Orthofix Medical Inc (OFIX) 2021 Q4 法說會逐字稿

Good morning, and welcome to today's Orthofix Medical Inc. Fourth Quarter 2021 Earnings Conference Call. My name is Candice and I will be your moderator for today's call. (Operator Instructions)

I would now like to pass the conference call over to our host, Alexa Huerta, Senior Director of Investor Relations. Please go ahead.

Thank you, operator, and good morning, everyone. Welcome to the Orthofix Fourth Quarter 2021 Earnings Call. Joining me on the call today are our President and Chief Executive Officer, Jon Serbousek; and Chief Financial Officer, Doug Rice. I'll start with the safe harbor statement and then pass it over to Jon. During the call, we will be making forward-looking statements that involve risks and uncertainties.

All statements other than those historical facts are forward-looking statements, including any earnings guidance we provide and any statements about our plans, beliefs, strategies, expectations, goals or objectives. Investors are cautioned not to place undue reliance on such forward-looking statements, as there is no assurance that the matter contained in such statements will occur. The forward-looking statements we will make on today's call are based on our beliefs and expectations as of today, February 25, 2022.

We do not undertake any obligation to revise or update such forward-looking statements. Some factors that could cause actual results to be materially different from the forward-looking statements made by us on the call include the risk factors disclosed under the heading Risk Factors in our Form 10-K for the year ended December 31, 2021, filed this morning, February 25, 2022, as well as additional SEC filings we make in the future.

If you need copies of these documents, please contact my office at Orthofix in Lewisville, Texas. In addition, on today's call, we will refer to various non-GAAP financial measures. We believe that in order to properly understand our short term and long term financial trends, investors may wish to review these matters as a supplement to the financial measures determined in accordance with U.S. GAAP. Please refer to today's press release announcing our fourth quarter 2021 results for reconciliations of these non-GAAP financial measures to our U.S. GAAP financial results.

At this point, I will turn the call over to Jon.

Thank you, Alexa. Welcome everyone and thank you for joining our fourth quarter and full year 2021 results conference call. On today's call I'll provide an update of our fourth quarter performance and review progress against our strategic initiatives before handing the call over to Doug, who will provide our financial update. I'll close with our perspective on the business in 2022 before opening lines for questions.

Turning to our fourth quarter performance, we're very pleased with what we were able to accomplish and the momentum we will continue to build despite the prevailing macro landscape. In the quarter we delivered a total revenue of $125 million, an increase of 6% on a reported basis and 7% on a constant currency basis compared to the prior year quarter. This growth was seen across both franchises, starting with the Global Spine Business Unit, the spinal implants' team executed another outstanding quarter with strong U.S. motion preservation performance and market share capture overall.

In our global orthopedics business unit, we executed double-digit growth year-over-year growth predominantly coming from our recovery among our international markets and share capture with FITBONE. On a sequential basis, we drove double-digit growth across all product categories compared to our third quarter of 2021. Now, shifting to the performance within each of our product categories, starting with our bone growth therapies or BGT, sales for the quarter were $50 million, down 2% versus prior year due to the negative impact of COVID, including nursing shortages on complex spine procedures within the fourth quarter, partially offset by continued market share capture with PhysioStim.

We are happy to announce that in the fourth quarter, we reached 1 million patients treated with our BGT portfolio. This major milestone demonstrates our committed leadership position in the bone growth stimulation, one that we look to continue to build upon in the future. Thank you to our BGT sales and corporate teams for your leadership and efforts in obtaining this remarkable, patient focused achievement. Moving to spinal implants, we are excited to report that global revenue was up 12%, representing the fourth quarter in a row of double-digit year-over-year growth.

As a reminder, this category is made up of our spine fixation and motion preservation projects, with the majority of which are used in procedures that are typically considered elective. The primary drivers of growth were increasing U.S. market share capture with 12% growth in the revenue from both new distributors and over 20% increase in total certain users and a rebound in international market procedure volumes. Turning to our biologics portfolio; revenue was down 1% compared to the fourth quarter of 2020, due primarily to the negative impact of COVID on procedures and nursing shortages in the fourth quarter, offset somewhat by sales growth from our fiberFUSE allografts, which continue to gain momentum with our fiberFUSE Strip introduction this past fiscal year.

Lastly, moving to our Global Orthopedics business, which is primarily focused on limb reconstruction and deformity correction, sales in the fourth quarter were up 21% over 2020. This increase is primarily a result of recovery of our international markets and share capture driven by the FITBONE intramedullary limb-lengthening system. During the fourth quarter, FITBONE generated over $2 million in sales, mainly in the European markets, bringing the full year revenue contribution from FITBONE to over $7 million. Thank you to our orthopedics team for their leadership and market success with FITBONE in its first full year of commercialization.

Before discussing our key initiatives, I want to share how excited we are that Thomas West joined our Board of Directors in December. He brings over 30 years of global experience in the medical device industry to Orthofix. Tom is currently the President and CEO and Director of Intersect ENT, where he's led the transformation of that business, resulting in a definitive agreement to be acquired by Medtronic. Prior to Intersect ENT, Tom served as a Division President of the Diagnostics Solutions at Hologic after spending over 20 years at Johnson & Johnson.

Tom's varied global experience will be an asset as we continue to scale the company and we look forward to working with him on our Board. Now, I would like to provide an overview of our progress we have made in the past year on key initiatives around product innovation, commercial channel and operational execution. Starting with product innovation and differentiation; during 2021 we made solid progress developing and acquiring products and procedural solutions to address unmet needs in the marketplace and strengthen our product portfolio. We introduced key products in our spinal implant portfolio with the launch of CONSTRUX Mini and FORZA 3D printed titanium interbodies.

While we are happy with the progress we've made in the year, we anticipate further growth acceleration of these products as they gain traction in the marketplace. We continue to also provide additional investments in the portfolio in both organic and inorganic technologies. Keeping the pipeline of new technology introductions is key to our strategy and will fuel future revenue growth. Within biologics, our goal is to have a comprehensive offering of products and solutions for surgeons to use in our spine and orthopedic procedures.

We significantly expanded our portfolio during the year with introductions of AlloQuent Structural Allografts Q-PACK, fiberFUSE strips and Opus MG Set. We also recently extended our exclusive partnership agreement with MTF Biologics for Trinity Cellular based allograft lines through 2032. Orthofix and MTF Biologics have a long history of bringing advanced biologics solutions to the market with over 350,000 patients treated and that number is growing. We anticipate this more robust portfolio will continue to help drive incremental pull through of our spine and orthopedics hardware products.

Finally, within orthopedics, we focused on investments in limb reconstruction and pediatric deformity, which included upgrades to our existing products, as well as new products with incremental indications to increase our addressable markets. The strong performance of FITBONE throughout the year following its global introduction in early 2021 is an example of the success we have been able to bring to this highly innovative technology to the market to address unmet needs. Turning to our second initiative, commercial channel development, for this initiative, we are focused on our U.S. channels for biologics, spinal implants, orthopedics, and working to make these channels as dedicated and predictable as our current BGT channel.

In Q4 our U.S. strategic channel partners, which we define as distributor partners that carry multiple Orthofix product categories like hardware and biologics generated over one third of our spinal implants, biologics and orthopedics U.S. revenue, and has grown 5% when compared to the prior year quarter and 15% compared to the fourth quarter of 2019. We will continue to invest in the development and optimization of these channels to support our growth initiatives moving forward. Moving on to our third and final initiative, operational execution, throughout 2021 we have managed through several supply chain challenges, including the microchip shortage without missing a beat.

We're very proud of how our team has managed through all of the macro challenges during the year and believe that we are well-positioned to continue to execute all aspects of our global supply chain. I'm very proud of what our organization has been able to accomplish during 2021, which was without a doubt a challenging year. The momentum we are able to generate was a direct result of a successful execution of our strategy, and we look forward to continuing that momentum into 2022 and beyond.

With that, I'll turn the call over to Doug to review our financial performance. Doug?

Thanks, Jon and Good morning, everyone. I will provide some additional details into our net sales and earnings results and then discuss some of our other financial measures. Because many of the financial measures covered in today's call or on a non-GAAP basis please refer to today's earnings release for further information regarding our non-GAAP reconciliations and disclosures. Starting with revenue, as Jon mentioned, total net sales in the quarter were $125 million, about 6% on a reported basis and 7% on a constant currency basis when compared to the fourth quarter of 2020. In the U.S., total net sales of $97 million or 78% of our global total revenue for the fourth quarter were up 2% over the fourth quarter of 2020 mainly due to U.S. M6-C growth, offset by the reduction in complex procedures seen early in the fourth quarter.

International total net sales of $28 million were up 23% as reported over the fourth quarter of 2020, reflecting the growth from our FITBONE limb-lengthening system as well as international market recovery. Gross margin in the fourth quarter of 2021 was 73% compared to 75% in the prior year period. The decrease was primarily due to changes in our sales mix from the timing of international orders, as well as a short-term increase in electronic procurement costs due to the global microchip shortage offset somewhat by decreased non-cash inventory reserve charges versus 2020.

For the full year 2021, gross margins were 75% of total net sales. For the full year 2022, we expect gross margin to be similar to 2021, or approximately 76%, which reflects the continued impact of the changes in our sales mix, as well as the expected short term increase in microchip costs in the first half of the year. Sales and marketing expenses in the fourth quarter of 2021 were 46% of net sales, flat to the fourth quarter of 2020.

Although we saw travel expenses and investments in our commercial channels increasing in the fourth quarter of 2021, these expenses were offset by the one-time $2.5 million expense reduction related to a decrease in our Italian medical device tax liability that resulted from a recent law change by the Italian government that provides limited COVID-related relief to certain suppliers of their public hospitals. This non-recurring credit is adjusted out of our non-GAAP earnings.

In 2022, we expect sales and marketing expenses to be in the range of 49% to 50% of net sales due to further investment in our U.S. BGT and Global Orthopedics direct distribution channels early in the year to support expected revenue growth, including our launch of AccelStim, as well as an increased travel and in-person events in anticipation of regional COVID restrictions easing throughout the year. GAAP G&A expenses in the fourth quarter of 2021 were flat on an absolute dollar basis and 15% of net sales on a relative basis, down from 16% in the prior year period.

Although we had increased spending on strategic investments in the fourth quarter of 2021 and certain employee benefits that have been suspended in 2020, the spend increases were offset by the completion of the GAAP charges related to the 2019 CEO transition, as well as decreased expenses related to COVID disruption. GAAP R&D expenses for the fourth quarter increased to 11% of net sales, up from 9% in the prior year period. This increase reflects our planned spending to support new product development, clinical studies, as well as costs associated with our EU MDR compliance efforts.

We will continue to ramp up our efforts to drive organic innovation and differentiation through investment in clinical trials such as the rotator cuff repair study within BGT and our M6-C 2-level indication study and continued spend to build a robust product pipeline in both spine and orthopedics. These investments will continue to cause our R&D spending growth to outpace revenue growth in the near. We expect 2022 GAAP R&D expense to be approximately 12% of net sales, including an impact of about 200 basis points related directly to our EU MDR implementation efforts for which we adjust within our non-GAAP financial metrics.

R&D spend will be somewhat front loaded this year based on the timing of certain product launches, clinical site enrollment and milestone payments. We expect our spending related to the 2024 EU MDR implementation requirements to taper somewhat after 2022. Adjusted EBITDA in the fourth quarter decreased to $17 million, or 14% of sales, compared to $22 million in the fourth quarter of 2020, driven by the investments we've made in R&D related to product development and clinical trials, as well as investments in building our commercial channel to accelerate future revenue growth.

Our cost of sales expenses have also increased with the changes in our sales mix, as well as increased procurement costs related to supply chain disruption. Adjusted EBITDA for the full year 2021 was 13% of total net sales, compared to 12% in the prior year. A quick note that based on our orthopedics reporting unit goodwill analysis, we incurred a non-cash GAAP write off of $12 million in the fourth quarter, which is reflected in the acquisition expense line item in our P&L. The write off reflects our current and planned investments in our growth, including our EU MDR implementation and FITBONE integration spend.

Now turning to tax, we had GAAP income tax expense for the quarter of $23 million or negative 240% of loss before income taxes as compared to GAAP income tax expense of $15 million or 270% of income before income taxes in the same period of 2020. In addition to the timing of earnings during the year, this quarter's tax provision was significantly impacted by a $25 million non-cash charge to increase the reserves against our U.S. deferred tax assets, due to the accounting recognition rules involving historical and forecasted GAAP earnings, which is a non-cash charge in the quarter.

We continue to expect to fully realize our NOL carry forwards and tax assets over time as the company grows and our profitability increases for our non-GAAP results we utilized a 27% long-term adjusted effective tax rate in the fourth quarter. However, we will prospectively utilize a 28% long-term adjusted effective tax rate in order to recognize the current and expected general increases in international statutory income tax rates, as well as our expected adjusted earnings and the elimination of certain non-cash tax impacts. For the fourth quarter of 2021 we reported GAAP loss of a $1.65 per share as compared to GAAP loss of $0.48 per share in the fourth quarter of 2020.

After adjusting for certain items and when normalizing for tax using our non-GAAP long term effective tax rate, adjusted earnings for the fourth quarter of 2021 was $0.27 per share compared to an adjusted EPS of $0.44 per share in the fourth quarter of 2020. This decrease was primarily driven by COVID impacted lower spending in 2020, as well as increased 2021 short term expenses due to the global microchip shortage, increased R&D spend to drive organic innovation and differentiation, and increased spend to build out our commercial channel.

Regarding cash, we continue to maintain a strong liquidity position with $88 million at the end of the fourth quarter of 2021, compared to $83 million at the end of the third quarter of 2021. We currently have no borrowings outstanding under our $300 million senior secured revolving credit facility. We commenced repayment of the $14 million 2020 Medicare Advance in the second quarter of 2021. The balance of the remaining advance as of December 31, 2021, was approximately $5 million. We still expect the repayment to be complete by early Q2 of 2022.

Net cash provided by operating activities was an inflow of $12 million in the quarter, down $10 million compared to an inflow of $22 million in the fourth quarter of last year, primarily due to the recruitment of the 2020 Medicare Advance in 2021, the change in accounts receivable due to an increase in net sales in 2021 over the prior year and the 2020 cost reduction initiatives such as 401(k) match suspension, travel freezes and conferences being held virtually. Capital expenditures were approximately $7 million in the quarter, compared to just over $4 million in the prior year period, due primarily to the timing of spend for instruments in U.S. Spine to support our strategy to bring in additional strategic distribution and future accelerated growth plans.

CapEx for the full year 2021 was $20 million. We expect capital expenditures in 2022 to be in the $25 million to $27 million range. This increase over the prior year is due to the investments in instrument sets to support distribution growth for our new product launches, investments in our technology abilities, as well as investments in our facilities and operations. Consistent with our decreased operating cash flow, our free cash flow, which we define as cash flow from operations minus capital expenditures was a $5 million inflow during the quarter, which was down from $18 million of inflow in the fourth quarter of 2020.

As anticipated, our free cash flow decreased significantly in 2021 compared to 2020 due to several items that we mentioned at the beginning of '21, including the partial repayment of the Medicare Advance investments in our sales channels and product innovation to support future sales growth, the Spinal Kinetics milestone payment and increased spending on EU MDR implementation efforts. For 2022, we expect cash flow from operations to increase modestly due to the timing of the 2021 Spinal Kinetics milestone payment and the payback of the Medicare Advance payment ending early in the second quarter of 2022.

Now, shifting to guidance; for the full year of 2022, we expect revenue to be in the range of $475 million to $490 million, which represents mid-single digit growth at constant currency. We are currently anticipating about a 1% headwind to our top line at reported rates due to the strength in U.S. dollar compared to 2021 FX rates. Similar to the experience of other companies in the medical device industry, in January and into February of this year, we saw a significant increase in elective procedure restrictions as a result of the increase in hospitalizations related to the Omicron variant.

From a macro perspective, we continued to expect the COVID overhang during the first half of the year with a revenue acceleration in the back half of the year as key products continue to gain momentum and COVID subsides throughout the year, as well as delayed or deferred procedures are being made up. We expect Q1 to be slightly down to flat for 2021 on a reported basis. We expect Q2 to be flat on a reported basis and Q3 likely to show strong growth versus 2021, in both cases, due to the COVID impact felt during the prior year's quarters.

Due to the inability to predict the impact or trend of the global pandemic, our guidance does not assume any additional surges in COVID variants at this point in time. For the full year 2022, we expect our adjusted EBITDA to be in a range of $56 million to $61 million or approximately 12% of revenue, and our adjusted EPS is expected to be between $0.58 and $0.73 using a non-GAAP long-term tax rate of 28%. These ranges reflect our continued investment in delivering a robust pipeline of differentiated product, expanding our distribution channel to accelerate our growth trajectory.

I'll now turn the call back over to Jon.

Thanks, Doug. Looking ahead, we view 2022 as an inflection point for our business. In recent years we have been a low single-digit topline growth company. As you just heard, our guidance for this year represents mid-single digit growth, which is largely a result of the investments we've made over the last 2 years across the organization, and in particular those investments into our talent leadership, product portfolio and commercial channels. As we move into '23 and beyond we expect to further accelerate our trajectory to become a mid- to high-single-digit growth company while still delivering a positive adjusted EBITDA.

To achieve that growth, we are focused on 2 areas. First, continued product innovation and differentiation. This includes delivering near-term growth through the increased adoption of recently launched products, as well as accelerating our organic and inorganic investments in new products, new indications and new solutions that build on our core strength as an organization. Second, the ongoing development of our commercial channels to drive our products into the hands of surgeons and physicians worldwide.

Beginning with product innovation differentiation, in a continuation of last year the primary drivers of growth in 2022 will be our M6-C cervical disc, our FITBONE limb-lengthening system and our recently bolstered technology leading inner body portfolio. We also expect additional top line growth to benefit from the over 20 new products we launched since 2020 and the products we will launch in 2022. As we work to drive accelerated growth in future years, we plan to increase the investments during 2022 in the key areas of strength within our product portfolio.

While we have a relatively broad product portfolio today, which is required to enable the type of distribution needed to compete in this market, we by no means want to be everything to everyone. There are several areas of our business where we have clearly differentiated ourselves and we're going to put capital to work in areas that leverage our expertise and current market position to accelerate our growth. These key areas of strength and opportunities are: First, Regenerative Technologies, a category that includes bone and soft tissue stimulation and biologics.

Second, Spinal Technologies which includes innovative implants and cervical solutions. Third, Limb Reconstruction and Pediatric Deformity. Fourth, Enabling Technologies; and lastly, Alternative Surgical Site Development and single-use sterile-pack product technologies. Starting with regenerative technologies, one of the fundamental aspects of our business that differentiates us from others in the spine and orthopedic space is our industry-leading regenerative portfolios. We offer a bone growth stimulation portfolio, which provides post-operative and adjunctive healing solutions in a biologic portfolio which provides surgical procedure-based healing solutions.

We are highly focused on investing in the development of both of these regenerative product portfolios. As previously noted, we recently submitted a PMA application to the FDA for the approval of [CellStim] bone healing therapy, a low-intensity pulse ultrasound product for the healing of both fresh fracture and nonunion fracture. Upon approval, this will expand our bone growth therapies portfolio and complement our current temp technologies that focus on nonunion fractures and spinal treatments. We continue to expect the initial market release during the second half of 2022.

We will also continue to invest in our ongoing rotator cuff IDE trial, which if successful will be our initial entry into the soft tissue regeneration market. As a first of its kind therapy to enhance patient care for those undergoing rotator cuff reconstruction we would have a first mover advantage to tap into the over 650,000 patients who receive rotator cuff repair surgery in the U.S. every year. We're making meaningful investments in our biologics regenerative portfolio has recently announced with our launch of our Opus Synthetic products and the extension through 2032 of our exclusive partnership with MTF Biologics for the flagship cellular allograft technologies.

As part of this partnership, we'll also look forward to launching 2 additional biologic products mid-year, one of which we believe will be an important differentiated solution in the market. We're striving to provide a full portfolio of biologics solutions to surgeons so that for any surgery procedure, there's an Orthofix solution that meets the specific needs of the surgeon and the patient. In spinal implants, we currently offer an extensive portfolio of products and technologies, including a comprehensive cervical offering and a differentiated artificial cervical disc.

Additionally, we've been reevaluating our portfolio to bring an additional innovative and differentiated products and procedures. In the first half of 2021, we initiated 5 key spine R&D projects. These projects are developing spine product innovations and solutions for anterior column support, a lumbar minimally invasive spinal platform, a posterior cervical system, and a deformity correction system in the FITSPINE Deformity Technology platform. These organic innovation programs have engaged key surgeons throughout the world to create innovations and clinical solutions, which will assist Orthofix to stand out in the market and create long-term topline growth.

We anticipate these developments to be introduced late this year and throughout 2023. Turning to limb reconstruction and pediatric deformity; another key area of differentiation for our business is our narrow and dedicated focus within orthopedics market. Many of our peers have exposure to highly competitive or crowded markets, such as hip and knee replacements. However, we are squarely focused on small segments of orthopedics where we have expertise and a long-standing track record of leadership and innovation in limb reconstruction and deformity correction.

While we have a number of projects ongoing in this space, I want to highlight 2. We plan to expand our TrueLok Ring Fixation system portfolio to become Radiolucent. This system was developed at Texas Scottish Rite Hospital for Children in Dallas, Texas, and allows precise alignment of fixation segments without compromised stability or -- and also enhancing imaging characteristics. We will also continue to invest in our cutting edge German engineered FITBONE technology with the development of new products in response to the input from leading U.S. pediatric orthopedic surgeons and identified need within the U.S. pediatric market.

We believe that with the extensions of the FITBONE system in early 2023, we'll be able to drive the same type of adoption and growth in the U.S. that we currently see in the European market. These 2 new projects, along with our JuniOrtho Plating System, which is a complete plating system designed to address specific demands and advanced deformity and trauma reconstructions of the lower extremities, will give Orthofix the broadest deformity care system in pediatrics.

Turning to enabling technologies; Orthofix is focused on the future of digital preoperative planning of limb reconstruction and deformity corrections for clinicians across the world. OrthoNext, our organically developed planning software will soon be connected to most of the major products within the orthopedics business. Our goal is to provide pre-operative planning and surgical systems to surgeons throughout our intuitive preplanning software in both pediatric and adult patients. In January, we also announced a partnership and investment agreement to jointly develop and co-market the innovative nView systems with cervical spine and pediatric limb deformity correction procedural solutions.

The nView s1 imaging and surgical guidance system features a unique ability to instantaneously capture 3D images with very low dose radiation, making the 3D images available throughout the surgery and enabling real-time visualization. This technology compliments our preoperative and postoperative software platforms and we are excited to collaborate with nView to broaden the use of this technology in cervical spine surgeries and pediatric procedures. Finally, under product differentiation and innovation, we're looking to continue to develop procedures for our alternative surgical sites of care as more procedures continue to be moved out of the hospitals and into ASCs.

Through our Neo partnership, we're developing single use sterile pack instrument technologies. We will focus on the continued expansion of our already robust cervical offering with an outpatient setting emphasis. Turning to the optimization of the commercial channel; we will invest further in the expansion of our distribution channel with the addition of targeted direct reps in our U.S. limb reconstruction and deformity business to increased focus on pediatrics in geographies where direct employees make sense. With the anticipated 2022 launch of the CellStim , we are making investments in our BGT channel to drive growth in long bone for nonunion and fresh fracture care.

We are also continuing to focus our efforts on driving synergies within our channels to increase the number of strategic channel partners carrying multiple Orthofix product lines which improves our product pull-through and provides for more predictable and reliable sales channel. In summary, we are very excited about the future of Orthofix. We generated tremendous momentum over the last 2 years and we're moving into an inflection period in our growth trajectory. We will continue to invest to accelerate growth in future years and importantly do so while remaining sustainably profitable.

With that, I would like to open the line for questions. Operator?

Thank you. (Operator Instructions) Our first question comes from Mathew Blackman of Stifel.

Great. Maybe just to start with a housekeeping question for Doug on the 2022 guidance. The one point top line currency headwind is there any way to quantify that drop through impact to EBITDA and/or EPS? And then I have a couple of follow ups.

It's a good question. So you're right about 1% on the top line. It's mostly reporting translation risk, obviously at the revenue level as well as the cost level. We're fairly naturally hedged in most of the geos where we have exposure primarily to the euro-dollar rate and some to the Brazilian real. So I would look at it as a lot less or fairly immaterial at the EBITDA and EPS level in terms of FX impact.

Got it. Great, and then, Jon, a couple for you, just to sort of think about the longer term expectation for upper single digit growth. What's the bridge to get there from mid-single digit growth? Is it another step up in spinal implant growth that gets you there? Does it contemplate rotator cuff and Bone Stim? Essentially, I'm just asking whether the acceleration would be balanced across the business or for be disproportionately weighted to any particular segment or new product launch and then one more follow up after that.

I think there's a general maturation of our, of our strategy going forward. I mean, it's a combination between new product innovation and launch, as well as differentiating the marketplace, which attracts new service to your organization, as well as building the commercial channel and those 2 go hand in hand. We continue to focus on commercial, commercial channel, both direct and indirect, as well as and we attract better talent and we have better portfolio, so they tied our back and forth across one another.

As far as where it's going to occur, we, we look at we've seen growth and we've been focused on both the orthopedics limb reconstruction and deformity sectors as well as the spine areas. And so you saw the performance in Europe at the limb-reconstruction deformity that's a combination of both our PL hex, our FITBONE and then also our JuniOrtho Plating Systems have a very comprehensive line to partner reports OrthoNext from a planning standpoint.

For spine, we saw that, we also had good performance in Europe and the other regions, but we'll continue to invest in that areas part of our investment strategy as well as in the U.S. and we continue to execute those plans not only in spine fixation but also in BGT. And then also at BGT we look forward to the new product innovation which has not occurred in many, many years within BGT with this [CellStim] and we look forward to launching in the second half of the year.

Great, thank you. And then the last question and I'm not asking for more explicit long term guidance. I appreciate what you gave this morning. But as we think about where EBITDA margins could go beyond 2022 is there anything structurally that prevents you from getting to the upper teens or even 20% of it. Really just trying to frame what the profitability profile could be with a higher single digit top line growth trajectory? Thanks.

We've stated consistently that as we build or rebuild the organization that we know where we're spending our dollars and as we basically get those product portfolio refreshed and sales channels put in place that we believe they'll be EBITDA to leverage in the out years. So that is by plan and design. And so from that standpoint we do expect to see EBITDA leverage in the out years and we should be able to operate at any -- in comparable to any other company of our size and style and increase our profitability over the near term in the park and in the mid-term.

Thank you. Our next question comes from Jeffrey Cohen of Ladenburg.

So a few from me and firstly was there any update on the M6 2 level study?

Jeff we continue to add enrollment sites, we continue to see enrollment within those sites we've already established and we are just on plan as far as the M6 2 level study

Could you talk a little bit about the [CellStim] technology and how that falls into the BGT platform and on a commercial standpoint it sounds like late this year or back half of 2022 you'll be commercial on that and those channels will be largely the same and kind of bolt on to your current platform?

Yes, Jeff. On the [CellStim] as a reminder that's a technology that we licensed from IGEA an Italian partner in that area and we have submitted that PMA last fall and we expect to have a PMA -- the PMA approval in this first half this year. It is a -- the indication will be for fresh fracture and non-union and we've been building our physio channel within our BGT, our commercial channel to basically be prepared for that. But also we have a very strong nonunion approval within our PMP technology that we've been executing with. And so we see the combination with our existing technology in PMP partnered with the new technology from a CellStim to be even a better momentum driver as we build that channel and we're investing in reps in those -- in that Physio channel and we have been over the last 12 months.

Would you expect the [CellStim] technology to as well as BGT to be largely focused domestically here?

Yes. We've contemplated looking outside the U.S., but really this is a U.S. position for our product. It has been for BGT for many years and it will be -- we will remain focused on the U.S.

Okay, got it. And a couple for Doug I guess I guess firstly the $23.3 million income tax expense, I know you've been carrying that for a number of years. And it's $23 million last quarter. So that heads to zero looks like, your actually is 1.77% on the balance, so we should expect that to remain at that very low level going forward. Is that a safe assumption?

Jeff, if I understand the question correctly, you're asking about the volatility in our income tax rate.

Yes, no, not the rate, the income tax expense that the $23.2 million in Q4 income tax expense was it something that -- that caused that to come toggled off because we were a bit unexpected that, that would come through now.

Right. So we're still normalizing to a long term rate. In the script, I mentioned that we're moving from 27% for an adjusted long term rate to 28% to reflect changes in the world. International tax rates starting to inch up in jurisdictions where we do business. But what you're seeing in Q4 was the GAAP charge. It was a non-GAAP charge of the expense related to evaluation allowance on our U.S. deferred tax assets because of our historical GAAP losses over the last couple of years.

You're seeing pressure on our ability to record full value around our DTAs. And so we were in a position in the U.S. similar to Italy last year to reserve our tax rate, so that -- that's about $25 million of tax expense additional in the fourth quarter. But I would simply look to the longer term rates for more normalized. We do continue to expect to fully realize all of our net operating loss carry forwards and tax assets as our earnings improve over time.

Okay. And then related to the acquisition related amortization re-measurement of 12.56 for the fourth quarter. What should we expect to watch remodel for '22 and going forward on that line item?

For the spinal kinetics final milestone, I would expect that in 2022 to accrete up a lot closer to the ultimate payment amount of $30 million. It may, it will happen semi ratably over, over each quarter, but you'll also notice in our balance sheet that the final milestone liability payment slip from long term to current. So that'll give you an idea of the speed of the accretion.

Okay, so is the 12.5 part of the $30 million, or should we expect $30 million during 2022?

The current liability is simply an accounting fair value that's discounted to today's dollars and we go through a lot of simulations with a third party to value that, that payment -- the ultimate payment. And so that the liability at the end of the fourth quarter was roughly $17 million. The 12 is just a part of the $30 million.

Okay, got it. And then lastly for us. Any specific commentary on labor issues that you've been seeing or you expect to see going forward into '22, both domestically as well as internationally?

Jeff, this is this is an ongoing issue. It's going to be an ongoing issue for all companies. I was just recently with 3 institutions east, mid and West Coast, very large institutions, and they see labor going out in 12 months to 18 months plus as far as just the dynamics that are going on in their institution. So the good news is that -- the good news I think the positive side of that is that those institutions as well as the surgeons are out there ready and motivated to care for those patients that come to them and we will be there with them as far as ready to do that.

Thank you. (Operator Instructions) Our next question comes from Jim Sidoti from Sidoti & Company.

And it's nice to hear somebody asking questions about the non-GAAP adjustments under the need for a change. So can you repeat what your guidance was for gross margin for 2022?

Gross margin for 2022 we expect to be at 70% -- at 76% approximately reflects sales mix. We've got some pressure in the first half of the year for the chip shortage that we experienced late last year and so those are the primary items at 76%.

Okay. All right and then I wanted to focus in on the capital spending because I think you said -- you're going to be roughly $25 million to $27 million for CapEx which is about $10 million more than you did this year. And I assume that's more mostly instrument sets. Is that primarily for the spine business and is that a function of the new products or the new distributors or combination of both?

It's a little bit of both, it's about a $7 million increase over a $20 million CapEx level in 2021 I would characterize it and just big buckets of about 2 thirds of that spend is related to instruments and the majority of that is just the increased distribution, right. It just takes more cash to support the increased distribution for our products like M6 and PhysioStim rolling out and so that's -- those are the primary drivers. We've also got some investments in our operations and some of our facilities as well.

Okay. And then last one for me and this is strictly long term question. But I mean, if you look at the new products you have coming out for STIM and you have the M6, you have the increased distribution. Do you think at some point that this becomes a double-digit grower? Because -- I mean, there just seems to be a lot of levers here that you can push. And I know that's not going to happen right away, but it just feels like growth could be -- could go even beyond that mid-single digit target at some point.

Jim, thanks for the question. We basically stated where our exchequer is at right now and also the new product activity does not include any M&As. And so we have this on the organic side. And so we see as markets grow and as we basically improve our portfolio, improve our channel that we see a good future for the Orthofix. I can't really say right now as far as where we're going to be at, as far as in the ultimate high singles, doubles and all the rest that I don't think that's fair to do that right now, but we are very confident where we're at in those guidance we provided.

Okay. And then I just wanted to just be clear on one thing. It's -- spending so seeing pools in Europe. Sounds like that's starting to taper off a little bit. I mean, that means there's a light at the end of the tunnel with regard to getting all those products registered?

Jim, I know your questions related to MDR and maintaining our CE marks in Europe and your questions about spending levels, you were -- we weren't getting each word you were saying there, but anticipating.

Is there a light at the end of the tunnel to that process?

Yes, so from a spending perspective, we are on track. We spent about $8 million in '21. We will spend, we called out about 200 basis points or about $10 million this year. And then we expected to start tapering as everything comes together in advance of the spring of 2024 deadline for MDR.

Thank you. There are no additional questions waiting at this time, so I'll pass the conference over to management team for closing remarks.

Thank you for everyone who joined the call today. Look forward to a very positive year in 2022 and beyond. And we'll be talking to you throughout the year. Have a wonderful day.

This concludes today's conference call. You may now disconnect your line.