SI-BONE Inc
NASDAQ:SIBN
Earnings Call Analysis
Q4-2023 Analysis
SI-BONE Inc
In a recent financial summary, the company reported a worldwide revenue of $38.9 million for their fourth quarter, marking a noteworthy 22% growth, while remarkably, the full year 2023 revenue surged by 31% to $138.9 million. The increase was driven predominantly by an increase in procedure volumes, especially in the U.S., where revenue climbed by approximately 32% to $130.6 million. The international revenue also ascended to $8.3 million, representing an 8% growth. Looking ahead, the company is steering towards an even brighter horizon, setting their revenue expectations for 2024 at $162 million to $165 million, suggesting a year-over-year growth of about 17% to 19%.
The business reported a healthy gross margin of 74% for the quarter and 79% for the full year. However, this includes a 4 percentage point impact from a $1.7 million excess inventory reserve related to one of their implant designs. Despite this, the company managed to maintain a high margin, which reflects the strength and efficiency of their operations. The adjusted EBITDA reflected a significant improvement with the full-year figure improving by approximately 48%. Going forward, they anticipate a gross margin around 78% for 2024 and expect operating expenses to grow by approximately 9%, signaling diligent cost management while investing in growth.
The company has been a pioneer in its space, innovating with products such as the iFuse 3D and TORQ. A recent focus on a broad product portfolio and an associated training regime led to significant advances. The newly launched iFuse INTRA and other anticipated product releases, like a noteworthy allograft product and dedication to the trauma segment, are set to expand their market reach significantly. The potential market for these new applications, as explained by the company, targets over 280,000 patients annually, which opens up substantial opportunities for market dominance and revenue growth.
The company has artfully balanced the ambition of growth with strategic steps towards achieving EBITDA breakeven. The guidance for operating expenses reflects this careful approach, absorbing standard merit increases and higher commissions due to revenue growth, with the anticipation of adding more territories. Investments will continue to be geared towards training, new products, and research and development, ensuring the company does not just chase top-line growth but also aims for an improved bottom line. The talks during the call highlighted a confidence in maintaining operating leverage and achieving significant adjusted EBITDA improvement, putting the goal of breakeven well within reach potentially by the end of 2024 or into 2025.
The company underscored an expected impact of product rollout timings on seasonal performance in 2024, similar to what was experienced in 2023. Nonetheless, they provided a modeling proxy, suggesting Q1 2024 to be about 67% lower than Q4 2023, while still remaining optimistic about execution improvements. New launches are slated in the short construct and pediatric deformity markets, targeting 100,000 and 10,000 procedures per year respectively. These efforts, combined with anticipated clearance for TORQ in EMEA by early 2025, are all strategic moves to capture market segments and boost international revenue, aligning with the company's long-term vision of scaling their operations to a $200 million revenue capability.
With the culmination of the call, it's clear that the company has laid out a detailed and robust plan for growth, underpinned by a strong product lineup and strategic market expansion. The financial fortitude exhibited through various indicators, such as gross margins and streamlined operating expenses, coupled with forward-looking revenue guidance, positions the company on a promising trajectory towards not only seizing market opportunity but also advancing towards a sustainable and profitable future.
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Good afternoon, and welcome to SI-BONE's Fourth Quarter 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 Saqib Iqbal, Senior Director of Investor Relations at SI-BONE for a few introductory comments.
Thank you for participating in today's call. Joining me are Laura Francis, Chief Executive Officer; and Anshul Maheshwari, Chief Financial Officer. Earlier today, SI-BONE released financial results for the quarter ended December 31, 2023. A copy of the press release is available on the company's website. Before we begin, I'd like to remind you that management will make statements during this call that include forward-looking statements within the meaning of federal securities laws, which are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995.
Any statements contained in this call that relate to expectations or predictions of future events, results or performance are forward-looking statements. These forward-looking statements are based on the company's current expectations and inherently involve risks and uncertainties. These risks include SI-BONE's ability to introduce and commercialize new products and indications, SI-BONE's ability to maintain favorable reimbursement for its products and procedures, the impact of potential economic weakness on the ability and desire of patients to undergo elective procedures, SI-BONE's ability to manage risks to supply chain, the impact of future capital requirements driven by new product introductions and risks to the continued renormalization of the health care operating environment.
Other forward-looking statements include our examination of operating trends and our future financial expectations, such as expectations for physician training and adoption, active physicians, new products and clinical trial enrollment and are based upon our current estimates and various assumptions. These statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements.
During this call, management may discuss certain non-GAAP measures, including the company's adjusted EBITDA results. For a reconciliation of these non-GAAP measures to GAAP accounting, please see the company's full earnings release issued earlier today. Accordingly, you should not place undue reliance on these statements.
For a list and description of the risks and uncertainties associated with our business, please refer to the Risk Factors section of our most recent Form 10-K and Form 10-Q filed with the Securities and Exchange Commission. SI-BONE disclaims any intention or obligation, except as required by law, to update or revise any financial projections or forward-looking statements, whether because of new information, future events or otherwise. This conference call contains time-sensitive information and is accurate only as of the live broadcast today, February 26, 2024. With that, I'll turn the call over to Laura.
Thanks, Saqib. Good afternoon, and thank you for joining us. 2023 was a stellar year for SI-BONE, our physician customers and their patients as we delivered record worldwide revenue and attained new heights in physician engagement. For the full year 2023, we generated worldwide revenue of $138.9 million, reflecting 31% growth compared to the full year 2022. This worldwide performance was led by robust U.S. demand as over 1,600 U.S. physicians performed more than 15,000 procedures.
We started 2023 with an initial revenue expectation of $124 million to $127 million. With the strong demand for our highly differentiated solutions, growing physician engagement and increases in our surgical capacity allowed us to significantly exceed that expectation. The momentum in the business was clearly evident at our national sales meeting in February. Our sales organization was not only enthusiastic about our performance in 2023 but was even more energized by the potential opportunity ahead of us in 2024.
Having been at the company for almost 9 years, I can say the mood in the company and the confidence in our future has never been stronger. Our foresight and discipline over the last few years in building scalable operating infrastructure in methodical fashion drove approximately 48% improvement in adjusted EBITDA in fiscal year 2023. We also reduced our cash usage while continuing to invest in R&D and clinical evidence to support the planned portfolio expansion in 2024.
Before I provide an update on our strategic priorities, I'd like to recognize our team. Working together to deliver 25% cumulative annual U.S. procedure volume growth since 2018, our first year as a public company, is a testament to your hard work. We transformed into a multiproduct company that is solving unmet clinical needs across multiple procedures. We're just getting started given the nearly 0.5 million target sacropelvic procedures per year. Your focus on delivering for our customers is allowing us to capture this large market opportunity and deliver strong and sustainable revenue growth.
Now let me provide an update on our key initiatives as we look to extend our leadership position and drive strong long-term growth. Starting with sales infrastructure. We're extremely proud of our sales and commercial team known for their industry-leading expertise and extensive experience across our target markets. Their execution has allowed us to build new markets and deliver several quarters of record revenue. We ended the year with 82 quota-carrying U.S. territory managers. We complement our territory manager bandwidth with clinical support specialists as well as a growing network of third-party sales agents for case coverage.
This hybrid strategy has worked well as we continue to see growth in revenue per territory. In 2023, revenue per territory was $1.6 million, reflecting 39% growth compared to the prior year. We're confident in our ability to further increase revenue per territory and get closer to the high end of our $1.5 million to $2 million target over time. In addition to growing territory productivity, we plan to selectively add to our 82 territories over the next few years. The expanded territory footprint will enable us to maximize the potential of our growing portfolio and facilitate deeper engagement with our physicians to capture the over $3 billion total addressable market opportunity.
Moving on to physician engagement. We exited the fourth quarter with nearly 1,130 active physicians, an increase of over 200 active physicians in the quarter compared to the prior year period. The 22% growth in U.S. active positions over the fourth quarter of 2022 was the 12th consecutive quarter of double-digit year-over-year growth. This elevated level of physician interest and engagement is a great forward-looking indicator and underscores the long-term growth trajectory of our business.
Patients suffering from SI joint dysfunction can undergo different types of care, ranging from nonsurgical pain management for short-term relief; interventional procedures, which can provide medium-term relief; and surgical procedures that provide long-term durable pain relief. Over the last few years, we've seen an increase in interest in SI joint stabilization procedures from interventionalists, particularly for cortical bone allograft.
Given that the SI joint fusion market is less than 10% penetrated today and the interventional spine physicians growing interest in the space, we've expanded our engagement with this specialty. We believe the partnership with our surgeons as well as interventional spine physicians, which include anesthesiologists, physical medicine and rehabilitation specialists and interventional radiologists, will accelerate our ability to capture this market opportunity.
Over the last 15 months, we've been targeting a subset of the estimated 4,500 interventionalists in the U.S. who have prior experience with other minimally invasive spine procedures. We've engaged and trained highly skilled interventionalists in our lateral technique using iFuse-TORQ. While still early, we're encouraged by the level of interest, the caliber of interventionalists we have trained and their pace of adoption.
Clinical evidence has always been an important part of SI-BONE'S commitment to its patients and physicians. In June 2023, we also initiated the STACI study, which is a prospective study on the use of iFuse-TORQ in patients with sacroiliac joint dysfunction by interventionalists. The enrollment is ongoing, and we expect to publish early results by the end of 2024. As the market leader, we believe that our broad product portfolio, training expertise, clinical evidence and experienced sales force are clear differentiators that are leading to strong interventional engagement.
Going forward, we expect active physician growth to remain strong as we engage the nearly 8,000 target surgeons and 4,500 target interventionalists. We also expect our growing product portfolio and publish clinical evidence to drive deeper engagement and increase procedure per physician over time.
Turning to Products and Solutions. We have a demonstrated track record of building innovative products and surgical techniques to address unmet clinical needs and improve patient outcome. The robust procedure volume growth we've experienced in the U.S. substantiates the value of our innovation. In 2024, we're launching new products in each of our target markets to further extend our leadership position.
Within SI joint dysfunction in degeneration, iFuse 3D and iFuse-TORQ provide the physicians with the most comprehensive solutions for minimally invasive SI joint fusion procedures reimbursed under CPT code 27279. Effective January 1, 2024, the AMA adopted a separate CPT code 27278 to describe minimally invasive sacroiliac procedure 1 performed using an intra-articular implant, typically a cortical bone allograft placed directly in a joint from a posterior approach.
As I shared earlier, this technique is more commonly used by interventional spine physician. With the new CPT code 27278 established for both facility and office-based procedure and with coverage likely available from some payers, we expanded our interventionalist training to also include our new allograft product, iFuse INTRA. iFuse INTRA builds on iFuse Bone, which was launched in 2019 with enhanced surgical techniques that enable accurate placement of the implant into the joint using a posterior approach.
We recently completed the first iFuse INTRA procedure in an office-based lab setting. With iFuse-TORQ and iFuse INTRA, we now offer interventionalists multiple products to address their treatment references. Moving to pelvic fixation. Based on the strong adoption demand and growing surgeon interest, we believe our breakthrough device iFuse Bedrock Granite can become the standard of care for fixation infusion of the SI joint, providing a strong foundation at the base of long construct adult deformity procedures.
A recent publication with early SILVIA results highlighted the prevalence of SI joint pain in 16% of the patients undergoing spinal deformity surgery, further underscoring the need for inclusion of pelvic fixation infusion as part of these procedures. On the Granite line extension at the end of January, we received 510(k) clearance from the FDA for the 9.5-millimeter diameter implant with S1 and pediatric deformity indication.
Since Granite was launched in 2022, approximately 40% of our Granite case volume has been in shorter 2 to 4 level constructs, which are generally degenerative spine fusion procedures. Based on published data, postoperative SI joint incidents in shorter level surgeries is estimated to be up to 20%. Additionally, some patients undergoing shorter level lumbar fusion procedures are at a higher risk of revision due to screw loosening and other hardware failure from underlying conditions such as high pelvic incidents, osteoporotic bone or high BMI.
The current adoption of the larger diameter Granite in these shorter level fusion procedures illustrates the increasing interest among the surgeon community and including pelvic fixation in high-risk patients. We believe the availability of the smaller diameter implant will provide an offering for the approximately 100,000 annual degenerative spine procedures that end at the sacrum as well as engage deformity surgeons who have expressed a preference for a smaller diameter implant. We plan to launch the smaller diameter Granite implant in the second quarter.
In trauma surgery, we've made significant progress over the last 12 months to develop the market for treating sacral insufficiency fractures. We're engaged with major trauma center thought leaders are encouraged by the pace of iFuse-TORQ adoption for treating these patients. Toward the end of 2024, we will launch another product targeting the pelvic trauma market. We believe the new product, combined with the initial results from a SAFFRON trial in late 2024, will be key to capturing the trauma opportunity.
With over 120,000 sacral insufficiency fractures a year and 1-year mortality rate of up to 25% for the patients who are treated with Bedrock, the trauma market will be a crucial long-term growth driver for us. With that, I'll hand the call over to Anshul to discuss our financial performance.
Thanks, Laura. Good afternoon, everyone. My comments today will be focused on fourth quarter and fiscal year revenue growth, gross margin, productivity and liquidity. Additionally, all the comparisons provided will be versus the same period in the prior year unless noted otherwise.
Starting with revenue growth. Our fourth quarter worldwide revenue was $38.9 million, representing growth of approximately 22%. U.S. revenue was $36.7 million, representing approximately 22% growth, predominantly from increase in procedure volume. International revenue in the fourth quarter was $2.2 million, representing approximately 12% growth. For the full year 2023, we generated worldwide revenue of $138.9 million, reflecting 31% growth. Our U.S. revenue grew approximately 32% to $130.6 million. U.S. revenue growth was driven by approximately 32% increase in procedure volume growth. International revenue for the full year 2023 was $8.3 million, representing 8% growth.
Moving to gross margin and productivity. Our gross margin for the fourth quarter and the full year 2023 was approximately 74% and 79%, respectively. The fourth quarter gross margin includes an approximate 4 percentage point impact from a $1.7 million excess inventory reserve. To provide some context, when we launched iFuse-TORQ in 2021, we introduced 2 designs, a fully threaded and a partially threaded lag implant to meet physician preference. We are seeing physicians prefer the fully threaded iFuse-TORQ across all our target markets, and in fact, demand for this implant type has exceeded our expectations. Accordingly, the reserve is related to our lag implant.
Operating expenses were $41.2 million in the quarter, representing approximately 8% growth. For the full year 2023, operating expenses increased approximately 4% to $156.4 million. The increase was driven by increase in compensation, higher commission related to revenue growth and research and development investments. Our net loss was $11 million or $0.27 per diluted share for the fourth quarter of 2023 as compared to a net loss of $11.2 million or $0.32 per diluted share in the prior year period.
For the full year 2023, net loss improved by approximately 29% to $43.3 million or $1.13 per diluted share as compared to a net loss of $61.3 million or $1.79 per diluted share in 2022. Net loss per diluted share, fourth quarter 2023 and full year 2023 includes the impact of increase in shares outstanding because of the follow-on stock offering in May 2023. Our adjusted EBITDA loss in the fourth quarter was $4.8 million compared to $4.2 million in the comparable period. Adjusted EBITDA loss in 2023 was $17.3 million compared to $33.2 million in 2022, reflecting approximately 48% improvement. Adjusted EBITDA for fourth quarter 2023 and full year 2023 was negatively impacted by the $1.7 million inventory reserve highlighted earlier.
Turning to liquidity. We exited 2023 with a strong balance sheet, including $166 million in cash and marketable securities. Our total cash usage in the fourth quarter was less than $800,000. Our strong liquidity position, combined with our continued progress towards adjusted EBITDA breakeven, provides us the flexibility to self-fund our long-term growth priorities.
Finally, moving to our outlook for 2024. As Laura noted, we have several tailwinds and growth initiatives coming into 2024. We expect 2024 worldwide revenue of $162 million to $165 million, implying year-over-year growth of approximately 17% to 19%. Our guidance assumes low to mid-single-digit ASP deterioration driven by site of service and procedure mix, moderate impact from new product launches accounting for timing of launch and pace of adoption and modest international revenue growth.
We expect 2024 annual gross margin to be approximately 78%. Based on current revenue guidance, planned product launches as well as commercial footprint expansion, we expect 2024 annual operating expenses to grow approximately 9%. Considering the anticipated operating leverage in the business, we expect significant year-over-year adjusted EBITDA improvement for full year 2024 putting us within reach of our adjusted EBITDA breakeven goal. With that, I will turn the call over to Laura.
Thanks, Anshul. I hope you can feel our excitement and confidence built on consistent innovation and execution coming into 2024. We believe the procedure demand will strengthen in 2024 as we roll out complementary products in each of our target markets. With a strong balance sheet, I believe we're uniquely positioned to deliver sustainable growth over the long term and have a clear line of sight to adjusted EBITDA breakeven.
With that, we're happy to take questions. Operator?
[Operator Instructions] Our first question comes from Craig Bijou with Bank of America.
Congrats on a good finish to the year. I wanted to start with kind of what you're seeing in the SI joint fusion market? And with respect to the new allograft product, so does the recent focus on allograft by pain docs, is that adding to SI joint fusion procedures? Or are they potentially taking away from the traditional implant market? And then maybe if you could just give us a little bit of more color on the strategy behind allograft and what you expect contribution either on a procedure basis or from a revenue perspective?
Craig, thanks for the question. And what I first want to do is just kind of [indiscernible] milestone year for us hitting new highs on revenue growing 31% worldwide, surgeon engagement growing to over 1,100, surgeons territory productivity growing almost 40% there and then the operating leverage, 48% improvement in our adjusted EBITDA. So what we're doing is we're coming into the [indiscernible] line and the bottom line.
And so what we're excited about as well is the opportunities that we have in 2024. So building on the momentum that we had in 2023 and [indiscernible] building out the [indiscernible] SI joint capitalizing on the launch of Granite 9 5 in order to capture more of the opportunities [indiscernible] with a new introduction of a product toward the end of the year that's targeting sacral insufficiency fracture.
And so when I talk a little bit about the primary SI joint fusion market, we're the undisputed leader in that market space, and we were the original pioneer that's here. And when you think about the patient journey and patients [indiscernible] joint what you're seeing is there is what I would call a continuum of care. And so they start out with medication, physical therapy, injections. And -- but there's also this interest in what I would call the next level or -- and continuum of care, which are these post [indiscernible] infusion procedures and those are typically performed by interventional spine specialists and they are done with cortical bone allografts.
And then you have the traditional lateral procedure that we have pioneered with our iFuse 3D product and then more recently with our TORQ product. And so as I mentioned in my [indiscernible] 15 months now, our STACI study was working directly with those interventionalists and they were actually trained on a lateral procedure with TORQ and we've seen good progress with that particular study.
Now at the beginning of the year, we actually launched a new allograft product called iFuse INTRA. And we think that it acts [indiscernible] somewhere in between where they're receiving injections and where they're potentially receiving a lateral procedure at the end of their journey. So what we did is as the market leader, we want to provide a broad product portfolio. And then what we do on top of it is use our training expertise, our clinical evidence and then our experience [indiscernible] to lead to strong interventional engagement.
So we believe we've targeted -- we've taken a targeted approach and it's really allowed us to thoughtfully leverage our experienced sales force to train the specialty and that it's an augment to our current strategy to reach more than the 280,000 target patients per year.
Great. And maybe for Anshul, you guys obviously saw a tremendous operating leverage in 2023. You're forecasting more operating leverage in '24, but not to the same extent. So they may just be conservative to start the year. But can you just talk about the guide and how you're balancing driving that top line growth and still working towards EBITDA breakeven? And I'm going to throw this in, could we see EBITDA breakeven come in 2025?
Craig, thank you for that question. Any case, if it's difficult to hear because of static, please let me know. So we are really proud of the operating leverage that we've demonstrated over the last couple of years as we benefited from the investments in the scalable infrastructure we've built throughout the pandemic. When we look at 2024 and [indiscernible] outpaces OpEx growth rate and and you can see that at the midpoint of our guidance range and the OpEx growth rate expectation of 9%, that's about 2x operating leverage.
Now we do have a huge opportunity ahead of us. So we want to make sure we're making thoughtful investments to capture the growth opportunities. Laura talked about several of those coming into 2024. And we think that investment will allow us to maintain that to [indiscernible] to accelerate our journey towards adjusted EBITDA breakeven. So when you think about our guide at 9%, what does that incorporate? You've got the standard merit increase that you build in. You've got the higher commissions and our strategy to add more territories, especially as we've expanded our portfolio coming into 2024. So we're going to add some more territories there.
You've got some more sales and marketing spend when it comes to the new products that we're going to launch [indiscernible] a lot of activity there, including training with the interventional side. And then just R&D, as we think about the portfolio into the future as well. But again, we feel really good about being able to continue to get the leverage and stay committed to it. Now in terms of timing, right, we're pretty confident that the operating leverage will translate into significant adjusted EBITDA improvement as we [indiscernible] a strong fourth quarter of '24.
Our approach to when we get to breakeven is just get there versus sort of project when that timing will be. But we're really happy with the progress that we're making, and we have a clear line of sight to that milestone.
our next question comes from Drew Ranieri, Morgan Stanley.
Maybe just to follow up on one Craig's questions about the allograft product that you're launching. Just to be absolutely clear, I just want to make sure that we're understanding this that you're not seeing really a significant change in underlying market dynamics from these products taking basically the surgery -- procedures away from surgeons? Just want to get a better read on that of like kind of what you're seeing on the underlying market.
And then Anshul, you did talk about some investments you're putting behind the iFuse INTRA product. So maybe just help us parse out like how much is actually going to be hitting the OpEx? How much are you spending there to really kind of start this journey with this new specialty?
[indiscernible] we're excited about the opportunity with interventional. If you think about our journey, we've been in business for 15 years at this point. We pioneered minimally invasive SI joint fusion. We've really built this market. We are the market leader in the space. And yet we're less than 10% penetrated into the market right now. And so what we see is an opportunity [indiscernible] our primary call point has always been spine surgeons, but we do think that we can reach more of these patients by working with interventionalists as well as spine surgeons and having multiple products that will meet their specific needs.
In addition, there was [indiscernible] my prepared remarks, 27278, which is specifically for these posterior procedures, typically allograft procedures, the physician fee is around 40% less than what it is for a lateral [indiscernible] done with our iFuse 3D or TORQ product. And then [indiscernible] are around 20% less. But with that said, once again, what it does is it gives us the opportunity in order to reach more of these patients and further build out the market.
So if you look at our performance in 2023, we had a great year, and that performance was driven by our core market in primary SI joint fusion as well in adjacent markets. So pelvic fixation, primarily as well as trauma which is developing. But -- so what we see is this opportunity to more rapidly capture this market opportunity that we've been pursuing for all of these years. And we're really excited to do it with both spine surgeons and interventionalists and it provides a unique [indiscernible]
Andrew, to your question on the OpEx side, majority of our OpEx increase is just the commissions, the pay increases that come standard as well as some territory expansions that we had always contemplated as we think about a model where we can do 2 million per territory. We've always said in the U.S. We won't [indiscernible] territories to have a business that can do $200 million of revenue.
We ended the year [indiscernible] do that. You're going to have some more training spend as well, but that's across the board between interventional and surgeons, especially with the degen opportunity with the 9 5 Granite as well. So I wouldn't say that there is any material shift in our OpEx strategy because of interventional. We've just got the opportunities that we've always wanted to go after.
Got it. And maybe just overall on some of the newer product launches, including INTRA, the small construct and the trauma product coming, you laid out you kind of expect another robust year of active surgeon ads. Can you be a little bit more specific there? And just how are you thinking about maybe the utilization -- or underlying utilization of active surgeons improving with some of these newer products?
Thank you. So we used to do both growing the number of physicians that we're working with as well as increasing the number of procedures per physician as well. So talking about interventional, by and large, those will be new physicians that are performing the procedure. So it gives us this opportunity. And as I said, there's around 4,500 interventionalists that are targets to [indiscernible]
In terms of increasing the number of procedures, we have always focused on increasing the number of primary SI joint fusion procedures that our surgeons are performing. And then with the addition of TORQ and with Granite, it gave us the opportunity to further increase those numbers, either in our primary market or in [indiscernible] Our Granite 9 5 product does is it gives us a product that's very specifically targeted toward these degenerative spine procedures. And the market opportunity there is around 100,000 procedures per year.
There will be short construct procedures that go to the SAFFRON. And so that's our bread and butter surgeon that [indiscernible] SI joint fusion, and now they have the opportunity to perform pelvic fixation with our new Granite product. So a great opportunity to deepen our relationship with our surgeons and increase the number of procedures that they're performing with us. [indiscernible] orderly annually.
Our next question comes from David Saxon with Needham & Company.
Congrats to a strong end to the year. Maybe I wanted to talk about TORQ to begin with. Laura, in your script, you talked a little bit about STACI. But I think another TORQ study is SAFFRON. And I think it's narrowing enrollment. So how should we think about SAFFRON as it relates to the market development for TORQ? Does that -- can that trial capitalize TORQ adoption? Or will it kind of continue to be more of a gradual ramp?
Thanks for the question, David. So on TORQ, you're right. The STACI study was actually specifically engaging interventional spine [indiscernible] implant. And as I said, that's going well. SAFFRON is actually a study that is engaging surgeons performing sacral insufficiency fractures. And so this is pelvic groin fractures. It's what we call our trauma product. And I do see a pretty significant opportunity there for us [indiscernible] in terms of is to have a publication that shows the results from SAFFRON by the end of 2024.
We're encouraged by what we're seeing currently with that. And then in terms of also what we're seeing on trauma, as I said, towards the end of the year, we expect to launch another product this year. And so I think given that these patients that have sacral insufficiency fractures, they're around [indiscernible] patients per year in the United States. They typically are treated in rehab their conservative care. They're typically not treated surgically. There's a big opportunity that's here for us. We do think the clinical data is going to be really important because of the fact that surgeons typically don't treat these patients.
We want to show the efficacy of [Indiscernible] sacrum will be important there. And then I'm not giving much information about the new products, but this new product will be another important part of targeting that particular market. So really excited about how we're going to finish 2024 in trauma and the opportunity to see that as a significant growth driver in 2025.
Great. That's super helpful, Laura. This one is probably for Anshul. I wanted to ask about the cadence of revenue throughout the year. Is there anything to call out in terms of seasonality? I think consensus is about $37 million for the first quarter, so down kind of mid-single digits sequentially, I think in '23, you were actually up in the first quarter sequentially. So anything they call out from a cadence perspective and any reaction to that first quarter?
Yes, Dave, thank you for that question. So from a seasonality standpoint, for a company in our stage of growth and innovation, we believe our seasonality in 2024 will continue to be impacted by the timing and pace of the rollout of the products. No different than what we saw in 2023 that the seasonality was not comparable to what we've historically seen [indiscernible] perspective, we don't believe the [indiscernible] the right way to look at the business, given the initiatives in 2024.
But from a modeling standpoint, if you're looking at a proxy, the Q1 tends to be about 67% lower than the fourth quarter. So that's a good enough proxy. And then our focus company is that through execution, we can improve on that. But I would say that historical trend of 6% to 7% is a good proxy.
Great. Super helpful...
Versus Q4.
Our next question comes from Sam Brodovsky with Truist Securities.
I guess just first one on the short contract launch. Can you guys just walk us through the puts and takes on that rolling out in 2Q versus the initial long construct launch that we saw with Granite? And how should we be thinking about the impact of that versus the initial rollout?
Yes. Good question, Sam. So I think that you'll see a more rapid roll out here. First of all, we were a little surprised at how quickly we received clear [indiscernible] So we already [indiscernible]
Hello?
You're coming in loud and clear.
And Sam, I'm going to answer your question once again, I'm not sure what you caught and what you didn't. So on the short construct loans, I was saying that we actually were surprised at how quickly the [indiscernible]
[indiscernible] cell phone, I'm sorry, I missed your call, but please leave your name, number and a brief message and I'll call you back later. [Operator Instructions]
[Technical Difficulty]
Hello?
Hello, Anshul. You're coming loud and clear right now.
Okay. Can you pass me?
You are live, loud and clear.
Thank you. Sorry about that. Some technical difficulties. Sam, I'm not sure what you caught on your question on short construct. Would you like me to restate that? Or did you capture most of it?
I think it would be great if you could just run it back for us.
Okay. Great. Great. So a short construct launch, we were actually quite excited about the opportunity that we have with our Granite 9.5 product. The product was actually cleared earlier than we anticipated. Just a great team effort here with our product team as well as our regulatory team. And the clearance, it was a line extension for us. And so we added a couple of different areas to the IFU, first of all, this S1 trajectory, which is really targeting shorter constructs and then also pediatric deformity as well.
And to get us to your question of rollout, this is a little bit different than the original Granite launch, primarily because the instrument trays that are currently in the field that are meeting our demand for our current Granite business, we will use those same instrument trays. So we already have the trays out in the field. The -- our territory managers have been speaking with our surgeons on these topics. We are in these hospitals on the approved list. And so we think that this should be a more rapid rollout. And ultimately, the goal primarily is to go after these 100,000 short construct cases in the U.S.
Great. And I'll just ask one on INTRA as well. Just in terms of pricing relative to iFuse, can you level set us there and how that's factored into the pricing
I'm sorry, what was the question?
Sorry. Just in terms of pricing for the new allograft, can you just level set us like where that is relative to iFuse?
Yes. From a pricing standpoint, what I would say, Sam, is you got to think about it as a construct pricing in terms of what a construct would be for a multi-implant primary SI joint fusion procedure. Our expectation is it should be pretty comparable.
Our next question comes from Caitlin Cronin with Canaccord Genuity.
Congrats on a great quarter. Just touching on the new focus on interventionalists. So you're training them in lateral procedures, so you're training them in 3D and TORQ. And then is the new allograft product employing your posterior approach?
Caitlin, thanks for the question. We're actually training them with our TORQ product for the lateral procedure. And then we are also training on the allograft product, typically not the iFuse 3D triangular shaped implant given the needs of interventionalists.
Got it. And then so is the revenue per procedure, would that be less for an interventionalists versus, say, a surgeon that perform the procedure?
The pricing is similar. So with the last question that we got from Sam that was asking about allograft pricing, but the pricing overall is very similar, whether we're selling to interventional or to spine surgeons.
Okay. Got it. And then just briefly on the OUS business, what are your expectations for this year? And when do you expect clearance for TORQ in EMEA? Has that happened yet?
Yes. So the OUS business, Caitlin, is about 6% of our worldwide revenue in 2023. And when we think about the guide for the year, France has been performing really well for us last year and the recovery in some of the other markets like U.K. and Germany, they will take longer than we had previously anticipated. And what our current guidance for the year at '17 to '19 does assume is a low to mid-single digit year-over-year increase in international revenue. So U.S. revenue will be closer to 18% to 20%.
Now the international market is important for us, and the team has been doing a lot of work around training new physicians, modifying our go-to-market models, which should reap benefits in 2025. And then in terms of TORQ, we are working really hard to get to TORQ into EMEA, which we believe could be a growth driver for the business, but likely to be in early 2025 would you start seeing any impact from that, just given the regulatory process.
[Operator Instructions] Our next question comes from Ross Osborn with Cantor Fitzgerald.
Congrats on the progress. So maybe just one for me. Would you discuss the pediatric deformity market just in terms of size, the current standard of care and where you see brand playing a role?
Sure. So it's small is a short answer to you. I think the target market size is around 10,000 procedures per year, Ross. And so it's not a big area of focus for us. The opportunity in degen spine is 100,000. So it's 10x that size. But we have received inquiries from pediatric deformity surgeons who are interested in pelvic fixation. We wanted to make sure it was an option for them on label and so the new Granite 9.5 does provide that for us.
Thank you. Now I will turn it over to Laura.
Thank you so much for your time. I really apologize for the technical issues. I hope that we've given you all of the answers that you needed. As I said earlier, we're thrilled with the year that we just came off of and really excited about 2024 with all the new opportunities in front of us and building on the momentum that we generated in 2023. So thank you again, and goodbye.
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