Earnings Call Transcript - SYK Q3 2021

Operator, Operator

Welcome to the Third Quarter 2021 Stryker Earnings Call. My name is Matti, and I'll be your operator for today's call. This conference is being recorded for replay purposes. Before we begin, I would like to remind you that the discussions during this conference call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also, during the discussions, we will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release that is an exhibit to Stryker's current report on Form 8-K filed today with the SEC. I will now turn the call over to Mr. Kevin Lobo, Chairman and Chief Executive Officer.

Kevin Lobo, CEO

Thank you. Welcome to Stryker's third quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO, and Preston Wells, Vice President of Investor Relations. For today's call, I will provide opening comments, followed by Preston with an update on the trends we saw during the quarter. Glenn will then provide additional details regarding our quarterly results before opening the call to Q&A. For the quarter, we posted organic sales growth of 8.4% versus 2019, driven by excellent double-digit growth from our MedSurg and Neurotechnology businesses, but this was offset by softer sales of hip, knee, and spine due to the resurgence of COVID-19. A slowdown in deferrable procedures primarily impacted the US and worsened through the quarter. While our implant businesses were challenged, we saw strong results for our Mako product technology and capital products across our MedSurg portfolio. In addition, we had strong performances from our more emergent businesses, including our core trauma business and another standout performance by Neurovascular. International organic growth of 12%, again outpaced growth in the US, representing robust performances and decreasing impacts of COVID-19 across most major geographies, including strong results across Europe, Australia, Canada, and emerging markets. Our year-to-date organic growth is 7.6%. With the continued uncertainty related to COVID recovery and health care staffing shortages, we are updating our full-year organic sales growth guidance to 7% to 8% compared to 2019. Our capital equipment order book remains strong, and we are well-positioned for the eventual procedure recovery. Our adjusted EPS grew 15% versus 2019, and we continued our focus on driving cash flow, leading to a year-to-date cash conversion of 87%. The EPS growth, although solid, was lower than our expectations and is reflected in our updated guidance, which Glenn will elaborate on. Meanwhile, we are pleased with our cash flow performance, which provides us with additional flexibility for future M&A opportunities. While the quarter did not progress as we had anticipated due to the Delta variant, we remain confident in the outlook for our businesses as evidenced by our strong international MedSurg and Neurotechnology performances. We expect these businesses to continue to perform at high levels with the uncertainty most concentrated in deferrable procedures in the United States. We continue to feel bullish about our longer-term prospects as the pandemic recedes with our proven strategy and strong fundamentals. We are excited to share more with you at our upcoming Analyst Day on November 18th. I will now turn the call over to Preston.

Preston Wells, Vice President of Investor Relations

Thanks, Kevin. My comments today will focus on providing additional insights into the current environment, including how certain products and geographies performed during the quarter. In addition, I will provide an update on the continued integration of Wright Medical, including the performance of our combined trauma and extremities business. During the quarter, significant spikes of the COVID-19 Delta variant drove increased infections and hospitalizations that required higher hospital bed utilization, which ultimately led to the deferral of elective procedures. In addition to increased hospitalization, hospital staffing shortages also pressured procedural volumes throughout the quarter. This primarily impacted our implant-related businesses, including hips, knees, and spine, which can be, in many cases, deferred for a period of time. However, the disease states that we treat are degenerative, and the patients that defer their procedures will eventually return to have those procedures completed. The impact on elective procedures was more pronounced in the United States than on other geographies outside the United States. Within the United States, there were areas of disruption in most states, but disruption was more widespread in the Southeast and Southwest portions of the country, impacting major markets like Florida and Texas throughout the quarter. Other markets around the world, including China, Japan, and Australia, experienced intermittent lockdowns throughout the quarter, which also drove uneven results across our implant-related businesses in those markets. During the quarter, Europe, which was more impacted by COVID in previous quarters, had impressive organic growth compared to 2019. COVID-related hospitalizations in the United States began to trend upwards towards the end of July and then progressively worsened, peaking at the beginning of September. At the end of the quarter, infection and hospitalization rates were declining in impacted regions and have continued into October. As a result, we are beginning to see some improvements in our more impacted businesses through the first few weeks of October. However, we expect the recovery will be partially muted by discontinued hospital staffing challenges and ongoing COVID-related volatility. Our assumption for the fourth quarter is that deferrable procedures will gradually return, starting with a low base in October before returning to more normal levels by the end of the quarter. As a result, we expect that the fourth-quarter growth rates for our more deferrable businesses will be similar to the third quarter. Despite the ongoing challenges with elective procedures, we had strong performances in our more emerging businesses like Neurovascular, which grew strong double digits compared to 2019 as a result of continued market expansion and ongoing global demand for our innovative technologies. In addition, demand for our capital equipment remains healthy, as evidenced by our continued strong sales performance and robust order book for small and large capital products, including our surgical technologies, emergency care, and neurosurgical businesses. The ongoing strength in capital is also reflected in the continued demand for our Mako robotic technology. Our industry-leading Mako robot continues to help surgeons improve patient outcomes by knowing more and cutting less. This trend across capital is expected to continue as hospitals take advantage of flexible financing and prioritize capital products like those within our portfolio that are critical to providing emergency care, driving profitable procedures, and ensuring safe working environments for caregivers and patients. Turning to the Wright Medical integration, which continues to progress in all regions and functions. United States commercial integration has moved past the sales force realignment and is now focused on continued business process improvements and system efficiencies. The teams have also developed a long-term product pipeline strategy. Outside the United States, we continue to work through integration activities, including sales force and indirect channel alignment across all key geographic regions. Overall, we remain pleased with the progress and the pace of integration over the past year. Including Wright Medical, the combined US Trauma and Extremities business has grown 8.1% year-to-date. The year-to-date growth in the United States has been driven by strong double-digit growth in both our core trauma and upper extremities businesses, reflecting the execution of the sales integration in the United States. Outside the United States, sales have declined 3.8% year-to-date, driven by timing of distributor conversions in Latin America and Asia Pacific and declines in our legacy Trauson and Trauma business in China as a result of the provincial tendering process. Considering the latest results, ongoing COVID-related volatility, and the provincial tenders in China, we now expect our combined Trauma and Extremities business to grow mid-single digits for the full year. With that, I will now turn the call over to Glenn.

Glenn Boehnlein, CFO

Thanks, Preston. Today, I will focus my comments on our third-quarter financial results and the related drivers. Our detailed financial results have been provided in today's press release. As a reminder, we are providing our comments in comparison to 2019 as it is a more normal baseline given the variability throughout 2020. Our organic sales growth was 8.4% in the quarter. The third quarter included the same number of average selling days as Q3 2019 and Q3 2020. Compared to 2019, the two-year impact from pricing in the quarter was unfavorable 2.2%. Versus Q3 2020, pricing was 0.7% unfavorable. Foreign currency had a favorable 1.2% impact on sales. Our MedSurg and Neurotech businesses saw another very strong quarter, continuing the growth momentum of the second quarter with double-digit growth in both segments. Our Orthopedics and Spine businesses have been adversely impacted by increases in hospitalization rates starting in early August, especially in the US as a result of the Delta variant. The corresponding impact on elective procedures has significantly slowed the recovery in our Orthopedics and Spine implant businesses. For the quarter, US organic sales increased 7.1%, reflecting the continued strong demand for Mako, instruments, medical, and neurovascular products. International organic sales showed strong growth of 12%, impacted by positive sales momentum in Europe, Australia, Canada, and emerging markets. Our adjusted quarterly EPS of $2.20 increased 15.2% from 2019, reflecting sales growth, gross margin expansion, and a lower quarterly effective tax rate, partially offset by the impact of business mix and higher interest charges resulting from the Wright acquisition. Our third-quarter EPS was positively impacted from foreign currency by $0.04. Now, I will provide some highlights around our segment performance. Orthopaedics had constant currency sales growth of 19.9% and organic sales growth of 2%, including organic growth of 1% in the US. This reflects the impact of the slowdown in elective procedures as a result of the Delta variant, which primarily impacted our hip and knee implant businesses. Our knee business grew 0.9% organically in the US, reflecting the previously mentioned impact on elective procedures, offset by continued adoption of our robotic platform for total knee procedures. Our US trauma business grew 8.8%, reflecting solid performances across the portfolio. Other ortho grew 19.8% in the US, primarily reflecting demand for our Mako robotic platform, partially offset by declines in bone cement. Internationally, Orthopaedics grew 4.1% organically, which reflects the strong performances in Europe and the momentum in Mako internationally, somewhat offset by the increased impact of restrictions imposed on elective procedures due to COVID, especially in Japan. For the quarter, our Trauma and Extremities business, which includes Wright Medical, delivered 3.2% growth on a comparable basis. In the US, comparable growth was 7.4%, which included double-digit growth in our upper extremities business. In the quarter, MedSurg had constant currency and organic sales growth of 12%, which included 12% US organic growth as well. Instruments had US organic sales growth of 15.9%, led by double-digit growth in their orthopedic implants and surgical technology businesses, which include power tools, waste management, smoke evacuation, and skin closure products. Endoscopy had US organic sales growth of 10.6%, reflecting strong performances across their portfolio, including video and general surgery products and strong double-digit growth of their communications and sports medicine businesses. The Medical division had US organic growth of 12.5%, reflecting double-digit performances in its emergency care and Sage businesses. Internationally, MedSurg had organic sales growth of 12%, reflecting strong growth in the Endoscopy, Instruments, and Medical businesses across Europe and Australia. Neurotechnology and Spine had organic growth of 11.8%. This growth reflects double-digit performances in our neurovascular, neurosurgical, and interventional spine businesses. Our Neurovascular business had particularly strong growth of approximately 26% and makes up roughly 30% of this segment. Our US Neurotech business posted an organic growth of 11.8%, reflecting strong product growth in Sonopet iQ, Bipolar Forceps, and Bone Mill. Our US Neurovascular business had significant growth in all categories of products, including hemorrhagic, flow diversion, and ischemic. Internationally, Neurotechnology and Spine had organic growth of 24.6%. This performance was driven by strong neurotech demand in China and other emerging markets, as well as Europe and Australia. Now I will focus on operating highlights in the third quarter. Our adjusted gross margin of 66.3% was favorable approximately 55 basis points from the third quarter 2019. Compared to the third quarter in 2019, gross margin was primarily impacted by acquisitions, which was partially offset by business mix and price. Adjusted R&D spending was 6.7% of sales, reflecting our continued focus on innovation. Our SG&A was 34.1% of sales, which was slightly negative as compared to the third quarter of 2019. This reflects continued cost discipline and fixed cost leverage, offset by ramping of certain expenses, hiring to support future growth, and the dilutive impact of the Wright Medical acquisition. In summary, for the quarter, our adjusted operating margin was 25.4% of sales, which is approximately the same as the third quarter 2019. This performance primarily resulted from our positive sales momentum, offset by the dilutive impact of acquisitions, primarily Wright Medical. Related to other income and expenses compared to the third quarter in 2019, we saw a decline in investment income earned on deposits and interest expense increases related to our debt outstanding for the funding of the Wright Medical acquisition. Our third quarter had an adjusted effective tax rate of 14%, which was impacted by our mix of US, non-US income and favorable discrete items during the quarter. Our year-to-date effective tax rate is 14.8%. For the year, we continue to expect an adjusted effective tax rate of 15% to 15.5%. Focusing on the balance sheet, we ended the third quarter with $2.6 billion of cash and marketable securities and total debt of $12.7 billion. Year-to-date, we have paid down $1.2 billion of debt. In October, we completed the refinancing of our revolving credit facility and increased that facility from $1.5 billion to $2.25 billion. Turning to cash flow. Our year-to-date cash from operations was approximately $2.3 billion. This performance reflects the results of earnings and continued focus on working capital management. Based on our performance in the third quarter, the continued volatility experienced as a result of COVID, procedural delays in hospital staffing shortages, as well as uncertainty around the pace of recovery in the fourth quarter, we expect 2021 organic net sales growth to be in the range of 7% to 8%. As it relates to sales expectations for Wright Medical, we now expect comparable growth for Trauma and Extremities to be in the mid-single digits for the full year when compared to the combined results for 2019. If foreign currency exchange rates hold near current levels, we expect net sales in the full year will be positively impacted by approximately 1%. Adjusted net earnings per diluted share will be positively impacted by approximately $0.05 to $0.10 in the full year, and this is included in our revised guidance range. Based on our performance in the first nine months and including consideration of the aforementioned volatility impacting the recovery of elective procedures and the full year Wright Medical impact, we now expect adjusted net earnings per diluted share to be in the range of $9.08 to $9.15. And now I will open the call for Q&A.

Operator, Operator

And your first question comes from Robbie Marcus with JPMorgan.

Robbie Marcus, Analyst

To begin with guidance, it appears October is starting slowly. Could you explain the different business lines and how they are performing in the fourth quarter so far? What factors give you confidence that we might see an uptick? Are orders increasing, and are doctors making more bookings? Please clarify what instills confidence for this potential increase.

Preston Wells, Vice President of Investor Relations

So in terms of Q4, and as I mentioned in my prepared remarks, we saw October starting to show some improvement as it relates to our implant-related businesses. We are seeing a bit of a pickup, but I think it's important to note that it's starting from a lower starting point. So while we do expect there to be some recovery happening in those implant businesses throughout the quarter, we do expect it to get back to more normal levels by the end. There are a few headwinds that are out there, as well, in terms of not only additional COVID hotspots or things like that, but also with staffing being a potential headwind as well. So we're definitely monitoring those as we go. But we are seeing some improvement early in October versus where we ended in Q3. As it relates to the other parts of the business, as both Kevin, Glenn and myself mentioned, our capital business continues to perform very well, and we still have high expectations that those are going to continue into Q4. Really and the way we look at that is just continuing to look at the order book as we ended the quarter and how that continues to progress in terms of growth. Same thing as we think about those more emergent businesses, whether it's trauma or neurovascular, again, those businesses are continuing to perform very well, and there's no reason to believe that they're going to slow down as we think about Q4. So hopefully, that helps for you.

Robbie Marcus, Analyst

And maybe one more just to dive in a little deeper on the Trauma & Extremities. You talked about double-digit growth within shoulder, but that was probably the biggest miss of any business versus the Street. So I was hoping you could give a little more detail there, was lower really slow? It doesn't sound like it's anything from the integration. So just hoping to get more color.

Preston Wells, Vice President of Investor Relations

No, I think it's important to understand that on those parts of the business like extremities, like shoulder, like foot and ankle, they are subject to some of the elective procedure slowdown as well. So while they did see some of that impact, we're still really happy with how they performed. I mean they really are still growing. The integration is going well. And as I mentioned, in terms of the international piece, there's a little bit slower pickup there on some of the international businesses as we go through the transition and integration in those parts of the business.

Operator, Operator

The next question comes from the line of Matt Miksic.

Matt Miksic, Analyst

So I had maybe first thing, I guess, I would say is at this point, I don't think your comments on COVID-related pressure and staffing challenges will come as much of a surprise to many folks who were sort of tracking this into the print and looking into Q4. But I did have a couple of questions on some aspects of your business. One, sort of COVID related and sort of related to one of your strategic initiatives around ASCs. If you could talk maybe a little bit about the activity that you're seeing there, what kinds of changes you made to your organization, what kinds of shifts in volumes you've seen and how you think that may affect sort of the intermediate term for those businesses? And I have one follow-up.

Kevin Lobo, CEO

We're continuing to see a shift to the ASC. The challenge we have right now is just the pace. So the capacity takes time to build, and every hospital system is in the process of trying to increase their capacity. So it is improving. And certainly, that will be a trend that had started prior to the pandemic and is continuing. We feel very good about our position in the ASC. It's way ahead of our expectations, frankly, going into the pandemic. One measure that we look at is our Sports Medicine business, and that performed in the United States was north of 20% growth in Q3. So we're seeing strength, but the challenge on the hip and knee side of it is just time to build capacity. So it's growing, but it's going to just take time before it becomes a really, really meaningful part of our business. But we believe we're extremely well positioned both with Mako and even without Mako, with our portfolio of everything that they need for an ASC.

Matt Miksic, Analyst

And then my follow-up is just on maybe trying to look past the pressure that I think many folks are reporting this earnings cycle similar to what you're describing and into sort of next year, and I'm not sort of about to try to provide guidance out of you or anything like that for 2022. But one of the things that we hear often from your businesses and across the board is this sort of demand for capital equipment and if we look at challenges and procedures and staffing issues. And then on the other hand, hospitals, apparently investing fairly heavily in their capital equipment and infrastructure around robotic surgery, et cetera. And I just would love to hear your thoughts on if you see a relationship that's seen in the past relationship between capital and your procedural businesses and what that sort of tells you about the next 12 to 18 months on the back of this demand?

Preston Wells, Vice President of Investor Relations

Well, I think the capital strength has really given the liquidity of hospitals. So hospitals, even though they're struggling through the pandemic, their liquidity is very good, partially due to the CARES funding that was put in place. They're in a strong position and they are getting ready for the future. As we talked about on the last question about ASCs and construction of ASCs and investments in hospitals, the demand for technology is very strong. Our order book for capital is very strong. There was actually, in Q3, some slight delays of some of the capital. There were some challenges of actually having staff to receive some of the capital equipment and put it in place. But I would say I'm feeling very bullish, and that capital cycle should continue speaking in the United States through all of next year. As it relates to the deferrable procedures, hips, knees, spine, those represent for Stryker a little less than 30% of our sales. And those are the ones that are most impacted. They will come back. And frankly, I'm excited about certainly hip and knee where the Mako volume continues to grow. When those procedures come back, we're in a terrific position to capitalize on those because the Mako procedures we're putting in, roughly half of those are going into competitive accounts. When volumes come back, we will be able to really take advantage of that, not just in our own Stryker friendly accounts, but even in competitive accounts.

Operator, Operator

Your next question comes from the line of Anthony Petrone with Jefferies.

Anthony Petrone, Analyst

A couple on just attempting to quantify the backlog specifically in OrthoRecon heading into 2022 as we navigate the current Delta spike and maybe extending that to capital? Are you actually seeing some level of pent-up demand for Mako? And maybe just to sneak a quick one in there. Maybe just some high-level comments on supply chain pressures that we're hearing across obviously this space and others. Is that a potential headwind to the capital business specifically as we head into 2022?

Preston Wells, Vice President of Investor Relations

So let me see if I can address those different parts. So in terms of the backlog itself, and so just starting with the implant-related backlog. I mean, obviously, the last 18 months has not been normal from a volume perspective. So while we've had some good quarters and some slower quarters, that backlog has continued to exist. In some cases, like this quarter, it's continued to build. It's hard to say exactly what it is because there's just so much variability happening across different regions. If we look at this past quarter, obviously, the US was more impacted than other areas. It's safe to say that the backlog still exists. Over time, as we get back to more normal levels, that backlog will begin to work down, and you'll see some improvement in terms of growth rates over time that will be sustained. You won't really see a big large, outsized growth rate that will happen in any one particular quarter with regards to the backlog. As we think about capital, there are areas for sure that there's been some pent-up demand and some of the uncertainty has just existed out there in terms of some of the hospital systems. We're still seeing very strong demand for our products, as we talked about before. The order book remains really strong, and it continues to grow as well as sales. We feel very bullish, as Kevin said, with regards to how we think about capital as we go forward into 2022. With regards to impacts from a raw material or supply chain perspective, what I would tell you is there certainly are challenges, just like everybody else has, with regards to whether it's the tight labor market or shortages in things like electronics or resins. But as of now, we've been able to really effectively meet all of our customer needs. Our supply chain has really had to be much more active in its support in its partnership with the various supplier base that we have. We've been able to maintain our safety stock levels and actively purchase critical components where necessary so that we can keep production going. Also just around logistics and distribution as well and actively working with those partners, all of that in anticipation of the fact that we think that there's going to continue to be some headwinds in this area. We have seen some increased costs as well in terms of inflation on those items. But to date, our supply chain and procurement teams have really just been able to manage that. We haven't seen any major impacts on our financials. While we expect that to continue into the rest of '21 and into 2022 as well, we want to make sure that whatever we have in our numbers has already factored in some of those raw material challenges that we have. We're going to continue to monitor the situation as it progresses.

Operator, Operator

The next question comes from Matt Taylor from UBS.

Young Lee, Analyst

This is Young Lee in for Matt. I guess I was wondering if you can share a little bit more color on the strength you're seeing in Mako, both in the US and OUS. How do you think it's positioned relative to the competition now that there's more entrants in the space? Can you also touch upon the Mako shoulder program? What should we expect in terms of the target that you are looking at, and any updates on timelines?

Preston Wells, Vice President of Investor Relations

So the Mako business momentum continues and it's been strong throughout the pandemic. In spite of the procedural slowdowns, we're seeing strong demand for our system. We clearly have the leading system on the market with a big head start versus the competition. The competition has actually raised the water level of robotics and emphasized the importance of robotics. We love our position, and we believe that it's just going to increase the demand for Mako. More and more systems are ordering their second, third, and fourth Mako. We know we have a winning solution for customers. We're very excited with our hip software and our new hip application, which has now penetrated in all of our Mako accounts, and we're seeing a nice uptick. Even though the overall volumes are down because of COVID, we are seeing a nice uptick in the hip adoption given the new software, which makes it easier to do the procedure. We feel like we're in a very good position, and the fact that there's more competitors in the space just validates the importance of orthopedics, and we like our chances. As it relates to the shoulder program, we do have an active program. We're not in a position right now to talk about timelines or dates for that. But as you saw with our results in Q3, our shoulder business is doing very well even before we have a solution with Mako.

Young Lee, Analyst

I guess maybe to follow up, I was wondering if you can talk about the M&A landscape. How actively are you looking at deals? What do you think about current valuations right now?

Preston Wells, Vice President of Investor Relations

We are always actively looking at deals at Stryker. Even after the Wright Medical deal, as you saw, we've done a couple of smaller deals with Orthosensor and Gauss Surgical. Because of the debt that we've had to pay down, we've been focused more on tuck-ins. But I'm really delighted with the cash flow performance that we've had, both last year as well as the first nine months of this year. Now we can start to look at, let's say, slightly larger tuck-ins while we continue to pay down the debt. Valuations are very high overall, but there's still a lot of targets, and we feel pretty confident that we'll be able to continue to run our M&A offense and find value-creating acquisitions for sure, for Stryker.

Operator, Operator

Your next question comes from the line of Matt O'Brien with Piper Sandler.

Drew Stafford, Analyst

This is Drew on for Matt. I just was wondering if you could talk about Mako in China and Japan. You said kind of bring spot in some areas and a mixed bag in others for a handful of companies that have reported so far. So just wondering how you would characterize that rollout in each of those geographies?

Preston Wells, Vice President of Investor Relations

In terms of Mako, as we think about outside the United States, we're really pleased with how that's progressing, and we're seeing good growth in all markets outside the US. As we think about Japan, for example, we know that the business continues to progress well, and the number of installs in Japan is increasing month-over-month. We're really happy with how the technology has been received and the feedback that we're getting, and the number of procedures that are being done on Mako in Japan continue to increase as well. As far as China is concerned, it's much earlier days in China from a Mako standpoint, but the momentum is really building there. We're still working through the impacts of the volume-based procurement activity. We expect Mako to be a key technology and play a key role for us as we think about our rebound business in China going forward.

Drew Stafford, Analyst

And then just a quick follow-up here on the Neurovascular side. The performance has been really, really strong in the last couple of quarters. So maybe you can kind of give us a sense for what you think the market growth rate looks like there? And then just a sense of what's driving your portfolio of products to really take share compared to quarters in the past.

Preston Wells, Vice President of Investor Relations

In terms of Neurovascular, obviously, it's a very hot market. But also when you look at our results with regards to that market, you're seeing a couple of things happen. You're seeing the impact of the technologies that we've been able to introduce over the past 12 to 18 months and taking advantage of really a product super cycle from our neurovascular team where we're expanding into some different areas. We're also seeing the market expand. If you think about places like China, for example, we're seeing market expansion happen there. Our results are really a result of both of those items.

Operator, Operator

Your next question comes from the line of Vijay Kumar with Evercore ISI.

Vijay Kumar, Analyst

Maybe one on the big picture and one on the finance side. Starting with the big picture. Kevin, it seems like there's a tale of two cities in device. Some of your peers have assumed Q4 sort of normalizing on the procedure side. Other companies certainly have called out Q4 being in line with 3Q levels and things worsening, or perhaps being similar to September trends. Is this more regional? Is this a basinal impact? Or is this ortho versus other parts of life science? Maybe just put things into perspective on why we're seeing a divergence and what are you assuming for the Q4 recovery?

Kevin Lobo, CEO

As Preston mentioned, Q4, we're assuming a similar growth rate as we saw in Q3, so versus 2019 we're expecting similar growth rates. Obviously, sequentially, we'll have an improvement because Q4 is a larger quarter than Q3. But year-over-year, we're expecting a similar growth rate. It's really ortho and spine-related that's the bigger factor. We have products that are used in general surgery and our Endoscopy division and smoke evacuation, and we're not seeing the same kind of fall-off in those areas as we're seeing in hips and spine. I do believe it's mostly procedure-related, which creates the difference that you're describing between us and some of the other med tech companies. There's also a regional impact. Stryker, of course, has a very strong presence in the United States. You even saw that with our own implant businesses that we had a more negative impact in the United States than we did internationally. I would say the primary factor for what you're seeing versus other companies is that these procedures, hip, knee, and spine are more deferrable than some of the other procedures in our other med tech peers.

Vijay Kumar, Analyst

And one on finance, Glenn, free cash conversion year-to-date, we're running pretty close to 90%. Has something changed here? I know people used to ask on free cash conversion, but just really an execution here despite some choppiness on the pandemic side, the margin execution, and free cash execution here seems to be stellar. So I'm curious, has anything changed for you guys on the free cash side?

Glenn Boehnlein, CFO

You're right, free cash flow of almost $2.1 billion year-to-date, an 87% conversion ratio has a lot to do with several factors. We've been priming the organization to really start focusing and delivering on cash flow. I think as we entered into COVID, it was a real alarm bell for, hey, let's really start focusing on this so that we can keep active in M&A, we can pay down debt, and we can meet a lot of the goals that we wanted to meet. I think we're feeling a bit of that. You look at performance on AR, we've started to move a lot of our AR into shared service centers, and so we're getting better on process. If you look at AP, we have a large initiative that's being driven by our GQO organization in terms of working with vendors and being smart about what our AP terms can be and should be. All of our divisions are very focused on inventory management and just being smarter about what the safety stock levels that you really need and what you don't need, and how can we make sure that we have the right inventory at the right time when we need it. We've also been fairly controlled and prudent as we look at allocating dollars to capital expenditures, and as you look at our Wright Medical integration, we've really been focused on that spend and are running probably a little ahead of where our goals were on that. I really do think that it's a muscle that the organization has learned and grown over the past two years, and it's something that I feel pretty strongly about we'll be able to continue from here on out.

Operator, Operator

Your next question comes from the line of Josh Jennings with Cowen.

Josh Jennings, Analyst

Just a question on staffing shortages and maybe a little bit granular, but just thinking about the different settings of care and staff shortages in hospitals, I think it's clear, but just wondering about ASCs. Is there a different dynamic in play at ASCs? If the staffing shortage headwind persists into 2022, do you think we can see even stronger migration trends of both surgeries into the ASCs, particularly in ortho?

Preston Wells, Vice President of Investor Relations

In terms of staffing shortages, we're seeing it holistically. I think it certainly is playing itself out more so in the hospital setting because there's a lot more fatigue there; there's COVID that still exists in the hospital setting. I think that it certainly is playing out a bit more in the hospital setting, and we haven't seen our procedural volumes in the ASP continue to go and have not been as impacted as those in the hospital. How that continues and how that impacts the shift is still really anybody's guess. We will continue to see products and procedures shifting to the ASC anyway because that trend that started has certainly accelerated over the last 18 months. That's going to continue to happen. The staffing shortage is something that I think we're going to live with for a little bit as well, and we'll continue to work through those challenges in the next year too.

Josh Jennings, Analyst

I want to just have a follow-up on Red. I know you reiterated multiple times on this call that integration is progressing nicely, and you're optimistic about the combined businesses in Trauma & Extremities. You've had to work through some dis-synergies associated with the integration of the pandemic headwinds at November close is coming up. But as we get into a normalized period, should we be thinking about the Trauma business as accretive to corporate-wide organic revenue growth as that integration's first year is complete, and hopefully we get into normalized grades in 2022?

Kevin Lobo, CEO

I'm absolutely bullish about the Wright Medical integration. It's been fantastic in the United States. As Preston mentioned, we still have work to do outside the United States. The timing is a little bit later with some of the conversions of our distributors. We're still working through with OUS. But in the US, very bullish about core trauma, upper extremities, and lower. Lower has been impacted somewhat by the deferral of procedures because they're more elective, a lot of the foot and ankle procedures. But love the leadership team that we have in place, love the pipeline that we have in place, and really believe that the entire business of trauma extremities will be accretive to overall Stryker. Extremities is probably the fastest-growing space within Orthopaedics. We have a fantastic combined portfolio in both upper and lower extremities. One of the side benefits of the Wright Medical integration has been for us to have a dedicated business just on trauma. Three dedicated businesses, three terrific leaders of all businesses and great leadership teams. We're seeing that, frankly, as you saw with the US number on a combined basis being over 8%—a terrific performance in spite of a slowdown in the foot and ankle space, and I do expect in '22 and beyond it will be accretive to Stryker's overall growth rate.

Operator, Operator

Your next question comes from the line of Larry Biegelsen with Wells Fargo.

Larry Biegelsen, Analyst

Two for me. One, you have an analyst meeting coming up in a few weeks. Could you guys give us a preview of what to expect, are you going to give us long-term financial goals? I have one follow-up.

Preston Wells, Vice President of Investor Relations

We're really going to talk about all the growth drivers that make Stryker special. As we think about emerging from the pandemic and all the different things that are going to help our business continue to grow into the future for sure. The long term financial goals will definitely be part of that.

Larry Biegelsen, Analyst

I know you're not going to talk specific guidance about next year. But Kevin or Glenn, how are you feeling about continuing to deliver top-tier revenue growth and the 30 to 50 basis points of leverage that you guys target? How are you feeling about that with the inflation headwinds that we're all paying close attention to?

Preston Wells, Vice President of Investor Relations

You've seen over the last nine years, we fully expect into the future to have organic sales growth at the high end of med tech. Clearly, COVID has put a crimp on that in hips, knees, and spine. Other than that, you're seeing that in all of the rest of our businesses. As the recovery happens, you should fully expect that we'll continue to be a top-tier grower. As it relates to margins, Glenn, do you want to?

Glenn Boehnlein, CFO

As I look at op margin, I look at this quarter, and given the impact of COVID and the dilution from Wright Medical, we're pretty happy that our op margin is pretty much flat with 2019. That's a good performance. We did not contemplate the impacts we're feeling from COVID in op margin guidance. We'll talk more at the analyst meeting about what we think that means. We have every intention to drive that goal once we exit the impacts of COVID. We'll expect to see some increases in spending probably in Q4, and those will set us up to grow in 2022. We will allow some of those sales force hiring and marketing initiatives to occur. As far as it relates to 30 to 50 basis points beyond what we feel from COVID, we will not back away from that goal.

Operator, Operator

The next question comes from Steve Lichtman from Oppenheimer.

Unidentified Analyst, Analyst

This is David on for Steve. I was just wondering if you could maybe talk about what you're seeing currently in terms of the China tenders and volume-based procurement and what your expectations for the impact of that next year?

Preston Wells, Vice President of Investor Relations

First of all, when we think about our business and China and the products and services that are impacted by the volume-based tendering, if we think about trauma and spine, those sales are less than 1% of the total Stryker revenue. It's a very small overall impact. Just focusing on the tender itself, in mid-September, the bidding was done for the national tender around joint replacements. Our bids were certainly competitive, and we secured a position for both hips and knees for our business. Overall, about an 80% price reduction from the end market sale is going to be taking place across the entire industry. That has an impact on us as we think about going forward, but there's a lot of work still left to be done in terms of how that's going to actually be executed. We're staying vigilant with the teams in China to try to understand how that's going to roll out. It's expected to roll out in the first quarter of next year, and it will remain dynamic until we really understand how it will execute. In terms of '22, we're not giving guidance at this point in time, and it will certainly be factored in as we give guidance on our fourth-quarter earnings call.

Unidentified Analyst, Analyst

Just one follow-up. What are your latest thoughts on the smart implants? What's your outlook for this market now having OrthoSensor under your umbrella for several quarters?

Preston Wells, Vice President of Investor Relations

With smart implants, we think that there's a role for them in orthopedics going forward. There's still a lot of work to be done in terms of understanding how that's going to be integrated from an implant standpoint and how that's going to play out from a monitoring standpoint going forward. It’s still early in the process. We're happy to have OrthoSensor under the Stryker name and with the expertise that they bring in sensor technology. Looking forward to updating you as we develop more around that product in the future.

Operator, Operator

Your next question comes from the line of Ryan Zimmerman with BTIG.

Ryan Zimmerman, Analyst

I just want to ask specifically based on the organic growth guidance of 7% to 8% versus ‘19 and kind of where consensus is landing. Obviously, there's a delta there. It's clear, obviously, around the elective areas in terms of the impact in the fourth quarter and kind of what you're guiding to. I guess I'm just curious, Kevin or Preston, is there anything to call out, particularly within the MedSurg areas from a headwind standpoint that you'd caution us about? Just because the delta versus the Street is somewhat meaningful as we think about our models. I just want to make sure that we're not skipping over any impact that you could have us contemplate within that?

Kevin Lobo, CEO

Just to reiterate what I said in my opening comments, we expect very high performance for MedSurg and Neurotechnology. You should expect similar growth out of MedSurg and Neurotechnology in Q4, as you saw in Q3. The delta versus the Street is in the hip, knee, and spine area. That's the area that's had the biggest impact from COVID. Our guidance is for a similar quarter in Q4 as Q3. We don't have a lot of visibility, but it's an uncertain environment. Hopefully, the recovery will be better than what we're calling, but that's the visibility we have thus far. As you saw that this quarter surprised us in Q3, and we're being cautious as we give our guidance for Q4.

Ryan Zimmerman, Analyst

And then just a follow-up. You have a new hip stem coming out. You've got the software now, I think, on the entire fleet of Mako. I’d love to understand just kind of your expectation on what that means for you, particularly within direct interiors that J&J has been so dominant in for some time?

Kevin Lobo, CEO

We're really excited about the new stem. The procedures are being launched this quarter—early launch, I'd call it, this quarter. We're building up towards a full launch of the hip stem at the AAOS meeting, which is towards the end of the first quarter. It will be a bit of a slow build, but we're really excited, and that stem will be married with Mako. That's one of the things we still have to do. You'll start to see pretty meaningful impact probably by the end of the second quarter, beginning of the third quarter. This is a product gap we've had for some time. Very excited about the position we're in. We're building the product right now. Surgeons who have seen the product are very excited about it. We do believe it's what we've needed in our hip portfolio. You'll start to see that again. You won't see a lot—nothing really in the fourth quarter, and you won't see much in the first quarter, but it will start to have an impact in the second quarter and definitely in the back half of next year.

Operator, Operator

There are no further questions at this time. I will now turn the conference over to Mr. Kevin Lobo for any closing remarks.

Kevin Lobo, CEO

Thank you all for joining our call. We hope that you can all join us in person on November 18th for our 2021 Analyst Meeting and product fair with our broader leadership team. Thank you.

Operator, Operator

Thank you, ladies and gentlemen. This concludes today's conference. Thank you for participating. You may now disconnect.