Stryker Q4 2023 Earnings Call Transcript

Presentation

[Operator]

Welcome to the Fourth Quarter and Full-Year 2023 Stryker Earnings Call. My name is Luke and I'll be your operator for today's call. [Operator Instructions] This conference call is being recorded for replay purposes.

Before we begin, I'd like to remind you that 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's an exhibit to Stryker's current report on Form 8-K filed today with the SEC.

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

[Kevin 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 Jason Beach, Vice-President of Investor Relations. For today's call, I'll provide opening comments, followed by Jason with the trends we saw during the quarter, make more performance insights and updates on recent acquisitions. Glenn will then provide additional details regarding our quarterly results and 2024 guidance before opening the call to Q&A.

First I want to recognize and celebrate our achievement of surpassing $20 billion in sales. We continue to be a high-growth company with a focus on our mission to deliver for our patients and customers. As we begin 2024, I am very excited about our future. We are in a strong position with a robust demand across both procedures and capital easing macro constraints and a strong pipeline of innovation. I want to thank our over 50,000 employees for their unrelenting determination, agility and performance. We delivered terrific sales growth of over 11% in Q4 and the full-year despite strong comparatives from the prior year. Our commercial execution, including many successful product introductions was excellent across our businesses and regions. Globally for both Q4 and the full-year, we had double-digit organic sales growth. In instruments, endoscopy, medical, neurocranial, hips, knees and trauma and extremities. For the full-year, we also had double-digit organic sales growth both in the US and internationally.

Spine and neurovascular also demonstrated good performances while making notable advances in future innovations and acquisitions. It was a comprehensive performance across our businesses. And we have built significant momentum entering 2024. For the sixth straight year our international sales growth, excluding China VBP, outpaced our strong US business. Canada, Australia and most emerging markets had double-digit growth, while Europe and Japan grew in high-single-digits. International continues to be a larger growth opportunity for us.

Next, we delivered quarterly and full-year adjusted EPS of $3.46 and $10.60, respectively, which represents 15% growth for Q4 and 13% growth compared to the full year of 2022. This was driven by our strong sales, but also demonstrates our continued operating margin recovery. We remain focused on driving high-growth now and in the future through investments in organic innovation and M&A. We expect to continue to deliver sales growth at the high-end of medtech, which is reflected in our full-year 2024 guidance of organic sales growth of 7.5% to 9%. This growth combined with an accelerated margin expansion plans translates to adjusted EPS of $11.70 to $12 per share.

I will now turn the call over to Jason.

[Jason Beach, Vice President, Investor Relations at Stryker]

Thanks, Kevin. My comments today will focus on providing an update on the current environment, as well as Mako, Vocera and our recently announced agreement to acquire SERF. During the quarter, we saw strong procedural demand. We continue to expect the ortho markets will remain strong in 2024, driven by continued adoption in robotic-assisted surgery, demographics, a more favorable pricing environment and healthy patient activity levels with surgeons.

While supply constraints continue in pockets around the globe, our supply is stable overall and gradually improving. Additionally, demand for our capital products remained very robust in the quarter with double-digit organic growth in medical instruments and endoscopy. Hospital capex budgets remain healthy and our capital order book remains elevated as we enter 2024.

Next, specific to Mako, we had a record quarter of installations globally. The progress of our Mako offerings, including our recent direct-to-consumer campaign has resulted in strong growth of our install base, alongside continued increases in utilization. In the US, we saw 60% of knees and 34% of hips performed using Mako as we exited the year. Globally, we exited the year with just over 40% of knees and nearing 20% of hips performed using Mako. We have momentum and a significant opportunity remains as Mako adoption increases.

We are nearing the two-year anniversary of our Vocera acquisition and remain very excited about the acquired assets as it provides a platform for us to be at the intersection of medical devices, software and clinical support. With integration activities now complete, which included a migration towards the cloud, as well as the commercial reorganization, we are pleased with the accelerating double-digit sales and order growth achieved as we exited the year.

In 2023, we saw many cross-sell wins, including new bed business, leveraging Vocera. Also, we completed a seamless experience created between the Vocera platform in both ProCuity and our new wireless stretcher. This year and beyond, we'll bring even more integrations and enhancements with a focus on scalability, user experience, automated workflow and documentation. We expect strong double-digit annual sales growth to continue for years to come, and we are excited to have Vocera as part of the Stryker family. Lastly, we are progressing with our recently-announced agreement to acquire SERF and we expect the deal will close this quarter.

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

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Thanks, Jason. Today I will focus my comments on our fourth quarter financial results and the related drivers, our detailed financial results have been provided in today's press release.

Our organic sales growth was 11.4% in the quarter compared to 13.2% organic growth in the fourth quarter of 2022. The fourth quarter of 2023 had the same number of selling days as 2022. The impact from pricing in the quarter was favorable by 0.7%. We continue to see a positive trend from our pricing initiatives, particularly in our MedSurg and Neurotech businesses, all of which contributed positive pricing for the quarter. Foreign currency had a 0.3% favorable impact on sales in the quarter.

In the quarter. US organic sales growth was 12.7%, International organic sales growth was 7.7% against a very strong comparable of over 18% in 2022. This performance included positive sales momentum across most of our international markets, particularly Australia, Canada, Japan and most emerging markets.

For the year, organic sales growth was 11.5%, with US organic sales growth of 11.7% and international organic sales growth of 10.9%. Excluding the impact of China VBP, international growth was 12.8%. The impact for pricing in the year was favorable 0.6%. Foreign currency had a 0.5% unfavorable impact and 2023 had the same number of selling days as 2022.

Our adjusted EPS of $3.46 in the quarter was up 15.3% from 2022, driven by higher sales and operating margin expansion, as well as lower other income and expenses. Foreign currency exchange translation had a favorable impact of $0.02. Our full-year adjusted EPS was $10.60, which represents growth of 13.5% from full-year 2022, reflecting the favorable impact of sales growth and operating margin expansion. Partially offset by the unfavorable impact of foreign currency exchange translation of $0.10.

Now. I will provide some highlights around our quarterly segment performance. In the quarter, MedSurg and Neurotechnology had constant-currency sales growth of 12% and organic sales growth of 11.8%, which included 13.8% of US organic growth and 5.7% of international growth. Instruments had US organic sales growth of 11.5% with strong double-digit growth across its surgical technology and orthopedic instruments businesses. From a product perspective, sales growth was led by power tools, Sterishield, Smoke Evacuation and surge account.

Endoscopy had US organic sales growth of 17.9% with double-digit growth in its communications, Endo B.U. and sports medicine businesses. From a product perspective, this included strong growth in booms, lights and video. During the quarter the Endoscopy business continued to see very strong momentum of the 1788 camera system, which had its full launch in September.

Medical had US organic sales growth of 12.9%, led by performances in its Vocera, Acute Care and Sage businesses. This included strong growth in Vocera badges, steths, stretchers and Prevalon repositioning products. All of this was against a very strong comparable growth of over 20% in 2022. Neurovascular had US organic sales growth of 7.6%, reflecting solid performance in our hemorrhagic business. Neurocranial had US organic sales growth of 14%, which included double-digit growth in the neurosurgical and ENT businesses with strong growth in high-speed drill and balloon dilation products.

Internationally, MedSurg and Neurotechnology had organic sales growth of 5.7%, reflecting double-digit growth in our Instruments and Neurocranial businesses. Geographically, this included strong performances in Australia, Canada and Japan. Orthopaedics and Spine had constant-currency and organic sales growth of 10.7% which included organic growth of 10.9% in the US and 10.1% internationally. Our US knee business grew 12.9% organically, which reflects our market-leading position in robotic-assisted knee procedures. Our US -- our US hip business also grew 12.9% organically, reflecting solid primary hip growth fueled by our Insignia Hip Stem. Our US Trauma and Extremities business grew 12.1% organically with strong performances across all of its businesses, including upper extremities, biologics, core trauma and foot and ankle.

Our US spine business grew 6%, led by the performance in our enabling technology and Interventional Spine businesses. Internationally Orthopaedics and Spine grew 10.1% organically, including strong performances in Canada and most emerging markets, particularly driven by Mako and strong knee performance across most geographies.

Now I will focus on operating highlights in the fourth quarter. Our adjusted gross margin of 63.9% was favorably -- was favorable approximately 120 basis points from the fourth-quarter of 2022. This improvement was primarily driven by the continued easing of certain cost pressures, including the elimination of spot buy purchases that we experienced in 2022 and the continued benefit of pricing initiatives. Adjusted R&D spending was 5.6% of sales, which was 10 basis points higher than the fourth-quarter of 2022.

Our adjusted SG&A was 31% of sales, which was 40 basis points higher than the fourth-quarter of 2022 due to continued investments, including sales growth incentives and a more normalized cadence of travel and meetings. In summary, for the fourth-quarter, our adjusted operating margin was 27.2% of sales, which was approximately 60 basis points favorable to the fourth-quarter of 2022.

For the full-year, our adjusted operating margin was 24.2% of sales, a 40 basis points increase over 2022. This performance was mainly driven by the easing of certain gross margin cost pressures throughout the second-half of the year, as well as the positive impact of our pricing actions. Adjusted other income and expense of $31 million for the quarter was $23 million lower than 2022, mainly driven by higher interest income and other favorable discrete items. For 2024, we expect our full-year other income and expense to be approximately $250 million. Our fourth-quarter and full-year had an adjusted effective tax rate of 14.6% and 14.1%, respectively, reflecting the impact of geographic mix and certain discrete tax items. For 2024, we expect our full-year effective tax rate to be in the range of 14% to 15%.

Focusing on the balance sheet, we ended the year with $3 billion of cash and marketable securities and total debt of $13 billion. During the year, we paid down the remaining $850 million outstanding on the $1.5 billion term loan associated with the Vocera acquisition and achieved our deleveraging commitments. In Q4, we also refinanced certain debt maturities, including pre-funding of $600 million that is due in May 2024.

Turning to cash flow, our year-to-date cash from operations was $3.7 billion. This performance reflects the results of net earnings and higher accounts receivable collections. For 2024, we anticipate that capital spending will be $650 million to $700 million. We do not anticipate any share buybacks.

And now I will provide 2024 full-year sales and earnings guidance. Based on our momentum from 2023 strong procedural volumes, healthy demand for capital products, and a stabilizing macro-economic environment we expect organic sales growth to be in the range of 7.5% to 9% for 2024. There is one additional selling day in 2024 compared to 2023 with one less day in Q1 and one more day in both Q3 and Q4. Based on the steady progress of our pricing actions, we would expect the full-year impact of price to be roughly flat.

If foreign exchange rates hold near current levels, we anticipate sales will be modestly unfavorably impacted for the full-year being more negative in the first-half of the year. EPS will be negatively impacted $0.05 to $0.10, this is included in our guidance. Finally, for the full-year 2024, we expect adjusted net earnings per diluted share to be in the range of $11.70 to $12, representing our commitment to accelerated operating margin expansion in 2024 as well as the stabilized -- stabilizing operating environment. While we do not provide quarterly guidance, we do expect seasonality for sales and related earnings to be similar to 2023, but adjusted for the quarterly differences in 2024 selling days.

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

Questions and Answers

[Operator]

[Operator Instructions] Our first question comes from Robbie Marcus with JPMorgan. Your line is now open, please go ahead.

[Robert Marcus, Analyst at JPMorgan Chase & Co.]

Great, thanks, and congrats on another fantastic quarter. Kevin, maybe to start I feel like it's a bit of deja vu where we were sitting here at exactly this time last year and investors were starting to worry after a good year in 2022 and how good can 2023 be and now people are wondering about '24. So I was hoping you could give a little color behind the 7.5% to 9% organic sales growth, how much of that is transitory? How much of that is durable pricing and any key drivers, you could point us to? Thanks.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Thanks, Robbie. It certainly was a terrific year in 2023. We had 9.7% organically the year before and over 11% organic in '23, and frankly, we feel very good going into '24. At some point, we think the comps will start to catch-up to a bit. And so, we think 7.5% to 9% is a strong guide. I can tell you coming off all of the domestic sales meetings, there is tremendous energy and excitement among our teams, procedure volumes are strong. The capital markets are very strong. Hospitals are spending. We have exited the year with more backlog than we began the year which means, obviously, our orders are continuing to be strong for capital equipment.

So we have a number of new launches, again, planned in 2024. Obviously, 2022 was a great year capitalizing on product launches whether it was system nine just in mind, whether it Nepture S, whether it was 1788, we have other launches coming again. So our pipeline of innovation is very strong. And so I expect us to continue to grow at the high-end of medtech in a medtech market that is quite healthy.

[Robert Marcus, Analyst at JPMorgan Chase & Co.]

Great. Maybe, Glenn, follow-up for you, and I appreciate you don't guide quarterly, but there's a lot you could do to help us get models in the right spot based on what you can say. And I guess really the question is my math is implying 50 basis points to 100 basis points of operating margin expansion. You talked about the top-line should look like 2023, and I imagine that looks like a normal comparable quarter in first-quarter and maybe some sharper seasonality than historically down 3Q up 4Q. Also anything down the P&L operating margin that we should be considering in that seasonality. Thanks.

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes, I think Robbie and I tried to sort of lay this out at the end of my guidance there, but I think a good place to start would be to look at sort of a cadence of sales and earnings in 2023 and really just adjust out for one selling day in Q1 and then adding two on the back-end. And so as you look at, hey, page Stryker how are you going to deliver op margin expansion throughout the year? It's probably a little more back-half loaded just based on the cadence that we will see through the year for sales and related op income.

[Operator]

Our next question will come from Lawrence Biegelsen with Wells Fargo. Your line is now open, please go ahead.

[Lawrence Biegelsen, Analyst at Wells Fargo Securities]

Got it, thanks for taking the question. And I'll echo Robbie's congratulations on a really strong year and finish to the year. Kevin, I'd love to hear your updated thoughts on M&A heading into 2024, your focus has been on paying down debt in 2023. Is your focus in '24 on smaller deals or openly considering something larger? I know the target area is the same as the ones you shared at the Orthopedic meeting last year, and I had one follow-up.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, thanks, Larry. I would say that we're back on M&A offense, what I'll call our normal M&A offense and as you've seen in the past with Stryker that typically mean larger volume of tuck-in deals and those can be large and they can also be small. During the pause, while we paid down debt, all of our BD teams worked very actively. Believe me, they have a long list of targets and we are going to be active now that we've gotten our leverage back to where we'd like to be. So, let's say, we're back to the normal Stryker off as expect us to be doing deals. We are open to larger deals, but our history would tell you that vast majority of our deals are going to be smaller tuck-ins, but we can do many deals versus being very limited last year.

[Lawrence Biegelsen, Analyst at Wells Fargo Securities]

That's helpful. And Glenn, to follow-up on Robbie's question on the margins. First, is it coming -- the margin expansion coming -- how much is coming from gross margin versus operating margin? And are you committed still to the 200 basis points getting back to the pre-COVID margin by 2025? I mean, it actually -- I don't know the math -- not to get too much into it, but it looks like -- I thought it looked like over 100 basis points implied in the guidance this year. So I assume we can all figure that out offline, but just any color on growth versus operating margin and the 200 basis points for the two-year sprinting back to pre-COVID margins would be helpful? Thanks.

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yeah, Larry, I think, first of all, we're not backing off of our sprint to 2019 margin at all. And we have clearly laid out a plan to get there by the end of 2025. As I said at Analyst Day, we have good opportunities in operating expenses and in gross margin. I think if you look at our delivery in 2023, we got about 80 basis points out of gross margin and we invested in some operating expenses that we had indicated would get back to sort of normalized spend.

So my thoughts on 2024 is that expansion will generally be led by operating expenses, but there continues to be really good opportunities in gross margins that we continue to work on. And if you think about some of these things, price isn't going away for us, we're still going to continue to work on that. We do elaborated on the benefit we have of low-cost manufacturing sites and we'll continue to see expansion there. We have opportunities in purchasing and procurement, supplier consolidation.

On the opex side we'll continue to expand into shared services in some of these low-cost areas where we have those. And then honestly from opex, we have a lot of natural leverage it just comes when you're growing at the rate that we're growing.

[Operator]

Our next question will come from Ryan Zimmerman with BTIG. Your line is now open, please go ahead.

[Ryan Zimmerman, Analyst at BTIG Research]

Yes. Thanks for taking the question. So I want to ask about Orthopaedics. It's just been stellar performance and we've heard from you and one of your peers and Kevin, I just would appreciate if you could kind of characterize the confidence that this continues to persist for '24 and how are you improving, or what are you doing to improve potentially productivity on the Mako units to capture the demand that continuing to be so strong?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, thanks. Look, we're delighted with the progress that we've made. 60% of US knees being done on the robotics is pretty remarkable given how long ago we launched the total knee application and seeing it's starting to really climb since we launched the 4.0 software has been terrific. Cementless continues to climb as well. And that tends to index much higher with the use of Mako. And as you know, we are clearly the leader in not just in robotic-assisted surgery, but clearly the leader in cementless as well.

So a lot of good things going on with a market that is obviously a little better than it has been historically. But Mako continues to be the engine of growth. And that's true in the hospital. That's true in the ASCs as well. And we're seeing continued growth in the ASC, where our Stryker offenses really winning at a pretty spectacular rates as it relates to newbuilds and big renovations. So we have a lot of momentum across all of those dimensions, which translates to terrific performance as you saw with hips and knees.

But the other part of our story is Trauma and Extremities. So the Wright Medical acquisition has been a complete homerun of a deal and you're seeing that. And not only has it been great for our Extremities business, but enabled us to focus a lot on our core trauma business. We really had all of our businesses in Trauma and Extremities humming as we exited the year and some great product lunches towards the end of the year and some more to come in 2024.

[Ryan Zimmerman, Analyst at BTIG Research]

Okay. And then maybe turning to Medical, because it is now I think the biggest unit inside the company and the comps are increasingly tougher in the first half of the this year. It's been exemplary growth through late-'22 and then in the first-half '23. Inside of that, you talked about Vocera continuing to be a double-digit grower. But if you can level-set us on the entire portfolio, how you think about the ability of that business to continue to be accretive to overall growth and maybe what the appropriate expectations are around the Medical segment, given how much is in that, in that segment?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Look, we love our Medical business and frankly, it's become a big and very fast-growing business. We continue to expect it to grow above Stryker's average growth rate. This is going to be true for the next five years. From quarter-to-quarter, it does bounce around a little bit because of course there is capital, a lot of large capital within Medical. But you also have increasingly more stable revenue with Sage, which is doing spectacularly well. And you've got obviously the AED demand which has exploded. And we have a terrific AED business. Tremendous innovation we launched the Xpedition Stair Chair in the early part of the year, the first powered Stair Chair, which the firehouses absolutely love. And then you've got a lot of new demand for wireless connection wireless stretchers. So just tremendous innovation, tremendous leadership position and now a much more diverse set of businesses than we had historically.

So I think Medical is the business in Stryker that's the most underestimated, because AED is are high-growth, our powered cots are high-growth and now our bed business is doing really well behind ProCuity. And then you have Vocera in addition to that. So really I would expect high-growth from all of those different businesses Sage, Vocera, bed, stretchers, AEDs because of innovation that we're constantly innovating and we have a couple of big launches in Medical coming this year as well. So it's an exciting time to be in Medical. And we also have an outstanding leadership team. They've really focused on talent for years and years and years. And so I'm very bullish on Medical. And I think, again whatever people have in their models, we've tended to beat Medical, if you go back for the last six years.

[Operator]

Our next question will come from Joanne Wuensch with Citi. Your line is now open, please go ahead.

[Joanne Wuensch, Analyst at Smith Barney Citigroup]

Good evening, and thank you for taking the question and very nice end to the year. I'm curious about where you are in your super-cycle. And not to use sports analogy, but are you halfway through half climbed or you just have a couple more innings to go? And I know I'm mixing my metaphor here. And also, sort of similarly AAOS, what should we be expecting for that? Thank you.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

I'll take the first part and then Jason can talk about AAOS. Look, I would say that our pipeline of innovation is incredibly strong. What I mentioned in terms super cycle, that really was referring to, let's call them, big platform launches. But the reality is we're driving tremendous growth even in some of the divisions that don't have big platform growth at launches if you think about Extremeties, if you think about foot and ankle. But I would say the big ones coming up.

We have this Pangea launch within our core trauma business which is a big platform launch. We have a new defibrillator that's coming, of course, pending FDA approval. It's a PMA device, but we're very excited that's what I would call a big platform launch. We have Mako coming into the third-quarter of this year. That's another big platform launched towards the end of the year. We have the Mako shoulder. And we have this product that we called Copilot which is very exciting product, that's going to be used by spine surgeons as well as neurosurgeons, which is within the same ecosystem as Mako and our Q navigation system.

So those are the ones that I'd point out to you, but what I'd tell you is every business has launches planned. And some of them -- accumulate a number of small launches and you end-up driving pretty terrific growth. But I would say maybe we're kind of midway through the large platforms, but I would tell you everything is reloading. So we launched 1788 and they're reloading and already working on 1888. So I think we've just hit sort of a cadence of innovation that's as good as it's ever been in my time at Stryker.

And so I don't expect that we're going to sort of come off this super-cycle and suddenly have some kind of a dip. We're just reloading and reloading and getting back on M&A offense also will help to continue to fuel that. So I'm very, very bullish really for the next couple of years that this innovation across our company will continue to fuel high-end growth for Stryker. And second part Jason.

[Jason Beach, Vice President, Investor Relations at Stryker]

Yes, Joanne, it's Jason. Happy to follow-up after the call as well. But AAOS will be exciting. Some of the products that Kevin just referred to we will be demoing at AAOS, starting with Blueprint, followed by Pangea 1788 camera will also be demoed as well. So it will be action-packed, so we'll plan on seeing out there.

[Operator]

Our next question will come from Vijay Kumar with Evercore ISI. Your line is now open, please go ahead.

[Vijay Kumar, Analyst at Evercore ISI]

Hey, guys. Congrats on a really strong print [Phonetic] here. I had two questions, maybe first one on the guidance here. 7.5% to 9% for the fiscal '24, what is being assumed for China VBP any backlog contribution and I'm looking at Q1, that's the toughest comp of the year? Should Q1 still be within that annual guidance range of 7.5% to 9%?

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. Hi, Vijay. Yes, as we look at -- I don't guide quarterly, but I would tell you that the cadence of what we're going to deliver from the midpoint will play out similar to 2023, but keep in mind going to back-out one selling day in Q1, is what I would say. And then on VBP, I'll let Jason.

[Jason Beach, Vice President, Investor Relations at Stryker]

Yes, Vijay, it's Jason. On VBP, I mean, we don't disclose in terms of the impact there. So we won't, but in terms of a follow-up to your capital question. As we think about the capital environment, really the tone has not changed there. We feel really good, orders are very healthy. I mentioned that we came into the year with elevated level. So we feel good. And just as a reminder, right, if you think about our capital sales. So our smaller capital being call it, 15% of our sales needs to continue to be refreshed as you think about kind of the procedural volume. And then large capital being 10% of our sales. Again, very healthy from both a order and backlog perspective. So we feel good about that in 2024.

[Vijay Kumar, Analyst at Evercore ISI]

Understood. And Kevin, maybe one for you on that, I saw that you mentioned, direct-to-consumer campaign on Mako was very successful. Could you just elaborate on that? And I'm curious, do you think like on the spine side, we could perhaps see adoption rate similar to me where half, 50%, 60% of spine procedures could be done on Mako at some point in the future?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yeah, well, first the direct-to-consumer has been terrific. And obviously, we have such a leading robotics as a surgion, we want to make sure that we're differentiating our products among the rest of products and the searches and impressions that we have exceeded our expectations. So really pleased we're going to continue that program for a good portion of this year. And so that's, that's certainly helped create a tremendous interest among consumers, as well as hospitals who actually watch the same ad as consumers. So we're very excited about that.

Spine, we couldn't be more happy because certainly that's been a gap in our portfolio relative to others. And this has got terrific workflow. And look I think the robotic adoption tends to really grow, no matter which procedure you're doing. If you have a good solution it will over time become the majority and eventually standard-of-care. And we obviously seen this in the general surgery world as it relates to prostate and starting to happen in other cases. And I think it's going to happen in orthopedics.

And so Spine might take a little longer, but I absolutely do believe it's going to be key for us in the future. We're extremely excited. We've been showing surgeons the Mako spine getting terrific feedback on the workflow and the speed and the efficiency. And again that's within the same ecosystem as Q Guidance. So we've been selling a lot of Q Guidance software, which used to navigate those procedures in that same camera, which is the fastest camera in the market, will be compatible with Mako when we launch it. So I do believe it will become pedicle screw placement at least the vast majority of the procedure in the future.

[Operator]

Our next question will come from Shagun Singh with RBC. Your line is now open, please go ahead.

[Shagun Chadha, Analyst at RBC Capital Markets]

Great, thank you so much. Kevin, I was hoping to get your thoughts on utilization. It's been a key topic this last week across some healthcare sectors. What trends are you seeing in healthcare utilization across different care settings? What is driving it and how do you think about the sustainability of it? Is it being driven by the aging demographics, is it innovation, is it just low market penetration? And I think you did indicate that there is still a backlog and it is contributing, but is it a meaningful contributor to growth on a year-over-year basis? And then I have a follow-up.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Okay. Well, I think, if you look at the hospitals and what they're saying that's kind of one of the indicators we look at they are busy. Hospitals are busy, patients definitely aging demographics plays for Stryker's portfolio. That definitely plays to our advantage and every day, 10,000 more people are turning 65. The activity levels are also increasing. Stryker Ball has been a terrific thing for our business. More active people who are elderly tend to --want to stay active and activity levels are kind of the biggest predictor of meeting our joint replacement and sports medicine procedures. And so we're seeing very good activity levels. And so I don't really want to talk about backlog.

I just think what we're seeing is patients presenting frankly some patients who are just wanting to be more active losing weight and then wanting to be more active and then being eligible for surgery. So we do see really good waiting lists for surgeries -- for surgeons in the orthopedic space. Hospitals ordering capital whether it's small capital or large capital, building more ASC, the ASC trend has actually really helped because patient love it. They go, they get home the same day. They had a terrific experience and they tell their friends. And that, word-of-mouth is spreading absolutely by the knee surgeries that is happening.

And our percent of procedures in ASCs continues to climb. So I think those are -- there's a number of factors I just outlined. All of them pointing to this at least for this year continued good demand, and I don't know that it's -- I don't know how temporary it is. This could be continuing frankly for a period of time because I think demographics and activity levels are the two drivers that we're seeing at least for our portfolio of businesses.

[Shagun Chadha, Analyst at RBC Capital Markets]

That's really helpful. And then just on guidance, you guys delivered a pretty -- or you put up a pretty strong initial guide out of the gates, does it give you room for upside as you move through the year? And I guess more specifically what areas could be potentially looked to drive that upside? Thank you for taking the questions.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

No, great question. First of all, we have a history that we generally like to follow and I would tell you that it's early days. We're here in January looking at 2024, we feel very confident about where we're going to perform on sale and driving op margin expansion. At this point I am not going to comment on the potential to go beyond that. But we feel very good about the guidance that we put out.

[Operator]

Our next question will come from Pito Chickering with Deutsche Bank. Your line is now open, please go ahead.

[Philip Chickering, Analyst at Deutsche Bank Aktiengesellschaft]

Hey, good afternoon. Thanks for taking my questions, and congrats on an amazing year. On the gross margins, can you help bridge the third quarter to fourth quarter gross margins? How much of the impact was mix? And then you have the good guys and bad guys can you help us understand that sequential change?

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. Sure, Pito. Without going into too much detail, I would say the single biggest item was really mix in terms of what was growing much faster in Q4 versus Q3, relative to sort of some of the other items. We also had really solid price performance in Q4 which contributed to that. And then -- and then lastly, in sort of in typical Stryker fashion, we hit a little bit of a hockey stick here in Q4, too. And so that actually benefits of the gross margin line.

[Philip Chickering, Analyst at Deutsche Bank Aktiengesellschaft]

Okay. Great. And then on pricing, back in third quarter, I think it was about 30 basis points favorable. It's 70 basis points favorable this quarter. Guidance assumes flat pricing for '24. I guess, should there be some positive pricing in '24 just as the fourth quarter comps out? And after you've gotten accelerating pricing throughout the year, I guess, why is your 2024 pricing flatten out? Thanks so much.

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

And keep in mind, flat is the average for the whole company. And the way that that pricing guide is calculated is legacy product over legacy product. So a lot of our pricing increases carry over into 2024. They're just comparing to the new higher price. I would also say too that flat is the average of some up and some down. And so we absolutely will see price increases across some of our businesses. And that will be balanced with some of the challenges we have in say, spine or some of our other orthopedic businesses. So I do think we haven't backed off our pricing strategy one bit and we fully expect to sort of maximize the benefit we're going to get out of pricing.

[Operator]

Our next question will come from Travis Steed with Bank of America. Your line is now open, please go ahead.

[Travis Steed, Analyst at Bank of America Merrill Lynch]

Hey, thanks for taking my question, Glenn, maybe just a finer point on some of the op margin guide. It looks like the 200 basis points, more than half of that is in 2024. Can you just confirm that? There's a little bit of kind of math going around. I just want to make sure we got the math in '24, correct. And then with such a big ramp in '24 on the guidance, just can you give a little more confidence on what you're doing to kind of achieve that 100 basis points plus in 2024 from what you're seeing on the cost input side, just to kind of drive confidence that that's achievable in '24?

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Sure. Yes, I think you can do the math as well as I can, especially given all the areas that I've guided in the full year. So I definitely think you're in the zip code for what we think will happen in 2024. And honestly, if we look at sort of what we've laid out and planned for the year, first of all, the natural leverage we get from growth versus fixed cost in operating expenses certainly will provide us some benefits. We also won't stand still in a lot of the gross margin initiatives that I mentioned, and those will move forward and also provide some benefits that we'll see in 2024.

And so I would tell you that we haven't walked lightly on this. I would say that across the globe, Stryker is very focused on these op margin expansion projects and sustainable op margin expansion for 2024 and 2025. And so we feel very confident that we'll be able to deliver that.

[Travis Steed, Analyst at Bank of America Merrill Lynch]

Great. Thanks. And then maybe one quick question on Mako shoulder just to make sure that's still expected to come in 2024. And anything else you want to say on that at this point? Thanks a lot.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Listen, as we've said from the beginning, Mako shoulder will launch at the end of '24. So I don't expect to have much at all of a revenue impact. That said, it's something like our shoulder business needs. Mako shoulder to be growing at strong double digits. They have terrific products within upper extremities with shoulder ID, with a number of really pyrocarbon humeral. We have a fracture stem for perform, which is incredible, a reverse perform stimulus. So we have four terrific launches in upper extremity. So they're going to do fine even before Mako. But Mako will be the end of the year. The feedback from surgeons have been terrific, but that will have much more of an impact in '25, not so much in '24.

[Operator]

Our next question will come from Matthew O'Brien with Piper Sandler. Your line is now open, please go ahead.

[Matthew O'Brien, Analyst at Piper Sandler & Co.]

Good afternoon. Thanks for taking my questions. Just on Mako, this question might be for Jason. Just the domestic number this quarter was a little bit soft, and we're hearing about one of your competitors just giving their system away, so it's not all that great. Can you talk about the dynamics that you're seeing in the market, especially domestically for Mako in terms of placing systems, selling systems and then just having to get really aggressive on the pricing side, just given the environment that you're in? And then conversely, the OUS number looks phenomenal again. Just where are we at in terms of growing that business over the next several years? And I do have one follow-up.

[Jason Beach, Vice President, Investor Relations at Stryker]

Yes, Matt, I'll start this and Kevin, feel free, obviously, to weigh in. But as we think about the Mako offense, and I think we've said this previously as well, when we think about the various options to bring Mako to market, we've been flexible, right? Whether it's leasing, rental, etc. So I think we're very competitive from that standpoint. And to your comment on kind of where we are, I would still say whether it's U.S. or internationally, early innings here. We've got a lot of runway relative to Mako. But as we think about the financing options, it's not going to be an impediment for us to expand the Mako footprint.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. The only thing I would add to Jason's comments are every ASC Mako that's installed is financed. Every one. And that's becoming a bigger percentage of the Mako installation. So what you're seeing is more finance, rentals and financed versus outright capital purchases. So that obviously, the revenue number and the revenue growth of 3% in U.S. is not installation growth. Installation growth is higher than what you're seeing. And over time, that will start to normalize and then you'll start to see the growth rate to be more reflective of the installation rate. But we're going through this kind of transition phase right now.

And we are giving them away. So we charge for it and we have different pricing models, obviously. And we want the customers to have skin in the game. So that if we just give it away, they had no incentive to use it. And what we don't want are a bunch of robots collecting dust. So we care a lot and we monitor utilization of the robots very, very significantly.

And then, of course, OUS, we're seeing terrific pickup and a lot more purchases than finance. We do offer financing around the world. But so far, in international, we're seeing a lot more purchases than we are financing, which is why you see the revenue spike. But again, international has a huge potential. It's kind of where we were in the U.S. about five years ago.

[Matthew O'Brien, Analyst at Piper Sandler & Co.]

Understood. Thanks for that. And then sticking with Mako. Kevin, you mentioned shoulder, you don't really need the application as much because you're crushing it on the shoulder side. But in spine, you're doing better in the last couple of quarters. I haven't really heard why that is. I don't know if it's just some of the dislocation or not. But I think it's probably a bigger opportunity on the spine side of the business going forward. These centers that already have Mako and use them for hips and knees, can you quickly transfer the system to the spine part of those institutions or facilities and start to pick up share fairly quickly? Or is this something that's going to take many, many quarters or talking '25, '26 before it really starts to impact the spine business? Thanks.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, what I'd say is, first of all, the Mako brand is extremely well-known. That's a very, very big positive. And I think what you're going to see is a much faster uptake than you would have seen had we not had already had Mako on hips and knees. We want to take a little bit of time, sure. Well, let's find surgeon who want to share the robot with hips and knees surgeons, not sure yet. Obviously, that's something we're going to see play out, whether they're going to want their own robot or they're going to be willing to operate on the days that hip and knee people aren't operating. So that's a whole dynamic, I think that will vary account by account.

So we're already working on our commercialization plans. I think part of the reason for our success is success of the guidance, which is one half of the system, to get out the Q Guidance. And then as well, Mako, they know it's coming now. Customers have gone to Leesburg, Virginia, our spine headquarters, to see Mako Spine, and many of them have stopped their purchases of other robots, knowing that this is coming. So I think that's what's helping to contribute to our, let's call it, somewhat improved performance, but we still would like to grow at a higher rate than we are right now. We know we need not just Mako, but also the CoPilot product.

So we're going to go from being behind to being ahead, and CoPilot should launch in a similar time frame, slightly ahead of Mako Spine. So you're not going to have the CoPilot product plus Mako Spine, where our competitors will just have their robot. The ones that have robot will just have a robot without CoPilot with haptic feedback that can do the laminectomy and desectomy portions of the procedure, which complements the pedicle screw placement.

So we're really going to be in a great position by the time third quarter comes around. Robots do take time. So the scaling will take time. But I think it will be certainly much faster than the initial people who came in with robotics. They know they benefit from it and they know they can trust the Mako brand.

[Operator]

Our next question will come from the line of Josh Jennings with TD Cowen. Your line is now open, please go ahead.

[Josh Jennings, Analyst at TD Cowen]

Hi, good evening. Thanks for taking the questions. I wanted to, hopefully, Kevin, ask about just get a temperature check on the healthcare delivery systems capacity for orthopedic procedure growth. I think heading into '23 after experiencing 2022, there were concerns around staffing shortages, etc., and potentially be creating a bottleneck for procedure volume growth. That clearly didn't play out in 2023. It doesn't sound like from your comments, it's going to play out -- you expect it to play out in 2024. But are there any capacity constraint issues in the U.S. healthcare delivery system for orthopedic procedure volume growth as we go forward in '24 and '25 or is that fully in the rearview mirror?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, I think it's largely in the rearview mirror. There's still niggling things here and there, but it's gotten very quiet. You saw that in Q4. It's just a boomer of a Q4. And kind of the normal seasonality, I think we now have finally a normalized year for you to compare against, of course, adjusted for selling days, but there is a normalized year finally. And yes, they've gotten their staffing issues solved largely, and they do prioritize orthopedics because orthopedics is a moneymaker for hospitals, right? Cardiovascular and orthopedic procedures are two money makers.

And so if they are short-staffed, they are going to prioritize staffing for orthopedics. I would say the only area that still has a lot of room to run is ASCs. So every hospital is constructing ASCs, and that's going to continue to be an engine of future growth. But I'd say we're in a very normalized environment. They have the capacity. They can operate additional days, which we saw some of that in Q4 again, which we hadn't seen for a couple of years. So I think the hospitals are absolutely ready now, and a lot of that is behind us.

[Josh Jennings, Analyst at TD Cowen]

Thanks. Just one follow-up on Mako, just with the record system placement quarter. Was hoping to just get some details on where -- what you're seeing in terms of second or even third system purchases by hospitals, hospital systems, any kind of percentage of total systems or -- or how big of an opportunity do you see kind of getting that second, third, maybe even fourth system into hospitals? Thanks for taking the questions.

[Jason Beach, Vice President, Investor Relations at Stryker]

Hey, Josh, it's Jason. First, I would say there are many hospital systems across the U.S. that are second, third system. For competitive reasons, we don't disclose kind of number of units installed. But you certainly see numerous systems with multiple Makos. I think as you fast forward to a shoulder and spine application, you're going to see more and more of that when you think about utilization and the need for future systems. So that's kind of how we think about that.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, frankly, I would say it's rare to have one Mako in a hospital now. There are some that have five, six, seven Makos. I think 60% of our knees are done on Makos, there's got to be a lot of Makos to be able to drive that kind of volume. So the days of people saying, well, this is my first Mako, those days in the U.S. are kind of fading. That phenomenon still exists outside the U.S.

[Operator]

Our next question will come from Chris Pasquale with Nephron. Your line is now open, please go ahead.

[Chris Pasquale, Analyst at Nephron Research]

Thanks. Just quickly on the SERF acquisition. Are there any particular portfolio gaps you closed with that deal? Or is it more about expanding your distribution footprint internationally?

[Jason Beach, Vice President, Investor Relations at Stryker]

Yes, Chris, it's Jason. And we'll talk about this more after the close. But it really is -- it helps from a hip portfolio perspective. But beyond that, we haven't said much at this point. And like I said in my prepared remarks, we're set to close this quarter, and then we'll certainly talk more to that.

[Chris Pasquale, Analyst at Nephron Research]

Okay. And then I'm curious how you're thinking about the outlook for neurovascular in '24. '23 was a better year for that segment in the U.S., but it kind of got offset by international. And along with Spine, it was really one of only two segments not to grow high single digits or better. So what's the game plan to drive better growth in that business? And do you have what you need internally? Or do you need to look for supplements to that?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Look, we continue to like the neuromuscular market, as there's still a large number of patients that are being treated. It's an attractive market growing high single digits. And we do expect to grow in line, at least in line with the market. We are obviously very hard hit by China this year with the VBP. We had a very big neurovascular business in China. So that hurt. I don't know that we completely lapped it, but it's going to -- we're going to get to the bottom of China pretty soon, and then that will be behind us.

We also have the SERF acquisition, which is off to a very good start outside the United States. We are seeking U.S. approval, I believe. That will be sometime in 2025, maybe beginning of '26. So we still have a bit of time to wait for that, but that is a fabulous product for intrasecular technology.

We are looking at an area like liquid embolic. We don't have that product, as you want to think about one that we we're going to be looking into. Every business has something they'd like to add. But we do have a good pipeline. We don't talk about neurovascular pipeline too much because they get subject to regulatory approval through the PMA process. So -- but the team does have some very good products that are lining up. And I do believe we're going to be back to kind of much closer market growth, slightly above market growth in the years ahead.

But as the market we continue to like, it obviously has gotten much more competitive on the Ischemic side, and we continue to have a very strong business on the hemorrhagic side. We launched a couple of products last year, the Vector 46 catheter, the Tetra coil and that kind of fueled some very good U.S. growth as you saw in the back half of the year. So we like the business. Yes, it's not as fast-growing as it was historically, but it's still a very good business. We're committed to it and do expect that, that will pick up as we put VBP in the rearview mirror.

[Chris Pasquale, Analyst at Nephron Research]

Great. Thanks, Kevin.

[Operator]

Our next question will come from Danielle Antalffy with UBS. Your line is now open, please go ahead.

[Danielle Antalffy, Analyst at UBS Group]

Hey, good afternoon guys. Thanks so much for taking the question. I'll echo everyone's congrats on a really strong end to the year and a strong start to 2024. Just a quick question on the orthopedics market in general. One of the things I've been trying to get a handle on is what's really happening in underlying market growth. Obviously, 2023 benefited from some semblance of a backlog work down. But it seems like yourselves and your competitors -- not that you have guided specifically for Ortho, but seem to be signaling higher than sort of normal, call it, pre-COVID market growth. And I'm curious, beyond pricing, what's really changed here? Has capacity increased? We talked about ASCs. What's changed fundamentally in the orthopedic -- large joint orthopedics market that might be driving higher -- sustainably higher growth versus pre-COVID levels?

[Jason Beach, Vice President, Investor Relations at Stryker]

Hey, Danielle, it's Jason. I think a couple of things, right? And Kevin even alluded to this, I think, earlier as well. But I think there's a variety of things around demographics. Kevin touched on activity levels. Certainly, that plays a part here. We talked about a more favorable pricing environment. Certainly, it plays a role. And then if you think just from an adoption standpoint with robotic-assisted surgery, I think there's a variety of dynamics at play here that have come into play in terms of elevated market levels. And if you saw what we published coming out of Investor Day, we've said over the next two to three years, we expect this to be in kind of that mid-single-digit range. So we're certainly confident in 2024 and beyond as we think about the Ortho markets.

[Danielle Antalffy, Analyst at UBS Group]

And I guess just a follow-up on that. How much of that is Stryker-specific though? Because given the innovation on Stryker side, the success of Mako and pull-through there, how much is market broadly versus Stryker-specific, if you can even remotely quantify that?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Thanks, Danielle. Look, we've always talked about outgrowing the market, let's call it, round numbers, 300 basis points ahead of the market. And in the past, there was time when hips weren't quite growing that fast until we launched it. But if you go back over the last decade, we have been growing roughly 300 basis points faster than market. So if the market moves up, then our numbers move up as well. And I think you've seen that all year this year, as you've seen in the last couple of years. So that's kind of the way I'd look at it is whatever the market grows, we should be roughly 300 basis points faster because we have this huge [Indecipherable] robotic-assisted surgery as well as cementless. And we just have a team that's firing on all cylinders.

[Operator]

Our next question will come from Matt Miksic with Barclays. Your line is now open, please go ahead.

[Matt Miksic, Analyst at Barclays]

Hey, everybody. Thanks so much. So maybe a couple of follow-ups, some of the things that have come up, but I'd love to try to get some additional color on M&A, you talked about sort of being back on offense, which is awesome. And just maybe if you could talk a little bit about what that means, large versus small, sort of new platform versus maybe something that strengthens one of your existing businesses? Like, I don't know, Neurotech or ENT? Or Neuromod has come up in the past, or anything that -- you could talk about that would be great. And then one have 1 follow-up.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, Matt, look, I can't get too specific. You know the nature of M&A. M&A is fluid, and the deals have to make sense financially after the buyer that's ready to sell when you want to acquire. I think because of the pent-up demand in the businesses, we have a lot of mouths to feed and they're hungry. And so I would think in the, let's say, at least the first half of the year, there'll probably be more of tucking things in that because we've been staying close to these companies, and we have a bunch of deals that are teed up. But then once you get through the first half of the year, I think it becomes open field. And then open field means maybe more tuck-ins, but it means maybe more things that are in the adjacency categories. We're always open to those. But a lot of things have to -- stars have to align in order to be able to do those deals.

But we're back on the normal Stryker offense. And again, what does that mean? It means most of the deals by number are going to be those tuck-in deals, but things like a Vocera and neurovascular and those types of the physio control, those kinds of deals are going to pop up that are more in the adjacent categories. But I can't predict this, honestly, because I don't know what's going to happen. But we are out hunting. And we are excited to get back to a more regular M&A. It's been a huge part of our offense. We know how to do this. We've gotten really good acumen around evaluations and around integrations, which -- early in my tenure, we weren't so good at integrations. And if I look at Wright Medical, it was just like -- it's just been a role model for how to integrate a complex business, and the results have been stunning.

[Matt Miksic, Analyst at Barclays]

That's great, thank you for that. And then just follow-up on ASCs, There's always sort of hot topic, I guess, for the last few years, particularly coming out of the pandemic. So just maybe some thoughts, if you could, on where you are in terms of the build-out of that of that opportunity? Maybe where -- like the percentage of is the needs that are now, do you think being done through that channel? And -- and then sort of back to the M&A side of it, is there -- are there other businesses that have some synergy there? You've obviously got all with equipment with Mako, with your OR, equipment and implant pull-through for these -- to these ASCs. But anything else makes sense to kind of bridge and lever that success you've had there? Thanks.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Thanks, Matt. Okay. I could spend a long time on this, but I'll just sort of cut to the chase and say that, look, things are continuing to progress in the ASC. We're now running between 12% to 15% of our hips and knees in the ASC. That's higher certainly than it was last year. So it continues to climb at a gradual rate because a great limiting factor is capacity and the build-outs of these ASCs. But it is definitely continuing a steady climb. We have everything we need for orthopedic ASCs. And when I say everything, I mean booms, lights, power tools, Steri-Shield, Neptune Waste Management, operating table. Every implant from foot and ankle to shoulder to hips to knees to spine. And I'm going to include spine in that because we just most recently did a really terrific ASC deal in spine, a lot of spine procedures moving to the ASC. We did this in Duluth, Minnesota, which is a really exciting deal and we were able to leverage spine in addition to a lot of other capital equipment in the ASC.

And some of those new builds and big renovations, we are absolutely beautifully positioned. What we're now looking at now that we're a little bit in the GI space with Neptune and the Palm acquisition that we have is what else can we do in that space and other things we could add in that space? Now it's not -- I'm not saying that specifically about ASC. It's about we are -- we like to be really busy in the call point. And now that we're in the GI call point, what every call point we go into, we say, what else can we bring to that call point, what other value can we bring? I'm not predicting that we'll do something in that space, but that's kind of how we look at it. But as it relates to the orthopedic ASP, we are in an incredibly good position to be able to win in the ASC market.

[Operator]

Our next question will come from Caitlin Cronin with Canaccord Genuity. Your line is now open, please go ahead.

[Caitlin Cronin, Analyst at Canaccord Genuity Group]

Hi, thanks for taking my questions and congrats on a great quarter. Just jumping up on Matt's question earlier. Momentum in spine really seems to be strong. Do you have any more clarity on how much you've been able to capitalize on the disruption in the space or expect to kind of capitalize from the disruption?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. I tell you, listen, our performance thus far has really nothing to do with the disruption of the consolidation. It's just starting. We've just started to hear some disruption in Texas as an example and a couple of other little spots. So I would say, very early days of disruption, and that's not the reason why we're doing better. We kind of really improved our offense in spine, especially as it relates to enabling tech. I think the Q Guidance was big shot in the arm for the spine business. They do a terrific job selling that and then, of course, leveraging that for implants. That's been more of a factor than disruption.

I think we're going to see the disruption starting this year. And hopefully, we'll be able to pick up on that. But thus far, there really hasn't been much in the way of disruption and we're going to see that play out over the course of this year.

[Caitlin Cronin, Analyst at Canaccord Genuity Group]

Got it. And then just a quick one on Mako shoulder. You noted a great feedback from docs. What's kind of going to be the use case for the docs? Is it going to be outcomes, time savings, etc.?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Just -- look, there's a whole series of outcomes. Just to simplify it, it makes a very hard procedure very easy to do. That's the way I would simplify it. Why was the partial knee so widely successful? It was a hard procedure to do, and the robot made it easy. And the shoulder is harder to do than a partial knee, and it's going to make a very hard procedure very easy to do, take stress off the surgeon, have very predictable results. That's been the value prop. There are surgeons I talk to you now that do the high volume of knees that tell me at the end of the day, I'm not tired anymore. This robot is taking away my stress. It's just making life easier for me, and you can multiply that by 10 for shoulder replacements.

[Operator]

Our next question will come from Steven Lichtman with Oppenheimer. Your line is now open, please go ahead.

[Steven Lichtman, Analyst at Oppenheimer]

Thank you. Good evening, guys. First on price, how are you thinking about the relative pricing outlook in '24 as you look at the major segments of MedSurg, Neuro versus Ortho, Spine? Anything meaningfully different than what we saw in '23 directionally? And I know we touched on this at Investor Day, but what gives you the confidence in the sustainability of this firmer pricing environment? And then I have a quick follow-up.

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. It's Glenn. So as we look at price, first of all, we've really honed in a strategy and a group that solely focuses on pricing for the whole company. If we think about sort of the segments, I don't think you'll see a lot of different performance in what we see out of our segments in general. MedSurg and Neurotech has more of an ability to gain pricing and we see price increases in those businesses. And honestly, even before the pandemic, we would see price increases coming out of the MedSurg businesses.

I would say on the Ortho side, the trend has really been that it's just been less negative. Also, if you think about those ortho contracts, they're generally three-year contracts. So we haven't really been cycled through all those contracts yet. We have real discussions around inflation in our business with our customers. They know it, their experience it themselves. And so we're just -- I'm not expecting to see positive come out of the Ortho side, but we'll probably continue to see less negative.

[Steven Lichtman, Analyst at Oppenheimer]

Got it. And then Glenn, just on PILLAR II. Is there an impact in '24 that you're offsetting? And how are you thinking about sort of the potential impact in 2025 based on what you know today?

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. No, good question. As we think about 2024, there is an impact for us. I think that through our tax planning and other strategies, we feel like we have fully offset that impact, and that's included in our effective tax rate guidance. For 2025, it's just -- it's too early to comment at this point, to be honest. It's something we're just starting to look at, and we'll have more on that probably a year from now.

[Operator]

Our next question will come from Mike Matson with Needham & Company, Inc. Your line is now open, please go ahead.

[Michael Matson, Analyst at Needham & Company LLC]

Yeah Thanks. It sounds like you're looking at doing some more M&A here. I was just curious if you could remind us where your leverage ratio is? And if you have a target as to how high you'd be willing to go there?

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. We generally tried to maintain a leverage ratio of 2.5 to 3. And I think if you do the calc on 2023, where we're sitting at year-end, we're squarely on the lower end of that range. So we do feel like there is some room, if needed, depending on sort of what we see in the acquisition landscape. But I fully expect that sort of given the normal cadence of acquisitions and that product tuck-ins are generally what we sort of normally go after. We likely won't be out borrowing to do those types of acquisitions.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. And so keep in mind that 3 is not necessarily an upper limit, right? So that's a normal landing zone for us, this 2.5 to 3 for the right deal at the right price. Could we go higher than 3? Sure, we would. And we have obviously have to commit to paying down the debt. But we don't really look at us as sort of being constrained that way. So for the right asset, if it's going to be value-creating for Stryker, we are not afraid to push beyond the 3. But that's kind of the land we like to live in as a landing zone.

[Michael Matson, Analyst at Needham & Company LLC]

Yes, I understand. And then just wanted to ask one about Sports Medicine. I didn't really hear much there. Do you feel like that business is kind of where you want it in terms of the product offering and the scale?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

I am so glad you asked about sports. It's absolutely a rocket ship of growth for us for the past five, six, seven years. They have a number of shoulder launches coming out this year, I believe, four different shoulder launches. They call it internally the shoulder seat [Phonetic], which is quite motivating. But we've done a terrific job with hip. We've had a terrific job with knee, but shoulder has been kind of the area that we've needed to have new products.

But they've been just an amazing business. It was a startup 12 years ago, and it just become a big, fast-growing business. It's really helped us win ASC deals. Frankly, having a really -- every ASC deal is -- orthopedic ASC deal involves sports. And because we have such a strong portfolio, we are able to win those deals. But historically, we wouldn't have been able to. And it's an incredibly exciting year of new product launches, particularly in shoulder.

And I think some of those hopefully might be shown in AAOS, I'll have to get back to you on that. But I'm very bullish. We have a fabulous leader who's been leading the sports medicine business since the start-up when we had just a camera and not really much in the way of implants. And we are now formidable in sport medicine. Certainly in the U.S., certainly in Europe, we still have work to do in the emerging markets in Asia Pacific, but really a fabulous business. And it's been part of the growth engine within Endoscopy. And you've seen Endoscopy post pretty impressive results, certainly last year and this year.

[Operator]

Our next question will come from Drew Ranieri with Morgan Stanley. Your line is now open, please go ahead.

[Drew Ranieri, Analyst at Morgan Stanley]

Hi, thanks for taking the questions. I'll put both of mine together. But Kevin, you were so early on in the orthopedic robotics landscape just with soft tissue robotics. What are your kind of your current thoughts on supporting that ecosystem today versus entering soft tissue robotics? Is it something that's concerning you? Or just how are you thinking about that opportunity? And then second, just could you talk about the ProStep launch from earlier in the fourth quarter or late third quarter? Just any metrics you can kind of share there on the foot business. Thank you.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes, sure. So as it relates to soft tissue robotics, listen, it's a very interesting space. As you know, there's a very large and very successful company that kind of dominates the space. We certainly don't have a problem selling Endoscopy, if you look at our numbers. Certainly, for our 1788 and our cameras, we're doing extremely well. We still have huge room for growth outside of being in soft tissue robotics. It's an area that we're certainly interested in, but very respectful of the large incumbent. And I'm not sure that we'd want to try to take them head-on, just like anybody trying to come and take us head-on in our space wouldn't be so easy.

But it is an area that we like. There are loads and loads of companies, start-ups in the space, and we're looking at them. And it's not inconceivable that we would make a move at some point. But again, not expecting to come out and launch something that would go head-to-head with the Goliath and try to take them down. So -- but it is a space we're pursuing, we're interested. We're looking at companies, and it's not impossible that we would make a move at some point in the future. It's just not an easy space. As you know, robots are hard. And we're going to be very thoughtful and very careful. But we don't see this kind of -- at this point anyways, as a major threat to our Endoscopy business at all.

[Operator]

Our next question will come from Matt Taylor with Jefferies. Your line is now open, please go ahead.

[Matt Taylor, Analyst at Jefferies Financial Group]

Hi, thanks for taking the question. I wanted to ask one about the sprint of margins here and ask you, you do produce some upside on the top line and the margins over the course of this year and next year. How do you think about delivering that to the bottom line versus reinvesting in above that goal to get back to your pre-COVID margins?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

I mean, first of all, it's heavily dependent on sort of the mix that we get if we overdeliver on sales in terms of how much margin we can get to. I would say that 200 basis points expansion is the absolute goal, and that will be the target. And we get there a little sooner, so be it. But we won't take our -- our eye off of making sure that we're doing what's right in the business so that we can deliver that 200 basis points.

[Matt Taylor, Analyst at Jefferies Financial Group]

And that -- I wanted to ask another one on Vocera. You talked a lot about it on this call, and it's obviously doing well. Can you talk a little bit about how that's expanding its tentacles kind of throughout your organization? And anything else we should expect from it in the future as it connects some of the different technologies and provides you some cross-selling opportunities?

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Yes. Great. Listen, I -- integrations are challenging. In this one, we had some challenges with the cloud. We had to restructure the sales force. We are already seeing terrific integration with both beds and now more recently with our wireless stretcher. We had -- they had a list before we bought the company, and we've expanded that list of connecting products and those products that we're going to connect to the ecosystem are not just Stryker products. So there are third-party companies that are coming to us and asking to be connected to our ecosystem.

So we want to be a vital resource within hospitals. We're even looking at emergency departments that don't have really well automated workflow that actually do the documentation that take cognitive load off of nurses. So the potential every day, it just keeps expanding and expanding it. So it's wildly exciting. And the team now -- the new sales team is really starting to hum. Our order growth is starting to really, really pick up in a big way.

And so we're super excited. We're not ready -- ready to talk about which products we'll be integrating. We'd rather do the integration and tell you about it. And we'd like to sort of give you a full-year update. So a year from now, I expect we'll give you kind of a wholesome update and include more of those products that will be attached to the ecosystem. But we are really, really excited about this acquisition. It's a platform.

So I'd say after Mako, this is the second platform acquisition that I've done during my tenure. The other deals we've done, none of them were platforms. And that means it has wild upside potential over time. Now it's not going to happen overnight. It's going to take time. But this is -- for us is -- it will be very sticky in hospitals. It will just be a renewal, recurring revenue. And then as you add more and more to the ecosystem, it becomes something that hospitals can't live without. So that's our dream, and we're pretty optimistic given where we are right now, given the momentum that we have, given the interest that we have, both from parts of Stryker as well as third-party companies wanting to integrate to the system.

[Matt Taylor, Analyst at Jefferies Financial Group]

Thanks, Kevin. Thanks a lot.

[Operator]

Our final question will come from Richard Newitter with Truist Securities. Your line is now open, please go ahead.

[Richard Newitter, Analyst at Leerink Partners]

Hi, thanks for taking the question. I'll just ask one here, and by the way, congrats again on a fantastic quarter, solid end to the year. So just clearly, you guys -- since your Analyst Day, in particular, you've been conveying how committed you are to margin expansion. You're kind of putting a stake in the ground, really strong guidance here for '24. I guess I'm just going to ask, how should we think about that margin guidance relative to the potential and willingness to take on margin dilution as you get more aggressive on the M&A front? Should we think of that as something that already had contemplated the potential to need to absorb some dilution? Is there -- are you more focused on top-line accretion and more sensitive to kind of margin accretion faster than historically? I would just love your thoughts there and how we should think about kind of this margin trajectory and sprinting back to pre-COVID with respect to deals and how that will fit in the P&L.

[Glenn Boehnlein, Vice President and Chief Financial Officer at Stryker]

Yes. Thanks, Rich. Thanks for the question. Look, I think back to '17, '18, '19, we were expanding margins before some dilution. We have around 80 basis points. And we were not growing at this kind of growth rate, right? We were growing in the 6s and 7s organically, not double-digit growth organically or high single-digit growth organically.

So with that higher growth, this is not a crazy level of margin expansion that we think we could do. But doing small deals. And if they're small tuck-in varieties, there's some dilution that will come with that. We expect we're going to eat that and be able to deliver the 200 basis points. If a deal came along, let's say, something like a Mako, which, as you know, occurs once a decade, maybe. It's not an everyday occurrence. That had dilution, but we felt it was just so great for the company that we had to do it. We would go ahead and do it. And then we would look at our numbers and say, is this something we can absorb or isn't it?

Our going-in assumption is that that's not a likely occurrence. It's not impossible though. And I never want to rule anything out when it comes to M&A. If something really delicious appears and we think that this is going to be great for our future, we're going to go ahead and do it, and then we'll do our math and figure out can we get there with the 200 basis points. But in the normal cadence of operations of Stryker and that means doing a number of deals that have a little bit of dilution here or there, we're going to eat it and we'll deliver our 200 basis points.

If something bigger happens like a Mako, as you know, was very dilutive but has proven to be a pretty terrific asset for our company, we're not going to say, well, we're going to wait two years and then we'll do it later. We're going to go ahead and do it. But again, I don't see that on the horizon. It's not obvious to me. But I'd never want to rule that out. It would be foolish, frankly, to be beholden to a certain financial target and pass up what could be very value-creating for our company. But again, it's not our current frame of mind, not our current thought process. But I don't want to rule out that that could be a possibility.

[Operator]

I will now turn the call back over to Mr. Kevin Lobo for closing remarks.

[Kevin Lobo, Chair and Chief Executive Officer at Stryker]

Thank you all for joining our call. As you can see, we have terrific momentum as we finish the year. We're excited about 2024, and we look forward to sharing our first quarter results with you in April. Thank you.

Participants

Corporate Executives

• Kevin Lobo, Chair and Chief Executive Officer
• Jason Beach, Vice President, Investor Relations
• Glenn Boehnlein, Vice President and Chief Financial Officer

Analysts

• Robert Marcus, JPMorgan Chase & Co.
• Lawrence Biegelsen, Wells Fargo Securities
• Ryan Zimmerman, BTIG Research
• Joanne Wuensch, Smith Barney Citigroup
• Vijay Kumar, Evercore ISI
• Shagun Chadha, RBC Capital Markets
• Philip Chickering, Deutsche Bank Aktiengesellschaft
• Travis Steed, Bank of America Merrill Lynch
• Matthew O'Brien, Piper Sandler & Co.
• Josh Jennings, TD Cowen
• Chris Pasquale, Nephron Research
• Danielle Antalffy, UBS Group AG
• Matt Miksic, Barclays PLC
• Caitlin Cronin, Canaccord Genuity Group Inc.
• Steven Lichtman, Oppenheimer Holdings Inc.
• Michael Matson, Needham & Company LLC
• Drew Ranieri, Morgan Stanley
• Matt Taylor, Jefferies Financial Group Inc.
• Richard Newitter, Leerink Partners