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Stryker Q4 2021 Earnings Call Transcript


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Participants

Corporate Executives

  • Kevin A. Lobo
    Chair and Chief Executive Officer
  • Preston Wells
    Vice President, Investor Relations
  • Glenn S. Boehnlein
    Vice President, Chief Financial Officer

Analysts

Presentation

Operator

Welcome to the Fourth Quarter 2021 Stryker Earnings Call. My name is Emily, and I'll be your operator for today's call. At this time, all participants are in a listen-only mode. Following the conference, we will conduct a question-and-answer session. During that time, participants will have the opportunity to ask one question and one follow-up question. [Operator Instructions]. This conference call is being recorded for replay purposes.

Before we begin, I would like to remind you that the discussions during this conference call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the Company's most recent filings with the SEC. Also the discussions will include certain non-GAAP financial measures, reconciliations to the most directly comparable GAAP financial measures can be found in today's press release, that is an exhibit to Stryker's current report on Form 8-K filed today with the SEC.

I will now turn the call over to Mr. Kevin Lobo, Chair and Chief Executive Officer. You may proceed, sir.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Welcome to Stryker's fourth quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO; and Preston Wells, Vice President of Investor Relations.

For today's call, I will provide opening comments followed by Preston with an update on the trends we saw during the quarter and our annual Mako update. Glenn will then provide additional details regarding our quarterly results, before opening the call to Q&A.

As a reminder as announced during our Analyst Day in November, we have reclassified our reporting segments into two Group, MedSurg and Neurotechnology and Orthopaedics and Spine. This better aligns to how our businesses are managed internally. We have also pulled out neurovascular on its own line and have the business units of neurosurgical instruments, CMF and ENT now grouped under neuro cranial.

As we have done all year, we will comment on our performance versus 2019, which we believe is a better basis for comparison.

For the quarter, organic sales growth exceeded 6% versus 2019, driven by double-digit growth from our MedSurg and Neurotechnology businesses, but offset by softer sales of our hips, knees and spine as COVID and hospital staffing challenges had a meaningful impact on elective procedures during the quarter. We posted double-digit organic growth in international compared to 2019 as our globalization efforts continue to bear fruit and our COVID impacts were generally less severe than in the US. While our more deferrable businesses were challenged, we saw excellent results from our Mako robotic technology, capital products across our MedSurg portfolio and continued double-digit organic growth in neurovascular, which reached approximately $1.2 billion in sales for the year. Despite the unanticipated Omicron variant, we were able to achieve full-year sales growth and adjusted EPS within our latest guidance ranges.

Our full-year organic growth exceeded 7% and reflects strong demand for our Mako and MedSurg capital equipment and strong double-digit sales growth within neurovascular and neuro cranial. In addition, we are very pleased with the Wright Medical integration particularly in the US.

Our full year adjusted EPS grew 10% versus 2019, and we delivered free cash flow conversion of 85%. The EPS growth was a strong result given the inflationary pressures that grew in the quarter and the COVID impact on our implant procedures. We continue to invest in R&D at a healthy rate of 6.6% of sales for the year and our new product pipelines are poised for continued success. Our strong cash flow performance provided us with additional flexibility to execute on M&A opportunities in the quarter, including Thermedics, a small tuck-in within endoscopy and the recently announced agreement to acquire Vocera. Despite the impacts of the pandemic throughout the year, we were able to surpass $15 billion, $16 billion and $17 billion in revenue for the first time, and we remain confident in the outlook for our business as the pandemic recedes.

We continue to execute on our key growth strategies, including the expansion of our ASC offense, continued product innovation and category leadership across our businesses.

Turning to 2022, the volatility caused by COVID variance remains ongoing and is further impacted by hospital staffing challenges and supply chain disruptions. In spite of this, we expect to continue to deliver above-market sales growth. However, given the pressures on our supply chain within MedSurg, we do not expect to deliver our typical degree of earnings leverage. We continue to be disciplined with our spending. However, we will continue to fuel new products with healthy R&D spending and we'll maintain our focus on above market growth, while we work through these cost pressures. As noted in the press release, we are guiding to 6% to 8% full-year organic sales growth and adjusted EPS of $9.60 to $10.00 per share.

As I conclude my comments, I remain confident in our strategy, talent and culture. I would like to thank our teams for continuing to persevere in these challenging times.

I will now turn the call over to Preston.

Preston Wells
Vice President, Investor Relations at Stryker

Thanks, Kevin. My comments today will focus on providing an update on the current environment, including the latest impacts of COVID-19 across certain products during the quarter. In addition, I will provide an update on Mako and recent acquisitions, including the continued integration of Wright Medical and the performance of our combined trauma and extremities business.

During the quarter, hospital bed and operating room capacities were challenged because of the Delta variant early in the quarter, and most recently by the Omicron variant, which started to pressure elective procedural volumes in December. In addition, ongoing nursing staffing shortages disrupted hospital scheduling of the procedural volumes. The delay in procedural volumes primarily impacted our implant related businesses including hips, knees, spine and foot and ankle, which can be in many cases deferred for a period of time. However, we know that most of these patients will eventually return to have those procedures completed as the impacts from COVID decline and procedural volumes return to more normal level.

Demand for our capital products was strong in the quarter, including double-digit orders and sales, which created a strong order book for capital products. Despite the strong capital demand, there were some headwinds in the quarter that primarily impacted our medical business, including installation delays caused by hospital staffing challenges and raw material shortages, primarily related to electronics that created some supply disruptions.

For the full-year 2021 versus 2020, our global Mako install base grew by 27% and we now have an install base that is approaching 1,500 Mako robot. This continues to grow - this growth continues to highlight the high demand for our differentiated Mako robotic technology. The strong double-digit growth also underscores our ongoing success installing robots in major teaching institutions, ASCs and competitive accounts, as well as our focus on expanding into international markets. In the fourth quarter, we saw a meaningful increase in the percentage of robots installed into a competitive account.

Turning to US knee procedures, in the fourth quarter, over 50% of our total knees were Mako knee procedures, a trend that continues to increase and demonstrates the outstanding utilization of the Mako install base. The shift towards cementless knees also continued, and in the fourth quarter, cementless knees made up 47% of our US knee procedures.

Additionally, in the fourth quarter, over 25% of our total hip procedures were Mako hip procedures, which similar to knees, continues to increase in utilization. Our recently launched Insignia hip stem will also be Mako capable by the end of the first quarter. We expect to further our leadership position in orthopedic robotic assisted surgery through the continued adoption of our Mako smart robotics platform on a global basis.

Shifting to our trauma and extremities business. We are now over one year into the integration of Wright Medical, which continues to progress well in all regions and across all functions. Despite the headwinds from COVID, including Wright Medical, the combined US Trauma and Extremities business grew high-single digits in 2021, which exceeded our expectations. The full year growth in the United States was driven by strong growth in core trauma and double-digit growth in the upper extremities business, which offset the COVID related impact on foot and ankle. This strong result reflects excellent execution of the sales integration and the strength of the product portfolio.

Finally, our dedicated divisional business development teams continue to identify and execute on meaningful acquisitions. As Kevin mentioned, we recently announced our agreement to acquire Vocera and enter the fast growing digital care coordination and communication segment. We expect the Vocera acquisition to close by the end of the first quarter. During the fourth quarter, we also finalized the acquisition of Thermedx. Thermedx is an innovative developer and manufacturer of fluid management solutions and will allow our endoscopy business to improve surgical visualization across the Women's Health segment, and advance the standard of care in the urology segment. We believe these and other acquisitions completed during the year, will help us continue to drive above market growth in the future.

The overall environment remains uncertain as a result of the continuing COVID pandemic, and we expect hospital staffing shortages, supply constraints and significant inflationary pressures caused by raw material shortages to persist throughout 2022. However, we believe that the underlying demand for our products remain strong, and coupled with a robust order book for our capital products, gives us confidence in our ability to drive market-leading growth when the impacts of the pandemic subside.

With that, I'll now turn the call over to Glenn.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Thanks, Preston. Today, I will focus my comments on our fourth quarter financial results and the related drivers. Today sales comments will be provided based on our new reporting structure, and as with previous quarters this year, all comments are in comparison to 2019 as it is a more normal baseline given the variability throughout 2020. Our detailed financial results have been provided in today's press release.

Our organic sales growth was 6.2% in the quarter. The fourth quarter included the same number of average selling days as Q4 2019 and Q4 2020. Compared to 2019, the two-year impact from pricing in the quarter was unfavorable 1.7% versus Q4 2020 pricing was 0.8% unfavorable. Foreign currency had a favorable 0.5% impact on sales.

For the quarter, US, organic sales increased by 4.7% reflecting the impact of COVID on elective procedures, hospital staffing shortages and disruptions of general hospital operations. This was offset by - partially by strong demand for Mako in our MedSurg and Neurotechnology products. International organic sales showed strong growth of 10.6%, impacted by positive sales momentum in Europe, Canada and emerging markets. For the year, organic sales growth was 7.2%, with US organic growth of 5.2% and international organic growth of 12.9%. 2021 had the same number of selling days as 2019 and one less selling day compared to 2020. Compared to 2019, the two-year price impact had an unfavorable 1.5% impact on sales. Versus full-year 2020, pricing was 0.8% unfavorable.

Our adjusted quarterly EPS of $2.71 increased 8.8% from 2019 reflecting sales growth and a lower quarterly effective tax rate, partially offset by the impact of business mix, increased adverse COVID related pressure on sales, gross margin inflationary pressures and higher interest charges resulting from the Wright Medical acquisition. Our full-year EPS of $9.09, which represents growth of 10% from full year 2019, reflects the favorable impacts of sales growth, operating expense discipline, Wright Medical, foreign currency and a lower effective tax rate, partially offset by increased investments in R&D, as well as higher interest charges resulting from the Wright acquisition.

Now, I will provide some highlights around our segment performance. In the quarter, MedSurg and Neurotech had constant currency sales - sales growth of 11.8%, with organic sales growth of 11.6%, which included 9.3% of US organic growth. Instruments had US organic sales growth of 10.6%, led by strong growth in their Orthopedic Instruments and Surgical Technologies businesses, highlighted by growth in their power tools, waste management, smoke evacuation and STERI-SHIELD products. Endoscopy had US organic sales growth of 11%, reflecting strong performances across their portfolio, including general surgery and fluorescence products and strong double-digit growth of their Sports Medicine and Communications businesses.

The Medical Division had US organic sales growth of 10.3%, reflecting solid performances in their Sage and Bed businesses. During the quarter, we also saw significant growth in orders across the medical portfolio driven by very strong demand. Assuming normalization of the customer environment and a reduction of certain supply constraints, we expect these orders to contribute to another strong year for Medical in 2022.

Our US neurovascular business posted organic growth of 7.4% reflecting solid growth in their hemorrhagic and aspiration project - products. The US Neuro Cranial business posted organic sales growth of 5.7%, which included solid growth in our [ Mako ] space, ENT Navigation and cryotherapy products, somewhat offset by continued COVID impacts.

Internationally MedSurg and Neurotech had organic sales growth of 18.6%, reflecting double-digit growth in the endoscopy, medical, neurovascular and neuro cranial businesses. Geographically, this included strong performances in Europe, Canada, China and in the neurotech businesses in the emerging markets.

Orthopaedics and Spine had constant currency sales growth of 15.2%, and an organic sales decline of 0.8% with an organic decline of 2% in the US. This reflects the impact of the slowdown in elective procedures during the quarter, as a result of the Delta and Omicron variants of COVID. Our US knee business grew 0.1% organically. As a reminder, during the fourth quarter of 2019, our US knee business had very strong growth of approximately 10.5%.

Our US Trauma and Extremities business grew 6.7% on a comparable basis with strong growth in our plating products, combined with double-digit growth in our upper extremities business. Spine declined 6.6% organically in the US, primarily resulting from COVID disruptions to their business. Other orthopaedics grew 21.5% organically in the US, primarily reflecting continued strong demand for our Mako robotic platform, which had growth in the US of 43.5%.

Internationally Orthopaedics and Spine grew 1.9% organically, which reflects the strong momentum of Mako in Japan, Korea, and emerging markets, somewhat offset by the impact of volume based pricing in China, primarily related to our Trauson business.

For the quarter, our Trauma and Extremities business, which includes Wright Medical delivered 4.1% constant currency growth on a comparable basis. The Wright Medical acquisition anniversaried in November 2021 and will be part of our organic sales throughout 2022.

Now, I will focus on operating highlights in the fourth quarter. Our adjusted gross margin was 65.8%, was unfavorable approximately 50 basis points from the fourth quarter of 2019. Compared to the fourth quarter in 2019, gross margin was adversely impacted by business mix, operator - operational inefficiencies due to COVID, including employee absenteeism and raw material inflation, primarily related to electronic components, steel and transportation costs. We expect these adverse impacts to continue throughout 2022 with a more pronounced impact in the first half of 2022.

Adjusted R&D spending was 6.4% of sales, which represents an 80 basis points increase versus the fourth quarter of 2019 and reflects our continued commitment to innovation funding and the related growth that it will provide. Our adjusted SG&A was 32.1% of sales, which was a 20 basis point improvement as compared to the fourth quarter of 2019. This reflects continued cost discipline and fixed cost leverage offset by the ramping of certain expenses and hiring to support future growth and the dilutive impact of the Wright Medical acquisition.

In summary for the quarter, our adjusted operating margin was 27.3% of sales, which is a 100 basis points unfavorable to the fourth quarter of 2019. This performance primarily resulted from adverse business mix, gross margin challenges, investments in R&D and the dilutive impact of acquisitions, primarily Wright Medical.

Other income and expense increased as compared to fourth quarter in 2019 primarily resulting from the interest expense increases related to our debt outstanding for the funding of the Wright Medical acquisition. Our fourth quarter had an adjusted effective tax rate of 15.2%. Our full-year adjusted effective tax rate is 14.9%, which was partially impacted favorably by one-time items during the year. For 2022, we expect our full-year effective tax rate to be in the range of 15% to 16%.

Focusing on the balance sheet, we ended the fourth quarter with $3 billion of cash and marketable securities, and total debt of $12.5 billion. For the year, we paid down $1.2 billion of debt.

Turning to cash flow. Our full-year cash from operations was approximately $3.3 billion. This strong performance reflects the results of net earnings and continued focus on working capital management. For 2022, we anticipate that the capital spending will be approximately $650 million. Again in 2022, we do not plan to do any share buybacks, given our anticipated focus on further debt reduction.

And now, I will provide you 2022 full-year guidance. As we assess the current operating environment, we believe that there will be continued volatility caused by ongoing COVID related impacts, hospital staffing challenges, and increasing supply chain disruptions, as well as significant inflationary risks. Given this variability, we expect organic sales growth to be in the range of 6% to 8% for the full-year 2022 when compared to 2021. There are the same number of selling days in 2022 compared to 2021. Consistent with the pricing environment we experienced in previous years, we would expect continued unfavorable price reductions of approximately 1%. If foreign exchange rates hold near current levels, we anticipate sales and EPS will be modestly unfavorably impacted as compared to 2021, and this is included in our guidance. Despite the top line and operational risks of COVID, we have good momentum in many parts of our business heading into 2022, including the continued demand for our Mako technology, a very robust order book for our capital products, continued execution of our combined T&E business and many, many product innovations.

For the full-year 2022, we do not expect to deliver our typical operating margin expansion as a result of the ongoing price escalation on supply constrained raw materials like electronic components and rising inflationary costs on raw materials, transportation and labor costs. As a result of the latest COVID wave and the current inflationary environment, we expect gross margin performance to be negatively impacted by 50 basis points to 100 basis points, with a more pronounced impact in the first half of the year. As we said during our Analyst Call in November, we plan to return to our normal delivery of our margin expansion once we reach a post COVID environment.

Finally, for 2022, we expect adjusted net earnings per diluted share to be in the range of $9.60 to $10.00 for the full year. This wider guidance range represents the ongoing variability in the operating environment. The upper end of our guidance range assumes the latest COVID wave subsides in Q1 with no additional major COVID disruptions during the year. In addition, it assumes that the supply chain stabilizes, by the end of the first half of the year. The low end of the guidance range assumes the continued COVID related volatility persists, including supply chain pressures that could impact revenues as well as costs and includes more transient spot buying and longer-term supply chain pressures. We will continue to evaluate the changing environment and we'll provide updates to our guidance as necessary.

And now, I will open up the call for Q&A.

Questions and Answers

Operator

Thank you. We will now begin the question-and-answer session. [Operator Instructions] Our first question today comes from the line of Robbie Marcus from J.P. Morgan. Robbie, your line is open.

Robert Marcus
Analyst at J.P. Morgan Securities

Thank you, and thanks for taking the question. Maybe we could start just following up on guidance, I think investors really would love to get a sense of cadence through the year. How are you thinking about, maybe first quarter, or first half relative to second half both on - on top and bottom line, so we can calibrate correctly?

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Sure. Yeah, Robbie, I think - I think right now, and obviously you kind of see it because of the wide range of guidance we provided both sort of top and bottom, but - but our thinking is, is that the real pronounced impact that we'll have on top line and on gross margin will be in the first half of the year. We'll really feel the impacts related to that very pronounced in the first quarter and lesser so in second quarter. And then we feel like things will start to stabilize by the time we get to third quarter and fourth quarter. But we do see real cost pressures, especially around our electronic components, which go in many, many of our products, especially on the MedSurg side of the business. And the buying of those products is many times in a spot market, where it's an auction process and we're paying significantly higher prices than what we normally would pay related to those.

Robert Marcus
Analyst at J.P. Morgan Securities

Got it. Maybe I could just tag on to that, as we think about first quarter here, we've heard other companies more muted, kind of flattish or low single-digit growth with the cadence improving over the back part of the year, is that a reasonable assumption? And then I'll jump back in the queue. Thanks.

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, I mean, Robbie, we're not obviously guiding for the - for the quarter. But certainly as we think about the fourth quarter and how the fourth quarter ended with regards to the COVID variants continuing into January, so I think, you can certainly think about it that way, that there are some of those pressures from a top line standpoint that are certainly continuing at the beginning of the year.

Operator

Our next question comes from the line of Joanne Wuensch from Citi. Joanne, your line is open.

Joanne Wuensch
Analyst at Smith Barney Citigroup

Thank you, and good evening. Two questions, the first one has to do with US Mako robotic placements, if I heard that correctly, that's a big number, should we interpret that as just general demand or maybe demand ahead of expectations for increasing procedures?

Preston Wells
Vice President, Investor Relations at Stryker

No, I think, Joanne, if the - the Mako numbers you're referring to are how we're continuing to utilize Mako as it becomes a bigger and bigger portion of our total knee business, I mean, this is just a continuation as we think about what we've talked about over the last few years. So again, we expect this to just continue to grow as we think about the utilization both on knees and what we're now seeing on hips as well. And then also as we think about cementless in the knee world. So we would expect that just to continue to go as we continue to place and install Mako's in different areas.

Joanne Wuensch
Analyst at Smith Barney Citigroup

All right, thank you. And then [indecipherable], if I'm hearing correctly, that this may be a year where you just sort of plow through and continue to invest even if it's a little bit rocky, is that the right way to think about things?

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Yes, Joanne, this is Kevin. That's exactly the right way to think about it. We have terrific product pipelines. We have a lot of new products for launching this year, including a new power caught being the Insignia hip stem, a number of foot and ankle launches, three launches in the upper extremity space, we have the end space balloon. So a lot of new products, but we're also gearing up for 2023, where we plan to have a next gen camera, a next generation power tool, next generation life pack. And as you know, these new products are really the lifeblood of our top line growth. So we are not going to slow down on the R&D investments. Of course, we'll look at the rest of our SG&A and be and be cautious just like you've seen us be cautious over the last two years. But yes, we are going to power through, but we do have a lot of tailwinds. We have a very strong order book in capital equipment. We're having a little trouble securing all the components to be able to ship all the products, but we have a healthy order book. We have good momentum. And obviously we need to write out the COVID challenges. But yes, we are going to continue to invest for the future.

Joanne Wuensch
Analyst at Smith Barney Citigroup

Thank you. Have a great night.

Operator

Our next question comes from Lawrence Biegelsen from Wells Fargo. Your line is open.

Lawrence H. Biegelsen
Analyst at Wells Fargo Securities

Thanks for taking the question. One for Glenn on margins and one on hips and knees. So on margins, Glenn, just to clarify the [ negative ] 50 basis points to 100 basis points of gross margin impact, is that the gross impact from inflation hitting the P&L and or is that the impact you expect the year-over-year change in the gross margin in 2022 versus 2021? And why are you confident the inflation will abate in the second half of the year and it won't linger. And I have one follow-up.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Yeah. Hi, Larry. Honestly, that's the year-over-year impact to gross margins, not the isolated necessarily inflationary impact that would include impacts from pricing pressures as well. Confidence that it will abate, I don't necessarily think that I have confidence that it will abate. I think it will moderate, is what will happen. I mean a lot of this pricing pressure is based on commodity pricing, which is highly driven by supply and demand. I do believe that supply will catch up. We are securing bulk purchases of demand. So I think that will help us even out our utilization of it as well. And so I do think by the back half of the year, we'll start to see moderation of those costs.

Lawrence H. Biegelsen
Analyst at Wells Fargo Securities

That's helpful. And it Kevin, typically knees are more deferrable then hips. This time your knee growth was much better than your hip growth. That's - I guess it's unusual. I don't I am not looking at - that all the historicals, but usually we think about hips being more - less deferrable, so why do you think knee growth was so much better than hip growth that this quarter for you guys? Thanks.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

For us knees has been really the engine of growth within our joint replacement business, if you look over the last two years, three years. The combination of Mako and cementless is just so powerful that we've had a disproportionate growth in knees relative to the market. In hips, we have a gap with that hip stem, which really the new stem that we - we're just in early launch right now, the full launch will be at at Academy at the end of the first quarter. That's really going to solve a gap in the direct interior procedure. So, I do expect that our hip business will pick up. You're right, that technically hip is a little less deferrable, but the mix, it's really the product portfolio that we have now, which has favored knees. It's not new in this quarter, it's been going on for the last couple of years, and we do expect our knee business to continue to thrive and we're excited about the new hip stem, especially when it becomes compatible with Mako at the end of the first quarter.

Operator

Our next question comes from Matt Miksic from Credit Suisse. Matt, your line is open.

Matthew Miksic
Analyst at Credit Suisse Securities

Hi, good evening. Thanks so much for taking our questions. So, I hand one for Glenn on sort of the margin trends and thoughts about sort of earnings growth over the - this year and intermediate, and then a follow-up for maybe, Kevin, on ASCs. So, Glenn this year, just a couple of questions, we've talked about, you mentioned in your prepared remarks these issues of inflationary pressure, hoping I guess by the end of the year that some of this is going to - you're going to able to manage through them a little bit better, but taking that in the context of your longer term outlook that you had given at your Analyst Day, could you talk a little bit about, sort of I guess reconciling this near-term outlook and expectations for earnings growth given the current environment versus what you had described over a longer term, which was sort of an open-ended long-term average EPS growth that obviously contemplates a different environment next year and the year after, then we're facing at this moment? And then as I mentioned, just one follow-up or for Kevin on ASCs, if I could.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Okay. Yeah, Matt, I think, first of all, at the Analyst Day, the guidance that we laid out was our long-term financial guidance. That guidance was specifically once we exit this kind of COVID environment, which clearly in 2022, we are not in a position that we're exiting the COVID environment. Right now just based on foundationally what is underlying those long-term financial plans in terms of what do we have lined up for growth, how do we think about M&A, how do we think about our product portfolio and new innovation, I see no reason why we would change our thoughts around that long-term growth. Now if you work your way down through the income statement and say, okay, how are you - how are you going to finagle your EPS to get to that growth challenge number, you know, I actually think in this year's growth number, if you look at the high end of our EPS, where we're not far away from what we're asserting is our long-term challenge. I do think that once COVID abates, we will get right back on our cost improvement initiatives, especially around direct purchasing. I don't see that changing at all. Throughout COVID, we have kept up pace in our CTG initiatives still, just in terms of focusing on shared service opportunities, looking at indirect purchasing opportunities, and so all of those foundational elements are still in place, and I do have all the confidence to think that once we exit COVID that we'll get right back into that cadence of delivering that.

Matthew Miksic
Analyst at Credit Suisse Securities

That's helpful. That's helpful, thanks. And then just on ASCs, you know, also kind of a big part of the - the presentation at your Analyst Meeting and it then came up again today, I think in your performance commentary for Q4. It would be great to get your perspective maybe on, as we think about Orthopaedics and large joints in particular moving into that channel over time, as folks have been talking about for a while, if you could give us any sense of what, if and when you'll be able to give us some sense of your percentage of your businesses there, you know, how the growth there differs say from growth in your sort of traditional larger centers. Is there any kind of color over or above what you gave just now on Q4 would be - would be super helpful.

Preston Wells
Vice President, Investor Relations at Stryker

Hey, Matt, it's Preston. So as we've talked about in the past, you know, we talked about our knees in particular being about 5% to 10% of our business being in the ASC. And as we've seen that continue to grow, as we came through the fourth quarter, we're seeing numbers that are actually reaching closer to that 10% number. So we are seeing that shift happen. I mean it certainly is happening when we think about where patients are wanting to get procedures done, certainly as we think about our focus from our often standpoint, as we think about the ASC, we are seeing the shift happen across our product line. So certainly we expect that to continue to go. We've talked about that, there is an opportunity for that to continue to grow over time. Certainly there are capacity constraints as ASCs are built out that will allow that continue to grow faster, but that's a shift that was already started and we don't see that slowing down anytime soon.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

And I'd just like to add that I would sort of large joints, we also have our Sports Medicine business, that's within endoscopy, it grew 30% in the fourth quarter. So that's a great sign of the overall success that Stryker's having in ASCs. That's really terrific growth in our Sports Medicine business.

Matthew Miksic
Analyst at Credit Suisse Securities

Thanks so much.

Operator

Our next question comes from Pito Chickering from Deutsche Bank. Pito, please go ahead.

Pito Chickering
Analyst at Deutsche Bank Aktiengesellschaft

Hi, good afternoon - good afternoon, guys. Thanks for taking my questions. As hospitals are struggling with the labor pressures in 2022, it could impact hospital cash flows. So, are you seeing hospitals take a pause with capital purchases until they understand now the cash flows will be impacted by the labor costs? I understand that the order book is quite strong, just thinking about how you're going to refresh your order book?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, Pito. No, we are not seeing that at all. I mean what we've continue to see throughout the pandemic, and while some of it early on was aided by some of the CARES funding and things of that nature, we are seeing strong balance sheets and we're seeing the continued need for capital products certainly as we think about the capital products that we supply that are either, you know, lending towards revenue generating for the hospital or towards safety and outcome for the hospital, so we are definitely seeing a continued strength in terms of the capital demand, especially for our products. I mean, our order book, as we had said is, is really strong heading into the year. And there's a lot of confidence given some of the products that Kevin even outlined earlier that that's going to continue throughout the year.

Pito Chickering
Analyst at Deutsche Bank Aktiengesellschaft

Okay, great. And then a follow-up of [indecipherable] questions. If gross margins are going to be impacted by 35 basis points at the midpoint, if you're thinking about some 40 basis points or so of SG&A leverage during the year and R&D flat on the year, just want to get a feeling for your G&A versus the gross margins? Thanks so much.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Sure. As you think about operating expenses, and I think - I think Kevin emphasized this, we've protected R&D through this entire period. We just, we know that's the lifeblood. We know we have to spend there and so we have not backed away from funding those innovation initiatives from a people standpoint or a technology standpoint. And that's important and we won't - we won't change there. On the SG&A front, we've been a little more prudent. I think you've seen us be - be smart about - about our spending, be smart about, obviously, we're not traveling a lot, so we're not feeling that. I think as 2022 unfolds, though, I mean a couple of things, obviously we'll continue to be prudent about hiring and bringing in costs, but we will start to see those costs that relate to growth, especially as it relates to interactions with customers, hiring sales forces, expanding territories, those types of costs will expand specifically in selling. Now that being said, we will continue to pressure G&A, corporate type spending and things like that to try to offset some of that, but that's kind of how those operating expenses will look throughout the year.

Operator

Our next question comes from Frank [ Pino ] from Jefferies. Frank, please go ahead.

Frank
Analyst at Jefferies Financial Group

Hi guys. Thank you for taking the question. Just two quick ones from me on - on Mako, clearly a strong quarter, you're now in 1,500 installs market lead. I'm just wondering at this point, Mako has been on the market for seven years, and given the level of success, and I think you're sort of seeing above 50% Mako procedures on knees, above 25% on hips. Where does that go? Does that go to 80% on knees? Does that go to 50% on hips over the next five years? And has your thinking on that opportunity at all changed US, OUS?

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Yeah this - this is really great to see the growth in robotics, it's obviously creating a new standard of care. It's becoming expected. Residents are expecting this as they enter the workforce in Orthopaedics and so we see the growth absolutely continuing. It's going to continue along the path that it's - that's been going on. I think we're going to see hips potentially hit an inflection point with our - with the launch of our new stem and start to really accelerate. So we're very excited about the future, we think, robotics is here to stay. As you've seen this happen in many other industries and so we do expect that the growth will continue. In the fourth quarter, we had an unusually high level of installs and competitive accounts, higher than normal. And we think that the fact that there are other entrants on the market is actually bringing more trialing of our systems and creating even more interest in Mako, than there had been previously. So it's a tailwind for the industry, and we're going to continue to ride that tailwind. And then as it relates to international -

Frank
Analyst at Jefferies Financial Group

Great. Thank you for that, Kevin.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

I would say, we're still, - we're still - Yeah, thank you. I'll just continue on international, I would say, we're still in the earlier phase of that, as you've seen with other with other robotic technologies, it starts off here and then sort of expands around the world. We're still in early phases in Japan and in China and in Latin America, but the growth is really starting to pick up there, the interest level is very high. And so I'm very bullish, but it's going to take longer. It's a little slower, the pathway there, but it's just as exciting in the international markets.

Frank
Analyst at Jefferies Financial Group

Great, thanks for that, Kevin. Just a quick follow-up. I'm just wondering if - if you have any updates on the spine or shoulder opportunity in robotics? And if you put any sort of brackets around that, with respect to timing or milestones at this point?

Preston Wells
Vice President, Investor Relations at Stryker

Hey, Frank. It's Preston. So at this point, as we said before, with regards to both of those different platforms that we certainly have active projects that are working on them, they are key priorities for our development teams. But at this point, we still do not have a timeline that we are sharing.

Operator

Our next question comes from Mike Matson from Needham and Co. Mike, please go ahead.

David Saxon
Analyst at Needham & Company, LLC

Good afternoon. This is David Saxon on for Mike. Thanks for taking the questions. My first one is just on spine, just wondering if - if you have any sense of, if you've gained or lost share in the quarter? And then looking at 2022, do you think you can grow off that 2019 base? And then I'll just ask my second question upfront, on the foot and ankle market, I think you called out some weakness there. Just wondering if that's, you know, it's a weak market or if you're seeing anything on the competitive front? Thanks so much.

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, so let me address your spine question first. I think as we've said in general throughout the pandemic, it's just very hard to get a read on - on how share changes are happening, given some of the COVID impacts and how they impact different things regionally also just in terms of where we are in the reporting cycle, it's very early. Certainly was spine, just like we saw with hips and knees, it was impacted from a COVID perspective throughout the quarter, early on, as we tried to recover from Delta, and then with Omicron coming in later on in the back part of the quarter. So not easy to say where everybody's going to shake out from that standpoint. But certainly outside of COVID, outside of the staffing issues that we talked about as well, we are pleased in general with our product portfolio, including enabling technologies that we have in the spine area, as we come back from COVID and as COVID abates, we would expect the growth to uptick in that area and certainly as we do with all of our businesses, expect to see growth on that business as we talk about year-over-year.

With regards to foot and ankle. Foot and ankle the market is still a very strong market, it's one that we're very happy about to be in, but unlike other products within the trauma or even upper extremities, foot and ankle was much more impacted from a COVID perspective during the quarter, and we've seen that throughout the year. But certainly as COVID abates in that area as well, we would expect that growth to really drive there, and Kevin mentioned, we have several product launches that are going to be happening in that space as well that we're very happy about. So we definitely look for growth, certainly as COVID is starting to abate a bit to really see the growth take off in that area.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Yeah, just to put a fine point on the foot and ankle, so it's really the forefoot procedures that are a little bit more elective and that's where a number of our launches will happen. The total ankle replacement was actually terrific in 2021, really great growth and we're going to continue to have very strong growth in total ankle replacement. It's really getting the forefoot procedures to come back to the office. And as that grows, we will continue to grow. And a lot of our launches are, our MIS products are specifically for forefoot.

David Saxon
Analyst at Needham & Company, LLC

Great, thank you.

Operator

Our next question comes from Chris Pasquale from Guggenheim Securities. Chris, your line is open.

Chris Pasquale
Analyst at Guggenheim Securities

Thanks. One question, high level for you Kevin, and one specific one on neurovascular. So given our interest you guys are in the hospital, I'm curious how you're thinking about the staffing challenges that we're hearing about around the healthcare complex? You shared some assumptions around when COVID and supply chain issues might be. When do you think we might put the staffing piece behind us?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah. So just in terms of staffing, this is Preston, you know, it just similar to some of these other - other headwinds that we talked about, the staffing challenges is a real one that certainly, it seems to be much more pronounced in periods of high COVID infection rates, obviously as those - as those nurses are either doing other things or are in fact impacted themselves from a COVID standpoint. So we certainly do expect that the staffing challenge to remain throughout the rest of this year, but we are seeing hospitals try to find ways to deal with it, whether it's looking at traveling nurses or adjusting wages or even adjusting how they're scheduling to get - to get through that. So while it will be a bit of a headwind, we certainly think that it's something that we will be able to work through, and as procedures return, we certainly expect to get the procedural volumes back to the levels that we would want them to be.

Chris Pasquale
Analyst at Guggenheim Securities

Okay. So, you don't see that as an impediment to a bounce back in activity once COVID recedes?

Preston Wells
Vice President, Investor Relations at Stryker

No.

Chris Pasquale
Analyst at Guggenheim Securities

Okay. And then just quickly on neurovascular, there's competitor recall in the flow diverter segment during 3Q, just curious how much you think that benefited you and if you've been able to take advantage of that get into some new accounts?

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Yeah, our flow diverting stent business has been really a strength for us and it's not really so much related to competitive activity, it's just getting surgeons trained on the product, as you know the Evolve stent is newer in many of the markets. It's a newer launch and we still haven't launched it in all countries around the world. But - but we're pretty excited about the product and it's been growing at a pretty healthy rate. And there was no, I would say, no change or no inflection point related to competitive activity.

Chris Pasquale
Analyst at Guggenheim Securities

Thanks.

Operator

Our next question is from Matthew O'Brien from Piper Sandler. Matthew, the floor is yours.

Matthew O'Brien
Analyst at Piper Sandler Companies

Yeah, good afternoon. Thanks for taking my question. I guess just bigger picture question for starters, as you kind of said at the Analyst Day, you're about an 8% top line grower and you're guiding now 6% to 8%, so 7% in the midpoint, you know, 100 basis points, $170 million bucks roughly. I'm just wondering, this year if that's really all just conservatism around, you know, the impact of COVID or if there is just some supply issues that are going to cause you to just have to back order a bunch of products and that's why you're taking a kind of down about 100 basis points versus, where I think we had all kinds of expected the top line guidance for the year? And then I do have one follow-up.

Preston Wells
Vice President, Investor Relations at Stryker

So, Matt, I think that as we look at 2022 and as we enter the year, similar to what we've seen in 2021, I mean there is still continues to be a lot of variability with just COVID. And so if we think about how we've entered this year with COVID being pretty high in some places, and while this variance seems to - to happen very fast and it seems to be peaking in some areas, which is encouraging, what we can't predict is, where the next wave is and what might happen from a next wave standpoint. So there's a lot of variability, just as we think about COVID, and then we add on top of that some of the challenges and the headwinds from a supply chain perspective and it's not to say that there is a big bolus of supply chain issues that we have, but just in general, if we think about electronics and components in some of the challenges, just with supply across all industries, that's certainly something that's out there in front of us as well. So there's just a lot of variability, as we think about this year in terms of some of those top line aspects that is - is one of the reasons why we have that wider spread and maybe a little bit lower than what some others were expecting. That being said, as Kevin outlined, there are - there are some really, really good tailwinds that we do have, as we think about entering this year, whether it be our Mako installation base and how that's going to - that's going to portray into future sales there, also, the new product launches that he's outlined, of course we have the Vocera deal that we're hoping to close in this quarter as well. So there is a lot of positive momentum that we have across our businesses that we're going to take you into this year. And so we're really pleased with that, which is balancing that with some of those headwinds that I outlined as well.

Matthew O'Brien
Analyst at Piper Sandler Companies

Okay. But you are assuming another wave then, Preston, just to be clear on that in the guidance?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, as Glenn outlined in the guidance that he went through, we do have some - some of that assumed as in that spread that we have.

Matthew O'Brien
Analyst at Piper Sandler Companies

Okay, thanks for that. And then as a follow-up, Kevin, the commentary about - about taking competitive share or are placing more Mako accounts in the competitive customers really caught my attention. And I - what I'm wondering is, if there was just a bunch of trialing that went on in Q2, Q3, you just had a massive Q4 quarter in terms of system placements and sales, are those, - is it primarily in accounts that have a competitive robot or are launching one right now, where you saw a majority of those incremental system placements here in Q4?

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

I don't really get into that level of detail. What I - what I'd just say is the mix - we used to report the mix is roughly 50% to 60% in competitive accounts. It was well north of that in the fourth quarter. And now I don't know if it's just a one quarter issue, or whether that will continue. There were a lot of accounts that were kind of waiting for other offerings to appear on the market. And once those offerings appeared then they would have trials and in most cases it was - in some cases, I know it was the first robot. In other cases, it may have been the second or the third robot in those accounts, I don't have exactly that level of information, but, - but it was higher than we've seen in the past. I can't say I was expecting it. It was higher than I expected, but I am expecting Mako to continue to grow and that's not new. It's just the mix was more - more competitive than we've seen previously. Now, we'll see if that continues, going forward. But the order book for Mako as well as for the MedSurg capital is strong at the end of the year. So that tells us that momentum will continue into 2022.

Operator

Our next question is from Steven Lichtman from Oppenheimer. Steven, please go ahead.

Steven M. Lichtman
Analyst at Oppenheimer & Co. Inc.

Thank you. Hi guys. Just one on the supply disruptions, particularly around electronics. Pardon if I missed this, but is the impact really on medical solely or does it potentially have an impact on your ability in other areas, particularly to keep up with demand in Mako?

Preston Wells
Vice President, Investor Relations at Stryker

So the impact is primarily impacting our medical business, but there are some smaller impacts that we're seeing on some of the other MedSurg related businesses. As we think about Mako, as we entered into 2022 and the expected demand that we have for Mako will feel comfortable where we are in terms of supply and any impacts on Mako are minimized at this point.

Steven M. Lichtman
Analyst at Oppenheimer & Co. Inc.

Okay, thanks, Preston. And then you guys mentioned I think versus 2019 international performance was better than US on an organic basis. As you look into 2022 in your guidance, do you assume constant currency growth for international, which will continue to be ahead of the US or is it more balanced? How are you thinking overall about your international business versus US, as you look into this year?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah. While we don't - we don't provide guidance at that level, we don't expect the momentum that we've generated throughout this year to slow down as we think about our international business. And quite frankly, as Kevin has pointed out in the past, this is something that we've been building towards as we think about our focus on international markets, and so there is no reason to believe that that will slow down.

Steven M. Lichtman
Analyst at Oppenheimer & Co. Inc.

Okay, thanks guys.

Operator

Our next question comes from the line of Matt Taylor from UBS. Matt, please go ahead.

Matthew Taylor
Analyst at UBS Group

Hi, thank you for taking the questions guys. I just had two quick ones. One is, on the supply chain assumptions, I didn't detect in your comments that you were saying supply chain specifically was impacting revenue, is that all a cost impact or is there actually some product that you're not able to get out, because you can get componentry and the like?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah. So I think it's a bit of a mixed bag. So there certainly are inflationary pressures that we're feeling as a result of the supply chain and just constraints on certain materials like electronics, but that is also in some cases, leading to some delays in terms of getting some products out. So we do have a bit of a mix, as we think about supply and certainly the procurement team, the direct procurement team is working on actively securing as much as possible. And as Glenn mentioned, sometimes what that means is going outside of our contracts into spot buys and that's what's generating some of the larger inflationary impacts as we think about the guidance that we gave. Obviously our goal is to protect our customer needs as best as possible, as we go through this, but there certainly is an impact on both the top end and the inflationary pieces that Glenn outlined as well.

Matthew Taylor
Analyst at UBS Group

Okay. Well, then, that makes sense. That's helpful. And then just one other follow-up, so it's encouraging to see the strong capital trends, especially in Mako. I guess I was wondering if you are seeing any places where the capital purchasing has been weak and I'm thinking especially beds, I think some investors are concerned that maybe beds were pulled forward, because of the pandemic. So we would love any comments on that, you know, pluses and minuses in capital spending that you're seeing.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Yeah, actually our capital order book is strong across the board, and in particular beds had a terrific finish at the end of the year in terms of orders, a huge number of orders for our new ProCuity bed. So, and it's a new launch. It takes some time to go through the trialing process, but we're extremely excited about our bed business. I think Glenn highlighted that in his - in his remarks, but the orders for our beds are very high, very strong and we now have to build all the beds and make sure we have all the parts to be able to ship them all, but we're very excited about the momentum. So it's broad based, it's said in our emergency care area, it's in Mako, it's in beds, it's in the Instruments division, the endoscopy division, the capital across the board is strong.

Matthew Taylor
Analyst at UBS Group

Good to hear. Thanks, Kevin.

Operator

Our next question comes from Joshua Jennings from Cowen. Joshua, your line is open.

Joshua T. Jennings
Analyst at Cowen & Co., LLC

Hi, good evening. Thanks a lot. I, kind of, was hoping to to pipeline questions. I mean you made a big winning bet on pairing robotics with transplant needs. I was wondering if you had any change in strategy on the implant side, anything on the manufacturing front, is it still cost prohibitive for 3D printing of the transplant and implant? And how do you see the knee implants evolving from here under Stryker's roof? And then the second question is, just robotics that a lot in the pipeline with Spine and Shoulder, are there any other areas, particularly, one of the question on neurovascular, where you see robotics or a killer app and in neurovascular any other business segments for Stryker? Thanks a lot.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Okay, great. Well, thanks. We would like to sort of wait till we have something proven before we kind of talk about it. We are looking at femurs, in particular cobalt chrome at different manufacturing processes for those. And once we're ready to talk about that, we'll share that. We have automated the beading that's used for the cementless part of the femur. We are constantly looking at different surface materials, but not ready to announce anything yet. I would say that the - the actual design of triathlon, we're really delighted with. As you saw, we came out with 3D printing tibial base plate, 3D printed patella to enable the cementless a solution, but not a fundamental change to the design. We've - we came out with 1 millimeter inserts, and we've made other changes and I'll say modifications to make it easier to have a more personalized knee solution, but not a fundamental redesign. So, I - so you would - shouldn't be expecting some kind of fundamental new design, but, but there will be things that we're working on that we'll be able to share with you on the knee side. Certainly on the hip side, we have a new implant, that we've talked about already earlier - earlier on that's fit for purpose for Direct Anterior, we're very excited about that. We have a fabulous 3D printed hip cup, but we do have instances where many surgeons are using our cup, but they're using a competitive stem, and with this we'll be able to convert all of their business. So that's very exciting for us. But on the knee side, I wouldn't expect anything major new - we are working on things, when we're ready, we'll be able to share that. As it relates to future applications, as you know, robotics are challenging. We're - our main focus is really shoulder and spine right now. There are some skunkworks projects looking at some other areas, but again I don't want to start talking about those yet, because they need to get more proven before we're ready to talk about it. In the areas of spine and shoulder, it's a matter of time. We are going to have robotic applications, but again, we don't have a timeline right now, but we have projects that are working on - teams that are working on it and making very good progress.

Joshua T. Jennings
Analyst at Cowen & Co., LLC

Great, thanks a lot, Kevin.

Operator

Our next question comes from Shagun Singh from RBC. Your line is open.

Shagun Singh Chadha
Analyst at RBC Capital Markets

Okay, great. Thank you for squeezing me in. Just a couple of quick ones from me. Firstly, what are you assuming specifically for margin expansion in the first half and the full year? And then on China VBP, do you expect trauma and spine to be included in this year's announcement? And then just lastly on ASCs, you know, it's a major theme that we're hearing from hospital companies including from HCA this morning that, ortho is the latest category that's in transition from inpatient to outpatient. And I think Kevin previously you'd indicated about, you know, that you expect about 50% of procedures to transition, and I think you gave a timeline as well. Can you provide us with an update there. Thank you for taking the questions.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Okay. I'll - I'll, this is Glen. I'll take the first one on margin expansions. We specifically did not really guide on margin expansions, is because there's a lot of volatility. I think we were trying to provide you with some good color around some of the pressures we were feeling especially on gross margin, we do expect that to be a little more pronounced in the first half of the year, especially as compared to prior year, and that's the extent of the guidance that we'll provide on on margin. And I'll hand it to Preston.

Preston Wells
Vice President, Investor Relations at Stryker

So yes, Shagun, just back to your ASC question, it as I - as I talked about before, we do expect that, that transition to continue. In terms of a timeline, I mean I think a lot of it is just going to depend on how capacity is built and how we're able to continue to transition patients and surgeons to that - to that setting. Certainly as we think about the ASC offense that we've created, we are here and actually helping to make that transition happen. So we certainly would expect our large joints to continue to make that - that shift as well. And I apologize I forgot your second question that you had in there.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

She is not there.

Preston Wells
Vice President, Investor Relations at Stryker

Emily, we can go to the next - the next question.

Operator

Our next question comes from Jayson Bedford of Raymond James. Jason, please go ahead.

Jayson Bedford
Analyst at Raymond James

Good afternoon and thanks for taking the questions. Just a couple of quick ones. First it's a little granular, but in those geographies that have seen COVID cases that have rolled over, have you seen a pickup in volume growth?

Preston Wells
Vice President, Investor Relations at Stryker

So, I would say that - that it's spotty. I mean, I think just like - just like how we've thought about COVID throughout the last 24 months or so, you will as COVID cases start to decline and as hospitals are able to get capacity up and running, we know they will. And so certainly, as that happens with this wave, we will start to see procedures picking back up in those areas as well.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

But it does vary by market. So in Australia, we definitely saw a big pickup as soon as they resume elective is to pickup is pretty swift. I would say the UK is similar, but then in other markets, whether it's Japan or whether it's in the Southern Europe, it's a little bit more gradual, the increase. So there isn't one answer, but we do know is these patients are going to need procedures. The pace of the recovery, honestly, is quite difficult to generalize, because it does behave differently by country. We are expecting that there will be a pickup and we look forward to that.

Jayson Bedford
Analyst at Raymond James

Okay, that's fair. And just secondly on the right integration, you guys have done a great job here in the US. Just wondering on the international, how much work is left on the integration and should we expect to see a pickup in international growth in 2022?

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, we - we continue to work through the international integration. I would say that as I mentioned in my prepared remarks, we continue to make progress in that space, and as we do certainly we should continue to see a pick up internationally as well.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

It's the international markets, certainly lag the US. We had distributor contracts and arrangements that we had to to get out of, and so we always plan for that to be a little later. And so we didn't have any the kind of results internationally that we did in the US, but that wasn't a surprise to us. And you will see a gradual pickup in the international markets. We're quite excited, because obviously Stryker has a larger footprint internationally and really a better home for the Wright Medical products and that should be an engine of growth in the years ahead.

Operator

Our next question comes from Jeff Johnson from Baird. Jeff, your line is open.

Jeffrey D. Johnson
Analyst at Robert W. Baird & Co. Incorporated

Thank you. Good afternoon. Most of my questions have been answered, but Glenn, you know, totally respect that you haven't guided to the operating margin line, but I think when we connect the dots between your revenue guidance, your gross margin guidance, or your EPS guidance. I mean simple math is kind of going to get me, it could be up, you know, operating margin to be up a very little bit to down 30 basis points, 40 basis points, just directionally is my math kind of right there, or should I read - rethink some of my math? Thanks.

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Yeah. Hi, Jeff. Yeah, I think, you know, your math is pretty obvious, I think if you take all the pieces, so I imagine that your model probably will reflect that.

Operator

Our next question comes from Danielle Antalffy from SVB Leerink. Daniel, your line is open.

Danielle Antalffy
Analyst at SVB Leerink

Thanks so much. Hi, guys, good afternoon, and thank you so much for squeezing me in here. I just have one question and sorry to belabor the whole COVID recovery et cetera point, but I'm just curious about how to think about this recovery post surge or post wave versus past recovery, you know, I am thinking of post Q - I'm sorry, Q2 of last year, and even really Q2 of 2020, when things first opened up, you really saw a bolus, but it feels like because of the hospital staffing shortages, this might be a little bit more linear in nature. I know it's probably very difficult to get granular here, but just curious about what you're hearing, how you guys are thinking about the recovery curve itself. Thanks so much.

Preston Wells
Vice President, Investor Relations at Stryker

Yeah, Danielle, you're right, it's - it is - it is a difficult thing to predict and certainly as we go back to 2020, I think you saw that big bolus pickup, if you remember how far down, it was at the end of Q2, and we certainly have not seen that same level of drop-off with these subsequent waves. So I think linear and gradual is probably the way to think about it, certainly muted, a little bit by some of the staffing pieces, but I would say linear and gradual as we continue to come out of this recovery.

Danielle Antalffy
Analyst at SVB Leerink

Okay, that's it for me. Thanks.

Operator

And our last question today comes from Drew Ranieri from Morgan Stanley. Drew, please proceed with your question.

Drew Ranieri
Analyst at Morgan Stanley & Co. LLC

Hi, thanks for taking the questions. Just maybe one for Glenn. Just on cash flow for 2022. Can you provide any type of framework for cash flow from operations? I know, I think you mentioned CapEx, but just curious what you're seeing and are expecting and any type of working capital improvements you're kind of working on in 2022?

Glenn S. Boehnlein
Vice President, Chief Financial Officer at Stryker

Yeah, no, great question. I think as we think about cash flow, we've really come a long way, especially from where we were in 2019, and especially a lot of the muscle and discipline that we've built around working capital management. So all of that will roll into this year 2022 and the benefits associated with that. I think there will be some spending that was somewhat muted and deferred in the past, especially around CapEx, and so right now we're estimating approximately $650 million of CapEx. That being said, we generally target that 70% to 80% free cash flow conversion number. I know we've beaten that over the last couple of years, but we've also seen reduced spending in a lot of areas that I think will start to pick up, especially as we exit this and kind of try to get to a more normal operating environment. So, I think that's probably what we're targeting, there could be some variability depending on how COVID plays out through the year.

Drew Ranieri
Analyst at Morgan Stanley & Co. LLC

Thanks. And Kevin, just one for you, you kind of touched on the Insignia launch and your expectation that's going to drive more Mako utilization over time, but near term, maybe in 2022, as you're launching this AAOS, I mean would you expect to get up to 30% utilization for hips on Mako? Or is there kind of a stretch goal that you have in mind for the year? Thank you.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

Yeah, actually for this year, I'm more concerned really with just getting great uptake with the stem, whether it's with Mako or without Mako. We've already done a limited launch. Feedback has been incredibly positive from surgeons in terms of the broaching of the implant, the size options, they - the experience that they're having is - it's really terrific. So in this first year that Mako utilization is less important to me than really satisfying the surgeons need for this product and really getting to [ DA ] and I expect that Mako number will continue to rise. It could 30%, absolutely. But more importantly it is really having success with the stem, both manually as well as, as with Mako. And the full launch, we expect will be in the second quarter. So we'll really start to see a bigger impact in the second half of the year. There will be some impact in the first half, but much more towards the second half of the year.

Operator

There are no further questions at this time. So, I will now turn the call back to Mr. Kevin Lobo for any closing remarks.

Kevin A. Lobo
Chair and Chief Executive Officer at Stryker

So thank you all for joining our call and for all your questions. As you can see, we had a very strong finished to 2021. We are working through the challenging environment right now and you can see that the company is well positioned to fight through it. We are going to continue to invest for the future and make sure that as things improve in the environment, that we're poised to capitalize on that and we look forward to sharing our first quarter results with you in April. Thank you.

Operator

Thank you. This concludes today's conference. Thank you for participating. You may now disconnect your lines.

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