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Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Good morning, ladies and gentlemen, and welcome to the Zimmer Biomet First Quarter 2021 Earnings Conference Call. [Operator Instructions]. As a reminder, this conference is being recorded today, May 4, 2021. Following today’s presentation, there will be a question-and-answer session. At this time, all participants are in a listen-only mode. [Operator Instructions]
I would now like to turn the conference over to Keri Mattox, Senior Vice President, Investor Relations and Chief Communications Officer. Please go ahead.
Thank you, Operator, and good morning, everyone. I hope you are all well and safe. Welcome to Zimmer Biomet's first quarter 2021 earnings conference call. Joining me virtually today are Bryan Hanson, our President and CEO; and CFO, Suky Upadhyay.
Before we get started, I'd like to remind you that our comments during this call will include forward-looking statements. Actual results may differ materially from those indicated by the forward-looking statements due to a variety of risks and uncertainties. Please note, we assume no obligation to update these forward-looking statements even if actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties, in addition to the inherent limitations of such forward-looking statements.
Additionally, the discussions on this call will include certain non-GAAP financial measures. Reconciliation of these measures to the most directly comparable GAAP financial measures is included within our Q1 earnings release, which can be found on our website, zimmerbiomet.com.
With that, I'll now turn the call over to Bryan. Bryan?
Alright, great. Thanks, Kerry. And I also want to say thanks to everyone for joining us this morning for our call. And before we actually get into the Q1 numbers and our guidance, I just want to take a second to say that I certainly hope that all of you and your families are continuing to stay safe. We're obviously very pleased to see that so many people now have access full access to the COVID-19 vaccinations. And that adoption has been pretty strong so far.
Now, of course, we'd like to see this even more broadly on a worldwide basis. But it certainly feels like we're making really important progress toward moving forward. And ultimately, as a result of that moving hopefully on from the pandemic. Now it's not over, I think all of us realize that. But I for one feel more optimistic than ever, that we're coming out, I think on the other side of COVID-19. And with that, much better days ahead.
And I guess with that, probably it's a good lead into our Q1 call. Q1 was a stronger quarter than we initially expected. And I'm pretty excited to discuss it with you, whenever you have a good quarter, obviously, earnings calls are a lot more fun. So clearly, we're excited about this one. And I'm going to try to keep my remarks relatively brief, this way I know you're kind of laughing at that, because it's not always easy for me to do that.
But I'm going to try to keep it brief. And that'll give Suky an opportunity to walk you through which you're really interested in, which is the financial results for the quarter, and really how that translates into our expectations for the full year 2021 guidance. And I also want to make sure that we leave time for questions, obviously.
So I'm just going to stick to really three topics as a result. Number one, I want to talk about the COVID recovery just briefly, and our execution inside of that recovery. And then ZB's ongoing transformation and our progress against that, that will be the second topic. And the third topic will just be around her long-term growth strategy. Just reiterating our position there and how we believe that's going to drive value for our shareholders and stakeholders overall.
So let's start with navigating COVID and how we're executing inside of it. COVID clearly is not over, just as I stated a minute ago. I'm very confident, we're going to continue to have surprises ahead and disruptions ahead. But, based on what we saw at the end of Q1 and what we're seeing in the beginning of Q2, and coupling that with the just the pace of vaccine rollouts right now, and we're clearly moving in the right direction. I don't think anybody can argue against that. And it's that shift toward what I would define is more stability. And I know it's on a relative basis when I talk about stability here. But that shift towards more stability really enabled us to give you the full year 2021 financial guidance.
Now inside of that guidance, there's going to be some important assumptions about trends and recovery timing that underpin our outlook. And Suky is going to get into more of that in just a few minutes. But overall, it feels good, feels good to have better insight into the broader market and greater confidence in what the rest of 2021 should look like for our business.
Now as we start to return to a more normal environment, I'm going to put "normal environment in air quotes given the situation right now. But when that happens, we expect that part of what we'll see is a pretty significant tailwind from the backlog of patients that has built up over the last year or more. Now, how fast that happens, how fast we work through that backlog, especially across certain regions is something we're going to have to pay attention to. We're going to have to watch and track, but we absolutely believe that the vast majority of those patients who put off an elective procedure will come back into the funnel, and that's going to provide a significant tailwind well into 2022. And I for one cannot wait for that tailwind.
And I can tell you that ZB is ready for them. They're ready for those patients, and we're ready to be able to help our customers, care for those patients. Speaking of being ready, as I've said here before, the things that ZB was able to directly control over the past year, I truly think the team has executed against. And I'm very proud of the ZB team for how they stood up and delivered against a backdrop of a whole lot of things that were absolutely out of their control.
And I know I talk a lot about the importance of our talent, our mission, our culture here at ZB. And I can say that each word absolutely critical for us in 2020, and continue to be in 2021 and well beyond. And with that in mind, we've made some additional changes to our leadership team here very recently. We've added a Chief Transformation Officer, again, to help us with all the transformation that we're going to continue to have as an organization.
We've appointed a new Chief Human Resource Officer to help us move our talent agenda forward, one of the key areas of focus for me, as we move forward as an organization. And promoting saying needs a Group President of Asia Pacific, he's now going to have some responsibilities of certain projects, OUS, He brings a real disciplined execution mindset. And he can absolutely help us outside of Asia Pacific. And then expanding upon Tornos' role as a Chief Operating Officer with the added leadership now of EMEA, which is a region that he has had deep responsibility for in the past and knows very, very well. And I know it can bring us value in that region.
So, I can tell you this continued focus on talent and development is not just contained to the executive ranks. Our entire ZB organization is hyper-focused on our people, on really getting the right team members in the right roles and giving them the tools and support, and really the opportunities to drive their performance, to develop an excel. And it's working, I can tell you, this focus on talent is working. And I believe it is going to continue to set us apart from the competition.
And in addition to the foundation built by our team members, our mission, our culture, our core business momentum is stronger than ever. The team's execution continues to be on point. Our market momentum is building, our commercial competence is higher than ever. And I can tell right now, we are very excited about the R&D innovation pipeline that we still have coming. That's an important part of our revenue growth.
Throughout Q1, and even in recent weeks, we've hit key milestones with our ZB products and our innovation. The application for partial knee now is available for ROSA, we just approved by the FDA. We've actually already had our first procedure using that application last week with very good results. And this is just the latest addition to our ROSA Robotics program, our platform here.
And it's also another launch inside of our ZBEdge suite of integrated digital and robotic technologies. Again, something we truly do believe will set us apart from the competition. So if I just look at ROSA overall in the quarter, we continue to see strong market demand and traction with our ROSA platform. The Q4 performance was fantastic, and that continued right into Q1, both in the U.S. and internationally. And our forward-looking robotics pipeline is very robust. And I can tell you that given our market share in partial knee, the partial application is only going to serve to bolster that going forward.
For Persona Revision, another strong performance, this continues to move forward in an amazing way. Q1 was ahead of our expectations. And it is another example of a tip of the spear product that we have that as we make the conversion of revision, we also have the opportunity then to go after the standard new business as well. So again, still exciting opportunities there for revision.
And then our Signature ONE planner for shoulder procedures, again demonstrated a very strong sequential growth from Q4. We're actually up 65% over Q4, when we look at registrations, again, that's a pretty significant move. And again, this provides that stickiness with our customers in that procedure. But, it also provides a mixed benefit wherever that pre-surgical planning is used.
As we come into Q2 and the rest of 2021, ZB has additional innovation that's coming, and it's pretty exciting innovation with our anticipated launch of Persona-IQ and also ROSA hip later in the year. And I can tell you for Persona-IQ, the initial feedback from evaluating surgeons has been very positive. And I can tell you that they're interested in being able to capture data from inside the body. And this is unique, they've not been able to do this before. And then ultimately, remotely monitoring those data and the hope would be that using that information to change the way that we care for patients.
So the excitement around this is very strong from our surgeons. And we can tell that the momentum is going to be strong when we do get regulatory approval. So all that to say the momentum on the innovation front is real here at ZB. This will allow us multiple shots on goal across a number of innovations, again with multiple robotics launches, continuing success with Persona Revision, Persona-IQ, new iterations of mymobility, and just really the broader ZBEdge ecosystem to drive mixed benefit for sure, but also competitive conversions.
And ultimately, we really believe change the way that we care for patients, change the treatment paradigm for patients. That's really what it's about. It's about driving the mission of this organization, truthfully to remove pain from patients around the world and improve the quality of their life. And we truly do believe ZBEdge can help us do that.
Okay, so let's move to the second topic that I have for you this morning. And that's the continued transformation of ZB. Now, you've heard me talk about the three phases of transformation. The first was winning the hearts and the minds of the organization of the team members, and really dealing with the execution challenges that we had that we spent a lot of time on in the first year.
And then second was moving to that longer-term, firm strategy for the organization that would drive innovation, it really building the structure around that strategy and the operating mechanisms to ensure that we move it forward.
And then third, where we are now is the portfolio transformation. And truly, that is where we sit, that is squarely where we are positioned today in Phase 3 of these three phases. And we have the ZB portfolio management strategy and process in place. And we have definitely built out our capabilities to move forward in this space. We're focused on what we're going to define as mission centric M&A, that is whenever repeated, that would absolutely increase our weighted average market growth and does not disrupt our best-in-class margin profile.
And as you've seen, we've moved this forward already, with selected tuck-in acquisitions that we did last year. And that really does illustrate the strategy of work. And those deals were smaller, no question they're smaller. And they're relatively immaterial when it comes to the initial revenue that we acquired. But they're absolutely designed to fill portfolio gaps and better position us in high growth markets.
Those high priority markets and sub-markets, where ZB has a path to leadership. And we believe a right to win in markets like sports medicine, ASC, and in the sternal closure market for us. And each of these deals gives us a gap filling, and we believe differentiated product portfolio to drive growth. And that's important to growth, but also to drive additional confidence in our S.E.T. business category.
And of course, inside of this active portfolio management phase, there's a planned spin-off transaction of our spine and dental business that we discussed back in Q4. That process of creating two independent, even stronger companies is on track. It's early days, obviously, but it is on track. And as you saw from our Q1 results, we do not believe it's causing distraction or disruption in our business. In fact, it's more of the opposite.
We've seen significant energy in the business to kind of jelling in the business, as a new co-team starts to come together, under CEO Vafa Jamali, and they begin to build out their own strategy and their focus. So again, it's early days, but we're very happy with the progress so far of the spin.
Alright, so that brings me to my third and final topic this morning that really around our ZB plan to drive long-term growth in ultimately deliver value as a result of that growth. And I can tell you that we remain fully committed and confident in ZB's long-term growth and margin expansion expectations. We've said before, and we'll say it again, that the spin-off of NewCo actually serves to de-risk and potentially accelerate our path to mid-single digit growth, and a best-in-class 30% operating margin profile by the end of 2023.
And we're confident that throughout this process, and as we achieve this growth and margin profile, we're also going to have the flexibility to reinvest for growth. And that is a key thing for us. We've got to continue to be disciplined, but ultimately invest for growth in this business. And that's what we will continue to do.
Now to get these growth levels and to achieve our top quartile performance in TSR, which I think you probably remember, is one of our strategic pillars. Now we're going to continue to execute in our priority growth areas. And just as a reminder, that means that we expect to drive above market growth sustainably in these, we plan to grow hips consistently at market, but then later this year, above market rates when we launch the ROSA hip application, and we expect to stabilize first and foremost, but also drive focus. And then ultimately, through that focus drive our S.E.T. business at the higher end of market rates there.
We're also very focused on driving change for ZB, a real evolution of the company from a metal and plastic provider of implants to a leading med tech innovator. Think of us as a high-tech company that happens to be in med tech. And that's the ZB brand that we're looking for that brand evolution of this company. And I can tell you that already, more than 70% of our product development dollars are being spent in this area, being spent on ZBEdge, that ecosystem of connected technologies.
Now, we're always going to be an implant company. And that's the center of the universe for this company. But the ZBEdge ecosystem around it is a way that we can differentiate ourselves versus the competition. And we already have exclusive relationships to help us here. We have relationships already with Apple, and several other tech companies that we truly do believe will drive future innovation that will delight our customers and ultimately benefit patients. And I believe fundamentally, that this shift is coming not only for us, this technology shift not only for us, but for the entire market that we play in them. And I truly do believe that the technology advancements potentially can reshape the growth curve of these markets.
I'll say that, again, I think the technology advancements that we're seeing and the value they bring can reshape the growth curve of the markets that we play in. And I think very importantly, also change the care paradigm for our customers and their patients.
Alright, let me close by saying that I continue to be highly confident in ZB team, and in our business momentum. I truly believe that we are well-positioned for success and our strategy is working. Our transformation is well underway. And I'm excited about the value that we can drive for our shareholders on a go forward basis, I truly am.
And before I hand it off to Suky, I just want to take a minute to say thank you, truly thank you to the entire ZB team. Your vigilance and dedication to our safety protocols over the past year or so has been absolutely critical. And you're focused on our mission, our strategy, and really just how you show up and execute every day, it's unmatched in my view. It truly is unmatched. You are what makes us ZB, I truly believe that. And what makes me confident who really is that we can absolutely continue to deliver on all fronts.
Okay, so with that, I'm going to turn the call over to Suky. He's going to give you more financial details on the quarter and obviously most importantly, our expectations looking forward. Okay, Suky?
Thanks, and good morning, everyone. As Bryan mentioned, our underlying fundamentals remain strong, as does our confidence in our outlook. For this morning's call, I'm going to focus on three topics. First, our Q1 results, including commentary on the impact of COVID, second, how that translates into our full year 2021 financial guidance that we provided this morning, and third, how ZB is positioned for long-term growth in 2022 and beyond.
Moving forward, unless otherwise noted, my statements will be about Q1, 2021, and how it compares to the same period in 2020. And my revenue and P&L commentary will be on a constant currency or adjusted basis.
Net sales in the first quarter were $1.847 billion, reported increase of 3.6% and a constant currency increase of 80 basis points, versus the same period in 2020. It's important to note that we had one fewer selling day resulting in approximately 150 basis point headwind to consolidated revenue growth.
Overall, consolidated and regional results were better than our initial expectations, as vaccine adoption continued to ramp up, and pandemic pressure eased across most markets in March versus January and February.
First, the Americas increased 1%. We continue to see variability by country, and while the region was in decline for most of the quarter, a sharp increase in U.S. procedures in March drove regional growth. As expected, the EMEA region was hardest hit by COVID-19, decreasing 10.3%, with all sub-markets in decline. While we did see some recovery or decrease in COVID pressure as we move through the quarter, some markets continue to operate under recently enacted restrictions and actions that are limiting the near-term recovery of elective procedures. So, we're continuing to monitor uptake very closely, and expect that recovery in EMEA will lag other regions by one to two quarters.
Lastly, Asia Pacific grew 15.5% with solid year-over-year growth across our three largest markets. Overall, we've seen a stabilization around COVID cases and surges in the region, but, we continue to see some significant delays and recovery across India and other smaller markets.
Turning to our business performance in Q1. Before jumping in, let me call out that we've updated our product category reporting to provide visibility into NewCo, to align products to categories based on how we internally evaluate performance of those businesses. Also, we have adjusted our historic reporting of revenue for these changes to assist in year-over-year comparisons.
First, our ROSA Robotics capital revenue has been moved from the knees category to the other category. And, our disposable revenue associated with robotic knee procedures have been moved from the other category into the knee category. This will allow us to more clearly indicate to investors the growth of our base knee business, and sets us up for reporting once we launch ROSA Hip, which is currently expected in the second-half of 2021.
We've also broken out our global spine and dental revenues this quarter in conjunction with NewCo reporting. And as a result, CMFT is now included within S.E.T. The global knee business declined 5.2% versus Q1, 2020, negatively impacted by ongoing pressure from COVID. Inside of that, we continue to see strong momentum from Persona and from ROSA Knee.
Our global hip business increased 0.3%. Both the Americas and Asia Pacific continue their growth trends increasing 0.9% and 11.2%, respectively. We continue to see strong demand and favorable feedback on the Avenir Complete Hip with adoption from both gold and platinum accounts.
Sports, extremity and trauma increased 7.2%, driven by solid growth in upper extremities, trauma and CMFT. In S.E.T., we continue to see strong surge in registrations of the Signature ONE surgical planning system for soldier procedures.
Our dental and spine segment grew 9.6% fuelled by outpaced recovery, especially in dental. New products and better commercial execution also drove growth in the quarter, with strong contributions from implants and digital solutions in our dental business, and from Mobi-C and Tether within spine.
Finally, our other category was down 2.5%. As mentioned earlier, this quarter our other category includes the contribution of ROSA Knee capital sales.
Moving on to the P&L. In the first quarter, we reported GAAP diluted earnings per share of $0.94 and adjusted diluted earnings per share of $1.71. Our reported GAAP diluted earnings per share were up significantly when compared to a reported GAAP diluted loss per share of $2.46 last year. The increase in year-over-year GAAP earnings was driven by higher revenue in the current period in tandem with prior year goodwill and product liability related charges.
On an adjusted basis, EPS was up about 60 basis points, driven by higher revenues with operating margins down slightly compared to 2020, and a higher share count. The adjusted tax rate of 16% in the quarter was better than expected, driven by the realization of excess stock compensation benefits and other smaller discrete items.
Turning to cash and liquidity, overall operating cash flows were $247 million and free cash flow totaled $137 million for the first quarter. We paid down an additional $200 million of debt, and ended the first quarter with cash and cash equivalents of $724 million. We continue to make good progress with another quarter of delivering the balance sheet.
Moving to our full year outlook and financial guidance. While we continue to see pressure due to the global pandemic, vaccine rollout and adoption is approaching meaningful levels, translating into a reduction of infection surges and hospitalizations in most markets. This increased stability gives us greater confidence that we'll return to normalize market growth in our key markets within the year, and also begin to see deferred patients re-enter as an added tailwind.
As a result, today, we provided financial guidance based on our latest expectations, and that is underpinned by two key assumptions. First, current vaccine adoption trends continue to strengthen, driving a decrease in the number of new COVID-19 cases through 2021. And second, hospitals increased capacity to work through some portion of patient backlog this year.
Against that backdrop, our current expectations for full year 2021 financial results are: reported revenue growth of 14% to 17% versus 2020, with an expected foreign currency exchange tailwind of approximately 150 basis points, adjusted operating profit margins of 26.5% 27.5% and adjusted tax rate of 16% to 16.5%, adjusted diluted earnings per share in the range of $7.60 to $8, and free cash flow of $900 million to $1.1 billion. Inside of that guidance, we expect to see seasonality in revenues in '21, that begins to resemble pre-COVID cadence.
Additionally, our investments in R&D and key commercial initiatives will increase throughout the year. However, we do expect operating margins to improve as we exit 2021, as a result of higher revenues.
Net interest expense is expected to step up about 5% versus 2020. And we expect fully diluted shares outstanding to be about 211 million shares for the full year. Of course, we will continue to update you on market dynamics and financial expectations, as we move through the year.
Let me now turn to our long-term growth profile. We continue to expect our structural organic revenue growth rate to accelerate to the mid-single digit range, with adjusted operating margins of at least 30%, as we exit 2023. We're confident in our expectations, are a result of the following proof points.
First, we have been delivering consistent strong performance versus the market. Second, we have the best new product pipeline in the company's history that will complement an already robust portfolio. And third, our global team members continue to ramp up execution across our strategic priorities.
In addition, our previously announced transformation initiatives are progressing well, and the addition of a Chief Transformation Officer has the potential to drive even greater investment opportunity for growth, while maintaining a leading margin profile.
To summarize, we are pleased with our better than expected revenue performance in Q1. While we anticipate or prepare for ongoing short-term market uncertainty due to COVID, and remain sensitive to ongoing challenges in a number of markets. From a financial standpoint, we believe the worst of the pandemic is behind us, and look forward to improving results as we execute on our strategy.
With that, I'll turn the call back over to Keri.
Thanks, Suky. [Operator Instructions] With that operator, may we have the first question, please?
Thank you. Ladies and gentlemen, at this time, we will now begin the question-and-answer session. [Operator Instructions] We'll take our first question from Mike Matson with Needham & Company.
Hi, good morning. Thanks for taking my questions. I guess, I wanted to start with the backlog that you mentioned. If your sales were down about 12% in 2020, does that equal to 12% around $1 billion for the backlog? And then, where do you think the capacity is among surgeons and hospitals to address that? And how much have you factored in your guidance for this year?
Yeah. So, thanks for the question. So, I would say it's not as simple math as that, but it's pretty close. Because you've got to remember, certain portions of our business would not have patients that would have a disease state that continues to adapt to deal with. In some not all of our revenue then is linked to procedures that have been deferred.
But, if I take those that that are, and we also have a kind of a percentage that we would assume will drop out of the funnel, we still have a very sizable backlog, hundreds of millions of dollars. So maybe not quite the number you're referencing, but the math logic makes sense, when you peel out some of those old pieces.
Now relative to the cadence or speed at which we're going to digest those patients is difficult to predict. I mean, we've never experienced anything of this size and magnitude in global impact. And so, I don't know that I have a perfect proxy to determine how quickly we can actually work through that backlog of patients. But my general feeling is that you look at just historical views of this, although much smaller and different. It's usually 12 to 18-months, you typically work through a backlog funnel. My guess is it will take at least that long, given the size and the magnitude of the backlog that we're talking about here.
And it's going to be different. It's going to be different depending on where you are in the world. Certain places in the world will move that backlog through much faster. And other places will go a lot slower, because the incentives are not there to be able to digest again, that patient flow as quickly. So again, I guess the takeaway is, it should be a very large backlog of patients. That will be pretty substantial dollars for us to be able to take advantage of this a tailwind. But the timing of that, the speed at which we work through is, we're just not sure yet.
Thank you.
Absolutely.
Our next question comes from Bob Hopkins with Bank of America.
Great. Thank you. And thanks for taking the questions. And appreciate those prepared remarks, Bryan. There is a lot to unpack in there. But for now, I'll keep my questions a little bit short-term just given how confusing an environment it is.
When Stryker reported, they said their hip and knee results for April were kind of already rebounding to up mid-single digit year-over-year. And I'm just curious directionally, if you're seeing sort of a similar thing here in the first part of the second quarter.
Maybe what I'll do is toss that one over to Suky, as he's going to give more color around either guidance or just what we're seeing going forward. So, Suky, do you want to take that one?
Sure. Hey, Bob, good morning. So, before I get into Q2, I think it's important to reflect on Q1 for a moment. Versus 2020, we were up just under 100 basis points, versus the prior year, better than our commentary earlier in the quarter, where we expected to be down low to mid-single digits. And that was really because of the sharp uptake, as I talked about in March, primarily in the U.S., and we saw greater stabilization, faster stabilization in Asia Pacific than we expected. That more than offset, a lingering headwind or below expectations for EMEA.
Versus 2020, things get a little bit choppy because of the comparisons to prior year and COVID. But if you look at Q1 versus 2019, we were down that implies about 8%. And as we exited March, we were also down versus 2019.
Now, our guidance moving forward when compared to 2019, assume sequential improvement and growth rate in Q2, Q3 and Q4. So far as we've entered into Q2, we've got confidence in that shaping for Q2. We expect to exit the second quarter at about 2019 levels, not for the full quarter, but as we exit. And inside of that, we expect Asia Pacific to be above Q2 of 2019, the Americas about flat to slightly up, and EMEA continuing to lag.
And again, the early start that we've seen so far in the second quarter, gives us positive proof points and confidence that we'll see that sequential step up in the second quarter.
Okay, that's helpful. Thank you. And then just for a quick follow-up, can you give us an update on the timing for Persona-IQ and your thoughts there in the U.S., and timing of that approval and launch?
Yeah, sure. We're actually waiting for the FDA approval right now. We're ready to go, obviously we're prepared and ready to launch. We've worked through our commercialization strategy. We did a really nice job about compliment the team here. We're getting a third-party engagement to do a apparently comprehensive survey of what we could expect upon commercialization price points, what people are willing to pay for it, and how interested people are for the data capture and using that data from a remote patient monitoring perspective.
So, I think we're really well-prepared for the commercialization. But at the end of the day, you can't do anything until you get the FDA approval. So that's what we're waiting on. And when we get that we'll be moving forward. My guess is, we'll be able to launch this over the next handful of months. But what I would just size this right, this is a unique launch for us, it's first of its kind. We're going to take our time. We're going to do a limited launch this year. I wouldn't expect material revenue in 2021. The full launch would really come towards the end of 2021, or 2022.
But we really want to make sure that we're concentrating on a few customers, going deep with those customers, really understanding data capturing the value that it brings, and then from there going in a more widespread way.
Now, if we pick up information quickly, and our confidence level grows more quickly than we're expecting, then you could see a difference this year than what I'm predicting right now. But I would think about it as launch this year, obviously, more limited in the way we would do that launch and then more aggressive launch, more full launch, as we come into 2022.
Great. Thanks, Bryan. Thanks, Suky.
Yeah.
Our next question comes from Jason Wittes with Northland Capital.
Hi, thanks for taking the question. Maybe follow-up on Persona-IQ. You actually mentioned, I think, 70% of your innovation pipeline is IT data-driven. I assume Persona-IQ is part of that. I'm just curious in terms of how you see that playing into the marketplace, which is simply share gains, ASP gains.
And then related to that, if you look at traditional ortho implants, they take about a year or so before they really impact the revenue line. Is that the kind of time I mean, you kind of laid that timeline out for Persona-IQ, but for some of the other products in the pipe should we expect it takes about a year or so plus gestation, before it really matters, I guess?
For us, I think it matters right out of the gate. To me, I look at this as first of all, absolutely, IQ was part of that stand that I talked about for the ZB ecosystem, right. And I think about ZBEdge, it is a very unique part of it, too. As I said in my prepared remarks, we're an implant company. This is where our bread and butter is for sure.
But what we want to do is, we want to elevate beyond that to make sure that we've got an ecosystem around it. And IQ, although extremely important in that is a variable in the overall equation. You still got mymobility that we connect with IQ, which would connect with ROSA. And OrthoIntel is kind of a backdrop to that, and would allow us to be able to collect data on a patient before surgery, interactively post-surgery, and then be able to use those data ultimately to change the way we care for the patient. And that's what's so exciting about it.
And so, I think you can't really compare this to a typical knee implant or another implant. And the timeline it might take up to drive real traction or materiality in the market, because it's that unique. It really is a connection point to this broader capability that just does not exist today. So it'll be interesting to see. We've got a pretty, pretty ambitious plan that we have in front of us. And the feedback so far from our valuating surgeons has been very strong.
And just generally in the marketplace, this desire to have data and be able to use the data to have better insights to be able to provide different care, better care is real.
And ultimately, what we're so excited about is, as we collect data right out of the gate, we're first to market obviously with a smart implant. But as we collect data, we'll stay out ahead of folks, because that data is really where the magic is.
The implant is interesting. You can listen to it right away. But as you collect a certain amount of data over a period of time, that is actually what provides the insights that are going to matter in the future. And so that gives us an opportunity to stay ahead. So we're very excited about it. It is part of that R&D spend. And we believe that it has the opportunity to have a better ramping curves than in a typical implant, just because it's so unique.
Okay. And then just a quick follow-up, you guys mentioned in your guidance you prefaced on the fact the idea that the hospitals are going to be able to increase capacity. I guess, have they indicated that months COVID clears, they're ready to basically double up or what have you?
And should we assume that is something that really happens towards the late third, fourth quarter in terms of when we might see that bump?
Yeah. So, what I would say is that it really varies depending on which customer you're talking to, what part of the world you're talking to them in. But, Suky maybe you could just provide a little more color on that, just to give a view of how we're thinking about the back half, and our view of how much backlog or not come through in the back half.
Yeah. Sure, Bryan. So Q2, again, we expect to be sort of a transitional quarter as we get into the back half of the year, guidance assumes sort of normalized growth rates to historic levels, or '19 levels. Inside of that, we would expect if you looked at sort of the midpoint of our guidance range, that, first of all, we expect COVID to continue to linger in many markets within the second-half of the year.
But broadly offsetting that will be some additional capacity that comes through hospital systems and other markets to basically net that out. And that's not uncommon. We saw that in the third quarter of last year, when we look at our results as COVID was stabilizing, you saw hospitals actually increased their capacity to start to bring that backlog through.
So again, at the midpoint of our range, we kind of assumed that lingering COVID is out there in certain markets, but that's offset by additional capacity in other markets. So net-net, you're effectively keeping your backlog steady.
For the bottom end of our range, we assume that COVID has a bigger impact than that backlog pulled through. And at the upper end of our range, we assume that backlog capacity, more than exceeds the COVID pressure that we expect to see lingering through the second-half of the year. So that's kind of how we see, again, we did see those proof points in the third quarter of last year. And as we expect to see, pull-through through this year and the backlog we expect it to resemble very much what we saw in the third quarter of last year.
Very helpful. Thank you very much.
Our next question comes from Jeff Johnson with Baird.
Thank you. Good morning, guys. I wanted to go to the spine and the dental segment if possible. I don't think I heard specifics on one versus the other, other than dental kind of led that growth. So Bryan, any way to break that out for us?
And then in the cervical disk space, you called out Mobi-C. You are seeing some good traction from a 10% competitor in the space. You got a new two level approval from another competitor. Just what's your outlook on the cervical disc side that would be helpful as well? Thanks.
Yeah, absolutely. I won't give specifics between the two businesses, but just know that both businesses did better than we expected in the quarter. Dental definitely was a stronger of the two. But, we know we're excited about seeing that progress. And it was a big, important quarter for us.
Because, remember, this is really the first full quarter, when the organization knew about the spin, really understood the spin. And there was always that risk, obviously, when you announce something like that, there could be some disruption. As you can tell, we're not seeing disruption, if anything, we're actually seeing momentum, which is great.
But, I would say on the cervical disk side, I kind of like the idea of others entering the market, because ultimately, I truly do believe that cervical disc is a better way to go in fusion. So if we have more people entering the space talking about it, I think we've got an opportunity to convert more of the businesses out there today in fusion, that's really the target. If we can increase the size of the cervical market, that's a good thing for everybody, good thing for patients, good thing for the overall business.
And it's an area we're going to continue to focus on. We're going to make sure that we shore up the customers that we have today, but we're going to continue to sell, and proactively get conversions.
Another big opportunity for us in spine is the Tether. I mean, it really is a unique technology for us, it helps scoliosis patients in a way that they cannot get otherwise. And that product is on fire, it's doing a great job. And it's extremely mission-centric to the organization. So that just kind of gives you a general overview. Again, happy with both businesses, dental was stronger in the quarter, but spine did also well.
Fair enough. And then maybe a quick follow up on IQ. Any timelines on actual reimbursement pathway on the monitoring side, just how to think about that getting reimbursed? And is that really going to be the rate limiting factor uptake of that product? Or do you think you could without monitoring reimbursement still sell the IQ product? Thanks.
Yeah. I think it would be nice to have for sure. In reality, it already exists. So, we believe that it will be something that people will be able to access, but we're going to make sure that we get smarter on that topic and help our customers understanding that detail as well. We don't believe it's the requirement though for uptake, I really do believe that people see this as an opportunity to capture the data, and through the data, be able to provide better care.
A couple things that I would say about that is, this is just the beginning. We've had a very strong relationship with Canary. It's a relationship that will go on for many, many years. And, it's not just -- it's going to be for hip, it's going to be for shoulder, there's going to be a whole pipeline of technologies that will launch.
This is just the beginning of the beginning, if you will, for sensors. And this idea of a closed loop is being able to have mymobility applications in each of the areas that we play, having smart implants, as well, having ROSA applications, having OrthoIntel that connects the dots across those, that is something that, ZBEdge ecosystem that we're going to use in each of the areas that we play.
So we're pretty excited about it. And so, I guess, to sum it up to say, the remote patient monitoring reimbursement is a great thing to have, and I think it's warranted, but it's not the reason why we believe we're going to get up thinking this. We truly do believe it's the data capture and what that data can tell us what's going to drive it.
Thank you.
Sure.
Our next question comes from Robbie Marcus with JPMorgan.
Great. Congrats on a really nice quarter. Maybe just two quick ones for me. One, you did the restatement, and I think it helps give us a little more clarity. But, there was a bit of movement out of knees and into other and other into knees. I was wondering if you give us any sort of net number on what ROSA was? And then I'll just ask the follow-up as well.
Really strong operating income results, but free cash flow and operating cash flow came in a bit lower than I was thinking. Any color there and how that should progress over the year? Thanks.
So Suky, maybe I'll toss that one over to you, and then maybe I'll take the follow-up.
Yeah, sure. So on the restatement, first of all, good to talk to you, Robbie. We did do it to provide a little bit more color into what's happening in our base knee business. So you've captured the moving parts correctly. We provide a lot of detail as to what those comparisons are. We're not going to break it down much further. But if there are additional questions after this, our IR team is happy to go through any additional quarterly breakdown.
But overall, we think that that's a good move, especially in the backdrop of -- we hope are going to be some expanding and growing indications for ROSA Robotics. So this will help clarify what's actually happening in those underlying indications relative to based business and capital sales.
Cash flow, overall, operating cash flows were about $245 million, with free cash flow about $145 million. It was a little bit lower than we had last year. Remember, that first quarter is seasonally lower than other quarters throughout the year. That's primarily because we have a lot of big payments that have in the first quarter around prior year rebates, as well as employee bonuses. There are a number of other things that happened in the first quarter that seasonally make that number lower.
In this quarter, two key things. One is we built some excess inventory. So working capital was higher. We do see a market recovery coming later this year. And we want to make sure that we've got a sufficient supply to meet that market demand. So one, we think that that was the right move.
Secondly, from a working capital standpoint, receivables were a bit lower than expected. If you remember, we had a pretty low fourth quarter of last year, that income or that cash comes in the first quarter of this year. And because of those lower sales, you're seeing less cash receipts in the first quarter of this year.
So again, not out of expectation for us, first quarter is generally lower. And those are some of the moving parts inside and inventory being a piece because we are excited about the recovery that's coming. We will, as you can see from our guidance, expect a step up in overall cash flow through the rest of the year.
I'd say it's more bias towards the second-half of the year. And it's really predicated on two things, higher earnings relative to greater sales in the back half of the year, as we've talked about on our revenue guidance. And the second thing is we would expect to see some improvements in working capital, and bringing those inventories down for the rest of the year, as we worked down that inventory we built this year in anticipation of the market recovery.
So hopefully that gives you some additional color on free cash flow.
Yeah, that's great. Thanks for the color.
Our next question comes from Matt Taylor with UBS.
Hi, thanks for taking the question. I wanted to ask you more about your recovery assumptions. I think you mentioned that expected Europe or EMEA to trail in recovery by a couple of quarters. Can you talk about what's informing that view? And when you mentioned, areas taking longer to go through the backlog, is that also Europe/EMEA?
Yeah. Just quickly maybe hit that backlog, recovery and Suky I'll turn it over to you. Yeah, Europe is typically one just based on the healthcare model there, that is a little slower to work through backlogs. The incentives just are not the same as you have in say, the U.S., for instance. So we would expect that to be a little slower in capturing the backlog. But interestingly enough, just because it's running behind probably will have one of the biggest backlogs as a percentage, right, help you look at the overall backlog versus the revenue in that region.
And it will likely take the longest to work through just based on what we just said. But Suky, outside of that maybe you can provide more color on our thinking, on why we believe it's going to be lagging behind.
Yeah, I think you summarized it well, Bryan as major is the vaccination rates are a bit slower than we had originally expected. Outside of that, outside of a EMEA, we also expect a few markets throughout Latin America, as well as the Asia Pacific to continue to lag, just based on so far the vaccination trend that we've been seeing.
Hopefully, the vaccinations begin, the vaccines begin to roll out as robustly as they have in the U.S. globally. But until then, we expect COVID to continue to have a lingering impact on elective procedures.
Great. And then, just wanted to ask on hips. You talked about the ROSA Hip launch later in the year, and that potentially driving you to your goal of above market performance. Can you talk about how sharp you expect the inflection to be and how quickly that can happen? Or any color on how much you think you can outgrow the market once you have that application?
Yeah, thanks. It's interesting, because I referenced that for sure, but actually, if you go back three or four quarters, we probably already in a share taking mode for hip. So just want to make sure that I give a complement to the team there. Having here complete has been a great launch. But just the portfolio that we had before once it gets fly out of the way, that team is really executing well. So I don't want to discount the fact that if you do look at the last three or four quarters, and you look at the other players in the market, we've done well versus the overall market.
The confidence though in sustaining that goes up with a ROSA Hip application. So it's more of the confidence in being able to sustain what's already happened and potentially even buoy it further. And our goal here would be able to launch that in the back half.
Again, the good news is we have a lot more experience with ROSA now, so our confidence level to go more to almost an immediate full launches there. So you're going to see a lot less time spent in limited launch for either partial or ROSA Hip. And we did -- we are going to a tailwind -- a significant tailwind for some time to come.
Thank you.
We'll take our next question from Richard Newitter with SVB Leerink.
Thank you. Bryan, first question, I think I've heard you mentioned when you're talking about Persona-IQ, how excited you are about the platform there, and that you guys have a multi-year kind of vision strategically with Canary, including into hip and shoulder. My understanding was you were only exclusively for now partnered on knees. But did something change? And are you guys more exclusively focused now in other areas as well?
Yeah. We've done a lot of work with Bill and team over Canary. A great, great team over there, by the way, just really good people. And, yeah, we've solidified a very long-term relationship, basically, perpetual, with proprietary use of the technology in all areas that we play, all areas that we placed.
So we are excited to be able to start to work on a very robust pipeline of technology. We've got to look at miniaturization, we've got to look at battery consumption, we've got to look at different form factors that would allow us to use the sensor in other implants. And that's something that we're going to be heavily concentrating on. And so, it's much broader than just knee [ph]. And the two organizations work really well together. And we're excited about the opportunity.
Great, congratulations on that. And then just to follow-up on ROSA Hip. Thanks to the revenue contribution commentary. But just, I guess more philosophically, we've seen robotics uptake in hip your competitor just be slower, is a little bit different type of value proposition. I'm curious, one, are you noticing a mindset shift amongst the customer base with respect to how they're perceiving robotics and hips that would suggest runway for you, as you're launching are different from what maybe your competitor experienced earlier on in there launch of the hip? Or is there something that ROSA does, specifically with robotics that's different there?
I think, it's probably a little bit of both, potentially. I mean, if I think about it, the way I would think about this is in hip, you've got pretty good outcomes right now. It's different than -- you still have most people that get hip procedure that that ultimately feel like, they don't remember having it, because it functions pretty well. Whereas a knee is we always talk about really good 20% of patients that are a little frustrated with the outcome, because they don't get exactly what they expected.
But on the hip side, because of that, most surgeons don't want to disrupt their flow, right. They don't want to take more time to do a procedure. And the key things that we do for ROSA perspective is to try to keep that pick -- that surgeon flow, that procedure flow, pretty consistent with what they're used to, and not as a result of that change the amount of time it takes to do a hip procedure. And I think that will be a very important differentiator here. We're not going to change the time needed to do this.
A couple other things that will be different about this is it is a painless application of robotics to be a first that we'll see in hip. We don't have to place these pins basically drill into the bone of the leg, to be able to have the robot know where the body is in space. So that's going to be unique to us.
The other thing that we're going to focus on here is the application out of the gate is going to be for direct anterior approach, which we know is the fastest growth subcategory hip right now. And it's a challenging procedure, because you don't have great visualization. And it's difficult as a result of that it’s a tough placement right. We're going to make both of those things easier through the ROSA application that we have.
So we think the Avenir Complete implants, we think with this ROSA application, not taking more time to be able to do this the, painless application, and being able to allow people to see where they can see and place the cup where they need to place, it is going to be a big deal. That's what we're betting on.
Thank you very much.
Sure.
So Lauren, I think we have time for maybe one or two final questions.
Thank you. Our next question comes from Steve Beuchaw with Wolfe Research.
Good morning, guys. Liza Garcia [ph] for Steve Beuchaw. Just a quick one on Signature ONE planner, that was a meaningful sequential uptick. And so, I'm just wondering if you could talk about that, relative to your targets.
And then also, if you could speak to ROSA Robotic placements in the quarter? And maybe I know, you said they were strong, but maybe if you could detail a little bit on the geographic trends there that you saw? Thank you.
Okay. So maybe I'll start quickly with that. We had a really strong quarter, again, as a reference pretty similar to what we saw in Q4 of last year. And I think, I want to be a little cautious there, because those are two exceptional quarters, and I feel very confident in our pipeline, but I wouldn't necessarily say that that becomes a new trend. And those are great, great quarters, for sure.
And again, the pipeline is strong. And I would say that my confidence level is extremely high that the overall placements this year will definitely be more than last year. But I just don't want people to think that those quarters are going to be every quarter from here on out, even though the pipeline is pretty strong at this point.
From a geographic mix standpoint, we continue to see really good traction OUS. So I've been very pleased with that, Asia Pacific in particular, but also Europe, Middle East and Africa. So it's been a good distribution around the world of robotic placements, which is one of the key things we wanted to concentrate on. So really strong quarter, the pipeline is very strong, Partial and ROSA Hip are going to help us with that, obviously. And that geographic distribution is a positive for us.
On the Signature ONE planner, yeah, I mean, we're excited about it. I mean, until every single procedure uses pre-surgical planning, we're not finished. We truly do believe it is a better way to care for patients. If you don't know what you're getting into relative to the anatomy, how can you be as prepared as you should be to be able to do the procedure. So we want to make it easier for a surgeon to be fully prepared for that patient, knowing what they're going to deal with when they're in surgery. And pre-surgical planning allows that to happen.
And the real benefit to us is that, number one, we feel the mission of the organization because we're going to do a better procedure, we truly believe that. And number two, we get that sidebar benefit of mix that more revenue per procedure, because if you know the anatomy challenging you're going to be dealing with, you're probably going to be able to get augments ahead of time and you're going to be able to ensure that you've got guides that you're going to need, and that's incremental spend, appropriate spend but incremental spend in the procedure. So that's the benefit for us.
But just know that, no matter what the increases that we talked about on a quarterly basis, sequentially, until we get 100% penetration, we're absolutely not finished there.
Great. Thanks so much.
Thanks, Liza. And Lauren, I think we have time for one final question.
Our final question comes from Pito Chickering with Deutsche Bank.
Good morning, guys. And thanks for squeezing me in here. When I look at the strong first quarter of back into the implied EPS guidance for the rest of the year is generally in line as to your expectations. I believe that like you mentioned 2Q as a transient quarter. So are there any inventory pull forward or regional impact that can have a large impact on 2Q EPS estimates, in which case 2Q EPS comes down, the back half year goes up? Or has history generally modeled in the cadence of 2021 in the right way?
Yeah. So, Pito thanks for the question. One of the comments I made earlier in my prepared remarks are about the seasonality and we're going to start to see that resembled war, pre-COVID cadence than what we saw in 2020. So, we would expect, again, Q2 to resemble that Q2, and Q4 tend to be our stronger quarters from a revenue perspective. These tend to see a little bit of seasonality and a dip in the third quarter. And we think that that's the same shaping for this year, perhaps not as pronounced as you would see in a undisturbed pre-COVID environment.
But again, beginning to resemble what we experienced in 2019. So hopefully, that gives you a little bit more on shaping of our revenue and our P&L cadence as we move through the year.
A quick follow-up question for you on ROSA. What's the breakdown between sales and leases in the first quarter? And I assume lease revenues are now located in the other revenues, how much lease revenue was there in the first quarter? Thanks so much.
Yeah. We don't want to provide specific breakdown of that next, but just know that we got multiple ways that you can place robotics and we track based on what the customer demand or need is. And we usually don't give any specific dollars, relative to what we can do with ROSA in a specific quarter.
But again, I'll just reiterate the fact that, that it was a positive quarter for us, ROSA. And it was a big benefit. And again, the most important thing isn't really the either the quarter that these are placed, it's the tailwind that they create on a go forward basis, because now you've got an opportunity to be able to build revenue around those robotic systems. And what we do when we place these, you get a commitment to competitive conversions.
But what we're finding is attracting this is that whatever we thought we were going to get, we actually get more. And a lot of times, it's not even in the knee business, it's in other businesses that just kind of come to it. It's almost like a halo effect that occurs in the product category.
So, it's always important, we concentrate on obviously what happens in the quarter. But more than anything, it's the annuity value of this that occurs post that placement. And I'm just going to say, maybe with a quick close here, I know we get an alpha spec over to you care of it to close it out, but I just want to make sure that every focus a little bit of attention, I know that there's a ton of focus right now on trying to predict the exact moment that the pandemic is behind us and as a result of that the impact on 2021.
And it's important, believe me, we're spending a lot of time on it too. But in reality, that's kind of the short-term thinking right now, in where I'm spending more of my time that organization is spending more of our time is, what does this look like post the pandemic, when it truly is fully behind us.
And I kind of think of it in a few ways, number one, right out of the gate, the obvious thing is, we're going to have a backlog of patients that's kind of buoy the market growth for some period of time. I said before, I can't predict the amount of time it is, but there's clearly going to be at least a year or more of this backlog that when the pandemic has gone, it's going to be able to get this kind of extraordinary growth in the marketplace. And that's exciting, although not obviously sustainable beyond that.
But there are other things that we're looking at now that truly give us a view that we could potentially reshape the curve of these large joint growth markets. And, big things for us kind of threefold. And the way I think about it, is there's no question is technology revolution is happening in orthopedics. We're going to help drive it, but others are doing it as well. And when that occurs, you're going to get a mixed benefit, you're going to see revenue premiums for every procedure, as this technology is adopted.
If you think about that over a five year period of time, as you get higher adoption, that clearly has an opportunity to drive up the growth rates of the market. Now, we got to do it, until you actually get it done, it doesn't happen. But the fact is, we see a pathway through technology advancements to be able to bend the curve of these growth markets.
The other thing that does too in my view or could do is that there's some hurdles associated with having this type of an ecosystem, this connected ecosystem. And that's going to create barriers to entry into the space where there really wasn't a lot before. And that gives you the byproduct benefit of longer-term contracts, deeper relationships with your customers, and probably better pricing stability. So those are something else that we're looking at with this technology.
And I think the third one, I think, very important as we get better outcomes for patients and the confidence level goes up for these procedures, I truly do believe there are patients on the sidelines today that should be getting the procedure but are fearful of it. When they start to hear better outcomes, more technology, you may see some of those patients out of the funnel. Again, all these things are potential building blocks. As we think about the future of orthopedics, it can make the space much more attractive. We got to deliver on it. They're not guaranteed. We got to make sure that it happens. But that's where we're focusing our attention now to make those things a reality.
So, I just want to leave you with those thoughts, because that's an exciting future, I believe for orthopedics. Keri, I'll turn it back to you.
Thanks, Bryan. I'm sure we'll be talking to many of you today for calls and follow-up questions. If you do have them, please don't hesitate to reach out to the IR Team. We're always available over phone or email. Lauren, I'll turn it back over to you to close out.
Thank you, again, for participating in today's conference call. You may now disconnect.