Alphatec Holdings Inc (ATEC) 2022 Q4 法說會逐字稿

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

大家下午好，歡迎收看 ATEC 第四季度財務業績的網絡直播。我們想提醒大家，電話會議的參與者將做出前瞻性陳述。這些陳述基於當前的預期，並受到可能導致實際結果存在重大差異的不確定性的影響。這些不確定性在定期向美國證券交易委員會提交的文件中有詳細說明。在這次電話會議中，您可能會聽到公司提到非 GAAP 或備考措施。我很抱歉。非 GAAP 措施與美國 GAAP 的對賬可以在新聞稿中的補充財務表中找到，這些表格確定並量化了所有被排除在外的項目，並提供了管理層對為什麼這些信息對投資者有用的看法。主持今天電話會議的是 ATEC 的董事長兼首席執行官 Pat Miles；首席財務官 Todd Koning。現在我將把電話轉給 Pat Miles。

Thank you, Angela, and welcome, everybody, to the Q4 2022 ATEC conference call. We will be providing some forward-looking statements, so please review that at your leisure. So our momentum by revolutionizing the approach to spine surgery continues. Our finish for 2022 was $351 million. We grew 44% over 4 years. We've grown at least 25% each year and at a 40% 4-year CAGR. And that comes via a year where we launched 10 new products, including our first expandable implant. We expanded lateral procedural sophistication with PTP and LTV, which includes a midline ALIF. We drove $48 million in EOS revenue, trained greater than 500 surgeons, achieved greater than 20% growth in surgeon users and increase our access to cash and liquidity to approximately $275 million. I believe much of our value creation is unlocked by our culture. So it is worthwhile describing who we are and who we're not. And I would say who we are is a winning culture focused solely on spine surgery, committed to moving the field of spine forward through informatic and procedural innovation. 

謝謝 Angela，歡迎大家參加 2022 年第四季度 ATEC 電話會議。我們將提供一些前瞻性陳述，因此請您在閒暇時查看。因此，我們革新脊柱手術方法的勢頭仍在繼續。我們 2022 年的完成額為 3.51 億美元。我們在 4 年內增長了 44%。我們每年至少增長 25%，4 年復合年增長率為 40%。那一年我們推出了 10 種新產品，包括我們的第一個可擴展植入物。我們通過 PTP 和 LTV 擴展了橫向程序的複雜性，其中包括中線 ALIF。我們推動了 4800 萬美元的 EOS 收入，培訓了 500 多名外科醫生，實現了超過 20% 的外科醫生用戶增長，並將我們獲得現金和流動資金的機會增加到約 2.75 億美元。我相信我們的大部分價值創造都是由我們的文化釋放的。因此，有必要描述一下我們是誰，我們不是誰。我想說的是，我們是一種只專注於脊柱外科的成功文化，致力於通過信息和程序創新推動脊柱領域向前發展。

So who are we not? I would say we're not a division of a division. We're not a conglometor acquiring growth and disinterested in froing technology or an implant-only transactions uncommitted to the full clinical experience. Our commitments haven't changed. We focus exclusively on spine fulfilling unmet clinical needs through integrating technology to create predictability. That we call creating clinical distinction. And so when we create clinical decision, we believe that we compel surgeon adoption. When we compel surgeon adoption, we believe we have access to a more effective sales force and an expanding sales force. So our clinical distinction view is different. Our 100% spine focus allows us to invest in procedural technology that further the predictability of spine surgery. Around here, we have the propensity to make up words like proceduralization. At the heart of our proceduralization is lateral. We like to say more distinction you draw to a subject you're more sophisticated. Lateral is a place of great sophistication at ATEC. Why would it not be? The gang who pioneered is here. 

那麼我們不是誰？我會說我們不是一個部門的一個部門。我們不是一家尋求增長的企業集團，對前瞻性技術或不致力於完整臨床經驗的僅植入物交易不感興趣。我們的承諾沒有改變。我們專注於通過整合技術創造可預測性來滿足未滿足的臨床需求的脊柱。我們稱之為創造臨床區別。因此，當我們制定臨床決策時，我們相信我們會強制採用外科醫生。當我們強制採用外科醫生時，我們相信我們可以獲得更有效的銷售隊伍和不斷擴大的銷售隊伍。所以我們的臨床鑑別觀點是不同的。我們 100% 專注於脊柱，使我們能夠投資於可進一步提高脊柱手術可預測性的程序技術。在這裡，我們傾向於編造像程序化這樣的詞。我們程序化的核心是橫向的。我們想說你對一個你更複雜的主題有更多的區分。 Lateral 是 ATEC 的一個非常複雜的地方。為什麼不是呢？先驅者就在這裡。

What makes a procedure predictable is removing variables? That requires designing from the ground up and applying technology where it is most required. To be successful in lateral surgery, you must not only have automated EMGs, but also automated SSEPs. It only makes sense when you start to think about lateral spine surgery, what exists between the skin and the spine from a lateral is soft tissue. A key part of the FSO tissue is the lumbar plexus. The #1 complication potential in lateral surgery is injury to the lumber flexes. So it's a requirement to have automated EMGs to know where the nerve is an automated SSEPs. We are the only company with those 2 technologies combined in a workflow that makes the information actionable. So we believe that actual information drives improved clinical decision-making. 

使程序可預測的原因是刪除變量？這需要從頭開始設計並在最需要的地方應用技術。要在外側手術中取得成功，您不僅必須擁有自動化 EMG，還必須擁有自動化 SSEP。只有當您開始考慮側向脊柱手術時才有意義，從側向來看，皮膚和脊柱之間存在的是軟組織。 FSO 組織的一個關鍵部分是腰叢。側向手術的第一大潛在並發症是腰椎屈曲損傷。因此，需要有自動化的 EMG 來了解自動化 SSEP 的神經在哪裡。我們是唯一一家將這兩種技術結合在一個使信息具有可操作性的工作流程中的公司。因此，我們相信實際信息會推動改進臨床決策。

Our view additionally is that experience should not stop with lateral. It is really the reason behind the informatic ecosystem that we are building. IMAX system is a standard. No other company has a front-to-back standard from which to build our opportunity to affect the operative experience through information starts with EOS. Bringing that information from preop to plan into the operating room is really key. Judging the plan in real time in the operating room against the same image post-op is the foundation for predictive analytics. The work has begun on the vision to inform better spine surgery. The opportunity for EOS is far beyond capital sales. We literally covet the information that comes out of the system. We've already spent significant time on the building of the cloud. The surgeon patient portal is in process, the automated alignment report. So when you take an image, the ability to automate the measures at the same time in real time with the image will be apparent. 

我們的另外一個觀點是，經驗不應該止於橫向。這確實是我們正在構建的信息生態系統背後的原因。 IMAX 系統是一個標準。沒有其他公司擁有從前端到後端的標準，我們可以從中建立機會，通過從 EOS 開始的信息來影響操作體驗。將術前計劃中的信息帶入手術室非常關鍵。在手術室中根據相同的術後圖像實時判斷計劃是預測分析的基礎。這項工作已經開始，旨在為更好的脊柱手術提供信息。 EOS 的機會遠不止資本銷售。我們從字面上貪圖來自系統的信息。我們已經在構建雲上花費了大量時間。外科醫生患者門戶正在處理中，自動對齊報告。因此，當您拍攝圖像時，能夠同時對圖像進行實時自動化測量的能力將顯而易見。

Our automating the surgical planning would be based upon having the alignment reports immediately and then patient-specific rod bending will also be availed. Our ability to reconcile that from an interoperative perspective is technology that we're working on today. There will also be a rep portal, and that won't slow our efforts with regard to continuing to refine our neurophysiology platform. So having an automated alignment report based upon the based against the preoperative plan and understanding the interoperative reconciliation is really the foundation for how the analytics will begin. So our analytics will only be patient related, but they'll also be operational related. And so we feel like that in looking forward, the opportunity to provide these analytics is really in its inception. And so the opportunity to go ahead and understand what type of release will be required in the spine. I think so often people require or rely upon implants to do the job of alignment, but it would be valuable to ultimately have the understanding as to what needs to be achieved not only from a surgical perspective, but from a building of lordosis perspective. 

我們的手術計劃自動化將基於立即獲得對準報告，然後還將使用針對特定患者的桿彎曲。我們從互操作的角度協調這一點的能力是我們今天正在研究的技術。還將有一個代表門戶，這不會減緩我們繼續完善我們的神經生理學平台的努力。因此，擁有基於術前計劃的自動對齊報告並了解術間協調確實是分析如何開始的基礎。所以我們的分析只會與患者相關，但它們也會與操作相關。因此，我們覺得在展望未來時，提供這些分析的機會真的才剛剛開始。因此，有機會繼續了解脊柱需要哪種類型的釋放。我認為人們經常需要或依賴植入物來完成對齊工作，但最終不僅從手術的角度，而且從構建脊柱前凸的角度了解需要實現的目標將是有價值的。

And so not only will we utilize the analytics to drive our engagement in specific alignment, but also the opportunity to continue to build procedural elements beyond the core elements of the procedure. So for instance, we will have corpectomy for both lateral as well as PTP -- lateral transpose as well as PTP as well as we will expand the offering in the cervical realm. So we believe that creating distinction, compel surgeon adoption. As you can see, we've increased surgeon adoption by 22% growth over previous year. There's more products per category at 2.3, and we train more than 500 surgeons. There is clear interest in what we're building here at ATEC. Additionally, the procedural thesis is working. More products per procedure reflects more surgeon buy-in. You can see we've gone from 1.5% in 2018 to 2.2 in 2022. We will be rewarded for our spine-only focus. Imagine if you're a surgeon or a salesperson who has committed to their entire career to Spine, would you not want to deal with a company that has done the same. 

因此，我們不僅將利用分析來推動我們參與特定的調整，而且還有機會繼續構建程序核心元素之外的程序元素。因此，例如，我們將對側向和 PTP 進行椎體切除術——側向轉位和 PTP，並且我們將擴大在頸椎領域的產品。所以我們相信，創造區別，迫使外科醫生採用。如您所見，我們的外科醫生採用率比上一年增長了 22%。每個類別的產品數量更多，為 2.3，我們培訓了 500 多名外科醫生。人們對我們在 ATEC 正在建設的東西很感興趣。此外，程序論點正在發揮作用。每個程序的更多產品反映了更多外科醫生的支持。你可以看到我們已經從 2018 年的 1.5% 上升到 2022 年的 2.2%。我們將因專注於脊柱而獲得回報。想像一下，如果您是一名外科醫生或一名銷售人員，並且將他們的整個職業生涯都獻給了 Spine，您會不想與一家這樣做的公司打交道嗎？

Our effort with regard to distribution is all focused on expanding the footprint, strategically filling in gaps and compelling new surgeon users. We are a less than 5% shareholder at this point. Our opportunity is endless. So additionally, one of the things that you want to know is are we growing independent of adding people. And the great reflection here is that in those people who have been with us for a period of time, their growth is in the 46% range of year-over-year revenue growth. And so that gives us great confidence in terms of we're growing in the established territories as well as we're growing with regard to adding individuals. And so our real focus here is increasing the contribution from the existing team and making sure that the clinical attitude continues to increase in the operating room. So we have a lot of work to do as we are focused and committed to distinguish ourselves by serving the requirement of spine surgery over the long haul. So we can't be more excited about where we are right now, but we have a heck of a big future in front of us. And with that, I'll turn it over to Todd.

我們在分銷方面的努力全部集中在擴大足跡、戰略性地填補空白和吸引新的外科醫生用戶。我們目前持股不到 5%。我們的機會是無限的。因此，另外，您想知道的一件事是我們是否獨立於增加人員而增長。這裡最大的反映是，在那些與我們在一起一段時間的人中，他們的收入同比增長在 46% 的範圍內。因此，這讓我們對我們在既定領域的發展以及我們在增加個人方面的增長充滿信心。因此，我們真正關注的是增加現有團隊的貢獻，並確保手術室的臨床態度繼續提高。因此，我們有很多工作要做，因為我們專注於並致力於通過長期滿足脊柱手術的要求來脫穎而出。所以我們對我們現在所處的位置感到非常興奮，但我們面前有一個廣闊的未來。有了這個，我會把它交給托德。

Thanks, Pat, and good afternoon, everybody. We appreciate you joining us on the call today. I'll begin with revenue. Fourth quarter total revenue was $106 million, reflecting 43% growth over the prior year and an 18% increase compared to the third quarter. $106 million in revenue is comprised of $91 million in surgical revenue and $15 million of EOS revenue, which grew 14% over prior year. Fourth quarter surgical revenue of $91 million increased 49% compared to the prior year. Procedural volume grew 26% in the fourth quarter with an average revenue per case, expanding 18% year-over-year as revenue mix continues to shift towards procedures with more products per case and greater complexity. The average revenue per lateral procedure is about 2x our overall average, and lateral related revenue continued to grow meaningfully faster than surgical revenue overall. 

謝謝帕特，大家下午好。感謝您今天加入我們的電話會議。我將從收入開始。第四季度總收入為 1.06 億美元，較上年同期增長 43%，較第三季度增長 18%。 1.06 億美元的收入包括 9100 萬美元的手術收入和 1500 萬美元的 EOS 收入，較上年增長 14%。第四季度手術收入為 9100 萬美元，比上年增長 49%。第四季度手術量增長了 26%，每例平均收入同比增長 18%，因為收入組合繼續轉向每例產品更多、複雜性更高的手術。每個側向手術的平均收入約為我們總體平均水平的 2 倍，並且側向相關收入的增長速度持續快於手術收入的整體增長速度。

And while lateral related revenue contributed the most to growth, revenue related to ALIF and Biologics also continued to grow solidly in the quarter. Turning to the full year 2022. Total revenue was $351 million, reflecting 44% growth compared to 2021. That is comprised of $303 million in surgical revenue and $48 million of EOS revenue. Full year Surgical revenue grew 43% compared to the prior year, driven by volume growth of 25% and average revenue per case growth of 14%, posting over 500 surgeon training events in 2022 field surgeon adoption and drove a 22% year-over-year increase in the number of surgeon users. As newly trained surgeons become increasingly familiar with ATEC clinical distinction and partner with us both for more cases and for more complex cases, utilization is also growing. Walking through the remainder of the P&L. Fourth quarter non-GAAP gross margin was 69%, down 120 basis points compared to the prior year. The pressure was attributable to increased EOS service costs as we continue to address the backlog of service needs created during the pandemic and an increase in our biologics attach rate, which features a meaningfully lower gross margin than our overall business. 

雖然橫向相關收入對增長貢獻最大，但與 ALIF 和生物製劑相關的收入在本季度也繼續穩步增長。轉向 2022 年全年。總收入為 3.51 億美元，與 2021 年相比增長了 44%。其中包括 3.03 億美元的手術收入和 4800 萬美元的 EOS 收入。全年手術收入與上一年相比增長 43%，這得益於銷量增長 25% 和每例平均收入增長 14%，在 2022 年現場外科醫生採用方面發布了 500 多次外科醫生培訓活動，並推動了 22% 的同比增長外科醫生用戶數量的年增長。隨著新培訓的外科醫生越來越熟悉 ATEC 臨床區別並與我們合作處理更多病例和更複雜的病例，利用率也在增長。瀏覽損益表的其餘部分。第四季度非美國通用會計準則毛利率為 69%，與去年同期相比下降 120 個基點。壓力歸因於 EOS 服務成本增加，因為我們繼續解決大流行期間造成的服務需求積壓，以及我們生物製劑附加率的增加，其毛利率明顯低於我們的整體業務。

As we begin to anniversary these impacts in 2023, we expect gross margin to improve on a full year basis. Fourth quarter non-GAAP R&D was $11 million and approximately 10% of sales compared to $8 million and 10% of sales in the prior year. The increase on an absolute dollar basis was driven by continued investments to organically expand our product portfolio and advance the EOS platform. Non-GAAP, SG&A was $74 million and approximately 70% of sales in the fourth quarter compared to $59 million and 79% of sales in the prior year period. We delivered 940 basis points of improvement. Consistent with our long-range plan, leverage of our SG&A infrastructure delivered about 70% of that improvement with the reduction in variable selling costs attributable for the balance. Total non-GAAP operating expenses amounted to $85 million and approximately 80% of sales in the fourth quarter compared to $66 million and 90% of sales in the prior year period, demonstrating 970 basis points of operating leverage year-over-year. 

當我們在 2023 年開始紀念這些影響時，我們預計毛利率將在全年基礎上有所改善。第四季度非 GAAP 研發為 1100 萬美元，約佔銷售額的 10%，而去年同期為 800 萬美元，佔銷售額的 10%。以絕對美元計算的增長是由持續投資推動的，以有機地擴展我們的產品組合併推進 EOS 平台。非美國通用會計準則、SG&A 為 7400 萬美元，約佔第四季度銷售額的 70%，而去年同期為 5900 萬美元，佔銷售額的 79%。我們提供了 940 個基點的改進。與我們的長期計劃一致，我們的 SG&A 基礎設施的槓桿作用帶來了大約 70% 的改進，並減少了余額所佔的可變銷售成本。第四季度非美國通用會計準則運營費用總額為 8500 萬美元，約佔銷售額的 80%，而去年同期為 6600 萬美元，佔銷售額的 90%，表明運營槓桿同比增長 970 個基點。

Adjusted EBITDA was a loss of $2.8 million and approximately 3% of sales in the fourth quarter compared to an $8 million loss and a negative 10% of sales in the prior year. The 750 basis point improvement as a percent of sales was driven by operating expense leverage, which is partially offset by gross margin. Sequentially, adjusted EBITDA improved $3 million on a revenue step-up of $16 million, resulting in 420 basis points of improvement sequentially and an indication of the leverage we can deliver as our business scales. Turning to full year 2022 results. Non-GAAP gross margin was 70%, down 250 basis points compared to the prior year. Non-GAAP R&D for the full year was $39 million and approximately 11% of sales compared to $28 million, an improvement of 40 basis points compared to prior year. 2022 non-GAAP SG&A was $267 million and approximately 76% of sales compared to $198 million, an improvement of 510 basis points compared to prior year. 

第四季度調整後的 EBITDA 虧損 280 萬美元，約佔銷售額的 3%，而去年同期虧損 800 萬美元，銷售額下降 10%。佔銷售額的 750 個基點的改善是由運營費用槓桿推動的，這部分被毛利率所抵消。隨後，調整後的 EBITDA 在收入增加 1600 萬美元的情況下增加了 300 萬美元，導致連續改善 420 個基點，並表明我們可以隨著業務規模的擴大而發揮槓桿作用。轉向 2022 年全年業績。非美國通用會計準則毛利率為 70%，比上年下降 250 個基點。全年非美國通用會計準則研發費用為 3900 萬美元，約佔銷售額的 11%，而銷售額為 2800 萬美元，比上年提高 40 個基點。 2022 年非 GAAP SG&A 為 2.67 億美元，與 1.98 億美元相比，約佔銷售額的 76%，比上年提高 510 個基點。

Non-GAAP operating expense for the full year amounted to $306 million and approximately 87% of sales compared to $226 million, an improvement of 550 basis points compared to the prior year period. 2022 adjusted EBITDA was a loss of $28 million and approximately 8% -- a negative 8% of sales, an improvement of 360 basis points compared to full year 2021. We ended the fourth quarter with $85 million in cash. Year-end debt at carrying value was $364 million, which included $316 million of the convertible debt and a drawdown of $35 million from the revolving credit facility. With the improvement in adjusted EBITDA, operating cash used improved relative to last quarter and totaled $22 million. We expect full year 2023 cash use to meaningfully improve relative to 2022 as adjusted EBITDA improves consistent with our long-term plan. 

全年非美國通用會計準則運營費用為 3.06 億美元，佔銷售額的 87% 左右，相比之下為 2.26 億美元，比上年同期提高 550 個基點。 2022 年調整後的 EBITDA 虧損 2800 萬美元，虧損約 8%——銷售額為負 8%，與 2021 年全年相比提高了 360 個基點。我們在第四季度末擁有 8500 萬美元的現金。按賬面價值計算的年終債務為 3.64 億美元，其中包括 3.16 億美元的可轉換債務和從循環信貸額度中提取的 3500 萬美元。隨著調整後 EBITDA 的改善，運營現金使用量較上一季度有所改善，總計 2200 萬美元。我們預計 2023 年全年的現金使用將相對於 2022 年顯著改善，因為調整後的 EBITDA 的改善與我們的長期計劃一致。

In January, we entered into an agreement with Bradwell securing a non-dilutive debt facility. With the new debt facility and the revolver, we now have cash and access to capital of up to $275 million. This provides us flexibility to invest further in instrument sets and working capital to support top line growth above our long-range plan and permits us to maintain a higher minimum cash balance. Now turning to our outlook for the full year 2023. In line with our January release our fourth quarter and full year financial results, we continue to expect full year 2023 total revenue to grow 25% and approximate $438 million. That includes 2023 surgical revenue growth of approximately 26% and $383 million and EOS revenue of approximately $55 million. As sales growth drives leverage across our business, we continue to expect to achieve adjusted EBITDA breakeven for the full year 2023 by delivering 800 basis points of expansion. 

1 月，我們與 Bradwell 達成協議，確保獲得非稀釋性債務融資。有了新的債務工具和循環貸款，我們現在擁有現金和高達 2.75 億美元的資本。這為我們提供了進一步投資於工具集和營運資金的靈活性，以支持高於我們長期計劃的收入增長，並使我們能夠維持更高的最低現金餘額。現在轉向我們對 2023 年全年的展望。根據我們 1 月份發布的第四季度和全年財務業績，我們繼續預計 2023 年全年總收入將增長 25%，約為 4.38 億美元。這包括 2023 年手術收入增長約 26% 和 3.83 億美元，以及 EOS 收入約 5500 萬美元。隨著銷售增長推動我們業務的槓桿作用，我們繼續期望通過實現 800 個基點的擴張，在 2023 年全年實現調整後的 EBITDA 盈虧平衡。

Now keep in mind that Q1 revenue is typically seasonally lower than Q4 and even with the 800 basis points of margin expansion, adjusted EBITDA would also be lower than Q4 sequentially. We anticipate delivering positive adjusted EBITDA beginning in the third quarter of 2023, which positions us well to achieve the profitability and free cash flow goals in our long-range plan. Now the next few slides provide additional context for our 2023 guidance. I'll start by sharing how our expectations for procedural volume growth and the expansion of average revenue per surgery shaped surgical revenue guidance. We will continue to train surgeons at a robust rate which drives both surgeon adoption and utilization. Training surgeons build loyalty and enables surgeons to work up the procedural complexity curve, both of which increased utilization. The middle chart is a testament to the consistent ramp in utilization that our surgeon cohorts have demonstrated each year. We expect these dynamics to fuel a mid-teens percent procedure volume growth for the full year 2023. 

請記住，第一季度收入通常季節性低於第四季度，即使利潤率擴大 800 個基點，調整後的 EBITDA 也將低於第四季度。我們預計從 2023 年第三季度開始實現正的調整後 EBITDA，這使我們能夠很好地實現我們長期計劃中的盈利能力和自由現金流目標。現在，接下來的幾張幻燈片為我們的 2023 年指南提供了更多背景信息。我將首先分享我們對手術量增長的預期和每次手術平均收入的增長如何影響手術收入指導。我們將繼續以強勁的速度培訓外科醫生，這將推動外科醫生的採用和使用。培訓外科醫生建立忠誠度並使外科醫生能夠提高程序複雜性曲線，這兩者都提高了利用率。中間的圖表證明了我們的外科醫生隊伍每年都在不斷提高利用率。我們預計這些動態將推動 2023 年全年手術量增長百分之十幾。

Average revenue per surgery grows is a mix shift towards procedures that require more products for surgery like PTP and LTP and towards surgeries with greater complexity, all of which feature higher revenue per procedure than our overall average. The gradual addition of expandable implants to our portfolio and increasing biologics attach rate are also enabling us to capture more of each procedural revenue opportunity. We expect these dynamics to drive growth in average revenue per surgery at a high single-digit percent rate for the full year 2023. Turning to EOS. We anticipate approximately $55 million in EOS revenue for the full year 2023 and expectation supported by the existing pipeline that we expect to be delivered and installed this year. In addition, just over 1/3 of EOS revenue is driven by a predictable recurring maintenance revenue stream that will contribute incrementally. And as EOS deliveries increasingly shift towards the domestic market over time, we will also see a gradual benefit to ASP. 

每次手術的平均收入增長是向需要更多手術產品（如 PTP 和 LTP）的手術和更複雜的手術的混合轉變，所有這些手術的每次手術收入都高於我們的總體平均水平。逐漸將可擴展植入物添加到我們的產品組合中以及提高生物製劑附著率也使我們能夠抓住更多的每個程序收入機會。我們預計這些動態將推動 2023 年全年每次手術的平均收入以高個位數的百分比增長。轉向 EOS。我們預計 2023 年全年的 EOS 收入約為 5500 萬美元，並得到我們預計今年交付和安裝的現有管道的支持。此外，超過 1/3 的 EOS 收入是由可預測的經常性維護收入流驅動的，該收入流將逐步貢獻。隨著時間的推移，EOS 交付越來越多地轉向國內市場，我們也將看到 ASP 逐漸受益。

Now with respect to the rest of the P&L, we began to demonstrate the operating leverage that sales growth can drive to the second half of 2022, and we expect that dynamic to continue in 2023. Our guidance for breakeven adjusted EBITDA this year implies 800 basis points of improvement relative to the negative 8% margin reported for the full year 2022. And the 810 basis points of adjusted EBITDA leverage delivered in the second half of 2022, gives us confidence in the continued progress that guidance implies for 2023. And the margin expansion we saw in the second half of 2022 was driven by SG&A infrastructure leverage as investments we made began to scale. And that dynamic will continue to play out in coming years, coupled with the benefits of an improving variable expense profile. 

現在關於其餘損益表，我們開始展示銷售增長可以推動到 2022 年下半年的經營槓桿，我們預計這種動態將在 2023 年繼續。我們對今年盈虧平衡調整後 EBITDA 的指導意味著 800 個基點相對於 2022 年全年報告的負 8% 利潤率而言，改善點。2022 年下半年交付的調整後 EBITDA 槓桿為 810 個基點，使我們對指導所暗示的 2023 年持續進步充滿信心。利潤率我們在 2022 年下半年看到的擴張是由 SG&A 基礎設施槓桿推動的，因為我們的投資開始擴大。這種動態將在未來幾年繼續發揮作用，再加上可變費用狀況改善的好處。

Like we saw in the second half of 2022, 60% to 70% of operating expense leverage will come from SG&A infrastructure with the balance from variable selling expense. We're looking forward to demonstrating meaningful P&L progress for the full year 2023, which will position us well to meet our adjusted EBITDA and free cash flow comes that we outlined in our Investor Day last May. So in closing, 2022 marked a pivotal year. The first year of the ATEC (inaudible) were about demonstrating sustainable demand for the clinically distinct procedural solutions our team is developing. And that question has been answered as we've delivered a 40% compounded annual growth rate over the past 4 years. Now we've entered the next phase of our company's growth where we are beginning to deliver a return on the investments we've made. As a result of this operating leverage, we expect to achieve adjusted EBITDA breakeven in 2023, which will improve our cash use as we walk towards cash flow breakeven in 2025. Clearly, the wheels of the growth story are in motion and the momentum behind what we are doing is strong. Now it is up to our team to continue to seize the opportunities in front of us and execute. It's my hope that our financial performance thus far has earned your confidence. This is the team that is serious about delivering on our commitments. And with that, I'll turn the call back over to Pat.

正如我們在 2022 年下半年看到的那樣，60% 至 70% 的運營費用槓桿將來自 SG&A 基礎設施，其餘部分來自可變銷售費用。我們期待在 2023 年全年展示有意義的損益進展，這將使我們能夠很好地滿足我們在去年 5 月投資者日概述的調整後 EBITDA 和自由現金流。因此，總而言之，2022 年是關鍵的一年。 ATEC 的第一年（聽不清）是關於展示對我們團隊正在開發的臨床獨特程序解決方案的可持續需求。這個問題已經得到解答，因為我們在過去 4 年中實現了 40% 的複合年增長率。現在我們已經進入公司發展的下一階段，我們開始為我們所做的投資帶來回報。由於這種經營槓桿，我們預計將在 2023 年實現調整後的 EBITDA 盈虧平衡，這將改善我們的現金使用，因為我們將在 2025 年實現現金流盈虧平衡。顯然，增長故事的車輪正在運轉，背後的動力是什麼我們做的是強。現在要靠我們的團隊繼續抓住我們面前的機會並執行。我希望我們迄今為止的財務表現能贏得您的信任。這是認真履行我們承諾的團隊。有了這個，我會把電話轉回給帕特。

Thanks much, Todd. I think what you'll find is our share earning strategy will not change. We will continue to garner value out of the investments that we made in procedures like PTP and LTP. What you will see is an expanding complexity of the type of pathologies that we will address through these different procedures. The investments have been made. Now the opportunity to exploit those investments is before us. That effort will allow us the confidence that we've created in a way that will enable a halo effect that will increase other product adoption. So an expanding portfolio adoption. That confidence in that expansion will ultimately compel sales people to come our way. Those sales people coming our way will avail more opportunity. 

非常感謝，托德。我想你會發現我們的股票盈利策略不會改變。我們將繼續從我們在 PTP 和 LTP 等程序中所做的投資中獲得價值。您將看到我們將通過這些不同的程序解決的病理類型的複雜性不斷增加。投資已經完成。現在，利用這些投資的機會就在我們面前。這項努力將使我們充滿信心，我們以一種能夠產生光環效應的方式創造了信心，從而增加了其他產品的採用率。因此，擴大投資組合的採用。對這種擴張的信心最終將迫使銷售人員走上我們的道路。那些來我們這裡的銷售人員將利用更多的機會。

We are continuing our early experience in the international marketplace as we stated, we will be direct and narrow and deep in those spaces. As it relates to EOS, we have only just begun. So we are literally laying the foundation for an opportunity that will avail itself in '24, '25, '26. We believe that the translation of the EOS information is before us, and that will be the real value creation, where we love to sell EOS units, it is an investment that will pay off in the future that will ultimately avail the translation of the various information that comes from those systems. So our enthusiasm is exceedingly high. Our opportunity to apply our nimble focus to improve spine care is massive. Our best days are yet ahead. With that, we will take questions.

正如我們所說，我們正在繼續我們在國際市場上的早期經驗，我們將在這些領域直接、狹窄和深入。至於 EOS，我們才剛剛開始。因此，我們實際上是在為將在 24 年、25 年、26 年利用的機會奠定基礎。我們相信 EOS 信息的翻譯就在我們面前，這將是真正的價值創造，我們喜歡出售 EOS 單位，這是一項在未來會得到回報的投資，最終將利用各種信息的翻譯來自這些系統的信息。所以我們的熱情非常高。我們運用我們靈活的注意力來改善脊柱護理的機會是巨大的。我們最好的日子還在前面。有了這個，我們將提出問題。

We will now open the floor for questions. (Operator Instructions) In the interest of time and in consideration of other questions, please limit yourself to one question. The first question comes from Matthew O'Brien with Piper Sanmen.

我們現在開始提問。 （操作員說明）為了節省時間並考慮其他問題，請將自己限制在一個問題上。第一個問題來自 Matthew O'Brien 和 Piper Sanmen。

This is Phil on for Matt. Just a multiparter here on guidance more so. What are your puts and takes with the industry as we move into 2023? What really gets you to the top end of the range and likewise, the bottom? And what are you seeing from the LTP standpoint there? I mean we're really excited by it, but what are you seeing there?

這是 Phil on for Matt。只是這裡的多方指導更是如此。隨著我們進入 2023 年，您對這個行業有何看法？是什麼真正讓你到達範圍的頂端，同樣，到達底部？從 LTP 的角度來看，你看到了什麼？我的意思是我們真的很興奮，但你在那裡看到了什麼？

So as always, I will let Todd quantify and all qualify. And it's just best. I guess the second one first. We're hugely bullish on LTP. And to not go overly deep into the -- each of the different reasons why just because I think I may lose the interest of the audience, the ability to ultimately change the position to get access to 5.1 is game changing. And so in places that we had historically been, they've tried to take a patient to a bed and do a lateral ALIF at 5.1. And it becomes very hard. And I think that surgeons agree that the best position to do in ALIF is supine. And so if you can get media-wise access between the bifurcation at 51, it's a game changer. And so to be able to go 4 to 1 from an LTP perspective and have a patient controlled orthogonally with a patient positioner and protecting the neural elements with things like SAF, it is a very valuable tool. And so when we start to think through the elements that ultimately avail the top end of our guidance, what we do is we say, gosh, what are we confident in? 

所以一如既往，我會讓托德量化，一切都合格。這是最好的。我猜是第二個。我們非常看好 LTP。並且不要過分深入 - 每個不同的原因只是因為我認為我可能會失去觀眾的興趣，最終改變位置以訪問 5.1 的能力正在改變遊戲規則。因此，在我們過去去過的地方，他們試圖將患者帶到床上並在 5.1 時進行側向 ALIF。這變得非常困難。而且我認為外科醫生同意在 ALIF 中最好的姿勢是仰臥。因此，如果您可以在 51 處的分叉點之間進行媒體訪問，這將改變遊戲規則。因此，從 LTP 的角度來看，能夠達到 4 比 1，讓患者與患者定位器正交控制，並用 SAF 等東西保護神經元件，這是一個非常有價值的工具。因此，當我們開始思考最終利用我們指南的頂端的元素時，我們所做的就是說，天哪，我們對什麼有信心？

And as the guys who pioneered lateral from the inception, our confidence is in our ability to compel the interest. And I think that you see signs of that through all of the surgeons who've come through the building. And so I would say that our confidence is in the volume of people are compelling to come through the building and then the clinical aspects of the lateral technique that ultimately will expand the halo effect across the portfolio. So PTP is still in its early infancy of a big run. We'd love to get LTP out there in a much more wide way. You start to see the expandables come in, and it speaks to a company that's just enjoying the early part of this momentum.

作為從一開始就開創橫向發展的人，我們的信心在於我們有能力激發興趣。我認為你從所有來過這棟大樓的外科醫生身上都看到了這一點。因此，我想說，我們的信心在於，有大量的人被迫通過大樓，然後是橫向技術的臨床方面，最終將擴大整個投資組合的光環效應。所以 PTP 還處於大運行的初期階段。我們很樂意以更廣泛的方式推出 LTP。你開始看到可擴展產品的出現，這說明一家公司剛剛享受這種勢頭的早期階段。

Yes. Absolutely, Pat. And Phil, I think as you kind of think about the $438 million guide growing 25%, you think about the surgical revenue component of that. And I laid that out in terms of procedural volume and procedural ASP. And our procedural ASP assumption being in the high single digits, and that's actually higher than what our long-range plan assumption was. And then if you look at our volume components, really being in the mid-teens growth over 2022 and that's really very much in line with our long-range plan. And I think you see our guidance philosophy coming through here being putting out numbers that we believe that we can achieve and have a reasonable opportunity to exceed. And so I think so much of your question, I think, was really about industry factors. And I can tell you, when we're guiding to 25%, I think our upside is really more about our ability to continue to compel surgeon adoption through, I think, all the things that Pat just laid out. And I think that will ultimately come through stronger volume relative to our guidance it. So that's kind of how I think about the range and where things can differ. It's probably mostly on the volume component. It's really dependent on our ability to continue to compel surgeon adoption through clinical distinction.

是的。絕對，帕特。菲爾，我想當你想到 4.38 億美元的指南增長 25% 時，你會想到其中的手術收入部分。我根據程序量和程序 ASP 列出了這一點。我們的程序 ASP 假設是高個位數，這實際上高於我們的長期計劃假設。然後，如果你看一下我們的數量組成部分，到 2022 年確實處於十幾歲中期的增長，這非常符合我們的長期計劃。而且我認為你看到我們的指導理念通過這裡提出我們相信我們可以實現並有合理機會超越的數字。所以我認為你的問題很多，我認為，實際上是關於行業因素的。我可以告訴你，當我們引導到 25% 時，我認為我們的優勢更多地在於我們有能力繼續通過 Pat 剛剛提出的所有事情來強制採用外科醫生。而且我認為，相對於我們的指導，這最終將通過更強勁的成交量來實現。所以這就是我對范圍和事情可能不同之處的看法。它可能主要在音量組件上。這真的取決於我們繼續通過臨床區別強制外科醫生採用的能力。

The next question comes from the line of Josh Jennings with Cowen and Company.

下一個問題來自 Josh Jennings 與 Cowen and Company 的對話。

This is Eric on for Josh. Just starting on PTP. It seems like adoption and utilization of the procedure has been really solid in recent months. How penetrated do you think PTP is right now? And is it still early innings for PTP adoption, you think?

這是喬希的埃里克。剛開始使用 PTP。近幾個月來，該程序的採用和利用似乎非常穩固。您認為 PTP 現在的滲透率如何？您認為採用 PTP 仍處於早期階段嗎？

It's fascinating, right? It's like if you -- what's been interesting for us is to really look at the established businesses that we have out there from a distribution perspective or a sales force perspective. Those people who are selling PTP are growing at a rate that is far surpasses those people who are -- who had less success with it. And that's what provides us such enthusiasm with regard to when you start to see like kind of the established distributors reflected growth of 46%. I would tell you it's in its absolute infancy. The beauty of the technique is the applicability to do multiple different pathologic states. And so the opportunity to utilize it in things like deformity, our enthusiasm to utilize it in things like corpectomy. And so it is such the early phase of PTP. And so the applicability is very, very wide. The thing that thrills me is we've made the foundational investments to ultimately exploit the opportunity. And so when someone learns how to apply the technique, they are going to apply to more unique pathologies expand what that avails us as an opportunity to design into those expanded applications. And so I would say that PTP is an absolute infancy and can't be more bullish with regard to where the thing is going.

這很迷人，對吧？就像你——對我們來說有趣的是，從分銷的角度或銷售隊伍的角度真正審視我們已經建立的業務。那些銷售 PTP 的人的增長速度遠遠超過那些不太成功的人。這就是當你開始看到老牌分銷商反映出 46% 的增長時讓我們如此熱情的原因。我會告訴你它還處於起步階段。該技術的優點在於適用於多種不同的病理狀態。因此，有機會在畸形等方面利用它，我們熱衷於在椎體切除術等方面利用它。所以這是 PTP 的早期階段。所以適用性非常非常廣泛。讓我興奮的是我們已經進行了基礎投資以最終利用這個機會。因此，當有人學習如何應用該技術時，他們將應用於更多獨特的病理學，從而擴展我們可以利用的機會來設計這些擴展的應用程序。因此，我想說 PTP 絕對處於起步階段，對於事情的發展方向再樂觀不過了。

And I think, Eric, the only thing I'd add to that would be when you look at PTP, it's applicability from a relatively straightforward single-level degenerative case to the complex procedures as Pat described, gives us such an opportunity kind of beyond the existing, as we've talked about, the $1 billion lateral market as it is today. And I think that is one of the true, I think, opportunities that PTT has availed us, which is to really expand that market well beyond the $1 billion as we've defined it. And frankly, well beyond just dealing with a single or 2 level degenerative cases but into complex cases as well. And so as you kind of think about our penetration in surgeon use, obviously, more surgeons is good. But I think the more complexity you can apply with the procedure or you can address through the procedure, you get more utilization out of the existing surgeon base.

我認為，埃里克，我唯一要補充的是當你看 PTP 時，它從相對簡單的單級退化案例到帕特描述的複雜程序的適用性，給了我們這樣一個機會，超越正如我們所討論的，現有的 10 億美元的橫向市場就像今天一樣。我認為這是 PTT 為我們提供的真正機會之一，即真正將該市場擴展到遠遠超過我們定義的 10 億美元。坦率地說，不僅僅是處理單個或 2 級退化病例，還包括複雜病例。因此，當您考慮我們在外科醫生使用方面的滲透時，顯然，更多的外科醫生是好的。但我認為你可以應用程序越複雜，或者你可以通過程序解決，你可以從現有的外科醫生基礎中得到更多的利用。

Yes. It's a great point. The reality is what we've seen in -- whenever a new technique is created and there becomes an adoption curve, there's people who run forward with more complexity. And when people who demonstrate more complexity, you'll get more people to get on the bandwagon of an early adoption type of technology.

是的。這是一個很好的觀點。現實就是我們所看到的——每當一項新技術被創造出來並形成一條採用曲線時，就會有人以更複雜的方式向前奔跑。當人們表現出更多的複雜性時，您就會讓更多的人加入早期採用類型技術的行列。

The next question comes from the line of Drew Ranieri with Morgan Stanley.

下一個問題來自 Drew Ranieri 與摩根士丹利的對話。

Maybe just to start, and I apologize, this is a multipart kind of question. But in kind of thinking about your revenue guidance and what you were able to do last year, just maybe how should we think about any upside potential dropping through to the bottom line just in the context of your commitment to EBITDA breakeven, are you more willing to let that fall? Or are you still really kind of in investment mode to drive volume and surgeon adoption? Just love your thoughts on kind of that dynamic. I have a follow-up.

也許只是開始，我很抱歉，這是一個多部分的問題。但是考慮到你的收入指導和你去年能夠做的事情，也許我們應該如何考慮在你對 EBITDA 盈虧平衡的承諾的背景下任何上升潛力下降到底線，你是否更願意讓它下降？或者您是否仍然在投資模式中推動數量和外科醫生的採用？只是喜歡你對那種動態的想法。我有後續行動。

Thanks, Drew. And I think the first thing I'd say is our guide implies about 30% drop-through on the year-over-year. And so that's a pretty big drop through. And so that's really kind of where we're starting. I think for you to think about how -- to the extent that we overachieve our guidance, how that might drop through the top line, really, the way we've kind of thought about it is after you go for the gross margin and the variable costs associated with the incremental revenue, what's left, probably 2/3 of that gets invested back in the business in R&D to drive growth and 1/3 of it kind of drops to the bottom line. And I think that's kind of how we're thinking about it. And ultimately, we believe that there's such an opportunity to continue to innovate, make spine surgery better and grow this business. We want to make sure that we're fueling the machine.

謝謝，德魯。我想我要說的第一件事是我們的指南暗示同比下降約 30%。所以這是一個很大的下降。所以這真的是我們開始的地方。我想你要考慮一下——在我們超額完成我們的指導的程度上，這可能會如何跌破頂線，真的，我們考慮它的方式是在你追求毛利率和與增量收入相關的可變成本，剩下的，可能有 2/3 被投資回研發業務以推動增長，其中 1/3 有點下降到底線。我認為這就是我們考慮的方式。最終，我們相信有這樣一個機會來繼續創新，使脊柱外科手術變得更好，並發展這項業務。我們要確保我們正在為機器加油。

Got it. And then still on the profitability context, but Pat, I mean, it sounded like you were calling out compelling and attracting sales force or sales reps, just given the environment that we're in, in the industry, I mean, are you seeing any more evidence of an acceleration in maybe sales force additions? And as you are thinking about that potentially, would you step back from the committed breakeven in EBITDA to greatly expand the sales force this year to drive a longer-term opportunity?

知道了。然後仍然在盈利能力方面，但是帕特，我的意思是，考慮到我們所處的行業環境，我的意思是，這聽起來像是你在呼籲引人注目和吸引銷售人員或銷售代表，我的意思是，你看到了嗎是否有更多證據表明銷售人員的增加可能在加速？當你考慮到這一點時，你是否會放棄 EBITDA 的盈虧平衡點，今年大幅擴大銷售隊伍以推動長期機會？

I guess, at least the way I'm thinking about is any way to make the team better since the inception of the company we've committed to. And I always love the view that companies are people and assemblies of people that are committed to making something better. And as those opportunities present themselves, we will make decisions that are in the best interest of our efforts. I don't see us coming off of our commitments. But I got to tell you, we will be opportunistic with regard to people who are aligned with our thinking. I got to tell you, being a spine-only force and committing our vocation to spine. There's a lot of people out there that, I think, feel the same way we do. And so our enthusiasm is to expand the team with people with great experience that have the same joy for spine that we do.

我想，至少我正在考慮的方式是自我們承諾的公司成立以來讓團隊變得更好的任何方式。我一直喜歡這樣一種觀點，即公司是致力於讓事情變得更好的人和人的集會。當這些機會出現時，我們將做出最符合我們努力利益的決定。我不認為我們會兌現我們的承諾。但我必須告訴你，對於與我們的想法一致的人，我們會投機取巧。我得告訴你，作為一支只專注於脊柱的力量，並將我們的使命奉獻給脊柱。我認為，有很多人和我們有同樣的感受。因此，我們的熱情是用經驗豐富的人來擴大團隊，這些人和我們一樣對脊柱感到高興。

And Drew, I think as you can appreciate, our plan, our guide assumes that we will be investing in the sales force. And so I think that's an important component to understand about our guidance. We're going into the year not only we'll be adding.

德魯，我想你可以理解，我們的計劃，我們的指南假設我們將投資於銷售隊伍。因此，我認為這是了解我們指南的重要組成部分。我們將進入新的一年，我們不僅會增加。

Got it. And just with the -- with your comments, maybe specifically on the cadence of the year on the first quarter, should we think about that as really like a mid-single-digit step down sequentially? Or is there any reason why it could be better given some of the growth drivers, tailwinds that you're back heading into '23?

知道了。就您的評論而言，也許特別是關於第一季度的年度節奏，我們是否應該將其視為真的像一個中等個位數的連續下降？或者有什麼理由可以更好地考慮到一些增長驅動因素，以及你回到 23 年的順風？

Yes. Drew, I think in terms of the -- what was the question on adjusted EBITDA or revenue related?

是的。德魯，我認為關於調整後的 EBITDA 或與收入相關的問題是什麼？

We can hit both.

我們兩個都可以打。

Yes. Perfect. I think on the top line, I guess typical seasonality from a revenue -- a surgical revenue perspective would probably lead you to -- we did $91 probably a couple of million dollars step down sequentially would be the typical seasonality you'd see. I think if you looked at the EOS seasonality from last year, it was another probably $2 million going from Q4 to Q1. So if we were at $106 million in the fourth quarter, you could probably think about $102-ish somewhere around those -- that area in the first quarter. We do know that one of our biggest investments in the organization is the people. Pat talked about that and some of the taxes and those types of things step up sequentially from Q4 to Q1. 

是的。完美的。我認為最重要的是，我猜從收入的典型季節性——手術收入的角度可能會引導你——我們做了 91 美元，可能連續下降幾百萬美元將是你會看到的典型季節性。我想如果你看看去年的 EOS 季節性，從第四季度到第一季度可能又增加了 200 萬美元。因此，如果我們在第四季度達到 1.06 億美元，那麼您可能會在第一季度的那個區域附近考慮 102 美元左右。我們確實知道，我們對組織最大的投資之一就是人員。帕特談到了這一點，一些稅收和那些類型的東西從第四季度到第一季度依次增加。

We also always have a national sales meeting that is an investment in the organization in Q1. And so from an expense profile standpoint, there's a bit of a sequential step up for those reasons. If you kind of think then about how that flows through to adjusted EBITDA, if you just take your 800 basis points margin expansion on the full year. And if you appreciate that it's probably 900-ish basis point improvement in the first half and a 700 basis point improvement in the second half. I think you kind of get to a mid-single-digit negative adjusted EBITDA absolute number in the first quarter. And so I think that obviously improves in the second quarter. And as I shared earlier, we do seeing a positive number in the third quarter.

我們也總是有一個全國銷售會議，這是對第一季度組織的投資。因此，從費用概況的角度來看，由於這些原因，有一些連續的步驟。如果您考慮一下它是如何流入調整後的 EBITDA 的，如果您只考慮全年 800 個基點的利潤率擴張。而且，如果你欣賞它可能在上半年提高 900 個基點，在下半年提高 700 個基點。我認為你在第一季度得到了一個中個位數的負調整 EBITDA 絕對數字。所以我認為第二季度情況明顯改善。正如我之前分享的那樣，我們確實在第三季度看到了一個積極的數字。

The next question comes from the line of Matthew Blackman with Stifel.

下一個問題來自 Matthew Blackman 與 Stifel 的對話。

This is Emily on for Matt. Just wanted to touch on EOS and the next kind of wave of product features. First is if there's anything in 2023 of note that we should be looking out for? And then further out, 2024, '25, I wonder if you could give us an example of how a surgeon might be using EOS today compared to how they might be using it then with all these new features in terms of procedures, product opportunity? And then what needs to be done on the product side to keep taste and optimize that product pull-through for EOS?

這是 Emily 為 Matt 做的。只是想談談 EOS 和下一波產品功能。首先是 2023 年是否有任何值得我們注意的事項？然後再往前，2024 年，25 年，我想知道你是否可以給我們舉個例子，說明外科醫生今天如何使用 EOS 與他們當時可能如何使用它以及在程序、產品機會方面的所有這些新功能相比？那麼在產品方面需要做些什麼來保持品味並優化 EOS 的產品拉動？

Emily, that's a question that was learned. I absolutely adore just the opportunity that EOS provides. And when you think about what the output is today, the output today is a standing wait bearing image in a biplanar view. So both the front and the side. And then what you can do is you can reconstruct the entire skeletal system in a single image. And so what the near term will provide, and I'll give you some time frames like this year, we'll go through the verification process of each of the different feature sets such that we know that they're perfectly operating and perfectly accurate. And so the effort this year will be really a verification of the elements. And so what we're doing right now is our IT team and the software team is building the cloud infrastructure with things like high trust and other elements that are required to ultimately house images in a hip friendly way. 

艾米麗，這是一個學到的問題。我非常喜歡 EOS 提供的機會。當您考慮今天的輸出時，今天的輸出是雙平面視圖中的站立等待軸承圖像。所以無論是正面還是側面。然後你可以做的是你可以在一張圖像中重建整個骨骼系統。所以近期會提供什麼，我會給你一些時間框架，比如今年，我們將完成每個不同功能集的驗證過程，這樣我們就知道它們可以完美運行並且非常準確.因此，今年的努力將真正驗證要素。因此，我們現在正在做的是我們的 IT 團隊和軟件團隊正在構建雲基礎架構，其中包括高度信任和最終以時尚友好的方式存儲圖像所需的其他元素。

And so those things are going on in the background. And so I would tell you the things that are going on right now is the automated measurements the preoperative planning elements, the ability to do patient-specific rods and some of the interoperative reconciliation. So those will be the first things that you see on the marketplace in, let's call it, mid- to late '24. We'll go through the verification process much sooner than that. And so they'll be in the marketplace late this year. And so our excitement associated with a surgeon having the ability to pull down an image from the portal, understand exactly what the imaging is, exactly what the plan is, what the interoperative experience was and then reconcile it back to the plan. That's the foundation of a predictive environment. And so when you start to say, why is spine surgery not great in the hands of the masses and it's the volume of variables. And we feel like that EOS provides us an opportunity to really address the different variables that exist today in spine. 

所以這些事情是在後台發生的。所以我會告訴你現在正在發生的事情是術前計劃元素的自動測量，進行針對患者的桿的能力以及一些術間協調。因此，這些將是您在 24 世紀中後期在市場上看到的第一件事。我們將比這更快地完成驗證過程。因此，它們將在今年晚些時候上市。因此，我們的興奮與外科醫生能夠從門戶網站上拉下圖像、準確理解成像是什麼、計劃是什麼、手術經驗是什麼然後將其與計劃協調一致有關。這是預測環境的基礎。所以當你開始說，為什麼脊柱手術在大眾手中並不好，這是變量的數量。我們覺得 EOS 為我們提供了一個真正解決當今脊柱中存在的不同變量的機會。

So when you start to think down into the future, there's other elements, and I'm not going to provide time lines on things like bone quality measure. But when you start to think about my ability to ultimately effectuate the objectivity of alignment, which is the greatest correlative to a durable long-term outcome and then say, gosh, what type of devices are we putting in what's the design of those devices are we putting into the foundational material, i.e., the bone knowing what that bone is. These types of things have become very, very profoundly important to surgeons. And so when you start to think about effectuating surgery over a long period of time, this foundational standard becomes so important. And so I would say that probably is the best without being overtly or both, even though I look for both. But anyway, it just becomes like when you start to think about informatics. Informatic is going to be what rules a day. It's not going to be the pitch on a pedicle screw. It's not going to be a specific antibody device. And our foundation of informatic sources is outstanding. And that's why the longevity of our view and the opportunity that we see that ultimately makes spine surgery better is so great.

所以當你開始考慮未來時，還有其他因素，我不會提供骨質量測量等方面的時間表。但是當你開始考慮我最終實現一致性的客觀性的能力時，這是與持久的長期結果最相關的，然後說，天哪，我們在其中放置什麼類型的設備這些設備的設計是什麼我們將基礎材料放入其中，即知道骨頭是什麼的骨頭。這些類型的東西對外科醫生來說已經變得非常非常重要。因此，當您開始考慮在很長一段時間內完成手術時，這個基本標準就變得非常重要。所以我會說這可能是最好的而不是公開的或兩者兼而有之，即使我尋找兩者。但是無論如何，當您開始考慮信息學時，它就變得像。信息化將成為日常規則。它不會成為椎弓根螺釘上的螺距。它不會成為特定的抗體設備。我們的信息源基礎非常出色。這就是為什麼我們的觀點經久不衰，我們看到最終使脊柱手術變得更好的機會如此之大。

The next question comes from Brooks O'Neil with Lake Street Capital Markets.

下一個問題來自 Lake Street Capital Markets 的 Brooks O'Neil。

I'm just hoping we kind of be there around the bush a little bit, but maybe you guys could talk about the impact of ongoing consolidation in the spine space and whether you see that as a positive or negative for ATEC.

我只是希望我們有點繞過灌木叢，但也許你們可以談談脊柱空間持續整合的影響，以及您是否認為這對 ATEC 是積極的還是消極的。

It's a question that clearly has come our way a fair amount. And my genuine view is what we need to do is create clinical distinction, compel surgeon adoption and expand the sales force. And I would tell you, there's a lot of people out there that are aligned with our thinking. And so what I would say is we're going to be opportunistic as we can be. The one thing that you know that we love is chaos. And if there's chaos out there, we're going to be opportunistic with regard to the chaos. And our interest is long beyond any consolidation. We are lapping today that we still have 95% of the market to address if we're a 5% market shareholder, we got a long runway. And our enthusiasm, as we've spoken from the beginning is to be the standard bearer, we want to be the guys that make the rules in this business because we understand the requirements better than anybody. And so that's how we think about it. Candidly, we're indifferent to anybody else. Our focus is on what we're doing.

這個問題顯然已經出現了相當多的問題。我的真實觀點是，我們需要做的是創造臨床差異化、強制採用外科醫生並擴大銷售隊伍。我會告訴你，有很多人與我們的想法一致。所以我要說的是，我們將盡可能地投機取巧。你知道我們喜歡的一件事就是混亂。如果那裡出現混亂，我們將對混亂採取機會主義態度。我們的興趣遠不止於任何合併。我們今天正在考慮，如果我們是 5% 的市場股東，我們仍然有 95% 的市場需要解決，我們有很長的路要走。正如我們從一開始所說的那樣，我們的熱情就是成為標準的承擔者，我們希望成為製定該行業規則的人，因為我們比任何人都更了解這些要求。這就是我們的想法。坦率地說，我們對任何人都漠不關心。我們的重點是我們正在做的事情。

Your next question comes from the line of Kyle Rose with Canaccord.

你的下一個問題來自 Kyle Rose 與 Canaccord 的合作。

So I just wanted to -- I understand the leverage commentary when we think about this year, about 30% drop-through on incremental revenues. Maybe just help us zoom out from a big picture perspective and how we should think about that on a longer-term basis. Obviously, as you scale the sales force and make additional investments, whether it's this year or you get productivity from previous cohorts, how should we think about that drop-through on a ratable basis beyond 2023?

所以我只想——當我們考慮今年時，我理解槓桿評論，增量收入下降了大約 30%。也許只是幫助我們從大局的角度縮小，以及我們應該如何從長遠的角度考慮這一點。顯然，隨著您擴大銷售隊伍並進行額外投資，無論是今年還是您從以前的隊列中獲得生產力，我們應該如何考慮 2023 年以後的可衡量基礎上的下降？

Well, Kyle, I think when we laid out our long-range plan, and we kind of said, going from 2021 to 2025 and 2025 being $555 million of revenue and $80 million of adjusted EBITDA. And I think that's about 12% -- 13% to 14% adjusted EBITDA margin in 2025. And so as we did that walk, we said, call it, 2/3 of that is going to come from our leveraging of the infrastructure and the investments that we've made and the balance will come from an improvement in our variable selling expenses. And ultimately, I think that's really where we're headed. And so I think on the margin, you can kind of do the math year-over-year on that. But ultimately, that's the direction we're heading the plan we've laid out relative to profitability profile.

好吧，凱爾，我想當我們制定長期計劃時，我們有點說，從 2021 年到 2025 年和 2025 年的收入為 5.55 億美元，調整後的 EBITDA 為 8000 萬美元。我認為 2025 年調整後的 EBITDA 利潤率約為 12% - 13% 至 14%。所以當我們走這條路時，我們說，稱之為，其中 2/3 將來自我們對基礎設施的利用和我們所做的投資和余額將來自可變銷售費用的改善。最終，我認為這確實是我們前進的方向。因此，我認為在邊際上，您可以逐年計算一下。但最終，這就是我們制定的與盈利狀況相關的計劃的方向。

Okay. And then I'll just -- I'll be greedy and take a follow-up here as well. You talked about the utilization increasing on a products per case basis as well as the productivity of surgeon, new surgeon users. Just wanted to see -- we saw the chart there, but if you could maybe just take it one level deeper. As you go to the wider group of physicians, how have you seen the procedural complexity curve elongate or be pulled forward? I'm just trying to understand how the utilization rates are changing in the last several cohorts at the market as "normalized" coming out of the pandemic?

好的。然後我會 - 我會很貪心，也會在這裡進行跟進。您談到了每個案例的產品利用率增加以及外科醫生和新外科醫生用戶的生產力。只是想看看——我們在那裡看到了圖表，但如果你能把它看得更深一層。當您接觸更廣泛的醫生群體時，您如何看待程序複雜性曲線拉長或向前拉？我只是想了解隨著大流行病的“正常化”，市場上最後幾個隊列的利用率是如何變化的？

Yes. I guess if I understand your question and tell me if I got it wrong, is what we've seen is people are compelled to come out here and what they'll do is they'll come out here for PTP. And so they will learn PTP. They will have had a successful experience in PTP and they will expand the utility into things like cervical and more of a commoditized degenerative utility of different products. And so we'll see the halo effect. The more experience they get with PTP, the more complexity they'll start to apply to the different procedures. I think that how it gets reflected is the dollars per procedure starts to incrementally lift. And so we'll start to see greater dollars in the PTP realm, and that will ultimately skew the math as it relates to the entirety of all the procedures and the contribution by PTP. I don't know if that answers your question.

是的。我想如果我理解你的問題並告訴我我是否弄錯了，我們所看到的是人們被迫來到這裡，他們會做的是他們會為了 PTP 來到這裡。因此他們將學習 PTP。他們將在 PTP 方面獲得成功的經驗，並將其效用擴展到宮頸等領域，以及更多不同產品的商品化退化效用。所以我們會看到光環效應。他們在 PTP 方面獲得的經驗越多，他們開始應用到不同程序的複雜性就越高。我認為它的反映方式是每個程序的美元開始逐漸增加。因此，我們將開始在 PTP 領域看到更多的資金，這最終將扭曲數學，因為它與所有程序的整體和 PTP 的貢獻有關。我不知道這是否回答了你的問題。

The next question comes from the line of David Saxon with Needham & Company.

下一個問題來自 Needham & Company 的 David Saxon。

I wanted to ask on LTP. I know it's early, but any overlap with docs doing PTP and those doing LTP. And if not, how we should think about the LTP opportunity and what it could mean for ATEC market share over the next, call it, 12 to 24 months? And then kind of looking at the chart showing the surgeon utilization ramp, is there any reason why you wouldn't be able to see that with the cohort of docs adopting LTP.

我想問LTP。我知道現在還早，但是與執行 PTP 的文檔和執行 LTP 的文檔有任何重疊。如果不是，我們應該如何考慮 LTP 機會以及它對 ATEC 市場份額在接下來的 12 到 24 個月內意味著什麼？然後看一下顯示外科醫生使用率上升的圖表，有什麼理由說明你無法在採用 LTP 的文檔隊列中看到這一點。

Yes. It's a great question. And I think we have a bunch of surgeons who do both PTP and LTP. And the dynamic is oftentimes it's dependent upon pathology. So like if you have pathology that's in this posterior and you want to do a decompression, if I were to do a single-position surgery, I don't want to do a decompression in the lateral position, so I will do it in the prone position. And so the way we're seeing this start to unfold is you're starting to see individual pathologies or individual types of surgeries being applied to individual patient positions. And so to us, what we don't want to do is we want the surgeons to drive the reflected utility of the different procedures. But what we're seeing is clearly a lot of excitement. And I think one of the things that has yet to be reflected and I think time will tell is the impact of LTP, as you say. -- what's -- at least our view is that the pendulum swinging back into your column at 5.1 is very, very big. 

是的。這是一個很好的問題。而且我認為我們有一群同時進行 PTP 和 LTP 的外科醫生。動態通常取決於病理。所以如果你的後路有病變並且你想做減壓，如果我要做單體位手術，我不想在側臥位做減壓，所以我會在俯臥位。因此，我們看到這種情況開始展開的方式是，你開始看到個別病症或個別類型的手術被應用於個別病人的體位。所以對我們來說，我們不想做的是我們希望外科醫生推動不同程序的反映效用。但我們所看到的顯然令人興奮。正如您所說，我認為尚未反映的一件事是 LTP 的影響，我認為時間會證明一切。 - 什麼 - 至少我們的觀點是鍾擺在 5.1 處擺回你的專欄是非常非常大的。

So when you hear people say, "Hey, there's a lot of ALIF contribution to the number." Realize what that means is surgeons are doing more ALIF. Surgeons want to do ALIFas close to a supine position as you possibly can, meaning land on your back. There's a bifurcation at 5.1 that you operate through. And the more we can get that from a positional perspective, the better we are. And so why we designed LTP is based upon our 20-plus years of experience in lateral, which means our understanding as to what the best patient position is for the respective requirements. And so we are totally bullish that we have a great solution from a PTP perspective, a great solution from an LTP perspective. And we think the momentum is really in its pre-game reflection because we have a lot to build on both fronts. And clearly, I think the dynamics in the marketplace is going to avail people the opportunity to give us an evaluation where maybe in past times they may not have.

所以當你聽到人們說，“嘿，這個數字有很多 ALIF 貢獻。”意識到這意味著外科醫生正在做更多的 ALIF。外科醫生希望盡可能接近仰臥位進行 ALIFas，這意味著仰臥著地。在 5.1 處有一個分叉點，您可以通過它操作。從位置的角度來看，我們越能做到這一點，我們就越好。因此，我們設計 LTP 的原因是基於我們 20 多年的橫向經驗，這意味著我們了解滿足各自要求的最佳患者體位。因此，我們完全樂觀地認為，從 PTP 的角度來看，我們有一個很好的解決方案，從 LTP 的角度來看，這是一個很好的解決方案。我們認為這種勢頭確實體現在賽前的反映中，因為我們在這兩個方面都有很多工作要做。很明顯，我認為市場的動態將使人們有機會給我們一個評估，而在過去他們可能沒有。

The next question comes from the line of Sean Lee with H.C. Wainwright.

下一個問題來自 Sean Lee 和 H.C.溫賴特。

So over the last couple of quarters, you have mentioned the potential to expand internationally as one of the avenues you're looking to grow. So I was wondering whether we would be seeing more of that this year? And if so, would you still be leading with EOS? Or would you be going for lateral as the main focus there in that arena as well.

因此，在過去幾個季度中，您提到了將國際擴張作為您尋求增長的途徑之一的潛力。所以我想知道今年我們是否會看到更多這樣的情況？如果是這樣，您還會繼續使用 EOS 嗎？或者您是否也將橫向作為該領域的主要焦點。

Yes. The one thing that we're excited about is our international team. And there's a guy internally here, Chris Lyons, who has started to assemble what is an outstanding team in Australia and New Zealand, and we're in the process of figuring out what to do in Japan. And so the Australia team will lead with our lateral kind of sophistication. They're steeped in a lateral experience. And so I like our chances in terms of building the foundation of a business. And I think as we start to translate, there's like 30 -- is there 30 EOS in Australia? Yes. So it has a nice foundation from which to build. And so I think just the ability to translate that down there is also an exciting place for us. And then clearly, Japan is a place that we are hugely enthusiastic about. And so we will continue to be very narrow and deep in these markets. And -- but I think so much of the future is about what the team looks like and we're very bullish in terms of the team that we've assembled in our international business.

是的。我們感到興奮的一件事是我們的國際團隊。這裡有一個內部人員，Chris Lyons，他已經開始在澳大利亞和新西蘭組建一支優秀的團隊，我們正在研究在日本做什麼。因此，澳大利亞團隊將以我們的橫向複雜性領先。他們沉浸在橫向體驗中。因此，我喜歡我們在建立業務基礎方面的機會。我認為當我們開始翻譯時，大約有 30 個——澳大利亞有 30 個 EOS 嗎？是的。所以它有一個很好的基礎來構建。因此，我認為將其翻譯下來的能力對我們來說也是一個令人興奮的地方。然後很明顯，日本是我們非常熱衷的地方。因此，我們將繼續在這些市場中非常狹窄和深入。而且 - 但我認為未來很大程度上取決於團隊的樣子，我們非常看好我們在國際業務中組建的團隊。

And Sean, when we kind of talk about narrow and deep, I think it does reflect our commitment to bringing the lateral sophistication to the international markets. And so that is definitely how we plan to ultimately serve our patients and customers there.

肖恩，當我們談論狹義和深度時，我認為這確實反映了我們致力於將橫向複雜性帶入國際市場。因此，這絕對是我們計劃最終為那裡的患者和客戶提供服務的方式。

There are no further questions at this time. I will now turn the call back over to Pat Miles for closing remarks.

目前沒有其他問題。我現在將把電話轉回給 Pat Miles 以作結束語。

Thanks very much, Angela, and thanks, everybody, for your interest in ATEC. We are just beginning. And so clearly, a lot of growth this year, but our best days are yet ahead, and we appreciate everybody's interest in ATEC. Thanks much.

非常感謝 Angela，也感謝大家對 ATEC 的關注。我們才剛剛開始。很明顯，今年有很多增長，但我們最好的日子還在後面，我們感謝大家對 ATEC 的興趣。非常感謝。

This concludes today's call. You may now disconnect.

今天的電話會議到此結束。您現在可以斷開連接。