Zimmer Biomet - Q4 2025
February 10, 2026
Transcript
Operator (participant)
As a reminder, this conference is being recorded today, February 10, 2026. Following today's presentation, there will be a question-and-answer session. At this time, all participants are in a listen-only mode. If you have a question, please press the star followed by the 1 on your push-button phone. I would now like to turn the conference over to David DeMartino, Senior Vice President, Investor Relations. Please go ahead.
David DeMartino (SVP of Investor Relations)
Thank you, Operator. Good morning, everyone. Welcome to Zimmer Biomet's fourth quarter 2025 earnings conference call. Joining me on today's call are Ivan Tornos, our Chairman, President, and CEO, and Suky Upadhyay, our CFO and EVP Finance, Operations, and Supply Chain. 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. For a detailed discussion of all these risks and uncertainties, in addition to the inherent limitations of such forward-looking statements, please refer to our SEC filings. Please note, we assume no obligation to update these forward-looking statements, even if actual results or future expectations change materially. Additionally, the discussions on this call will include certain non-GAAP financial measures, some of which are forward-looking non-GAAP financial measures.
Reconciliation on these measures to the most directly comparable GAAP financial measures and an explanation of our basis for calculating these measures is included within our fourth quarter earnings release, which can be found on our website, zimmerbiomet.com. With that, I'll turn the call over to Ivan. Ivan?
Ivan Tornos (Chairman, President, and CEO)
Good morning, everyone, and thank you for joining today's call. I would like to start the way that I always do, by sharing my gratitude toward Zimmer Biomet team members around the world who move our business and mission forward each and every day. Thank you for your tireless work. Thank you for your dedication to solving the most pressing challenges in healthcare. Thank you for your relentless commitment to serving our customers and their patients. Today, Zimmer Biomet is a totally different company than it was just a few short years ago, and this is no doubt thanks to your efforts. During my prepared remarks this morning, I'll cover four key areas. I'll start summarizing our fourth quarter results and the results for the fiscal year 2025. Second, I'll provide an update on the plan which we are executing upon to evolve our U.S. commercial organization.
Thirdly, I'll introduce our 2026 guidance. Lastly, I'll briefly cover the progress that we have made across our key strategic priorities, those being people and culture, operational excellence, and thirdly, innovation and diversification. Starting with the year and the fourth quarter, I'm proud to have the team ended the year 2025 delivering on our commitments on sales growth, EPS, and free cash flow while navigating quite a complex challenge in the year: tariff headwinds and integrating three acquisitions within one year. From a constant currency organic revenue standpoint, we ended 2025 right at the middle of our initial yearly guidance, marking the fifth consecutive year for Zimmer Biomet growing mid-single digit or above. Looking at the fourth quarter results, we grew sales on an organic constant currency basis by 5.4% against a mid-single digit growth comparable, with our critical U.S. business increasing 5.7% and international growing 5%.
Healthy end markets, new product momentum, the ongoing evolution of our U.S. sales channel, and the recent leadership additions continue to drive an acceleration in our critical U.S. business. U.S. Knee growth of 6% in the quarter was driven by increased penetration of Persona OsseoTi, or total cementless knee, which ended the year roughly at around 35% penetration. Our Oxford Partial Cementless Knee continues to deliver above expectations, with adoption rates post-training continuing to be very high with great conversions from competitive accounts. Notably, our DTP, direct-to-patient awareness campaign, in partnership with Arnold Schwarzenegger, drove accelerated momentum in the second half of the year, with the personalized knee campaign yielding very meaningful results.
Turning to our hips franchise, Z1, or triple taper stem, penetration fueled U.S. hip growth of nearly 8% in the quarter, with the implant, Z1, now representing over 35% of our U.S. hip stems and gaining meaningful competitive conversions. Next, our robotics and navigation strategy of offering a comprehensive suite of customer-centric technology solutions continues to pay strong dividends. Our U.S. technology and data, bone cement, and surgical cells increased over 10% in the quarter, driven by the strongest robotic capital sales quarter in over 2 years. Finally, in S.E.T., our U.S. CMFT, cranio-maxillofacial thoracic business, continues to perform strongly, growing mid-teens in the quarter led by a continuous shift in external fixation from wires to plating. Upper Extremities had another great quarter of high single-digit growth in the U.S., where our Identity Shoulder and OsseoFit Stemless Shoulder continued to convert competitive accounts.
Looking now at 2026, we're accelerating the transition to a dedicated and specialized U.S. sales channel in order to drive more durable and consistent growth. By the end of 2027, we expect the vast majority of the conversion to dedicated ZBH, Zimmer Biomet employees, to be complete, and also expect a substantial increase in the number of reps specialized in the higher growth areas such as S.E.T., robotics, and in our ASC channel, Ambulatory Surgical Center channel. We have already addressed one-third of these organizational changes and have best-in-class plans and project management capabilities with third-party help to ensure a smooth transition for the last two-thirds of this evolution. With a robust innovation cycle in place, we feel it's the opportune time to move faster, and we will.
With that context, we now expect full-year organic constant currency revenue growth for 2026 in the low single-digit range, or 1%-3% growth, with an adjusted EPS, earnings per share, of $8.30-$8.45, which includes the contribution from Paragon 28 beginning April 21st, the one-year anniversary of the deal closing. Suky will provide further details during his remarks. The evolution of the U.S. Salesforce represents the final core initiative in our transformation. And while it might create some short-term disruption across pockets of our organization, it is by far the most crucial step in order to convert Zimmer Biomet into a durable mid-single-digit-plus growth company for the long term.
Turning now to our three key strategic priorities for Zimmer Biomet, starting with number one, people and culture, we remain committed to having the right people in the right roles to maintain our leading position in the key areas where we compete. By having a dedicated and specialized U.S. sales channel, we will now enhance our ability to consistently, and with no surprises, execute our strategy. This will drive increased productivity while enabling us to be more competitive in high-growth segments, as mentioned before, such as robotics, ASCs, and the growth drivers within S.E.T., where we have tremendous opportunity ahead and we are still under-penetrated. Secondly, on the second priority of operational excellence, we believe our disciplined cost management and robust capital allocation strategy will enable EPS growth while allowing us to invest in the business for the long term.
Further, given our operating rigor, we expect to continue to grow free cash flow in the upper single-digit to double-digit range in 2026, marking the fourth consecutive year delivering meaningful free cash flow growth. Against that backdrop, we plan to prioritize meaningful return of capital to shareholders over M&A. Lastly, on our third priority of innovation and diversification, we're making significant advancements. Over the past two years, we have closed all core portfolio gaps with the introduction of the Magnificent Seven platform, and we now have the potential to change the standard of care with solutions such as the Oxford Partial Cementless Knee, iodine-coated devices recently launched in Japan, our second-largest market globally, ROSA Shoulder, and the mBôs semi- and fully autonomous AI-driven orthopedic robotic system that we acquired via the Monogram acquisition.
In addition to this, we continue to invest internally and partner externally to strengthen our pipeline of new product launches, which is today 3x what it was just a few short years ago. Given the strength of our innovation cycle, we feel once again that this is the right time to accelerate the evolution of our U.S. channel so we can fully capitalize on a dedicated and specialized Salesforce. I'll tell you, having traveled to all key sales meetings across the U.S. in the month of January, the excitement behind our innovation story is very high, and so is the engagement. It is now up to us to execute on the plans via this transformation. In conclusion, we are very proud of the progress in our organization, but we are far from being satisfied with where we are at today.
In 2026, to close our core turnaround efforts, we are going to be laser-focused on the U.S. go-to-market commercial transformation while we continue to showcase the strength of our robust innovation cycle across the globe. As we then enter 2027, we'll be ready to transform the musculoskeletal space with the launch of mBôs and other disruptive technology platforms while responsibly accelerating our diversification strategy, gaining access to a higher growth market environment. And with this behind, in 2028 and beyond, Zimmer Biomet will look and act like a totally different company. With that, I'll now turn the call over to Suky. Thank you.
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Thanks, and good morning, everyone. In the fourth quarter, we grew sales 5.4% on an organic constant currency basis and delivered adjusted earnings per share of $2.42, which was up 4.8% year-over-year despite dilution from the Paragon 28 transaction, the impact of tariffs, and continued investments in our commercial organization. On a full-year basis, we grew organic constant currency sales 3.9% and generated $8.20 in adjusted EPS and $1,172,000,000 in free cash flow. As we get into the details of these results, unless otherwise noted, my statements will be about the fourth quarter of 2025 and how it compares to the same period in 2024. My commentary will be on a constant currency and adjusted operating basis. 2025 organic constant currency commentary excludes the impact from Paragon 28 acquisition that closed in April of 2025.
Net sales were $2,244,000,000, an increase of 10.9% on a reported basis and 5.4% excluding the impact of foreign currency and the Paragon 28 acquisition. Consolidated pricing was 50 basis points negative in the quarter. Our U.S. business grew 5.7% on an organic constant currency basis, which, as Ivan mentioned, reflects continued momentum for our recently launched products, strong robotic sales, and end-of-year customer purchases and capital sales above historic levels. Internationally, we grew revenue by 5% on an organic constant currency basis driven by continued new product momentum and strong robotic sales. Turning to our P&L, we reported GAAP-diluted earnings per share of $0.70 compared to GAAP-diluted earnings per share of $1.20 in the prior year quarter.
Higher revenue and a lower share count were more than offset by a one-time charge related to a brand rationalization initiative and restructuring charges related to a reduction in workforce, as well as higher interest expense associated with the Paragon 28 transaction. On an adjusted basis, we delivered diluted earnings per share of $2.42 compared to $2.31 in the prior year quarter. This increase was driven by higher revenue, higher adjusted gross margin, and a lower share count, partially offset by an increase in SG&A and a step-up in interest expense tied to Paragon 28. Adjusted gross margin was 72.4% higher than the fourth quarter of 2024 due to lower manufacturing costs and favorable mix. Adjusted operating margin was 29.1% lower than the prior year quarter as a result of increased commercial investments and the addition of Paragon 28.
Adjusted net interest and non-operating expenses were $71 million, above the prior year driven by higher debt related to Paragon 28 and higher interest rates on refinanced debt that matured in 2024. Our adjusted effective tax rate was 17.9%, and fully diluted shares outstanding were 198.1 million, down year-over-year due to share repurchases in 2025, including $250 million during the fourth quarter. Now turning to cash and liquidity, we had another strong quarter of cash generation with operating cash flows of $517 million and free cash flow of $368 million. We ended the year generating $1.172 billion of free cash flow, growing over 11% year-over-year, marking the third consecutive year of at least high single-digit free cash flow growth. We ended with approximately $592 million in cash and cash equivalents.
Now regarding our outlook for full year 2026, unless otherwise noted, my commentary will be on a constant currency and adjusted operating basis and will include the contribution from Paragon 28 in organic growth beginning in April 2026, marking the one-year anniversary of the deal closing. We expect organic constant currency revenue growth of 1%-3%, with growth roughly consistent throughout the year. In addition, we expect adjusted EPS of $8.30-$8.45, with free cash flow growth of 8%-10%, which would mark the fourth consecutive year of high single-digit or greater free cash flow growth, quickly approaching 80% free cash flow conversion. This guidance contemplates end-market growth in line with 2025, the risk of disruption from the U.S. Salesforce transition, continued evolution of our international go-to-market models, up to 100 basis points of pricing erosion, and a stable tariff and policy environment.
Now let's walk through the moving parts that impact our reported revenue guidance. At current rates, we expect FX to be approximately a 50 basis point tailwind to full-year revenue growth, which includes approximately 250 basis points of tailwind in the first quarter. We expect Paragon 28 to contribute around 100 basis points to reported sales growth in 2026 before being reflected in organic growth in April. As we have discussed previously, we expect our operating margins to be down about 50 basis points from 2025, which contemplates lower gross margins, dilutions from the Paragon 28 acquisition, and increased investments in our U.S. commercial channel. Operating margins in the first quarter are expected to be down about 100 basis points from the first quarter of 2025 before increasing sequentially by about 100 basis points into the second quarter.
For the full year, we expect adjusted net interest and other non-operating expenses to be approximately $295 million, our adjusted effective tax rate to be about 18%, and to end the year with about 194-195 million shares outstanding. This share count reflects a share buyback program in 2026 of up to $750 million. I'd like to close by thanking the entire ZB team for their hard work and dedication. We continue to make meaningful, positive changes across the business while investing to accelerate long-term growth. And with that, I'll turn the call back over to David.
David DeMartino (SVP of Investor Relations)
Thank you, Suky. Operator, let's open up for questions. In order for us to take as many questions as possible, please limit yourself to one question. Operator, please go ahead.
Operator (participant)
Thank you. If you would like to ask a question, please signal by pressing star 1 on your telephone keypad. If you're using a speakerphone, please make sure your mute function is turned off to allow your signal to reach our equipment. Please limit yourself to one question and one follow-up. Again, please press star 1 to ask a question. We'll pause for just a moment to allow everyone an opportunity to signal for questions. We'll go first to Mathew Blackman with TD Cowen.
Mathew Blackman (Managing Director)
Hello?
Operator (participant)
Mr. Blackman, you might have the mic.
Mathew Blackman (Managing Director)
Good morning. Yes, you can. Okay, good. You can hear me okay. Appreciate you taking my question. Ivan, we're obviously all focused on the near-term impact of the Salesforce optimization initiatives, but maybe take a step back. You did touch on this a bit in the script, but tell us why now, how heavy the lift ahead is, and perhaps most important, what could the business look like if this is executed well, and where and when across the franchises could we see visible returns? Is it exiting it this year? Is it 2027? Just any color would be helpful. Appreciate it.
Ivan Tornos (Chairman, President, and CEO)
Absolutely, Matt. So what I'll do here, maybe I'll provide a longer answer than usual, and then maybe this says sometime in future questions this morning. But maybe start with what it is that we're doing, because I'm seeing some people are confusing the what. Then we'll talk about the why we're doing it. I'll directly answer your question of why we're doing it right now. I'll talk about how we're doing it to reassure everyone that we're taking a very prudent approach that is very state-centric. And then when do we see the benefits? So I'll break mine into those four or five key areas. So what it is that we're doing? We're moving from being a company, or rather a channel here in the U.S., that has a lot of non-dedicated employees. But non-dedicated, this is not a legal 1099 W-2 committed, no committed.
We got people that have two, three jobs while working at Zimmer Biomet. It's part of the nature of the 1099 model here in the U.S. That's not something that we want to keep. We want to have 100% of our U.S. Salesforce being dedicated. Again, not to be confused, W-2, 1099, fully dedicated. That's number one. We believe in specialization, just like best-in-class companies believe in specialization. You can have sales reps selling hips, knees, components of technology, shoulders, etc., etc. Today, our current specialization rate is around 25%. I won't quote what is the end number, but we're going to make sure that we specialize the Salesforce so that we can compete at the level that we can compete in the higher growth segments. To that end, we are in something like 200+ sales reps in robotics, countless reps in S.E.T., ASC, etc., etc.
So that is the what, moving from non-dedicated to dedicated. Why are we doing this now? Well, look, we got no gaps in the portfolio. We've done significant work when it comes to technology in data, robotics, and whatnot. We've added a ton of new products when it comes to S.E.T.. We just got to have dedicated people to leverage that great new product cycle. We couldn't do this 3, 5, 10 years ago because candidly, we didn't have the products, not to mention we're dealing with other challenges. So now that we have the products, we have to leverage the channel to sell those products at a higher rate. Our productivity rates in the U.S., we do a lot of third-party benchmarking, are roughly half of what some of our direct competitors have. So in plain English, we're doing half as many cases as some of our direct competitors.
That's something we're going to be addressing. That's the why. We're doing it because of new products. We're doing it because of timing. We're doing it because we got a pretty significant productivity gap here in the U.S., not to mention our penetration in ASC and S.E.T. still is very high, so low penetration. How we're going to do it? We got third-party resources. We got a dedicated team. We have hired people that have done this in the previous life. I'm personally involved in the project. I'm going to continue to remain involved. We're going to take a staged approach to getting it done. We've done one-third of this transformation already. We have locked in a significant percentage of the organization. I feel that we've been very prudent when it comes to how we're doing it. We learn a lot from the one-third we've done.
It's actually gone better than expected. We did 5 conversions already, late 2025, early 2026. Those are going as expected, if not better. And then just to close this summary, Matt, when are we going to get this done by? We expect the entire transformation to be done as we exit 2027. So that is the what, the why, the how, and the when. And it is the final step in the transformation of Zimmer Biomet. We addressed the operational challenges in the past. We have addressed the leadership gaps that we had. We have built a best-in-class portfolio, remediated all the gaps, and now with significant product launches to change the standard of care. If we don't modify or use U.S. go-to-market structure, we're never going to have the durability and sustainable growth that are referenced in my prepared remarks. Thank you for your question, Matt.
Mathew Blackman (Managing Director)
Appreciate it. Thank you.
Operator (participant)
We'll go next to Rick Wise with Stifel.
Rick Wise (Managing Director)
Good morning, Ivan. Thank you for all the comments. You highlighted in your comments, Ivan, that obviously the reality that Zimmer has grown mid-single digits for four consecutive years. Now you're offering tempered guidance and guiding to low single-digit growth. Help us better understand what's embedded at a high level in that thinking. I mean, clearly, you're trying to be respectful of the uncertainties about the sales transition process, but that seems to be going well. So what have you baked in? And maybe help us think about the year ahead in terms of is the disruption greater in the first half and therefore the second half could be better? Just maybe help us think through those factors. Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Rick. Actually, it is 5 years of mid-single-digit revenue growth, not 4. We are very excited with how we exited 2025 growing in the second half, 5+. But we got to keep it or we got to make it durable. So to your question on what's embedded in the guidance, really, we're looking at 3 things. Number one, obviously, is the U.S. Salesforce transition. That is deep priority in 2026. If it goes better than expected, obviously, our number exiting 2026 will be higher. If we don't do the job that I expect we're going to do, then we may move towards the lower range of that guidance. So that's item number one. Number two, we're paying close attention to the new product cycle and the adoption of these new products, namely the Magnificent Seven.
If you look at the performance in Q4, very solid across hips and knees. Similar performance in the U.S. in Q3. So now we need to make sure that we're going to be able to do the same or better as we enter 2026. So that's the second item we pay attention to. And then number 3, international. As we've been discussing, it has been a fragile business now for a couple of quarters. Since 1 quarter, we do really well. The next quarter, something happens. So again, we got to pay attention in making sure that we do have the right go-to-market models. We are focusing the right growth areas in the right country. So those are the 3 things we pay attention to: the U.S. Salesforce transition, the new product adoption cycle, and the international performance in key geographies. Thank you, Rick.
Rick Wise (Managing Director)
Thank you. Thank you.
Operator (participant)
We'll go next to Patrick Wood with Morgan Stanley.
Patrick Wood (Managing Director)
Beautiful. Thank you so much for taking the question. I'd love to just ask a slightly boring one, but on pricing, moving to a negative 100 basis points erosion in the 2026 guide. Inflation is kind of at the same spot that it was before, and I'm guessing your customers are in a pretty healthy spot from procedure volumes. Just curious why you're thinking pricing stays in the negative territory. I know that's where it was historically, but any outlook on how you think about pricing makes it be super helpful. Thanks.
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Yeah, Patrick, this is Suky. Thanks for the question. So overall, for the year 2025, we ended on flat pricing at a consolidated level, so taking all the regions into account. The fourth quarter, as I said in my prepared remarks, was down about 50 basis points. For 2026, you're right. We're saying up to 100 basis points of erosion, which is consistent with our analyst day commentary almost two years ago. And as you noted, it is a significant improvement to sort of pre-pandemic price profile. The reason we expect to see some level of stepdown between 2025 and 2026, and we've talked about this a bit over the last few quarters, is we expect to see a moderation in some of the price increases we've been able to take across EMEA.
We do expect Asia-Pacific to be down year-over-year, primarily because of the Japan biannual price decrease, which happens. It's a normal part of our business. Also, we expect to be slightly down in China as we continue to reconfigure our go-to-market strategies. The Americas are expected to be down sort of similar profile to what we saw in 2025. When you put all those together, we do expect to see a modest stepdown into 2026, but again, well within our overall guidance that we provided at our analyst day.
Patrick Wood (Managing Director)
Appreciate the color. Thanks, guys.
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you.
Operator (participant)
We'll go next to Vijay Kumar with Evercore ISI.
Vijay Kumar (Senior Managing Director of Equity Research)
Hey, guys. Congrats on a nice execution, Q4, and free cash. Thank you for taking my question. Suky or Ivan, can you give us a bridge from back half, right? When you did mid-singles to 2% guidance at the midpoint for fiscal 2026, how much of this is Salesforce reorg impact? And Ivan, you mentioned that you've already completed one-third of this transition. What's been your prior experience, right? When you look at the pacing of disruption, was it front-loaded? And when does productivity increase to offset this? Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you for the question. Look, for 2026, it's all about this Salesforce transformation. So yes, we exited 2025 growing strong in the mid-single digit. As we provide guidance for 2026, we just want to be responsible in realizing that this is a significant transformation we're undertaking. I've made public commentary around the fact that in the U.S., we got roughly 2,500 reps across 34 territories. There's a lot of legacy issues in the channel that we're addressing. And we're going to be responsible. We're going to do it over two years. And we believe there'll be some disruption. So that's why we're giving the guidance that we're giving today. So that's the answer on why we're going from, call it, 5+ in the second half of 2025 to a midpoint of 2 here as we enter 2026.
What we have learned as we go through these transitions is that disruption happens sometimes in the early stages. You go and negotiate your contracts with your distributors, and they say, "No, we're not interested in the new model." And rarely happens towards the end. Once they sign up, they sign up and they stay. And again, many lessons learned from the work we've done already, one-third behind. As I referenced in my previous answer to Matt, I believe it was, we already have done 5 additional distributor changes here in the last 4, 5 months, and they're going really, really well. And we have active negotiations going on with roughly 40% of the channel as we speak, and those are going better than expected. In terms of when will we see the outcomes? Towards the end of 2027 is when you start to see increases in productivity. Thank you.
Operator (participant)
We'll go next to Robbie Marcus from JPMorgan.
Robbie Marcus (Senior Analyst)
Oh, great. Good morning, and thanks for taking the questions. I know it's one, but I have two quick clarification questions I have a lot of investors asking, so figure I get it out in the call here. First, really strong fourth quarter performance, particularly in the U.S. across large joints. Just want to make sure there was no one-time items or above-normal sales there. And then, Suky, as you think about first quarter and first half, getting the cadence right has been really important, particularly over the past few years. And I know you've mentioned it in the script even. So just how do you want people to think about first quarter and first half, top and bottom line? The guide is 1%-3% on the top and bottom line, and you exited at 5.
So help us bridge expectations, how much disruption is built in, and help us get the numbers set for the beginning of the year. Thanks a lot.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Robbie. I'll start and then I'll let Suky comment on the phasing for the year. In terms of performance in Q4, the main driver behind the solid growth in the U.S., and I'm frankly very pleased with where we landed, all U.S., is new product acceleration. We did benefit from some additional capital sales in the quarter. We had some modest uptick when it comes to some of the sales that we do towards ASCs. But I would say the lion's share of the performance is better execution. We did, Robbie, benefit internationally in knees. If you look at the knee number, we grew 8.2%. That is some of the revenue in Q3. You may recall that Q3, we didn't end where we expected, some Middle East revenue that got into Q4.
But very, very, very pleased with the execution when it comes to new products, both in the U.S. and international. Suky, you want to talk about phasing?
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Yeah. So thanks, Robbie, for the question. So on phasing, it's very consistent with what I said in my prepared remarks, which we expect on the top line for growth to be roughly consistent, plus or minus, from quarter to quarter throughout the year. And that takes into account what Ivan's talked about relative to the sort of U.S. phenomenon on Salesforce and optimization there, as well as some of the elements that he's been teeing up for some time around international and go-to-market changes. So both of those have been reflected and sort of contribute to sort of that, sorry, second half of 2025 into 2026 stepdown. Relative to P&L, from an operating margin standpoint, some of the building blocks there are we do expect gross margin to be down for the full year. We've talked about that for quite some time.
We're going to make a lot of that up through SG&A efficiency inside of operating margins, but we do expect that to be down 50 basis points, as I talked about in my prepared remarks. Overall earnings, we expect to grow in line with constant currency organic growth. And that's going to be assisted by some of the share buyback that we plan to do this year. Now, taking those building blocks into phasing, operating margins, we do expect to be down in the first quarter, year-over-year, by about 100 basis points. That's largely driven by Paragon 28, which was not yet anniversaried because we did the deal in the second quarter of 2025. We're going to have higher commercial investments as part of this overall optimization in the U.S.
As Ivan's talked about, yes, it is specialization, but it's also augmentation where we're adding reps in a couple of key areas. And then, as I said, gross margin will be down in the first quarter. So again, operating margin's down year-over-year in the first quarter, about 100 basis points. From there, we expect to see a sequential step-up in the second quarter as we anniversary out of Paragon 28. That'll be an increase sequentially in the second quarter of about 100 basis points. And then, as we move into the back end of the year, we expect operating margins to be roughly in line with 2025. So hopefully, that gives you a bit, again, top line, roughly consistent growth rate throughout the quarters, plus or minus, and then the operating margins, as I talk
Robbie Marcus (Senior Analyst)
ed about. Very helpful. Appreciate it. Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Robbie.
Thank you.
Operator (participant)
We'll go next to Travis Steed with Bank of America.
Travis Steed (Managing Director of Equity Research and Medical Technology)
Hey. Just wanted to kind of follow up on Robbie's question in terms of on the margins, how you're thinking about the cost of the Salesforce transition. What you've kind of baked in on the margins from that. And then a question in terms of you've already done a third of this transition already. So one question I get often is, why does it actually take two years to do all this, and when do you start to see some green shoots here?
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Yeah. So thanks for the call or, sorry, for the question, Travis. Overall, the impact of the Salesforce transition, there's a modest impact to overall operating margins inside of SG&A. I think you start to see that in the fourth quarter or really the back half of last year. You're going to see that continue into 2026. That near-term headwind has been accounted for in our guidance for 2026. But the opportunity, I think, is more attractive as you think mid to longer term. One, it does give us the opportunity to do some restructuring and offset some of that headwind through more productivity, as Ivan talked about. We're at about half of some of our peers. And secondly, the whole idea behind this is that it generates better revenue growth, more durable sort of market, better than market growth rates.
And at those levels, that provides a significant amount of leverage into our P&L. So near term, yes, headwind, modest headwind incorporated into the guide. Mid to long term, we do see it being a benefit.
Ivan Tornos (Chairman, President, and CEO)
Then, Travis, relative to your question on why two years, no more complex than we're going to be responsible. As I mentioned, we don't want third. So 2,500 reps, done a third, that's, what, 1,600 reps that we got to get through across multiple states. So we're going to take our time in understanding what's the right sequence, locking in the contracts. We have segmented areas by contract status, by market-set status. So it's a project that we're not going to take lightly. So that's why it takes two years. And we're going to go slowly to then go fast later on. Thanks.
Travis Steed (Managing Director of Equity Research and Medical Technology)
Great. Thank you.
Operator (participant)
We'll go next to Matt Taylor with Jefferies.
Matt Taylor (Managing Director)
Hi. Thanks for taking the question. I wanted to just follow up on gross margins. I know you said down for the year, and we touched on pricing, but was hoping that you could go through all the puts and takes on gross margin this year and also maybe just talk at a high level about the trajectory beyond 2026 for gross profit.
Suky Upadhyay (CFO and EVP of Finance, Operations, and Supply Chain)
Sure. Thanks for the question, Matt. Yeah. So we expect gross margins for 2026 to be in the range of 70%-71%. It is a step down from a pretty good year in 2025. We've been sort of telegraphing that. Your key drivers are really the biggest one is around the lower growth profile, as you see in the revenue. We get a lot of leverage in our P&L when the revenue growth rate's at a higher level. And of course, the opposite works at a lower growth level. So volumes are the biggest contributor to that step down. Secondly, we've talked a bit about the FX hedge gains that we've seen in 2025 tapering off in 2026 as we've seen a weakening of the dollar through 2025.
The next big area, again, is around price and geographic mix, which we expect to be a headwind compared to 2025. And then the last piece is really on tariffs, which on a net basis, year-over-year, is not a significant increase, but it will be choppy through the quarters, primarily because of certain credits from 2025 that we expect to realize into 2026. So those are your moving parts that really step you down from 2025 into 2026. But I would say we're making up a very large percentage of that through our SG&A restructuring that I talked about in my prepared remarks. And so while gross margins will be down 100 basis points or more, we're making more than half of that up through SG&A efficiencies, even while we're incrementally investing in some portions of our commercial business.
It's too early to tell on gross margin outlook beyond 2026. I think the largest component, which is driving this year, will drive future gross margin, which is really around volumes and sales levels. Beyond that, I can tell you we continue to emphasize efficiency, continue to make great progress in the areas of sourcing improvements. We continue to build out low-cost manufacturing. I think you'll see that in the stepped-up PP&E in 2025. Then lastly, I talked about a pretty large-scale portfolio rationalization charge we took in the fourth quarter. We believe that that's going to have significant, meaningful midterm and long-term results or benefits, I should say, into cost of goods. Longer term, a little bit too early to tell.
Again, it will depend on revenue growth, but we continue to push very hard on a number of efficiency gains and are making good progress. Thanks for the question, Matt.
Matt Taylor (Managing Director)
Thanks, Suky.
Operator (participant)
Our next question comes from the line of Ryan Zimmerman with BTIG.
Ryan Zimmerman (Equity Research Analyst of Medical Technology)
Good morning. Thanks for taking the question. I'm going to turn to Paragon, actually, because a lot of questions have been asked on guidance. And just ask, I mean, the contribution this quarter was lower than we expected. And if I look at the outlook for 2026, I think it's about 100 basis points, which, again, is a little lower, excuse me, than we expected. And so, Ivan, can you just talk about kind of what you're seeing there? I mean, we have heard, obviously, chatter about kind of the health of the foot and ankle market, particularly in 2025 being softer, and kind of what you expect and where you're seeing specific parts of weakness versus maybe parts that are offsetting that.
Ivan Tornos (Chairman, President, and CEO)
Yes. Thanks for the question, Ryan. So we've been at it for two quarters, right? So we've done two quarters as a consolidated company. They both came in in the upper single-digit range. Recall that for the year 2025, we said we'll get around 270 basis points of revenue accretion thanks to or due to Paragon 28. We came in roughly 20 basis points behind that, so not a huge gap. We have made a commitment that we're going to grow this business double-digit in 2026, early in 2026, but we like what we see. I would say mostly everything is going in line. Our revenue, again, is slightly behind what we anticipated, but again, only two quarters. In terms of the EPS dilution, everything is on track, if not better than expected.
Committed to a 3% dilution in year one, came in slightly better, around 1% in the second year. We expect to deliver on that. And then the integration costs and everything associated with Paragon is also better than expected. We're not seeing any dramatic changes when it comes to market growth. We continue to monitor that. If anything, we've seen that the shift to the ASC continues to move in the right direction. So we're very excited about the business. Again, 2 quarters behind. I just left the sales meeting in San Diego a couple of weeks ago. I'll tell you, Ryan, that with 8 new products being launched in 2026, with virtually the same legacy Paragon 28 employees being now with Zimmer Biomet, the excitement is high, and we expect to deliver double-digit growth in 2026. Thank you, Ryan.
Matt Taylor (Managing Director)
Thank you.
Operator (participant)
We'll go next to Danielle Antalffy with UBS.
Danielle Antalffy (Senior Analyst)
Good morning, guys. Thanks so much for taking the question. Just on this Salesforce transition, I'm just curious sort of what gives you the confidence? Appreciate a third has been done so far. But just coming to the decision to make this move, was it best practices at competitors, market research, physician feedback? And then I appreciate you probably can't comment on 2027 right now, but should 2027 be conceptually a year of growth acceleration versus 2026 wherever you end up, just given you'll be further along in the Salesforce transition, or are there other factors we should be considering as we put a finer point on 2027 on our models today? Thanks so much.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Danielle. So let's start with the easy one. We're not going to talk about 2027. So that's something we'll do later on in the year. But right now, we're going to focus on 2026. What gives us the confidence that this is the right time and the right project is data. No more complex than that. We look at productivity rates for Zimmer Biomet versus direct competitors that are fully dedicated, fully specialized. And again, I mentioned when it comes to caseload, when it comes to overall productivity, we're behind. And given the strength of the new product portfolio, the time to do it is now. We do a lot of benchmarking in terms of those territories that are fully dedicated and specialized versus those territories that are non-dedicated and they're non-specialized. And it's literally night and day. We see a much greater productivity.
No surprise there, Danielle, in those dedicated and specialized territories. If we don't get the U.S. right - and by that, I mean, if we don't get the U.S. to be consistently mid-single digit, at some point upper single digit - this company will never realize the aspirations that we have for this company. The U.S. is 62%-63% of the revenue. It's north of half of the profit of the company. We got to get it right. So we got the leadership in place. We made a lot of changes. We got the new product cycle in full motion. We're about to enter a new stage when it comes to innovation in 2027 with Monogram. We just have to do it. So it will create some short-term disruption, but it's going to set up the company very nicely as we enter 2027 and beyond.
Thank you so much for your question, Danielle.
Danielle Antalffy (Senior Analyst)
Thank you.
Operator (participant)
Our next question comes from the line of Larry Biegelsen with Wells Fargo.
Larry Biegelsen (Senior Medical Device Equity Research Analyst)
Good morning. Thanks for taking the question. So, Suky, I wanted to ask about capital allocation. It feels like a change in terms of prioritizing returning free cash flow to shareholders over M&A. So my question is, why the change? I think there was a time not too long ago when you talked about diversification and any color on what percent of free cash flow you'll return to shareholders through buybacks each year, and what can we expect on M&A going forward? Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Larry. Great to hear from you. I wouldn't say it's a change. I would say that it's a pause. Recall that we've done three acquisitions between OrthoGrid, late 2024, Paragon 28, April of 2025, and then a few months after that, Monogram. I mean, these are pretty significant projects. And then add on top of that, this transformation of the U.S. channel, this is not the time to add more complexity. This is not the time to run more projects. This is the time to be nimble and laser-focused on getting those three integrations right and ensure minimal disruption out of this U.S. transformation. So that is no more complex than that. At the right time, we'll continue to diversify responsibly. So no, we're not throwing in the white towel.
We aspire to have a higher weighted average market growth rate as we continue to evolve the company. But right now, it's all about focus on these three integrations and this project. As you, might have, read, we got approval yesterday from the board to do up to $1.5 billion in buybacks. We like where the stock of Zimmer Biomet is today. We acquired $250 million of shares in the fourth quarter of 2025. And we're going to continue to acquire shares of Zimmer Biomet given the current valuation. Love the free cash flow generation of this business. You heard Suky in his prepared remarks, upper single-digit to double-digit in 2026. This company generates tremendous cash flow. We got very solid firepower, a light debt profile.
At the right time, we'll get back to doing the things that we need to do. In 2026, those are the priorities. Thank you so much.
Larry Biegelsen (Senior Medical Device Equity Research Analyst)
Thank you.
Operator (participant)
We'll go next to Chris Pasquale with Nephron.
Chris Pasquale (Partner and Senior Analyst of Medical Devices and Supplies)
Thanks. Ivan, you highlighted strong performances from CMFT, Upper Extremities, but organic growth for S.E.T still did step down a bit. Can you talk a little bit about the other S.E.T. segments, how they performed in the quarter, and then how you're thinking about that business once Paragon becomes sort of part of the organic piece going forward? Thank you.
Ivan Tornos (Chairman, President, and CEO)
Sure. Sure. Thanks for the question. So net-net, in the year, S.E.T. delivered mid-single digit growth again. So now there has been a cadence of quarters and years in what we've seen this business perform. To your point, CMFT, meetings, growth, shoulders, upper single digit, if not double digit, sports, in and out of the upper single digit territory. Obviously, foot and ankle is double digit given Paragon. But we do have two problem children, our trauma business and our restorative therapies business, HA injections here in the U.S. So those are the two headwinds that we got. We spoke about that openly in the Q3 call, that our HA business in the U.S. has been struggling. We exited the year more or less in line with our expectations, but those expectations were very low.
As we enter 2026, we're going to continue to invest in the four key growth drivers. We are in a ton of reps in shoulder with expanding our CMFT, craniomaxillofacial and thoracic Salesforce. We put in new processes, new people to make sure that the true problem children, trauma, and restorative therapies don't become the headwind in 2026 that became in 2025. Thank you.
Chris Pasquale (Partner and Senior Analyst of Medical Devices and Supplies)
Thanks.
Operator (participant)
We'll take our next question, excuse me, from Caitlin Cronin with Canaccord.
Caitlin Cronin (Director of MedTech Equity Research)
Hi. Thanks for taking the questions. How do you see ASCs as a part of your revamped U.S. strategy? Where did you end the year with ASC penetration in hips, knees, and shoulder?
Ivan Tornos (Chairman, President, and CEO)
Thank you, Caitlin. So we ended 2025 on knees and hips. I do not know, to be honest with you, the final number for shoulder. But we exited 2025 in the 20%-22% range. So 20%-22% of all the hips and knees that we did in the U.S. were done in ASC. And I speculate the shoulder number is higher than that. But right now, I don't recall that number, so I don't want to mislead you. In terms of our strategy, we've spoken about the fact we need to have dedicated people. We need to have the portfolio. I need to have the partnerships. And speaking of people, really excited about the additions that we brought to the team in 2025, new President for ASCs, who's a superstar, Greg Ziller.
He's brought in great people across the entire U.S. with actively hiring people into the ASC channel. As Suky mentioned, it's not just specialization. It's also augmentation. So I think we are rapidly getting the right amount of people and the right type of people to win in ASCs. As far as the portfolio, there are no gaps whatsoever. We're really excited about the opportunity that Monogram will bring to an ASC environment where speed, efficiency, and accuracy matter most. But in addition to that, we got another 7-10 products that make a lot of sense in the ASC. And in the partnerships, we continue to see great momentum with our partnership with Getinge. We are doing new contracts. We got a couple of large groups that we are actively involved in final negotiations. So we're very bullish when it comes to our ASC strategy.
We'll follow up with you on the number for penetration for shoulder. Thank you.
Caitlin Cronin (Director of MedTech Equity Research)
Awesome. Thank you.
Operator (participant)
We'll go next to Joanne Wuensch with Citibank.
Joanne Wuensch (Managing Director)
Good morning. And thank you for taking the question. I'll put two right up front. I'm sorry. I'm only allowed to ask one. One, AAOS, what should we be expecting there? And I suspect this is where you'll be showcasing the mBôs system. How do you anticipate folding that into your robotics portfolio and platform? Thank you.
Ivan Tornos (Chairman, President, and CEO)
Thank you, Joanne. As far as I'm concerned, you can ask 50 questions if you want, so. But anyway, what should you expect at the Academy meeting in New Orleans? We're going to have a lot of new products there. We're going to showcase, again, the Mag Seven. We're going to show next-generation S.E.T products. But to your point, the main event is going to be mBôs, the fully autonomous and semi-autonomous robotic platform that we acquired from Monogram. This is technology that we strongly believe that will change the standard of care. It's definitely the step of moving from guided robotics to smart robotics. It has best-in-class ease of use. The registration speed that we've seen in the clinical trials is better than anything that is in the market today. You can literally do the cases. And I hope you come to the booth in a hands-free approach.
The workflow is as streamlined as it gets. And again, it's highly accurate, extremely reproducible. And it's got all the right guardrails to make it the safest robot out there. So we'll be talking about all of that. We debuted mBôs at the Hip and Knee Society meeting in Dallas. And since then, we've gotten just tremendous feedback. We expect to have a large group of surgeons when it comes to New Orleans. So looking forward to sharing this excitement with you and the other investors. But beyond that, we'll have our entire suite of technology. And I will be describing why it makes sense to have this category depth. Second part of your question, how you expect to integrate it? Look, we got the optionality of integrating all things into one platform if we choose to do that.
But so far, the data and the feedback validates that since not all customers are created equal, not all technology should be created equal. We believe in optionality. We believe in large footprint robotics, small footprint robotics. Sounds like our competitors do as well now. We believe in CT scan for some customers that want to have a CT scan. But we also have a large percentage of customers, namely outside the U.S., that want to use imageless. We got some surgeons that want to be more in control of the surgery. And you got some that are okay with semi and fully autonomy. So we have the optionality to integrate at the right time. But right now, we like to have the category breadth that we have. And so far, as you saw in the results in Q4, it seems to be working out.
Thank you so much, Joanne.
Operator (participant)
We'll go next to Matt Miksic with Barclays.
Matt Miksic (Equity Research Analyst)
Hey. Thanks so much for taking the question. Just maybe looking at some of the strength in knees and the core geographically, and maybe talk a little bit about pockets of strength, where you're seeing success, the sort of cadence of the iodine-coated launch in Japan, sort of the geographic breakdown. Any color you can provide would be great. Thanks so much.
Ivan Tornos (Chairman, President, and CEO)
Thanks, Matt. Look, great quarter. Q4 was a great quarter. We delivered 6% growth in U.S. knees and 8.2% for international. In the U.S., it's the combination of all the things that I mentioned in my prepared remarks. Oxford Partial Cementless continues to do better than expected, and it's really early in the journey. Recall, it's the only FDA-approved partial cementless knee, which is gaining tremendous adoption in an ASC setting. Our Persona OsseoTi or Cementless platform exited 2025, somewhere around 35% penetration, again, with very rapid adoption in an ASC setting as well. Internationally, we saw great momentum with Persona Revision in Europe exiting 2025. Recall that this is only two, three quarters into the launch. We think that the ramp-up can be very compelling as it has been here in the U.S. In terms of iodine, we had minimal sales of iodine in Q4.
The real launch has happened here in Q1. This is a product that we've been working on for 10 years with robust data out of the University of Yokohama in Japan. We expect to have a very meaningful contribution out of this product internationally in 2026. We're doing cases pretty much every day now. We get a 40% price uplift when it comes to iodine versus non-iodine. And again, the data around prolonged elution, the fixation stability, how this product reacts to bacteria is just very, very, very compelling. So really excited about iodine. And we look forward to bringing this product to other geographies down the road. Thank you.
Operator (participant)
This concludes the question and answer portion of this call. I would like to turn the call over to Ivan Tornos for any closing remarks.
Ivan Tornos (Chairman, President, and CEO)
Thank you. I'll close the way that I started with gratitude. Thanks to all of you for being here today. Thank you to the Zimmer Biomet team. Great exit to 2025. Love the performance that we saw in Q3 and Q4. Really encouraged about the opportunities we have ahead. Excited about 2026. While there be some disruption associated with the U.S. go-to-market transformation, we strongly believe this is the right step to take at the right time so that we can create a company that we all aspire to create. Thank you for your time this morning.
Operator (participant)
Thank you again for participating in today's conference call. You may now disconnect.