Alphatec Q1 2025 Earnings Call Transcript

Quartr
Provided by Quartr
May 1, 2025

There are 11 speakers on the call.

Operator

Good afternoon, everyone, and welcome to the webcast of ATEC's First Quarter Financial Results. We would like to remind everyone that participants on the call will make forward looking statements. These statements are based on current expectations and are subject to uncertainties that could cause actual results to differ materially. These uncertainties are detailed in documents filed regularly with the SEC. During this call, you may hear the company refer to non GAAP or adjusted measures.

Operator

Reconciliations of these measures to U. S. GAAP can be found in the supplemental financial tables included in today's press release, which identify and quantify all excluded items and provide management's view of why this information is useful to investors. Leading today's call will be ATEC's Chairman and CEO, Pat Miles and CFO, Todd Koning. Now I will turn the call over to Pat Miles.

Speaker 1

Thanks much, Greg, and welcome everybody to the Q1 twenty twenty five financial results ATEC earning call. There will be a few forward looking statements, I would ask for you to review at your leisure. So really a great start to 2025. Enjoyed revenue growth at 22%, with surgical growth at 24%. That's about four times the market if you're keeping track.

Speaker 1

This is really a a phenomenal result for the largest pure play spine company in ATEC. So Q1 is always a little challenging seasonally when it comes to profitability and cash flow. As cash flow or case volume slows compared to Q4, taxes reset, we see a disproportionate share of meetings and events. But in spite of all of that, we delivered $11,000,000 of adjusted EBITDA, which is our second best quarter ever and above expectations. And from a cash flow perspective, our cash burn in Q1 was at the low end of the range at $15,000,000 So profitability and cash flow performance in Q1 has really put us in a great position to meet or exceed our twenty twenty five goals.

Speaker 1

And I think if we hearken back the changes we made last year resulted in a much more cash efficient organization. And so we are 100% committed to continuing to operate the company in a deliberate manner and deliver growth, profitability and cash flow commitments as stated. So the revenue came in at $169,000,000 Really, key thing I'd like to highlight is the strength of the surgical growth where we saw 24% year over year growth. Underpinning this growth was an 18% increase in the number of surgeons utilizing ATEC procedures. The fact that revenue grew 23% in established territory demonstrates how we continue to gain surgeon and territory penetration where we have established representation.

Speaker 1

And so what I would tell you is our thesis is working and where we have representation that's been established, we continue to compel adoption. And so the durable revenue growth drives profitability and cash flow clearly. EOS order growth was also a record for which we're very, very encouraged. It's a foundation of our strategy. And finally, as the largest pure play, we continue to be the preferred destination spine.

Speaker 1

The environment for recruiting sales talent couldn't be better and really we're off to a great start with great confidence in terms of moving into the year. So anyway, with that, I'll turn it over to Todd.

Speaker 2

Well, thank you, Pat, and good afternoon, everybody. I'll begin today with the first quarter twenty twenty five P and L highlights. Total revenue was 169,000,000 up 22% compared to the prior year. The $169,000,000 in revenue was comprised of $152,000,000 in surgical revenue and $17,000,000 of EOS revenue. First quarter surgical revenue of $152,000,000 grew 24% compared to the prior year period.

Speaker 2

That represents nearly $30,000,000 in year over year growth. When normalizing for selling days, we grew $32,000,000 year over year or 26%. Procedural volume growth was 17%, driven by strong surgeon adoption of 18%. This level of adoption clearly reflects the compelling nature of our portfolio and is supported by the ongoing investments in the sales force. Average revenue per procedure growth was a strong 6% as we continue to capture more of the procedural revenue opportunity.

Speaker 2

Same store sales or sales that come from sales agents that have been in territory for a year or more grew 23% year over year, which demonstrates that we continue to grow significantly in the markets where we are already established through growing both our share of wallet with existing surgeons and new surgeon adoption. EOS revenue increased $17,000,000 in the first quarter, up 8% compared to last year. Record order volume has fueled a 28% year over year increase in the order book, evidence of the demand for our unique end to end informatics solution, and positions us for strong system installations and the accompanied implant pull through in the coming years. Turning to the remainder of the P and L. First quarter non GAAP gross margin was 70%, down 50 basis points compared to the previous year and up 70 basis points sequentially, primarily driven by product mix.

Speaker 2

Non GAAP R and D was $13,000,000 and approximately 8% of sales. Top line growth drove two thirty basis points of leverage, while absolute spend has remained roughly flat. Non GAAP SG and A was $111,000,000 and approximately 66% of sales. Approximately 400 basis points of year over year improvement came from variable expense rate improvement, while the balance came from infrastructure leverage. We reported total non GAAP operating expense of $124,000,000 which was approximately 74% of sales.

Speaker 2

By maintaining disciplined cost management, we delivered a modest 8% increase in operating expenses while continuing to invest in the growth drivers of the business. Those efforts, along with our durable top line growth, drove a 900 basis point expansion in our operating margin year over year. I'll turn next to adjusted EBITDA, which was positive for the fourth consecutive quarter. Our first quarter adjusted EBITDA was $11,000,000 equating to a 6% margin and over 800 basis points of improvement compared to the prior year period. We are very pleased with this performance as it is the second best performance we've had since the start of ATEC's transformation.

Speaker 2

This quarter also ATEC's marks our second consecutive period with an over 40% drop through on a year over year revenue growth to adjusted EBITDA, reflecting both infrastructure scalability and an improving variable selling expense profile. You can see in the chart in the slide that the profit margin expansion that we are executing has been significant and consistent. This quarter marks 12 consecutive quarters of adjusted EBITDA margin expansion. We entered 2025 a stronger company, and that is clearly reflected in our first quarter results. This progress stems from the changes we implemented last year to improve in two key areas: firstly, the management and prioritization of our human resources and secondly, strengthened focus and operational improvements in managing inventory and instrumentation sets.

Speaker 2

We are driving meaningful margin expansion that aligns with the priorities outlined in our long range plan and as a result of disciplined execution. These deliberate results give us great confidence in our ability to continue delivering on our financial commitments and translate revenue growth into profit and cash flow. Turning now to the balance sheet. We ended the first quarter with $153,000,000 in cash on hand. Additionally, we had access to $60,000,000 of available borrowing on our revolving credit line, which was undrawn at quarter end, making our total cash and available cash $213,000,000 Our free cash use of $15,000,000 in the first quarter represents a $55,000,000 improvement in cash use over the first quarter twenty twenty four.

Speaker 2

We managed our free cash use performance to the favorable end of the 15,000,000 to $20,000,000 range that we previously communicated and would have beat if not for working capital headwinds. And these headwinds were modest and transient, and we believe the metrics will improve over the course of 2025. Our first quarter cash management execution and the underlying dynamics of the business reinforces our confidence that we will be cash flow positive for the full year. In March, we successfully refinanced our 2026 convertible note. Refinancing effectively pushed out the maturity to 02/1930, provided dilution protection up to $23.46 and maintained the same low coupon rate of 75 basis points.

Speaker 2

We used the $4.00 $5,000,000 of proceeds to pay for the fees and the capped call and bought back 80% of the existing convert, the maximum allowed under creeping tender rules. The net proceeds of $82,000,000 gives us flexibility to address the remaining $63,000,000 of the 26 notes when the time is right. Our financial outlook for the year expects continued strong revenue growth to drive incremental profit margin expansion. As we exited the first quarter of the year and contemplated our full year outlook, we felt it prudent to simply flow through the beat on the top and bottom line. This approach is consistent with our philosophy of guiding the numbers we believe we can achieve and have a reasonable opportunity to exceed.

Speaker 2

As it relates to cash flow, our first quarter performance further reinforces that we will be cash flow positive for the full year 2025. With respect to the cadence of our cash flows for the remainder of 'twenty five, we expect the second quarter to range from $0 to $5,000,000 with the third and the fourth quarters generating positive cash flow, resulting in us being cash flow positive for the full year 2025. Our revenue outlook for the full year 2025 expects adoption of our unique procedural approach to drive revenue growth of 20% to approximately $734,000,000 compared to our previous guidance of $732,000,000 That includes Surgical revenue growth of 21% to approximately $658,000,000 which will be fueled by mid teens Surgical volume growth and mid single digit revenue per Surgery growth. We expect EOS revenue of approximately $76,000,000 Turning to the outlook for the full year 2025 adjusted EBITDA. We expect sales growth to continue to leverage the infrastructure we have built, contributing to an adjusted EBITDA of $78,000,000 versus our prior guidance of $75,000,000 This includes us absorbing the impact of expected tariffs in the second half of the year.

Speaker 2

Our direct exposure to tariffs is limited to the EOS units we import from France to support The U. S. Installations and the associated repair parts. We estimate the impact of tariffs on our cost of goods sold to be in the low single digit millions of dollars. The chart on the slide depicts the consistency of the profitability progress we are making.

Speaker 2

Our adjusted EBITDA guidance of $78,000,000 will generate an adjusted EBITDA margin of 11%. That implies a 39% drop through of the incremental growth in revenue dollars to adjusted EBITDA. This trajectory positions us well to achieve our 2027 adjusted EBITDA margin goal of 18% at $1,000,000,000 in revenue. So in conclusion, through our investments in the team and infrastructure, we have built a fast growing 100% spine focused company. We are delivering on a return on those investments through durable revenue growth leadership and consistent operating leverage improvement, which is beginning to inflect the cash flow generation.

Speaker 2

With that, I'll turn the call back over to Pat.

Speaker 1

Thank you much, Todd. I want to spend a few slides just kind of walking through a couple of strategic imperatives. As as I would say. Our strategy has been steadfast and our execution relentless. And and so we have been consistent not only in who we intend to be, but the execution of it all.

Speaker 1

So we are creating clinical distinction. It's undeniable. We have and will continue to architect unparalleled procedural solutions that improve patient outcomes. I think PTP and LTP are are are clearly we're heading into the to deformity in a similar way. The revenue growth and surgeon user growth affirms we are compelling adoption.

Speaker 1

So we are doing this by furthering clinical value. We talk a lot about furthering value by minimizing surgical variables with technology, and this is happening. Additionally, we're expanding our sales force and getting better in the field. So I would say that we are scaling and we are winning. Something that's near and dear, think, is really the growing validation of our EOS and informatics thesis.

Speaker 1

We've talked a lot about the unusually high revision rates in spine surgery versus hip and knee, which just speaks to the opportunity. The volume of variables in spine surgery far outnumbers that in single joint surgery. Our view is that many of the issues driving revision surgery, spine surgery can be effectuated by controlling variables through improved informatics, hence, the the foundational commitment. So I think that there's a misplaced notion that revision is most often caused by interoperative surgery due to a lack of precision. The reality is that most revision surgery is not due to error in implant or pedicle screw placement, but rather error prior to the surgery due to a lack of surgical planning.

Speaker 1

It is for this reason, we are strong we strongly believe that the spine field needs more automated informatics. And so we view our pre, intra, and post op informatics drive much more, will drive much more predictable surgery, than the incremental precision associated with pedicle screw placement. Hence our thesis to thesis committed to ES and informatics. Much like we said in the early days of ATEC the ATEC turnaround, spine needs ATEC. I would say that spine surgery needs automated alignment planning and predictive analytics, and and we're bringing that to you with with EOS.

Speaker 1

And so super enthusiastic with regard to to that. There's nothing better than having a a and and then have it reflect in the specific patient outcomes, and and that's, that's what we're doing. And so I would tell you that our our history is one of technological furtherance. And and much like when we acquired SafeOp and integrated different, modalities, the auto EMG, auto SSEPs, and facilitate MEPs, we further the technology to a point of great clinical influence on lateral surgery. And so if you wanna look at a proxy, SafeOp is a proxy for what we're doing for EO.

Speaker 1

So the the same effect is happening with EO. So, below in fixorially, what you see is you see a patient with a pre op scan gave not only spinal alignment parameters in an automated way, but also where the spine should be normatively. And so not just, numeric reflection, so bringing objective measure, but really where the spine should be. A surgical plan was assembled and executed with a post op scan of six and twelve weeks. So you'll see that the pre op picture reflects not only automated measures, but but where the the normative position is, Where the spine should be based upon age and demographic.

Speaker 1

The plan provides a simulation of values required to achieve the surgical goals. And then the the six and twelve week provides assessment for surgical plans. You could tell exactly how you did. This is a much more comprehensive clinical approach to what is commonly done today. If alignment is a key quota to a successful long term outcome, meaning it impacts or lessens the revision rate, it is this type of information that brings about objective measure and meaning and makes for a meaningful difference.

Speaker 1

So we cannot be more excited about where we are with the EO strategy. Clearly, there's a lot of enthusiasm with regard to the acquisition of the units, and we are headed to a future of predictive analytics and that we find to be extraordinarily exciting. If you think about what's fueled the company today, it's really kind of the architecting procedures for really architecting procedures. And what we see is we see expanding complexity. So, our procedural strategy continues to expand application and grow in volume.

Speaker 1

For us, it is quite clear that if your objective is to lessen variables that undermine clinical predictability, then assembling all the elements of a procedure will create demand and compel adoption. We have seen our lateral franchise grow in both total procedures and addressable pathologies. Like most new techniques, surgeons start their adoption in short segment, simple type of applications. And then as they see success, they continue to expand utility to more levels and greater complexity. That has clearly been the case with what we've done from a lateral perspective.

Speaker 1

Then we have recently launched our fully integrated corpectomy system that includes not only implants, but a specifically designed retractor for unique, for the unique requirements, of this surgery. Because, many times vertebral fracture is in the thoracic spine, it is vitally important to monitor the spinal cord. Enter SAFA three and MEP modality. Monitoring motor functions throughout these complex surgeries is a requirement. A big reason we are growing at the rate that we are is that these spine procedures are fully thought out.

Speaker 1

They include patient positioner specific monitoring, customized surgical exposure with indication specific retractors, implants and soon to come integrated navigation to reduce radiation and increase precision. It is no wonder that we will continue to expand our footprint in lateral surgery and beyond. A nemesis in spine has been the requirement for surgeons to make do without fully contemplated spine procedures. That is no longer the case as we continue to expand our significant influence. In speaking about compelling adoption and winning access, as I previously described, our lateral business is a perfect proxy for our procedural strategy.

Speaker 1

We are taking the learnings from that experience and applying across other techniques. Our growth rate is reflective of compelling adoption. Surgeons are growing, growing utility to increase volume and expand the application. What is also true is that with EOS, we are gaining access to more surgeons, academic institution and hospital systems. The very thesis that we contemplated is coming to fruition in front of our eyes.

Speaker 1

The clinical credibility of our foundational informatics technology enables us to win access. Our informatics ecosystem is the most comprehensive and scalable in the business. The recently launched EOS Insight software enables us to scan a patient, automate alignment measures for assessment, simulate the surgical effect through our planning software, integrate the surgical plan into the OR so as to reflect the plan and confirm intraoperatively. However, the most exciting piece really is the correlation, not only immediately after surgery to understand the veracity of the surgical plan execution, but also to understand how things evolve over time through longitudinal correlation. So correlation is the foundation of AI.

Speaker 1

We have the makings of an informatics system that will be predictive as we move forward and gain a deeper understanding for improved decision making. So I would tell you that it's fine as your vocation. I don't know of a better place than ATEC. That is why we know it to be the preferred destination. So I'm excited to continue to grow the ATEC faithful and with that we'll take questions.

Operator

All right. Thank you. And we will now open up the floor for questions. I would like to remind everyone that in order to ask a question, All right. Looks like our first question today comes from the line of Brooks O'Neil with Lake Street Capital Markets.

Operator

Brooks, please go ahead.

Speaker 3

Thank you. Good afternoon, guys. Congratulations on the good start to the year. Pat, you're just talking a lot about the new Corpectomy system, and I'm hoping you could give us a little bit of a feel for how big you think that market segment might be and maybe what the competitive dynamics are as it relates to other players that already have products or systems to address the need?

Speaker 1

Yeah. Thanks, Brooks. I appreciate the question. In terms of valuing the market, it's a bit of a tough one. What you see is from a marketplace perspective, I would tell you that we're the only ones doing this in the prone position.

Speaker 1

And when you have instability based upon fracture, which is oftentimes mostly tumor and trauma are the are the the utility for a clopectomy. And so when you have instability, what you want is access to the front and the back of the spine. And the beauty of PTP is that you have access to the front and the back of the spine in the same setting. And so this is really a unique approach for us. Others have tried to do it in the lateral position and have done it in the lateral position.

Speaker 1

To do it in a prone position is highly advantageous. And so super excited about it. It's completely reflective of what we intended in terms of the whole, you start simple and you continue to walk. And what you see is you see not only expansion in the volume of procedures applied, but also the number of applications and reasons why someone should learn the technique and apply it to their practice. And so we're seeing it in spades.

Speaker 1

The reason I brought up the EOS and academic access is a lot of these get shipped over to academic institutions just because of the complexity and because these are oftentimes seriously ill patients. And so the whole EOS play and the whole dynamic of continue to march up the complexity curve, I think play together. And so maybe more color than you wanted, but, just a little bit about the system itself. From an engineering perspective, it's outstanding. The retractor and just the versatility of an exposure system specific for corpectomy and then the the implant itself is outstanding.

Speaker 1

You know, the the type of mechanical prowess we have around here is unbelievable. And then it ties in well with the other things that we're doing, as I said, with MEPs from a safe op perspective and otherwise.

Speaker 3

Alright, Pat. That was awesome. Do you mind if I just ask, do do you think you will ultimately incorporate any functionality from EOS in that particular procedure or no?

Speaker 1

You know, the the the beauty of what we're doing with EOS is that is that our ability to measure the alignment, parameters, with a patient like that, that's rarely done. So to be able to get an EO scan and then integrate that element into the operative experience and make sure that the patient walks away not only fixed from a stability perspective, but fixed in alignment. Whenever we talk about the goals of surgery being decompression stabilization alignment, we will have fulfilled them based upon the sophistication of not only the procedure, but also the type of informatics that drives a behavior. And so anyway, it's exciting to know that because oftentimes this may be a young person. If they have a traumatic accident, and the last thing you wanna do is have them have an adjacent level disease because you fix them in a wrong place.

Speaker 1

And so anyway, the alignment piece is a big part of it, and you can utilize EOS as a proxy for alignment that we integrate into the operative experience.

Speaker 3

Great. Thank you very much.

Speaker 1

Yep. Thank you.

Speaker 2

Thanks, Brooks. And our next

Operator

question comes from the line of Vic Chopra with Wells Fargo. Vic, please go ahead.

Speaker 4

Hey, good afternoon and thanks so much for taking the question. Two for me. I was just wondering if you could just talk about the tariff exposure in 2025, when you expect that to hit the P and L and maybe what percent of your products are sourced from or manufactured in Mexico, China and The EU? And then just had a quick follow-up, please.

Speaker 2

Yes. Vic, good afternoon. Thanks for the call or the question rather. The tariff exposure as I laid out in my prepared remarks, we size that to be approximately low single digit millions hitting our cost of goods sold line, largely in the second half of this year. And our exposure is really limited to our EOS equipment and, any related replacement parts associated with EOS, largely because we manufacture our EOS machines in France and we import, The US volume, into America for, the installed base.

Speaker 2

And so, that's that's the exposure. We really don't have a direct tariff exposure in our implant business.

Speaker 4

Okay. That's super helpful. Thanks for clarifying that, Todd. And my follow-up question is any update on your robot launch plan? And maybe just talk about how Valens will fit into the company's overall strategy?

Speaker 4

Thank you.

Speaker 1

Yeah. Thanks, Vic. The, everything is going as planned. We are doing cases. As a matter of fact, I was in a case recently, everything is going as planned.

Speaker 1

And so, the whole verification process in my mind becomes the most important. A big part of our thesis is procedures. And I was in a place recently we did we as if I did it, there are seven PTPs done before 1PM. And it just speaks to the efficiency of the workflow. And the last thing we want to do is slow the workflow because there's some goofy interaction with regard to our robotic piece or our navigation piece.

Speaker 1

And so we're in the alpha phase. Everything is going as planned. Looking forward to integrating the navigation piece to that and this should be an end of the year launch. And so really I'm trying to think of any other color that would be of interest. But think that I'm as excited about the navigation piece and the integrated workflow as I am the robotic piece.

Operator

All right. Thank you, Vic. And our next question comes from the line of Matt Miksic with Barclays. Matt, please go ahead.

Speaker 5

Hi. Thanks so much for taking the question. So wanted to ask if you could maybe Todd dive into a little bit more color on the cash outlay. I know that was a big subject last year. You exceeded or beat our number this first quarter as hoped.

Speaker 5

Maybe just talk about where how the cash use is changing, maybe what the trends for the rest of the year should look like? Then I have one quick follow-up.

Speaker 1

Hey, Matt, because I don't do numeric things very well, I'm going to tell you just a little color. What thrills me is when you start to think about cash utility, I immediately think of sets and the like. And the one place that I didn't mention in my prepared remarks, but we're getting just light years better is in terms of asset utility and asset place. And so it's a situation to where as we continue to mature and I think about it clinically, we continue to get better in such profound ways. We're also getting profoundly better with regard to our operational prowess.

Speaker 1

And so I would say that that's a big part of cash utility. And before Todd gets into the specific numbers, just want to mention the investment in our Memphis facility several years ago, the type of sophistication that's going on there, the discontinued evolution and maturity internally here, our field force is getting better and the people who are managing in the field is getting better. So anyway, I just want to make mention that because I think it's so important.

Speaker 2

Agreed, Pat. And so, Matt, maybe I'll step back and hit a couple of things. One, I think the timing question is real. And so last quarter, we said Q1 would be a cash use between fifteen and twenty and we clearly hit the low end of that range and feel really good about that execution. On my prepared remarks, I said Q2 you should expect a zero to plus five and then positive in Q3 and positive in Q4 to get you something north of zero on the full year.

Speaker 2

And so that's the cadence that we expect. I think your question really was of like why do we do better? How do we think about the balance of the year? What gives us confidence? And so I think, first off, why do we do better?

Speaker 2

And I did make mention of the fact that we saw some modest yet transient working capital headwinds. Our kind of assumption coming into the year was accounts receivable DSO would be around forty five days. We were at the high 40s here in the month, and some of that just kind of comes down to timing and whatnot. But for us to be able to achieve a $15,000,000 cash use and still withstand a little bit of that headwind on the working capital front, I feel very good. So that tells me that I feel good about where I'm at because I think that working capital metrics will essentially go back to where we expect them to for the balance of the year, which gives me some level of confidence that we can continue to make progress on cash flow just from that standpoint.

Speaker 2

You think about the fact that our adjusted EBITDA was significantly better, about $3,000,000 better than we anticipated here in the first quarter. And so some of that falls through to your cash flow. And I think the ongoing profitability profile that we have seen and are expecting to see give us confidence in our ability to hit our cash flow goals. And then I think this year and going into next year and beyond is really what Pat I think is also talking to, which is the asset utilization is getting better. We've got a long ways to go, of course, but it's getting better.

Speaker 2

And when you see the dynamics of top line growth, expanding profitability, certainly in this quarter ahead of what we expected and an improving asset utilization environment, you feel really good about your ability to be cash efficient.

Speaker 5

That's super helpful. And just maybe one question if I could on some of the competitive dynamics in spine right now. You may have commented on it. I'm juggling a few calls right now. But any color you have on the quality of reps, the type of reps, the number of inbound, like the posture of the company right now in terms of adding reps and important part of growing the way you're growing?

Speaker 5

Any color would be appreciated. Thanks.

Speaker 1

Yeah. We were trying to be subtle with regard to the preferred destination piece. You know, it's one of those things where it's like, you know, in all sincerity though, if you think about if your vocation is spine surgery, you want to be aligned with a company that is existence is dependent upon being great in spine surgery. And candidly, that's us and we're the pure play. And so we're unapologetically evangelical about this space.

Speaker 1

We know that we're able to make it better. You look outside and you see how things have spun the private equity in a couple of instances. We've already made a big investment that we're scaling off of over the next years ahead. And so we feel like our ecosystem just avails continued improvement, continued evolution, continued capacity to make things better. I would say that the guys who have spun out have a big investment ahead of them.

Speaker 1

And this a expensive place. And so we're seeing a lot of people realizing that. I think when you start to see the volume of new surgeons that are coming over, then you start to wonder will their rep come with them and the answer is clearly a straight commission guys, yes. And so we're seeing, you know, X Stryker, we're seeing Medtronic, we're seeing Globus, we're seeing and so as as we talked about, jeez, a year ago, these things play out over long periods of time because everybody has their own individual dynamics that drive their their change. But I would tell you, if you'd have told me seven years ago when we started this turnaround that we'd be sitting here as the largest pure play spine company with the opportunity to run the table, I would say I'd be surprised.

Speaker 1

But that's where we sit today and we can't be more excited about the opportunity.

Speaker 5

Well, on all the progress. Thanks for taking the questions.

Speaker 1

Thanks, Matt.

Operator

Thank you, Matt. And our next question comes from the line of Matthew Blackman with Stifel. Matthew, please go ahead.

Speaker 6

All right. Good afternoon, everybody. And just upfront, I had every intention to respect your one question request, but no one else has, so I guess I won't either, so apologies in advance. But if I could start and Pat, you sort of alluded to it, Todd, maybe to the extent you can maybe layer in some numbers if applicable. But I was hoping to sort of get a state of the union on the Salesforce today, where they are in terms of your productivity relative to expectations, particularly the reps that you've recruited and onboarded over the last couple of years?

Speaker 6

Do they have all the sets and implants they need? Are you finding more opportunities than you expected these new with these new reps? Just again, we're a year plus out. I think everybody's got what they need. Just how the rep footprint is performing and how that performed in the first quarter?

Speaker 1

Yes. Matt, it's really like this is no kiss up. It's such the good question because it's like what happens oftentimes is demographically, you know, the the the rep that comes over reflects the the, configuration of what he'd previously sold. Then what we see is over time they evolve into this whole kind of more lateral type of business. And so as as we said, it takes twelve to eighteen months to ultimately reflect in a momentum of any kind.

Speaker 1

And so what we're seeing is geographically different footprint of the types of sales that they're doing. And then what they're doing is evolving. So probably the one that comes to mind is up in the Northeast. Initially, we were being very conventional with regard to the reflected product utility. We're evolving now more into a more proprietary type of sales reflection.

Speaker 1

And so it's fun to see that start to come forth. And so we have the sets. As I said, we're being more efficient with the sets, which avails more opportunity to place them in different locations. The thing that is is super attractive is is we're in a bunch of academic institutions, which we weren't before. I think just the the reputational dynamic of of not only having a unique tool with PTP, but then also coming forth with EOS and translating that in the operative experience avails access.

Speaker 1

And so, those are the things that we contemplated in the acquisition of the technology and how we would ultimately evolve it. But, but, you know, just some color in terms of just the generalities of of of of what we're seeing. We're we we have a long way to go with regard to the build out of the Salesforce in any meaningful density. We're still, I would tell you, young in the process.

Speaker 2

Agreed. And and, Matt, you know, I think maybe I'd just give you two two data points here. One, we talk about same store sales. So growth in sales agent territories that have been with us for a year or more, growing at 23%, and that's relative to a 24% growth in our overall surgical surgical revenue in the in the first quarter. So that that tells you that, people show up and year after year after year after year, they grow, on the territory that they have.

Speaker 2

And so I think that tells you both that one, you get more of a share of your existing surgeons business, plus you're able to expand kind of across the territory and attract more surgeons into that territory. And I think that's demonstrated by the fact if you look at the absolute dollar growth, and again, if you normalize this quarter for sixty four days versus sixty three days, over the last two years, we've added more than $60,000,000 and so that's, you know, about a $30,000,000 a year clip. And and that really kind of accelerate here in in 2025 over 2024. So I would tell you that, yeah, the investments we're making are are certainly paying off and that's a reflection of demand profile that's there, which is a function of the clinical distinction or procedural approach.

Speaker 6

I appreciate that. And then my follow-up, it's actually, I think, good segue on Pat's commentary on EOS. I'm just I'm curious, can you give us just even in the roughest sense how EOS placements today are splitting out between new accounts to ATEC, under indexed accounts and core ATEC users just from a who's using the portfolio and not today? Then on top of that, you mentioned it, we've done a lot of work. We've obviously seen it, this playbook at other companies with enabling technology.

Speaker 6

But is there a number you can point to in terms of you put an EOS system in, you get this type of magnitude of portfolio pull through? And I guess specifically, maybe the Holy Grail for EOS is getting you into these complex procedures where you're definitely under indexed for peers. Is that happening? Is that a tipping point ahead for that happening? Just any color on EOS would be helpful.

Speaker 6

Appreciate it. Thank you.

Speaker 1

Yes. Thanks, Matt. And clearly, that's the long play, right? I think that we've been pretty deliberate with regard to turning this company around and doing something unique was reflective of our expertise in lateral and that's clearly playing out exactly as planned. I think the EOS element, I wanted to show you an example.

Speaker 1

I can show you a bunch of examples of watching the EOS thing play out in real time. You know, when we when you start talking about, you know, gosh, you know, are are we gaining access and how is it different? It's like, I I recall when we had zero access. And and and so, you know, when when you see places like, you know, hospital for special surgery having, you know, I think nine of them or something to that effect, and you have all of these very highly sought after institutions having a bunch of them, you know, clearly, it is a it is a valuable tool. When you look at at at the the demographics of who's getting them, I would tell you that that, most of the people buying ESs were not customers of ours before.

Speaker 1

They are customers of ours now. Historically, it's been more of a pediatric type of a tool. We've been very under indexed in pediatric surgery, but we're heading in that direction. And so the great thing is is what we contemplated when we initially bought the asset was how do we be relevant in adult deformity first? And and because the the pediatric utility was robust and wasn't a place that we felt like we could make immediate type of influence.

Speaker 1

As we've continued to get more adoption in the the adult deformity realm, you'll see, the adolescent impedes thing follow suit. And so, we think that our best is yet to come, and we say things like that really numerically minded because we haven't touched parts of this thing that ultimately are highly valuable from a clinical perspective.

Speaker 6

Alright. I appreciate it, guys. And I promise we'll all try harder next quarter to limit ourselves to one question. Thanks.

Speaker 1

Thanks. Thanks,

Operator

Matt. And next question comes from the line of Matthew O'Brien with Piper Sandler. Matthew, please go ahead.

Speaker 7

This is Samantha on for Matt. Thank you for taking our question. I guess we just wanted to touch on just overall volumes, how those are trending and then also, any feedback on growth in the ASCs as well?

Speaker 1

Yeah. I would say, you know, our view is the is the is the market is healthy and and, volumes are good. And, you know, I don't think it grew 24% surgically if if it's not the case. And so and so just kind of a a 60,000 foot view, I'll let Todd pipe in if if if if he like to add any specifics. The ASC is a long play.

Speaker 1

And and, you know, what what happens is is is the most simple type of pathology gets done in a place where there's greatest you know, where the surgeon has the greatest comfort and the greatest predictability. And so I think over time, you're gonna see that change. I think there's guys today doing PTP in an outpatient setting. They're doing very simple single level type of things. But what happens is is your ability to control pain for a patient and your ability to limit the potential for complication is really kind of the driving forces of the ASC.

Speaker 1

And and so a lot of work, like decompression and single level and maybe two level cervical, and those are the major things going on there today, but I think you're seeing an evolution that's gonna just take time.

Speaker 7

Awesome. Thank you. That's great. And then I know we previously touched on the the robot that's, coming out, I think you said, the end of this year. I just wanted to touch on that again and kind of any feedback on kind of what's left to get it launched and any feedback you've had from physicians?

Speaker 7

Thank you.

Speaker 1

Yeah. Thanks. The feedback has been great. It it places screws accurately, which is what robots in the spine space do. And and so the the software is very intuitive.

Speaker 1

The utility has been expedient. My greatest concerns are always workflow. Are we taking, are we increasing anesthetic time because we're trying to place a screw slightly more precisely It ultimately doesn't effectuate the clinical dynamic. I think that's you know, I don't want that. And so we wanna make sure that the workflow is very seamless.

Speaker 1

And so really what we're waiting on is is our our navigation piece and such that what we're doing is we're navigating an entire procedure. So meaning, we're navigating the lateral space. We're integrating the the robot in the posterior space. You know, the the the beauty of PTP and to be able to watch a a surgery whereby a surgeon has access to the anterior column, navigates that that access, the PA closes while the while the surgeon operates on the back, like, that level of experience and that level of elegance from a workflow perspective is nonexistent today. And so our opportunity to continue to be the purveyors of that is very apparent.

Speaker 1

And so anyway so any we're seeing the very thing that it's supposed to do with regard to the robotic piece. And, is all a robot is is part of a is part of a stabilization workflow. That's it. And, I think, there's been some romanticizing of it that is misdirected.

Speaker 7

Thank you.

Operator

Thanks, Samantha. And our next question comes from the line of Young Lee with Jefferies. Young, please go ahead.

Speaker 8

All right. Good afternoon and thanks for taking the question. I'll just keep it to one. On the buying market, I guess I'm kind of

Speaker 2

curious

Speaker 8

about the deferability and the resiliency of the market due to an economic downturn. Maybe try to jog your memory a little bit on, you know, if you remember sort of what happened to the spine market during the, financial crisis. That's kind of like a worst case scenario for any potential upcoming macro headwinds?

Speaker 1

Yeah. I guess and and Todd could pipe in, you know, but, you know, I guess I I I I shutter to say, you know, I was around in 02/2008 and and not that my recollection is gonna be very precise as it relates to the different years, but, you know, spine is not elective. And and and I think that there there there becomes this dynamic to where it's like, you know, can they put it off? And if you have neural pain, you're not gonna put it off. And, and so I would tell you that it's it's highly resilient in the volatility of the you know, I'll speak to the current, economic uncertainty.

Speaker 1

It's like we're not seeing changes in volumes. We're seeing a lot of demand for what we're doing. And so I would tell you nothing has changed other than there's high demand for what we're doing. There's a robust backlog of things to do, and we're leaning in as aggressively as we can to this market. We love this market.

Speaker 1

We think it's helping people. We know it's helping people. And so that will continue.

Speaker 2

And Jung, I think to put a finer point on history a little bit, think to Pat's point, you go back to the financial crisis, I think the analysis we've done would suggest that our market was reasonably robust during that point in time. And I think the other point is as you looked at volumes that went through COVID, while there were certainly some staffing influence to to the volume moving around, but the fundamental demand did not go away. And so We agree with that here. Exactly. And so I I I feel like we're in a pretty good spot.

Speaker 8

Great. Appreciate it.

Operator

All right. Thanks, Young. And our next question comes from the line of Josh Jennings with TD Cowen. Josh, please go ahead.

Speaker 9

Hi, this is Eric on for Josh. Thank you guys for taking the question. I wanted to ask your latest thoughts around expansion into international markets. I know Australia and New Zealand have been a focus. You had your first surgeries in Japan not too long ago.

Speaker 9

Specifically, I was just curious if your thinking internationally changes at all given the current macro landscape or maybe not at all, but how should we be thinking about that?

Speaker 1

Yeah. I think that we've been so affirmed by our approach. And and the way we built the structure of the company is we we haven't built a huge international infrastructure to serve a place that's not profitable. And, and so we've been, totally bullish on on Australia, New Zealand. You know, I I I just because it's a top of mind, got a note today in terms of people reaching well north of a hundred in their PTP experience down in Australia.

Speaker 1

So, like, the thing is going as we intended. And and so we don't have a big infrastructure, but we have a very narrow business that shares the same type of a a surgical perspective as we do. And so love that. We are in such the early phase of the second largest market in the world of of Japan, and we have, you know, we have a light years to go in that market. So, I love kind of our thesis as it relates to, let's stay focal, let's stay completely committed to a marketplace.

Speaker 1

Japan also is a great deformity market. They love EOS. Our opportunity to ultimately lay the foundation with lateral and evolve into the EOS translation is so apparent. And so, anyway, I I think that the we're we're well positioned. There's really not a lot of interest to to go outside that dynamic.

Speaker 1

I think our internal build thesis has reflected as much.

Speaker 2

Eric, narrow in deep. That's what we've always said, and I think that's what we're seeing. And to Pat's point, I think the strategy is paying off, we got a huge run-in front of us in international in the markets that we've chosen. Great.

Speaker 9

Understood. Yeah. That makes sense. And if I could ask one quick follow-up, just on pricing generally. If I think about commentary from some med device management teams lately in ortho specifically, it seems like in the last year or so we sort of entered a new era for pricing, certainly for companies that are introducing innovation to their respective markets.

Speaker 9

And when I think about spine, ATEC definitely fits the bill there. So I was just curious how your team is thinking about pricing.

Speaker 1

One quick point and Todd will put the specific on it is, we still believe in this whole convoyed sales thing in terms of the procedural price. And what we're seeing is more products increment per procedure. And so as it relates to historical pricing degradation, we're not seeing it because ultimately what we're seeing is a reflection of the convoyed sales, accumulation of the procedural elements.

Speaker 2

Yes. We often talk about kind of same product, same store year over year being very low single digit decline there. Our innovation engine, the ability for us to launch new product and really mix our way out of some of those headwinds has been our history, will continue to be our history. And to Pat's point, we're just getting more of the procedural revenue opportunity as we continue to grow.

Speaker 9

That makes sense. Thank you for the questions.

Operator

Thanks, Eric. And our next question comes from the line of David Saxon with Needham. David, please go ahead.

Speaker 6

Great. Good afternoon. Thanks for taking my question and congrats on the quarter. I think this is probably more for Todd. But Todd, you've talked historically maybe two years ago or over the course of a couple of years ago about letting 10% of the top line outperformance drop through to the bottom line.

Speaker 6

I mean, as the numbers get bigger, maybe the upside gets a little smaller. But is that still a good way to think about it? Or has the size of the business or kind of how you think about the near term opportunity changed that framework at all? Thanks so much.

Speaker 2

Yes. Thanks, David. I think you look at our drop through in absolute terms, in Q4 of last year was 49%. We delivered 44% of the incremental revenue year over year to drop through to adjusted EBITDA. And I think even on the beat, we dropped through a significant amount of that to the bottom line as well.

Speaker 2

And I think you're just seeing a level of focus and effort on driving profitability and cash utility. I think you'll continue to see that through the balance of the year.

Speaker 8

Great. Thank you.

Operator

All right. Thanks, David. And our next question comes from the line of Caitlin Cronin with Canaccord. Caitlin, please go ahead.

Speaker 7

Hey, guys. It's Mikaela filling in for Caitlin. Thanks for taking the question. We've seen a focus with some recent M and A on the interventionalist call point. So I was just wondering if there are any plans to leverage the interventionalist call point or how you're thinking about that.

Speaker 1

No. I'm just being snarky. You know, our our business is the spine surgeon and the alignment with what the spine surgeon does. And we feel very strongly that that that we have a customer with whom we have aligned interest. We have a Salesforce with whom we have aligned interest.

Speaker 1

And, you know, we we think that, defocusing our organization into a interventionalist or pain environment would be a huge mistake. And so, that's just our candid view.

Speaker 7

Got it. Thanks so much.

Operator

Thank you, Mikaela. And our next question comes from the line of Sean Lee with H. C. Wainwright. Sean, please go ahead.

Speaker 10

Hi, good afternoon guys. Congrats on a good quarter and thanks for taking my question. For the last couple of years, you guys have been making a big push on the yields and informatics and let's say, whole pre op planning, the interrupt monitoring, the post op analysis. So I was wondering if you can provide some color on which parts of this system are seeing the most used right now and where do you think the biggest growth is gonna come from in the future? Thanks.

Speaker 1

Yeah. It's a great question, Sean. The the, I think, you know, the the dynamic is one of maturity. And and, you know, when when you when you say, gosh, how have you built the business from, you know, gosh, back in 02/2018, it was, like, 89,000,000 headed south to, you know, what's our our guidance is seven Seven thirty four. Seven 30 four heading north.

Speaker 1

And and I would tell you that what's what's created the uniqueness in our our lateral effort, a core part of it is telling a surgeon, hey. There's a nerve right there, and this is the health of the nerve. And then now we've added you could understand the motor pathway of the nerve. Like, these things, if you look at your skin to spine from a lateral perspective in the flank, the most concerning anatomy is is neural. And so but to be able to provide that level of neural precision and and sophistication is is not done anywhere.

Speaker 1

And this is why, you know, it's not a coincidence that we're growing at the rate that we are. We are the lateral maven. And, and so then you say, gosh. When did we buy and when did we start the integration process with EOS? And I would say, really, '21.

Speaker 1

And and, really, in earnest, you know, you you you get together as a company. You fund the things that can't really weren't being funded. You start to get on the road of automating things. So we spent, you know, '22 and and and, you know, '23 shoring up the unit and designing some of the software elements. And, gosh, we we recently, last year, launched the insight software such that that's the translational tool.

Speaker 1

And so I would say we're in, like, the the, first inning from a EOS perspective, and we're in the third inning from a a safe op perspective. And, and so there's such a runway on both those things. I think surgeons are yearning for it. You know, the challenge with this environment's been people have been consumed with the currency, which everybody wants to sell pedicle screws, but you sell pedicle screws and implants based upon your shared interest with the surgeon who's trying to care for a patient and understanding what the procedural requirements are to execute.

Speaker 10

A lot. That's very helpful.

Operator

All right. Thank you, Sean. And that is all the questions we have today. So I will now turn the call back over to Pat Miles for closing comments. Pat?

Speaker 1

Thanks, Greg. Just want to thank everybody for their interest in ATEC. I want to remind you that we are the preferred destination and excited about the business that we serve. And so thanks for your time.

Speaker 2

Thanks, Pat. And ladies

Operator

and gentlemen, that concludes today's call. Again, thanks for joining and you may now disconnect. Have a great day, everyone.

Speaker 2

Thank you.

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Earnings Conference Call
Alphatec Q1 2025
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