SI-BONE Inc (SIBN) 2023 Q1 法說會逐字稿

Good afternoon, and welcome to SI-BONE's First Quarter Earnings Conference Call. (Operator Instructions) As a reminder, this call is being recorded for replay purposes.

I would now like to turn the call over to Marissa Bych from the Gilmartin Group for a few introductory comments.

Thank you for participating in today's call. Joining me are Laura Francis, Chief Executive Officer; and Anshul Maheshwari, Chief Financial Officer. Earlier today, SI-BONE released financial results for the quarter ended March 31, 2023. A copy of the press release is available on the company's website.

Before we begin, I'd like to remind you that management will make statements during this call that include forward-looking statements within the meaning of federal securities laws, which are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Any statements contained in this call that relate to expectations or predictions of future events, results, or performance are forward-looking statements. These forward-looking statements are based on the company's current expectations and inherently involve risks and uncertainties.

These risks include SI-BONE's ability to introduce and commercialize new products and indications, SI-BONE's ability to maintain favorable reimbursement for its products and procedures, the impact of potential economic weakness on the ability and desire of patients to undergo elective procedures, SI-BONE's ability to manage risks to its supply chain, the impact of future capital requirements driven by new product introductions and risks to the continued renormalization of the health care operating environment. 

Other forward-looking statements include our examination of operating trends and our future financial expectations, such as expectations for surgeon training and adoption, active surgeons, new products, and clinical trial enrollment, and are based upon our current estimates and various assumptions. These statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements.

Accordingly, you should not place undue reliance on these statements. For a list and description of the risks and uncertainties associated with our business, please refer to the Risk Factors section of our most recent Form 10-K and 10-Q filed with the Securities and Exchange Commission. SI-BONE disclaims any intention or obligation, except as required by law, to update or revise any financial projections or forward-looking statements, whether because of new information, future events, or otherwise. This conference call contains time-sensitive information and is after only as of the live broadcast today, May 1, 2023.

And with that, I will turn the call over to Lee.

Thanks, Marissa. Good afternoon, and thank you for joining us. I am thrilled with our stellar start to 2023. The exceptional performance in the first quarter reaffirms the accelerating procedure demand over the last several quarters. Overall, year-over-year worldwide revenue growth has increased each quarter since the first quarter of 2022, rising from 10% for that period to approximately 46% in the first quarter of 2023. The record revenue and active surgeon-based milestones we achieved in the first quarter reflect our consistent investments over several years to build a world-class commercial organization, introduce innovative products to create new markets, and drive surgeon and referring physician education. As I look forward, I remain highly confident that our commercial execution, combined with our differentiated product pipeline, will allow us to further expand our total addressable market, drive revenue growth and improve our bottom line. 

Before I discuss the quarter, I want to recognize our biggest asset, our employees, your grit and perseverance have put us in the enviable position to capitalize on the expanding demand for our differentiated solutions and to deliver strong, sustainable revenue growth as well as operating leverage. Now moving to our first quarter performance. In the first quarter of 2023, we generated worldwide revenue of $32.7 million, an increase of approximately 46% compared to the first quarter of 2022. On a sequential basis, worldwide revenue tapped our fourth quarter of 2022, which you may recall was our previous best quarter. This sequential growth trend is extremely encouraging since it's the first time as a public company we've seen the first quarter performance exceed our seasonally strong fourth quarter. 

The strong quarterly performance was led by record U.S. revenue of $30.5 million, which represents U.S. revenue growth of approximately 50% compared to the prior year period. With the normalizing operating environment, robust surgeon engagement across our broadened portfolio, and reimbursement tailwinds, we're excited about the potential ahead of us. Now let me provide an update on our key initiatives as we look to extend our leadership position and drive strong long-term growth. Starting with sales infrastructure. Over the last 3 years, we've made significant investments in expanding our direct commercial infrastructure to ensure we build a seasoned sales force to support growing surgeon demand. Our strong revenue growth and accelerating operating leverage over the last several quarters reaffirmed that the commercial strategy is delivering. 

At the end of our first quarter, our U.S. commercial organization comprised 87 quota-bearing territory reps. We complement our direct sales team with a growing network of agents for case coverage and are selectively evaluating strategies to place instrument tests at high-volume hospitals to meet the demand. At the end of our first quarter, our trailing 12-month average revenue per territory in the U.S. was approximately $1.3 million, representing a 28% productivity gain over the comparable trailing 12-month period ended the first quarter of 2022. We're confident that our hybrid strategy will allow our territory managers to drive surgeon engagement, deliver strong top-line growth, and achieve higher productivity. 

Moving on to surgeon engagement. Surgeon adoption is one of the best leading indicators of long-term procedure demand. We exited the first quarter with over 950 active surgeons, an all-time high. This equates to over 40% growth in our active surgeon base over the first quarter of 2022. This was the highest quarterly growth rate in our active surgeon base since becoming a public company and the ninth consecutive quarter of double-digit year-over-year growth in our active surgeon base. Sequentially, our active surgeon base increased as compared to the fourth quarter of 2022. It's also encouraging to see surgeon overlap across our procedures. We expect our complementary portfolio to drive deeper engagement and increase procedures per surgeon over time. These trends in the active surgeon base reaffirm that our portfolio expansion strategy and investment in surgeon education are resonating with our customers. 

Academic programs, which we initiated in 2018, have been a strategic priority for us to engage surgeons early on in their careers. We're seeing great success in these training activities and are encouraged by the steady adoption of our procedures by these fellows and residents in the quarters and years that follow their education. In the first quarter of 2023, the procedure revenue in the cohort of surgeons who were trained as follows in residents increased nearly threefold compared to the first quarter of 2022. Turning to Products & Solutions. With iFuse-3D, iFuse-TORQ, and now iFuse Bedrock Granite, the value of our innovative, versatile, and complementary product portfolio has positioned us as the top choice for surgeons looking for faker-public solutions. Demand for iFuse-TORQ, which recently completed its second anniversary, remains strong. It provides a complementary technology to iFuse-3D for existing surgeons and has allowed us to engage new surgeons performing minimally invasive SI joint fusion.

With the expanded clearance covering SI joint dysfunction, trauma, and adult deformity, iFuse-TORQ is a key growth driver for the company. We're experiencing increased use of iFuse-TORQ as the second point of fixation for adult deformity procedures. In trauma, we remain in the early stages of market development, and we're encouraged by the steady revenue growth we're seeing in iFuse-TORQ and sacral insufficiency for actors. The trauma opportunity is of strategic importance to us as the sacropelvic solutions leader and is an important avenue for our growth over the long term. 

Moving to iFuse Bedrock Granite. As we approach the first anniversary of the Granite launch, we're extremely pleased with the strong surgeon reception and increasing demand for this breakthrough product. With Granite now on the approved product list at over 2,600 hospitals, we believe this differentiated device has the potential to become the standard of care for stabilizing the base of long constructs in adult deformity procedures. Along with the strong demand for Granite, we're seeing a consistent trend in surgeons using some combination of our products with Granite to achieve 2 points of fixation across the SI joint on the inside. This is driving a significant pull-through opportunity for the overall portfolio and a higher procedure average selling price. 

In addition to the use of Granite and long construct adult deformity procedures, we're encouraged by the steady increase in the use of the product to stabilize the base of shorter multilevel constructs in degenerative spine procedures. Nearly 40% of our Granite cases have been in these short construct procedures. There are over 100,000 shorter multi-level spinal fusion procedures to the sacrum per year in the United States. Given our success with Granite, we intend to introduce a new product in the Granite family in 2024, more targeted toward these shorter construct procedures. We believe the expanded portfolio will allow us to target additional degenerative procedures to sacrum, potentially expanding our total addressable market for the Granite family products by nearly $700 million to nearly $1 billion. 

Before I pass the call on to Anshul, let me provide a quick update on our intellectual property. Last week, we were able to extend patent protection covering our first-generation iFuse implant by approximately 13 months to December 2025. As a reminder, the patents covering iFuse-3D, our 3D-printed and fenestrated triangular titanium implants, expire in 2035.

I'll now turn the call over to Anshul to provide more details on our financial results.

Thanks, Laura. Good afternoon, everyone. My comments today will be focused on first-quarter revenue trends, operating leverage, and liquidity and end with our updated 2023 guidance. Starting with our first quarter revenue. As Laura noted, our worldwide revenue in the first quarter was $32.7 million, representing growth of approximately 46% compared to the prior year period. We are thrilled with this growth but do want to note as a reminder that the first quarter of 2022 was significantly impacted by COVID. 

First quarter U.S. revenue was $30.5 million, increasing approximately 50% compared to the prior year period. This strong U.S. performance was driven by growth in procedure volumes, which rose by approximately 48% compared to the prior year period. Looking sequentially, U.S. revenue in the first quarter increased compared to the fourth quarter of 2022. This is encouraging as historically, first-quarter revenue was sequentially lower than the fourth quarter. Additionally, the sequential monthly U.S. revenue growth as we progress through the quarter reaffirms the growing demand for our solutions. In addition to strong volume growth, our U.S. average selling price in the first quarter of 2023 was modestly positive compared to the prior year period. 

International revenue was $2.3 million, reflecting a growth of 9% compared to the prior year period. Across Europe, France maintained strong volume growth, offset by underperformance in Germany and the U.K. Moving to gross margin and operating leverage. In the first quarter of 2023, our gross margin was approximately 82%, in line with our expectations. As anticipated, the gross margin reflects the impact of procedure and product mix due to the higher total cost of iFuse-TORQ and Granite, increasing depreciation from the deployment of instrument trays to support the strong demand for these products, depreciation associated with our second facility in Santa Clara and highest freight costs. Operating expenses were $38.1 million in the first quarter of 2023 versus $36.3 million in the prior year period. This 5% increase in operating expenses was mainly driven by higher commissions associated with the revenue growth. We are pleased that we have now demonstrated several consecutive quarters of operating leverage while investing in R&D and clinical research, which are crucial to expand our portfolio and create a platform to deliver strong and sustainable revenue growth over time. 

Our net loss was $11.1 million or $0.32 per diluted share for the first quarter of 2023 as compared to a net loss of $17.4 million or $0.52 per diluted share in the prior year period, representing a 38% improvement. Adjusted EBITDA in the first quarter improved significantly to negative $3.9 million versus an adjusted EBITDA of negative $10.7 million in the prior year period. This change translates to approximately 63% improvement in adjusted EBITDA. Adjusted EBITDA also improved sequentially compared to the fourth quarter of 2022. 

Turning to liquidity. We ended the quarter with $86 million in cash and marketable securities. Our decrease in cash and marketable securities in the first quarter was $11.3 million, an improvement of over 30% compared to the prior year period. As a reminder, first-quarter cash outflows include the payment of prior year annual sales. We are pleased with the trajectory of our cash utilization in the last few quarters while continuing our investment in growth initiatives. 

Finally, moving to our updated guidance for the year. Based on the strong execution in the first quarter, robust surgeon engagement, and demand for our portfolio of solutions, we are increasing our 2023 worldwide revenue guidance to $128 million to $131 million, up from a prior guidance of $124 million to $127 million. This revised guidance translates to year-over-year growth of approximately 20% to 23% versus the prior range of 17% to 19%. We continue to expect 2023 annual gross margins to be approximately 80%. Based on the updated revenue guidance, we anticipate operating expenses will grow mid-single-digit percent in 2023 relative to 2022, and adjusted EBITDA loss will continue to improve year-over-year in 2023.

With that, I will turn the call over for questions to the operator.

(Operator Instructions) Our first question is coming from Craig Bijou of Bank of America.

I guess I wanted to start, I think we've seen a number of companies report pretty robust procedure growth in Q1. And you guys obviously had very, very strong growth, even when considering the comp. So I guess I wanted your view on what you saw on the procedure side. Was there a pent-up demand? Or I guess the factors that have been influencing procedure growth over the last several years, like staffing, just willingness to get a procedure done. Are those easing? And maybe just from a high-level, perspective, what are you seeing on the procedure side?

Craig, this is Laura. Thanks so much for the question. And yes, we are thrilled with the record Q1 performance that we had, 46% growth is something that we're quite proud of. And even off of the comp compared to last year that was COVID impacted it still is quite an extraordinary performance that we've seen. The momentum is coming from the KOL business as well as from new products as well. We've been making a lot of investments, as you know, in the business throughout the pandemic. And what we're seeing is those investments are coming to fruition for us. And so what we've really done is with these years of investments across our product development, our clinical research, our commercial infrastructure, and surgeon education, we're building an industry-leading platform here for sacropelvic solutions. 

So in particular, though, what I would tell you is this is the first time since we've been a public company that we've seen sequential growth between the seasonally strong fourth quarter and the first quarter. So I think that really tells you the extensive acceleration that we're seeing in our business. So it certainly is macro factors. We do think that those macro factors are easing over time. But even with all of that in consideration, we're very excited about what we saw in the first quarter as well as based on the momentum exiting the first quarter, we're excited about our outlook as we continue to move further away from the pandemic.

And maybe just on guidance and I appreciate the comments that the Q1 comp was easier than maybe some of the other quarters that you're going to see throughout the rest of the year. But even on a comp-adjusted basis, it still looks a little bit below Q1. And I guess the question is, how should we think about the cadence of that through the year? And is it simply some conservatism? Or is there anything else that we should be thinking about for the rest of the year?

Craig, this is Anshul. Thanks for that question. So from a guidance perspective, look, Laura already alluded to this, we had a great start to the year, and that's clearly a continuation of the momentum we were seeing throughout 2022, just (inaudible), and when we provided our initial guidance, Craig, if you recall, we talked about risk-adjusted guidance where we took a lot of the tailwinds that we have in the business, ASP trends, Granite rollout, Europe stabilization, procedure volume coming back. And we were -- I think we were appropriately thoughtful coming into the year with those estimates on the risk adjustment side. And what we've seen already in our Q1 numbers is some of those things have played out better than we had risk-adjusted. So our ASP trends. 

If you recall, we had said we were pricing in about a mid-single-digit decline, and we came in positive on the ASP side, and the Granite rollout has continued very well for us. So we really feel good coming out of the first quarter that some of those tailwinds are playing out better than what we expected in our original guidance. Now we are in the early stages of what we think is a prolonged recovery, but we think it's best to be thoughtful right now. And just in our guidance, what you see, the increase is pretty much the beat that we've had in Q1, and we're not making any changes to our risk-adjusted assumptions for the rest of the year, even though we've seen them play out a little bit. So there's a fair bit of conservatism in there, but we think that's appropriate given how early we are still in the year.

(Operator Instructions) And our next question will come from Andrew Ranieri of Morgan Stanley.

As we're kind of thinking about some of the new products and Laura, I think you said you have a new Granite product coming out in 2020, but you've made a lot of investments in your sales force. You have multiple tailwinds at your back, but just how are you thinking about adding in new technology to not just capture additional procedure wallet share, but maybe even to further enter into adjacencies like trauma and even deformity? Just any more detail on that would be great.

Thanks, Drew. We really have built a significant base of products here over the last couple of years when we first started the company, iFuse and iFuse-3D were our primary products and minimally invasive SI joint fusion and continue to form the basis for the company, but we have been very pleased with the reception to our TORQ products both in our primary market and minimally invasive SI joint fusion and also in the trauma market. And then last year, with the introduction of Granite, we are really pleased with what we're seeing there as well. Our primary focus there was on the adult deformity market, and it is a differentiated product, addressing an unmet clinical need there with ensuring that we deal with fixation failure in those long constructs with pulsation with the product. And -- but what we were really interested in here is we've developed this product with Granite. That's a breakthrough that has a new technology and add-on payments associated with it. 

But what we're seeing is that market actually is significantly larger than the adult deformity market that we originally had targeted. And in fact, around 40% of Granite procedures are being done in shorter constructs, so 2 to 4-level constructs versus the longer constructs with scoliosis cases. And so, I specifically mentioned new products there that we're currently working on a product that will be more targeted towards those short constructs given the opportunity that's there, the market size that's there. If you add together the opportunity that we have in pelvic fixation, we think the opportunity overall, the TAM is around $1 billion in total. And so that is an area of focus for us. And given that we're already working with the surgeons, these are orthopedic and neurosurgeons that are doing spine procedures, we see a big opportunity for our sales force to be working closely with those surgeons on these additional products.

And one last one. Just as we are thinking about your updated guidance and to piggyback off a bit of Craig's question, but can you maybe just talk about some of the utilization that you're seeing with surgeons? I mean, the 950 surgeons in the quarter is really impressive. But just maybe just talk to us about what the utilization ramp looks like now and maybe what's driving kind of that inflection point a bit more.

Yes. So I did mention that we had a record 950 surgeons who have done at least 1 procedure in the first quarter. So that's a growth of over 40% year-over-year, and it was even an increase over the fourth quarter as well, which is typically our strongest quarter. So it's 9 consecutive quarters of double-digit year-over-year growth, and quite frankly, the highest year-over-year growth rate that we've seen as a public company. We do -- as your question -- to get to your question, we do see a significant amount of overlap where surgeons are performing multiple procedures. So they're performing procedures for minimally invasive SI joint fusion, adult deformity, degenerative cases, trauma cases with our products. And so it really is a testament to our execution here. And we started this company with a focus on education and outreach on these unmet clinical needs. And what we're seeing is that building with the group of products that we've developed. 

In terms of the time frame for surgeons to perform a procedure, it is a little bit different depending upon which procedure type we look at. And our primary SI joint fusion procedure, there usually is a longer lead time because you have to identify the surgeon, you need to convince that surgeon of the prevalence of SI joint dysfunction, you need to help them to understand how to diagnose this, then they need to identify a patient and then perform a procedure. So what we've typically said is that it takes around 12 months to truly ramp up a surgeon. In the case of pelvic fixation, we're seeing something different than that because what we're doing here with pelvic fixation is really bringing a new product that provides not just pelvic fixation but also fusion into the short and long-construct cases. And so it really is fitting very nicely into the surgeon workflow and it's something that we're seeing a more rapid adoption period versus our KOL product.

Our next question will come from Xuyang Li of Jefferies.

I guess, the first question, just on the 40% growth in U.S. active surgeons now up to 950. I was wondering what's driving that? How much is coming from previously trained but inactive surgeons sort of coming back into the fold versus new surgeon ads? And how much of that is driven by the new products or the portfolio effect?

Yes. In terms of the active surgeon growth, you mentioned are we seeing reactivations. We certainly are seeing reactivations, but the majority of the growth that we're seeing is in new surgeons. And if we look even in our KOL market, our target is around 7,500 surgeons in total. And so there's a lot of room that we still have to grow from a surgeon's perspective. So we are seeing a lot of additional surgeons that are coming on board and doing procedures for the first time. Some of them are competitive conversions as well because they're moving from one product to, in most cases, our TORQ product for those newer surgeons that are conversions. 

In terms of the product portfolio, when we look at the product portfolio, around half of the increase in the number of new surgeons are coming from our KOL primary minimally invasive SI joint fusion procedure. And then the other half are actually coming from these new procedures in pelvic fixation infusion or internal procedure. So it's really across the board that we're seeing the increase.

My follow-up question, I guess, I'm just wondering, so very good progress on EBITDA loss narrowing. I guess I'm wondering if you can provide us with the latest thoughts on the sort of EBITDA breakeven or the progression towards that. It seems like if you sort of maintain this type of progress, you could get there quicker than what consensus is assuming.

Yes. So Yang, thanks for that question. We're really pleased with what we've done from a leverage perspective. And our operating leverage is pretty linear to top-line growth. So as our revenue accelerated in 2022 and the first quarter of 2023, our leverage accelerated as well. And a lot of that is driven by the investments that we've made that were required to support the level of growth that we're now seeing in the business.

Now in terms of when do we get to break even, we're not going to be providing specific details on breakeven, but we really like the trajectory of how we leverage. We have a lot of opportunities ahead of us, and we want to be thoughtful about making investments to be able to drive the market penetration and growth. But we continue to expect operating leverage to improve year-over-year throughout 2023. And that will help us progress towards achieving that adjusted EBITDA breakeven like you said, in not that far future.

Our next question will come from Sam Brodovsky of Truist.

Just go back to guidance quickly, and I appreciate the commentary on conservatism earlier on, but it would look like it implies a sequential decline in revenue in Q2. So it would be great to hear what you're seeing when you see in April and how you think about growth in the second quarter versus Q1.

Yes. No, happy to take that first congrats on your role as well. Look, on a sequential basis, it's really difficult because the first half of this year over the last 3 years actually has been significantly distorted by COVID. And for us, even if you look back to 2019 to see sequentially what the trend was, the portfolio is much broader now. So we really don't have a good precedent for sequential trends coming into 2023. But what we take confidence in is the sequential monthly trends that Laura talked about in the U.S. revenue growth as we progress through the first quarter of the record active surgeon base that we exited the quarter with -- these are exciting forward-looking indicators for us that we might be entering a period of strong demand. So we like what we saw in the first quarter, exiting the first quarter, but I don't think I want to put too much emphasis on the quarter-by-quarter trends at this point, especially this early with the expanded portfolio.

And then one on ASP. Just to make sure, it sounds like there's no change in terms of the forward guidance to the expectation for ASP to decline in the low to mid-single digits. Is that right? And if you could give us any color on why that would be different than what we saw in 1Q?

Yes. No, you're accurate. Our guidance for the rest of the year does not assume any changes to our risk-adjusted metrics that we considered. So the ASP expectation in that original guidance was a mid-single-digit decline. So we're not changing that. Look, we've already done better than that in the first quarter. And we feel good about it. But again, it's 1 quarter. We want to be able to see the trends sustain itself as we progress through the year, and that will be reflected in user revenue numbers.

Our next question will come from Dave Turkaly of JMP Securities.

Laura, I know you mentioned a second facility in Santa Clara. I was just curious if you might make a comment on capacity and what you're doing there versus the original.

Yes. In terms of our capacity, we do actually have 2 facilities now in Santa Clara. There's one facility that primarily has office operations. The second specific is our warehouse and some of the assembly that we do here specifically for instruments that also have an R&D lab that's there as well. So that building is more of an operational facility. So we do feel comfortable that we have the capacity to grow at the rate that we're growing at. We also have some great suppliers and partners, third-party manufacturers that are able to help us to meet the demands of this sort of growth. So we're planning accordingly, and I think you may recall last year, we actually hired a new Senior Vice President of Operations and IT, Jeff Bertolini. He came from NuVasive, and had 10 years of experience heading up operations over there. So he's been a huge add for us because we really have moved very quickly from our initial KOL primary SI joint fusion business to a multiproduct business, and we're not missing a beat.

That's good to hear. And my follow-up would be on the new Granite. So I think I heard you say when you originally launched the Granite that you thought that might deformity might be at $250 million, and now you're saying with a shorter concept, maybe that goes to $1 billion, so there's, I think, $750 million incremental. Could you just walk us through the math there like ASP or implants? And then would that construct possibly qualify for -- and new technology add-on payment as well?

Yes. Thanks for the question. So you're right, Granite was originally developed for the adult deformity market. When we thought about Granite as a product, we are focused on long constructs, and we are making an assumption of a certain number of cases, around 30,000 cases with 2 implants. And so what we're seeing, however, even in that KOL market in adult deformity is that the ASP is actually higher. The number of cases is the same, but the ASP is higher because in quite a few of those cases. In fact, the majority that are long construct cases we're actually seeing surgeons use 4 implants versus 2. And so that total addressable market is now closer to around $300 million. 

What has been really exciting for us is to actually see how many surgeons want to use this product in short-construct degenerate spine cases. And as I said, it was nearly 40% of our granite cases that were done using our product in short construct cases. So that's been a surprise as to how large that number has actually been. It's really more about patient selection in those cases, which short construct cases are appropriate for pelvic fixation, but a much larger market in total. So there's around 100,000 cases that go down to the SAFFRON, those 2 to 4-level cases. And so versus the 30,000, you're talking about a much larger market size this year. In all cases, it's usually 2 implants instead of the 4. But if you add it all together, you're getting an incremental market opportunity of $600 million to $700 million in the short construct market. And certainly, we're looking at the product itself, and we're looking at the reimbursement opportunity there too as we have in all of these other cases. And so what it shows us is the big opportunity that we have in pelvic fixation infusion.

And our next question will come from Kyle Rose of Canaccord.

So look, I just wanted to dig one layer deeper into some of the upsides you're seeing. I guess, maybe can you just help us understand how much of that's coming from primary SIJ versus some of the deformity in the trauma side? Obviously, you've got some big initiatives with the broader portfolio. And then I'll just ask my second question now. We've seen pretty strong growth in the number of distributors you're working with. So I just wondered if you could help us understand how much of the performance or the growth in 2023 expectations, should we think about coming from that distributor group versus the direct and the territory manager in CSS Group?

Thanks, Kyle. So I mean, as you know, we don't break out separately product by product, what our growth rates were. We now have our 3 primary products with iFuse-3D, TORQ, and Granite. These are all sacropelvic solutions. But what I will tell you is that we saw in Q1, the growth -- there were significant contributions in growth both from the KOL markets as well as the strong demand for Granite as well. And so it really was covering both of those markets for primary SI joint fusion as well as for pelvic fixation. In terms of the distributors that you asked about, we have increased the number of distributors pretty significantly in the United States. And that increase has largely been led by covering Granite cases. Granite cases do tend to be different than a primary FI joint fusion. So I said that Granite cases, we see a much more rapid adoption of those particular cases because they fit into the workflow very quickly, and there's not necessarily the same education process. However, those cases do tend to be longer cases, especially the adult deformity cases. So it's a typical primary SI joint fusion case is going to be around 45 minutes, a typical adult deformity case is probably around 6 hours in total. 

And so what we're doing is we're gaining leverage by working with distributors that are covering these particular cases. And what it does is it's allowing us to increase the rep productivity. I had mentioned that we had a 28% increase year-over-year. We're at around $1.3 million in productivity. So it's helping us to gain operating leverage on the business. And that model is working very well for us.

And Kyle, just one clarification. These are agents, not what you -- typically to get distributors.

I think what he means by that, just to be clear, is a distributor typically just selling products to them. This is -- we're not doing that. This is just the case where the cases are being covered by an agent.

And our next question will come from Ross Osborn of Cantor Fitz.

So maybe just one for me on the NTAP. Did you see more cases during the quarter relative to the fourth quarter where the NTAP is being paid out?

Yes, it's a good question. So we do think the NTAP is really important to our Granite business. So we did receive breakthrough device designation on the product, and that breakthrough device actually helped us to gain an NTAP. And in this particular case, with our technology, the hospital can receive up to an additional $9,800 of payment for an adult deformity procedure. And as you may imagine, that's important to the hospital, and it's important to the surgeon as well. So it's something that we educate on with the facility as well as with the surgeons. We are continuing to see the acceleration that's here. There is data on who is using the NTAP, but it is -- there are significant delays on that data. So to be honest with you, we do not have that information yet. It's usually available a couple of times a year. And so we expect to see something in late summer, or early fall to really understand what the use of the NTAP has been. But for right now, we know information anecdotally, and we also know that the health economics of the procedure are very important to the surgeon (inaudible) facility.

And our next question will come from David Saxon of Needham & Company.

I wanted to start on TORQ in trauma. I think in the script, you called out it was your second anniversary. So I wanted to ask, what inning are we in, in terms of Fed deployment? And how is the sales force doing just given that it's a different call point?

Yes. Thanks for the question, David. The opportunity in trauma is a pretty large opportunity. Our best estimate is around $350 million in total for pelvic fractures, and most of that is in sacral insufficiency fractures typically with patients that have osteoporotic bone. And however, you're asking a question about TORQ and there's really 2 different applications of TORQ. And the ones that we've seen a significant uplift in usage has been more in the primary SI joint fusion market, a lot of competitive conversions, and also further expanding the KOL market using TORQ. The trauma opportunity we do see as a longer-term opportunity. In some cases, it's a different call point. It's a general ortho surgeon that's focused on trauma. In some cases, it's actually our typical ortho or neuro spine surgeon. And we do think that our Sacral study is going to be an important element to educating surgeons on the treatment of the sacral insufficiency fractures. 

Right now, surgeons typically don't treat these particular patients, and what we'd like to show with our Sacral study is that treating these patients versus (inaudible) special care, which is usually rehab, is absolutely critical to treating the patients. So we do see this as a little longer-term opportunity, but very, very familiar to us. It feels a lot like starting out in our minimally invasive SI joint fusion market, where we had to really educate on the condition, and we needed to encourage surgeons to treat cases that previously they weren't treating. So it's a great long-term opportunity for us. In terms of the set deployment implants and so on, we have been doing a good job keeping up with all of that. But as I said, I would say most of the deployment has been for the KOL market versus trauma.

And then maybe for my second, when the sales force is talking to prospective doctors, are you hearing any of the same points of pushback you did kind of earlier on in the launch? Or is the idea that the SI joint can be a source of pain, is that becoming accepted by kind of a broader portion of the physician community?

Yes. I would say that it is a very different conversation. We started the company. We mentioned that we just celebrated our 15th anniversary of the company. And at that time, there were very few surgeons who believe that the SI joint was a pain generator but with a lot of work in education and clinical data, over 80,000 cases later, over 3,000 surgeons using our products, what we've seen and universal coverage out there as well in the United States. There aren't many surgeons that you'll speak to anymore that will say they don't think the FI joint is a pain generator. And now what we're really trying to do is make sure that they understand the product, the educational approach, the reimbursement, the health economics, the quality of the data, and to get them to just regularly include the SI joint in their differential diagnosis of lower back pain.

And I'm showing no further questions. I would now like to turn the call back to Laura for closing remarks.

I just want to say thank you all for joining the call today. I am really excited about the growth potential ahead of us this year and even beyond. We have all the pieces in place to deliver exceptional outcomes for patients, support our surgeons, expand our portfolio, and create significant value for our shareholders, too. So once again, thank you for your ongoing support and trust in our company. Goodbye.

And this concludes today's conference call. Thank you for participating. You may now disconnect.