Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker
Thanks, Preston. Today, I will focus my comments on our third quarter financial results and the related drivers. Our detailed financial results have been provided in today's press release. As a reminder, we are providing our comments in comparison to 2019 as it is a more normal baseline given the variability throughout 2020. Our organic sales growth was 8.4% in the quarter. The third quarter included the same number of average selling days as Q3 2019 and Q3 2020. Compared to 2019, the two year impact from pricing in the quarter was unfavorable 2.2%. Versus Q3 2020, pricing was 0.7% unfavorable. Foreign currency had a favorable 1.2% impact on sales. Our MedSurg and Neurotech businesses saw another very strong quarter, continuing the growth momentum of the second quarter with double digit growth in both segments. Our Orthopedics and Spine businesses have been adversely impacted by increases in hospitalization rates starting in early August, especially in the US as a result of the Delta variant. The corresponding impact on elective procedures has significantly slowed the recovery in our Orthopedics and Spine implant businesses. For the quarter, US organic sales increased 7.1%, reflecting the continued strong demand for Mako, instruments, medical and neurovascular products. International organic sales showed strong growth of 12%, impacted by positive sales momentum in Europe, Australia, Canada and emerging markets. Our adjusted quarterly EPS of $2.20 increased 15.2% from 2019, reflecting sales growth, gross margin expansion and a lower quarterly effective tax rate, partially offset by the impact of business mix and higher interest charges resulting from the Wright acquisition. Our third quarter EPS was positively impacted from foreign currency by $0.04.
Now I will provide some highlights around our segment performance. Orthopaedics had constant currency sales growth of 19.9% and organic sales growth of 2%, including organic growth of 1% in the US. This reflects the impact of the slowdown in elective procedures as a result of the Delta variant, which primarily impacted our hip and knee implant businesses. Our knee business grew 0.9% organically in the US, reflecting the previously mentioned impact on elective procedures, offset by continued adoption of our robotic platform for total knee procedures. Our US trauma business grew 8.8%, reflecting solid performances across the portfolio. Other ortho grew 19.8% in the US, primarily reflecting demand for our Mako robotic platform, partially offset by declines in bone cement. Internationally, Orthopaedics grew 4.1% organically, which reflects the strong performances in Europe and the momentum in Mako internationally, somewhat offset by the increased impact of restrictions imposed on elective procedures due to COVID, especially in Japan.
For the quarter, our Trauma and Extremities business, which includes Writer Medical delivered 3.2% growth on a comparable basis. In the US, comparable growth was 7.4%, which included double digital growth in our upper extremities business. In the quarter, MedSurg had constant currency and organic sales growth of 12%,,which included 12% US organic growth as well. Instruments had US organic sales growth of 15.9%, led by double digit growth in their orthopedic implants and surgical technology businesses, which include power tools, waste management, smoke evacuation and skin closure products. Endoscopy had US organic sales growth of 10.6%, reflecting strong performances across their portfolio, including video and general surgery products and strong double digit growth of their communications and sports medicine businesses. The Medical division had US organic growth of 12.5%, reflecting double-digit performances in its emergency care and Sage businesses. Internationally, MedSurg had organic sales growth of 12%, reflecting strong growth in the Endoscopy, Instruments and Medical businesses across Europe and Australia. Neurotechnology and Spine had organic growth of 11.8%. This growth reflects double digit performances in our neurovascular, neurosurgical and interventional spine businesses.
Our Neurovascular business had particularly strong growth of approximately 26% and makes up roughly 30% of this segment. Our US Neurotech business posted an organic growth of 11.8%, reflecting strong product growth in Sonopet iQ, Bipolar Forceps and Bone Mill. Our US Neurovascular business had significant growth in all categories of products, including hemorrhagic, flow diversion and ischemic. Internationally, Neurotechnology and Spine had organic growth of 24.6%. This performance was driven by strong neurotech demand in China and other emerging markets as well as Europe and Australia. Now I will focus on operating highlights in the third quarter. Our adjusted gross margin of 66.3% was favorable approximately 55 basis points from third quarter 2019. Compared to the third quarter in 2019, gross margin was primarily impacted by acquisitions, which was partially offset by business mix and price. Adjusted R&D spending was 6.7% of sales, reflecting our continued focus on innovation.
Our SG&A was 34.1% of sales, which was slightly negative as compared to the third quarter of 2019. This reflects continued cost discipline and fixed cost leverage, offset by ramping of certain expenses, hiring to support future growth and the dilutive impact of the Wright Medical acquisition. In summary, for the quarter, our adjusted operating margin was 25.4% of sales, which is approximately the same as third quarter 2019. This performance primarily resulted from our positive sales momentum, offset by the dilutive impact of acquisitions, primarily Wright Medical. Related to other income and expenses compared to the third quarter in 2019, we saw a decline in investment income earned on deposits and interest expense increases related to our debt outstanding for the funding of the Wright Medical acquisition. Our third quarter had an adjusted effective tax rate of 14%, which was impacted by our mix of US, non-US income and favorable discrete items during the quarter. Our year-to-date effective tax rate is 14.8%. For the year, we continue to expect an adjusted effective tax rate of 15% to 15.5%. Focusing on the balance sheet, we ended the third quarter with $2.6 billion of cash and marketable securities and total debt of $12.7 billion. year-to-date, we have paid down $1.2 billion of debt. In October, we completed the refinancing of our revolving credit facility and increased that facility from $1.5 billion to $2.25 billion.
Turning to cash flow. Our year-to-date cash from operations was approximately $2.3 billion. This performance reflects the results of earnings and continued focus on working capital management. Based on our performance in the third quarter, the continued volatility experienced as a result of COVID, procedural delays in hospital staffing shortages as well as uncertainty around the pace of recovery in the fourth quarter, we expect 2021 organic net sales growth to be in the range of 7% to 8%. As it relates to sales expectations for Wright Medical, we now expect comparable growth for Trauma and Extremities to be in the mid single digits for the full year when compared to the combined results for 2019. If foreign currency exchange rates hold near current levels, we expect net sales in the full year will be positively impacted by approximately 1%. Adjusted net earnings per diluted share will be positively impacted by approximately $0.05 to $0.10 in the full year and this is included in our revised guidance range. Based on our performance in the first nine months and including consideration of the aforementioned volatility impacting the recovery of elective procedures and the full year Wright Medical impact, we now expect adjusted net earnings per diluted share to be in the range of $9.08 to $9.15.
And now I will open the call for Q&A.