Globus Medical, Inc. (NYSE:GMED) Q3 2024 Earnings Conference Call November 5, 2024 6:00 PM ET

Company Participants

Brian Kearns - SVP, Business Development and IR
Daniel Scavilla - President and CEO
Keith Pfeil - COO and CFO

Conference Call Participants

Matthew Miksic - Barclays
Dino Weinstock - Wells Fargo
Young Li - Jefferies
Shagun Singh - RBC Capital Markets
Phil Dantoin - Piper Sandler
David Saxon - Needham & Company
Steven Lichtman - Oppenheimer
Matthew Blackman - Stifel
Ryan Zimmerman - BTIG
Craig Bijou - BofA
Caitlin Cronin - Canaccord
Richard Newitter - Truist Securities

Operator

Welcome to Globus Medical's Third Quarter 2024 Earnings Call. At this time, all lines will be on mute and a Q&A session will be held after the prepared remarks. I will now turn the call over to Brian Kearns, Senior Vice President of Development and Investor Relations. Mr. Kearns, please go ahead.

Brian Kearns

Thank you, Victor, and thank you everyone for being with us today. Joining today's call from Globus Medical will be Dan Scavilla, President and CEO; and Keith Pfeil, Chief Operating Officer and Chief Financial Officer. This review is being made available via webcast accessible through the Investor Relations section of the Globus Medical website at www.globusmedical.com.

Before we begin, let me remind you that some of the statements made during this review are or may be considered forward-looking statements. Our form 10-K for the 2023 fiscal year and our subsequent filings with the Securities and Exchange Commission identifies certain factors that could cause our actual results to differ materially from those projected in any forward-looking statements made today.

Our SEC filings, including the 10-K are available on our website. We do not undertake to update any forward-looking statements as a result of new information or future events or developments. Our discussion today will also include certain financial measures that are not calculated in accordance with Generally Accepted Accounting Principles or GAAP.

We believe these non-GAAP financial measures provide additional information pertinent to our business performance. These non-GAAP financial measures should not be considered replacements for and should be read together with the most directly comparable GAAP financial measures.

Reconciliations to the most directly comparable GAAP measures are available in the schedules accompanying the press release and on the Investor Relations section of the Globus Medical website. With that, I will now turn the call over to Dan Scavilla, our President and CEO.

Daniel Scavilla

Thanks, Brian, and good afternoon, everyone. September 1st marked the one year anniversary of the Globus NuVasive merger, making this quarter the fourth consecutive combined earnings release with sales growth, strong financial performance and best in class innovative product launches.

Globus delivered an exceptional third quarter with sales of $626 million, growing 63% or $242 million. Non-GAAP EPS was a record $0.83, increasing 45% even with the 20% increase in diluted shares versus prior year. We also had a record free cash flow of $162 million in Q3. This amount is equivalent to our 2023 full-year free cash flow. These results reflect our continued drive in market penetration, synergy acceleration and sustained profitable growth through financial discipline.

Based on our results so far, I would like to compliment the entire Globus team for their speed and effort in completing the most successful spine merger in history. There's still a great deal of work ahead of us, but I look forward to building from this base and accelerating growth as we move into the future. In addition to our great financial performance, Globus launched four new products in Q3 across our businesses, reaching 13 product launches year-to-date and more to come this year. These results are a testament to our incredible team working tirelessly around the clock to drive integration, overcome challenges and create scalable solutions so that we can reach steady state quickly and shape the markets in which we compete while delivering innovation to our surgeons.

Focusing on the performance of our business, U.S. spine grew 55% in Q3 with significant gains across our product portfolio in expandables, MIS screws, biologics, lateral and cervical offerings. The growth is driven by several factors, including a high retention rate at all levels of our field sales team, successful distributor-to-direct conversions, the strength of our combined product offering, increasing product cross-selling, implant pull through from robotic procedures and contributions from prior period competitive rep recruiting. Competitive rep recruiting remained strong in Q3 and the pipeline is solid as we enter Q4. 2024 is positioned to be one of the strongest competitive recruiting years as we continue to attract the most successful and tenured competitive professional reps who see the power and future we can offer them as a destination of choice for innovation and growth.

As mentioned earlier, we continue to flex our innovation muscle, launching four new products from our prolific R&D pipeline in Q3. I want to share these meaningful launches with you. The Excelsius navigation Hub pairs navigational accuracy with innovative patient safety features such as patient array shift tracking and navigation of door pro-oscillating instruments. The Hub seamlessly integrates with Globus products and procedures, offering enhanced navigation of best in class instruments and implants for a complete procedural solution from the cervical spine to the sacrum. It is the only freehand navigation system on the market to offer the versatility of three distinct imaging workflows.

The first is with Excelsius 3D imaging with automatic registration for optimized flexibility and efficiency. The second is preoperative CT fluoroscopy merging and the third is interoperative 2D fluoroscopy. Excelsius helped navigated instruments are an expansive and comprehensive suite of navigated instruments that enable the navigation of a wide variety of open and minimally invasive spine procedures, including XLIF, T-lift, posterior cervical fusion, Toracco lumbar fusion and SI Joint fusion. They are designed for optimal camera tracking throughout the procedure and are compatible with innovative angled navigation arrays that reduce the need for interoperative camera adjustments, streamlining all workflows, while maintaining backward compatibility with existing Excelsius GPS navigated instruments.

The Actify 3D Total Knee system is a contemporary Total knee solution that pairs cementless reconstruction with operative efficiency and anatomic fit. Compatible with manual robotic-assisted workflows, Actify 3D is engineered to combine implant endurance and a porous Lattice interface for cementless fixation, addressing surgeon preferences and varying patient anatomies. Actify 3D complements the ExcelsiusFlex robot with the TKA total knee Arthroplasty application that received FDA clearance in late Q2. E-Flex enables consistent accurate [indiscernible] cuts while maintaining surgeon flexibility and tactile feel. It accommodates varying surgeon preferences by offering imageless and CT based workflows, ergonomic and unrestricted jigless resections and restores surgeon control while active tracking is engaged.

The system features advanced registration and planning algorithms to enable streamlined and efficient procedures. The system is slated for launch in Q4. For trauma, the CAPTIVATE SOLA headless compression screw system provides a fast and efficient solution for fracture repair, bone reconstruction, joint fusion, osteotomy and arthroadesis. This headless screw is capable of accommodating a wide range of patient anatomies, the intuitive graphic case design aids efficiency and reduces space in the OR. In addition to driving growth from the 13 products we've launched so far this year, I look forward to sharing future impactful launches as we go through the rest of 2024. This is a year of record launches for us and this innovation is key to building long-term growth while working through near-term merger integration. We are investing significantly in comprehensive product development training to harmonize our product development processes between, Autobahn, San Diego and the [indiscernible].

And this is expected to further expand our significant lead over the competition in IP generation and new product development. Enabling technology sales were $38 million, an increase of 39% versus prior year. Q3 was the highest number of unit placements since launch, growing 50% over prior Q3, including the acceleration of our rental program where unlike unit sales, we recognized revenue over the rental contract life. Robotic procedures continue to accelerate, growing 34% versus prior year and exceeding 84,000 robotic procedures performed since launch. As mentioned earlier, the ExcelsiusHub launch in Q3 is going well as we enter the free hand navigation market, opening the largest market segment of navigation for Globus innovation and growth. The combination of the E3D imaging system with the EHUB navigation platform gives Globus the most comprehensive and sophisticated navigation offering available. We also plan to advance navigation further in the near future with our XR augmented reality headset designed to work with the ExcelsiusHub.

We expect to gain FDA clearance of the headset in Q4. The DuraPro and Versera power tool systems launched in Q1 continue to differentiate our power tool offerings and pair seamlessly with our enabling tech portfolio. The unique ability of DuraPro oscillating drill to add extra safety around soft tissue structures, including neurovascular anatomy, while allowing for easy removal of bone helps surgeons work safely and efficiently. Market interest remains high for our state-of-the-art Excelsius 3D imaging system, with most surgeons immediately recognizing and appreciating the stark differentiation over existing systems and seeing the value of combining E3D with the ExcelsiusGPS or Hub. We're delivering on our promise to create and launch our enabling tech ecosystem, an ecosystem that is designed and built from the ground up to communicate together seamlessly.

Investment in this area remains strong as we enhance our ecosystem offering and bring about more functionality in our imaging, navigation and robotic current and future portfolio. Our international spinal implant business delivered record sales in Q3, growing 86% on a constant currency basis compared to prior year with high-double-digit growth in most markets, strong dollar contribution driven by Japan, Germany, the UK, Italy, Brazil and Colombia. We have yet to fully harness the power of the combined Globus NuVasive product offerings internationally and feel this will be a significant tailwind moving forward in 2025 and beyond.

The combined trauma and NSO business delivered 99% growth for Q3, driven by the continued powerful performance and market penetration of our base trauma business combined with the fast uptake of the NuVasive specialty orthopedic growth now. The combination of these two businesses is one of the strengths of our merger, offering a broad range of products and market changing innovation. Integration is progressing well as we continue to cross-train our field, implement common global systems, expand our investment in sets and bring new products to market.

There has been a great deal of progress from our teams and we're fortunate to have such strong leaders throughout the world. You can see from this quarter's financials, synergies have been identified and actions have begun to realize benefits, focusing on out of pocket spending and prioritizing investments to match future growth plans. In-house organizational structures have been implemented and we're working towards reaching steady state by year end. I believe the potential for Globus has never been greater. It's up to us to harness our resources and shape the future of our markets. We have at our fingertips everything we need to realize this.

I want to thank the worldwide Globus team for your dedication and support, delivering an incredible quarter and furthering the pathway to becoming the preeminent musculoskeletal technology company in the world. I will now turn the call over to Keith.

Keith Pfeil

Thanks, Dan, and good afternoon, everyone. During our third quarter, we passed the one year mark since the closing of the NuVasive merger. Much work has been done thus far in becoming the most successful spine integration at the one-year mark. Much work remains. We are hard at work to continue in this vein. I'm extremely pleased with the outstanding results of our third quarter. As I look at sales performance, profitability, the balance sheet, cash flow and cash generation, I see Q3 as a fundamentally complete quarter. All facets of the business performed and the outcomes are clearly visible in our third quarter results.

Revenue for the third quarter was $625.7 million, growing 63.1% as reported. Day adjusted sales growth was 60.8% with one more selling day in the U.S. versus Q3 of 2023. Our Q3 GAAP net income was $51.8 million, resulting in $0.38 of fully diluted earnings per share. This compares to GAAP net income of $1 million and $0.01 of fully diluted earnings per share in the prior year quarter. Q3 2024 non-GAAP net income was $114 million, growing 73.9% versus the prior year quarter, resulting in $0.83 of fully diluted earnings per share. Third quarter non-GAAP earnings per share grew 45% despite a 20% increase in diluted shares as a result of the merger.

Our third quarter adjusted EBITDA was 31% and free cash flow was a record $161.7 million. Musculoskeletal revenue in the third quarter was $587.4 million, growing 65% as compared to the prior year quarter, driven mainly by the contributions from the NuVasive merger. On a pro forma basis, assuming NuVasive was in our prior period results, musculoskeletal revenue grew 5.4% compared to Q3 of 2023. Growth was again led this quarter by U.S. spine and our international spine business. Our Q3 Enabling Technologies revenue was $38.3 million, growing 38.5% versus the prior year quarter. Growth was driven by increased sales within the U.S. market across our EGPS and E3D products.

In addition, we also sold and shipped our first EHUB units during the quarter. Overall, the third quarter represented a record for total Excelsius units placed in the quarter. Looking ahead to our fourth quarter, the capital market remains healthy and we are well positioned with a strong pipeline and seek to close the year strong. U.S. revenue in the third quarter was $495.8 million, growing 60.3% as reported compared to the prior year quarter.

Looking at the quarter on a pro forma basis, U.S. revenue grew 7.3%, driven predominantly by U.S. spine and Enabling Technologies. Looking back on the past year since the merger closed, I call attention to the fact that our U.S. business has grown on a pro forma basis in each of the four quarters, led predominantly by our U.S. spine and Enabling Technologies businesses. International revenue during the third quarter was $129.9 million, growing 74.8% as reported compared to the prior year quarter. On a pro forma basis, international revenue grew 5.1%, driven by strong implant growth, primarily in our EMEA countries, partially offset by lower capital sales.

Q3 GAAP gross profit was 53% compared to 62.2% in the prior year quarter, which is inclusive of product related intangible amortization for both periods presented. The decline in GAAP gross profit is primarily the result of step up amortization from the NuVasive merger, which will end during our fiscal fourth quarter. Excluding the impacts of step up amortization, non-GAAP gross profit was 66.5% compared to 69.7% in the prior year quarter. The decline in gross profit rate was driven primarily by the inclusion of NuVasive in our consolidated results as well as a higher mix of capital sales in the quarter. We expect the full-year adjusted gross profit rate to be in the range of 67% to 68% for the full-year 2024. Looking ahead, we expect to work back towards the goal of a mid-70s adjusted gross profit margin as we complete the integration and realize all of the synergies across manufacturing, operations and vendor management.

Research and development expenses in the third quarter were $35.4 million or 5.7% of sales compared to $29.3 million or 7.6% of sales in the prior year quarter. The increase in spending is the inclusion of NuVasive in our consolidated results, partially offset by synergy actions taken. Consistent with our previous expectations, we still expect R&D expenses to be in the range of 6.5% to 7% for the full-year 2024. SG&A expenses for the third quarter were $240.7 million or 38.5% of sales compared to $156.2 million or 40.7% of sales in the third quarter of the prior year. Consistent with prior quarters, the increase in total SG&A dollars is directly the result of the NuVasive merger, partially offset by cost actions taken and fixed cost leverage on spending. Consistent with our comments last quarter, we still expect full-year SG&A expenses to improve 1 to 2 percentage points over the full-year 2023 SG&A expense as a percentage of sales.

Net interest expense in the third quarter of 2024 was $0.8 million compared to net interest income of $7.8 million in the prior year quarter. The resulting $8.6 million pre-tax unfavorable impact is driven by the use of cash to A, fund an NuVasive line of credit paydown at merger close, B, fund share repurchases related to our buyback plan and C, interest expense from the senior convertible note, which is assumed from NuVasive at merger close.

The GAAP tax rate for the third quarter was 9.1% compared to 60.7% in the prior year quarter. The prior year rate was impacted by the low level of GAAP pre-tax income in the prior year quarter as well as a non-recurring benefit in the current year quarter related to a reserve reversal, which favorably impacted the rate by approximately 11%. Our non-GAAP tax rate for the quarter was 29.1% and does not include this non-recurring benefit. We expect our full-year non-GAAP tax rate to be in the range of 24% to 25% for the full-year 2024. Shifting to cash flow. Our third quarter results were stellar with both record operating cash and free cash flow.

Operating cash flow was $203.7 million and free cash flow was $161.7 million. As Dan mentioned earlier, our Q3 2024 free cash flow was essentially our entire cash flow for fiscal 2023, which was $165.2 million. The drivers of the improved cash flow are twofold. One, we are seeing the cash benefit of synergy capture roll through our P&L as our cash earnings continue to improve and two, we are unwinding the impacts of the system go live to accounts receivable, which I commented on during our first quarter call.

Specifically, our U.S. systems go live in Q1 temporarily impacted accounts receivable, which resulted in a higher working capital investment. As expected, we are seeing this issue improve and expected to drive working capital improvements through the fourth quarter and into early 2025. Our record free cash flow was also achieved in a quarter where capital expenditures were approximately 6.7% of sales, showing evidence of our investment in the business, namely spine sets during the quarter. Our expectation is that full-year 2024 CapEx will be in the range of 4.5% to 5.5% of sales.

I began my remarks today commenting that I viewed our third quarter results as a fundamentally complete quarter. A key driver of that statement was based on our cash flow for the quarter. To further highlight, now that we have a full four quarters behind us since the merger, we are starting to see the financial vision we envisioned for the merged Globus company become more of a reality.

In these trailing four quarters, operating cash flow was $415 million and free cash flow was $293.8 million. Our capital allocation priorities remain unchanged. Our long-term vision is to maintain strong financial discipline with little to no debt, invest in organic and inorganic opportunities, while providing a return to shareholders through share repurchases. Share repurchases have and will remain an integral part of our approach moving forward. I remind everyone that since the merger closed, we've spent a total of $310.3 million on share repurchases. Shifting over to debt and looking ahead to early 2025, it is our intent to use existing cash reserves to repay the $450 million senior convertible notes, which are due to mature in March of 2025.

Now I'd like to spend a few minutes discussing our integration progress and synergy capture. Looking back on the decisions made and actions taken thus far in 2024, we are heavily focused on our U.S. operations, namely territory realignments, elimination of cost redundancies, facility consolidations, system integrations and contract renegotiations. Year two efforts will focus on further refinement of our international systems and its footprint, the implementation of additional warehouse efficiencies and most importantly, product insourcing efforts. We've begun ordering the machinery and equipment that will drive our insourcing initiatives that will encompass both of our manufacturing facilities in Pennsylvania and Ohio.

As we execute this, we will seek to expand our manufacturing know-how with new and expanded capabilities, all while fostering a sense of teamwork and collaboration as we bring together the knowledge and approaches of both legacy organizations. As it relates to synergy capture, we previously communicated our expectation of $170 million of synergies over three years with the ability to realize 40% or $68 million in year one, 40% or an incremental $68 million in year two and 20% or an incremental $34 million in year three.

While we expect and remain committed to achieving the $170 million in savings over three years, we are updating the time phasing of these savings. We now expect to realize 55% or approximately $94 million in year one, 30% or $51 million in year two and 15% or $25 million by the end of the third year. This timing improvement in savings ties back to our Globus culture of moving with a sense of urgency as our employees are relentlessly changing patients' lives. We'll provide additional updates to our projections when necessary as we move ahead. Based upon our Q3 performance and outlook for the remainder of the year, we are again increasing our previously provided guidance. We now expect 2024 net sales to be in the range of $2.49 billion to $2.5 billion.

Our revised net sales guidance implies 3.9% to 4.3% growth over 2023 pro forma revenues of $2.396 billion. We are delivering sales growth in a year of extensive integration. Before I provide a revised fully diluted non-GAAP EPS guidance, I'd like to call attention to a change we made during the quarter related to our non-GAAP reporting where we will no longer adjust for the impact of the acquisition of in-process research and development. This change in reporting will unfavorably impact our previously provided 2024 non-GAAP EPS guidance by $0.09 as a result of our Q1 2024 IP R&D acquisition. Given this change as well as our expectations on business performance, our revised fully diluted non-GAAP EPS is now expected to be in the range of $2.90 to $3 per fully diluted share.

Our revised guidance range assumes a $0.19 increase to operational performance, partially offset by the $0.09 impact due to no longer adjusting for the acquisition of IP R&D as previously stated. Overall, this change reflects our views of enhanced profitability, driven by improving business performance, while more closely aligning our non-GAAP reporting with the most comparable GAAP measure. Our Q3 performance reflected the underlying strength of our business. We achieved meaningful sales growth, drove enhanced profitability and generated record free cash flow, all while still investing in our business. I'm extremely pleased with our results and remain excited for what's to come.

Closing out on my comments, I'd like to once again thank our employees for their commitment and dedication. In a state of change, we've continued to deliver innovation and new products to our partners based on our culture of maintaining operational excellence and a focused, disciplined approach to cost, thus ensuring we have the right product at the right price and on time.

We will now open the call for questions.

Question-and-Answer Session

Operator

Thank you. And at this time, we'll conduct a question-and-answer session. [Operator Instructions] Please stand by while we compile the Q&A roster. One moment for our first question. And our first question comes from the line of Matt Miksic from Barclays. Your line is open.

Matthew Miksic

Hey, good evening and congrats on a really strong quarter, guys.

Daniel Scavilla

Thanks. Thank you.

Matthew Miksic

So one quick sort of question on margins and then a follow-up on robots, if I could. So margins, obviously, EBITDA margins popped up nicely. You mentioned some of the things that were driving that sort of acceleration into the low-30s. Could you maybe highlight the large moving pieces that sort of that got you there faster certainly faster than we were expecting and street was expecting. And then I mentioned I have one quick follow-up.

Daniel Scavilla

Sure. So Matt, I'll take the first part of that question, actually I'll take the first part of what you stated. Really, when you look back on the year, we aggressively went after eliminating cost redundancies as well as facility consolidation like I commented on in the quarter. As we got into the year, we identified more and more places where we felt that there was opportunity for savings. And really as we -- as we looked at the year coming together, the key focus for us is driving cash savings. I'm not super interested in driving or finding ways to generate non-cash savings. We really took a look at four wall spending and said what do we need to do to really drive improved profitability. It's really -- it's really about it.

Matthew Miksic

Okay. Well, I'm sure there'll be follow-ups on that. But on robots, one of the things I think we've asked about since the beginning and since the merger was announced is, behind this mission of doubling the field force and selling a robot across a broader -- broader field force, what's the -- what has the progress been like on the on the NuVasive side and reps getting into getting you into accounts and kind of what's the look forward on that? Thanks.

Keith Pfeil

Hey, Matt, I'll take that one. So it's been progressing well. It's really been several fold. The first one is we have been training our reps on the system itself. So we've been bringing our team in, making them experts, getting them comfortable with that so that they understand how to perform this.

And I've seen dozens and dozens of teams from the former NuVasive team in our labs running through that. At the same time, our product development team has been working to take the great Nuvasive products like ReLine or modulus and get those onto the software that's been done. We're actually working now to and we're waiting for approvals of that to come through to go. It's really the combination of those two that will allow us to make that more functional. In addition to that, we've already been obviously seeding through conversations with surgeons, bringing them in for VIPs, having conversations with that.

I'll tell you, I'm pleased where it is. The real thing we need to do is get the approvals to use those NuVasive products out on our system. And I think that's really what 2025 is going to be for us.

Operator

Thank you. One moment for our next question. And our next question comes from the line of Vic Chopra from Wells Fargo. Your line is open.

Dino Weinstock

Hi, congrats on the quarter. This is Dino on for Vic. I just wanted to ask about if you have an update on the FDA warning letter that recently came out. What update can you provide on it and what are the next steps. Do you expect it to be resolved soon. And what, if any is the commercial impact?

Keith Pfeil

Thanks. Dino, I'll take that as well. So just again to remind everybody, that warning letter was really about our internal processes of how we handle complaints. It was not directed towards the actual robot, nor did it imply any issues with the robot or with patient safety. It was about how we handle complaints.

And it was really about the array of criteria we selected when we're analyzing complaints. The FDA would like us to do more, in which case we did. We went back to the very first complaint and went through every single one of them, realized that our outcome would not change with all the additional criteria. We've agreed to put that going forward. We've submitted that out to the FDA. We've had a few back and forth for clarification and now we're in the phase of just proving it out as an effective approach and we're willing and we're excited to actually have them come back in for reinspection to get this behind us.

Warning letters in the past from other companies tend to last in a year or excess of the year. So we're seeing if we can close that down and do that faster than that normal curve. As far as sales, there's no doubt there's probably been a few customers that were worry about this. We've gone out and had direct conversations with them. We've assured them in several different ways, but it's not a product related issue. And while there's some impact, I wouldn't quantify it, and I don't feel that it's been significant to date.

Dino Weinstock

Got it. That's helpful. And then one follow-up. On the capital equipment environment, just what's your view on the capital equipment environment heading into Q4. And how are you feeling about 2025 after two of your competitors recently received FDA approval for their spine robots. Thanks.

Keith Pfeil

So this is Keith. I'll take that. I think about going into Q4, we feel good about where the capital environment is. Our pipeline remains strong. There's a lot of inbound interest. There's lots of quotes getting turned around. As I think about going into 2025, competition is coming, we knew competition would be coming at some point.

And at this point, we're leaning in and we're really focusing on selling our robot, which we still feel is best in class technology.

Daniel Scavilla

And if you remember, one of the premises of the merger was to actually double our total available market and introduce this to more surgeons through the NuVasive side. That is and will remain our focus. We will willingly compete head to head with any competition in any account, but our main focus is going to be taking advantage of the surgeons we're active with to place those units through next year.

Operator

Thank you. One moment for our next question. Our next question comes from the line of Matt Taylor from Jefferies. Your line is open.

Young Li

All right. Great. This is Young Li in for Matt. Thanks for taking our questions. I guess to start, one on reps. It's been a little bit more than a year since the deal closed. Can you level set us on how many reps might have guarantees that are expiring. Is it a material number for revenue for NuVasive. It sounds like you're seeing pretty good reduction on the reps. I guess, are you also may be seeing some competitive responses from the other companies on your reps.

Daniel Scavilla

Thanks, Young Li. I'll take that as well. There was word in the street falsely spread that the majority of our people are on contracts. I'm not sure why someone would come up with that. It's simply untrue. It shows that people are disconnected with the industry. We have historically had few people who are on contracts and to date even combined is one that still remains very low for us. It is not a significant impact by any stretch with that. And like regular business, we aggressively go after competitive recruits and our competition goes after competitive recruits. We're not seeing anything unusual with that related to this merger at that point. But I do want to stress the word in the street is simply incorrect.

We do not have the majority of folks on guarantees at all. It's a very manageable number. It has been managed that way. We expect our people to perform with a best in class portfolio. And unlike other companies, we don't have to guarantee them to do that. The products and the innovation allow them to self-sustain.

Young Li

All right. Great. Thanks for the clarification there. I guess one to follow-up on really strong growth OUS. You increased investments in the OUS business. I wanted to hear a little bit about your thoughts on the international spine business profitability. There's a lot of opportunities and tailwinds on the revenue side, but can OUS EBITDA back up versus the U.S.

Keith Pfeil

This is Keith. I'll take that question. I mean, absolutely. I mean, international profitability is going to vary country to country, but a couple of things you got to think about is we're operating in places where pricing may be favorable and you're driving volume growth of the same products that we're making here in the U.S. So as you -- as you incrementally add more product internationally, you can drop more variable profit to the bottomline just by the nature of what you're selling. So absolutely, there's an ability to create more of a of enhanced profitability internationally as we move forward, which can having a compounding effect on the larger business.

Young Li

All right. Great. Thanks so much for the color and looking forward to seeing you guys in London.

Keith Pfeil

Thank you.

Operator

One moment for our next question. Our next question comes from the line of Shagan Singh from RBC Capital Markets. Your line is open.

Shagun Singh

Great. Thank you for taking the questions and congratulations on a really strong quarter. I guess just two for me. The first on the ReconRobotic launch, you did call out you what the features are going to be. Can you maybe elaborate on what do you think is going to be most differentiated, what's your commercial strategy and how we should think about the impact in 2025.

And then I guess for my second question on capital allocation, you had previously called out a focus on complementary M&A. It seems like you still have more work to do on NuVasive, but the big chunk is behind you. So can you just elaborate on your appetite and preference for deal size, et cetera. Thank you for taking the questions.

Daniel Scavilla

Thanks, Shagun. I'll take the first part of it. I think what we're excited about with the robot is it's obviously newly designed, built from scratch. I feel like the movement of its arm itself is really a benefit of what we do. I think the accuracy of what we can come up with using all latest technology is really good as well. I think ultimately, it can be many different things where we want to get into. The big thing I like about this is the multiple workflows, whether you want to do CT or image list with that and the fact that it can instantly go, you don't need to send something away for planning of it to get it organized. So there's a lot of flow and efficiency. There's a lot of flexibility that I think put in the hands of a surgeon coupled with the newness and latest technology built from the ground up, I think can be meaningful and impactful.

Keith Pfeil

And, Shagun, this is Keith. I'll take the second part. As it relates to capital allocation and driving M&A, really go back to our mission. We're a musculoskeletal company looking to improve the lives of patients with musculoskeletal disorders. So as you think about that in our products, we want to fill out the bag of what is not in our product portfolio yet. And as I think about kind of what we look at, you could look at your shoulders, you can look at enhancing our joint portfolio. There's lots of places to look, but it's also looking at complementary pieces of technology that could really help develop something or bring something to market quicker.

I wouldn't comment on a specific size or scale at this point. As we work through the integration of NuVasive acquisition, we want to make sure we get all of this right. There's still more work to do. And I think that as time passes, we'll see what opportunity is out there and really move based on what we see as a fit for us as we move forward.

Shagun Singh

Thank you.

Operator

Thank you. One moment for our next question. Our next question comes from the line of Matthew O'Brien from Piper Sandler. Your line is open.

Phil Dantoin

Hey, this is Phil on for Matt. Thanks for taking our questions and congrats on the great quarter. I really wanted to ask about the guidance update. You beat it in Q3, and I hate to ask it this bluntly, but you beat the Street by a bit over $20 million, raised by $15 million. I think it implies Q4 revenues growing in the 2%, 3% range. Is that the right way to think about things. And any color on how that's broken out between musculoskeletal and enabling technologies.

Keith Pfeil

Sure. So this is Keith. I'll take the question. I mean, really, when we provide guidance, we're providing guidance on the full-year. Obviously, we had a strong quarter, but we're still maintaining appropriate conservatism going into Q4. In saying that though, we remain extremely positive about the progress that's made and where it's going. We don't provide breakouts between enabling tech and musculoskeletal. I would really just fall back on the comments that I had on the call. Our musculoskeletal business really has grown this year led by U.S. -- by U.S. spine and international spine and our enabling tech business looking into Q4, the pipeline remains strong and we remain positive about it.

Phil Dantoin

That's helpful. And in that context and then relatedly, I know you described the new and improved Globus as a high singles, low doubles grower into the future. Just curious to get your take and I understand it will probably be light, but any color on next year. I think the Street set 7%, but just any way to help her adjust between this year and next. Thank you so much.

Keith Pfeil

Thanks for that second part of the second question. I mean, at this point, we're not looking too much into 2025 or providing color at this point. We're coming out of this year. We've managed to work through bringing the businesses together. And we remain positive and really we stick by what we said we still think Globus could be a mid-to-high-digit mid-to-high-single-digit grower.

Daniel Scavilla

I think one of the indications for that as well as we keep talking about our strong competitive recruiting activity and our strong product launches that we're putting out to build the platform for future growth.

Phil Dantoin

Thank you.

Operator

Thank you. One moment for our next question. And our next question will come from the line of David Saxon from Needham and Company. Your line is open.

David Saxon

Great. Good afternoon, Dan and Keith. Congrats on the quarter and thanks for taking my questions. I wanted to follow up on the guidance question. It is kind of low-single-digits sequential growth. I think in a normal year, we're closer to high-single-digits. So I mean, I heard you say kind of appropriate conservatism that's baked into the guide. But I just want to be clear, are you seeing anything in the market that kind of would you be a risk in your view and then I guess second to that is, I thought guidance assumed around $150 million of dis-synergies this year. Is that still a case in any way to kind of gauge where we are on with dis-synergies and then I'll have a quick follow-up.

Keith Pfeil

Sure, sure. So as it relates to guidance, as I think about the year, we're extremely positive with where we are and how we finished. The $150 million dis-synergy, you'll note that I did not reference it in my prepared remarks. I think that as time passes, we feel more and more confident. Is there the risk of having synergies in the future. Sure, there could be risks, but at the same time, at what point does it become part of just running your business. We remain appropriately conservative like I said earlier, but going into Q4 and into 2025, we remain positive. If I think about anything specifically that we looked at, we did see a little bit of an impact related to some of the hurricanes and some shortages related to IV bags. That's really the only main thing that I would call out as I go into my Q4 and get into it deeper.

David Saxon

Okay. Super helpful. Thanks for that. And then just on the trauma portfolio, I heard the combined NSO and trauma was like 99%. I think trauma historically has kind of been in the 40% to 50%. Is that still the case. And any way you can give us a sense for the size of that portfolio in terms of revenue contribution. Thanks so much.

Daniel Scavilla

Yes, we don't actually break that out right now with where that is. Both have great uptake. They're both growing well, super high double-digits with it. But we're really not in a position to split them out or actually lay out what the dollar impact is right now.

Operator

Thank you. One moment for our next question. Our next question comes from the line of Steve Lichtman from Oppenheimer. Your line is open.

Steven Lichtman

Thank you. Evening, guys, and congratulations. Dan, one of the drivers you mentioned up top for this quarter was a successful distributor to direct conversions. Can you talk about what the impact is of those conversions and where you are in that process.

Daniel Scavilla

Yes, Steve, glad to. So we started out with Globus years ago doing those conversions and coming into more direct exclusive sales force. We obviously did the same with several of the former NUVA distributors bringing them in. And what that is, it just allows us to invest better in those markets, hire people, push through, get the right amount of reps, share that risk with the former distributors so that we can get more rapid growth out of that type of approach.

That's truly the benefit. There's some more out there that have not converted or chose not to convert, which is fine. But where we do have that opportunity, we're taking advantage again more to use the power and cash of Globus to create further growth and faster impacts into those areas.

Steven Lichtman

So you'd say, Dan that you're kind of toward the end of that process. Is that right?

Daniel Scavilla

I don't know if I'd say towards the end of that process. We're year end, we've done several. I would say there's probably several more. I don't want to reveal numbers or locations yet. And I think it's really several things. We want to make sure that people get comfortable with us, we get through the startups. We'll continue to work with it. We're not going to mandate it, but it's clear for anyone who has gone through that and it's a very big benefit to them when we start using these approaches. And I think the goal, Steve, is to remain focused on that just for the sake of controlling our salesforce in a better way and really accelerating how we can invest in there.

Steven Lichtman

Okay, got it. And then on orthopedics, your focus initially is in total primary knees where, of course, it was most synergistic with robotics. As you approach accounts, whether hospital or ASC, how are you looking to overcome like not having as full a bag as the major players. Do you see a need to sort of rapidly advance products like Uni or others. How are you thinking about that?

Daniel Scavilla

Yes. No, great question. Everything that we need is in progress. Nothing is ever fast enough for me, just the nature of what it is. But the Unis developed and honestly ready to go. We're really far down the path with what I think is a fabulous revision knee. Everything related to hip is really either approved or in play and we're moving the robot further along in the hip development itself. Like anything, it's a journey. I would tell you we're going to be in a stronger spot this time next year. But I think when surgeons understand that and see where we're investing and how they're willing to come along with us. And so again, I think the real start of this is going to be in 2025.

And look, fine, it will be a slow journey as we go and make inroads unlike what we did with robots, which was a big bang. I think this is going to be one of those steady climbs that we get out there. But I really do think 2025 will become the meaningful year of impact there.

Steven Lichtman

Got it. Thanks, Dan.

Operator

One moment for our next question. Our next question will come from the line of Matthew Blackman from Stifel. Your line is open.

Mathew Blackman

Good afternoon, everybody. Thanks for taking my question. Just one, and look, I appreciate you're not going to want to talk too much about 2025. But Keith, can you maybe just help us to think through maybe in the broadest sense, the most important puts and takes on the top and bottomline next year.

Is there anything you'd call out tonight as we think through our 2025 numbers. And I'm just reflecting on this quarter's performance, you're back to market levels of growth. You posted 31% plus EBITDA margins and there's still incremental cost synergies next year? And then I look at consensus at something like $333 or something in that neighborhood, just given this quarter's results, that number feels low, but would love to hear what you guys think and if at the least the thought process I just laid out is sound and I'm not missing anything. Thanks.

Keith Pfeil

So thanks for the question. I think qualitatively, stepping back and looking at the business, year two, what do you think or what do you expect could happen. You would expect more cross-selling to occur as the team further integrates in the U.S. and international. You would expect to see greater cross-selling of the robots.

There was a question earlier that I believe Dan commented on that there's a lot of -- there's a lot of inbound interest from legacy NuVasive customers related to EGPS. We're continuing to come out with more and more technology products. So that all points to a positive when you think about the topline. As you as you move to the bottomline, you're going to annualize some of the synergy capture that you generated this year, plus you're going to drive some slight improvements, I think early on operationally. But really as I think about the synergy capture from in sourcing, that benefit is really the back half of 2025 and into 2026.

Again, when you get into year two, the focus really is again on managing your four wall spending. So what is four wall spending. It's looking at things like consulting spend and outside spend. How do you identify ways to either reduce that spend or find ways to bring it in house. That's really going back to the strategy of Globus, and we're going to continue to focus on that in year two.

Operator

Thank you. One moment for our next question. Our next question will come from the line of Ryan Zimmerman from BTIG. Your line is open.

Ryan Zimmerman

Hey, good evening. I'll echo everyone's sentiments. We came out of NAS in probably what I would argue is one of the best spine markets we've seen in years. Just judging by some of the feedback and commentary from management teams. And I'm wondering, Dan, if you can give your thoughts about just the durability of that what you see as kind of the spine market and what's driving that and also maybe kind of your thoughts on how it can continue.

Daniel Scavilla

Thanks, Ryan. It does seem to be a strong year this year and I would tell you that it seems to be above historical growth, the normal growth. I don't think any of us could ever say it's pent up demand from COVID or anything like that, like we went through in the past. That said, I think when you run your historics on this kind of data, the market does tend to be about a 3% to 3.5% growth.

And I think I'll still set my sights there to say probably over the long-term, this will be somewhere between a 3% to 4% growth. While I think changing demographics can be some of the lift, I think some of the income and people having jobs, therefore, having insurance to do it can be part of a lift. I don't know if we're looking towards a future where you've got 5% to 7% growth in the spine market. I think it's going to just get back down to my guess and it is an absolute guess just based on history, somewhere between the 3% to 4% is a normalized state and just progress that way.

Ryan Zimmerman

That's fair. Then -- excuse me, if I could ask Keith, a couple of conceptual questions as I think about the future for year two of the merger. Keith, you talked about just some of those in-house manufacturing dynamics. It doesn't sound like you want to put numbers out there. I imagine you have some ideas, but maybe you could help give us some guardrails around some of that in-house manufacturing initiatives for next year as it relates to kind of what you could or couldn't do from a margin perspective.

And the second part of my question is more on the R&D side, which is you're moving into these markets like [indiscernible] and Recon. You talked about R&D at 6.5% to 7%, but I would imagine you have to maybe step up conceptually R&D to develop more products as we think about 2025 and beyond. And so am I thinking about that correctly as well. Any color on those two would be appreciated.

Daniel Scavilla

Brian, let me jump in. We'll kind of start with the back part of that first. Keep in mind that we always spend, I consider heavily in R&D. And so everything that we need is currently in the margins we have and in the percents we have. There's nothing we're waiting to do. And it's not like we're at a milestone before we start. And so just keep in mind that the R&D spending you have encompasses everything that we're putting out and think that we want to do and we talk about. I don't think it's a step up. We'll take the opportunity to discover new things and go in new areas and we'll certainly increase spending there. I think as Keith has always said, maybe looking around 7% of sales will be a great target to go to. But I don't feel like we have a portfolio that's been untouched. I feel like everything is moving. So I just want to answer that one first and I'll kind of turn over the first part of your question to Keith.

Keith Pfeil

So as you think about in-sourcing and what's planned, I mean, obviously, we got to get all the machinery and equipment into each of the locations and get the machines program to run. But at the end of the day, the goal is really to -- really drive a lower cost per unit. And as you drive a lower cost per unit for what you're in-sourcing, you're also going to get fixed cost leverages across both locations. As we do this also, the goal here is to cross-pollinate both of the -- or both of the manufacturing facilities that they can make both Globus and legacy NuVasive product that helps lower our risk, but it also allows us to become more efficient with how we plan both existing products and then new product development.

Over time, that creates the flywheel effect to drive some of your fixed cost savings. I would also say, Ryan, just keeping you've got to burn through the existing inventory that's on the shelf and then go work that through. And so we'll look to see what that impact is next year, but recognize it's more of a long-term play than a splash and that really ties back, Ryan, to what I had said earlier on a previous question is that any -- any gross profit improvement really is going to be smaller in 2025, but it's the back half of the year. As we get into the year, I would expect to see that benefit first coming through in cash because your working capital investment is going to change because of your insourcing the inventory.

Ryan Zimmerman

Congrats again, guys. Very stellar quarter. Thank you.

Daniel Scavilla

Thank you.

Operator

Thank you. One moment for our next question. [Operator Instructions] Our next question comes from the line of Craig Beju from Bank of America Securities. Your line is open.

Craig Bijou

Good afternoon, guys, and congrats on the quarter. I wanted to start when you did the NUVA deal, you looked at it on a really with the synergies on a three-year period. And just taking your Q4 guidance that 2% to 3% and then your aspirational goal to get to the mid-to-high-single-digits. So I guess I kind of wanted to ask you if you need like if it's a three-year period to get to that aspirational goal or with some of the cross-selling synergies that you expect to come through soon, can that happen faster. I think investors are just trying to get a sense for where -- what can that acceleration look like or when can we see you guys reach that mid-to-high-single-digit growth?

Keith Pfeil

Thanks, Craig for the question. This is Keith. I mean, as I think about going into next year, we should start to be able to see the growth rates accelerate -- accelerating. I don't want to give too much color yet on 2025, but it is our expectation that as we get into next year, it really ties back to some of the things I had said earlier that you would expect more cross-selling to occur both across musculoskeletal enabling tech. You should start to realize that next year.

Daniel Scavilla

Yes. And Craig, one of the things I'd add to that, and that's what we're pulling out in our commentary is we're putting in place all of the pieces to achieve that, whether it's the manufacturing and expanding the investment in sets, everything that we've been calling out, the launching of products, the retention of the salesforce, the competitive recruiting, we're really putting all the building blocks in place here to deliver that.

We're not in a position to commit yet because just to be honest, we haven't run through 2025 yet. We haven't had a chance to get it approved internally. As you know, something we'll release as we get into January as normal. But we feel confident with everything that we're doing and we feel like we're in a really strong spot to deliver what we've committed to here. And of course, like anything, we'll strive to beat that and accelerate where we can.

Craig Bijou

Got it. Okay, that's helpful. And if I could just ask on the power tools. I know just launched this year, it's probably not a huge dollar revenue contribution. But I did want to see if there is -- if you'd be willing to provide anything on kind of the size or the ramp or growth of the power tools specifically. And then one, just clarification of where you book those revenues.

Daniel Scavilla

I will handle that first part. We're really pleased with the launch. We think that the potential and the interest that we see with the surgeons, whether it be through VIP or the feedback we're getting when they are being used in the operating room is very positive. The pull through that we're seeing of disposables and its usage is again a very good leading indicator that these things are being well adapted.

Keep in mind that this is one part of a procedural solution. And so while we look to them as a standalone truly, it's really about how well they can go free hand with our navigation hub or how they work with the Excelsius robot, et cetera, right. So it's all part of the entire program that goes.

The application that we see longer-term within trauma and joints as well, very promising. So you're right, we're not going to really call it out, but I would tell you that what we see is this can be a significant growth driver as we thought it would be in the upcoming years and it's doing well for this year. And it is a component of musculoskeletal.

Craig Bijou

Got it. Thanks, guys.

Daniel Scavilla

Thank you.

Operator

Thank you. One moment for our next question. Our next question comes from the line of Caitlin Cronin from Canaccord. Your line is open.

Caitlin Cronin

Hi, thanks for taking the question. Congrats on a great quarter. Just starting with the ortho robot, maybe a reminder of what's the value prop here over competitor systems, i.e. the price point, footprint, et cetera.

Daniel Scavilla

Thanks. I'll take that. I would say that footprint is certainly one of them to be considered, especially as you work in ASCs. We've looked at this and we're really pleased with how we've designed it to go in there. One of the things Keith and I had mentioned earlier is I think that just the fact that it's a newer robot that we've really built within the last year or two using some of the newest componentry, the ability to have smooth and articulating movements that I think are really good. The fact that you can do a registration with or without CT, how you want to operate this. We don't need pre-planning to be sent away. It's something that a surgeon can decide to do either the day before or right in the OR. So we'll build more on that and get through that. We're still working how to put that out with our Q4 launch. But all in all, I think the main components of that I've just laid out, we just probably have a lot more polish than what I just laid out for you.

Caitlin Cronin

Awesome. And then just with the NAV, who has been the early customers and where do you see uptake of this technology over time. Is it more in hospital outpatient or ASC?

Daniel Scavilla

Yes, it's a great question. I'm going to say the answer is all the above with that. I'm really pleased with the ones we've put together so far. The procedures that have occurred have really been strong. There's a lot of excitement out in the field and also with our surgeons with these. Given that it is currently the largest section of navigation entering into that actually opens up a brand new field for us. While we think the long-term play will be robotics. We obviously recognize there's always going to be multiple avenues for surgeons to treat patients. And so we want to just offer that as best we can, whether it be robotic or free hand.

But I would tell you again with the activity we've seen so far late in the third quarter. I think that this can be meaningful for us as we set our eyes on what to do and grow and achieve some of our goals in 2025 and beyond.

Caitlin Cronin

Thanks so much.

Operator

[Operator Instructions] One moment for our next question. Our next question comes from the line of Richard Newitter from Truist Securities. Your line is open.

Richard Newitter

Hi, guys. Thanks for taking the questions. Congrats on the quarter.

Keith Pfeil

Thanks.

Richard Newitter

The first question, I --

Keith Pfeil

Yes, nice job.

Richard Newitter

The first question I had, Dan, I think you had said that you expect meaningful contribution from the ortho robotic initiative in 2025 or something to that tune. I thought you had kind of suggested that would probably be a little bit more of a gradual ramp into the out years. I guess, is that a change in expectation. Did I hear that right?

Daniel Scavilla

Yes. No, you heard the right words, Rich, and I'll articulate thanks for calling it out. Given the fact that it has not been contributing much to us at all, this is one of the pathways for it to become a growth engine. So keep in mind that obviously the ortho market has doubled out of the spine, one would say $20 million versus $10 million with that and us piecing together all of the implants and getting them designed and ready to go now with the robot at our fingertips, I'm thinking that it can add to our dollars. I don't think it will become the growth driver of Globus as we come out with next year's forecast. But I'm saying that it can actually get out from the R&D side or lower contribution into something that will mean a bit more for us in the company and set the stage for 2025, 2026 and onward. But again, not a main growth driver of 2025, but I would want to see the change in its revenue contribution to the company really starting in 2025 with all of those components in play.

Richard Newitter

Okay. That's helpful clarification. And this question is kind of another angle to 2025. So directionally, if I think about the -- if you -- if you were going to deliver overage relative to kind of where the Street is sitting, if it's about 7% pro forma growth to 2025 on the topline, about 31% or 100% about 100 basis point margin improvement. Where do you think you or where do you have more confidence that you could -- you have more cushion or more ability to achieve overage relative to those estimates. I'm just trying to get a sense, is it on the topline or is it maybe some of the visibility you have on the cost savings. Would love to just hear your kind of thoughts on that.

Keith Pfeil

Yes, Rich, this is Keith. I'll take that question. As I think about it, the place that I would look really would be COGS, the cost of goods sold, do you have the ability to take out more spending or turn the inventory quicker in-house to drive greater profitability in the 2025. That would be the place. I think that -- I think we continue to look at spending outside of COGS or outside of the gross profit caption. But I think that if it was going to accelerate anywhere to drive more profitability, it would be in the core product cost.

Richard Newitter

Thank you.

Keith Pfeil

You're welcome.

Operator

Thank you. And with no further questions in the queue, that concludes the Globus Medical Earnings Call. Thank you for participating. You may now disconnect. Everyone, have a great day.