Treace Medical Concepts, Inc. (TMCI) Earnings Call Transcript & Summary

January 14, 2025

NASDAQ US Health Care Health Care Equipment and Supplies conference_presentation 39 min

Earnings Call Speaker Segments

Lilia-Celine Lozada

analyst
#1

All right. Hi, everyone. Thanks for joining us today. My name is Lily Lozada. I'm on the Med Tech Team here at JP Morgan, and I'm happy to have the Treace management team with us here today. I'll turn it over to CEO, John Treace for a presentation, and then we'll jump into some Q&A.

John Treace

executive
#2

Thanks, Lily. Good morning, everyone, and thanks for joining us today. It's great to be here at the JP Morgan Healthcare Conference and talk a little bit about Treace Medical. Since our IPO in 2021, we continue to execute on our strategic plans, resulting in strong U.S. revenue growth and encouraging adjusted EBITDA progress with continued gains across our key operating metrics, and a rapid expansion of our bunion focused product lines, reaffirming we have the right strategies in place to expand market penetration with our differentiated technologies. Our safe harbor disclosures are here. Please refer to our SEC filings available on our website. Non-GAAP reconciliations are available at the end of this presentation on our website. So Treace Medical is a high-growth med tech company focused on improving surgical outcomes for patients with suffering from painful lifestyle limiting bunion and related midfoot deformities. We pioneered and patented the Lapiplasty-3D Bunion Correction Procedure to bring surgeons a better solution, so they can deliver better outcomes for their patients. The surgical treatment of bunion has been our specialty since day one, and we have a sizable market to tap. Our flagship product, Lapiplasty, is backed by strong IP, compelling clinical data sets and is marketed by the industry's only bunion focused sales force. Our Lapiplasty solution has attracted over 3,100 surgeon users in 2024 and has established Treace Medical as the largest dollar share player in the rapidly evolving and highly attractive U.S. bunion market. Our growth has been strategic, focused on continuous improvements to our flagship Lapiplasty System while also introducing complementary procedures and technologies. And now we're developing -- delivering a significantly expanded portfolio of new bunion-focused solutions to our large established customer base, which we believe will speed our penetration into the market. As a high-growth company with high gross margins, targeting a large market with rapidly expanding portfolio with improving profitability all coming together here in 2025, we believe Treace Medical presents a compelling opportunity for investors. Our disruptive Lapiplasty Procedure and expanding bunion portfolio target a $5 billion-plus addressable market in the U.S. with continued high interest from surgeons and in the and in the surgeon foot and ankle community. With 1 in 4 adults affected by bunion deformities, we believe the bunion market represents one of the most compelling opportunities in med tech today. Bunions are hereditary and progressive in nature and result in about 4.5 million Americans seeking medical attention for their bunion pain each year. And we estimate about 25% of those patients are symptomatic surgical candidates. And it's a group of just over 1 million patients that represents our $5 billion plus U.S. TAM. This said, less than half of these candidates are opting to have surgery, and we believe that this is largely due to the deficiencies of conventional surgical treatments, resulting in patient reluctance -- to receive surgical relief. So there's a misconception that bunion is just a painful growth of bone on the side of the big toe. In actuality bunions are complex 3-Plane deformities caused by an unstable joint in the middle of the foot. And it's this unstable joint that allows the long metatarsal bone to shift outward creating the visible and painful bump. There are 3-Planes involved in the bunion as shown in the illustrations on the right-hand side of this slide, and modern research demonstrates how important correcting the third or frontal plan is on surgical outcomes, as failure to properly corrected -- can result in a 10x to 12x greater risk that the patient's bunion will return. And it's this third frontal or rotational plane that's been historically unrecognized and unaddressed in conventional surgical treatments until our company and surgeon advisers targeted and developed a solution over 9 years ago. So here we have the 2 conventional 2-dimensional surgical approaches that are currently used for most bunion procedures today. The metatarsal osteotomy accounts for roughly 70% of cases. This procedure targets the bump itself, cutting the metatarsal bone below the bump, and shifting the inwards. On the positive, it's a relatively straightforward procedure for the surgeon and the patient can begin to bear weight on their operative foot in a few days to a couple of weeks following surgery. But because it does not address the third frontal plane or the unstable joint, it's associated with some of the higher recurrence rates in the clinical literature, some as high as 63% to 78%. The traditional 2D-Lapidus Fusion is the alternative procedure and because it does secure the unstable joint, it is generally associated with lower recurrence rates than osteotomies. But since Lapidus is a more challenging freehand operation for the surgeon and requires much longer and restrictive recovery for the patient. It's typically reserved for the most severe bunions, those that an osteotome cannot address. So with Lapiplasty, surgeons and patients have an option that offers a 3D fix for their 3D problem, and one that addresses the root cause of the bunion by fusing the unstable join in the middle of the foot, and one that allows patients to start weight bearing in a matter of days post surgery in a surgical boot. As these illustrations show, Lapiplasty offers proprietary instrumentation and surgical method that allows the surgeon to confidently and reproducibly correct all 3-Planes of the bunion in 4 straightforward steps. Without the patented Lapiplasty tools and method, this is a very challenging procedure for surgeons to perform freehand. So what we've effectively done is given surgeons a paint-by-numbers approach to 3-Plane Lapidus Bunion Correction. And in doing so, we've enabled our Lapoplossy Procedure to be adopted by the broad foot and ankle surgeon community and usable across a broad spectrum of bunion patients. Lapiplasty supported by leading clinical evidence in a large number of clinical data sets and publications. In fact, we believe that we are the only industry participant with this level of data clinical data on a surgical bunion technology. Last September, at the annual AOFAS conference, we presented our 4-year primary endpoint data from our flagship ALIGN3D clinical study. ALIGN3D is a robust 7-center -- 13 surgeon study with 173 enrolled patients. And ALIGN3D is demonstrating sustained significant improvements in pain, radiographic correction, and validated patient-reported outcome scores in patients treated with the Lapiplasty Procedure. We believe the positive data coming from our differentiated Lapiplasty study resonates with surgeons and patient communities and is reinforcing market adoption of the Lapiplasty Procedure. With respect to reimbursement, last year, in November, CMS announced significant reimbursement changes for hospital outpatient and ASC settings, which went into effect January 1 of this year. The final rule is the reassignment of CPT Code-28297, a primary code used for Lapidus Fusion and one usually used for the Lapiplasty Procedure reimbursement to APC Code-115 with a hospital outpatient payment rate increase of 89% over 2024, and in the ASC setting, the payment rate was an increase of 100% over 2024. We're pleased that this final rule recognizes the value that Lapidus Fusion offers patients suffering from these painful lifestyle limiting bunion deformities. And we're just getting started. So now that we've established a powerful direct bunion focused sales team and a growing base of over 3,100 surgeon customers, we're advancing our leadership position in the market from being a Lapiplasty company to a comprehensive Bunion Solutions company. In 2018, our Surgeon Advisory Board posted a peer-reviewed paper describing 4 classes of bunion deformities. As a business, we initially focused our efforts on advancing a single standard of care across this full spectrum of bunion repair with our patented Lapiplasty System. And many of our surgeon customers have adopted Lapiplasty instrumentation and implants across all 4 of these classes as they mastered the technique and experienced great patient outcomes. This approach has been very successful to the point we are the dollar share leader in the U.S. bunion market today. And it's been our strategy all along to address all 4 of these large market subsegments with additional disruptive solutions, giving a broader range of surgeons, more options to address the evolving needs of their patients. So I'd like to take a moment to explain in greater detail the new technologies we have designed to give more surgeons a broader range of specialized options for these different bunion classes. At a high level, our product innovation strategy is focused on making bunion procedures less invasive, which we believe translates to less pain and quicker recovery for the patients and not only makes our procedure more attractive today. But we believe, over time, can expand our reach up funnel and appeal to a larger portion of the 4.5 million Americans seeking treatment for their bunion pain each year. When it comes to addressing bunions across a broad spectrum of severity, our patented Lapiplasty System continues to lead the way in market position and innovation with over 120,000 patients treated since late 2015. We've innovated our flagship Lapiplasty instrumentation and implant technology [ 3x ] now over the last several years. And today, our Lapiplasty Procedure can be performed through a discrete 2-centimeter incision with our latest micro Lapiplasty option. And in late 2021, we launched the Adductoplasty, the first and only instrumented solution for bunions with a concomitant mid-foot deformity, which presents in up to 30% of bunion patients. And in our drive to allow less invasive approaches for patients and expand surgeon interest, we recently introduced Mini Adductoplasty, which allows our procedure to be performed through a 3.5 to 4-centimeter incision, leveraging our SpeedPlate implant technology. For the milder classes of bunions, while Lapiplasty is used by many of our surgeon customers as their go-to procedure of choice, there are many surgeons who prefer metatarsal osteotomies to treat most of the patients within this class. And for these surgeons, minimally invasive osteotomies represent the fastest-growing subsegment of these 300,000 procedures as osteotomies. So to broaden our procedure solutions and appeal to preferences of surgeons and their patients, we're introducing 2 new differentiated osteotomy systems. For background, we estimate around 10% to 15% of all the metatarsal osteotomies today are being performed with minimally invasive or MIS techniques. And we believe the biggest rate limiter to broader adoption is the technical difficulty and steep learning curves associated with the conventional Freehand MIS techniques. For example, surgeons that train on these techniques -- we'll talk about a 40 to 50 case learning curve before a surgeon can become proficient in doing them. We see this as a tremendous opportunity for Treace to change the landscape and allow MIS surgeries to be performed by a broader base of surgeons with control and confidence, effectively democratizing these -- once challenging operations just like we have done and we continue to do with Lapiplasty. Our approach to MIS Osteotomies is consistent with our core philosophy of anatomic 3-Plane Bunion Correction in order to support best patient outcomes, and also offering user-friendly instrumentation to make these complex procedures controlled and reproducible for the surgeon. Our 2 new 3D MIS procedures are both performed through small cosmetically appealing incisions, which we believe results in less pain and quicker recovery for the patient. Our first system, Nanoplasty, offers a controlled, instrumented 3-Plane procedure and utilize the familiar powered saw to cut the bone as opposed to a powered cutting bur, which is used today in most traditional MIS Osteotomies. So no new cutting techniques have to be learned by the surgeon to perform the procedure. For fixation, Nanoplasty utilizes a titanium intramedullary implant with locking screws to provide stability during healing. Our second MIS platform, Percuplasty, is designed to be a new standard for surgeons who already use the conventional approach to MIS osteotomies, namely powered cutting burs and screws for fixation. As with Nanoplasty, Percuplasty delivers elegant instrumentation to provide greater confidence and control to allow the surgeon to dial in that important 3-Plane correction. For fixation, Percuplasty uses 2 specialized titanium screws to secure the bones during healing. And we round out this comprehensive portfolio with a new and innovative option for a sizable segment of the bunion market, and these are patients with arthritic great toe joints. This class of bunion is treated at the toe joint itself, typically by fusing that joint. Our innovative solution here, SpeedMTP, leverages our market-leading speed plate fixation implant technology. We're experiencing very positive early responses on these 4 technologies from both existing and new Treace customers. And we expect to ramp availability of these new offerings progressively through the first half of this year and see more material impact on the top line in the back half of the year as we build supply chain and train more surgeons. We believe this robust portfolio of best-in-class instrumented solutions targeting all 4 classes of bunions marketed by the industry's only b focused sales force, puts Treace in a unique and powerful position to extend our market leadership and speed our penetration into the b and related midfoot markets. In addition to our 4 classes of Procedure Solutions, we also have enabling technology platforms that we use to drive our innovation pipeline. We couldn't be more excited about our IntelliGuide PSI platform, industry's first and only pre-op planning and cut/guide system for bunion and mid-foot deformities. Our acquired RedPoint medical technology and processes have been integrated into Treace and now positively impacting patients' lives with personalized surgical treatment. And during Q4 last year, we announced expanded surgeon access of our IntelliGuide PSI technology for both Lapiplasty and Adductoplasty applications. With IntelliGuide, we can take a patient CT scan and using proprietary software, manipulate the bones virtually in 3-Planes to the desired corrected state and produce a preoperative plan and a patient-specific cutting guide for the surgeon. Not only can IntelliGuide streamlined surgical procedures, reducing steps in instrumentation, but importantly, it gives surgeons greater confidence and control, particularly in more challenging and revisional operations. We look forward to continuing to advance our work with IntelliGuide across our procedure spectrum and continuing to scale our availability of this important technology to benefit more doctors and patients through 2025 and beyond. Our enabling SpeedPlate technology platform has been another exciting first and only from Treace Medical and has been embraced with enthusiasm by our customers for Lapiplasty at Adductoplasty and a variety of other bone fusion procedures throughout the foot. As mentioned a moment ago, we just introduced our SpeedMTP, which is a specialized solution for patients with arthritic to joints. SpeedPlate offers the strength and stability of a titanium lock plate with a dynamic compression and insertion speed of a nitinol staple. This is a very attractive combination for surgeons that agree that within just 12 months on the market, SpeedPlate kits make up the majority of our overall fixation kit sales. And not only does SpeedPlate offer broader versatility but as our premium technology also commands a premium price point. So it helps in building our average blended selling price per case. You can see by the release dates on these different designs that we've been very active, applying this differentiated platform to meet the needs of our customers to the benefit of their patients. And we continue to have a robust pipeline of additional procedure specific designs using this technology in the works, as we continue to expand our footprint -- strategically across the foot and ankle market. Our focused business model allows us to expand in a very capital-efficient manner. While traditional ortho extremity companies grow their -- with a very inventory-intensive model, some offering 10,000 or more sellable products. We currently have about 50 sellable SKUs supporting our over $200 million in revenue. And the 5 new products and technologies discussed today will only add about 80 sellable SKUs to the mix. This focus not only allows us to deploy less capital for inventory and also rapidly innovate our products to drive deeper into the bunion market and defend our market positions. On the left is an assortment of our reusable instrument trays. These trays are small and lightweight and low cost, and they're easy for our sales reps to transport and for facilities to process, which is important for our outpatient and ASC customer setting. On the right-hand side are high-margin sterile implant kits, these are the items we actually sell. And the economics here is such that the margin from just one surgical case covers the capital cost of the instrument tray, and these trays can service 30 or more procedures per year. So this unique model and the positive margin it generates has allowed us to capitalize on our opportunities and will allow us to continue to efficiently scale our business, as we expand our comprehensive [ bunion market ] solutions portfolio. Speaking a little bit to our go-to-market strategy. As the pioneer in the treatment of surgical correction a bunions as 3 plain deformities, our medical education efforts are aimed at training surgeons how to best correct these 3D deformities with our differentiated technologies. As we continue to advance into a comprehensive bunion solutions company, we've modified our certain training curriculum to address management of all 4 of these classes of bunions in a comprehensive educational event that we've actually branded Bunion Masters. In these events, attending surgeons committed to being experts in bunion surgery will engage with our experienced faculty and learn how to properly use our best-in-class suite of 3D product solutions. From Lapiplasty to a Adductoplasty, Nanoplasty, Percuplasty, Speed MTP and more. These comprehensive events not only educate our existing customers on the safe and effective use of our new offerings, but they're also integral to continued on-boarding of new surgeons and ensuring they are properly trained as well. As a result, as a baseline, we estimate adding 200 or so more additional surgeons to our base annually going forward as a baseline. Our intent is to educate patients and have them ask for our surgical treatments by name. We utilize targeted patient outreach initiatives, directing patients to our website, where they can become educated on our technologies and connect with qualified surgeons in their area who perform our procedure and schedule is consultation. Our direct-to-patient efforts have resulted in hundreds of thousands of patients visiting our website every month on average to educate themselves about our technologies, and tens of thousands of patients searching for surgeons using Treace technologies. Our established bunion focused sales channel is poised and ready to introduce this expanded portfolio to our growing base of over 3,100 surgeon customers. Our direct channel has been an area of significant investment over the past 5 years and today represents over 82% of our revenue mix. We have established a large and experienced sales team when you include our senior and associate sales representatives, clinical specialists and sales managers, our fleet today totals approximately 330, and now that we have this large commercial organization in place, we expect to see leverage of this maturing team on the P&L during 2025 and beyond, while still being able to add sales personnel to ensure our customers receive best-in-class support as we rapidly expand our product portfolio. Our goal is to increase our greater penetration in the bunion market, while expanding wallet share of wallet share per surgeon customer. And we'll do this by introducing several new technologies comprehensively addressing all 4 classes of bunions to our large and expanding base of surgeon users. We made significant progress towards this goal by increasing our surgeon customer base from 997 active surgeons back in 2019 to over 3,100 active surgeons in 2024 for a 26% CAGR in surgeon user growth over the past 5 years. And our surgeon customer base, on average, uses more and more of our products each year, as they choose to treat more of their patients with our growing portfolio of best-in-class procedure solutions and technologies. Average annual revenue per surgeon has grown to nearly $67,000 in 2024, a 48% increase over the past 4 years. We grew our top line in -- at 12% in 2024, which we believe to be approximately 2x market growth for foot and ankle. As we continue to penetrate across a broad spectrum of b with our Lapiplasty and Adductoplasty Systems, as well as sustained market adoption of our speed play technology and other complementary products. This said, which is 7% of the overall bunion market penetrated, we have an incredible opportunity to accelerate our share across all bunion classes with these new targeted solutions. We've also made significant progress on our pathway to profitability. During 2024, we said we would rightsize our P&L. And in Q3, we improved our adjusted EBITDA by 40% compared to the prior year. And we'll have significantly more positive adjusted EBITDA in Q4, our seasonally strongest quarter compared to Q4 of 2023. We expect operating leverage to continue to improve in coming quarters and expect breakeven adjusted EBITDA for full year 2025 and breakeven cash flow for 2026. As a leader in this large dynamic subsegment of the foot and ankle market, we're advancing our company from a single technology player to a diversified and comprehensive 3D Bunion Solutions company with several new product offerings and technology launches already underway targeting of large subsegments of the bunion patient population. And we have a robust R&D pipeline behind this plus multiple additional drivers we expect to continue to fuel our growth while generating breakeven adjusted EBITDA in 2025 and breakeven cash flow in 2026. With that, thank you for your time. All right.

Lilia-Celine Lozada

analyst
#3

You preannounced good fourth quarter results. So maybe we could there. Revenues came in a few million above expectations. So what sort of trends did you see in fourth quarter? And what would you attribute that strength and upside to?

Mark Hair

executive
#4

Yes. Thanks Lilly. I'll start with that one. We -- fourth quarter is always our seasonally strongest quarter of the year. We've seen that year after year. And so a lot of the same dynamics that we had anticipated a large uptick in volumes happen again this year, and we feel really good about the strength that we saw, and it came in really as anticipated.

Lilia-Celine Lozada

analyst
#5

Great. There's been a lot of moving pieces over the last few quarters is competition from some of your ortho peers has started to ramp and docs have shown an interest in MIS, osteotomy solutions. So how have you seen competitive dynamics evolve over the last few months? And are you seeing physicians come back to Lapiplasty at all after initially trialing some of these competitive solutions?

John Treace

executive
#6

Yes. Lily, great question. We definitely felt some of those pressures over the summer months, and whether that was all competition or some other dynamics that other companies or bigger companies have cited and softness. Irrespective of that, in the fourth quarter, at the end of the third quarter and in the fourth quarter, it feels like it's abated a bit, it's sort of stabilized. And as surgeons get into their active busy season, they want to go with the companies and the products that they trust. And it's a very high volume time for them, and we found a lot of these surgeons that were dabbling over the summer months with competitive or new entries into the marketplace came back to Lapiplasty when it was time to really have to perform game time for them. So we are pleased with seeing that. We think it's sort of leveled out. And as we've introduced 4 new limited market releases exciting technologies. We've been training a lot of doctors on these for the past several months, getting them ready for the launch. And we're seeing that enthusiasm for Treace Medical in our Med-Ed Events. Our sales force morale is extremely high, and they're really ready to take these into the market and they feel like they're going to be going on a pretty heavy offense, once we get this product flowing.

Lilia-Celine Lozada

analyst
#7

I guess on the topic of these new products, I know you're still pretty early in the launch of Nanoplasty and Percuplasty, but maybe you could share some early feedback and receptivity that you've been seeing in the limited launch?

John Treace

executive
#8

Sure. And we've had a number of training events, and it's exciting to be able to see the doctors respond to these. A lot of the doctors we're bringing in are surgeons that maybe have not been our customers before and they -- either using or experimenting with MIS, osteotomy solutions. And they get in the lab and they see the way Nanoplasty performs, and they'll just tell you, there's nothing like this on the market. This is totally different. And I want to -- how soon can I use this? So we're just seeing a tremendous amount of enthusiasm. Saturday, we had a big lab in Orlando, and a doctor was there that had done 5 Nanoplasties over the past several weeks and was actually so excited about it. He was training one of the doctors there. I thought he was faculty. But he said, "Yes, I used to use the [ Arthrex ] 2-screw technique, and I'm converted to this. This is so much faster, so much easier and very what I'm seeing. So those are the types of responses we're seeing. Our Speed MTP very early on, but a lot of excitement over that. The first time that Treace Medicals' really had a specific offering for that pretty significant segment of bunion patients we were missing. Patients would learn about Lapiplasty online and going to see a doctor and they find out, well, the doctors got and say, well, you got an arthritic toe join, I have to fix your bunion in different location and the toe joint. And they wouldn't use a Treace product. Now we're handing the Treace product, so we can capture that now. So we're hitting this these 300,000 procedures in an osteotomy segment with targeted strikes that are very exciting and hitting this other end with the arthritic toe that we've never really approached before. So these are incremental new opportunities for us to penetrate this market deeper.

Lilia-Celine Lozada

analyst
#9

And how do Nanoplasty and Percuplasty compared to some of the other MIS Osteotome Solutions that are available right now?

John Treace

executive
#10

Yes. Great question. So I think this is a situation where Treace is in a really great being a little later to the market. When I say late, it's no later than when we introduced Lapiplasty to the market, Lapidus was about 10% of surgeries. So minimally invasive osteotomies are still a pretty minimal part of that 300,000 osteotome base. So what we're bringing to the front here is 3-Plane Correction, that philosophy. There hasn't been a lot of focus on that third plant of correction and most of the conventional MIS techniques. Number two, really elegant refined instrumentation that makes these procedures super approachable and extremely doable in the OR, the day after they get trained in a Cadaver. And we typically send in a clinical specialist to make sure they follow all the steps, but you follow the steps. And we've got a procedure and you don't go through 40 to 50 cases. You get trained and you're immediately doing these cases in your OR and you're getting good results. And that's what we're so great at is, developing elegant controlled instrumentation that can help democratize these procedures that were once in the hands of very few surgeons and -- being performed in a limited fashion. So, and then the third part is we're delivering it through a sales team that is highly experienced and expert in bunion correction, all facets of it. And that level of confidence in the OR that the doctor has when they're employing this new procedure, that's critically important. And a lot of diversified players just have a hard time having that concentrated level of expertise that we bring to this.

Lilia-Celine Lozada

analyst
#11

Do you think data is important as you roll out these products? I know that was one of the key frontiers as you initially launched Lapiplasty. So should we expect you to be investing in studies or trials in future?

John Treace

executive
#12

Yes, that's a core philosophy of ours and we'll continue to -- once we get to the right point embark on studies to follow the results of these procedures, yes.

Lilia-Celine Lozada

analyst
#13

I guess how do you see both Lapiplasty and these new MIS Osteotome Solutions fitting into the -- your portfolio and the treatment paradigm for bunions more broadly. Do you think there are certain patient populations that are better suited for one versus the other?

John Treace

executive
#14

Yes. It's another great question. And I think, yes, the we've been very successful in driving Lapiplasty into a lot of doctors' hands to use across a broad sector -- but if you look at our 3,100 customers today, we're only getting on aggregate 25% of their bunion cases. So there is a huge opportunity to bring these technologies into our current base and get a pretty quick update. We just have to train them on them and support them. That said, Lapiplasty is generally in most surgeons' minds a more moderate to severe treatment. And the majority of our customers probably use it predominantly there. where these new focus technologies are coming into play is in the mild or moderate segment. So I think they will target that segment a little more strongly. And then course, the arthritic toe segment is a complete greenfield for us and a new application will be able hit as well.

Lilia-Celine Lozada

analyst
#15

Got it. I appreciate that you haven't formally guided for the year yet, and it's still early, but any thoughts you can share on how to think about growth this year and especially in light of new product launches and competition dynamics, any headwinds or tailwinds qualitatively that we keeping in mind?

Mark Hair

executive
#16

Yes, another great question. And so the way we think about it is really what John was talking about. We believe that we have a lot of tailwinds as we come into 2025. The first and foremost is all these new products that we have. I think it provides a very new approach for our sales reps going into customer accounts and having really a solution for a bunion deformity and for their patient needs. So that's first. That's a great tailwind for us. Secondly, as John presented, we continue to add new surgeons every year. So we've got a growing base of surgeons. We ended with 3,135, but that continues to grow. And so we're anticipating further growth in our surgeon base. On top of that we continue to get more revenue on average per surgeon every year. So that continues to ramp. And that's what these new products are going to do. So that's going to be another tailwind. In addition to that, we have even a more tenured direct sales channel. And so we feel like they are very energetic. They're excited about this broader portfolio. They won't miss out on the opportunities with our customers. And then finally, reimbursement, that's significant. And so we believe that, that could be another tailwind for us. So with all that, there's a lot going for us in 2025. We haven't -- and today, we're not giving specific guidance on 2025. There will be a little bit of a cadence of how this will roll out. Our new products really are in limited market release. That means they're in limited hands right now. And we will build and ramp those volumes of inventory in the kits to support that really through mid-half, midway through this year. So it's going to be more of a back end of 2025 story as far as the opportunity to really benefit from these new products.

Lilia-Celine Lozada

analyst
#17

Got it. I appreciate that you're not breaking out kits and physician count regularly anymore, but could you qualitatively talk through how you're thinking about utilization and new doc adds trending into 2025 and how do you see each of those pieces contributing to growth this year? And where do you see the biggest opportunity?

Mark Hair

executive
#18

Yes. So John mentioned that as a baseline, we're thinking about adding around 200 new customers in 2025. And the reason why our focus is a little bit shifting is we will continue to add and bring on new customers, but really our focus this year is we have a very large customer base -- and we have lots of new products for them. And so the quickest way that we can benefit from all these new products is to go after and to provide this large customer base with all of our new technologies. And so that's a little bit of a shift in our focus. We think it's going to be the biggest return and the best way to move the top line this year. So that's why we're thinking in terms of the quantities maybe a little bit of a step down versus what we just experienced in 2024, but we think we can have a larger movement and benefit to the top line by focusing on this large customer base.

Lilia-Celine Lozada

analyst
#19

You've been able to keep ASPs moving consistently higher as you've added more and more ancillary products to the portfolio. So should we expect that to continue in 2025? Or does competition being greater than in the past, change that dynamic at all?

Mark Hair

executive
#20

Yes. Maybe I'll take a shot and John can answer as well. So ASPs have continued to grow. One of the benefits that we've had is our newer technology, SpeedPlate technologies, that's a premium pricing. And we've had really through 2024, going from a very small mix of our overall revenue and procedures to over 50% in 1 year. So our surgeons really see the benefits of this new fixation technology, and so they continue to adopt that. So there'll be opportunities there. The other opportunities that we have are that -- when we talk about a Adductoplasty or that midfoot deformity, we continue to see year after year a higher adoption rate. So when patients are receiving Lapiplasty, they're also receiving Adductoplasty, and that really comes at the same price point as the Lapiplasty. So as that attachment rate continues to increase, that's going to be another benefit to us overall -- to contribute to increased revenue in 2025.

Lilia-Celine Lozada

analyst
#21

Got it. You mentioned reimbursement earlier that's stepping up close to 100%, I think, in both the ASC and the hospital setting. So how meaningful of an impact do you think that could have on adoption this year? And does that create even more room for taking price?

John Treace

executive
#22

Yes. It's an exciting development -- it's one that we view that it could be nothing but helpful. We surveyed some of our surgeons. They've given us some of their perspectives on what they think it may and could do and how it could benefit, but we're very early here. We're 2 weeks into January, and I think we get back -- we get to our Q1 call and maybe we'll have a little more insight to share on to what material impacts this might be having.

Mark Hair

executive
#23

And one other thing that I'll mention that Lily, we've had the question a lot of times, are we taking price as a result. So we're not proactively changing our price structure for our customers. But what we see -- and going back to your prior question, what we see is greater adoption of our premium technologies or a higher attachment rate of Adductoplasty. So we continue to see maybe that ASP or that revenue per case lifting, but we're not we're not taking price because of this reimbursement. But we do think it could be definitely positive. And we'll see how that plays out. It's -- we're really early into January right now.

Lilia-Celine Lozada

analyst
#24

Got it. Maybe shifting gears a little bit. You talked about being adjusted EBITDA breakeven this year. So first, could you talk through the key levers in the P&L that will get you there? And Second, how are you balancing driving P&L leverage while still investing behind reinvigorating the top line and supporting all these new product launches that you have?

Mark Hair

executive
#25

Yes, great. Do you want to that one or should I jump in?

John Treace

executive
#26

Yes. No, it's a little -- it's pretty straightforward. The sales team, we've been having to invest very aggressively. Now we've got the sales team -- we want -- they're maturing, more of them are on straight commission. We're not splitting aggressively and paying double commissions and salaries plus. So we're getting a lot of natural leverage just from the maturation and productivity of that sales team that's been established. So the sales and marketing line, there's a lot of opportunity for leverage there just naturally. And then in terms of being able to grow, this is very straightforward for us capital-light product development model with low inventory requirements. We can just drop these products that we've been working on for the past 3 years into our sales force's hands and ramp the top line. So we can do both at the same time. And so it's a great year for this, and we're excited about it.

Mark Hair

executive
#27

And one of the best drivers for that profitability is we have a great gross margin -- and so we've been 80-plus percent. So that benefits us. And as we continue to grow, a lot of that's going to drop through. And there will -- we're not anticipating any incremental either as we have all these new products, because it's this capital-light model, that John was talking about. So we believe we can introduce all these new innovations and product offerings and not really drive a lot of cash needs for the CapEx to deliver that top line revenue growth.

Lilia-Celine Lozada

analyst
#28

A question from the group here. You talked about adding new products and that helping keep ASPs moving in the right direction. So where do you think average revenue per surgeon can go taking into account all these new products that you're adding to the bag?

Mark Hair

executive
#29

Yes. So going back to what John has said and the way we view the market, a lot of our surgeons right now are giving us, let's call it, 25%, 30% of their overall bunion cases. And so as we add these new products, we have the opportunity to gain that other missing 70%, 75% of procedure volume. So there's a huge opportunity. We don't necessarily believe we're going to get all that immediately this year, but we will continue to ramp, train more surgeons and it will continually have them adopt these new technologies. But that's the huge opportunity that we have is a lot of this volume that we're not getting today.

Lilia-Celine Lozada

analyst
#30

Got it. I think we're just about at the top of the hour here, so maybe we can wrap it up there. Thanks so much to the Trees team for being here, and thanks for everyone for joining.

John Treace

executive
#31

Thanks Lily.

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