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Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Welcome to the First Quarter 2019 Stryker Earnings Call. My name is Jesse and I'll be your operator for today's call. At this time all participants are in a listen-only mode. Following the conference, we will conduct a question-and-answer session. [Operator Instructions] This conference call is being recorded for replay purposes.
Before we begin, I would like to remind you that the discussions during the conference call today will include forward-looking statements factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also the discussions will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release. There is an exhibit to Stryker's current report on Form 8-K filed today with the SEC.
I will now turn the call over to Mr. Kevin Lobo, Chairman and Chief Executive Officer. You may proceed sir.
Welcome to Stryker's first quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO; and Katherine Owen, Vice President of Strategy and Investor Relations.
For today's call, I'll provide opening comments followed by Katherine with updates on Mako and K2M. Glenn will then provide additional details regarding our quarterly results before we open the call to Q&A.
Following an excellent 2018, our Q1 results reflect continued momentum across our three segments, with over 7% organic sales growth. This growth was balanced between U.S. and international at roughly 7% each with particularly robust gains in emerging markets and Europe.
By segment, MedSurg led the way with 9% worldwide organic growth driven by impressive mid-teens organic growth at instruments. Orthopedics grew 5% globally with knees growing 7% behind Mako and hips gaining 4% benefiting from the recent 3D printed acetabular cup launch. NeuroTech and spine had worldwide organic growth of 8% as NeuroTech’s double-digit growth powered by neurovascular was offset by low-single-digit spine growth.
Turning to the P&L, adjusted operating margin improved by 10 basis points despite absorbing significant deal-related dilution. With the strong top-line and continued progress with our cost transformation for growth initiatives, we remain on track to achieve our full year target of 30 to 50 basis points of operating margin expansion. We continue to effectively integrate acquisitions and also make meaningful investments in R&D which ensures a steady cadence of new product introductions such as endoscopy’s recently launched 1688 camera.
Overall driven by the sales growth at the high-end of Medtech, we achieved adjusted per-share earnings of $1.88 up 12%. Looking ahead to the full year, we are confident in sustaining this momentum and in our ability to deliver on our commitments to our customers, employees, and shareholders. This is reflected in our adjusted guidance, which raises the bottom end of both our full year organic sales growth and adjusted EPS ranges. With that I will now turn the call over to Katherine.
Thanks Kevin.
Starting with Mako, we installed a total of 35 robots globally in the quarter with 27 in the U.S. By comparison in the comparable quarter a year ago, we installed a total of 28 robots, of which 24 were in the U.S. Globally our installed base of robots is approaching 700 with over 550 in the U.S. Looking at U.S. procedures, in Q1, Mako total knee procedures exceeded 15,000 increasing over 80% from the prior year quarter while total Mako procedures approximated 24,000. These results indicate we are continuing to build on the momentum we saw in 2018 where total Mako knee procedures for the year topped 45,000.
With a continued healthy order book, we anticipate strong robot sales in 2019 as hospital and surgeon interest in robotic programs for orthopedics continues to increase. We also expect to continue to build on the clinical data that demonstrates the unique benefits of the Mako technology.
Turning to K2M, we are pleased with the continued progress on the integration front. With the organizational structure in place, we are building inventory to help support cross training for our combined selling organization. On a combined constant currency basis, our sales grew 2% in the quarter and we anticipate a continued sequential ramp in sales for the full year, and we are on track to achieve combined spine sales growth in the mid-single digits for 2019. With that, I'll now turn the call over to Glenn.
Thanks Katherine.
Today I will focus my comments on our first quarter financial results and the related drivers. Our detailed financial results have been provided in today's press release.
Our organic sales growth was 7.3% in the quarter. As a reminder, this quarter included the same number of selling days as Q1 2018. Pricing in the quarter was unfavorable 1.4% from the prior quarter, while foreign currency had an unfavorable 2.1% impact on sales. For the quarter, U.S. sales continued to demonstrate strong momentum with organic growth at 7.4% reflecting solid performances across our portfolio. International sales grew 6.9% organically which was balanced across the regions.
Our adjusted quarterly EPS of $1.88 increased 11.9% from the prior year reflecting strong drop through on sales growth combined with good operating expense control and some favorability on our quarterly effective tax rate. Our first quarter EPS included an approximate $0.05 negative impact from exchange rates including translational and transactional. This is versus a $0.02 to $0.04 that we had anticipated at the start of the quarter.
Now, I’ll provide some highlights around our segment performance. Orthopedics delivered constant currency growth of 5.1% and organic growth of 5%. U.S. organic growth of 4.4% is highlighted by knees which grew 6.6% and mid-teen growth of orthopedic capital. This was offset by anticipated decline in bone cement related to the continued growth in cementless and the timing of bulk orders.
Within the knee segment, we continued to see strong demand for our Mako TKA platform, our cementless knee and other 3D printed products. U.S. trauma grew 3% against a tough comparison and was impacted by a delay in the full commercial launch of T2 Alpha, which has been pushed back to midyear.
Internationally, orthopedics delivered organic growth of 6.4% which reflects solid performances in Europe, Australia, and emerging markets with particularly strong growth in China. MedSurg continued to have strong growth across all businesses in the quarter with constant currency growth of 10% and organic gains of 8.9%, which included a 10.6% increase in the U.S.
Instruments had U.S. organic growth of 17.5% led by impressive gains across its power tool and waste management products. Endoscopy delivered U.S. organic growth of 7.5%; endoscopy had strong performances across its NOVADAQ sports medicine, communications, and ProCare businesses.
Late in the quarter, endoscopy launched its new 1688 video platform and began to ship initial units. The medical division had U.S. organic growth of 9.2%, reflecting solid performance in its bed, stretcher, and sage businesses. Internationally, MedSurg had organic growth of 2.7% with strong performance in China and other emerging markets partially offset by softer performance in Japan and Australia.
Neurotechnology and spine had constant currency growth of 23.2% driven by our K2M acquisition and organic growth of 7.8%. This growth reflects good performance within our Neurotech product lines, including high teen growth performance of our neurovascular business.
Our U.S. Neurotech business had organic growth of 8.3% for the quarter highlighted by strong double-digit growth of our neurovascular business offset by expected softness in neuro powered instruments ahead of the planned Sonopet IQ launch. Underlying the overall growth though, we continue to see strong demand for our hemorrhagic, ischemic stroke, and CMF products.
We made significant progress in our integration of K2M especially on the execution of our planned cost synergies. Our sales integration is ongoing and we continue to manage through the anticipated sales force disruption, which primarily impacted our U.S. growth. Internationally, neurotechnology and spine had organic growth of 14.3%. This performance was driven by continued strong demand in Europe, China, and other emerging markets.
Now I will focus on operating highlights in the first quarter. Our adjusted gross margin of 65.8% was unfavorable 50 basis points from the prior year quarter. Compared to the prior year quarter gross margin expansion was favorably impacted by acquisitions, but offset by price and business mix.
R&D spending was 6.2% of sales, our adjusted SG&A was 34.5% of sales which was favorable to the prior quarter by 50 basis points. This reflects the continued focus on operating expense improvements through our cost transformation for growth, CTG program including key projects focused on indirect purchasing and shared services. This is offset by negative impact of acquisitions and continued planned investments in other CTG programs like our ERP project which has been expanded in scope given our acquisition activity.
In summary for the quarter, our adjusted day operating margin was 25.1% of sales which was approximately 10 basis points favorable to the prior year quarter. Our operating margin primarily reflects good leverage and continued operational savings offset by investments in acquisitions, the latter of which had an approximately 50 basis points negative impact on the quarter.
Next, I will provide some highlights some other income and expense. Other expenses decreased from prior quarter primarily due to favorable interest rates and other income. Our first quarter adjusted effective tax rate was 14.4%, which primarily reflects the benefit related to stock compensation expenses. As a reminder, we are still forecasting a full year effective tax rate between 16% and 17%.
Focusing on the balance sheet, we continue to maintain a strong position with $1.8 billion of cash and marketable securities of which 45% was held outside the U.S. Total debt on the balance sheet was $8.5 billion.
Turning to cash flow, our year-to-date cash from operations was approximately $113 million. This reflects the net impact from increased adjusted earnings. Certain acquisition and integration charges related to K2M and the receipt of a legal settlement payment. In January 2019, we repurchased approximately 1.9 million shares for $307 million and now I will discuss our second quarter guidance.
As a reminder Q2 and Q4 have the same number of selling days as 2018. While Q3 has one more selling day. Even our first quarter performance and continued momentum we now expect organic sales growth to be in the range of 6.8% to 7.5% for 2019 a foreign currency exchange rates hold near current levels. We expect net sales in the second quarter will be negatively impacted by approximately 1.5% and the full year will be negatively impacted by approximately 1%.
Net earnings per diluted share will be negatively impacted by $0.01 to $0.03 in the second quarter and negatively impacted by $0.05 to $0.10 in the full year. We also now believe our adjusted net earnings per diluted share will be in the range of 805 to 820 for the full year. For the second quarter we anticipated adjusted net earnings per diluted share to be in the range of $1.90 to $1.95. This guidance full year and second quarter include anticipated impacts from acquisition dilution and the net foreign currency exchange including both translational and transactional impacts.
And now I will open up the call for Q&A.
Thank you. [Operator Instructions] Your first question comes from the line of Bob Hopkins with Bank of America. You may proceed.
Oh, great. Thank you very much for taking the questions. I guess to start out congrats on a really strong quarter. I want you -- two things stuck out to me. One, I wanted to get a little bit better sense for your commentary on Europe and emerging markets. Is that strong Stryker performance, is that strong market, or is that kind of both? Thank you. For the first question.
I would say Bob that it's really our efforts. As you know, we are underpenetrated in these markets versus the competition and we've been upgrading our talent and changed our commercial offense in Europe, and I think it's primarily our efforts and market conditions, and Europe continued to be pretty challenged. But, we had a particularly strong quarter. We did benefit from the comparison in the prior year. If you remember the UK had debt blockages, so we didn't have that comparison this year; and in emerging markets, it's really -- we've been getting our offense rolling. Last year, we had double-digit growth and we had strong double-digit growth this year in emerging markets. I'd say it's more of a Stryker story, but that's really due to our relative position versus others.
Okay. And then for the follow-up, I was just wondering if you could talk about a little bit about the growth drivers over the course of the rest of this year. It sounds like the camera obviously was a little early for that to have any impact, but endo had a good growth rate anyway. And now, the camera should kick in for the rest of the year, but what are the things that we should be thinking about as we consider the rest of the year in terms of growth drivers. Obviously, from my vantage point, there's one big obvious incremental positive but what are the other things that we should be thinking about?
Bob, as you mentioned, 1688, we did just start the commercial launch at the end of the quarter, and similar to prior camera launches, as you know, it's usually a couple of quarters before they really hit their stride. So, I would think about that having a more meaningful contribution to endo in the second half of the year. We also feel really good about the Mako order book, so we expect continued strong demand for the robot and continued strong utilization there. So that will be a driver. If you look across the portfolio, as you know we're a lot of singles and doubles. I think we've got some product launches coming like our next generation Sonopet which will have an impact. And as you get really kind of around mid-year and then trauma was impacted by some delays tied to the full commercial release of T2, and so that's probably going to be in a full commercial release mode around mid-year, so that will have more of an impact on trauma in the second half of the year, so that's just a few of the ones I would highlight.
Great. Thank you.
Your next call comes from the line of David Lewis with Morgan Stanley. Your line is open.
Good afternoon. Just a couple questions for me. I thought Kevin, if we could start just kind of post AOS on the broader ortho market. I think everyone talked about ortho growth in 2018 and maybe the fourth quarter was not as strong as some had hoped. Your numbers first quarter seemed pretty in line, the Mako number was strong. I noticed the Mako procedure number was more flattish sequentially. I want to just sort of talk about your thoughts on Mako procedure sequentially, the orthopedic market volumes sort of first quarter versus expectations, and your outlook for these sort of businesses post AOS.
I will take the Mako part, first, and I think you've got to keep in mind the cadence of procedure volumes when you go from Q4 which is always the strongest quarterly number for recon into Q1. So, we always have fewer volume of procedures in the first quarter and also the Mako placement which was very robust in the fourth quarter don't factor in until we have them out for a full quarter. So, it's just the normal cadence. We had roughly 30% year-over-year growth in the utilization rates. For the robot, we had really healthy procedure growth of around 80% year-over-year. So, I'd focus less on sequential and more year over year unless you're going to adjust for just the variance in sequential patterns. We feel great about what we're seeing with Mako, the order book, the demand for new robots. And so, nothing I'd read into beyond just normal quarterly variance.
And on your second question about the orthopedic market, last year was a slow market in general, and we had indicated that we thought this year would be slightly better, and I would say at this stage of the year, we do believe that the market will be slightly better in '19 than it was in '18.
Okay. Very helpful. And Kevin just, you are focusing on the key upside driver in the quarter obviously was MedSurg, Bob obviously talked about the camera which will start contributing into the back half of the year. But, obviously, in recent weeks there has been a lot of concern about Medicare for All, the impact it would have on capital providers. Can you just spend a moment talk to really two things, how this business has transitioned in the last four to five years from a durability perspective, and as you think about the balance of the year and the ability to deliver strong MedSurg numbers in the order book, how you're feeling about the balance of the year. Thanks so much.
David, I would say there is really no change. If you go back to our analyst meeting that we had back in November, I said I expected 2019 to be every bit as good as 2018, or a very similar year, and at this stage for 2019 that holds. And that's really across our businesses. As you've seen since the beginning of '18, we've got very good balance both across our businesses and across our geographies which is different than the story we had four or five years ago. So, I feel like all our businesses are in healthy position. We have as you know a number of new products that the timing of which vary from business to business, but feel very good about the durability of our sales performance.
Your next call comes from the line of Vijay Kumar with Evercore ISI. You may proceed.
Hey guys. Thanks for taking my question. So maybe I'll start with Mako. Kevin there was some concern in a comparative entry, it looks like numbers are really strong. I'm just curious on how you see the market evolving with a new player. Is this a case where the market is accelerating and both players benefit or are in any thoughts and the competitive landscape but then would be a helpful starting point?
Yes. Thanks for the question. I think first of all keep in mind that penetration rates in our own business are still very low. So, there's a lot of opportunity here for growth in robotics. And so, we believe the competition is going to do what it typically does in most markets, it's going to raise awareness and interest and help to grow the overall space. Now clearly, we're the leader here we've got robots features including haptics and the ability to do multiple joint procedures, so we expect our momentum to continue. We're seeing a ramp up in our customers, hospitals with multiple Mako's as well as new installs into hospitals. So, given where penetration rates are and given the unique features and benefits and mounting clinical data in support of our robot we feel really bullish about the outlook.
And as Katherine said in her opening comments, the order book continues to be strong. So, we expect another strong year for Mako in 2019.
That's helpful. One quick one for Glenn, on the guidance comments here. It looks like FX worsened for you guys, but yet you raised a low end of the guidance. It looks like the underlying operating margin execution is coming in really well despite the increased investments that you spoke about maybe just comment on margins and what gives you the confidence you're just given the amount of deals you guys have done. Thank you.
Yes. First off, I guess I would say on the FX issue, you're right it came in a little bit less favorably than we thought for first quarter. But looking at what happened to rates last year and where we think you know rates strengthen in the second half of last year I think that we'll still stay within our 0% to 10% range for the full year impact it'll just -- the impact will be more pronounced early on in the year and less so in the latter half of the year.
In terms of op margin a couple of things that Katherine just highlighted, first of all, a lot of really robust new product launches that we'll have that mix will come into play later on in the year. I think in Q2 you're still going to feel the impact from K2 as we're still working through sales integration in the second quarter, so we'll still have a little bit of heavy dilution coming in from K2 for Q2. And then, I think what you'll see beyond that is we'll start to see sales expansion on the new products. We'll also see continued improvement in our shared service efforts, continued ramping of our indirect spend efforts and that'll start to offset some of these other things. So I really do still remain very confident in our ability to hit 30 to 50 basis points expansion.
Your next call comes from the line of Richard Newitter with SVB Leerink. You may proceed.
Hi. Thanks for taking the questions. Just wanted to start, sorry if I missed it in the opening comments. But can you characterize just how the K2 integration efforts are going relative to your initial expectations and when do you think we'll see some of the true synergies kind of playing out from that deal.
I would say it's very much tracking as we anticipated. We closed late in the quarter and as I mentioned on the call, we feel really good with the progress, the organizational structures in place, we're building inventory to help support cross-training for the combined selling organization. There's no change to our target of mid-single digit combined growth for the full year. So, everything is going as expected. We expected sales to synergies and higher dilution in the early part as you would assume. And then, we expect to see a continued sequential ramp in revenues as the year unfolds. So, really nothing…
Yes. Kevin just going back to David's question on the underlying ortho and knee market growth rates. It's encouraging to hear that you feel confident that compared to last year a slight step up in market rates. But, I guess my question here is, just want to I appreciate seasonality volumes are a little lighter than what they are in season's 4Q, but you need growth rates, kind of flattish even on a comp adjusted basis. I mean what more can you give that you're seeing in the marketplace that continues to give you confidence that there's that step up and growth for the year. Thanks.
Yes. I just think last year was a bit of an anomaly. It was the lowest growth in the market that we've seen since 2011 and we don't see anything underlying in terms of demand and the hospital dynamics that would cause that to be a situation that would continue. So, I just think you get one of those kind of years every seven or eight years, it's unlikely that that would continue. So, I just think the underlying conditions in the market are good. We can see with Mako that there's huge interest in continuing to advance the robotic offerings in knees in particular. So, it's just one of those, it's a feeling, right. I don't have a crystal ball, but it's just based on what we're seeing and what we're hearing in the marketplace. I think that right now, our intent at the beginning of year we said we believe it'll be a better year. There's nothing I've seen that that leads me to believe it won't be. But I'm not expecting, it's not going to double or triple. It'll be a modest improvement in 2019.
Your next call comes from the line of Kristen Stewart with Barclays. You may proceed.
Hi. I was just wondering in terms of the gross margin if you can maybe help us parse out how much of it was just kind of a mix effect versus anything else?
Yes. Kristen, I can give you sort of directionally what we felt. We really we've gotten away from guiding on gross margin and really focus on our margin but for the quarter, we definitely first of all had some positive effect coming from adding in K2 because K2 has very strong margins, but really offsetting that were some of the big negatives especially price brought that down.
And then, secondly, just mix if you look at sort of the growth rates of orthopedics versus the growth rates of MedSurg, you really are going to have sort of skewing to sort of lower gross margins because that's the way the capital businesses perform.
That's helpful. And then, just in terms of the tax guidance, I think you said, you've reiterated the 16% to 17%. Do you feel like the lower end might be a little bit more likely just given the performance in 1Q?
Yes. I mean keep in mind usually the cadence of how the effective tax rate plays out it's usually lower in the first quarter. We have a lot of stock comp that flows through the first quarter. And the other thing that hit us in this quarter was maybe a higher expected stock price than we had planned on initially. But based on our forecasting, I'm still angling sort of to the midpoint between 16% and 17% for the full year.
Your next call comes from Robbie Marcus with JPMorgan. You may proceed.
All right. Thanks for taking the question and congrats on a good quarter. Can you give us sort of your latest thoughts here on capital allocation? Maybe first how free cash flow is trending and how we should think about that this year? And then, maybe as we sit here a good chunk of the way into the integrations of your acquisitions, how you're thinking about further M&A and how you see the universe out there right now?
I think, first of all, as we reiterated several times we really have not changed our capital allocation strategy. The bulk of our cash will go towards M&A. And then, we'll have cash that we'll use for dividend expansion. And then, lastly, for share repurchases. This year, we've completed our share repurchases and really just purchased enough to offset dilution.
I think moving over to cash flow keep in mind that first quarter is always seasonally sort of the lowest relative to our cash flow performance. If you look at this year, we versus 2018, we had a lot more integration spending than we normally have because of the timing of K2. I think offsetting that we did get a legal settlement that came in and then beyond that, I think if you just look at sort of working capital performance as Katherine had mentioned with K2, but also with other acquisitions we'll continue to expand inventory as we ramp up those acquired businesses. And so working capital will perform a little more negative early on in the year.
In terms of guidance, we are not backing away from our free cash flow performance in the range of 70% to 80% of adjusted net earnings that's what we're targeting and the whole business is lined up behind that.
Great. And maybe just one quick follow up on the neurovascular business and other nice quarter double-digit growth. Can you just give us the latest status of your product launches? I know you have number of them coming over the course of this year. Just give us the latest on where you stand and when we should start to see that throughout 2019? Thanks.
Yes. We continued to be pleased with the performance on both the hemorrhagic and ischemia side and particularly with the ischemic market expansion likely to continue based on just the really compelling clinical data. For our flow diverting stent surpass, we're excited about that. As we've said before for both that and our aspiration those are going to be slow launches and really ramp up into the year it's an exciting opportunity. But you've also got established competitors there. So, I think it'll be a bigger driver of growth for that as we head into 2020.
Your next call comes from the line of Larry Biegelsen with Wells Fargo. You may proceed.
This is Shagun in for Larry. Thank you for taking the question. So, Stryker recently acquired OrthoSpace in a U.S. clinical study is underway, according to clinicaltrials.gov, the study completion date is April 2019. I was just wondering if you've seen the pivotal data yet. What are your latest thoughts on the opportunity. And is a U.S. launch likely in 2020. And then I have a follow up.
Yes. We have not seen the pivotal data yet. I'm not sure about the April 2019 date. We'll have to get back to you on that. We don't have plans to launch OrthoSpace this year. I can't really comment on when that'll be, we'll probably do that on the next earnings call. But we are very pleased with the data O-U.S. is really, really compelling surgeon feedback is outstanding. It solves a huge unmet need of a large rotator cuff repairs which today are not treatable. So, we're really excited about the future prospects, but in terms of timing for U.S. launch, something we'll get back to on the next quarter's call.
Got it. And then, just as a follow up, Kevin, I was hoping to get your comments here some companies have indicated that the FDA is becoming more conservative with respect to product approvals, product classifications and as well as post-market surveillance. As the CEO of Stryker and the new head of AdvaMed, what are you seeing on your end and what is your sense of FDA's direction going forward. Thank you.
Yes. I know. So, for the Stryker portfolio products were not really seeing much of a change. I think we have seen a couple of decisions recently whether it's related to [indiscernible] or most more recently related to the -- for the slings the vaginal mesh products. We've seen some decisions that the FDA has made which might be deemed a little bit abrupt. But overall our relationship industry with FDA has been very good and frankly has improved pretty measurably from five years ago. I think our user fee agreements that we've had with the FDA have been terrific. And frankly most of the companies we talked to have more issues with CMS than they do with FDA.
So I don't think there's a big change going on in FDA. There's been a couple of recent decisions that were maybe a little bit more abrupt than what we were used to. But overall, I would say I would characterize the entire relationship between Stryker and the FDA and the AdvaMed [indiscernible] FDA has a very healthy relationship. Keep in mind that Jeff Shuren who is the Head of CDRHs still in his role and we're very pleased with the progress he's made with the device group and have a good relationship with him. So, in spite of the change of the commissioner there hasn't been a change in terms of the CDRH branch. So I would say things are very good still with the FDA.
Your next call comes from the line of Chris Pasquale with Guggenheim. Please proceed.
Instruments was strong again this quarter. Can you just talk a little bit about what you're seeing in that business and the comps get a lot tougher starting in 2Q, so how do you think about the growth potential of that segment going forward?
Thanks Chris. You're correct. It was a really strong quarter, candidly it came in better than we expected. We did split the sales force at the start of the year and that really helped bolster the revenue you often see that when you split the sales force in the initial months. I do think you need to be cognizant of comparisons and the fact that I wouldn't necessarily extrapolate just how strong the first quarter results were as you do your modeling for the remainder of the year. They'll have very healthy growth but this is a particularly robust quarter.
Okay. And then just on the trauma business, you mentioned the T2 Alpha launch had been delayed just what happened there and absent the impact of that what are you seeing in those end markets in trauma and extremities?
That was really the biggest factor for us. We target a launch timing and sometimes it comes in earlier than expected as the case was with our 1688 camera and sometimes they get pushed out a few months or a couple of quarters. If you're trying to thread a needle pretty tightly here so just working through some final issues as we get ready to launch it. And we do expect a pretty big impact but it's probably it's in limited release. We're probably looking at full commercial release more like mid-year. That was the biggest factor in the quarter.
Your next call comes from the line of Pito Chickering with Deutsche Bank. You may proceed.
Hi, guys. Thanks for taking my questions. Two questions for you on Mako. I do understand that the order book remains robust at this point, but has Mako sales cycle lengthened since the launch of the ROSA? And the second one, you previously disclosed 40% to 50% of Mako robot sales are in competitive counts. Has that changed at all again since the launch of the ROSA.
So, we haven't seen any difference or any change in time in terms of the order cycle for Mako. And we are continuing to see significant placement, it was about 55% in the quarter went into competitive accounts where we have no market share or very little market share. I will note though that going forward we will no longer be providing that level of detail, we'll continue to give you robust sales both U.S. and globally we'll continue to give you Mako procedures, so you can track the growth there and we'll continue to give you a clean knee number that allows you to accurately track knee implant growth and market share gains.
But beyond that the detail we gave previously was really intended in the early days of the initial launch to validate the acquisition and the strength of the technology. We're coming up on three years from the limited launch. So, we think we've established the success of Mako with 700 robots out there. So, we think limiting it really for competitive reasons to total robot sales, procedures and new revenue is what we're going to be doing going forward. But for the quarter, yes, we continue to see strong placements and competitive accounts at north of 50%.
Perfect. One question on guidance. How much of the 30, 50 basis points of operating margin improvement you got to in 2019 comes from the product mix?
Yes. We're not going to guide that specifically. I mean I will say when we looked at gross margin performance because MedSurg and neuro technology are just growing faster, we'll see sort of moderating of gross margin. But beyond that I'm not going to comment on sort of the mix within the gross margin.
Your next call comes from the line of Craig Bijou with Cantor Fitzgerald. You may proceed.
Great. Thanks for taking the questions. Maybe Kevin I wanted to start with the foot and ankle business. Wanted to see if you can parse that out and I think on the Q4, parse out the growth for this quarter and I think on the Q4 call, you said that growth was trending maybe more in line with the market. So, kind of want to get your updated thoughts there and what you guys are doing to -- is that how we should think about that business going forward kind of in-line with the market? Or will there be innovation in new products that is going to accelerate that over the next couple of years?
Yes. I know we love our foot and ankle business as you know we've become sort of the market leader and on a par with the Rite Medical from a position five or six years ago where we really had a very, very small place in the market. And so, we expect to continue to grow well. We do have a number of small innovations within foot and ankle that we'll be launching this year just to round out our portfolio and we expect to continue to grow really in line with market potentially above market. We're the first to report, so it will be -- we'll have to wait to see how everybody else comes in. But it continues to be a strong grower for us. Within trauma it obviously grows faster than the overall trauma and extremities business. And that was true again in the first quarter.
Great. That's helpful. And as a follow up just on cementless knees and other metric that you guys have provided before. Wanted to see if you're still willing to provide the percentage of your knees that were cementless? And then, any updated thoughts after AAOS. going forward where that can -- where that percentage can land?
Yes. So, it continues to climb and that's part of the reason why if you look at our other ortho number which includes robot sales and bone cement -- declines in our bone cement revenue. And that was one of the contributing factor that continues to ramp into the 30% it was up sequentially and up year-over-year in terms of the penetration we probably have a lot of runway. I don't think it's going to get to the level that you see with hips, but certainly we're expecting it to continue to climb.
Your next call comes from the line of Matt Taylor with UBS. You may proceed.
Hi, guys. Thanks for taking the question. So, the first one I wanted to ask was just about some of the leading indicators that you're looking at that give you the confidence in raising the lower end for the year. You talked about the order book, last time you gave a lot of detail on that across different businesses. I was wondering if you could expand on that comment or anything else that you're seeing in the market that gives you good visibility that we'll see sustained growth through the year?
Yes. So, a lot of the momentum that we had last year is continuing into this year. Keep in mind, we started the year with the highest organic revenue guide that we've had in over a decade at 6.5 to 7.5. And despite some difficult comps we came in this quarter at 7.3 organic growth. We have a number of businesses with healthy order books and it's across the capital businesses obviously endo being capital with 1688 rollout, while the big impact in the back half of the year. And we're seeing great momentum across endo with NOVADAQ as well. And Mako momentum is continuing. So, it's really across the portfolio when you're as big and diversified, there's always some challenges as we noted trauma the full commercial launch of T2 is going to be closer to mid-year. But, across the board starting the year at 7.3 and the visibility we have across the businesses and product launches is really what drove us to have the comfort level and raising or tightening the range towards the higher end.
Thanks. And just to follow-up on the environment, I was wondering if you could comment -- if you've seen anything notable in terms of changes in customer behavior whether it's on the pricing side or in the market dynamics around insurance approvals or pushback?
Literally nothing. No changes whatsoever.
Your next call comes from William Inglis with Piper Jaffray. You may proceed.
Great. Thanks for taking the questions. Building off the previous OrthoSpace question, your sports med franchise has been one of your quieter growth drivers, I believe. And you called out your domestic share position as number three at your recent Analyst Day. Just curious if you have any sense of when you could be number two and if there are any particular launches beyond the 1688 we should be thinking about this year is meaningful growth drivers or if it's just a combination of singles?
Yes. So, as you know, our sports medicine business has had very strong double-digit growth for a number of years as we've built out our implant portfolio both internally developed as well as acquired through a number of smaller acquisitions. We're actually the market leader in hip arthroscopy, on the heels of our Pivot acquisition as well as the Pivot Guardian Table, which we launched internally. And we still have room to grow in both knee and shoulder. We have a couple of shoulder product launches planned for this year that will bolster that part of the portfolio. So I expect continued strong double-digit growth out of sports medicine, did have a very strong first quarter.
We still have runway to go and we're very pleased though to now be one of the leaders in sports medicine which clearly wasn't the case years ago and continue to look for acquisitions there aren't as many sort of mid to larger sized companies so we tend to have to pick off small companies like you saw with OrthoSpace. But, still plenty of room for innovation and we're excited about building our strength more in the knee and the shoulder and the shoulder this year is a big priority with a number of new product launches.
Great. Thanks for that. And just a general question on the ischemic stroke market. The early adopters of the expanded treatment window were certainly a nice growth driver. Curious what inning you think we're in in terms of patients having access and benefiting from the drawn guidelines and the cadence of patients being funneled to comprehensive stroke centers.
Yes. We're in the early stages there. This is a market that you're going to see swings in market growth quarter-to-quarter whether it's our new clinical data that comes out or infrastructure bill. There's a lot of work that needs to be done to be able to get patients to the right comprehensive stroke center for the right treatment. So, that's market development that we along with others in this market are doing together. But I think you're in the early innings in terms of the overall opportunity for ischemic stroke device based treatments.
Your next call comes from Larry Keusch with Raymond James. You may proceed.
Thanks. Two questions. Number one, I was just hoping you might be able to give us a little bit of flavor on the capital environment in particular in medical that was obviously strong. So just any thoughts on sort of that backdrop there?
Yes. The overall capital environment whether it's medical or other capital businesses continues to be favorable, I wouldn't say we've seen a big change from what we saw in 2018. It's healthy but capital varies. We have strong product cycles across a number of our businesses that have capital offerings and so some of it is specific to Stryker and against the backdrop of an overall stable hospital CapEx environment.
Okay. Perfect. And then, Kevin, you said in a unique position in the sense that you're CEO of a very large medical device company you're also highly involved in AdvaMed and the leadership there. So, I was wondering if you might provide just some thoughts on what do you think is the reality or viability of a single payer system in the U.S.
Yes. At this point in the political cycle any comment would be purely speculative. I personally view the likelihood of Medicare for all as highly improbable.
Your next call comes from Matt Miksic with Credit Suisse. You may proceed.
Hey guys. This is Vic in for Matt. Can you hear me okay?
Yes. We can.
Hi. So just two questions first. Thanks for the helpful color on volumes. And on volumes and utilization for Mako and just given how these trends are going we were hoping you could help us out and talk a little bit about the potential capacity and throughput of your current installed base. Where you think you are now, what you think that looks like over time and any color you could offer on how long it takes for an average to reach some of those levels? And I have a follow up after that.
That's a really difficult question to give you some real analytics around that. It varies based on the surgeon and it varies based on their volume, it varies based on the size of the physician group. And generally though once you're trained and you don't come back into practice and start doing 100% of your knees or hips on Mako, you gradually ramp up as you get more comfortable with the technology and we can see that can be anywhere from 12 months or so. But again, that's an average or something that varies considerably.
We do pay a lot of attention to the utilization rate and this is why it's so important that when we place the robot there is the surgeon champion and oftentimes that surgeon champion grows as other surgeons get exposure to the Mako robot. And as I mentioned on the call, we continue to see strong growth year-over-year and utilization rates have been increasing every quarter it was up 30% year-over-year this quarter and as we get more robots in the installed base we expect that to continue to grow. How big it eventually gets and that's difficult to say, but we do believe we have ample runway to continue to take market share for years.
And when they do reach capacity there always is the option of buying a second robot. And as we've mentioned previously about 10% of the hospitals where we have a robot have a second robot and maybe a third robot. We have some systems are very, very large system that has four or five robots. So, the ability to sell additional robots when the capacity is reached is something that we can certainly continue to do.
Got that. That's very helpful. And just one follow up on endoscopy and the potential impact of the 1688 camera. Wondering if you could just kind of talk about any thoughts you have on driving further into the consumable space for some of these end markets like sports medicine or general surgery? Thank you.
So, for the camera we feel really good about the impact as we roll that out. And if you look at prior launches 1588, 1488, you see a very similar trend. Momentum builds in the first year particularly in the second half of the year and it's really starting to hit its stride in the second full year of the launch and we would expect something very similar here and also helped by the NOVADAQ acquisition where we continue to see really strong momentum. And we've become a bigger player in sports medicine there's still a lot of room to go before we're a category leader, but we've brought innovative technologies in there and continue to see the benefit to the overall endo business from sports medicine.
And we had this [1680] [ph] on display at the Sages conference and received terrific surgeon feedback. The overlay of fluorescence imaging is really incredible. It's just a beautiful picture. We also improved the backlighting, so that lends itself to better performance in ENT and sports medicine procedures as well as having a 4k picture as well as like light source. So, a lot of improvements in the 1688. We expect this to be a winner of a product launch just as you saw with 1588, we had terrific growth as Katherine mentioned sort of picks up in the second year. But, I would expect a strong second half of the year for endoscopy and frankly we're very pleased with the first quarter given 1588 was sort of towards the end of its cycle, we had really strong performance in sports, strong performance in communications and strong performance with NOVADAQ. So, we have a really great leadership team at Stryker endoscopy and I expect continued strong performance there.
Your next call comes from the line of Kyle Rose with Canaccord Genuity. You may proceed.
Great. Thank you very much for taking the question. We touched on the extremities business with respect to trauma and then on the sports side. I wondered if you could just talk a little bit about the overall shoulder recon market. I think you have some new products that are launching over the course of the next 12 months and just kind of how you think about that market.
Yes. It's a good market and we've been a very small player sub-10% market share player in shoulder. I've been playing catch up on our product portfolio. We have a total shoulder, we have reverse shoulder, we have a fracture system and we're launching the short stem really right now in this in the second quarter on a limited basis have bit more of an impact later. And we still don't have a [stemral] [ph] shoulder that's in our pipeline. So, we've been progressively adding to our portfolio our shoulder is growing well, but from admittedly a smaller base. But we do like the shoulder market and we now have a competitive product offering to start to gain business and we're pleased with the performance so far. We're excited about the short stem launch and we'll see again more of that result in the second half than you'll see in the first half.
And then, you're coming out of AAOS obviously a big focus on robotics, but yes, there was another focus specifically related to procedural trends in the outpatient setting. Just wanted to see you obviously have a good viewpoint there. Given the product portfolio, but how do you view the outpatient market now. I mean what really needs to happen to actually drive that as a catalyst to driving procedures there and maybe some broader perspective would be helpful. Thank you.
Yes. We've mentioned this before that the trend towards outpatient will continue. I don't think there's any question about that over time. But, until Medicare provides coverage in the outpatient setting, you're not going to see a big spike. They are covering it now in the hospital outpatient, but that's not the same thing as a surgery center. And so, we haven't seen any signs of that happening at least not in the near term. But once that happens then I think that'll be the extra catalyst to drive a lot more volume.
Right now, there's a lot of talk about shifting [indiscernible] care that the actual numbers are not that great at the current time. Clearly, we're present in the surgery center with our sports medicine business and we expect the procedures will continue to graduate towards the surgery center. But I think the timing is really uncertain and for me the inflection point will be when we get Medicare coverage.
Your next call comes from Josh Jennings with Cohen. You may proceed.
Hi. [Indiscernible] for Josh I appreciate that question. So to start on M&A spine as a market where historically you have what category leadership and as you progress through kind of early integration of K2M, is this an asset that you believe can give you an upscale on the market over time or do you see for incremental M&A to kind of achieve that category leadership that Stryker typically aspires for?
Yes. You can imagine that the organization is totally focused right now on ensuring that successful integration of K2M and we believe this is absolutely the portfolio, the offering and the leadership team and the selling organization that can get us to category leadership. So, we would expect to be in a position where we're taking market share. We've got that mid-single digit target on a combined basis for this year and we expect it to accelerate after that. So, the timeframe to get to category leadership would be premature to state that, but we absolutely believe this is a portfolio that will get us there.
And what I would say is, that every business of Stryker is on the hunt for new acquisitions. I think right now we're focused on integration, but at some point I would think that the spine business will that come forward with some types of acquisitions to bolster their portfolio. As you saw with the ENT, we did Entellus. And then within one year of doing Entellus, we've done our Arrinex. So, once we get into space, we're not going to do one deal and then stop. I can expect that we'll do a spine deal in the next six months. We're going to be very busy with integration, but beyond that if there's product holes in the portfolio that we'd like to fill in every business of Stryker will possibly be looking at rounding out their portfolio either internally developed or by acquisitions.
Okay, great. And then, separately can you remind us of the upcoming Mako DSS, you expect to publish in the near-term timing of that -- to your dataset and anything else worth highlighting?
Yes. So, we're coming up on the three year mark from the initial launch and so we'd be hopeful we'll be getting closer to having two year follow-up data for the Mako total knee which is you know in the world of Orthopedics and joint replacement is near term data. And the timing of that it's tough to know we have to hit the two-year mark we have to crunch the data and then you've got to submit it. So, whether or not it's at [indiscernible] or AAOS or sometime in between, I don't know yet but that was that probably one of the next datasets that we would anticipate.
Your next call comes from Jeff Johnson with Baird. You may proceed.
Thank you. Good afternoon. Just a couple of follow up questions. Kevin, you mentioned Japan and Australia some sluggishness there, is that macro or anything else to call out?
Yes. They had some sluggishness with their capital equipment and to us that's just timing we have very good businesses there they've been performing very well over a number of years. I expect that those business will pick back up for the remainder of the year. Really capital timing related. The ortho business is super fine.
Okay. Thank you. And then, on China it seems like stimulus efforts there might be helping macro in China a little bit. Are you seeing that or was the China strength you referenced more Stryker related?
It's more Stryker related just given how small we are. We are far, far, far from the market leaders in China and so whatever progress we make, we can make this kind of progress irrespective of any kind of stimulus efforts. It's just been turning to gain our fair share of the business.
Your next call comes from Steven Lichtman with Oppenheimer. You may proceed.
Thank you. Hi guys. So obviously, most of Mako placements continue to be in the U.S. Just wondering what you are seeing as potential for additional opportunities outside of the U.S., countries or regions where you see is ripe for expansion of Mako.
Yes. We are really excited for the future of our China and Japan. Those are going to be two very good markets. Today we only have approval for the hip in those markets. We need to get the knee approvals which are pending right now. And then, those will who really take off as big, big markets we built a training center in Hong Kong in the fourth quarter of last year which we'll be using to train surgeons in those two markets. Those are really -- I'll call them the lagging markets and even in India we sold our first Mako recently in India. That could be a good market as well. But the bigger -- the big markets that are really untapped so far are China and Japan, it has really been because of regulatory. It's just taking us longer to get Mako approved in those markets, but those will be great markets for long-term.
Got it. Thanks Kevin. And then, Glenn, I think you mentioned 50 basis points of headwind from acquisitions this past quarter. What are you looking for the full year on that score what's embedded within guidance for full year of headwind.
Yes. We typically don't give out that number because there's lots of acquisitions that are still needing to be integrated. What I will say is that over the past few years, it's been around 50 basis points for full year dilution and my guess is based on the current set of acquisitions that we have right now in Q1 that we're trending very similar to that.
There are no further questions at this time. I'll now turn the conference over to Mr. Kevin Lobo for any closing remarks.
Thank you for joining our call. As you can see our momentum continues and we look forward to sharing our Q2 results with you in July. Thank you.
Thank you, ladies and gentlemen. This concludes today's conference. Thank you for participating. You may now disconnect.