Stryker Q3 2024 Earnings Call Transcript

Presentation

[Operator]

Welcome to the Third Quarter 2024 Stryker Earning Call. My name is Luke, and I'll be your operator for today's call. [Operator Instructions].

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

I'll now turn the call 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 third quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO; and Jason Beach, Vice President of Finance and Investor Relations. For today's call, I'll provide opening comments, followed by Jason with the trends we saw during the quarter and some product updates. Glenn will then provide additional details regarding our quarterly results before opening the call to Q&A.

In the third quarter, we delivered robust organic sales growth of 11.5%. Our performance included strong double-digit growth within MedSurg and Neurotechnology and nearly 10% growth in Orthopedics and Spine. This broad performance reflects healthy demand across our diverse product portfolio and our team's steadfast commercial execution.

Our strong results reflect double-digit organic growth from our Medical, Neuro Cranial, Endoscopy, Trauma and Extremities, Hips and Knees businesses. Our growth was well-balanced between the US and international with both rising double-digits organically. All international regions showed strength in the quarter and we continue to see international markets as key catalysts for our long-term growth.

We stayed active on the M&A front, completing several deals in the quarter. In September, we acquired care.ai, which strengthens our healthcare IT and wirelessly connected offerings. We also acquired NICO Corporation, which enables minimally invasive surgery for tumor and intracerebral hemorrhage procedures. Lastly, we acquired Vertos Medical, which provides minimally invasive solution for treating chronic lower back pain caused by spinal stenosis and enhances our pain management portfolio.

We remain committed to complementing our growth through acquisitions and have a strong deal pipeline and healthy financial capacity. We delivered adjusted quarterly EPS of $2.87, reflecting 16.7% growth compared to the third quarter of 2023. Finally, we are narrowing our expectations for 2024 to the high-end of our previously provided guidance ranges and now anticipate full-year organic sales growth of 9.5% to 10% and adjusted EPS of $12 to $12.10.

Our updated guidance reflects the continued momentum from our product innovation, healthy procedure volumes and terrific commercial execution across the globe. We are on track and remain committed to our goal of 200 basis points of margin expansion by the end of 2025. This includes 100 basis points of margin expansion this year, while offsetting dilution from an M&A.

I will now turn the call over to Jason.

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

Thanks, Kevin. My comments today will focus on providing an update on the current environment, capital demand and recent acquisitions. Procedural volumes remained healthy in the third quarter, in line with our expectations and underscored by continued adoption of robotic-assisted surgery. We continue to expect strength in procedural demand through the end of the year.

Demand for our capital products was strong in the quarter with an elevated backlog across our capital businesses. Patient and customer interest in Mako was highlighted by record Q3 installations, both worldwide and in the US with high utilization rates across the globe. We expect the sustained momentum from installations and utilization will continue to drive growth in our hips and knees businesses.

Our latest platform launches continue to experience success in the marketplace. Our Pangea Plating System is progressing well with a full launch expected in the US by the second half of 2025. Our LIFEPAK 35 defibrillator and monitor has a strong order book and sales have begun to ramp. Additionally, robust adoption of our 1788 visualization platform continues to contribute to the growth we are seeing in our Endoscopy business.

Lastly, we begun early cases with both our Spine Guidance 5 Software featuring Copilot and our Mako Spine robot. As with prior product launches, these spine offerings will be on a limited market release for some time as we refine training protocols. Mako Shoulder is on track to launch at the end of the year. We continue to receive positive feedback from surgeons who have seen these products.

From an inorganic perspective, our 2024 acquisitions reinforce our dedication to improving outcomes across the continuum of care and our commitment to meeting our customers' needs. Year-to-date, we have closed seven acquisitions while investing approximately $1.6 billion to complete. In 2025, we expect these acquisitions will contribute approximately $300 million to sales.

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

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

Thanks, Jason. Today, I will focus my comments on our third quarter financial results and the related drivers. Our detailed financial results have been provided in today's press release. Our organic sales growth was 11.5% in the quarter compared to 9.2% in the third quarter of 2023. This quarter had one more selling day than 2023. We had a 1.2% favorable impact from pricing. We continue to see a positive trend in our pricing initiatives, both in the US and international markets and both with our MedSurg and Neurotech and Orthopedic and Spine segments, each contributing positive pricing for the quarter.

Foreign currency had a 0.1% unfavorable impact on sales. In the US, organic sales growth was 11.4%. International organic sales growth was 11.7%, driven by positive sales momentum across our international markets. Our adjusted EPS of $2.87 in the quarter was up 16.7% from 2023, driven by strong sales growth and continued margin expansion. Foreign currency exchange translation had minimal impact on our adjusted EPS for the quarter.

Now, I will provide some highlights around our quarterly segment performance. In the quarter, MedSurg and Neurotechnology had constant-currency sales growth of 12.9% and organic sales growth of 12.7%, which included 13.2% of US organic growth and 11.2% of international organic growth. Instruments had US organic sales growth of 9.9%, led by strong double-digit growth in the Surgical Technologies business. From a product perspective, sales growth was led by waste management, smoke evacuation, tourniquet cuffs, Steri-Shield and power tools.

Endoscopy had US organic sales growth of 10.9% with strong growth across all businesses. Growth in the quarter was fueled by robust demand for our OR infrastructure and renovations and the continued success of the 1788 Platform and sports medicine shoulder products. Medical had US organic sales growth of 18.5%, driven by strong performances across all of its businesses, Acute Care, Sage and Emergency Care. From a product perspective, the Medical business was led by strong sales growth in beds and stretchers, Sage products, transport capital and defibrillators. The order pipeline for LIFEPAK 35 is robust and continues to drive excitement in the market.

Neurovascular had US organic sales growth of 1.5%, which reflects solid performance in our core hemorrhagic products, offset by recovering performance in our flow diverting stent products due to supply chain issues earlier in the year and competitive pressures in our ischemic business. And finally, Neuro Cranial had US organic sales growth of 16.1%, led by strong growth in our bone mill, high-speed drills, bipolar forceps and craniomaxillofacial products.

Internationally, MedSurg and Neurotechnology had organic sales growth of 11.2%, led by double-digit organic growth in our Endoscopy and Medical businesses. Geographically, this included strong performances in Canada, the United Kingdom, Australia, New Zealand, Japan and most of our emerging markets. Orthopedics and Spine had constant-currency sales growth of 10.8% and organic sales growth of 9.7%, which included organic growth of 8.6% in the US and 12.3% internationally.

Our US Knee business grew 8.4% organically, reflecting our market-leading position in robotic-assisted knee procedures and the continued strength of our installed Mako base as well as continued momentum in new Mako installations. Our US Hip business grew 10.9% organically, driven by the continued success of our Insignia Hip Stem and momentum from our Mako Robotic Hip platform.

Our US Trauma and Extremities businesses, business grew 11.8% organically with double-digit sales growth across our core trauma, upper extremities and biologics businesses. Our US Spine business grew 2.4% organically, led by performance in our interventional spine business. Our US Other Ortho business had a slight decline organically of 0.6%, driven by seasonal Mako deal mix and a decline in bone cement. Internationally, Orthopedics and Spine grew 12.3% organically, including strong performances in South Korea, Japan, Canada, Europe and most of our emerging markets.

Now I will focus on operating highlights in the second quarter. Our adjusted gross margin of 64.5% was 20 basis points unfavorable from third quarter of 2023. This variance resulted primarily from mix. Adjusted R&D spending was 6.6% of sales, which was 20 basis points lower than the third quarter of 2023. Our adjusted SG&A was 33.2% of sales, which was 130 basis points lower than the third quarter of 2023, due to natural expense leverage combined with spending discipline, somewhat offset by investments to support growth.

In summary, for the quarter, our adjusted operating margin was 24.7% of sales, which was 130 basis points favorable to third quarter of 2023. Net adjusted other income and expense of $42 million for the quarter was $19 million lower than 2023, driven by favorable interest income on our invested cash balances. We expect our full-year net adjusted income and expense to be in the range of $230 million to $240 million. The third quarter of 2024 had an adjusted effective tax rate of 15.8%, reflecting the impact of geographic mix and certain discrete tax items. We now expect our full-year adjusted effective tax rate to be at the high-end of our previously communicated range of 14% to 15%.

Focusing on the balance sheet, we ended the third quarter with approximately $4.7 billion of cash, marketable securities and short-term investments. Total debt was approximately $15.5 billion. This debt includes approximately $3 billion from our bond offerings in September 2024, a portion of which will be used to pay down upcoming debt maturities in the fourth quarter.

Turning to cash flow, our year-to-date cash from operations is $2.3 billion, an increase of $120 million from 2023, driven mainly by higher earnings and improvements in inventory and accounts payable, partially offset by higher accounts receivable from sales timing and other expense timing.

Based on our year-to-date performance, sustained demand for our capital products and healthy procedural volumes, we now expect full-year 2024 organic sales growth to be in the range of 9.5% to 10%. This includes a favorable pricing impact of 0.5% to 1%. If foreign exchange rates hold near current levels, we anticipate full-year sales will be slightly unfavorably impacted and adjusted EPS will be negatively impacted by approximately $0.10, both of which are reflected in our guidance.

With a strong first nine months of the year, strong Q4 sales and operating margin momentum, we now expect adjusted net earnings per diluted share to be in the range of $12 to $12.10.

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

Questions and Answers

[Operator]

At this time, we will open the floor for questions. [Operator Instructions]. Okay. Our first question comes from Robbie Marcus with J.P. Morgan. Your line is now open. Please go ahead.

[Robert Marcus, Analyst at J.P. Morgan]

Oh, great. Thanks for taking the questions and congrats on a great third quarter here. Kevin, I wanted to ask, Medical really stands out, 60% is now, of sales is now in that MedSurg and Neurotech and Medical grew closer to 20% this quarter. You called out the, the LIFEPAK had really good orders, but also beds and stretchers as well. There's a lot in that Medical line item. So just wanted to see what's going on there, how much is one-time versus sustainable? And then I have a follow-up. Thanks.

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

Yeah. Thanks, Robbie. We love our Medical business. If you look over the past five years, it's probably been our highest growing division pretty consistently. Now from quarter-to-quarter, it does move around a little bit given the capital equipment nature of the business, but it's not unusual for us to post an 18% growth. If you just look back over the past, let's say, eight quarters to 12 quarters, why? Because we have tremendous innovation and momentum behind ProCurity, wireless stretchers, LIFEPAK 35, the Sage business is just on fire and has been performing extremely well. You have Vocera in the mix and more recently we've acquired care.ai. Of course, nothing really showing for that this quarter, but all of this is just feeding an engine of momentum, great leadership team, great talent and culture. And so I don't see medical slowing down anytime soon. Will we have 18s every quarter? Probably not, but you can expect double-digit growth for the Medical division for a long-time to come.

[Robert Marcus, Analyst at J.P. Morgan]

Great. Maybe just a follow-up. The fourth quarter implied guide with the updated guidance is still a really good number, but it looks to be just a bit below trend at least on sales versus year-to-date. Is there, is there any impact that we're seeing from the hurricanes or any other disruptions we should be thinking about in, in fourth quarter? Thanks.

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

Yeah. No, we don't, we're not really counting on any disruption from the hurricanes. Sure, there was a little bit here or there, but we expect those procedures to be made up in the quarter. So no effect whatsoever to do with weather. I think it's a reasonable guide. We moved it up. But clearly, we, we are hoping and aiming to finish at the high end of that guide closer to the 10%, which you've seen us do in the past couple of years. So that's where we're aiming, but we have big comps, right? Last year's fourth quarter was 11.5%. So we're running against big numbers, but, but certainly, we don't, we don't have anything negative in terms of the vibes that we're feeling on the business. The momentum is good. Just running against big numbers and we've moved it up what we feel is a reasonable amount and we're going to shoot for the high-end. So, it's certainly possible that we'll have a 10% organic growth quarter in Q4 and full-year.

[Robert Marcus, Analyst at J.P. Morgan]

Understood. Thanks a lot.

[Operator]

Okay. Our next question will come from Larry Biegelsen with Wells Fargo Securities. Your line is now open. Please go ahead.

[Lawrence H. Biegelsen, Analyst at Wells Fargo Securities]

Yeah. Good afternoon. Thanks for taking the question. And I'll echo Robbie's congratulations on a really nice quarter here. So Kevin, I wanted to ask a little bit about 2025. You're guiding to 9.5% to 10% this year. How sustainable is the momentum in the top line growth we're seeing? And what are the drivers of the 100 basis points of margin expansion that you called out on the call? And Glenn, given the recent refinement, I think should we be thinking about below the line for interest expense differently next year? And I have one follow-up. Thanks.

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

Hey, Larry, it's Jason. I'll jump in here and handle the 2025 piece and then maybe Glenn can speak to the 100 basis points of op margin expansion as we land this year. As we think about next year, we'll talk more obviously about that in January. The one thing I would say, we're certainly happy with the momentum in the business. We stand very committed to the 100 basis points of op margin expansion again [Phonetic] next year. But beyond that, we'll certainly get into in January.

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

Yeah. And then just as it relates [Speech Overlap]. Go ahead, I'm sorry.

[Lawrence H. Biegelsen, Analyst at Wells Fargo Securities]

No, no, no. My apologies. Please go ahead.

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

Okay. Yeah, I just wanted to give you some comments and color around the sort of 100 basis points op margin expansion that we're fully expecting to deliver on this year and the 100 basis points op margin expansion that will carry over into next year as well.

First of all, if you look at our results for Q3, we had great momentum and we feel like that momentum definitely will carry forward into Q4. Just as a reminder, during the year and honestly, even last year, we started several initiatives to drive this improved leverage. These included looking at low cost manufacturing sites, looking at insourcing opportunities, looking at site rationalization, working hard on freight optimization coming off of the supply chain crisis. Also even looking at R&D product design opportunities, how can we make things cheaper? And then we also looked at sort of ramping up our direct sourcing negotiations with vendors to offset a lot of the inflationary increases that came across post-pandemic.

Moving down to operating expenses, our shared services footprint continues to expand. We continue to push more transactional work into those shared services. We're also seeing good results from sort of IT system rationalization and that means we're putting more and more of our businesses on similar systems. And it's just a lot inexpensive to operate that way.

And then of course, coming off of sort of this hybrid work environment, we also are focusing on office space rationalization. So I have all of that, that is ongoing and in process and starting to really deliver. I also, am seeing strong price performance like you just heard, and there is an ongoing focus there. And then lastly, Q4 is our biggest sales quarter of the year and the amount of natural leverage that will drive because sales are going to go up and our fixed costs are not growing. We'll create a lot of natural leverage that we'll benefit from.

And then the last point I would make and we talk about this internally in Stryker all the time, the target that we're reaching for is not something we haven't seen before. We've been there. We know what that kind of leverage looks like. So nobody at Stryker doesn't know how that feels, or how do you deliver on that? And so there's a lot of confidence and you heard it from Kevin that we'll deliver the 100 basis points this year and we'll deliver it next year.

[Lawrence H. Biegelsen, Analyst at Wells Fargo Securities]

That's super helpful. Just for my follow-up. The Hip growth was really strong in Q3, especially outside the US. What, what drove that? And how should we think about the sustainability? Thank you.

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

Yeah. Thanks, Larry. We're super excited with the Hip performance. It's not just a one quarter thing. Of course, this quarter did pop a little bit more. But Insignia launch, it's now starting to spread around the world. We were kind of constrained on supply and had to delay some of the international markets. They are now starting to receive that product and driving that. In addition, we have Mako Hip really starting to take off. We've got a bit of additional reimbursement in Japan.

And then if you look organically, obviously, the growth was double digits. It looks even bigger because of the SERF acquisition. So there is an inorganic component to the Hip business in Europe. That acquisition is off to a great start ahead of the deal model. So we're really excited about that, that European acquisition, primarily in France, but also in other European markets. But overall, we're delighted with the progress of our Hip business, not just international, but also in the US, I think we posted a very strong number in the US as well. So our Hip business has tremendous momentum.

[Lawrence H. Biegelsen, Analyst at Wells Fargo Securities]

Thank you.

[Operator]

Our next question will come from the line of Joanne Wuensch with Citi. Your line is now open. Please go ahead.

[Joanne Wuensch, Analyst at Smith Barney Citigroup]

Hi, can you hear me, okay?

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

Yes, we can. Yeah.

[Joanne Wuensch, Analyst at Smith Barney Citigroup]

Excellent. Very nice quarter. What are the things that I think that investors struggle with is when they see this kind of growth in ortho, an impression that this is not sustainable and either at some level of pent-up demand and volume or pricing that has moved positively that may not remain positively. Can you please address that? Tell me about it's right or wrong? Thank you.

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

Thanks, Joanne. I don't know how many quarters it takes for you to start to believe that, it's going to be a good market. It's, this has been going on for some time now. I think obviously, potentially long memories, but we've called the market up more than a year ago. We said that we expected this to be an elevated market just based on looking at surgery schedules and level of activity and the aging demographics and the great outcomes from these procedures. So I said this, I think one quarter or two quarters ago, that this feels like we're kind of in a bit of a new normal.

And of course, no one has a crystal ball. We can't predict exactly how the market will evolve. But all signs and signals are pointing to this being kind of like a new normal, at least, for the market growth being no longer low single kind of a mid-single-digit growing. And of course, we're achieving a higher growth rate just based on our innovation and our sales execution. So to me, I'm not surprised to see these kind of numbers. We're excited about these numbers. And maybe I'll ask Glenn to comment a little bit about pricing.

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

Yeah. And Joanne, I think one of the things that you've seen us deliver on quarter-over-quarter, and I think even with Orthopedics is just, we have a very big focus on these contracts as they're coming up and the negotiations related to those contracts. And we're seeing the results. We're seeing that, okay, we're not always getting into positive territory on Orthopedics, but we are seeing less negative than we had seen before. And so I don't see that focus going away anytime soon.

[Joanne Wuensch, Analyst at Smith Barney Citigroup]

Well, as my follow-up, can you comment on early feedback for Mako Spine, and thank you.

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

Yeah. Thanks, Joanne. It's very early. So, so far, so good. That's all I can say. We've just started the cases literally just in the last week or so. So, it is a little bit early to give you more color. Certainly, on the next call, we'll be able to provide a lot more feedback. But so far, in the early stages, it is performing kind of as we expected. We're also excited about Copilot, which is part of that same ecosystem. We've had actually a bit more experience with Copilot, so that launched a little bit ahead of Mako Spine.

So what's exciting for me is that robotics launches typically tend to be delayed, right? If you just look at the industry at large, it's not always easy to launch a robotic application on time, and these two came right on time, right on schedule. And so far, we're getting very good feedback, but it's early. And, and it's not going to have a big impact on our sales for a little while, because we do want to make sure everything is going as it should. We get the training right, not just for the surgeon, but also for their staffs. As we've learned with previous launches, it pays to go a little bit slow at the beginning to make sure you get everything nailed before you really start to scale. But all signs and signals are pointing to these two products being really successful for our Spine business.

[Joanne Wuensch, Analyst at Smith Barney Citigroup]

Excellent. Thank you.

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

Thank you.

[Operator]

Our next question will come from the line of Ryan Zimmerman with BTIG. Your line is now open. Please go ahead.

[Ryan Zimmerman, Analyst at BTIG Research]

Thank you, and congrats on the quarter. Kevin, we have a chance to see the Vocera acquisition really be integrated into your beds, your stretchers, even to some extent, the LIFEPAK 35 products. And I'm wondering if you could just talk a little bit about kind of where Stryker's headed from a software versus hardware standpoint? How to think about maybe some of the recurring revenue that you expect to get as you, you create this ecosystem with Vocera and now maybe care.ai to some extent and other products? And kind of where you're driving the business to versus what we've historically thought of as more traditional med-tech, if you will. I'm just curious your thoughts on that focus.

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

Yeah. Thanks. Listen, we focus on solving customer problems. That's fundamentally how we think about it. We know our customers, customers very intimately. And we have been evolving as a company. We moved into 3D printing. We moved into Robotics. We've moved into Digital. We're now moving into workflow and Software-as-a-Service. So this is not something that's sort of new. It's been a gradual progression over a number of years. But I do see us getting more and more involved in connected services for our customers. And these are all high growth spaces with, with very good margin profiles.

And I think care.ai is incredibly exciting, getting into virtual nursing, which solves a lot of the problems that hospital customers are having around staffing and being able to integrate that with Vocera. So I, we're not done. I would say we're going to continue to expand both organically with follow on software upgrades, because these things you have to have continual upgrade cycles, but also looking at other acquisitions to continue to bolt-on to the Vocera and care.ai solution. We're looking at expanding Vocera into areas like the emergency department of hospitals. So there's a lot more footprint that we can actually extend these technologies into.

So to me, it's an incredibly exciting platform opportunity for us in the future. These wireless and digital solutions. But, but just think about it as us continuing to, to look for ways to get into high growth spaces that solve customer problems, and we'll just continue to extend it and expand it. But it's not a shift. We're still very focused on Hips and Knees and Neuro and our Other businesses are also, as you see from our results today, are also high growth and, and we do that with sometimes traditional methods of producing our products and sometimes getting into new technologies like 3D printing.

So do expect more of the same and this diversification towards MedSurg, it's been going on for a decade. And they do have a lot more opportunities for new innovations than you would see in the traditional implant business. So, I would expect this diversification story to probably continue going forward.

[Ryan Zimmerman, Analyst at BTIG Research]

Fair enough. And Jason, you made the comment that you expect procedures to be healthy through year-end. You've historically made those comments in kind of a three-month to six-month window. And I know this is trivial, and it's kind of a follow-up to Joanne's question, but any reason why early thoughts on, early '25 wouldn't result in any type of similar procedure environment? I mean, it seems like it would suggest even into the first quarter of '25, that there wouldn't be some type of slowdown. And again, I know it's a more near term question.

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

Yeah. No, Ryan, I think what I would say is, we don't have any indication that would suggest there's any level of slowdown. And I'd tell you, as a reminder, Kevin kind of made this point as well. If you go back to as far back as our Investor Day, right, we said we kind of see these markets as mid-single-digit growing markets. I think that's how you're going to see kind of this year play out, and we're going to perform 200 basis points to 300 basis points above that. I don't have any reason to believe as we, as we turn the page and go to January, that there will be some material slowdown. So we, we feel good about how we think we'll end the year and then start off 2025.

[Ryan Zimmerman, Analyst at BTIG Research]

Thank you.

[Operator]

Our next question comes from the line of Travis Steed with Bank of America. Your line is not open. Please go ahead.

[Travis Steed, Analyst at Bank of America]

To the question, I wanted to ask one on, on LIFEPAK. Any sense for if you could comment on, on the order backlog compared to kind of typical product backlog, some of the early feedback. Do you think this is enough for, for medical to grow and accelerate the growth rate of medical next year? And then just wanted to make sure on the installed base, the 100,000-plus, is that an installed-base of the market? Or is that an installed base for Stryker? There's some confusing comments out there. So I wanted to clarify that here.

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

Hey, Travis, this is Jason. First off, on the backlog, I'm not going to try to quantify it for LP 35 specifically, but I'll say it's healthy, right? And there is a ton of excitement in the marketplace here. And we certainly think it will be one of the pieces, as Kevin talked about Medical being a double-digit grower. LP 35 is certainly going to play into that.

In terms of installed base, yeah, the 100,000 that you referenced, it's a good worldwide number for us as we think about that Stryker specifically.

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

Yeah. So that, just to be clear, that's, that's our installed base. That's the life back installed base, which I think was the root of your question. And given the replacement cycle, you should think of this as a multi-year tailwind for Medical. It's just, it's not a one-year, two-year, it's just going to be a three-year, four-year, five-year tailwind just given the lengthy life cycle of each product.

[Travis Steed, Analyst at Bank of America]

Great. And I have a follow-up. Just kind of a two-part, one for you, Kevin. That's how you're thinking about the overall M&A environment and sizable deals later this year, early next year. And Jason, the $300 million you called out on M&A contribution. Is that all in organic revenue? Is any of that flow into organic? And I'm curious how fast that, that piece of revenue is growing?

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

Yeah. So, thanks. First of all, on the question on the organic or inorganic. Obviously, these deals happened over the course of this year, the seven deals, right? So we're going to give our guidance for organic sales growth in January, and you should assume that roughly half of the sales that were, that we talked about, roughly half of that $300 million will end up being inorganic next year. The other roughly half will, will appear in our organic guide for the year. But I wanted to give you a sort of a sense for all of these. They're small tuck-ins for the most part, but actually very exciting for each one of those individual businesses. So that's the first part.

[Travis Steed, Analyst at Bank of America]

M&A environment.

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

Oh, M&A environment continues to be great. So we have a very healthy pipeline of deals. We've been active with a large number of deals. We're going to continue to stay active on the M&A front. We do have still significant financial capacity having only spent $1.6 billion and continue to generate strong cash. So, that will be the number one use of, of our cash going forward, just as it has been in the past, and we look forward to staying active on the M&A front.

[Travis Steed, Analyst at Bank of America]

Great. Thanks a lot.

[Operator]

Our next question comes from the line of Matthew O'Brien with Piper Sandler Companies. The line is now open. Please go ahead.

[Matthew O'Brien, Analyst at Piper Sandler Companies]

Afternoon. Thanks for taking the questions. Just maybe, maybe I don't know if this is for you, Kevin, or Glenn, but just help reconcile the commentary on, I think you said record new Mako installations, but then the, but then the other line was essentially flat this quarter. So, and I think you said there was some international pressure that you saw this quarter. So that would imply, I think you're saying that the domestic Mako number was, I want to say bananas, but very, very strong. Is that the case? Are you starting to see a lot of interest build in the multi-platform capability of Mako? Or is there something else just going on where you're seeing such strong domestic demand for Mako?

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

Yeah. Just, just to clarify, in that other ortho line, the two biggest components are revenue from Mako installations and then bone cement. The revenue from Mako installation comes from outright cash sales, finance deals through capital and rentals. And as the year progresses, what we typically see in the back half of the year is that more of our customers choose rental agreements, which ultimately, usually end up in purchase agreements a year later. And so even though we have a large number of installations, we're only booking rental income on a monthly basis. And so that's what you feel revenue-wise in that line.

Then the other thing is that I mentioned is that bone cement continues to decline, and that really is primarily just a factor of the growth we're seeing in our cementless business. And so those are the two pieces that make that up.

[Matthew O'Brien, Analyst at Piper Sandler Companies]

Okay. So I guess just specifically then, I mean, did the domestic Mako number surprised to the upside in the quarter in terms of the installation.

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

It didn't surprise to the upside, it continued to be strong. So we've had continued strength in installations, both in the US as well as international. Sometimes the revenue number, it looks volatile because of deal mix primarily, where you have a lot of cash sales versus a lot of finance deals, but steady, I would call it, steady good growth in installations both internationally and in US.

[Matthew O'Brien, Analyst at Piper Sandler Companies]

Okay. Okay. And then as I look at the Ortho business, and I know Medical has got a ton of growth in front of it. But the Ortho business in your three biggest buckets is, continues to be well above market averages in terms of growth. And I think Trauma and Extremity actually accelerated here in Q3. So just the confidence that you can continue to take this much market share. I don't know if you benefited from your competitor issues in large joint here in Q3 or not. But just the confidence in the ability to unnecessarily [Phonetic] put up this level of growth, but to grow so much faster than the market in '25 and even in '26. Thanks.

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

Well, can I start, I'll start with Trauma and Extremities, because if you look, they had a very big comp from last year, it still posted a very significant number. And we're very confident in the future of Trauma and Extremities. Shoulder, as you know, has been a very strong grower double-digits pretty consistently. Last week, I had a chance to go to the Orthopedic Trauma Association, which is our core trauma business unit, the biggest of the three business units within Trauma and Extremities. And I would say I got to see the full force of our Trauma team at that meeting with the Pangea launch with the Volar plating, plating launch for distal radius fractures. They are absolutely on fire. And I see core trauma continuing to be a very strong grower. And Pangea is just getting started, and they're already posting tremendous growth, fantastic management team, very engaged. I'll tell you, it was a very exhilarating conference to see that last week and, and that momentum will continue.

And then foot and ankle and biologics. Biologics was very strong double-digit growth. Foot and ankle used to be kind of a high single-digit grower, a little bit lower than that this year. So, in spite of that, you're still seeing these very, very big growth rates. And we're, we're actually bullish that the foot and ankle will start to pick up a little bit, and that will contribute to future growth. So I would say Trauma and Extremities is a big business and a double-digit kind of overall grower at least for the foreseeable future.

And then getting back to Hips and Knees, we just continue to grow the Mako sort of percent of procedures done in Knees, percent of procedures done in Hips. Cementless continues to grow quarter after quarter after quarter. Insignia was obviously a massively important launch for our Hip business. We launched the Hinge product for revisions for Knees that is going extremely well. So tremendous product momentum across the board from quarter-to-quarter, how much market share will we take hard to predict exactly. But we've said for quite some time now, we're going to grow above the market. What level above the market, let's, let's see how that plays out. But we're in a very good position with our portfolio, with our talent, with our culture across all of these orthopedic businesses.

[Operator]

Our next question will come from the line of Vijay Kumar with Evercore ISI. Your line is now open. Please go ahead.

[Vijay Kumar, Analyst at Evercore ISI]

Hey, guys. Thanks for taking my question and congrats on a nice print here. Kevin, maybe my first one on Mako here. I think, I think in the past, you mentioned about a certain percentage of Hips being, being performed robotically in the US. I think that number was maybe 25%, 30%. Where are we on Mako utilization? Any qualitative numbers? And is it up mid-singles up double digits? How should we think about utilization? What percentage of hips are being done robotically right now?

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

Hey, Vijay, it's Jason. I'll dial that number in for you a bit more precisely in January. But what I would tell you is, those numbers continue to progress in a positive direction quarter after quarter. And with the offense that we're playing, we certainly think that will, that will continue that pace in the fourth quarter and beyond.

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

Yeah. We moved, Vijay, we moved to a once a year disclosure of that given that our competitors don't disclose their percentage that are done on their robotic platforms.

[Vijay Kumar, Analyst at Evercore ISI]

Understood. And maybe, Kevin, one on the macro environment here. I know you've said procedure environment remains healthy. I think in the past, you've spoken about wait times as sort of being a leading indicator. When you look at those wait times, where are we right now from procedure scheduling perspective? And I think on the capital side backlog, does it still remain robust did it grow sequentially? Thank you.

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

It's just on scheduled times. The reason we sort of say we still think the market is healthy as wait times are about, this is again not super scientific, just given the data we have, but it's roughly double the wait times that were pre-pandemic. So average wait times were kind of two months or so. Scheduled, surgery schedules were booked out about two months now they're booked out more like four months. There are some surgeons that are booked out an entire year. And so we're just not seeing that go back. It's staying at that kind of normalized level, which gives us, it doesn't give us a full year visibility, but it gives us visibility out of at least probably four months to six months, because it's a good idea. You'd start to see things slowing down on the intake ahead of time. So that's why we feel pretty good about it. But again, every quarter, we get a chance to talk to you, if we see something change, we'll let you know, but we're not seeing any, any change whatsoever, at least not now.

[Vijay Kumar, Analyst at Evercore ISI]

That's helpful. Thank you, guys.

[Operator]

Our next question comes from the line of Matt Miksic with Barclays. Your line is now open. Please go ahead.

[Matthew Miksic, Analyst at Barclays]

Hey, thanks so much for fitting me in. Just a couple of clarifying questions on Mako. So one, there was a Matt's question on some color around that product line and ways of purchasing and so on. So just a quick one, I think is, is the mix on leasing in the US versus the mix on leasing OUS more, more cash purchases in one geography and other that kind of, that kind of color might be helpful. And then I had just one quick follow-up.

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

Hi, Matt. In terms of our leasing business relative to Mako's, we see more leasing and financing in the US versus OUS. And I would agree that, that we also see more rentals in the US than OUS.

[Matthew Miksic, Analyst at Barclays]

Okay. That's super helpful. And then kind of mixed question, given the strength in that business and frankly, in Ortho general is, can you give us any color on the, maybe the change in the percentage of new robots installations going into ASCs as a site of care versus more traditional acute care centers or patch centers that would be super helpful, if you're willing to share any color. Thanks.

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

Yeah. Thanks. Just like we said before on the previous question, we're going to, once a year, kind of give you those kind of metrics rather than doing it every single quarter just for competitive reasons. But suffice to say that the percentage of Mako is going into ASCs is going up with the increase in the number of ASCs. We love our ASC offense. And typically, as we win our ASC deals, at least one of those operating groups tends to have a Mako in it. And so we'll share that more of that at the end of the year.

[Matthew Miksic, Analyst at Barclays]

Great. Thank you.

[Operator]

Our next question comes from the line of Steven Lichtman with Oppenheimer & Co. Your line is now open. Please go ahead.

[Steven Lichtman, Analyst at Oppenheimer & Co. Inc.]

Thank you. Hi, guys. Just on Spine. You are obviously increasing your presence on the enabling technologies here. Do you see your platform there, obviously, led by Mako as sort of the driver for accelerated growth as you look ahead? Or are there other pipeline products or M&A areas that you think could help bolster growth in that segment as well?

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

Well, in the short-term, I would say the enabling tech is really the engine for growth, both Mako Spine as well as Copilot. Of course, like every business, we have a number of products that the teams are working on. And as those products launch, they'll also be contributors. But for us, the robot was a major gap in the portfolio and Copilot is, gives us a bit of a leap forward and spine surgeons are more than ever interested in enabling technologies. And we know what that's done to Hips and Knees and are hopeful that, that will really put us back on offense. We've been kind of playing defense for Spine for quite some time. So, I would say that's our immediate focus. The team, of course, are working on other innovative products. But this is the biggest area of opportunity for us, at least in the short-term.

[Steven Lichtman, Analyst at Oppenheimer & Co. Inc.]

Got it. Thanks. And then, Glenn, just I think following up on Larry's question from earlier, looking at below the line expenses next year, any direction you can provide on sort of interest expense compared to 2024 based on what you guys have do and a refinancing?

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

Hey, Steven, it's Jason. We'll get into more of that certainly in January. But at this point, we won't provide any more guidance relative to 2025.

[Steven Lichtman, Analyst at Oppenheimer & Co. Inc.]

Okay, understood. Thank you guys.

[Operator]

Our next question comes from the line of David Roman with Goldman Sachs. Your line is now open. Please go ahead.

[David Roman, Analyst at The Goldman Sachs Group]

Thank you and good afternoon. I wanted just to dive a little bit more deeply on the international side. And I appreciate, Kevin, this is something that you've been focused on for several years. As we look across the portfolio now, you're still ending up in the 25-ish percent of sales being OUS. Can you give us a sense of which businesses perhaps don't lend themselves to significant OUS expansion versus those that do. And then a number of your competitors have talked about exiting markets OUS. And does that provide an opportunity to accelerate your penetration into those geographies?

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

Yeah. The biggest opportunity we have isn't really taking advantage of competitors exiting. It's really taking our technologies to these markets and earning our fair share. And by far, the biggest opportunities are in the MedSurg portion of our portfolio. Neurovascular is already very well penetrated internationally. But actually, it's the reverse of the rest of Stryker, where the majority of their sales are actually outside the United States. And then we have some other business like Hips that are quite strong internationally. Trauma is very strong internationally. But basically, all the other divisions of our company, especially in the MedSurg, we have massive opportunities.

The business that are a little less likely to be great internationally, something like a Sage those products are terrific, but they involve extra cost to prevent infections, and there are certain markets that are just not as interested in those businesses. But I would call them more of one-off types of businesses. But the vast majority of our, our MedSurg portfolio lends itself very well to international deployments. Not something like Vocera will take time. We have to do translation. So these things just take time.

The reason, one of the biggest reasons why we have such a high percentage of US sales is because we keep buying companies that have only US revenue. And then it takes us time to then take those products to international markets. But the way you should think about it is this is a multi-year 10-year, 15-year tailwind for our company just given our starting position. If you think of something like power tools, where we had 33% market share five years, six years ago, we've now crossed 50%. But we're far from the market share we have in the United States.

And it's just not something that spikes dramatically in one-year. It takes the steady drumbeat of adding sales forces and penetrating and providing training and education. And so it's a very nice gentle push to our revenue and being able to grow double digits organically as we have the last couple of years. We're going to continue to do that for many years to come. So that, that for Stryker provides tremendous upside versus other companies that are already well, well penetrated in international markets.

[David Roman, Analyst at The Goldman Sachs Group]

That's very helpful. And maybe on the Mako expanded application in Shoulder and Spine, as you think about what Mako has been able to accomplish on the Hip and Knee side, really consolidating a lot of market share around robotics as that's become increasingly so standard of care. What, should we expect to see something similar on the Shoulder and Spine side, where the application of robotics ends up being a significant share driver overall? And is this the path to catalyzing your Spine business, maybe more specifically to a number one or number two position?

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

Well, if I, I'll start with Spine. So in the case of Spine, our Mako robotic solution, I wouldn't say is, is materially different than the other offerings. So, it's a very competitive offering. It's a good offering, but we're not first, and it's not incredibly differentiated. The Copilot product is fabulous. So our ecosystem I'm delighted with. If you take the Q guidance and incredibly fast camera plus Copilot plus Mako Spine together as a system, very exciting. A robot by itself isn't not as differentiating as it is in Hips and Knees.

When I think about Shoulder, I'm wildly excited about the potential. Now, we don't necessarily need it. Our Shoulder business is, is absolutely humming and growing extremely well with great implants. We already have the Blueprint software, which is fabulous for surgical pre-planning. But that Blueprint will feed Mako, and we will do bone preparation. And so it will, it will make a very hard procedure much more easy to accomplish. So I am extremely bullish on its potential and shoulder, I would say, as much as I am in the Knee business. So shoulder should be great. Spine, I think it will make us very competitive, and it will be good, but not as transformational as the potential is in Shoulder.

[David Roman, Analyst at The Goldman Sachs Group]

Great. I appreciate you taking the questions.

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

No problem.

[Operator]

Our next question comes from the line of Chris Pasquale with Nephron Research. Your line is now open. Please go ahead.

[Christopher Pasquale, Analyst at Nephron Research]

Thanks. Kevin, I wanted to ask about the Vertos acquisition. Pain is a therapeutic area that you had expressed interest in for some time. You're there now or at least there now in a bigger way with Vertos. You talk about your plans for that mild procedure? And do you see that as a platform that you can build on to add other solutions in interventional pain? Or do you view that as more of a one-off tuck-in?

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

It's definitely not a one-off. We're really excited. We have an amazing IBS business. It's been high performing for quite some time. It's not the first deal we've done. We did the SpineJack acquisition. We did the curve balloons that we bought from CareFusion during the BD acquisition of CareFusion. We picked up the curve balloons. We've had our own internal innovation as well. We launched OptaBlate, so we have both the pain as well as the oncology business within our IBS business, but it is a fabulous business. This is solving real problems that, that patients have in the debulks that the ligament and then the pain subsides and then that obviously obviates the need for more serious surgery.

So we're very excited. We want to fill the bag up. We have an amazing leadership team there in sales force that, that knows how to win. And I wouldn't say we're going to stop. I think we do have another internal innovation that's planned we haven't communicated yet. We'll probably communicate that in the first quarter, which we're very excited about. And so that business will continue to be a high grower for Stryker in the future. And I wouldn't say we're done.

[Christopher Pasquale, Analyst at Nephron Research]

Great, thanks.

[Operator]

Our next question comes from the line of Jason Wittes with Roth MKM. Your line is now open. Please go ahead.

[Jason Wittes, Analyst at Roth Mkm]

Hi, thanks for taking the questions. So clearly, one of the biggest trends in Knees is the move towards cementless Knees. But if you look at the data, it's almost entirely driven by Mako. Recent numbers I've seen are well above 75% or so. So just looking at the competition, is there any other commercial robot out there that's even capable of making the appropriate cuts to put in a cementless Knee, or is that kind of what's driving sort of this dominance here?

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

Well, let's start just sort of we wanted to take. We've been 10 years in the market with cementless. So we launched cementless prior to Mako. And we have incredible long-term data that shows that our cementless offering provides fantastic results. We have good long-term data, five-year industry data that's 99% success rate. So, this is a huge advantage for us. When a surgeon is thinking of moving to cementless, knowing they have a proven implant is big. You're right that the cut and the precision of our cut lends itself to, to really doing a press-fit Knee or cementless Knee.

And our percentage of cementless with Mako is much higher than our percentage of cementless with standard instruments. But we do have quite a lot of surgeons doing standard Knee replacement with cementless offering. And the competition is much later in providing their offering. Some of them are just launching a cementless now. It takes, it took us time. Surgeons aren't going to switch right away. They're going to want to make sure that there's no aseptic loosening. They're going to follow their patients very carefully for the first six months, one-year. Some of the prior versions of cementless hasn't gone well. So some of them have scarred from that.

So I think for the competition, it's just going to take time, just like it did for us. It took us time early on. We just have a massive head-start in the timing. And now we have long-term data, which proves that this is a terrific solution. So we love our position. That was our bet. We bet on cementless and robotics and did not launch a brand-new Knee system, and we're in a good position right now because of it.

[Jason Wittes, Analyst at Roth Mkm]

Yeah, agreed. And if I think about Hips, I mean, same, same game plan. I mean, obviously different, slightly different approach, but you're obviously a first mover in terms of just the implant or just the technology. Do you see sort of those things position you better in Hips right now than everybody else? Or how should we think about how that's going to sort of work its way through because obviously Knees were kind of the first focus and obviously Hips have, not that they're new, but they're kind of followed Knees.

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

Yeah. Look, the need in Knee is more obvious, because there's a lot more dissatisfied patients in Knees and Hips has a much higher satisfaction. So sometimes it's not as obvious. The need for Hips and that's why we try to get it in front of surgeons so they can see the power of Mako with pelvic tilt information. We also have, of course, the Insignia stem, which is doing great. I forgot to mention the Trident II hip cup. So we have a 3D-printed hip cup, which surgeons absolutely love. That's actually our first, I'd call it replacement product. Most of the 3D printing products we've done across our business, including CMF as well as our Hips and Knees business. I've mostly been innovation around 3D printing to enable cementless as an example. But we actually have replaced our hip cup with 3D-printed hip cup, which provides fantastic fixation.

And with Mako, you actually don't need to have fluoroscopy during the direct anterior procedure. So getting led out of the operating group is a big deal. And we're only just starting to market that. And as surgeons realize that initially, they'll reduce the number of shots, because it gives them comfort and security doing the direct anterior method of procedure, but we're starting to see more and more surgeons reduce the number of shots and then actually get it out of, get radiation out of the operating, which not only makes the surgeon happy, it makes all the surgical staff very happy. And you can do that with Mako for Hips. So that is one of the compelling advantages that our system has, that we're going to continue to start to push. So that, that should, over time increase the uptake from Mako Hips.

And of course, outside the United States, there's a lot more Hip procedures done. It's not nearly as weighted to Knees. Other than India, the rest of the world has much more balance between Hips and Knees, and they're seeing the benefit of the Hip application and Japan is a good example where they, they have businesses doing extremely well on Mako. So yes, there's a lot more upside. It takes a little longer because it's not as obvious that you're going to get these benefits until you actually try it, and that's what we're trying to educate our customers on these benefits.

[Jason Wittes, Analyst at Roth Mkm]

Great. Thanks for all the detail, Kevin. I'll jump back in queue.

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

No problem.

[Operator]

Our next question comes from Mike Matson with Needham & Company. Your line is now open. Please go ahead.

[Michael Matson, Analyst at Needham & Company LLC]

Yeah, thanks. Just have another one on, on Mako. I guess with Spine and Shoulder coming you're kind of a different position as a company because you have such a huge installed base already of systems that are out there. So, is it safe to assume that, that your existing installed base will provide an advantage and that you could potentially upgrade some of those to either do Spine and/or Shoulder? Or do you expect most of those or about doing those procedures to be sort of more greenfield placements?

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

I think the answer is probably a bit of both. But what we most benefit from is the brand of Mako. Mako is a brand that is trusted that is known that they have success and experience buying already. And so having another application on a proven robot, I think is a massive advantage, whether they add the application to existing robots or whether they purchase a standalone robot for their Spine Surgeon. In either case, they have experience with the robot. They have trust with the robot. They have trust with the brand of Mako. I think that gives us a massive advantage, absolutely.

[Michael Matson, Analyst at Needham & Company LLC]

Okay. Got it. And then just the pricing looks good this year. I know you're not giving guidance for next year, but maybe you can just talk about what you're seeing there, kind of the areas where you're seeing better or worse pricing and just the, your expectation of the sustainability?

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

Yeah, Mike, I think, gosh, how the years unfolded, you think about Q1, we had positive 0.7, Q2 positive 1.1, and now Q3, positive 1.2. So we are, we're seeing good results from the programs that we put in place. And keep in mind, too, the programs sort of span the gauntlet from working with large healthcare systems contractually, but even working on smaller scale individual hospitals or even ASCs drive better pricing, and an understanding of why we are driving that kind of pricing.

And so I do think that we, we've exercised this muscle across our business, both in the US and international that now has just become systemic in our business. And so it is something that will get attention in every deal that we do. Moving forward, I don't expect that to change. I'm sure things could get more competitive, and we'll provide that kind of guidance when we hit January. But right now, we're very bullish on this year and where we're going to get to with pricing.

[Michael Matson, Analyst at Needham & Company LLC]

Okay. Got it. Thank you.

[Operator]

Our next question comes from the line of Danielle Antalffy with UBS Equities. Your line is now open. Please go ahead.

[Danielle Antalffy, Analyst at UBS Equities]

Hey, everyone. Good afternoon. Thanks so much for taking the question. Congrats on a, on a really good quarter here. Clearly, a lot of momentum here. I was wondering if I could focus the conversation on the Orthopedics business, large joint Orthopedics. And I appreciate your position, your competitive position with Mako and things like that. But I guess I'm just curious at a high level, I mean, you guys continue to, it seems like you continue to gain share here.

And I'm curious what is the leading driver there? I mean, is it led by the robot? Is it led by the product offering and Stryker's ability to provide a broad swath of product offerings to the ASC? And then follow-up, now the follow-up is on ASC specifically, and where we are in the transition of procedures, large joint Orthopedic procedures to the ASC? Thanks so much.

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

Hey, Danielle, it's Jason. I would say, in terms of our ability to win here, it's a combination of probably all the things that you just listed, frankly. But I would say we've been very consistent here in terms of, of the messaging of how we're going to win in the market, how the market is going to play out for several quarters now, right? If you look and just start with our Mako installed base, and we've had a number of quarters now of record installations. If you think about how that translates into growth in our Hips and Knees business, that's certainly a positive.

And then when you think about from a utilization standpoint, obviously, I commented that we'll add a bit more color in January. But that continues to go up. So again, just a variety of positive factors. Glenn talked about price, that certainly is a piece of what we see as well. But certainly, several factors. Your question on the ASC environment, Kevin commented on this earlier as well, where we continue to see the Mako footprint built out in the ASC environment, again, helping the Hips and Knees business. I can, I'll provide in January. We typically view this once a year in terms of percentage of large joints down in the ASC, but that continues to go up as well. So, it's certainly a variety of factors that are attributing to our growth over time.

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

Yeah. The last thing I'd add is, when you see sustained performance over time, that's one of the things we really value at Stryker. If you look at our, if you go to our national sales meetings, and we have numerous awards for performance over time. To sustain something requires, yes, you need the portfolio, but people catch up and sometimes someone jumps ahead of you. And so the portfolio by itself is not ever going to be enough to have sustained high performance. It's also the culture and the sales force, the way we hire our sales force, how engaged our sales forces are, how well they execute.

I mean, that, that has been a hallmark of Stryker, and it spans the, the entire corporation, the way we add sales forces and split territories and split divisions. And we are an incredibly sales driven organization, and our teams are highly engaged and they're very high-performing and sometimes not always with, with a leading product in some cases, but they know how to sell. And that's, that's been a strength for a long, long time at Stryker. And that is still very alive today.

[Danielle Antalffy, Analyst at UBS Equities]

Thank you.

[Operator]

Our next question comes from the line of Richard Newitter with Truist Securities. Your line is now open. Please go ahead.

[Richard Newitter, Analyst at Truist Securities]

Hi, thanks for taking the questions, and congrats on a really strong third quarter performance. So my first question. Can you guys put any quantification around the amount of dilution or earnings dilution from the roughly $300 million of deals you did in '24 that you need to overcome? And is all of that going to be absorbed in '24. Is there going to be any, any kind of impact from a dilution standpoint in '25? And can you quantify either?

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

Yeah. Hi, hi, Richard. We, the only thing we've really commented on, and I think Kevin said this, is that we will cover the dilution, and it's contemplated in the guidance that we have provided for this full year. And it's anticipated that, that dilution will be covered next year as well.

[Richard Newitter, Analyst at Truist Securities]

Okay. Thanks. And if you could actually, I'll take another one in, just what divisions, the key acquisitions go into, if you could just remind us for modeling?

And then my second question, a real second question, ischemic stroke, Kevin, what, what do you think it's going to take to turn that business around? Is that a product fix? Is that a sales organization fixed? How can you reaccelerate the momentum in that franchise? Thank you.

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

Yeah, thanks. Look, the ischemic segment has been more demanding and challenging. We had some supply challenges on our flow diverting stent portfolio. So that, that is being rectified. So we're feeling better about that as we end this year and go into next year.

On the aspiration side, there's just a large number of competitors. We do have, we've launched really, the Vecta 46, a really good catheter and aspiration cap is doing well. But we are looking at some sales force changes perhaps because in some cases, the competitors that only sell that and our sales force has to sell a broad suite of products. And so we have had a little bit of experimentation on some dedicated sales reps that are only selling a shoe mix.

So we're looking at a number of different options to try to short that business. But I would say, we still love the neurovascular space. It's just that the segment has become very competitive with a lot of new entrants. And, and we're looking at different options to be able to improve that. So we do have a good portfolio. So the portfolio isn't the biggest part of the problem. We did have a supply chain issue as getting down.

[Richard Newitter, Analyst at Truist Securities]

Thank you.

[Operator]

Our next question comes from the line of Matt Taylor with Jefferies. Your line is now open. Please go ahead.

[Matthew Taylor, Analyst at Jefferies Financial Group]

Hey guys. Thanks for taking the question. I wanted to ask you about sustainability of the pricing trends, which have been better over time in the '25? And then also, if you have to think about an upside scenario for '25, what will be the source of that? Is it better Ortho growth or MedSurg outperformance? Where do you think you could surprise?

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

Yeah, Matt. On pricing, I think we've told you everything we can on 2024 to be honest. And in January, we'll provide full guidance on where we think pricing will come out for 2025.

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

Yeah. Matt, I would just say also, as it relates to kind of sustainability of growth, probably the same answer there that as we think about the different areas of the business, we'll certainly get into more in January as we think about areas of growth.

[Matthew Taylor, Analyst at Jefferies Financial Group]

Okay. Thanks guys.

[Operator]

Our next question comes from the line of Jeff Johnson with Robert W. Baird & Co. Your line is now open. Please go ahead.

[Jeffrey Johnson, Analyst at Robert W. Baird & Co. Inc.]

Thank you. Good afternoon, guys. I'll try to be quick here at the end. So Glenn, I know you said you've said about everything you can on price. But can I just confirm, I think this is your first quarter of positive Orthopedic pricing, at least as far back as my model goes in 2012, and if memory serves, I'll bet it's acted like 2006 or 2007 when Orthopedic pricing first really started to slip across the industry? And how much of that is Stryker flexing its muscle the way you kind of qualified it earlier in your comments versus just hospitals have realized they kind of cut the bone and in an inflationary environment, if they want innovation out of all of your manufacturers, you need to start, they need to maybe stop asking for those, those bigger price cuts every year and things like that. Thanks.

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

Yeah. I think, first of all, you're correct. This is the first quarter for positive orthopedic pricing growth. Keep in mind, a lot of that was driven in international markets and then especially in international markets where we saw more extreme FX and inflationary pressures, which we, we obviously adjust our pricing in those markets to match that. I would say in the US Orthopedic market, we're seeing good performance, but we're not necessarily seeing positive performance on pricing in the US Orthopedics market.

[Jeffrey Johnson, Analyst at Robert W. Baird & Co. Inc.]

All right. That's helpful. And then Kevin, just last one. Just I think way back many years ago, we used to think about like Medical, Endo and Instruments. One would be going through a new cycle double-digit, strong double-digit growth. One would be coming up against tough comps from a cycle, maybe 18 months, 24 months earlier, it was in the mid-single digits and then one of the other segments kind of in between. Your double digits in all those segments here year-to-date. Are we, is there just so much diversity now, diversification in those three units, and they're so big that you can just kind of keep up product cycles across to all three, and we don't really have to think about at least the valley part of that in any of these segments and given years down to 5% growth or something like that? Just think about conceptually the balance between Medical, Endo and Instruments. Thanks.

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

Look, listen, I think that was extremely well said. The way you just described is exactly what the strategy has been to diversify away from purely capital businesses to get into high growth segments to, to make these bigger, stronger businesses that's underneath the noise of the business. You can have some parts of the business may be slowing a little bit, but other parts accelerating. And overall, living in the double-digit growth land for the overall division. So that is very well said. And frankly, that's what we've experienced, if you look at the last three years. You're not seeing the peaks and troughs you used to see in those businesses, if you go back six years, seven years, eight years, nine years ago, and you should expect going forward that you're going to have much more sort of sustainable, consistent growth at those divisional levels. So, well said.

[Jeffrey Johnson, Analyst at Robert W. Baird & Co. Inc.]

Thank you.

[Operator]

Our next question comes from the line of Caitlin Cronin with Canaccord Genuity. Your line is now open. Please go ahead.

[Caitlin Cronin, Analyst at Canaccord Genuity Group]

Hi, congrats on a great quarter, and thanks for taking the question. I guess just turning back to M&A. I think you've been focused on top line growth through acquisitions, but I've also noted that the margin expansion expectations is really inclusive of the recent acquisitions. I guess just stepping back, how do you think about the margins of potential acquisitions? Is there a floor? Or is it more fluid, if you're able to see how you can drive efficiencies.

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

Yeah, Caitlin, I think as we, as we look at our modeling for M&A, obviously, we're looking for fast growing markets. We're looking for things that are accretive to Stryker. And sometimes that accretion is over a longer period of time and sometimes it's over a shorter period of time. I mean, ultimately, we're going to drive all these acquisitions to be accretive and accretive to the op margin line, and especially accretive with the EPS line. But the modeling and the timing of that can extend over a period of time. For product tuck-ins, those are fairly immediate for close adjacencies, those maybe take a little bit longer.

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

But being a high growth acquirer, we're not going to look at, at dilution as something that scares us off. And as we said, if there are tuck-in deals, we're going to just absorb the early dilution, and we know that that's going to then become accretive to come over time.

[Caitlin Cronin, Analyst at Canaccord Genuity Group]

Got it. Thanks so much.

[Operator]

Our final question comes from the line of Josh Jennings from TD Cowen. Your line is now open. Please go ahead.

[Eric, Analyst at TD Cowen]

Great. Thank you. This is Eric [Phonetic] on for Josh. Thanks for taking the question. On Ortho, congrats on a really strong quarter and results there. One of your competitors has shared that they're going through a restructuring of their Ortho business. I was just curious if you've seen any impact from that? And to what extent it may have been a benefit this quarter? Thank you.

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

Eric, it's Jason. I would say typically, we don't, we don't comment on competitor comments. And continue to rely on the offense that we're playing. So we'll certainly continue to do that as we move forward.

[Operator]

There are no further questions. I will now turn the call over to Kevin Lobo for closing remarks.

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

Thank you all for joining our call. We are excited about the business momentum that we have going forward and look forward to sharing the fourth quarter and full year results with you in January. Thank you.

[Operator]

[Operator Closing Remarks]

Participants

Corporate Executives

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

Analysts

• Robert Marcus, J.P. Morgan
• Lawrence H. Biegelsen, Wells Fargo Securities
• Joanne Wuensch, Smith Barney Citigroup
• Ryan Zimmerman, BTIG Research
• Travis Steed, Bank of America Co.
• Matthew O'Brien, Piper Sandler Companies
• Vijay Kumar, Evercore ISI
• Matthew Miksic, Barclays PLC
• Steven Lichtman, Oppenheimer & Co. Inc.
• David Roman, The Goldman Sachs Group, Inc.
• Christopher Pasquale, Nephron Research
• Jason Wittes, Roth Mkm
• Michael Matson, Needham & Company LLC
• Danielle Antalffy, UBS Equities
• Richard Newitter, Truist Securities
• Matthew Taylor, Jefferies Financial Group Inc.
• Jeffrey Johnson, Robert W. Baird & Co. Inc.
• Caitlin Cronin, Canaccord Genuity Group Inc.
• Eric, TD Cowen