Alphatec Holdings, Inc. (NASDAQ:ATEC) Q1 2023 Earnings Call Transcript May 6, 2023

Operator: Good afternoon, everyone. And welcome to the webcast of ATEC’s First 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, pro forma or adjusted measures. Reconciliations of non-GAAP measures to U.S. GAAP can be found in the supplemental financial tables included in today’s press release, which identify and quantify all excluded items and provide management’s view of why this information is useful to investors. Leading 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.

Pat Miles: Thanks very much, Audra. And welcome, everybody, to the Q1 2023 financial results for ATEC. I am going to be providing some forward-looking statements, so please read at your leisure. The momentum for the company is exceedingly strong and very pleased to report Q1 2023 revenue at $109 million, which is 54% growth, 40% surgical volume growth and adjusted EBITDA margin improvement 1,080 bps and so some recent highlights, extended momentum of PTPs was the strongest contributor to Q1 growth. Fully launched LTP and we will go more into that, which is very exciting. Introduced Invictus direct Vitera rotation AIS system, which is — I will go into that a little bit more as well, drove $15 million in EOS revenue and we acquired the navigational robotics platform to enhance precision of our procedural strategy and so a lot of good things going on and a lot of momentum.

And I think if you look back at the momentum, you could look back to really kind of our established commitments all the way back to 2018 and that is to create clinical distinction. If we are not doing something better, we are not going to be able to compel surgeon adoption. If we are not compelling adoption, then it would be very difficult to garner the type of distribution that we are looking for. And so when we talk about clinical distinction. I think that the momentum would suggest that we are compelling adoption. And when you start to build procedures from the ground up and you are furthering procedural momentum, you could really look at PTP and LTP and look at things like the patient positioners and the retractors and information. And now the — so excited to add the navigation-enabled robotics piece.

And so this whole view of distinction being different and how they are creating it, I think, is starting to be reflected at least procedural. We got the ways to go in terms of reflecting the EOS piece. But, yes, we are more excited about the influence it’s having both on idiopathic and adult deformity, and again, I will speak a little bit more on that as we roll forward. And so an area of profound familiarity to the company is lateral. And when you start to think about sophistication being demonstrated through multiple distinctions of the same subject, I would tell you that lateral is a profound competency. And so when we talk about designing procedures from the ground up, we can’t be more excited about what we are doing with regard to the lateral LTP TransFills approach and so what you have seen in the marketplace is a big swing back to ALIF.

And so what surgeons want to do is they want to do a conventional midline ALIF and the beauty of this procedure is that it provides the ability to do ALIF at 51 in a position of great familiarity. And so the most talent treated levels are L3 to S1. We want to be able to have a solution for a lateral approach surgery. LTP is a reflection of all of our know-how internally and can’t be more excited about it. It really does enhance economics. When you don’t have to turn the room over, you don’t forego all the expenses associated with all of the disposables in the surgery, as well as just the — you start to think about a patient under anesthesia. So the beauty of the economics, the ergonomics and the optionality provided by this is exceedingly valuable.

And then what we get to do is we get to integrate some of the experiences that we had on the patient positioners, as well as what we have done exceedingly well on the SafeOp front. So just super excited about the momentum and all that’s going on in that arena. Our momentum clearly on the procedural front is fantastic. Our run with EOS is yet ahead. And just because we are — have been very focused and candidly successful on the momentum creation portion with proceduralization in the lateral space. It doesn’t mean that we can’t commit the same type of prowess procedurally for things like AIS. And I thought it would be valuable to just provide a little bit of a vision on how we are leveraging EOS to increase our influence in deformity and really beginning to extend procedural strategy really beyond lateral and advanced care in something like AIS, which is adolescent idiopathic scoliosis.

And so I mentioned that we launched the Invictus DVR direct Vitera rotation, instrumentation. And so the great part is, is we have launched that instrumentation, but now when you start to say, gosh, how are we going to have influence across something that’s been somewhat of a mature market. And when you think about what we are calling our Alpha Informatix platform, you think about EOS and you think about how we are automating measures. And so if a patient goes in and gets automated measures and they get a preoperative plan and you realize through the automated measures that there is a rotational deformity. When a patient gets derotated or a surgeon derotate a spine via a system like DVR, what they are going to use ultimately is they are going to use SafeOp in a way that Altium provides motor both potentials, such that when they derotate the spine, provide them a confidence that everything is okay neurologically.

And so you start to see, gosh, how does SafeOp start to provide influence in that surgery and it becomes relatively apparent. And then just the ability to say, how do we integrate the information that we got from the EOS interoperatively and that will be with an interoperative assessment that will be available in 2024. And then the ability to ultimately take that information from EOS and applied vending cores preoperatively such that we can understand exactly what’s going to go on with the surgery is, again, another opportunity to influence what’s going on in AIS surgery. And then, lastly, a position that ultimately effectuates the ability to more precisely and more amenably placed implants based upon the patient’s position. And so we feel like there’s a ton of opportunities to proceduralize outside of lateral and really create momentum for the company outside of what’s previously going on.

This is a — I think really kind of a key slide and a kind of a thesis that really hits home with us is we think it’s entertaining and it’s something that spine is commoditized and I think that they look at the inflation of spine surgeries as implants or screws. And when you start to look at outcomes, you start to see how our spine outcomes versus orthopedics and they are less predictable versus orthopedics. And so if you start to look at the graph and you say, gosh, what’s the revision rate of a total knee surgery in five years and it’s 3%, and you say, gosh, what’s a total hip replacement revision in 10 years and it’s around 5%. But then you start to look at spine surgery, you look at degenerative surgery and it’s 10% to 15% in one year to three years and adult deformity, it could be up to 25% to 30% in two years to five years and so it’s fascinating to us that people think, gosh, this is a commoditized environment when we realize there’s still a ton to do to make this stuff better.

And our view is that really, it’s about how do you start to mitigate variables, and if your commitment is to mitigate variables, that doesn’t mean more screws. What it means is more information and that’s how we ultimately expand the influence of EOS. And so developing and integrating spines most pace information-based variable mitigation system has really been a commitment that we have made with regard to EOS. And so just to be able to understand the preoperative phase and what you are going to start to see through the EOS system is automation. And so the days of surgeons measuring all of the different parameters that they are trying to achieve through the intervention is going to be gone, because ultimately, we are going to do that in an automated way, which will mostly help automate surgical planning and it will help with the diagnostic process.

The other thing is going to be fun is to bring this stuff into the operating room and really understand what the type of changes that we are able to garner with regard to some of the patient specific type of rods, understanding a patient’s bone quality, utilizing reconciliation inneroperatively to make sure that you are getting what you are trying to achieve based upon what your original surgical plan was and then assessment and follow-up. And then again, if you keep doing that a bunch of times, there’s a predictive analytic reflection that ultimately creates just much greater predictability. But our variable mitigation doesn’t stop at EOS. It’s like such an exciting part of the platform becomes is, how do we continue to even interoperatively become more sophisticated?

How do we become more précised? And that’s what’s so exciting about the investment that we just made in the Fusion Robotics platform. And so our intention is to improve procedural predictability and efficiency while reducing radiation exposure. And so why would we think of these things, we think of that how we would integrate them procedurally. And if you look at the picture on the far left, you get really, the opportunity to intervene and place robotically navigated EMG verified pedicle screws. That means combining two technologies, both navigation and robotics plus EMG so that you are affirmed in terms of this group placements. But it doesn’t stop there and this is where we think that our opportunity is to integrate these things procedurally.

And then what we will be able to do is we will be able to navigate the lateral incision, planned bony anatomy trajectory, facilitate precise dilator and retractor placement with integrated automated neuro navigation that provides real-time information, location and health of nurse interoperatively. So just the good to assemble these technologies to create one more precision to make it a much safer surgery. So we believe that, that’s going to, again, mitigate variables as it relates to the intervention. And then navigation-enabled robotics platform enhances predictability monitoring the retractor migration throughout the surgery, while doing this prep and interbody placing again adds an element of precision. And so, again, I think that, all of these things ultimately drive a variable mitigation effort that again makes for a greater level of predictability.

So I just can’t be more excited about the distinction the deck continues to provide which ultimately compels adoption, which ultimately confuses enable us to build our sales force. And so as discussed on the most recent call, we cannot be more enthusiastic about the team that’s around the Fusion Robotics platform. And we love to say, gosh, those guys aren’t guessing with regard to what the requirements are to make this stuff seamlessly integrated into what we do with regard to procedures. And so the founders who we have talked a little bit about Brad Plate and Kevin Foley, have been around this since the mid-1990s and they know its fuel exceedingly well and we just believe that our capacity to integrate this technology into the procedures, as I just described, is the opportunity.

And so we get to do so with a foundationally versatile platform that ultimately has a very small footprint, which we think is also a great advantage. And so we believe ourselves to be really uniquely well positioned for the informatics arms race that’s going to ensue. And so I think with regard to the preoperative capabilities and all that I described earlier, all of the interoperative elements that drive a procedural sophistication. And then an understanding of what happens postoperatively in us feeding that being that back in, such that surgeons will have an understanding of the type of experience that the patient had, we feel like is a recipe for forward success. And so, I think that statistically, as we are to-date, the whole compelling surgeon adoption is being reflected as we continue to increase the blended products per category.

The other, I think, element of a reflection is the continued interest in our surgeon education, which was 100 this quarter and the demand continues to be profoundly robust. I expect we will do 400 to 500 again this year and so very excited about continuing to host surgeons here at our facility in Carlsbad. Lastly, I think that the distribution team is getting better and better. We are still a small company, we are less than 5% market share and so our focus really is how do we strategically fill in large geographic gaps, how do we continue to compel new surgeon adopters and so that really remains our focus. The one thing that’s got to make you exceedingly bullish is that those people who have been around a long time are growing at 48%. And there’s nothing that I think makes us more confident in the trajectory of what’s going on is that the people who have been around us a long time understand that they have a clinical attribute are growing in a great way.

And so what we are trying to do is compete to advance that clinical attitude, earn increased share by — share of existing surgeon users and further penetrate adjacent geographies within the existing areas. And so that’s the color commentary on the business and I will turn it over to Todd to talk about financials.

Todd Koning: Thanks, Pat, and good afternoon, everyone. We appreciate you joining the call today. So I will begin with revenue. First quarter total revenue was $109 million, reflecting 54% growth over the prior year and a 3% increase compared to the previous quarter. The $109 million in revenue is comprised of $94 million in surgical revenue and $15 million of revenue. First quarter surgical revenue of $94 million increased 55% compared to the prior year period. Procedural volume grew 40% in the first quarter, with average revenue per case expanding 11% year-over-year as revenue mix continues to shift for its procedures with more products per case and greater complexity. And while lateral related revenue contribute the most to growth, revenue related to our recently launched posterior expandable cage and biologics also grew solidly in the quarter.

EOS revenue in the first quarter was $15 million, up 46% compared to last year, with solid execution on deliveries and installations in addition to an order that was delivered in a nonstrategic international geography. For to the remainder of the P&L. First quarter non-GAAP gross margin was 72.4%, up 20 basis points compared to the prior year. First quarter non-GAAP R&D was $12 million and approximately 11% of sales, compared to $9 million and 12% 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 Alpha Informatix platform. Non-GAAP SG&A was $81 million and approximately 74% of sales in the first quarter, compared to $61 million and 85% of sales in the prior year period.

We delivered over 1,100 basis points of improvement. Consistent with our long range plan, approximately 40% of the leverage came from variable selling rate improvement, while the balance was driven by leveraging the infrastructure investments we have made. Total non-GAAP operating expense amounted to $93 million and approximately 85% of sales in the first quarter, compared to $69 million and 98% of sales in the prior year period, demonstrating 1,270 basis points of operating leverage year-over-year. Adjusted EBITDA was a loss of $5.2 million and approximately 5% of sales in the first quarter, compared to an $11 million adjusted EBITDA loss and 16% of sales in the prior year. The 1,080 basis point improvement as a percent of sales was driven primarily by SG&A leverage.

These results continue to demonstrate the leverage we can deliver as our business goes. We ended the first quarter with $117 million in cash. That includes $95 million in net proceeds from the gradual term loan, offset by $28 million paydown of our revolving credit facility. Operating cash use totaled $35 million, which was predominantly related to investments in inventory and instruments to support sales growth and new product launches. First quarter of each year is also seasonally burdened with some compensation related payments. We continue to expect full year 2023 cash use to meaningfully improve relative to 2022 as adjusted EBITDA improves, consistent with our long-term plan. Debt and carrying value was $449 million. We continue to have undrawn and available borrowings under both the mid-cap revolving credit facility and the Braidwell Term Loan.

Now turning our look to the full year 2023. In line with the pre-release of first quarter financial results a few weeks ago, we continue to expect full year 2023 total revenue to grow 28% to approximate $450 million. That includes 2023 surgical revenue growth of approximately 30% to $393 million and EOS revenue of approximately $57 million. As sales growth drives leverage across our business, we continue to expect to achieve adjusted EBITDA breakeven for the full year 2023. The strength of our revenue results in 2023 enables us to absorb about $4 million of investment in the robotic navigation technology we acquired, while continuing to deliver on our commitment to achieving 100 basis points of adjusted EBITDA margin expansion. Clearly, the momentum of the business is strong, which positions us well to achieve the profitability and free cash flow goals in our long range plan.

The next few slides provide additional context for our 2023 guidance and I will start by sharing how our expectations for procedural volume growth and the expansion of average revenue per surgery shape surgical revenue guidance. We will continue to train surgeons at a robust rate, which tracks both surgeon adoption and utilization. Treating surgeons build loyalty and enables surgeons to work up the procedural complexity curve, both of which increased utilization. The middle charge is a testament to the consistent ramp in utilization that our surgeon cohorts have demonstrated each year. We now expect these dynamics to fuel high-teens percent procedure volume growth for the full year 2023, compared to the mid-teens volume growth we expected previously.

Average revenue per surgery grows as our mix shift towards procedures that require more products per surgery like PTP and LTP, and for 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 rates 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 of 2023. Now with respect to the rest of the P&L, we have begun to demonstrate how this business scales as we grow and we expect that dynamic to continue through 2023. Guidance for breakeven adjusted EBITDA this year implied 800 basis points of improvement relative to full year 2022.

Now our confidence in delivering that level of operating leverage for the full year 2023 is shaped by the 800 basis points of margin expansion we drove in the second half of 2022 and by the strong 1,080 basis points we drove in the first quarter of 2023. Additionally, the components driving this leverage as we grow, are consistent with what we described in our long range plan last May. So we are pleased to be able to continue investing in the priorities that support business growth while achieving our financial commitments. So in closing, 2023 has started out strong and we continue to see great momentum in the business. Surgeon interest is strong, as demonstrated by the training metrics Pat shared earlier. This is a leading indicator of adoption, which ultimately drives the magnitude of procedure growth we are achieving.

It is clear to us when you enable surgeons to do better surgery, you earn their trust in a greater share of their overall procedural volume. You can see our commitment to invest in innovation through our prioritization of research and development. Our organic innovation machine is completely focused on revolutionizing the approach to spine surgery. Through the recent acquisition of the Fusion Robotics assets, we added a tremendously knowledgeable team of people that will lead the integration of navigation-enabled robotics into our procedural offering. We are laser-focused on executing our strategy and I can’t think of a place that rather be than in the middle of what we are doing here at ATEC. And as you might expect, we have an active IR calendar over the next few months and I hope to connect with many of you in person.

With that, I will turn the call back over to Pat.

Pat Miles: Thank you very much, Todd. Really appreciate it. So our view is that spine’s future will be defined by information. Our foundation of the SafeOp platform, the EOS asset, as well as the Fusion Robotics asset that we have most recently added will be foundational to our success. And so only ATEC has the knowhow and technological foundation to set to find information standard and that’s where we are heading. So, with that, we will take questions.

Operator: Thank you. [Operator Instructions] We will go first to Matt Blackman at Stifel.

Q&A Session

Operator: We will move next to Brooks O’Neil at Lake Street Capital Markets.

Operator: We will go next to Josh Jennings at TD Cowen.

Operator: I will take our next question from Sean Lee at H.C. Wainwright.

Operator: That does conclude our question-and-answer session. At this time, I would like to turn the call back to Pat Miles for closing remarks.

Pat Miles: Thanks very much, Audra. I appreciate everybody’s interest and excitement about ATEC. We are literally just getting started. We have a heck of a long run and excited about the potential. So, anyway, thanks very much.

Operator: And that does conclude today’s conference. Again, thank you for your participation. You may now disconnect.