Alphatec - Earnings Call - Q1 2025

Transcript

Operator (participant)

Good afternoon, everyone, and welcome to the webcast of ATEC's Q1 financial results. We would like to remind everyone that participants on the call will make forward-looking statements. These statements are based on current expectations and are subject to uncertainties that could cause actual results to differ materially. These uncertainties are detailed in documents filed regularly with the SEC. During this call, you may hear the company refer to non-GAAP or adjusted measures. Reconciliations of these measures to US GAAP can be found in the supplemental financial tables included in today's press release, which identify and quantify all excluded items and provide management's view of why this information is useful to investors. Leading today's call will be ATEC's Chairman and CEO, Pat Miles, and CFO, Todd Koning. Now, I will turn the call over to Pat Miles.

Patrick Miles (Chairman, President and CEO)

Thanks so much, Greg, and welcome everybody to the Q1 2025 financial results ATEC earnings call. There will be a few forward-looking statements, which I would ask for you to review at your leisure. Really a great start to 2025. Enjoyed revenue growth at 22% with surgical growth at 24%. That's about four times the market if you're keeping track. This is really a phenomenal result for the largest pure-play spine company in ATEC. Q1 is always a little challenging seasonally when it comes to profitability and cash flow. As cash flow or case volume slows compared to Q4, taxes reset, and we see a disproportionate share of meetings and events. In spite of all of that, we delivered $11 million of adjusted EBITDA, which was our second-best quarter ever and above expectations.

From a cash flow perspective, our cash burn in Q1 was at the low end of the range at $15 million. Profitability and cash flow performance in Q1 has really put us in a great position to meet or exceed our 2025 goals. I think if we hearken back, the changes we made last year have resulted in a much more cash-efficient organization. We are 100% committed to continuing to operate the company in a deliberate manner and deliver growth, profitability, and cash flow commitments as stated. The revenue came in at $169 million. Really, the key thing I'd like to highlight is the strength of the surgical growth, where we saw 24% year-over-year growth. Underpinning this growth was an 18% increase in the number of surgeons utilizing ATEC procedures.

The fact that revenue grew 23% in established territory demonstrates how we continue to gain surgeon and territory penetration where we have established representation. What I would tell you is our thesis is working, and where we have representation that's been established, we continue to compel adoption. The durable revenue growth drives profitability and cash flow clearly. EOS order growth was also a record for which we're very, very encouraged. It's a foundation of our strategy. Finally, as the largest pure play, we continue to be the preferred destination spine. The environment for recruiting sales talent couldn't be better. Really, we're off to a great start with great confidence in terms of moving into the year. With that, I'll turn it over to Todd.

Todd Koning (Executive VP and CFO)

Thank you, Pat, and good afternoon, everybody. I'll begin today with the Q1 2025 P&L highlights. Total revenue was $169 million, up 22% compared to the prior year. The $169 million in revenue was comprised of $152 million in surgical revenue and $17 million of EOS revenue. Q1 surgical revenue of $152 million grew 24% compared to the prior year period. That represents nearly $30 million in year-over-year growth. When normalizing for selling days, we grew $32 million year-over-year, or 26%. Procedural volume growth was 17%, driven by strong surgeon adoption of 18%. This level of adoption clearly reflects the compelling nature of our portfolio and is supported by the ongoing investments in the sales force. Average revenue per procedure growth was a strong 6% as we continue to capture more of the procedural revenue opportunity.

Same-store sales, or sales that come from sales agents that have been in territory for a year or more, grew 23% year-over-year, which demonstrates that we continue to grow significantly in the markets where we are already established through growing both our share of wallet with existing surgeons and new surgeon adoption. EOS revenue increased $17 million in the Q1, up 8% compared to last year. Record order volume has fueled a 28% year-over-year increase in the order book, evidence of the demand for our unique end-to-end informatics solution, and positions us for strong system installations and the accompanied implant pull-through in the coming years. Turning to the remainder of the P&L, Q1 non-GAAP gross margin was 70%, down 50 basis points compared to the previous year and up 70 basis points sequentially, primarily driven by product mix. Non-GAAP R&D was $13 million and approximately 8% of sales.

Top-line growth drove 230 basis points of leverage, while absolute spend has remained roughly flat. Non-GAAP SG&A was $111 million and approximately 66% of sales. Approximately 400 basis points of year-over-year improvement came from variable expense rate improvement, while the balance came from infrastructure leverage. We reported total non-GAAP operating expense of $124 million, which was approximately 74% of sales. By maintaining disciplined cost management, we delivered a modest 8% increase in operating expenses while continuing to invest in the growth drivers of the business. Those efforts, along with our durable top-line growth, drove a 900 basis point expansion in our operating margin year-over-year. I'll turn next to adjusted EBITDA, which was positive for the fourth consecutive quarter. Our Q1 adjusted EBITDA was $11 million, equating to a 6% margin and over 800 basis points of improvement compared to the prior year period.

We are very pleased with this performance. It is the second best performance we've had since the start of ATEC's transformation. This quarter also marks our second consecutive period with an over 40% drop-through on a year-over-year revenue growth to adjusted EBITDA, reflecting both infrastructure scalability and an improving variable selling expense profile. You can see in the chart on this slide that the profit margin expansion that we are executing has been significant and consistent. This quarter marks 12 consecutive quarters of adjusted EBITDA margin expansion. We entered 2025 a stronger company, and that is clearly reflected in our Q1 results. This progress stems from the changes we implemented last year to improve in two key areas. Firstly, the management and prioritization of our human resources, and secondly, strengthened focus and operational improvements in managing inventory and instrumentation sets.

We are driving meaningful margin expansion that aligns with the priorities outlined in our long-range plan and is a result of disciplined execution. These deliberate results give us great confidence in our ability to continue delivering on our financial commitments and translate revenue growth into profit and cash flow. Turning now to the balance sheet, we ended the Q1 with $153 million in cash on hand. Additionally, we had access to $60 million of available borrowing on our revolving credit line, which was undrawn at quarter end, making our total cash and available cash $213 million. Our free cash use of $15 million in the Q1 represents a $55 million improvement in cash use over the Q1 2024.

We managed our free cash use performance to the favorable end of the $15-$20 million range that we previously communicated and would have beat if not for working capital headwinds. These headwinds were modest and transient, and we believe the metrics will improve over the course of 2025. Our Q1 cash management execution and the underlying dynamics of the business reinforces our confidence that we will be cash flow positive for the full year. In March, we successfully refinanced our 2026 convertible note. Refinancing effectively pushed out the maturity to 2030, provided dilution protection up to $23.46, and maintained the same low coupon rate of 75 basis points. We used the $405 million of proceeds to pay for the fees and the cap call and bought back 80% of the existing convert, the maximum allowed under creeping tender rules.

The net proceeds of $82 million gives us flexibility to address the remaining $63 million of the 2026 notes when the time is right. Our financial outlook for the year expects continued strong revenue growth to drive incremental profit margin expansion. As we exited the Q1 of the year and contemplated our full year outlook, we felt it prudent to simply flow through the beat on the top and bottom line. This approach is consistent with our philosophy of guiding the numbers we believe we can achieve and have a reasonable opportunity to exceed. As it relates to cash flow, our Q1 performance further reinforces that we will be cash flow positive for the full year 2025.

With respect to the cadence of our cash flows for the remainder of 2025, we expect the Q2 to range from $0 to $5 million, with the third and the Q4 generating positive cash flow, resulting in us being cash flow positive for the full year 2025. Our revenue outlook for the full year 2025 expects adoption of our unique procedural approach to drive revenue growth of 20% to approximately $734 million compared to our previous guidance of $732 million. That includes surgical revenue growth of 21% to approximately $658 million, which will be fueled by mid-teen surgical volume growth and mid-single digit revenue per surgery growth. We expect EOS revenue approximately $76 million.

Turning to the outlook for the full year 2025 adjusted EBITDA, we expect sales growth to continue to leverage the infrastructure we have built, contributing to an adjusted EBITDA of $78 million versus our prior guidance of $75 million. This includes us absorbing the impact of expected tariffs in the second half of the year. Our direct exposure to tariffs is limited to the EOS units. We import from France to support the U.S. installations and the associated repair parts. We estimate the impact of tariffs on our cost of goods sold to be in the low single-digit millions of dollars. The chart on the slide depicts the consistency of the profitability progress we are making. Our adjusted EBITDA guidance of $78 million will generate an adjusted EBITDA margin of 11%. That implies a 39% drop-through of the incremental growth in revenue dollars to adjusted EBITDA.

This trajectory positions us well to achieve our 2027 adjusted EBITDA margin goal of 18% at $1 billion in revenue. In conclusion, through our investments in the team and infrastructure, we have built a fast-growing, 100% spine-focused company. We are delivering on a return on those investments through durable revenue growth leadership and consistent operating leverage improvement, which is beginning to inflect the cash flow generation. With that, I'll turn the call back over to Pat.

Patrick Miles (Chairman, President and CEO)

Thank you much, Todd. I want to spend a few slides just kind of walking through a couple of strategic imperatives, as I would say. Our strategy has been steadfast and our execution relentless. We have been consistent not only in who we intend to be, but the execution of it all. We are creating clinical distinction. It's undeniable. We have and will continue to architect unparalleled procedural solutions that improve patient outcomes. I think PTP and LTP are clearly—we're heading into deformity in a similar way. The revenue growth and surgeon user growth affirms we are compelling adoption. We are doing this by furthering clinical value. We talk a lot about furthering value by minimizing surgical variables with technology, and this is happening. Additionally, we're expanding our sales force and getting better in the field.

I would say that we are scaling and we are winning. Something that's near and dear, I think, is really the growing validation of our EOS and informatics thesis. We've talked a lot about the unusually high revision rates in spine surgery versus hip and knee, which just speaks to the opportunity. The volume of variables in spine surgery far outnumbers that in single joint surgery. Our view is that many of the issues driving revision spine surgery can be effectuated by controlling variables through improved informatics, hence the foundational commitment. I think that there's a misplaced notion that revision is most often caused by intraoperative surgeon error due to a lack of precision. The reality is that most revision surgery is not due to error in implant or pedicle screw placement, but rather error prior to the surgery due to a lack of surgical planning.

It is for this reason we strongly believe that the spine field needs more automated informatics. We view our pre, intra, and post-op informatics will drive much more predictable surgery than the incremental precision associated with pedicle screw placement. Hence our thesis committed to EOS and informatics. Much like we said in the early days of the ATEC turnaround, spine needs ATEC. I would tell you that spine surgery needs automated alignment planning and predictive analytics, and we're bringing that to you with EOS. Super enthusiastic with regard to that. There's nothing better than having a thesis and then have it reflect in the specific patient outcomes, and that's what we're doing. I would tell you that our history is one of technological furtherance.

Much like when we acquired SafeOp and integrated different modalities, the auto EMG, auto SSEPs, and facilitated MEPs, we furthered the technology to a point of great clinical influence on lateral surgery. If you want to look at a proxy, SafeOp is a proxy for what we are doing for EOS. The same effect is happening with EOS. Below and pictorially, what you see is you see a patient where the pre-op scan gave not only spine alignment parameters in an automated way, but also where the spine should be normatively. Not just numeric reflections of bringing objective measure, but really where the spine should be. A surgical plan was assembled and executed with a post-op scan at 6 and 12 weeks.

You will see that the pre-op picture reflects not only automated measures, but where the normative position is, where the spine should be based upon age and demographic. The plan provides a simulation of values required to achieve the surgical goals. The 6 and 12 week provides assessment for surgical plans. You could tell exactly how you did. This is a much more comprehensive clinical approach to what is commonly done today. If alignment is a key quota to a successful long-term outcome, meaning it impacts or lessens the revision rate, it is this type of information that brings about objective measure and makes for a meaningful difference. We cannot be more excited about where we are with the EOS strategy.

Clearly, there's a lot of enthusiasm with regard to the acquisition of the units, and we are headed to a future of predictive analytics, and that we find to be extraordinarily exciting. If you think about what's fueled the company today, it's really kind of the architecting of procedures for really architecting procedures. What we see is we see an expanding complexity. Our procedural strategy continues to expand application and grow in volume. For us, it is quite clear that if your objective is to lessen variables that undermine clinical predictability, then assembling all the elements of a procedure will create demand and compel adoption. We have seen our lateral franchise grow in both total procedures and addressable pathologies.

Like most new techniques, surgeons start their adoption in short segment, simple type of applications, and then as they see success, they continue to expand utility to more levels and greater complexity. That has clearly been the case with what we've done from a lateral perspective. We have recently launched our fully integrated corpectomy system that includes not only implants, but a specifically designed retractor for the unique requirements of this surgery. Because many times vertebral fracture is in the thoracic spine, it is vitally important to monitor the spinal cord, enter SafeOp 3 and the MEP modality. Monitoring motor function throughout these complex surgeries is a requirement. A big reason we are growing at the rate that we are is that these spine procedures are fully thought out.

They include patient positioners, specific monitoring, customized surgical exposure with indication-specific retractors, implants, and soon-to-come integrated navigation to reduce radiation and increase precision. It is no wonder that we will continue to expand our footprint in lateral surgery and beyond. A nemesis in spine has been the requirement for surgeons to make do without fully contemplated spine procedures. That is no longer the case as we continue to expand our significant influence. In speaking about compelling adoption and winning access, as I previously described, our lateral business is the perfect proxy for our procedural strategy. We are taking the learnings from that experience and applying it across other techniques. Our growth rate is reflective of compelling adoption. Surgeons are growing utility through increased volume and expanded application. What is also true is that with EOS, we are gaining access to more surgeons, academic institutions, and hospital systems.

The very thesis that we contemplated is coming to fruition in front of our eyes. The clinical credibility of our foundational informatics technology enables us to win access. Our informatic ecosystem is the most comprehensive and scalable in the business. The recently launched EOS Insight software enables us to scan a patient, automate alignment measures for assessment, simulate the surgical effect through our planning software, integrate the surgical plan into the OR so as to reflect the plan and confirm intraoperatively. However, the most exciting piece really is the correlation, not only immediately after surgery to understand the veracity of the surgical plan execution, but also to understand how things evolve over time through longitudinal correlation. Correlation is the foundation of AI. We have the makings of an informatic system that will be predictive as we move forward and gain a deeper understanding for improved decision-making.

I would tell you that if spine is your vocation, I don't know of a better place than ATEC. That is why we know it to be the preferred destination. I'm excited to continue to grow the ATEC faithful, and with that, we'll take questions.

Operator (participant)

All right. Thank you. We will now open up the floor for questions. I would like to remind everyone that in order to ask a question, it is pressing star one on your telephone keypad. In consideration of others, please limit yourself to one question. Thank you very much. We will pause just a moment to compile the Q&A roster. All right. Looks like our first question today comes from the line of Brooks O'Neil with Lake Street Capital Markets. Brooks, please go ahead.

Brooks O'Neil (Senior Research Analyst)

Thank you. Good afternoon, guys. Congratulations on a good start to the year. Pat, you're just talking a lot about the new corpectomy system, and I'm hoping you could give us a little bit of a feel for how big you think that market segment might be and maybe what the competitive dynamics are as it relates to other players that already have products or systems to address the need.

Patrick Miles (Chairman, President and CEO)

Yeah. Thanks, Brooks. I appreciate the question. In terms of valuing the market, that's a bit of a tough one. What you see is, from a marketplace perspective, I would tell you that we're the only ones doing this in the prone position. When you have instability based upon fracture, which is oftentimes mostly tumor and trauma are the utility for a corpectomy. When you have instability, what you want is access to the front and the back of the spine. The beauty of PTP is that you have access to the front and the back of the spine in the same setting. This is really a unique approach for us. Others have tried to do it in the lateral position and have done it in the lateral position. To do it in a prone position is highly advantageous.

Super excited about it. It's completely reflective of what we intended in terms of the whole you start simple and you continue to walk. What you see is you see not only expansion in the volume of procedures applied, but also the number of applications and reasons why someone should learn the technique and apply it to their practice. We're seeing it in spades. The reason I brought up the EOS and academic access is a lot of these get shipped over to academic institutions just because of the complexity and because these are oftentimes seriously ill patients. The whole EOS play and the whole dynamic of continuing to march up the complexity curve, I think, play together. Maybe more color than you wanted, but just a little bit about the system itself. From an engineering perspective, it's outstanding.

The retractor and just the versatility of an exposure system specific for corpectomy and then the implant itself is outstanding. The type of mechanical prowess we have around here is unbelievable. It ties in well with the other things that we're doing, as I said, with MEPs from a SafeOp perspective and otherwise.

Brooks O'Neil (Senior Research Analyst)

All right, Pat, that was awesome. Do you mind if I just ask you, do you think you will ultimately incorporate any functionality from EOS in that particular procedure or no?

Patrick Miles (Chairman, President and CEO)

You know, the beauty of what we're doing with EOS is that our ability to measure the alignment parameters with a patient like that, that's rarely done. To be able to get an EOS scan and then integrate that element into the operative experience and make sure that the patient walks away not only fixed from a stability perspective, but fixed in alignment. Whenever we talk about the goals of surgery being decompression, stabilization, and alignment, we will have fulfilled them based upon the sophistication of not only the procedure, but also the type of informatic that drives a behavior. Anyway, it's exciting to know that because oftentimes this may be a young person. If they have a traumatic accident, the last thing you want to do is have them have an adjacent level disease because you fix them in the wrong place.

Anyway, the alignment piece is a big part of it, and you can utilize EOS as a proxy for alignment that we integrate into the operative experience.

Brooks O'Neil (Senior Research Analyst)

Great. Thank you very much.

Patrick Miles (Chairman, President and CEO)

Yep. Thank you.

Operator (participant)

Thanks, Brooks. Our next question comes from the line of Vik Chopra with Wells Fargo. Vik, please go ahead.

Vik Chopra (Executive Director and Equity Research Analyst)

Hey, good afternoon, and thanks so much for taking the question. Two for me. I was just wondering if you could just talk about the tariff exposure in 2025, when you expect that to hit the P&L, and maybe what % of your products are sourced from or manufactured in Mexico, China, and the EU. I just had a quick follow-up, please.

Todd Koning (Executive VP and CFO)

Yeah, Vic, good afternoon. Thanks for the call or the question, rather. The tariff exposure, as I laid out in my prepared remarks, we size that to be approximately low single-digit millions hitting our cost of goods sold line, largely in the second half of this year. Our exposure is really limited to our EOS equipment and any related replacement parts associated with EOS, largely because we manufacture our EOS machines in France and we import the U.S. volume into America for the installed base. That's the exposure. We really don't have direct tariff exposure in our implant business.

Vik Chopra (Executive Director and Equity Research Analyst)

Okay. That's super helpful. Thanks for clarifying that, Todd. My follow-up question is, any update on your robot launch plans and maybe just talk about how Valence will fit into the company's overall strategy? Thank you.

Patrick Miles (Chairman, President and CEO)

Yeah. Thanks, Vic. Everything is going as planned. We are doing cases. As a matter of fact, I was in a case recently, and everything is going as planned. The whole verification process, in my mind, becomes the most important. Such a big part of our thesis is procedures. I was in a place recently; we did, as if I did it, there are seven PTPs done before 1:00 P.M. It just speaks to the efficiency of the workflow. The last thing we want to do is slow the workflow because there's some goofy interaction with regard to our robotic piece or our navigation piece. We are in the alpha phase. Everything is going as planned. Looking forward to integrating the navigation piece to that. This should be an end-of-the-year launch.

Really, I'm trying to think of any other color that would be of interest, but I think that I'm as excited about the navigation piece in the integrated workflow as I am the robotic piece.

Operator (participant)

All right. Thank you, Vic. Our next question comes from the line of Matt Miksic with Barclays. Matt, please go ahead.

Matt Miksic (Managing Director and Senior Equity Research Analyst)

Hi. Thanks so much for taking the question. Wanted to ask if you could maybe, Todd, dive into a little bit more color on the cash outlay. I know that was a big subject last year. You exceeded or beat our number this Q1, as hoped. Maybe just talk about how the cash use is changing, maybe what the trends for the rest of the year should look like, and then I have one quick follow-up.

Patrick Miles (Chairman, President and CEO)

Hey, Matt, because I don't do numeric things very well, I'm going to tell you just a little color. You know what thrills me is when you start to think about cash utility, I immediately think of sets and the like. The one place that I didn't mention in my prepared remarks, but we're getting just light years better, is in terms of asset utility and asset place. It's a situation to where, as we continue to mature, and I think about it clinically, we continue to get better in such profound ways. We're also getting profoundly better with regard to our operational prowess. I would tell you that that's a big part of cash utility.

Before Todd gets into the specific numbers, I just want to mention the investment in our Memphis facility several years ago, the type of sophistication that's going on there, the just continued evolution and maturity internally here. Our field force is getting better, and the people who are managing in the field are getting better. I just want to make mention of that because I think it's so important.

Todd Koning (Executive VP and CFO)

Agreed, Pat. Matt, maybe I'll step back and hit a couple of things. One, I think the timing question is real. Last quarter, we said Q1 would be a cash use between $15 million and $20 million, and we clearly hit the low end of that range and feel really good about that execution. In my prepared remarks, I said Q2, you should expect a zero to plus five, and then positive in Q3 and positive in Q4 to get you something north of zero on the full year. That's the cadence that we expect. I think your question really was, why do we do better? How do we think about the balance of the year? What gives us confidence? I think, first off, why do we do better?

I did make mention of the fact that we saw some modest, yet transient working capital headwinds. Our kind of assumption coming into the year was accounts receivable, DSO would be around 45 days. We were at the high 40s here in the month, and some of that just kind of comes down to timing and whatnot. For us to be able to achieve a $15 million cash use and still withstand a little bit of that headwind on the working capital front, I feel very good. That tells me that I feel good about where I'm at because I think that working capital metrics will essentially go back to where we expect them to for the balance of the year, which gives me a level of confidence that we can continue to make progress on cash flow just from that standpoint.

You think about the fact that our adjusted EBITDA was significantly better, about $3 million better than we anticipated here in the Q1. Some of that falls through to your cash flow. I think the ongoing profitability profile that we have seen and are expecting to see gives us confidence in our ability to hit our cash flow goals. I think this year and going into next year and beyond is really what Pat, I think, is also talking to, which is the asset utilization is getting better. We have got a long ways to go, of course, but it is getting better. When you see the dynamics of top-line growth, expanding profitability, certainly in this quarter ahead of what we expected, and an improving asset utilization environment, you feel really good about your ability to be cash efficient.

Matt Miksic (Managing Director and Senior Equity Research Analyst)

That's super helpful. Just maybe one question, if I could, on some of the competitive dynamics in Spine right now. You may have commented on it. I'm juggling a few calls right now. Any color you have on the quality of reps, the type of reps, the number of inbound, the posture of the company right now in terms of adding reps and an important part of growing the way you're growing, any color would be appreciated. Thanks.

Patrick Miles (Chairman, President and CEO)

Yeah. We were trying to be subtle with regard to the preferred destination piece. It's one of those things where it's like, in all sincerity, though, if you think about if your vocation is spine surgery, you want to be aligned with a company that existence is dependent upon being great in spine surgery. And candidly, that's us, and we're the pure play. We're unapologetically evangelical about this space. We know that we're able to make it better. You look outside and you see how things have spun to private equity in a couple of instances. We've already made a big investment that we're scaling off of over the next years ahead. We feel like our ecosystem just avails continued improvement, continued evolution, continued capacity to make things better. I would say the guys who have spun out have a big investment ahead of them.

This is an expensive place. We're seeing a lot of people realizing that. I think when you start to see the volume of new surgeons that are coming over, you start to wonder, will their rep come with them? The answer is clearly, as straight commission guys, yes. We're seeing ex-Stryker, we're seeing Medtronic, we're seeing Globus, we're seeing... As we talked about, geez, a year ago, these things play out over long periods of time because everybody has their own individual dynamics that drive their change. I would tell you, if you'd have told me seven years ago when we started this turnaround that we'd be sitting here as the largest pure-play spine company with the opportunity to run the table, I would say I'd be surprised.

That is where we sit today, and we can't be more excited about the opportunity.

Matt Miksic (Managing Director and Senior Equity Research Analyst)

Wow. Congrats on all the progress. Thanks for taking the questions.

Patrick Miles (Chairman, President and CEO)

Thanks, Matt.

Operator (participant)

Thank you, Matt. Our next question comes from the line of Matthew Blackman with Stifel. Matthew, please go ahead.

Mathew Blackman (Managing Director and Supplies Equity Research Analyst)

Hi. Good afternoon, everybody. Just upfront, I had every intention to respect your one question request, but no one else has, I guess I won't either. Apologies in advance. If I could start, Pat, you sort of alluded to it, Todd, maybe to the extent you can, maybe layer in some numbers if applicable. I was hoping to sort of get a state of the union on the salesforce today, where they are in terms of productivity relative to expectations, particularly the reps that you've recruited and onboarded over the last couple of years. Do they have all the sets and implants they need? Are you finding more opportunities than you expected with these new reps? Again, we're a year plus out. I think everybody's got what they need.

Just how the rep footprint is performing and how that performed in the Q1.

Patrick Miles (Chairman, President and CEO)

Yeah. Matt, it's really like, and this is no kiss-up. It's such the good question because it's like, what happens oftentimes is demographically, the rep that comes over reflects the configuration of what he previously sold. What we see is, over time, they evolve into this whole kind of more lateral type of business. As we said, it takes 12 to 18 months to ultimately reflect in a momentum of any kind. What we're seeing is geographically different footprints of the types of sales that they're doing, and then what they're doing is evolving. Probably the one that comes to mind is up in the Northeast. Initially, we were being very conventional with regard to the reflected product utility. We're evolving now more into a more proprietary type of sales reflection. It's fun to see that start to come forth.

We have the sets. As I said, we're being more efficient with the sets, which avails more opportunity to place them in different locations. The thing that is super attractive is we're in a bunch of academic institutions, which we weren't before. I think just the reputational dynamic of not only having a unique tool with PTP, but then also coming forth with EOS and translating that into the operative experience avails access. Those are the things that we contemplated in the acquisition of the technology and how we would ultimately evolve it. Just some color in terms of just the generalities of what we're seeing. We have a long way to go with regard to the build-out of the salesforce in any meaningful density. We're still, I would tell you, young in the process.

Todd Koning (Executive VP and CFO)

Agreed. Matt, I think maybe I just give you two data points here. One, we talk about same-store sales, so growth in sales agent territories that have been with us for a year or more, growing at 23%. That is relative to a 24% growth in our overall surgical revenue in the Q1. That tells you that people show up, and year after year after year after year, they grow on the territory that they have. I think that tells you both that, one, you get more of a share of your existing surgeons' business, plus you are able to expand kind of across the territory and attract more surgeons into that territory. I think that is demonstrated by the fact if you look at the absolute dollar growth.

If you normalize this quarter for 64 days versus 63 days, over the last two years, we've added more than $60 million. That's about a $30 million a year clip. That really kind of accelerated here in 2025 over 2024. I would tell you that, yeah, the investments we're making are certainly paying off. That's a reflection of the, I think, the demand profile that's there, which is a function of the clinical distinction and our procedural approach.

Mathew Blackman (Managing Director and Supplies Equity Research Analyst)

I appreciate that. My follow-up, it's actually, I think, a good segue on Pat's commentary on EOS. I'm curious, can you give us just even in the roughest sense how EOS placements today are splitting out between new accounts to ATEC, under-indexed accounts, and core ATEC users, just from who's using the portfolio and not today? You mentioned it. We've done a lot of work. We've obviously seen this playbook at other companies with enabling technology. Is there a number you can point to in terms of you put an EOS system in, you get this type of magnitude of portfolio pull-through? I guess specifically, maybe the Holy Grail for EOS is getting you into these complex procedures where you're definitely under-indexed for peers. Is that happening? Is that a tipping point ahead for that happening?

Just any color on EOS would be helpful. Appreciate it. Thank you.

Patrick Miles (Chairman, President and CEO)

Yeah. Thanks, Matt. Clearly, that's the long play, right? I think that we've been pretty deliberate with regard to turning this company around and doing something unique that was reflective of our expertise in lateral. That's clearly playing out exactly as planned. I think the EOS element, I wanted to show you an example. I could show you a bunch of examples of watching the EOS things play out in real time. When you start talking about, gosh, are we gaining access and how is it different? It's like, I recall when we had zero access. When you see places like Hospital for Special Surgery having, I think, nine of them or something to that effect, and you have all of these very highly sought-after institutions having a bunch of them, clearly, it is a valuable tool.

When you look at the demographics of who's getting them, I would tell you that most of the people buying EOSs were not customers of ours before. They are customers of ours now. Historically, it's been more of a pediatric type of a tool. We've been very under-indexed in pediatric surgery, but we're heading in that direction. The great thing is what we contemplated when we initially bought the asset was, how do we be relevant in adult deformity first? Because the pediatric utility was robust and it wasn't a place that we felt like we could make immediate type of influence. As we've continued to get more adoption in the adult deformity realm, you'll see the adolescent impeding thing follow suit. We think that our best is yet to come.

We say things like that really numerically minded because we haven't touched parts of this thing that ultimately are highly valuable from a clinical perspective.

Mathew Blackman (Managing Director and Supplies Equity Research Analyst)

All right. I appreciate it, guys. I promise we'll all try harder next quarter to limit ourselves to one question. Thanks.

Patrick Miles (Chairman, President and CEO)

Thanks.

Operator (participant)

Thanks, Matt. Next question comes from the line of Matthew O'Brien with Piper Sandler. Matthew, please go ahead.

Samantha Graham (Vice President and Equity Research Analyst)

This is Samantha on from Matt. Thank you for taking our question. I guess we just wanted to touch on just overall volumes, how those are trending, and then also any feedback on growth in the ASCs as well.

Patrick Miles (Chairman, President and CEO)

Yeah. I would say our view is the market is healthy and volumes are good. I don't think it grew 24% surgically if it's not the case. Just kind of a 60,000-footview view, I'll let Todd pipe in if he'd like to add any specifics. The ASC is a long play. What happens is the most simple type of pathology gets done in a place where there's greatest, where the surgeon has the greatest comfort and the greatest predictability. I think over time, you're going to see that change. I think there's guys today doing PTP in an outpatient setting. They're doing very simple single-level type of things. What happens is your ability to control pain for a patient and your ability to limit the potential for complication is really kind of the driving forces of the ASC.

A lot of work like decompression and single-level and maybe two-level cervical. Those are the major things going on there today. I think you're seeing an evolution that's going to just take time.

Samantha Graham (Vice President and Equity Research Analyst)

Awesome. Thank you. That's great. I know we previously touched on the robot that's coming out, I think you said at the end of this year. I guess just wanted to touch on that again and kind of any feedback on kind of what's left to get it launched and any feedback you've had from physicians. Thank you.

Patrick Miles (Chairman, President and CEO)

Yeah. Thanks. The feedback's been great. It places screws accurately, which is what robots in the spine space do. The software is very intuitive. The utility has been expedient. My greatest concerns are always workflow. Are we taking, are we increasing anesthetic time because we're trying to place a screw slightly more precisely? It ultimately doesn't effectuate the clinical dynamic. I think that's, yeah, I don't want that. We want to make sure that the workflow is very seamless. Really, what we're waiting on is our navigation piece and such that what we're doing is we're navigating an entire procedure. So meaning we're navigating the lateral space. We're integrating the robot in the posterior space.

The beauty of PTP and to be able to watch a surgery whereby a surgeon has access to the anterior column, navigates that access, the PA closes while the surgeon operates on the back. That level of expedience and that level of elegance from a workflow perspective is nonexistent today. Our opportunity to continue to be the purveyors of that is very apparent. Anyway, we're seeing the very thing that it's supposed to do with regard to the robotic piece. As all a robot is, is part of a stabilization workflow. That's it. I think there's been some romanticizing of it that is misdirected.

Samantha Graham (Vice President and Equity Research Analyst)

Thank you.

Operator (participant)

Thanks, Samantha. Our next question comes from the line of Young Lee with Jefferies. Young, please go ahead.

Young Li (SVP and Equity Research Analyst)

All right. Good afternoon. Thanks for taking the question. I'll just keep it to one. On the spine market, I guess I'm kind of curious about the deferrability and the resiliency of the market during an economic downturn. Maybe try to jog your memory a little bit on if you remember sort of what happened to the spine market during the financial crisis as kind of like a worst-case scenario for any potential upcoming macro headwind.

Patrick Miles (Chairman, President and CEO)

Yeah. I guess, and Todd could pipe in. I shudder to say I was around in 2008. Not that my recollection is going to be very precise as it relates to the different years, but spine is not elective. I think that there becomes this dynamic to where it's like, "Hey, can they put it off?" If you have neural pain, you're not going to put it off. I would tell you that it's highly resilient in the volatility of the, I'll speak to the current economic uncertainty. It's like we're not seeing changes in volumes. We're seeing a lot of demand for what we're doing. I would tell you nothing has changed other than there's high demand for what we're doing. There's a robust backlog of things to do.

We are leaning in as aggressively as we can to this market. We love this market. We think it's helping people. We know it's helping people. That will continue.

Todd Koning (Executive VP and CFO)

Young, I think to put a finer point on history a little bit, I think to Pat's point, you go back to the financial crisis. I think the analysis we've done would suggest that our market was reasonably robust during that point in time. I think the other point is, as you looked at volumes that went through COVID, while there was certainly some staffing influence to the volume moving around, the fundamental demand did not go away.

Patrick Miles (Chairman, President and CEO)

We grew for those years.

Todd Koning (Executive VP and CFO)

Exactly. I feel like we're in a pretty good spot.

Young Li (SVP and Equity Research Analyst)

All right. Great. Appreciate it.

Operator (participant)

All right. Thanks, Young. Our next question comes from the line of Josh Jennings with TD Cowen. Josh, please go ahead.

Eric Alm (Analyst)

Hi. This is Eric Alm for Josh. Thank you, guys, for taking the question. I wanted to ask your latest thoughts around expansion into international markets. I know Australia and New Zealand have been a focus. You had your first surgeries in Japan not too long ago. Specifically, I was just curious if your thinking internationally changes at all given the current macro landscape or maybe not at all, but how should we be thinking about that?

Patrick Miles (Chairman, President and CEO)

Yeah. I think that we've been so affirmed by our approach. The way we built the structure of the company is we haven't built a huge international infrastructure to serve a place that's not profitable. We've been totally bullish on Australia and New Zealand just because it's top of mind. Got a note today in terms of people reaching well north of 100 in their PTP experience down in Australia. The thing is going as we intended. We don't have a big infrastructure, but we have a very narrow business that shares the same type of a surgical perspective as we do. Love that. We are in such the early phase of the second largest market in the world of Japan. We have light years to go in that market.

I love kind of our thesis as it relates to, let's say, focal, let's say, completely committed to a marketplace. Japan also is a great deformity market. They love EOS. Our opportunity to ultimately lay the foundation with lateral and evolve into the EOS translation is so apparent. Anyway, I think that we're well positioned. There's really not a lot of interest to go outside that dynamic. I think our internal build thesis has reflected as much.

Todd Koning (Executive VP and CFO)

To Eric, narrow and deep. That is what we have always said. I think that is what we are seeing. To Pat's point, I think the strategy is paying off. We got a huge road in front of us internationally in the markets that we have chosen.

Patrick Miles (Chairman, President and CEO)

Agreed.

Eric Alm (Analyst)

Understood. Yeah, that makes sense. If I could ask one quick follow-up just on pricing generally, if I think about commentary from some med device management teams lately in ortho specifically, it seems like in the last year or so, we sort of entered a new era for pricing, certainly for companies that are introducing innovation to their respective markets. When I think about spine, ATEC definitely fits the bill there. I was just curious how your team is thinking about pricing.

Patrick Miles (Chairman, President and CEO)

One quick point, and Todd will put the specific on it, is we still believe in this whole convoy sales thing in terms of the procedural price. What we're seeing is more products increment per procedure. As it relates to historical pricing degradation, we're not seeing it because ultimately what we're seeing is the reflection of the convoy sales, the accumulation of the procedural elements.

Todd Koning (Executive VP and CFO)

Yeah. We often talk about kind of same product, same store year over year being a very low single-digit decline there. Our innovation engine, the ability for us to launch new product and really mix our way out of some of those headwinds has been our history and will continue to be our history. To Pat's point, we're just getting more of the procedural revenue opportunity as we continue to grow.

Eric Alm (Analyst)

That makes sense. Thank you for the questions.

Operator (participant)

Thanks, Eric. Our next question comes from the line of David Saxon with Needham. David, please go ahead.

David Saxon (Senior Analyst)

Oh, great. Good afternoon. Thanks for taking my question and congrats on the quarter. I think this is probably more for Todd, but Todd, you've talked historically maybe two years ago or over the course of a couple of years ago about letting 10% of the top line outperformance drop through to the bottom line. I mean, as the numbers get bigger, maybe the upside gets a little smaller. Is that still a good way to think about it? Or has the size of the business or kind of how you think about the near-term opportunity changed that framework at all? Thanks so much.

Todd Koning (Executive VP and CFO)

Yeah. Thanks, David. I think you look at our drop-through in absolute terms in Q4 of last year was 49%. We delivered 44% of the incremental revenue year over year to drop through to adjusted EBITDA. I think even on the beat, we dropped through a significant amount of that to the bottom line as well. I think you're just seeing a level of focus and effort on driving profitability and cash utility. I think you'll continue to see that through the balance of the year.

David Saxon (Senior Analyst)

Great. Thank you.

Operator (participant)

All right. Thanks, David. Our next question comes from the line of Caitlin Cronin with Canaccord. Caitlin, please go ahead.

Michaela Smith (Equity Research Associate)

Hey, guys. It's Michaela filling in for Caitlin. Thanks for taking the question. We've seen a focus with some recent M&A on the interventionalist call point. I was just wondering if there are any plans to leverage the interventionalist call point or how you're thinking about that.

Patrick Miles (Chairman, President and CEO)

No. I'm just being snarky. Our business is the spine surgeon and the alignment with what the spine surgeon does. We feel very strongly that we have a customer with whom we have aligned interest. We have a salesforce with whom we have aligned interest. We think that defocusing our organization into an interventionalist or pain environment would be a huge mistake. That's just our candid view.

Samantha Graham (Vice President and Equity Research Analyst)

Got it. Thanks so much.

Operator (participant)

Thank you, Michaela. Our next question comes from the line of Sean Lee with H.C. Wainwright. Sean, please go ahead.

Sean Lee (VP Equity Research)

Hi. Good afternoon, guys. Congrats on a good quarter. Thanks for taking my question. For the last couple of years, you guys have been making a big push on the EOS and informatics and, say, follow-up, the whole pre-op planning, the intra-op monitoring, and the post-op analysis. I was wondering if you can provide some color on which parts of this system is seeing the most use right now and where do you think the biggest growth is going to come from in the future. Thanks.

Patrick Miles (Chairman, President and CEO)

Yeah. It's a great question, Sean. I think the dynamic is one of maturity. And when you say, "Gosh, how have you built the business from, gosh, back in 2018, it was like $89 million headed south to what's our guidance is 7.

Todd Koning (Executive VP and CFO)

734.

Patrick Miles (Chairman, President and CEO)

734 heading north." I would tell you what's created the uniqueness in our lateral effort, a core part of it is telling a surgeon, "Hey, there's a nerve right there, and this is the health of the nerve." Now we've added, "You can understand the motor pathway of the nerve." These things, if you look at your skin to spine from a lateral perspective in the flank, the most concerning anatomy is neural. To be able to provide that level of neural precision and sophistication is not done anywhere. This is why it's not a coincidence that we're growing at the rate that we are. We are the lateral maven. You say, "Gosh, when did we buy and when did we start the integration process with EOS?" I would tell you really 2021.

Really in earnest, you get together as a company, you fund the things that really were not being funded, and you start to get on the road of automating things. We spent 2022 and 2023 shoring up the unit and designing some of the software elements. Gosh, we recently last year launched the Insight software such that that's the translational tool. I would say we're in the first inning from an EOS perspective, and we're in the third inning from a SafeOp perspective. There is such a runway on both those things. I think surgeons are yearning for it. The challenge with this environment has been people have been consumed with the currency, which everybody wants to sell pedicle screws.

You sell pedicle screws and implants based upon your shared interest with the surgeon who's trying to care for a patient and understanding what the procedural requirements are to execute.

Sean Lee (VP Equity Research)

Thanks for that. That's very helpful.

Operator (participant)

All right. Thank you, Sean. That is all the questions we have today. I will now turn the call back over to Pat Miles for closing comments. Pat?

Patrick Miles (Chairman, President and CEO)

Thanks, Greg. Just want to thank everybody for their interest in ATEC. I want to remind you that we are the preferred destination and excited about the business that we serve. Thanks for your time.

Operator (participant)

Thanks, Pat. Ladies and gentlemen, that concludes today's call. Again, thanks for joining, and you may now disconnect. Have a great day, everyone.

Todd Koning (Executive VP and CFO)

Thank you.