Zimmer Biomet - Earnings Call - Q4 2020

Transcript

Operator (participant)

Good morning, ladies and gentlemen, and welcome to the Zimmer Biomet Fourth Quarter 2020 Earnings Conference Call. If anyone needs assistance at any time during the conference, please press the star followed by the zero. As a reminder, this conference is being recorded today, February 5th, 2021. 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 one on your push-button phone. I would now like to turn the conference over to Keri Mattox, Senior Vice President, Investor Relations and Chief Communications Officer. Please go ahead.

Keri Mattox (SVP of Investor Relations and Chief Communications Officer)

Thank you, Operator, and good morning, everyone. I hope you are all well and safe. Welcome to Zimmer Biomet's Quarterly Earnings Conference Call. Joining me virtually today are Bryan Hanson, our President and CEO, and CFO Suky Upadhyay. Before we get started, I'd like to remind you that our comments during this call will include forward-looking statements. Actual results may differ materially from those indicated by the forward-looking statements due to a variety of risks and uncertainties. Please note we assume no obligation to update these forward-looking statements, even if actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties, in addition to the inherent limitations of such forward-looking statements. Additionally, the discussions on this call will include certain non-GAAP financial measures.

Reconciliation of these measures to the most directly comparable GAAP financial measures is included within our earnings release. As a note to all call participants, we provided updates via two press releases issued this morning, and we have also posted an investor presentation to our website, ZimmerBiomet.com. With that, I'll now turn the call over to Bryan. Bryan?

Bryan Hanson (President and CEO)

All right, great. Thanks, Keri. I also want to say just thanks to everyone for joining us on the call here this morning. As you saw from our announcements earlier today, we clearly have a few updates that we want to fill you in on, and I am looking forward to a very productive call this morning. Just given the backdrop of COVID, let me just start by saying that I certainly hope that all of you are doing well and staying safe and continuing to, as much as it is frustrating, I am sure by now, continuing to social distance and wear your masks. I think that at this point, we are all pretty good at it, so let us make sure that we continue to do it.

To all of the ZB team members joining the call this morning and/or listening at a later time, I just want to let you know I'm thinking about you as well. I just want to say thanks. Thanks for everything that you do and have done and will do, actually, to continue to follow our protocols to keep yourself safe, obviously, but also your teammates safe. As a result of that, continue to deliver for our customers and our patients and move our mission forward. I just continue to be very proud of everything this team has accomplished against a significantly challenging backdrop in 2020. I'm proud of you. I'm glad to see what you've been able to do, and I'm looking forward to what you're going to do in 2021. Here we are, right?

We're in 2021, and there's going to be challenges we've seen already early on in 2021, but I'm confident that we're ready to deal with the challenges as ZB, and I'm pretty confident that we're going to see some real opportunities for 2021 as well. There are just a lot of updates that I want to share with you today, but I'm going to keep my comments to a minimum if possible. I really want to make sure that we have time for Suky to get into a little more detail on Q4 and then ultimately say how that's going to translate into 2021. Now, we're not going to give too many specifics on 2021, but he'll give you some color on what we're seeing from Q4 and, again, the impact we think that's going to have on 2021.

I want to make sure that we leave time for questions as well. For today, I'm just going to kind of keep it to three main topics. The first is really how we're continuing to navigate COVID-19 and to continue inside of that to ensure that we're executing against our strategy. The second one is really going to talk about the ongoing transformation of the company. We really are making sure that we're moving forward with active portfolio management, and obviously, we're taking the next steps there with the planned spin-off of our spine and dental business, so we'll talk a bit about that. The third, I want to make sure that we, again, touch upon our long-term growth strategy and how it positions us to drive growth, obviously, as a company, but also value for you and value for us.

Let's start, again, navigating the challenges and executing here in the short term. There's just no doubt that COVID, unfortunately, remains a challenge. Coming out of Q4, we're seeing the pandemic pressure and the surges continue and, frankly, worsen across pretty much all of our regions and markets. There's clearly more lockdown measures that we're seeing throughout Europe, the Middle East, and Africa, to a far lesser extent, but still impacting Asia-Pacific as well. Certainly in the Americas, we're all seeing it in the U.S., maybe different by state, but we're clearly seeing increased pressure as a result of surges in the pandemic. All of that is kind of the backdrop that we saw coming out of Q4. Unfortunately, this pressure and the corresponding decline in elective procedures grew throughout Q4 and actually was worse at the end of December.

At this point, we expect that increase in pressure will continue throughout Q1 at least and will impact all three of our regions. As a matter of fact, we're actually seeing this probably increase in pressure coming out of Q4. We would expect Q1 to be a little more challenging than even what we saw in Q4. Even given that backdrop, I'd say that I'm optimistic. Sounds crazy to just say what I said, but say that I'm also optimistic, but that's thanks to the approved vaccines. We're currently rolling those out around the world. We do believe the vaccines are going to change the COVID-19 dynamic, and we're going to see positive impact as a result of it.

As soon as we start to see the surges stop, we see the impact of COVID end, and we're confident that the recovery is going to mean that the normal patient flow is going to start again, and we're going to have the pull-through effect of a sizable patient backlog that's been created over the past number of quarters. We expect that when that recovery occurs, we're going to see a period of what I would define as normal market growth augmented by deferred procedures that will be coming in as well. We're going to be ready for that, and we're excited about that. As much as it's going to be a little rocky in the short term and potentially even more challenging than what we saw in the fourth quarter, we see a light at the end of the tunnel, and that's a good thing.

The big question is when. When is that going to happen? We know the vaccine's going to have the impact. The big question is when, and that is certainly going to be the key variable we are going to be looking at as we try to predict what 2021 is going to look like. I would just say, against this backdrop of COVID, what is clear to us is we cannot control when the vaccines allow the surges to stop, but what we can control inside of that is how we execute our strategy. I have confidence we are going to continue to move it forward. Our core business is strong. Our execution is on point. I would just say momentum around our key commercial launches and programs continues to be strong. I would say that overall, our commercial confidence is better than it has ever been.

I'll just give you a few examples of this. I can say it all day long, but unless we talk about it and actually it reflects in the numbers, who cares? Let's first start with ROSA Knee. Obviously, this is something that everyone's going to be paying attention to. Certainly, I am. I'll note we said we're going to hit between 200-300 cumulative placements by the end of 2020. Obviously, you know that we were in that range as of Q3. I'm happy to report that not only did we achieve that goal, we achieved the high end of that goal, and I would tell you that the momentum is strong coming into 2021. Q4 was actually our strongest quarter as of the date of launch of ROSA Knee. We've had some pretty strong quarters in the past.

Q4 was our best, and we were on the high end of the goal that we set for the year. As I said before, with some of the new launches that we have coming, specifically associated with the uni, I feel pretty confident that 2021 is going to continue to show that kind of resilience and strength for ROSA Knee. On the Persona Revision side, again, this product continues to be very successful for us. We now show that in Q4, we actually had the strongest quarter-over-quarter growth that we've seen since launch. We did realize our 2020 expectations of $100 million in gross revenue and almost $40 million in net of cannibalization revenue during the year. I would just tell you that that's just the beginning because Persona Revision serves as a really compelling tip of the spear product for our commercial team.

Once we get Persona Revision in, we've got an opportunity to hunt for the typical primary ni as well. We are very excited about that launch, and it continues to be strong. On the hip side, Avenir Complete continues to be a strong one for us. Even in the pandemic, it continues to beat our expectations. If I just look at Q4 specifically, we grew about 30% over Q3, again, even with the increased pressures of the pandemic in Q4. We are very excited with what we are able to do with Avenir Complete, and we expect big things to continue with this product throughout 2021. As you obviously know, we also expect at the end of 2021 to launch the ROSA Hip, which again gives us a lot of confidence in the hip category for our business.

Finally, for Signature One Planner, we demonstrated just, again, strong sequential growth with registrations up nearly 25% in Q4 over Q3, and we expect utilization to continue to expand significantly in 2021 with really a goal of having more than 50% of our shoulder procedures using presurgical planning. That is important for a lot of reasons. Remember, the presurgical planning creates stickiness with the customer, but it also enhances our ability to get more guides and augments using the procedure, which can really take up the ASP for that procedure. Exciting stuff with Signature One Planner as well. All in, we continue to execute. We continue to execute as a team. The way we're showing up every day, the way we're showing up in the market, frankly, versus our peers gives me confidence in our business, as does our continued innovation and our product launches.

We're going to see more this year, some pretty pivotal innovation that we're going to see this year. As I mentioned before, we're going to see ROSA Partial Knee. We're going to see ROSA Hip, and we're also going to see the first smart implant, Persona IQ, launched this year. Definitely exciting for us from an innovation standpoint in 2021. That leads me to really my second topic this morning. We continue the transformation of Zimmer Biomet. That's been the goal since I got here. You've heard me talk about our three phases of transformation. First was the hearts and minds and the execution challenges that we had in the very beginning. That's what we talked about a lot in the beginning. The second phase of this was really building a more robust longer-term strategy, making sure that we brought innovation to the market and getting our execution straight.

We're clearly well into that phase. Third is our portfolio transformation. That is the goal of active portfolio management to change the complexion of the organization so that we can have better goal of sustained missing a digit growth. I'm proud to say that we're squarely positioned in phase three now as well. As you've seen by our recent announcement, we're going to continue to move this forward. We have the portfolio management strategy and the process in place and have built a pretty strong capability to move us forward in this area. Late last year, we executed a number of smaller, but still important M&A deals to fill portfolio gaps and to better position us in higher growth areas that we do believe we have a right to win in.

Just this morning, we announced our intent to spin off our spine and dental businesses, ultimately creating, we believe, two independent publicly traded companies, both Zimmer Biomet and the new company called Nuco, that are going to be better positioned separate. I truly believe by separating out these businesses, we're going to create two stronger companies, two companies that are going to be better positioned to meet customer needs and improve patient lives and ultimately, and very importantly, deliver greater value to you, our shareholders. Let me give you a bit more detail on why we believe this is an opportunity for value creation and really why we think it delivers value for both ZB and Nuco. First of all, the transaction increases our management focus and resource prioritization. We truly do believe for both companies.

We think about Nuco, and we think it's going to thrive as an independent company with prioritized capital allocations, pursue strategies and growth opportunities, and truly investments inside of spine and dental that has not been a focus for Zimmer Biomet. It will absolutely be a focus for Nuco. For Zimmer Biomet, the transaction is an important next step in our transition into a more streamlined company with sharper focus and greater and more optimized resource allocation towards innovation in those core businesses that we are committed to that are profitable for us, where we see attractive markets with a right to win in those markets and be market leaders. The second thing is it's going to drive increased growth and efficiency for both companies. We really do believe that.

Simply put, we expect that these two companies, with their simplified operating models and just reduced complexity and increased focus, will be able to grow revenue, margin, and earnings per share faster than they would if we remain combined as one company. Suket is going to talk more about the specific financial impact that we expect in just a few minutes, but just know it's positive for both organizations, financially speaking, as we separate the organizations. Third, it's going to enhance value creation for our patients, our providers, and all of our key stakeholders, including our own team members. This is the next step in ZB's transformation, and it underscores our commitment to ensuring long-term priorities remain aligned with shareholders' best interests.

It's going to drive the business forward to meet customer needs and advance our mission to alleviate pain and improve the quality of life for people around the world. We think we can do it better as two separate organizations. That is the backdrop of the spin. Today, obviously, is just day one in terms of announcements around this process. You can absolutely expect that we're going to continue to provide updates as we move forward, as Nuco takes shape, and as we move toward the transaction close, which we're currently expecting to be around mid-2022. We are confident in these steps we're taking and our ability to keep executing and in our overall ZB strategy. That brings me really to the third and really the final topic that I have for these remarks.

It is our plan to drive long-term growth and ultimately, as a result of that, deliver increased value for you. To do that, we remain fully committed and confident in ZB's long-term growth and margin expansion expectations. In fact, the spin-off transaction that we are going to do over the next year serves to de-risk, if not accelerate, our path to that 4%-5% growth rate we have talked about and our 30% operating margin profile by the end of 2023. To get there, to be able to deliver on both of those, we are going to have to be committed to our priority growth areas. We have talked about these in the past, but I am going to remind you of them again. The key area of concentration for us would be knees, hips, and set.

If we think about knees first and foremost, we need to be able to grow above market rates here. We are going to continue to focus on the fastest growth sub-markets of knees. For us, that's going to be robotics, data and informatics, cementless and revision. We feel we have plenty of innovation and momentum here to continue to grow sustainably above market rates in knee. From a hip perspective, it's a little less ambitious than the beginning. We just said that we need to grow at market in the short term, with the idea that over the long term, particularly after ROSA Hip is launched, that we would grow above market in hip as well.

I can tell you, based on our performance so far, the ROSA Hip application being launched later in 2021 and the Avenir Complete momentum that we have, we feel confident we're going to be able to do that as well. As far as tech goes, we just want to grow at market, if not the higher end of market. To do that, we're going to focus on the most attractive sub-elements of set for us. That's for us, again, going to be sports, medicine, and extremities. Those are key areas of concentration for us that we're going to invest internally. We're going to look for external ways to build scale, and we're going to build commercial infrastructure as well. All right, let me close by saying that I continue to be more confident about ZB's future than ever.

I know I say that a lot recently, but I really do feel the momentum right now. I truly believe that we are well positioned for success and that our strategy is absolutely working. Our transformation is well underway, and our proven ability to rise to challenges and face adversity, I think it's prepared us well for navigating the current environment and really, for that matter, any environment in front of us. I just want to, again, say thanks to the entire ZB team. Your focus on our mission, our strategy, and how we show up and execute every day is unmatched. It's what makes ZB and what makes me confident that we're going to continue to deliver. With that, I'm going to turn the call over to Suketu for more financial details of the quarter and also looking forward. Okay, Suketu.

Suketu Upadhyay (CFO)

Thanks. Good morning, everyone.

Before jumping into the details, I'd like to summarize the quarter as one where we made significant progress across a number of strategic and operational fronts, all in the backdrop of heightened market pressure. While revenue and profitability were challenged due to the pandemic, we executed extremely well against the things we can control, positioning ourselves to win through eventual market recovery and beyond. Now, for this morning's call, I'm going to focus on two topics. First, our Q4 results, including commentary on the COVID impact and what we're seeing so far in Q1. Second, how Zimmer Biomet is positioned for long-term growth, specifically how we believe the spinoff transaction we announced this morning is expected to impact us post-execution. Moving forward, unless otherwise noted, revenue and P&L commentary will be on a constant currency or adjusted basis.

Net sales in the fourth quarter were $2.085 billion, a reported decrease of 1.9% and a constant currency decrease of 3.7% versus 2019. We did not experience any material day rate differences in our year-over-year comparisons. Our consolidated regional results were in line with expectations despite deepening pandemic pressure on global elective procedures as we exited the year. While the market softened through the quarter, execution remained strong across all regions. Beginning with Asia-Pacific, the region grew 2% versus Q4 2019 with growth across all three of our largest markets of Japan, China, and Australia, New Zealand. While COVID pressure on elective procedures increased towards the end of the quarter, the impact is less pronounced than what we are seeing in EMEA and the Americas. We are excited about the uptake we're seeing in ROSA in the region and with the solid performance across our knee and hip businesses.

As expected, the EMEA region was hardest hit by COVID-19, decreasing 17.5% versus 2019, with all sub-regions in decline. Surges in the virus leading to policy actions and government lockdowns negatively impacted elective procedures across the region. Lastly, the Americas region was about flat, decreasing 0.3% compared to 2019, driven by continued COVID headwinds in Latin America in tandem with a softening U.S. market. The U.S. was flat despite increased pressure on elective procedures. Performance was buoyed by continued strong demand for recent innovative product introductions, strong execution by our commercial organization, and some favorable impact related to the order timing and year-end purchases, as some accounts increased their buying patterns to utilize remaining 2020 budgets. Turning to our business performance for Q4, the global knee business declined 4.8%, negatively impacted by the ongoing pressures in EMEA.

However, the U.S. knee business continued to grow, increasing 1.8%, and Asia-Pacific knee business returned to growth, increasing 2.9%. Overall, execution was strong with continued momentum for Persona and ROSA Knee. Our global hip business decreased 3.4%, again driven by declines in EMEA. Both U.S. hips and APAC hips continued their growth trends, increasing 1.4% and 1.3%, respectively. Sports, extremity, and trauma sales declined 3.3%. Dental, spine, and CMST continued to deliver better execution, increasing 0.8%. Finally, our other category was down 9.3%. Moving to the P&L, we reported GAAP-diluted earnings per share of $1.59 and adjusted diluted earnings per share of $2.11. Additional details on our GAAP results can be viewed in our press release issued this morning.

On an adjusted basis, with revenue down 3.7%, EPS was down about 10%, driven by a lower operating margin and a higher share count, which more than offset the favorable tax rate in the quarter. Lower adjusted operating margin was driven by lower revenue and an expected year-over-year decline in gross margins. Adjusted gross margin was 71.3%, sequentially better than Q3, but lower than Q4 2019. Versus the prior year, favorable geographic mix was more than offset by lower volumes, ongoing pricing pressure, and the impact from prior period deferred costs. OpEx was down versus the prior year as we implemented several cost containment initiatives as part of our response to the pandemic, in addition to the realization of our transformation programs that were ultimately reinvested back into R&D and commercial infrastructure to help drive consistent above-market growth in priority areas.

Based on our performance versus market over the recent quarters, our reinvestment of efficiency savings is translating into strong returns. The Q4 adjusted tax rate of 15% was better than the previous year due to geographic mix of income and certain discrete benefits in the quarter related to recent audit settlements. Turning to cash and liquidity in the quarter, free cash flow totaled $329 million, higher than the same period in 2019, driven by better working capital and lower capital expenditures. We utilized better-than-expected cash flow to pay down $250 million of debt ahead of schedule, ending the year with cash and cash equivalents of approximately $800 million. Now, moving to 2021. Due to the ongoing uncertainty related to COVID-19 and its impact on elective procedures, we will not be providing full-year financial guidance at this time.

We recognize that this is challenging for you as you build your 2021 models. However, we will reserve financial guidance until we have more certainty around the outlook of elective procedures relative to COVID surges and related vaccine adoption. We strive to be credible and transparent, and to that end, I will provide additional quarterly details and broader full-year shaping as an interim measure. So far, through January, we've seen COVID pressure continuing to intensify from the end of December. Based on what we've seen so far in the quarter and in tandem with our latest estimates for procedure cadence, we project that Q1 revenue will be down in the low single-digit to mid-single-digit % range versus Q1 2020. Now, we have optimism and confidence that we'll see a positive vaccine impact on elective procedures this year.

Once we do, we expect elective procedure volumes to return to pre-pandemic levels and the sizable patient backlog to serve as a tailwind to underlying market growth. As we turn to the P&L, we expect that the impact of COVID-19 on sales volumes will put pressure on adjusted operating margins and earnings leverage until we return to consistent pre-COVID revenue levels and growth rates, as I just discussed. Despite this near-term pressure, our confidence in the market recovery and the longer-term financial profile of the company is driving continued investment into priority areas of the business. We expect that adjusted gross margin will stabilize in 2021, with quarterly margin levels broadly in line with what we saw in the back half of 2020.

We could see some fluctuation from quarter to quarter, depending on a number of variables, including volumes, price, foreign currency, mix, and other drivers that can change results over time. Regarding operating expenses, sequentially versus the fourth quarter of 2020, we expect non-commission spending in Q1 to be modestly lower, with increases in future quarters' OpEx investments as the impact of the pandemic abates. We expect interest expense to increase in the mid-single digit % versus 2020, as the benefit from lower debt balances is more than offset by the renewal of net investment hedge positions. Our tax rate is expected to be modestly higher than the full-year 2020 rate and could fluctuate over the year as a result of variability in geographic mix of income due to the pandemic. Also, we are not projecting any material U.S. corporate tax reform to be implemented in 2021.

We project that the full-year share count in 2021 will continue to increase modestly versus Q4 2020, and we are not planning for any share buybacks in the year. In terms of capital allocation, we remain committed to maintaining our investment grade rating and are planning to pay down an additional $500 million of debt in 2021. Now, let's turn to today's announcement related to our intent to expand the spine and dental businesses into an independent publicly traded company. The transaction will be structured as a tax redistribution of newly issued Nuco shares to Zimmer Biomet shareholders. As Bryan mentioned, we believe that this tax-efficient transaction, which is expected to close in mid-2022, subject to certain conditions, will drive greater focus for each company with enhanced prioritization of capital allocation while accelerating growth and providing the platform for greater shareholder value.

In terms of the Nuco financial profile, 2019 and 2020 pro forma revenues totaled approximately $1.022 billion and $897 million, respectively, and is supported by a diversified geographic base with real opportunities for enhanced growth and margin expansion. We expect Nuco to have a financial profile generally in line with its peer group and a capital structure supportive of innovation and investment over time. Importantly, the transaction will empower Nuco to pursue a more focused investment and execution strategy. ZB delivered 2019 and 2020 pro forma revenue of $6.96 billion and $6.128 billion, respectively. For post-SPIN ZB, the transaction is expected to deliver an improved growth profile with accretion to our revenue growth of approximately 50 basis points over the course of our five-year strategic planning period. We also expect that it will expand our adjusted EBITDA and operating margins on a pro forma basis by approximately 125 basis points.

With that, we should have even greater confidence in our operating margin expansion goals. We remain committed to at least 30% adjusted operating margins by the end of 2023, and with this transaction, we have the opportunity to accelerate the timing of that goal. However, we will continue to balance margin acceleration against investment opportunities to accelerate durable top-line growth. Ultimately, this transaction provides greater optionality to invest more in the business while delivering a leading margin profile, and that's an incredibly powerful lever. In terms of capital structure, post-spin, we will prioritize proceeds towards debt paydown to maintain our investment grade rating. We're truly excited about this transformational opportunity to increase value for our investors and will continue to provide more details as execution of the spin progresses.

To summarize, while the pandemic continued to pressure our growth and earnings profile in the quarter, we made substantial progress on many fronts, including very strong performance versus the market, progress on our efficiency programs that enabled increased investment for growth, free cash flow generation that was ahead of revenue growth, strengthening of our balance sheet through early paydown of debt, integrating our strategic and accretive tuck-in and M&A deals, and positioning ourselves to execute the spin-off of our spine and dental business as a platform for greater value. I'm truly proud of what the ZB team accomplished in the quarter and throughout 2020. With that, I'll turn the call back over to Keri.

Keri Mattox (SVP of Investor Relations and Chief Communications Officer)

Thanks, Suky. Before we start the Q&A session, a reminder to please limit yourself to a single question and one follow-up so that we can get through as many questions as possible during the call. With that, operator, may we have the first question, please?

Operator (participant)

Thank you. Ladies and gentlemen, at this time, we will now begin the question and answer session. One moment, please, for the first question. Our first question comes from Steven Weinstein with Oppenheimer & Company.

Steven Weinstein (Analyst)

Thank you. Good morning. Bryan, as you continue in phase three, obviously accelerated with today's announcement, I was wondering if you could provide your latest thoughts on capital allocation. Are you still targeting tuck-in? Are you doing larger deals? Any color would be helpful. I'll follow up on COVID.

Bryan Hanson (President and CEO)

Okay. Yeah. I'll just briefly answer your first question, and then I'll pass it over to Suky. Yeah, our capital allocation strategy remains the same. We do want to look at tuck-in acquisitions that we think would have low disincentive risk, and we have a right to win in the space. That's what we're going to continue to do. This does not change that. Suky, you want to give maybe a little more color just overall on the overall capital allocation strategy?

Suketu Upadhyay (CFO)

Yeah, sure. We made good progress. Even in the backdrop of the pandemic in 2020, we're going to continue to make progress in strengthening our balance sheet and creating firepower moving forward. As I said in my earlier remarks, we expect to pay down about $500 million of maturing debt this year. As cash flows improve as the virus abates throughout 2021, that'll increase and expand our opportunity for our power opportunity for continued tuck-in M&A. Again, consistent with how we talked about previously, first priority is to maintain investment grade, pay down debt, de-lever. Our second priority from a capital allocation standpoint is to continue to grow that top line and bottom line through accretive strategic tuck-in M&A. This now gives us even greater focus through our spin transaction.

Steven Weinstein (Analyst)

Great. Just on COVID, where do you think the size of deferred procedures is? I know we've talked about it in the past. I know it's a tough number to tease out, obviously. Any comments there would be great as we hopefully see end market conditions improve as the year goes on.

Bryan Hanson (President and CEO)

Yeah. It's a fantastic question, truthfully, and one that we track quite a bit and try to estimate. I would just tell you that without being able to be a fine point to it, it's hundreds of millions of dollars is the way that we view it. That's what gets us pretty excited about the fact that the end of the pandemic, in our view, is on the horizon. Once that occurs, we've got a heck of a backlog that we need to work through. Now, the timing of when you work through it is based on capacity, capabilities in different markets, and those types of things. We feel it's very sizable, and we're excited to start working through it.

Steven Weinstein (Analyst)

Thanks, guys.

Bryan Hanson (President and CEO)

We will take our next question from David Lewis with Morgan Stanley.

David Lewis (Financial Advisor)

Oh, good morning, and thanks for taking the question. It's just two for me, and I'll start strategically on the spin. Bryan, a lot of times in spins, we create a lot of value through multiple arbitrage between the two assets. We haven't finished our math here. My sense is the multiple spread won't be that wide here. The real value creation for Zimmer is sort of to execute your goals or grow faster. When you say 50 basis points of growth, Bryan, does this get you to 4-5% growth faster, or are we talking about it's just going to get you to a higher WAMG or a higher structural growth rate at some point towards the end of the LRP? I have a quick follow-up for Suky.

Bryan Hanson (President and CEO)

Yeah, yeah. For us, when we just think about growth rate, we're kind of sticking to that 4-5% that we've been talking about. What we should look at here is that you should have greater confidence, obviously, in our ability to do that and potentially be on the higher end of that range. That is a key focus for us. Really, the significant value for us is that ability to focus. Remember, we talked before about getting to 4-5%. You had a number of variables associated with it. One of those variables, even though we didn't have the same level of investment in these businesses, was that they had to grow at least at the lower end of market. Over time, if you're not investing appropriately in businesses, there's risk in that.

We have eliminated that risk as we spin these out. We have unlocked value for Nuco because ultimately, they are going to invest more intently in those businesses. It provides value in both ways. Go ahead on your second question then.

David Lewis (Financial Advisor)

Sure. Sorry, Bryan, can we think about our conference to suggest that maybe 4-5% growth is possible the next two years to just get you there any faster? I'll ask my other question for Suki Ritz real quick. Suki, a lot of focus this call on the USD number. Can you just give us any sense as it relates to the USD number? What was the impact of those strategic deals or bulk purchase deals on the fourth quarter, and how the ROSA contribution in the fourth quarter on a revenue basis looked relative to the third quarter? Thanks so much, Steve.

Bryan Hanson (President and CEO)

Suky, if you're talking, you're on mute.

Suketu Upadhyay (CFO)

Yep. Thank you, Bryan. Thank you for the question, David. On your first question relative to the year-end and the US number, it's not uncommon at the end of any quarter, especially at the end of year-end, to see higher sales and some potential timing favorability or headwinds for that matter. In this quarter, we actually saw some incremental uptake in our U.S. business. Again, probably not different than what many others saw across our sector as many accounts were utilizing their year-end budgets to bring in some product. For us, we look at it. It was a modest benefit on the total company. It was in the low single digits. Again, it was something that was above our normal trend, so we wanted to make sure we called it out.

Any impact that that might have into 2021 is reflected in those Q1 estimates that I've already provided. Overall, still a very, very strong quarter for the company versus market, both in knee and hip. Your second question relative to ROSA, we did see a shift in the fourth quarter, especially with those expanded hospital budgets or remaining budgets, I should say, more dollar sales on installments than we've previously seen in Q2 and Q3. Year-over-year, Q4 last year to this year, it was not a major material headwind or tailwind on our overall growth numbers.

Keri Mattox (SVP of Investor Relations and Chief Communications Officer)

Thanks. Operator, can we have the next question, please?

Operator (participant)

Thank you. We'll take our next question from Larry Bieg with Raymond James.

Larry Bieg (Analyst)

Thanks. Good morning, everyone. Just wanted to first come back to the spin-off here. I guess what I'm really curious about is why is now the right time for the spin-off? Along with that, why a spin versus a sale? Then I'll come back to the second question.

Bryan Hanson (President and CEO)

Yeah. The timing of it fits right into the phases of where we look at transforming the business. For us, it was sequential. We wanted to make sure that phase one in our transformation was in great shape, and it is. Phase two would need to be well underway before we'd want to take something like this on. I think based on our performance over the last few quarters versus our competitors, it's pretty clear that phase two is working quite well. Now it's time. It's time for active portfolio management. In a time when we do not have as much capital to work with, this is clearly one of the most significant ways that we can impact and influence the portfolio in a positive way for both companies. I truly do believe that. That's the why now. We're excited about it. We truly are.

We're excited about it for our organization, our main Co, and we're excited about it for Nuco. We'll be in it together for the next year, year and a half, and even post that. That's from our view, the why now. We've looked at multiple ways to drive value with these businesses. Just know that this isn't the only option that we've looked at. Given the number of options on the table, we felt that this was the most significant way we could drive value for our shareholders, our businesses, and our team members. That's the reason for the spin.

Larry Bieg (Analyst)

Okay. Very good. Bryan, look, you guys seem to be increasingly well-positioned in creating sort of this digital ecosystem in orthopedics. If I think about it, you've got presurgical planning, you've got robotics, you've got my mobility, you've got Persona IQ. Maybe just talk about how you see the product offering evolving at Zimmer and how the ecosystem can help improve outcomes. What are you thinking about sort of reimbursement for Persona IQ for both the implant and the remote monitoring aspect of it?

Bryan Hanson (President and CEO)

Yeah. I will not get into specifics on reimbursement for Persona IQ, but we definitely see it as a very important piece of the puzzle when we think about the ecosystem that you are referencing. I would just say that we are taking it very seriously when we look at ecosystem versus just the typical implant. We have had a significant shift in our research and development dollars towards robotics, towards data and informatics to build that ecosystem that is going to be meaningful for patients and for our customers alike. I have to say, there is a lot of excitement around that in our organization, a lot of excitement from our customer base as well. The competency that we have built over the last few years in this area is, in my opinion, second to none.

Where we do not have the competency, we have been working with external partners that have pretty significant names like Apple. You are going to hear more about those coming up as well. We feel really good about where we are today. We feel, in my opinion anyway, that these ecosystems to be able to capture data before, during, and after a procedure are going to be a significant benefit for patient outcomes. Ultimately, at some point, when we pick up enough data and have the data available to us, we will be able to have predictive analytics to make better care decisions before the surgery occurs. That is really the intent. We are very excited about it. We have shifted dramatically the research and development in this area. We feel we are ahead right now versus our competitors.

Larry Bieg (Analyst)

Okay. Great. Thank you.

Bryan Hanson (President and CEO)

Sure.

Operator (participant)

Our next question comes from Larry Zingeser with Wells Fargo.

Larry Zingeser (Analyst)

Good morning. Thanks for taking the question. Just two financial questions for me, probably both for Suki. Suki, the margins of the spine and dental businesses, how do they compare to the new or current Zimmer? You talked about them being similar to peers, but there are a lot of different peers out there. Can you give us a little bit more color on the margins of those businesses, please? I have one follow-up.

Suketu Upadhyay (CFO)

Sure. Good morning, Larry. The first thing I would say is we've provided some color on the pro forma accretion impact on our main Co, even on operating margins, which should give you a good initial view as to what the Nuco margins could look like. Just stepping back, overall, both those businesses, our spine, dental, and our bone healing business, have a gross margin profile that's a little bit below the overall company average. I would say bone healing is actually a little bit above the company average. It really comes down to the cost to serve, where the spending levels in both those businesses are much higher than the company average, which overall drives the operating margin for both spine and dental lower than where ZB Whole Co is from a standalone basis.

As we think about margin opportunity going forward in both those businesses, we do think that there's opportunity to enhance margins. One will come through, we believe, a real opportunity to accelerate top-line growth, which will bring some operating leverage to the business. There is also opportunity for makeshift and potential efficiency within the existing cost structure. Hopefully, that gives you a little bit more color on how to think about margins in those businesses going forward.

Larry Zingeser (Analyst)

That's helpful. On 2021, you gave some helpful color on Q1 revenue growth with Suky. Maybe you could talk about sales growth cadence through the year, just any reaction to consensus, which assumes about 2% growth over 2019. I know you don't have guidance out there, but just directionally and operating margins. In the past, I think you said they could come close to 2019, but maybe lag a bit. How should we be thinking about that for full year 2021? Thanks for taking the question.

Suketu Upadhyay (CFO)

Yeah. Yep. Absolutely. First, on revenue, why we're not providing guidance is because there are a number of variables that are just really difficult to predict at this time with any level of credibility or confidence. The first being, where is the trough in this most recent surge that we're seeing, January, February? Where does it land in Q1? What does that uptake look like post-adoption of vaccine? When do you ultimately return to normalized market growth and potential tailwind from the deferred procedures? We're running a number of scenarios. There are some scenarios where absolutely we could see a path to growth versus 2019. Again, those variables are at this point just too uncertain.

Clearly, I think just stepping back, once we do have adoption, wide adoption of that vaccine, which we believe we'll have at some point in 2021, we think that there's a real opportunity for some strong growth again once we return to normalized market and are augmented by that tailwind. It is just too difficult to say what that cadence looks like at this time. Regarding margins, you're absolutely right. As the margins or revenue continues to improve throughout the year, which we believe it will once we have good uptake with the vaccine, the margins should follow. There may be a slight lag consistent with how we've talked about things before as we catch up on certain investments. Make no mistake, they will expand. We do see the opportunity for significant margin expansion over time as we normalize our revenue uptake.

Larry Zingeser (Analyst)

Thank you.

Operator (participant)

Our next question comes from Amit Huzon with Goldman Sachs.

Amit Hazan (Managing Director)

Okay. Hey. Good morning. I wanted to start on the U.S. market for knees and hips. Obviously, with the dollars, there's a lot of noise, as you mentioned. Just from an underlying basis, I'm wondering what you think about market share, what you think what happened to market share in the fourth quarter for you in both knees and hips in the U.S. from a volume perspective.

Bryan Hanson (President and CEO)

Yeah. Yeah. What I would say is I try not to look at any specific quarter and draw too much of a conclusion. I would, now saying that, I'd much rather have what we just saw in the fourth quarter, where we're significantly above market growth. That always feels good. Instead, I more look at a trend. If I just go back, let's call it three quarters, that gives you more of a sense of how we're doing versus market. If I think about U.S., which is probably the cleanest way to look at this because there's a lot of noise in the mix and everything else that people may have outside of the U.S., if we just look at U.S., we're somewhere in the neighborhood.

We just think about large joints of 500-600 basis points over the last three quarters above market, above our key competitors. Knees is a little better than hips, but we're seeing outperformance in both. Knees probably more 600-700 and hips more like 500-600 basis points better. That is what I look at. Not a single quarter, but a combination of quarters and where we're seeing that trend. By the way, I fully expect us to continue that trend. I've talked about the innovation that is going to be pretty pivotal this year in both hips and knees. With the current momentum that we already have, with the commercial prowess that we have as an organization, and that innovation is still yet to come, my confidence level is pretty high.

Amit Hazan (Managing Director)

I just wanted to follow up, focus on R&D. As we look at just the absolute number for the year, I would say you haven't spent this little on R&D in several years. It's down 15% for the year. That's kind of separating from other companies and MedTech, in large tech MedTech to some extent. I'm wondering if you can give some color to where you've made the cuts, how you're prioritizing that budget, and how that impacts your future product gains.

Bryan Hanson (President and CEO)

That I like to, and the team likes to run a business, it's first and foremost always assessing how are you spending research and development dollars and then making makeshift spend to make sure that you're spending it wisely. That is why you saw me not seeing research and development increase. You just saw some slight compression there. It really was just to get straight on what are we going to spend our dollars on. We killed a lot of projects. It just did not have the returns that we expected. That is the cleanup, if you will. What you're going to see from here, though, is an increase for sure in research and development. I always want to make sure that we're spending money wisely before we say whether we're spending enough or too little, or do we need to spend more.

We have a real good feel now for what we should be spending money on, that we're spending money in a disciplined fashion, and we have a lot of things in the bullpen now that we want to turn on. As we look forward, you should expect to see increased spend in research and development, but increased spend in a very disciplined way.

Amit Hazan (Managing Director)

Thanks, guys.

Operator (participant)

Our next question comes from Bob Hopkins with Bank of America.

Bob Hopkins (Managing Director)

Thanks. Good morning, everybody. I'll just state my two questions up front in the interest of time. The first one is just to come back to something people have been asking about already. I was wondering if we could get just a little bit of a better sense for the impact of the bulk orders that you're calling out on Q4, specifically on U.S. hips and U.S. knees. The reason I ask is that your hip and knee growth in the U.S. is so materially above what we're seeing from peers, and the gap was just very, very wide this quarter. Any sense as to the quantification on U.S. hips and U.S. knees from those bulk orders would be great.

On the second question, which is on the spin announcement, Bryan, I mean, I don't think it's unfair to say that spine and dental are two relatively subscale businesses with not a lot of synergies between them. I guess my question is, why not sell them to the folks with scale? It just seemed like that would be a lot cleaner. We'd love your take on that. Thank you.

Bryan Hanson (President and CEO)

Yeah. First of all, on the quarter itself, again, we feel great about our quarter performance. I would say that when you're looking at this year and COVID in particular, there was a lot of money that folks had to spend. We always see in the fourth quarter, we see purchases that occur. We see it every quarter, but fourth quarter in particular. It is not abnormal to see it as Suky had referenced before. If I was going to try to put a number to it, I'd say maybe in the 2-300 basis points of benefit that we saw if you're thinking about large joints. It was important for us in a normal quarter, given this quarter differential between us and competitors, not as material. I would be surprised, quite frankly, if others did not see the same thing.

Either way, we just want to make sure we call it out as being transparent as we possibly can. That was the order of magnitude that we saw in the quarter. As far as the spin and having both dental and spine together, if you're going to spin a business, you want to make sure that it has a reasonable amount of scale, obviously, for it to be a viable, publicly traded company. We feel that a billion plus is kind of that number. Although there's not obvious reasons that you would look at from a strategic standpoint that those businesses would be together from a commercial perspective, there is a lot of capability and know-how and materials that are used for implants across dental as well as spine that there is some value in.

It was really more around the idea of scale and the importance of that scale and utilizing those competencies, if you will, and those raw materials that go across those two businesses. That was the reason why we spun both together.

Bob Hopkins (Managing Director)

Okay. Thank you.

Operator (participant)

Thanks, Bob. Our next question comes from Joanne Wuensch with Citibank.

Joanne Wuensch (Managing Director)

Good morning, everybody. Thanks for taking the question. As you think about spinning this out in the next 18 months, what do you need to prepare? Does it accelerate talking acquisitions or anything in terms of spending so that the next company heads into its stand-up phase in a good position? Thank you.

Bryan Hanson (President and CEO)

Yeah. I would say it's generally business as usual for most of the organizations. We're going to continue to focus where we have. We've got pretty good separation between businesses, so it's not going to be highly disruptive. There's a lot of work to be done, don't get me wrong, for the spin to occur and to occur as effectively as we want it to. It's not going to be disruptive to the two organizations because they're pretty, again, separated today. Yeah, we're actually increasing, not a significant amount, but increasing spend in these businesses to get them a good tailwind coming into the spin itself. If there were small opportunities for us to spend capital over the next 12 months that would make sense, again, to bolster that portfolio, we would certainly consider it in the same way that we would have beforehand.

We want to make sure that we're setting up Nuco for success. We're very close on a CEO to bring in, and that person will bring leadership right out of the gate. That's really the way we're looking at it. If we can give them a little more money to spend to get things going, that's what we're going to do here in 2021. If, again, very small deals, but if there were things that we could do to, again, bolster their portfolio, we would do that as well.

Joanne Wuensch (Managing Director)

A quick follow-up question for Suky. How do you think about us modeling over the coming quarters in terms of sequential improvement, starting with the fourth quarter commentary? Thank you.

Suketu Upadhyay (CFO)

Yeah. Hey, Joanne. Yeah. Hope you can hear me now. Joanne, as I said, it's difficult to predict at this point until we start to see a little bit more stabilization in some of our key or larger markets. If you go back to last year, we're hopeful that this is a one to two-month trough, and we begin to see a V-shaped recovery as we did last year within Q2, leading into Q3. If that happens into Q2 and we start to see stabilization of market growth in the back end of the year, and then potentially that tailwind that we've been talking about with deferred patients, that could present a nice trajectory for us and one of those pathways to potential growth for this year. It really is just too early to tell.

As we've done over 2020, we will keep you updated as we learn more and as we understand how this impacts our business.

Operator (participant)

Thank you. Our next question comes from Chris Pasquale with Guggenheim.

Chris Pasquale (Managing Director and Senior MedTech Analyst)

Thanks. First one for me, just hoping you give us any more clarity on the timing of the new ROSA uni and hip applications. I think I heard you say late 2021 for hips. Just trying to get a sense for whether either of those can really have an impact this year.

Bryan Hanson (President and CEO)

Yeah. We think both will have an impact this year. Obviously, the uni will be first. That will be in the first half of the year. That's one that we are very excited about. We have a significant share of the uni market, and we're excited to be able to bring robotics to that market. Hip will be the second half of the year. Even though it's second half, we still believe it'll have an opportunity for us to buoy the hip number in the back half of the year.

Chris Pasquale (Managing Director and Senior MedTech Analyst)

Great. That's helpful. Can you talk a little bit more about the performance of S&P and how you see those individual businesses positioned heading into 2021? I'm curious whether there's any notable differences between them in terms of how they finish the year and whether you're seeing any opportunities within extremities in particular to take advantage of some of the disruption in that market.

Bryan Hanson (President and CEO)

Yeah. I mean, for us, obviously, set is not all created equal. We've talked about sports and extremities as being key focus. Upper extremities is the here and the now. Lower extremities will be more in the future. Sports is the here and the now with the recent acquisition that we did to Tuck in to fill in some product gaps that we have. We feel good about all three of those areas. Our ASC presence, again, with the Tuck in acquisition that we recently did to give us more scale in the ASC and the contracting team that we put into place. It's not as fulsome yet as what is hip or knee, but it's getting there pretty quick. Our confidence level is high that we're going to see the growth rate that we need in set, and it's going to be driven by sports.

It's going to be driven by extremities, and it's going to be driven by our presence in the ASC.

Chris Pasquale (Managing Director and Senior MedTech Analyst)

Thanks.

Operator (participant)

We'll take our next question from Kyle Rose with Canaccord.

Kyle Rose (Managing Director)

Great. Thank you for taking the question. I'll ask both of mine up front. First is, Bryan, you talked a lot about data and the ecosystem, connected ecosystem. Can you kind of just help us understand how that translates relative to revenues or driving lower costs? I mean, do you change the commercial model? Does this help you develop better technologies? I mean, these have good long-term outcomes, but I'm just trying to understand how this drives incremental growth longer term. Obviously, you're having great success with ROSA and robot placement. Help us understand maybe utilization there and then maybe any benefits you're seeing with respect to price and mix on the actual implant side. Thank you.

Bryan Hanson (President and CEO)

Yeah. If you think about it, what we're trying to attack is the fact that 20% of patients in the knee right now are still not satisfied with the outcome that they have. That's a pretty significant number. We truly do believe that the ecosystem is going to be able to help resolve that disappointment in the knee procedure. That's good for everybody, by the way. As we move down this path, we make those outcomes look better as a result of capturing the data and then making different decisions as a result of the data. That's going to allow us to get better outcomes. When that occurs, you're going to have more patients get bold enough to move into the funnel because it's underserved today.

There are patients that need a knee procedure that are afraid of the outcome, are not confident as a result of it, and they're not entering the funnel. As we can change that outcome, and we believe we can, then we're going to have more people enter the funnel, and that's good for the entire market. That's the way we're thinking about data and informatics and driving better outcomes over time. As far as ROSA goes, I'll tell you, I'm excited. We've got one application in our robotic system. I think that's what people remind people of. Just one application. We've got two more coming this year, but it's one right now. I mentioned in my preparatory remarks that we were at the higher end of our placement goal in 2020. What I would tell you is that in reality, we were above that number.

When I say higher end, I actually meant above 300. The quarter was significant. I think this is really important. We placed over 115 units in the fourth quarter, which was just an outstanding performance by the team. What I love about that is that happened in concert with one of our other players in the marketplace, one of our competitors, also having a record quarter in the fourth quarter. That is good news because that tells you that orthopedics is open for robotics, wide open for robotics. That tells you that you have got an opportunity for all boats to rise as a result. We truly do believe that the market is accepting of robotics. It is moving quickly. It is hitting a pivot point. It is going to be very accepting, we believe, as well, of the data and informatics that can come with it.

Suketu Upadhyay (CFO)

Yeah. If I could just build on what Bryan said, there was a question earlier about the strength of our U.S. number in recon. Yeah, absolutely, we had some benefit due to timing. One of the great things about some of that benefit that we saw was really it came because of some stocking because of new accounts and account conversion. I think that's yet another proof point of the strength that we're seeing in our commercial execution and with our new products. We had a really strong quarter, no doubt, in the US. We're continuing to see momentum for all the products that Bryan mentioned earlier. That's just actually accelerating the fourth quarter. Now we've shown it consistently for a few quarters.

We're pretty excited about where this is leading into 2021 and even more excited about where that could potentially lead us through recovery and post-recovery.

Bryan Hanson (President and CEO)

Thanks, Suky. I think we have time for maybe one last question before we hit the 9:30 time. Our next question comes from Kyla Krum with Truist Securities.

Kyle Rose (Managing Director)

Great. Thanks for taking our questions. Just two quick ones on portfolio management. I mean, it sounds like you'll continue to do tuck-ins. I mean, first, is it fair to say you'll now focus on these core areas in orthopedics? Then second, I'm curious, do you think that a different portfolio of spine products with greater scale can be more synergistic with your ortho business? Or do you simply think that there are limited synergies between the spine and ortho markets overall? Thank you.

Yeah. Our strategy around M&A and how we would spend capital dollars to augment the portfolios is unchanged. There are certain categories that we've talked about in the past where we believe we have a right to win, that we have a brand recognition that gives us that right to win, and there is a path for leadership as a result of that. They are profitable. Those are really the main things we're focused on. How do we enter into spaces, build scale, faster growth markets where we have a right to win, we have a path to leadership, and they are profitable businesses? That was not the case for us, for spine. It does not mean that spine cannot be a very attractive business.

It's just not one that we would invest in to become a leader because there's other opportunities for us to spend in sports or extremities or thoracic that are just more attractive markets and more profitable. We would look at these as being better as a result of that as separate businesses versus a part of our portfolio. I don't believe, and we certainly haven't seen, that there's a real benefit in having even a fulsome spine business in concert with large joints or set. We just don't see a lot of contracting, large contracts that pull through either one of those businesses.

Great. Thank you.

Bryan Hanson (President and CEO)

Sure.

Operator (participant)

All right. I think that takes us to 9:30. We'd like to thank everyone for joining us on this morning's call. Of course, the IR team and Cogent B team will be available today if there are any further questions. I'm sure we'll be talking to all of you. Thanks so much, and have a great day.

Bryan Hanson (President and CEO)

Thanks, Anne.

Operator (participant)

Thank you again for participating in today's call. You may now disconnect.