in robotics, but we're bringing a lot of other technologies to bear. I've been very excited to see all companies kind of doubling down on the technology front, robotics and data. We're all moving in that direction. I'm hearing from our customer base that they're looking for it, and very importantly, willing to pay for the value that it brings. That's really important because if that type of innovation comes into a marketplace, particularly in med tech, it usually doesn't leave. When you do bring that kind of technology, it is more sticky than previous technology. It does have the ability to impact pricing dynamics. Because the more technology that has stickiness to it, the longer the term contracts and the better stability you have in pricing.
You also get this benefit of increased, it's called share of wallet or mix per every procedure. If you can bring technology in to the very same procedure you had yesterday, you get more revenue for that procedure. As we see that adoption continue to move up of things like robotics and data or cementless technologies in knee, that actually allows a mix benefit for the entire market. That could buoy the overall market growth rate, taking pricing stability, moving that forward, bringing more revenue per procedure. That has a real positive effect for the overall orthopedic space. That's a dynamic that's happening real-time that's pretty exciting in my view anyway. I'll open it up to anyone else if they want to add anything.
Maybe quickly here, Bryan, I'll just recap some of what you said in 4 bullet points here. Number 1, as it was mentioned earlier, the shift of care onto the ASC, and frankly, in some cases, some things getting done at home, like physical therapy is real. No longer is all about the inpatient unit. There's a real shift of care, again, to ASC. Then post-surgery, some of the stuff getting done at home. That's number 1. Number 2, clearly, the decision maker is not just the physician or the provider. The patient plays a role. That's why we're excited about some of the technologies that we're launching that directly target consumers, patients. It's no longer just the physician, provider. It's patient, physician, provider and payer.
Some of the data and the technology that Bryan is talking about becomes really a powerful tool for us to engage payers in demonstrating that we are not just a solid, clinical value proposition, but also an economic value proposition. Number 3, I think this align with the pricing story, there is an emphasis in discussing value just as much as pricing. Some of the discussions that we're having today around length of stay, reducing length of stay, some of the discussions we're having around lowering readmission rates, increasing patient satisfaction, having a shorter surgery with the same outcomes were not discussions that were happening maybe 3 years ago, and they're happening right now. Number 4, the role of innovation. I've been in med tech for 28 years. I was working in orthopedics 15 years ago.
When I joined orthopedics again 4 years ago, I would say that things were pretty much the same, aside from a couple of robotic introductions. Over the last 3-4 years, we've seen a lot of innovation coming to orthopedics in mixed reality, in infection management, in bringing machine learning, in really thinking about the entire episode of care. I would say those are the 4 key things I would pay attention to. I would think we have a competitive advantage in those areas.
Very helpful. Thank you.
We'll take our next question from Richard Newitter with Truist Securities.
Thanks for taking the questions. I wanted to just follow up first, Bryan, on what you were talking about on kinda some of the pricing opportunities you mentioned with new technology, mixed reality, smart implants. I'm curious, within the buckets of mix, the ability just to preserve your pricing as contracts roll off and discrete opportunities to charge for some of these newer areas, particularly on that third bucket, can you give some examples of where these new technologies might be able to fall into that third category? Or which of those buckets should we expect more of the pricing impact from?
Yeah. I'm making sure that I understand your question specifically, but when I think about the innovation that we're bringing, and not just us, by the way. That's what I like about it. There's momentum across the entire orthopedic space, and all the major players are moving in this direction. I think in certain areas, we're ahead. Make no mistake, everyone's moving in this direction. If I just take a couple of examples, and hopefully this will answer the question that you're asking. Think about mymobility, for instance, which is one of the first launches that we had in data collection, leveraging a relationship that we have with Apple. This uses an Apple Watch to collect data and then ultimately uses machine learning to be able to do some predictive analysis.
We're actually now looking at that through an opportunity to tell a surgeon and a patient when they're falling out of the norm for recovery. Okay, that's the type of thing that we're able to do, and we do sell that. There's an opportunity to monetize that application. It's not just giving it to them and getting pull-through of implants. It certainly is getting the pull-through of implants because you get that natural gravitational pull once you bring technology in, but there's also a discrete way of making money or monetizing that mymobility application. That's 1 example. Another example is robotics. I mean, robotics comes in, you get that natural gravitational pull for competitive surgeons to come over, but you also get an uplift every time they use a robotic procedure because you get the uptick in disposable value.
That procedure now costs more for the account to do, but you get the benefit of robotics inside of that, so it's a fair trade. Those are 2 examples of the way technology is leaning in that way. Same thing with Persona IQ. That's the first smart implant that'll be on the market. It's collecting data in a very compliant way because you can't take it off, right? It's there nonstop for the patient. That will also drive a premium in the marketplace. If you're gonna use Persona IQ, you're gonna pay discretely for that sensor capability. That's the way we're monetizing this.
You could see a combination of things where we monetize the technology, or sometimes it just brings value that is unique to us that would allow us to pull in additional implants. It's some combination of those 2 things. Again, Ivan, if you wanted to add anything else, or Suky or anybody else.
I think you've done a very thorough job, Bryan. We can go to our next question.
Great. Just on Persona IQ, it seems like the infection prevention capability or the ability to detect an infection before it occurs, that's probably gonna be the killer app for a product like that'll allow you to get that kind of premium. I guess, what should we think of timelines on the data collection to be able to get an approval for infection prevention indication?
Yeah.
I can take that one, Bryan.
What I've learned over the years is, you know, committing to timelines in a situation like this is always a bad idea. What I can say is that we are absolutely sprinting and using our limited launch focused on getting users that will use significant quantities and be able to collect data with us so that we can ultimately look for different ways of providing insights that will matter to our customers. The things that we wanna focus on first would be what are those things that we could predict that will obviously be good for the patient, but also reduce the cost associated with caring for the patient, so reduce the cost of caring for the patient. An infection is great. That's. If you could get there, that's fantastic.
If we could predict a risk of infection before it occurs, that would be fantastic. Certainly something that we're gonna be looking to do, but it doesn't happen very often, so you just think about the power, the number of patients you're gonna have to have, the amount of data, it's gonna take us a little longer to get there. What we're also gonna be looking at, though, is just, you know, loosening, which also happens. Can we predict loosening before it happens? You're looking at stiffening. There, there's certain things you've got to do from a stiffening perspective that if we can get out ahead of, we can reduce the amount of, you know, care that needs to be provided to the patient.
There's a lot of other things that we're looking at to try to predict that will derail the cost or reduce the cost of caring for the patient and make sure for better outcomes for the patient. I don't want people to get hyper-focused on infection. It's something that we're gonna pursue. It'll take longer. The real goal right now is to be able to look at the data that we're collecting, which is significant already, and then be able to derive those insights that will change the way we care for our patients. Once we get to those and we can define those, that will really begin to bolster that value proposition that we have for the product and be able to support a higher price point for Persona IQ.
Thank you.
Sure.
We'll take our next question.
Operator, can we go to the next question in the queue?
We'll take our next question from Jeff Johnson with Baird.
Yeah, thanks. Good morning, guys. Bryan, maybe even building further out on this pricing discussion, I think it's all interesting stuff. You know, the premiums you can get on new technologies, on sensor-based technologies, you know, moving that mix higher and all that all makes sense. You know, I'm more interested or equally interested, I guess I should say, on kind of your base business. I don't know what your vitality index is right now, but let's say 70% or 80% of your revenue is generated on products that are a few years or older in the portfolio. You know, where are hospitals at in understanding that they can't keep extracting 2 or 3 points of price even out of those base products every single year if you're going to continue to invest and develop this new technology in that?
Are those conversations with hospitals improving at all in this, especially in this inflationary environment?
Yeah. You know, probably what I'll do is I'll turn this one over to Suky because we don't look at pricing just through 1 vector or 1 lens. There's multiple variables that we have in that equation that we think are gonna benefit the company going forward. Maybe, Suky, you could talk about the variables that we do look at when we think about pricing, and I know, Ivan, you probably have some color as well you wanna provide.
Yeah. We do think overall that this can help pricing discussions. They're becoming much more strategic in nature and more centered around value. We're not completely there where we wanna be, but we're starting the dialogue more around value versus just straight price in transactions. But maybe, Ivan, you wanna talk a little bit, because I know you've got some real-world experience.
Yeah, absolutely. It's a real discussion. It's happening, Jeff, in pretty much every country. As you think about our vitality index, there is a direct correlation between improvements in vitality index, percentage of sales coming from new products, and stability around price.
It may not be, it can all be mixed, the product launch itself that you launch in a given year. As you launch, as an example, a Persona IQ, that creates a category contracting opportunity where we contract that for the rest of the portfolio needs, they gotta keep a certain price. Again, that is a real discussion, 1 very real example of how we think about it. We do that in knees, we do that in hips across the board. Again, a very direct correlation between new product introductions, vitality index, and keeping the price premiums for the product a couple of years later, but also for the category of products in a given space.
Yeah, that's helpful. Thank you. Maybe just a follow-up, and I think, Suky, it's probably for you, but as I think about this placement strategy with ROSA or kind of how the market has shifted over the last 6-12 months to more of a placement strategy, and it sounds like that's probably gonna continue, at least for the foreseeable future. You know, when do we get that crossover where the minimum purchase commitments, maybe the minimum price points, things like that are guaranteed in those contracts, those start to outweigh on the good guy side versus I'm sure which are some upfront costs you're having to eat here on this placement strategy, and it's probably not helpful in the very short run on the margins, things like that.
Just when does that crossover happen that the longer tail of those positives really start to kick in? Thanks.
Yeah. I'll start with it and turn it over to Ivan. You're thinking about it the right way, right? Upfront here, there is some investment relative to those placements 'cause you start that depreciation and you really haven't ramped up that overall growth commitment. We're still in the early innings on that, but maybe Ivan, you wanna talk a little more.
Yeah. I would say the governance when it comes to robotics is second to none. When we do install, place a robotic unit in any center globally, there is a minimum commitment of cases that the center has to perform or we take the unit back. You know, 1 reason is financial. The other reason, perhaps more importantly, is from a compliance standpoint. You know, giving a fair market value exchanges, we cannot have capital equipment in centers that are not delivering on the contracted number of cases. That's why we keep talking about how we prefer to place units versus sending units, so we get the annuity. On the other side of the equation, as we think about those cases, there is also a governance around disposables.
There is 0 latitude when it comes to pricing discounts on the disposables, the peripheral items that are part of the robotic case. Again, I would say that the robotic governance is second to none and really early innings here in terms of where we are in the journey.
Thank you.
Yeah. Thanks for the question. Yeah. I think, operator, we have time for maybe 1 more.
We'll take our next question from Matthew O'Brien with Piper Sandler.
Morning. Thanks for taking the questions. Just maybe I'll just stick with 1, and Bryan, I just wanna put a finer point on this top line number that you're talking about for next year. First of all, is that 4% kind of the floor that you're thinking about for the business next year? Just as I think about the components that you're talking about between VBP and pricing and, you know, ASCs, et cetera, it just seems like the environment for hips and knees specifically is gonna get more robust. You're really levered to hips and knees. Y you know, why wouldn't 4% be the floor and there's the potential for, you know, some meaningful upside to that, as we head into next year? Thanks.
Hey, hey, the positive news is that's the question I'm getting and not a question of whether we can deliver the 4. We're making progress there. I would tell you that I still think that, you know, as I talked about before, there are a lot of headwinds that we have to pay attention to. I don't wanna say that, first of all, we're giving more color than we would ever give in a normal year, just given all the, you know, the challenges that everybody's facing, trying to help you out here. I would say 4 is a number that I'm saying is doable. We see a pathway to 4.
Make no mistake that there are challenges that are out in the market, macro challenges, not things that are internal to our own organization that could stress that. There are opportunities from a macro perspective that we just talked about that could also help that. We're trying to take a balanced view of what could happen, positive or negative, to what we think organically we can do in 2023. That's the reason why I would say for you should not consider a floor. For you should consider, you know, a good way to look at all things considered, a fair way to look at growth in 2023.
By the way, if 2023 was just a normal year, and we didn't have all these noises, we believe that 4% is about the right way to think about our business. You know, given all the portfolio moves that we've made, the WAMGR-directed improvements that we've made, the innovation flywheel that we now have moving, we believe that's what we deserve. Could we do more than that? Certainly, particularly as we start to continue to move our active portfolio management strategy, we have more financial flexibility, and we continue to move that weighted average market growth rate north. I don't want people thinking that I mean 4 as a floor. I didn't mean to intend that.
Understood. Thank you.
Sure.
All right. Operator, I think we're a little past 9:30. Unless there's any closing remarks or Bryan, anything you'd add, we're probably good to end the call.
Yeah. I probably just said it. I think I want people to continue to focus on the transformation that has occurred at Zimmer Biomet. We've been extremely disciplined in our portfolio decisions. Portfolio to me is in all aspects of the business. We are biasing our spend, whether it be research and development, commercial infrastructure, the way we compensate people in active portfolio management through M&A on ensuring that we're increasing the weighted average market growth of our business and diversifying our business over time. That is happening. It has already happened, and more of it will happen on a go-forward basis. I keep talking about that innovation flywheel, but that was nonexistent just a few years ago. The vitality index is moving in the right direction in a rapid way, and we expect that to continue.
All of that combined with the execution that we're seeing from the field is putting us in a good place in a very challenging market. I guess I'll leave it with that, Keri.
Thanks so much, Bryan. Thanks everyone for joining the call this morning. Of course, if you have questions, please feel free to reach out to the IR team. I know we'll speak to many of you today. Thanks for joining.
Thank you again for participating in today's conference call. You may now disconnect.