OrthoPediatrics Corp
NASDAQ:KIDS
Earnings Call Analysis
Q4-2023 Analysis
OrthoPediatrics Corp
OrthoPediatrics has advanced its market position in the nonsurgical specialty bracing space, particularly for pediatric orthopedic care. The acquisition of Boston Orthotics & Prosthetics bolsters their portfolio with cutting-edge braces used in treating conditions like scoliosis, plagiocephaly, and various neuromuscular disorders. This segment, predominantly focused on scoliosis bracing and deformity correction, represents a sizable $500 million opportunity within the top U.S. children's hospitals. The nonoperative treatments offered via Boston O&P's technology align with OrthoPediatrics' mission to provide comprehensive solutions surrounding pediatric orthopedic surgeons, aiming to be the leading market provider.
The company is on track to amplify growth with three core initiatives: enlarging its sales force, advancing its product portfolio, and inaugurating new clinics. These efforts underpin the aggressive scale-up plan for its Orthotic and Prosthetic Services Business (OPSB) with expectations of elevating the business to over $100 million in the foreseeable future. The sales force augmentation specifically involves integrating new OPSB-focused reps into the company's agency network, essential for rapid organic revenue growth. The thriving trajectory is further buttressed by product development teams across multiple sites, aiming to introduce 4-5 innovative products annually starting from 2024.
Driven by robust sales across the company's broader portfolio, including Trauma and Deformity, domestic Scoliosis, and OPSB, OrthoPediatrics reported a worldwide revenue of $37.6 million for the fourth quarter of 2023, a 21% increase year-over-year. The company has improved its gross profit margin and exercised cost control across its operations, culminating in adjusted EBITDA of $1.3 million for the same period. Looking forward, OrthoPediatrics reiterates its revenue guidance for 2024 in the range of $197 million to $200 million, potentially marking a growth of 32% to 34% and expecting adjusted EBITDA between $8 million to $9 million. Set deployments are expected to be less than $20 million, signalling a strategic pivot towards driving the business to cash flow breakeven sooner.
OrthoPediatrics is poised for sustained growth, fueled by the success in its U.S. scoliosis business and a resurgence in international markets. The company anticipates robust sales from legacy products and newly launched offerings, following substantial investment in product deployments. With a strong cash position and access to debt, the company's long-term profitability plans are well-supported, setting the stage for achieving market leadership and driving positive impact in pediatric health care globally.
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Good morning, and welcome to OrthoPediatrics Corporation's Fourth Quarter and Full Year 2023 Earnings Conference Call. [Operator Instructions] As a reminder, this call is being recorded for replay purposes.
I would now like to turn the call over to Trip Taylor from the Gilmartin Group for a few introductory comments.
Thank you for joining today's call. With me from the company are David Bailey, President and Chief Executive Officer; and Fred Hite, Chief Operating and Financial Officer.
Before we begin today, let me remind you that the company's remarks include forward-looking statements within the meaning of the federal securities laws, including the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements are subject to numerous risks and uncertainties, and the company's actual results may differ materially. For a discussion of risk factors, I encourage you to review the company's most recent annual report on Form 10-K, which will be filed with the SEC in the near future.
During the call today, management will also discuss certain non-GAAP financial measures, which are supplemental measures of performance. The company believes these measures provide useful information for investors in evaluating its operations period-over-period. Each non-GAAP financial measure referenced on this call, the company has included a reconciliation of the non-GAAP financial measures to the most directly comparable GAAP financial measures in its earnings release. Please note that these non-GAAP financial measures have limitations as analytical tools and should not be considered in isolation or as a substitute for OrthoPediatrics financial results prepared in accordance with GAAP.
In addition, the content of this conference call contains time-sensitive information that is accurate only as of the date of this live broadcast today, March 7, 2024. Except as required by law, the company undertakes no obligation to revise or update any statements to reflect events or circumstances taking place after the date of this call.
With that, I would like to turn the call over to David Bailey, President and Chief Executive Officer.
Thanks, Trip. Good morning, everyone, and thank you for joining us on our fourth quarter and full year 2023 conference call. As we start all earnings call, I'd like to begin by highlighting that we helped over 82,000 kids in 2023, a new record for OrthoPediatrics.
Since inception, we've helped over 710,000 kids and including Boston O&P, our combined organizations have helped more than 1 million kids. This continues to be the most important metric of success for OrthoPediatrics and each year, we strive to increase our impact and benefit more kids. In line with our preannouncement from early January, for the fourth quarter of 2023, we generated quarterly revenue of $37.6 million, representing growth of 21% compared to the fourth quarter of 2022.
For the full year of 2023, we generated record revenue of $148.7 million, representing growth of 22% compared to the full year of 2022, driven by favorable leverage in the cash portion of G&A, disciplined expense management, strong margins and healthy revenue growth, we are excited to report that we outperformed our original adjusted EBITDA expectations producing a record adjusted EBITDA of $5 million in 2023.
In addition, we are thrilled to see our prior acquisitions fully integrated and performing well with robust top line revenue contributions and profitability. Looking closer at the quarter, revenue and surgery scheduling was strong throughout, except during the final 2 weeks of December, when we started to experience lighter surgical volumes due to an uptick in RSV. After RSV rates rose rapidly at the end of December and extended into early January, volumes quickly returned to more normalized levels.
Hospitals appear to be managing their spikes of the respiratory season better and mitigating the impact on case schedules. Altogether, volumes and staffing continued to improve month over month. And while still not running full tilt, we are encouraged recovery in the environment is tracking our expectations for modest sequential improvement. Overall, we feel this headwind is lessening, and we will remain cautious until we see further normalization. The diverse nature of our business continued to benefit OrthoPediatrics in the quarter. The global trauma and deformity, domestic scoliosis and OPSB business were very strong, offset by lower growth in international scoliosis.
Fourth quarter global T&D was very strong at 23%, with growth led by sales of Pega products, PNP Femur, early sales of PNP Tibia, and growth within the OPSB franchise. U.S. Scoliosis revenue bounced back aggressively in the fourth quarter with 35% growth despite a very slow few weeks at the end of December. New scoliosis users continue to increase significantly across the response and ApiFix product lines.
Overall, global scoliosis growth was slightly muted by a continuation of slower-than-expected ordering in our Latin and South American business resulting in a 31% reduction in OUS scoliosis sales and negatively impacting overall growth. We expect OUS scoliosis to rebound in 2024 and to act as a tailwind for the year beginning as early as Q1. With multiple opportunities, including continuing legacy product growth, several key new organic product launches, Pega sales expansion, normalization of international markets, positive longer-term ApiFix data publication, a newly formed and rapidly expanding specialty bracing business, OPSB, and an early start in digital health care. We are confident in our growth prospects for 2024 and beyond.
Importantly, we remain in an extremely secure financial position and are confident that our current balance sheet enables us to execute our long-term strategy without additional equity capital. Therefore, we are reiterating our revenue guidance for the full year 2024 of $197 million to $200 million including Boston O&P historical revenue of $25 million, representing overall growth of 32% to 34%.
We are also issuing our full year EBITDA guidance of $8 million to $9 million, and our expectation for set deployments of less than $20 million as we continue to focus on improving profitability and reducing cash usage. We closed 2023 on an extremely high note. We achieved a record number of children helped, record revenue and generated record adjusted EBITDA. We continue to balance top line revenue growth with improved profitability on our way to cash flow breakeven sooner, a trend we expect to carry into 2024.
Moving to our revenue segments. In the fourth quarter of 2023, we generated total Trauma and Deformity revenue of $27.1 million, representing growth of 23% compared to the prior year period. Strong performances from Pega products, Trauma, eX-Fix, and OPSB led revenue growth in the quarter. We saw continued record Pega product performance with substantial growth of 59% in the U.S. and 32% outside of the U.S. Sales of Pega continued to be better than we ever expected. And as we more deeply penetrate our U.S. accounts with the full Pega product portfolio and ramp international sales, we believe Pega growth will continue to be very strong globally in 2024 and beyond.
Elsewhere in T&D, we continue to take share across our entire T&D portfolio, a trend we expect to maintain for several years. We enjoy a leading share position in the T&D franchise within the U.S. children's hospitals and we plan to continue to execute our market-dominant strategy with set deployment, new product development and superior service. On the R&D side, we received FDA approval and beta launched the PNP Tibia system in Q3 and performed more cases than we expected in Q4. Initial surgeries have gone extremely well.
So far, the surgeon usage rate has been higher than we forecasted, which bodes well for our full market launch of the PNP Tibia scheduled to start in the first half of 2024. We expect PNP Tibia to be an important growth driver in 2024 and for the next several years and expect the full release of the new Pega GIRO product to make a positive impact as well. Driven by continued execution of our key account conversion strategy, we have seen an increase in the number of customers and the quantity of products used.
Now with more high-technology products coming to the market, and a robust pipeline that was strengthened by the Pega acquisition, our T&D business is positioned to deliver sustainable growth over the next several years as we execute our long-term strategy to capture greater than 50% market share. We also have several prominent R&D projects in process within the surgical side of the T&D business. We're making great progress on the development of our entirely new pediatric plating platform, the P3 project which we expect will be world-class and spawn further share-taking opportunities for us within our plating franchise.
We are also making solid strides on new external fixation devices that will continue the growth trajectory of our eX-Fix franchise. Further, we expect numerous new EU MDR approved products that we'll be launching in the EU market in the coming year to be impactful. Our OrthoPediatrics nonsurgical specialty bracing business, or OPSB, continues to perform extremely well. And I'd like to spend a little more time today outlining this significant opportunity that we have here. We recently announced the official OrthoPediatric Specialty Bracing brand, or OPSB, featuring a new website that incorporates the full MDO clubfoot and Rhino product portfolio, along with several new products, as well as the acquisition of Boston O&P. We believe the OPSB franchise represents a large new source of capital-friendly revenue growth.
It's estimated that 80% of the pediatric orthopedic care happens before and after surgery. And we're extremely excited to now be better positioned to address this important segment. We estimate the U.S. nonsurgical specialty bracing market is at minimum $775 million in total and conservatively $500 million of opportunity in the top 300 children's hospitals. Importantly, these custom fit braces do not require the upfront capital investment in consigned inventory or instrument sets. It has always been our aspiration to surround the pediatric orthopedic surgeon with all the products they needed to treat children. And we're thrilled about this opportunity to provide our surgeon customers with more of the products they use to treat their patients every day.
Boston Orthotics and Prosthetics is the only sizable company with an exclusive focus on pediatric orthotic management, offering leading custom bracing, orthotic and prosthetic technology for the nonoperative treatment of children whose lives have been impacted by scoliosis, plagiocephaly and various neuromuscular disorders. Their portfolio of some of the most advanced individualized braces available to treat pediatric orthopedic conditions, includes custom pediatric-specific Boston bracing for scoliosis, lower limb orthosis and dynamic movement orthosis DMO as well as the Boston band for plagiocephaly, partnering with world-class medical facilities, including Boston Children's Hospital, Children's Hospital of Philadelphia, Nationwide Children's Hospital in Columbus, Ohio and Phoenix Children's Hospital, just to name a few. Boston O&P maintains 26 patient care clinics primarily concentrated in the Northeast.
Boston O&P's annual historical revenue is approximately $25 million. As we mentioned on our previous call, we continue to successfully execute a build aggressively strategy in OPSB and anticipate it to grow very rapidly in the coming several years. We see many of the same characteristics in the OPSB opportunity that we witnessed when we started OP 17 years ago. These include a large $775 million U.S. TAM, $500 million of which is in the top 300 U.S. children's hospitals, a very limited competition, a general lack of ongoing innovation and the opportunities to provide elite level of customer service and support clinical education and training. We also see an opportunity for strong margins, healthy profits and the potential to build a large business in a very capital-friendly manner.
Beyond all of that, nonsurgical specialty bracing fits with our goal of providing our customers with all of the products they need to treat children with orthopedic conditions and building further brand loyalty across our entire surgical and nonsurgical portfolio. We do not plan to just scratch the surface of this segment of the pediatric orthopedic market. And we believe the Boston O&P acquisition makes that very clear. This is another market dominance play, where we plan to be very aggressive and to scale this business rapidly until we are the clear cut market leader. This has been a historically fragmented market, and we are able to leverage our current channel to increase access and most importantly, provide service required to achieve optimal patient outcomes in a way that allows us to increase the partnership with all of our customers. While the integration of Boston O&P will happen throughout 2024, we expect the rest of the OPSB franchise to organically grow aggressively this year.
Once integrated, our strategy to aggressively drill Boston will produce many years of future growth. Our strategy for the OPSB business is rooted in 3 core initiatives that we believe will enable OrthoPediatrics to deliver outsized growth. These include sales force expansion to drive adoption and scale usage, product development to build a competitive and comprehensive portfolio, and the addition of new clinics to enhance profitability. While we're in the early innings of this growth journey, we believe we are well on our way to growing this business to be in excess of $100 million in coming years. Turning to the first initiative of sales force expansion. In anticipation of the Boston O&P acquisition and to support the OPSB business as a whole, we have been preemptively recruiting OPSB specific sales representatives that will be integrated into our existing agency sales network. We continue to actively recruit and train new associates. And so far, we are pleased with the types of people we are attracting. With our pre-existing customer relationships, we expect to see rapid organic revenue ramp in each territory where our new OPSB reps are partnering with our existing surgical sales teams.
Regarding the second initiative, product development within the MDO team in Iowa, the OPSB team in Warsaw and now the Boston O&P team at our OPSB headquarters in Boston, we are now staffed to deliver our aspiration to launch 4 to 5 new products every year beginning in 2024. This cadence, along with the launch of several products in 2023, such as the MP Lite, MP+, the Move Bar, DF2, the Rhino Cruiser and the Ora Medical Levity device set us up nicely for strong growth. Beyond these product launches and partnerships, there will be several more in the coming months and quarters, supporting our thesis that we can build a scale business in this space in the coming years.
Looking at the third initiative. Over the last several years, we have completed multiple acquisitions and partnerships, all of which we have successfully grown and will continue to grow, but never have we seen such a favorable response for our customers as when we announced our partnership with Boston O&P in early January. This is a true testament to the legacy of amazing service, products and patient care. The Boston O&P has provided our customers through their 26 clinics, largely in the upper New England. Our customers' feedback makes clear their desire to have a true partner in the nonsurgical treatment of their patients and validates the large unmet need in the nonsurgical support of their patients.
In addition, it signifies our customer support of our growth strategy to scale Boston O&P to the rest of our 300 children's hospitals around the U.S. and in certain international markets. It will take us a little time, but we feel this is an important first step that will open a larger opportunity for our company. Importantly, the operating economics for each of our existing clinics and future clinics is favorable for OrthoPediatrics. Generally speaking, we expect modest setup costs with limited initial capital outlay, consisting mainly of leased office space, limited build-out and staffing orthotist growing with the scale of the opportunity. Consistent with Boston O&P's historical revenue, we expect each new clinic will have the capacity to generate between $1 million and $3 million in revenue and produce a profit rapidly once fully operational. Again, it will take us some time for us to integrate Boston O&P and ramp the strategy, but we are already working to build a large funnel of opportunity and expect this to have a material contribution to revenue growth as early as 2025.
Moving to the Scoliosis business. In the fourth quarter of 2023, we generated revenue of $9.7 million, representing global growth of 20% compared to the prior year. This global growth was led by an extremely strong domestic performance of 35% growth and muted by a few slower weeks in the back of December due to RSV rates and a slower quarter internationally. Fourth quarter international sales declined by 31% and were lighter due to continued choppy ordering patterns from a few large international stocking distributors in Latin and South America. Despite this, we started to see a rebound across the international Scoliosis business, and we expect improved international Scoliosis in 2024 as we lap these difficult comparables, Latin and South America and ordering improves and new revenue growth opportunities materialize as we launch scoliosis in Europe.
We're very proud of the way this business has rebound and have a clear line of sight into continued improvement for the coming year. A highlight in the quarter is the success of our U.S. scoliosis business, which outpaced a rebounding international business. The fourth quarter saw strong U.S. growth of 35%, driven from more users of response in ApiFix and the successful execution of new launches this year. In addition, we're pleased to report that the surgeons from the 3 largest sites who transitioned to new practice locations are now settled in and have ramped up to speed starting to perform more cases and returning to more normalized levels. This significant growth in U.S. scoliosis is representative of both the strength of this business and the opportunity we have for the future.
We are bullish on 2024 scoliosis growth as we exit 2023 with 25% more total users of response on ApiFix, several new products that were launched in 2023, such as Response cannulated screws and Response power; strengthening ApiFix data, a robust pipeline of 7D placements and an improving international outlook. Further, the 2024 R&D pipeline is rich with extremely novel technologies that solve major unmet needs for our customers, specifically for patients with early onset scoliosis, an area historically we've never had products. We recently announced the FDA approval and beta launch of our first EOS product, Response rib and pelvic and expect to have the new verticalized growing spine system FDA approved in 2024.
Beyond that, we'll launch our new rod reduction instrumentation in 2024 that will support both the Response spine system and our new Fusion system currently in development. Lastly, we continued progress on the development of our electromechanical growing rod, although its launch will be a few more years. Notably, U.S. surgery scheduling trends strengthened late in Q3 and continued into Q4, but for a few weeks at the end of the year. We expect this strength to continue into 2024 as the elective market normalizes. Moving on to international. In the fourth quarter of 2023, we generated international revenue of $9.3 million, delivering 13% growth on top of 67% growth in the fourth quarter of 2022.
Fourth quarter 2023 growth was led by extremely solid performance with our T&D products offset by slow scoliosis sales to stocking distributors in South America. We're pleased to see a continuation of the rebound in our international business in the fourth quarter and expect it to continue throughout 2024. International Agency market sales continue to be particularly strong, both in Trauma and Deformity and Scoliosis. Progress in our German direct sales model continues to track favorably and should produce good growth in 2024.
We have onboarded several new users, and we look forward to increasing penetration in the German market. We expect strong Pega product sales to continue into 2024 and likely 2025 as we deploy inventory and train our sales channel. Despite the scoliosis softness we experienced from Latin and South America, we're making great progress launching scoliosis in Europe. We're performing first surgeries in new markets and with new surgeon customers. Additionally, we're making good headway in growing Australia and entering New Zealand as we have had added cases and leadership in support of our long-standing agency partner, and we're starting cases in Canada following recent approvals and launch.
Overall, we've got a really nice setup for our international business, and we believe that 2024 will show great improvement beginning as early as Q1. That brings us to surgeon training and education. In Q4, we hosted 98 unique training experiences for over 2,600 health care professionals. Among these events, our premier sponsorship of the Akron Resident Review Course and the Annual International Pediatric Orthopedic Society Meeting, IPOS, which takes place in Orlando every December.
In 2023, we unveiled a new sponsorship level for the Pediatric Orthopedic Society of North America, POSNA and IPOS as the first ever Emerald level sponsor. Our presence at IPOS this year was marked by multiple hands-on workshops, featuring 5 sessions, including one for our new specialty bracing business and the DF2 brace for kids with femur fractures. The full year 2023 saw record numbers of educational moments for pediatric orthopedic surgeons and other allied health professionals. Globally, we advanced our partnership with multiple surgical societies, including the European Pediatric Orthopedic Society, as well as special scoliosis meetings in the U.K. and Germany, each hosting several hundred European surgeons.
We conducted a total of 391 learning experiences for our surgeon customers, thus advancing our ongoing commitment to training the next generation of pediatric orthopedic surgeons, and leading innovation in our subspecialty around the world. Lastly, continued focus on our people is a critical part of our competitive advantage, which is why it's so important that we recently announced for the eighth time OrthoPediatrics was named as one of the best places to work in the state of Indiana. We are committed to fostering a culture that is positive, engaging and allows our associates to do their best work. This important culture allows us to further our mission and successfully help more kids all over the world. With that, I'd like to turn the call over to Fred to provide more detail on our financial results. Fred?
Thanks, Dave. Our fourth quarter 2023 worldwide revenue of $37.6 million increased 21% compared to the fourth quarter of 2022. Growth in the quarter was driven primarily by the strong performance across global Trauma and Deformity, domestic Scoliosis and the OPSB. U.S. revenue of $28.3 million, a 24% increase from the fourth quarter of 2022. Growth in the quarter was primarily driven by our Trauma and Deformity product lines, Scoliosis and OPSB.
We generated total international revenue of $9.3 million, representing growth of 13% compared to the fourth quarter of 2022, which grew by 67%. Growth in the quarter was primarily driven by trauma and deformity, offset by lower scoliosis sales to stocking distributors in South America. In the fourth quarter of 2023, Trauma and Deformity global revenue of $27.1 million increased 23% compared to the prior year period. Growth in the quarter was driven primarily by share gain across our entire portfolio with strong contributions from Pega products, trauma, eX-Fix, and OPSB.
In the fourth quarter of 2023, Scoliosis revenue of $9.7 million increased 20% compared to the prior year period. Growth was primarily driven by increased U.S. growth of 35%, partially offset by canceled cases in late December from RSV and lower-than-expected orders in Latin and South America. Finally, Sports medicine/other revenue in the fourth quarter of 2023 was $0.9 million compared to $0.9 million in the prior year period.
Turning to set deployment. $5.9 million of sets were consigned in the fourth quarter of 2023 compared to $6.3 million in the fourth quarter of 2022. For the full year of 2023, we deployed $22.0 million compared to $20.1 million in 2022. The increase was driven by significant new product development deployments, significant Pega deployments, as well as multiple consigned 70 units. Touching briefly on a few key metrics. For the fourth quarter of 2023, gross profit margin was 71.0% compared to 68.5% for the fourth quarter of 2022. The slight increase in gross profit margin was driven primarily by lower set sales to international stocking distributors. Total operating expenses increased $5.2 million or 18% to $34.8 million in the fourth quarter of 2023.
The increase was mainly driven by increased volume-related commissions as well as incremental personnel required to support the growth in the company. Sales and marketing expenses increased $1.5 million or 14% to $12.4 million in the fourth quarter of 2023. The increase was primarily driven by increased sales commission expenses. General and administrative expenses increased $3.0 million or 18% to $19.6 million in the fourth quarter of 2023. The increase was driven primarily by the addition of personnel and resources to support the continued expansion of the business and an increase in depreciation and amortization expense.
Research and development expenses increased $0.7 million or 35% to $2.7 million in the fourth quarter of 2023, driven by additional resources as well as increased payments to third-party providers. Total other income was $1.2 million for the fourth quarter of 2023 compared to $0.4 million for the same period last year. Adjusted EBITDA was $1.3 million in the fourth quarter of 2023. This compares to a loss of $2.2 million in the fourth quarter of 2022. This increase was driven by incremental revenue combined with cost controls across the organization. Net loss for the full year of 2023 was $21.0 million compared to a net income of $1.3 million last year. Fair value adjustment of contingent consideration for the total year 2023 was a favorable $3 million compared to a favorable $26 million in 2022.
Adjusted EBITDA for the full year of 2023 was $5.0 million compared to $0.2 million for the full year of 2022. We ended the fourth quarter with $82.3 million in cash, short-term investments and restricted cash. As of December 31, 2023, $10.0 million had been drawn on our new term loan with Midcap. Post closing, the Boston O&P acquisition in January of 2024, our cash and restricted cash balance was approximately $60 million. With our current cash position as well as our new debt facility, we are well capitalized to continue to execute on our strategy. Given our strong balance sheet, positive adjusted EBITDA, our line of sight to cash flow breakeven and our recent acquisitions, we are in a position of tremendous strength.
Turning to guidance. We are reiterating our expectation for full year 2024 revenue to be in the range of $197 million to $200 million, representing year-over-year growth of 32% to 34%. Additionally, we now expect to generate between $8.0 million to $9.0 million of adjusted EBITDA in 2024. We expect less than $20 million of new set deployed in 2024, representing our continued focus on driving the business to cash flow breakeven sooner rather than later. Lastly, our S-3 shelf registration filed in 2020 was fully sold in 2022. In keeping up with good corporate housekeeping, we will likely establish another universal shelf in 2024. As discussed previously, we have no need or plans to raise capital in the near term, but we believe maintaining shelf is consistent with good corporate practices. I'll now turn the call back over to Dave for closing remarks.
Thanks, Fred. As we look back on 2023, we're proud of all that we've achieved and are confident that we have the right growth drivers in place for continued success in 2024. We expect positive trends in the business to continue, including robust top line revenue growth and continued profitability growth as we move to our cash flow breakeven earlier than anticipated. In addition, in 2023, we launched 8 new products, including Response power scoliosis, the GIRO growth modulation system, Pediatric Nailing platform, Tibia system, the DF2 Brace, Mitchell Ponseti Plus Bar and the Levity Device. We continue to expect strong performance from our legacy products as a result of our heavy investment in set deployments in 2022 and 2023.
However, our recent acquisitions, along with ApiFix and Orthex and our most recent organic product launches, such as PNP Femur and Tibia, Drive Rail and DF2 require less capital deployment to drive growth due to a faster return on invested capital. This, combined with the launch and the growth of the OPSB franchise ensure we can maintain our high rate of growth while using less cash for inventory deployment, thus ensuring we drive the cash flow breakeven much sooner than earlier anticipated.
All of our long-term plans, including profitability growth are supported by our robust balance sheet, strong cash position and access to debt. I've been with OP for nearly 17 years now, and I'm not sure I've ever been more excited. We are in an extremely strong position with all the tools in place to help more children than ever before. And I think our customers feel the same way. Together, our OP associates, our customers and our shareholders are building something special and that is happening a profound impact on the lives of children. The future is bright for OrthoPediatrics, and we are just getting started.
In closing, I'd like to thank our surgeon partners, my OP associates, our investors and all the innovators in pediatric health care for standing together to help kids. Operator, let's open the call for Q&A.
[Operator Instructions] Our first question comes from Matthew O'Brien with Piper Sandler.
Good. Yes. Excellent. So just maybe starting obviously with the Boston O&P commentary. First of all, I'm sorry, it's going to be a multiparter. Is that going to be split out separately, Fred. You're saying this morning, clearly, you're not going to need additional capital because you have plenty of funding for that to build out these facilities because I don't think they're that expensive? And then how do we model this growth going forward off of this base that you have today as you're adding new clinics across the U.S.
Yes. So good question. Boston is approximately 30% scoliosis bracing, custom braces and the other 70% is deformity correction. And so that's how the sales will show up in those 2 segments going forward. The business has a different seasonality than our typical business. They don't have the big summer selling season the way we do in our scoliosis and deformity correction business. Their fourth quarter is a few points, a few percentage points higher than the other quarters. And typically, their first quarter is a few percentage points lower. The middle quarters are roughly 25% of the year.
The growth of this business, obviously, we're still working on that for 2025, but we would expect this to grow faster than the overall business as the sales force becomes effective, as new products are introduced, and we are looking to open new clinics starting next year. That does take some time to get the hospital to approve it, to find the facility to get the, obviously, specialists trained in the pediatric space. But overall, I would say that this segment is going to grow much faster than the overall business for the next several years.
Yes, Matt, I think what we're trying to signal here is the clinic side, kind of as I walk through the 3-point strategy, we expect no question, as we add sales reps, and we've already done that. We expect the sales of the OPSB franchise which is still inclusive, obviously, of MD Orthopedics and Rhino and Ora and organic products that we launched last year, DF2 and the new stuff we're going to launch this year, we would expect that business to continue to grow well in excess of 20%. That's kind of what we -- what it's done ever since we acquired MDO and then started adding products to that. I think what we're saying here is it's going to take a little bit of time on the clinic side, obviously, to get that side of the Boston business ramp. But we're definitely expecting growth in the rest of that business, again, as we've seen for the last couple of years.
Okay. And just on the upfront cost side, can you just comment a little bit there? And then I'll just ask my second question here. Just expectations for ApiFix this year. Is that going to start to be a bigger contributor? Or is it more still the kind of 25 event?
Yes, I think our view on ApiFix is the data continues to get stronger. There's no question. And as the data gets stronger, we expect this to continue to go up into the right. I think we're -- we've kind of come off as position that there's going to be some quarter or some specific moment where it's this watershed moment where every surgeon agrees that this is the right treatment. But there's no question that the entire nonfusion segment of pediatric spine is super interesting. It's still embryonic. It's still generally growing, a lot of questions. We think we're answering those questions with the data. And generally, we expect ApiFix to continue to outpace the growth of our Fusion business, and that's kind of how we're modeling it for 2024.
And specifically on the cost. So today, Boston has 26 clinics. They're all leased facilities. So really the cost, if we were to open a new facility is minimal upfront. It's just building out the space, hiring and training the actual clinicians and then hiring more clinicians as the volume ramps. So I don't know, $1 million, I would say max to open one of these, maybe less, and then the revenue starts coming in pretty quick because we're not going to open one unless we have commitments from the surgeons at the hospital that obviously, they're going to be using the clinic.
Our next question comes from Rick Wise with Stifel.
Sorry, there was a glitch, I couldn't hear. Just to start off on a big picture question. If I'm hearing you correctly, it sounds like a lot of the headwinds that you've experienced over the last year or so are either going away, gone way or sort of resolved on the staffing front, on the RSV front, on the variety of things. And so I mean that sounds very encouraging. Am I hearing you correctly, Dave?
I think that we are another quarter into this improvement. And I think we're seeing that improvement here in Q1 as well. And so yes, I think what we have said for a while here is we think that this is probably something that's behind us, let's say, by midyear -- we're a little cautious just because we recognize that June, July, August, these are our -- obviously, our big months on the surgical side. So until we see that June, July and August, I don't know that we're going to declare victory, but it's certainly encouraging that we're seeing this come through. It's also encouraging that as the business further diversifies on the specialty bracing side that a lot of the headwinds that we saw in the OR setting, we don't see on the specialty bracing side. And so as that business becomes bigger, it enables us to kind of mitigate some of the risks associated with -- the environmental risk that we saw over the last few years. And I think that's also encouraging us that overall the business should be less affected by those types of environmental abnormalities that we've experienced over the last few years.
Got you. And Fred, help us think through the quarterly setup for the year, it went back quickly. I wasn't sure if you -- I thought at one point maybe is relative to a product and not overall. I thought you were talking about maybe sequentially better first quarter revenues overall. But help us level set the right place to start thinking about the first quarter? And especially given the Boston O&P mix in there now, thank you for the specific guidance that you gave about it in terms of their quarters. But how should we think about the flow of "the new orphan pediatric quarterly flow overall for the 24 years."
Yes, absolutely. So traditionally, the pre-COVID in particular, because the last several years have been so unusual. The first quarter is typically around 5% or 6% lower than the fourth quarter. And so if you think about the legacy business in those factors, the first quarter revenue would come down. However, with the addition of Boston that is going to generate a first quarter revenue number that's actually higher than the fourth quarter. And I would bet or I would assume that it's probably in that $41.5 million, $42 million range. So definitely a nice increase over the third quarter -- over the fourth quarter at $37.6 million.
Right. And somehow in the past, you've broken the overall company quarters as a percentage of sales. So you're guiding us to that $197 million to $200 million range, how would you frame the -- as a percentage of sales in rough terms, the flow of the quarters as you contemplate 2024?
Yes. I mean, Boston is still right, $25 million out of $200 million. So it's not going to have a dramatic first year impact on changing the overall metrics. So the third quarter, we still would anticipate as by far the largest and followed by the second quarter and then the fourth quarter and the first quarter, obviously be the smallest number. So I think it's going to be pretty similar, honestly, to historical with a slight change with Boston, but not much.
Got you. And I'm going to squeeze in one more, if you don't mind. I know that you don't guide to gross margins. But if I'm hearing you correctly, Boston is going to be above average. Also, you've got new products launching, you've got recovery, a variety of other things. Help us understand a little more clearly the -- again, the cadence and how we should be thinking about gross margins in '24 and put that in perspective relative to the, as always, seasonally slow fourth quarter performance given the mix of business, typically.
Yes, absolutely. So the fourth quarter of 2023 gross margin at 71%, obviously lower than the third quarter, which is always our highest revenue and highest gross margin quarter. The 71% was an improvement year-over-year versus the 68.5% we saw in the fourth quarter previously. And so the gross margin in 2024, I would expect would continue to follow the sales. So it's going to be highest in the third quarter, a little lower in the second quarter, come down again in the fourth quarter and a little softer in the first quarter. I think overall, the business was under 75% in 2023, and we would expect to see a similar type of result between 74.5%, 75%. for 2024. The Boston business gross margin is good. If you think about it, it's really 2 businesses in 1. It's a manufacturing business, and so we get the manufacturing margin from their products they manufacture. And it's a retail business in the clinics. So we're getting the retail pricing and the margins associated with that. And so overall, very strong similar gross margins to our overall business. But historically, they've had very little sales commissions, if you will. So the contribution margin from that business is very strong, better than our legacy business and even adding some sales force into that to grow higher revenue. The contribution margin was still very strong in that business, which is very attractive, obviously, to the bottom line for us.
Our next question comes from Ryan Zimmerman with BTIG.
One follow-up. A couple of questions for me. A lot already been asked on the Boston O&P side. Just first, Dave, the last few weeks of December, any quantification there to think about and that impact and the flow through potentially the first quarter as a result of some of those cases?
Yes. Good question. So I guess what I would say is that we were really, really doing well throughout the entirety of the quarter, and we saw a kind of a screeching halt in the last 2 weeks. Last 2 weeks are traditionally 2 of the largest weeks for us. These are weeks when kids are out of school. And so it was a pretty steep drop and kind of having all of a sudden, and it did extend into the early part of January. So maybe, Ryan, it's a couple of points probably of total top line revenue growth for us, and it was a bit unfortunate. But not a lot we can do about it. What we did see though in the quarter is this quarter now is that, obviously, after the hospital systems were hit, seems like handling that much better, particularly on the electric surgical side and seen a really nice rebound in Q1. It seems like cases that were scheduled are starting to get put back on and get done. And so I think that's why you hear fairly bullish commentary about the way the hospitals are handling the RSV situation, how rapidly it went up, affected us and came back down here in the first quarter, and things seems to be really normal going forward.
Okay. That's helpful. And then just you're going to build out like more of this OPSB sales force. You already started doing that. When I think about kind of all the heads and FTEs that are dedicated to OrthoPediatrics. I'm just kind of wondering if you could kind of size and scale kind of what that is relative to the existing sales force as your distributors and dedicated sales agents kind of ramp up over the coming years for OPSB.
Sure. Good question. So -- we've already factored some of those heads in. Obviously, we started some of the hiring here in Q4 and early in Q1. So just to be clear, the expense associated with that is captured in our guide for the $8 million to $9 million in EBITDA. I think orders of magnitude you might expect over the year for us to add or have maybe 20 people or so in the U.S. that are focusing more heavily or exclusively on the OPSB side of the business. Obviously, that's up from 0 this time last year. So we -- that's why we're pretty bullish about that sales force's capacity to help us drive revenue with the MDO products and Rhino and Ora and all the -- DF2, all the things that we've come out within the last year. But if you remember, these people aren't spending time standing in the operating room, right? And so it doesn't take as many people to cover the geographies that we want to cover. We also have, obviously, really strong relationships with our surgeons in the operating room. And when you partner with these OPSB sales force with our existing sales force and our existing sales force so far has been really great about receiving these people in and working as a team. We just think the combination of the great people we have in the field already in the 200-plus strong OR-based sales reps that we have, combined with 20 or so of these more clinical-based sales reps, it's a real tonic for us to grow. And Ryan, over the course of the next several years, we'll see maybe that sales force grows out larger, but we're not committing to that at this point.
Yes. Okay. Just real quick, one quick modeling question for Fred. You already gave the split between scolio and deformity correction on the Boston O&P business. And it's all U.S. based, though, right? Fred. I mean, is there any international revenue there just from a modeling perspective, I want to make sure we take care of that correctly?
Yes. Sorry, great question. We haven't clarified that. It is 100% domestic as of today, but that in '25, '26, '27 may be an opportunity for us to enhance the growth of that business as well.
Our next question comes from Mike Matson with Needham and Company.
This is Joseph, on for Mike. So you guys have a lot of growth prospects moving forward. International expansion, Pega, eX-Fix ramping, new product launches. But I guess the comments today, it seems like OrthoPediatrics has shifted its strategy to favoring maybe growth and profitability -- or profitability over growth. So I guess maybe could you just give you a little bit more color, a little bit more of your thoughts on maybe the shift in the strategy and why that's good moving forward?
Yes, Joseph, I don't think I would characterize our strategy as a focus of profit over growth. We're heads down focusing on growth, but also recognizing that balancing growth with profitability with the aspiration to get to cash flow breakeven is probably a more prudent or rational course, particularly in the current financial environment. And so this is not a new -- I guess, I don't view this as a new thing for us. Just over the last 3 years has been our aspiration to continue to focus more heavily on top line revenue growth, and I think that was one of the reasons why we were excited about the OPSB side and all the product launches going on in the legacy side and all the steps that we've deployed over the last 2 years, we think all of those are going to generate really nice growth for the business for the next several years, but we also think that the growth is going to come -- be more profitable growth, and the cash usage associated with that is going to be lower, which is kind of what we've been trying to get to over the course of the last 3 years, and I think we're well positioned to do it. So we still see this as an aggressive top line growth strategy. There's no question about that. We just think that it's a bit unique and that this is an aggressive top line growth strategy that's also going to be profitable and generate its own cash. And I think that's pretty unique right now in the marketplace.
Okay. Yes, that's super helpful. Maybe just touch on that a little bit more. We estimate your organic growth to be in the mid-teens or so for the last 2 years. But do you think you can maybe get back to the 20% plus number? Or do you think mid-teens is more of a realistic expectation for organic growth moving forward?
Yes. So obviously, the guide implies mid-teens. And I think, we -- everything we're doing here internally and the setup, particularly on the OPSB and the legacy product launch is pointing us towards driving top line revenue growth in excess of mid-teens. But I think as we model, as we guide, we're not going to get ahead of ourselves here. And so that's what you see in the guide. But you can rest assured that our team is aligned around a growth rate that's in excess of 20%. And obviously, with the acquisition, it's in excess of 30 for 2024. So we're putting the drivers in place.
And I think, again, on the OPSB side, we're trying to put a driver in place that we have really low share, really good competitive opportunities here and a really big TAM for us. And we see that as a catalyst to hopefully get to where we're achieving higher in the upper teens or maybe reaching back over the 20s. And that's a real feat when you're a business that's much larger now and in the future than we have been when we were consistently growing 20%, 22%. It's our aspiration to continue to do that, but we're just not going to guide to that at this stage.
Our next question comes from Dave Turkaly with Citizens JMP.
Dave, I think when you announced the [BOP] deal, it said $22 million upfront. I was just curious if you might comment on any milestones or sales-related targets. Is that the all-in price? Or is there additional payments to come?
That is the all-in price. There are no contingent additional payments.
It's [Indiscernible] pretty good deal on the sales [Indiscernible], thanks for all the detail on the business. To follow up on -- I think it was Ryan's question about the scolio business, the RSV, the impact maybe being a couple of points, when you look at the lower sales to stocking distributors in South America, maybe the lower-than-expected orders in Latin and South America. I mean, is that another point? Or is that -- I guess I'm trying to quantify, you grew 20% in scolio and you had kind of 3 things you called out, I don't know, maybe it's even more than a couple of points.
Yes. Certainly, the situation that we've had in the last few quarters in Latin America, while fairly unexpected. This one had a pretty big impact. It was a pretty big headwind on the scolio growth overall and on the company's growth overall. And it was disappointing to see, but I think at this stage, we feel good about that being behind us and being able to diversify our scoliosis business now that we're in markets like Canada and the rest of Europe, again, that's a small segment right now, but it's going to grow and it's going to be all pure growth for us in 2024 because it essentially grows off a 0 base. So yes, I think that's behind us. I don't know. We would call it a couple of points. Yes, we haven't really quantified it. But we don't expect it to continue and have a pretty good line of sight into that. As we head into this -- as we're in 2024, we expect that to be a tailwind for our business, not a headwind.
And just one last one, if I could. The [OPSB], you mentioned gross margin. I think you said the profile was pretty similar, but operating margin-wise, I'm just curious, if that's higher than sort of where you stand today, I know the EBITDA guide of 8% to 9% was higher than the Street 7. I'm thinking 7 that's coming from that acquisition. But any comment sort of on the bottom line contribution as that scales.
Yes, absolutely. So very similar to MDO when we bought it, this business, Boston is profitable. It's positive adjusted EBITDA, it's positive net income, positive cash flow. And, however, historically hadn't been growing tremendously fast. And so we will be investing a little bit of money into that business, obviously, the sales force. But yes, you are correct in assuming that, that business is more profitable than our overall business was in 2023. That is correct. And we would expect that to continue going forward.
Our next question comes from Samuel Brodovsky with Truist Securities.
I'll just ask one more on Boston to start off. I think you'd mentioned a $1 million to $3 million revenue number per clinic and 26 clinics that implies a pretty nice opportunity to ramp revenue there or without adding new clinics. Is that something we should think about being able to be achieved quickly sort of after the integration is completed? Or is that going to be a steady ramp over time as new products come in?
Yes, it's a good question. So it definitely is an opportunity for us to drive the efficiency of the existing clinics and the kind of flow of patients through the existing clinics as well as the products used at the existing clinics with the added sales channel. It's not something we've modeled aggressively yet because it's so new. But I do think you're right, it's probably an opportunity there. And part of the reason that, that is such is that these clinics are primarily surrounded around Boston, around Philadelphia, kind of upper Northeast, which are major population centers as well as major hospitals that are using Boston's products. And so it takes a few maybe more clinics in those areas where patients are coming from a longer distance because of their catchment. And so maybe some of those clients are doing a little less than they would if there were fewer. It isn't our intent to consolidate, but it is our intent to drive more volume through the existing. So that is a possibility. But I also think you've got this right, though. And when you think about our capacity over the course of the next several years, our intent is to scale this to every major children's hospital jurisdiction in the United States and then some internationally. And when you start thinking about those 26 clinics, we think they're serving, give or take, 15 children's hospitals right now. I mean, when you think about the math there, is a really big opportunity for us to scale this into the other 285 children's hospitals that aren't active users or don't have active Boston clinics in their area. So yes, that's obviously why we're -- one of the reasons why we think we should be pretty excited about the opportunity here.
Great. And then just switching to guidance. Can you just remind us what's factored in, in terms of sort of respiratory illness season as I know, I think coming into '23, you factored in a pretty worst-case scenario. Is that how we should be thinking about it this year? And then just philosophically, it's a pretty tight range, especially given the acquisition coming into revenue. Just how do you settle out of the range? And how should we think about the high and low end?
Yes. So similar to last year, 2024 guidance assumes that we will see a similar RSV environment in the fourth quarter of 2024 that we saw in 2023. So we're not assuming that it goes away, we're not assuming it's worse. And as far as the guidance goes, it's a tight range. We have a pretty good line of sight on the core business as well as Boston coming into this, and it is kind of what it is, I guess. So I don't have any philosophy on why it's as tight as it is, but we're pretty confident in those numbers.
There are no further questions. I'd like to turn the call back over to David Bailey for any closing remarks.
Thanks, operator. Well, I appreciate you all joining us today on the call. Today's call a little bit longer. Just wanting to make sure that we can fully explain the Boston acquisition and the opportunity we have on OPSB combined with everything else that's going on. So thanks for your time today, and we look forward to seeing you all at meetings in the next several months. Have a great day.
Thank you for your participation. This does conclude the program. You may now disconnect. Good day.