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.