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Transcript Summary

SI-BONE delivered a strong Q1 2026 performance with $52.6 million in revenue, an 11.2% increase over the prior year. Growth was powered by record physician engagement, with active users up 17% to 1,650. Management highlighted a transformative CMS proposal for new DRGs that could boost Granite procedure reimbursement by up to $50,000 per case, potentially making the spinal pelvic market SI-BONE's largest revenue contributor. Strategic initiatives including the launch of INTRA Ti and a trauma partnership with Smith+Nephew are expected to drive significant second-half acceleration. The company remains on track to launch its third breakthrough device in Q4 2026. Financially, SI-BONE achieved nearly 80% gross margins and $2.5 million in adjusted EBITDA, demonstrating 2.5x operating leverage. Consequently, the company raised its full-year 2026 revenue guidance to $230-$233 million and upped its gross margin outlook. With $144.7 million in cash, SI-BONE is well-capitalized to reach free cash flow breakeven while expanding its territory footprint to approximately 100 managers. The outlook for 2027 remains positive as these secular tailwinds in reimbursement and product innovation begin to yield full benefits.

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SI-BONE, INC.: Growth Story Tethered to a DOJ Anti-Kickback Anchor

Full Earnings Call Transcript — Q1 • 2026-05-12

Operator: Good afternoon, and welcome to SI-BONE's First Quarter 2026 Earnings Conference Call. [Operator Instructions] As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Saqib Iqbal, Vice President, FP&A and Investor Relations at SI-BONE for a few introductory comments.
Saqib Iqbal: Earlier today, SI-BONE released financial results for the quarter ended March 31, 2026. A copy of the press release is available on the company's website. Before we begin, I'd like to remind you that management's remarks today may include forward-looking statements within the meaning of federal securities laws, which are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements are subject to a number of risks and uncertainties, including those set forth in our SEC filings, such as our most recent Form 10-K, and actual results may differ materially from any forward-looking statements that we make today. Accordingly, you should not place undue reliance on these statements. These forward-looking statements speak only as of the date that they are made, and we do not assume any obligation to update any forward-looking statements, except as required by law. During the call, management may also discuss certain non-GAAP measures, including adjusted EBITDA and free cash flow. Unless otherwise noted, any reference to profitability is in terms of positive adjusted EBITDA. For a reconciliation of these non-GAAP measures to GAAP accounting, please see the company's full earnings release issued earlier today. Unless otherwise noted, all results are compared to the comparable period in the prior year. With that, I'll return the call over to Laura.
Laura Francis: Thanks, Saqib. Good afternoon, and thank you for joining us. In the first quarter, we advanced our platform strategy on multiple fronts. Underpinning these strategic priorities is our clear focus on developing disruptive technologies that address unmet clinical needs for surgeons and interventionalists when treating patients with compromised bone. Our technologies are differentiated and how they uniquely adhere to low-density bone to enable more durable fusion and better outcomes relative to the current standards of care. We have never been better positioned as we accelerate growth through 2026 and into 2027. Our raised full year outlook reflects that confidence. To better frame our progress in the quarter, let me connect our recent activities around product launches and commercial partnerships to our overarching strategy. We're focused on expanding into high-value clinical segments, extending our leadership position across global markets and doing so efficiently through our hybrid commercial model, including strategic collaborations. INTRA Ti, which was launched in the quarter, is not just an expansion of our SI joint portfolio. It's a deliberate focus to further build the interventional segment with a solution that aligns with the physician workflow and site of care while also providing another compelling solution for surgeons. In Europe, the introduction of TNT TORQ expands our pelvic trauma portfolio and builds on the success we're seeing with TORQ. In Australia, the launch of TORQ extends our leadership in SI joint fusion and gives us a beachhead in pelvic fixation. The recently announced partnership with Smith+Nephew enables us to broaden our access to trauma while keeping our direct team focused on driving depth and density in spine and interventional. In the quarter, our worldwide revenue was $52.6 million, representing over 11% growth. In the U.S., revenue was $49.3 million, reflecting approximately 10% growth. International revenue for the quarter was $3.3 million, representing an impressive 34% growth. Our 2-year stacked worldwide and U.S. revenue growth of 18% highlights the durability of demand for our solutions. Importantly, this growth was delivered with strong operating discipline. Our operating expenses grew just over 4%, significantly below revenue growth, reflecting nearly 2.5x operating leverage. This demonstrates our ability to drive growth while progressing towards sustained profitability and cash flow generation. Before I provide an update on our strategic priorities, let me provide insight into the recently announced reimbursement proposal. This will positively impact our spinal pelvic market opportunity with Granite if finalized as proposed. As you may recall, last year, we had requested CMS to assign pelvic fixation procedures incorporating Granite to a higher severity level within existing DRGs. Based on analysis of the complexity and cost profile of these procedures, CMS has instead proposed creation of new DRG families for supporting extensive or complex spinal fusion procedures, including those that incorporate Granite. We appreciate the acknowledgment by CMS of the higher procedure complexity in cases where Granite is used. Overall, we believe the proposal more appropriately aligns reimbursement with the cost of these procedures. The increase in the average hospital payment under the proposed new DRGs could be as high as $50,000 per procedure, depending upon specifics of the patient's diagnosis and severity. This reimbursement change would be effective October 1 of this calendar year. We believe this incremental reimbursement would support continued adoption of our differentiated technology and ensure patients, surgeons and hospitals maintain long-term access to Granite. It will remove cost as a potential objection and further substantiate Granite as the standard of care in spinal pelvic procedures. Taken together, we made significant progress toward building a durable growth engine with record physician engagement, a broadening procedural footprint, expanding commercial scale and favorable reimbursement backdrop. This gives us confidence that we're positioned to accelerate our revenue growth going forward. Now I'll highlight the progress we've made on our 4 key priorities: innovation and market development, physician engagement, commercial execution and operational excellence. Starting with innovation and market development. We're a category leader in developing and commercializing differentiated procedural solutions for patients with compromised bone. To date, our focus on the sacroiliac joint across 3 distinct disease states has resulted in nearly 150,000 procedures and has established our deep competencies around enabling fixation and fusions of low-density bone. We're now leveraging this biomechanical leadership and our proprietary technology to expand beyond the sacroiliac joint into high-value clinical adjacencies and musculoskeletal care with a focus on patients with compromised often osteoporotic bone. With nearly 300,000 annual target procedures, fixation and fusion to treat SI joint dysfunction remains our largest opportunity. As we know, the sacrum has relatively low density bone. We are the undisputed leader with multiple RCTs that demonstrate the effectiveness of our technologies in treating this disease state. We have the most comprehensive platform that includes technologies and placement trajectories to address patient concerns and physician preferences across all sites of service. The recent launch of INTRA Ti, our 3D titanium solution further extends our leadership by combining the clinical benefits of metal implants with the speed and simplicity of what we call our INTRA or posterior approach-based workflow. Our INTRA platform is a crucial enabler of our strategy to drive strong adoption among our fast-growing base of interventionalists and accelerating our penetration in the ASC and OBL sites of care. With the ongoing migration of procedures to these settings of care, we see a significant untapped market opportunity and a long runway for sustained growth. Spinal pelvic fusion is our fastest scaling market. As life spans increase, we expect a rise in spinal pelvic procedures for patients with bone compromising conditions like osteoporosis or osteopenia. Building on the success of Granite, we're leveraging our expertise to develop targeted and competitively differentiated solutions that will complement Granite, address other areas of procedural failures, thereby improving outcomes for this growing patient population. Since the launch of Granite, our spinal pelvic revenue growth has meaningfully outpaced the broader deformity market growth rate, supported by strong physician adoption and compelling clinical outcomes. The superiority of Granite was reaffirmed in the 160-patient PALLAS study published in March. The study demonstrated 0 Granite breakage or pull out while delivering clinically meaningful improvements in both pain and disability scores at 12 months. Granite benefits from favorable reimbursement dynamics, including the existing transitional pass-through with 0 device offset in the outpatient and ASC settings. The new DRGs proposed by CMS also reinforce Granite's economic attractiveness in inpatient settings by providing enduring reimbursement for our hospital customers and providing a framework for our commercial payers to follow suit. With nearly 130,000 target procedures, intuitive surgeon workflow, superior clinical outcomes and highly supportive reimbursement, we believe that Granite as well as our future platform technologies can potentially make the spinal pelvic fusion market, our largest revenue contributor in the coming years. In pelvic trauma, the majority of our approximately 60,000 target procedures are to treat low-intensity sacral insufficiency fractures. Our iFuse-TORQ TNT system is well aligned with existing surgeon workflows, benefits from favorable reimbursement, including NTAP of over $4,000 and is supported by our strategic partnership with Smith+Nephew. With the strong reception for TNT in Europe, we expect the pelvic trauma market to be an attractive contributor to global growth. Finally, our multiyear pipeline is also advancing ahead of plan, reinforcing our position as an innovation leader. Our third breakthrough device is advancing on schedule, verification and validation are nearing completion, and we're targeting a 510(k) submission in the early third quarter. We have clear line of sight to a commercial launch, which we expect to meaningfully expand our total addressable market, deepen engagement with our spine surgeons and represent a significant new revenue driver over the next several years. This technology addresses a significant unmet need in spine surgery and is designed to deepen our platform's utility in procedures our surgeons are already performing. Now let's move on to physician engagement. We had over 1,650 active physicians in the quarter, representing more than 17% growth. This extends our track record of another quarter of double-digit growth across all call points, including spine, interventional and trauma. Our expanding platform positions us to build cross-procedure relationships and increase the number of procedures performed per physician. In the first quarter, physicians active in the current quarter and prior year grew faster than the overall base, reinforcing our ability to retain physician engagement while expanding their use of our platform. These physicians generated 3x the case volume of new users, reinforcing the value of long-term deep engagement. We're also seeing continued progress in cross-procedure adoption. The number of physicians performing more than one procedure type increased 10% in the quarter compared to the prior year period. Today, only 25% of physicians performing SI joint fusion utilize our platform across additional indications, highlighting a significant opportunity to expand within our existing base. With Granite and our upcoming technologies, we're well positioned to accelerate that expansion. Now let's turn to commercial execution. We ended the quarter with 89 quota-carrying territory managers. Annual revenue per territory was $2.2 million, reflecting 11% year-over-year growth. This marks the 14th consecutive quarter of double-digit territory productivity growth. Our hybrid sales model, which is comprised of the territory managers, territory representatives and over 300 third-party agents continues to be a competitive advantage. Our hybrid sales model has been particularly effective in expanding the reach of our direct sales force, especially in the spinal pelvic and pelvic trauma markets. Our territory managers are considered clinical experts and thought leaders and the hybrid approach allows them to prioritize engagement activities and maximize their impact in the field. With Smith+Nephew, we completed the first phase of field rollout in April and expect training and surgical capacity rollout to be substantially complete by the end of the second quarter. We anticipate revenue contribution to begin building in the third quarter and accelerate into the fourth quarter. This is consistent with how trauma volume seasonally concentrates in the back half of the year. While it's still early, the initial physician and field reception has been encouraging, and we'll provide more specific updates as the partnership matures. Finally, we remain on track to expand to approximately 100 territories over the next 12 months, aligning our commercial capacity with our strategy to bring several unique platform technologies to the market in the coming years. Before I turn the call over to Anshul, I want to thank our employees for their continued focus and execution. We've built one of the fastest-growing differentiated technology platforms with deep expertise in addressing the needs of patients with compromised bone. That focus continues to guide our innovation and expansion into new indications that will improve the lives of hundreds of thousands of patients over the next several years. The fundamentals of this business across physician engagement, commercial productivity and a broadening innovation pipeline give us real conviction in the trajectory ahead. Anshul will now take you through the fourth priority of operational excellence as well as provide financial details and our updated guidance, which reflects that confidence.
Anshul Maheshwari: Thanks, Laura. Good afternoon, everyone. My comments today will focus on first quarter revenue growth, profitability and liquidity. All of the comparisons provided will be versus the same period in the prior year, unless noted otherwise. Starting with revenue growth. Our worldwide revenue was $52.6 million, representing growth of 11.2%. U.S. revenue was $49.3 million, increasing 10%, even with the stronger prior year comparison that benefited from 3 product launches. The first quarter performance was modestly impacted by the weather-related disruptions early in the quarter and our decision to deliberately pace trauma distributor onboarding while finalizing the Smith+Nephew partnership. Revenue momentum accelerated as the quarter progressed, driven by expanding adoption of our portfolio by a record number of physicians across all sites of service. International revenue was $3.3 million, increasing an impressive 33.9%, reflecting accelerating demand for iFuse-TORQ across Europe and Australia. This trend, combined with the early enthusiasm for iFuse-TORQ TNT in Europe, reinforces our confidence in the significant long-term opportunity across our international markets. Moving to profitability. Our gross profit was $41.9 million, an increase of $4.2 million or 11.3%. Our gross margin for the quarter was flat year-over-year at 79.8% and remains among the best in the industry. Better-than-anticipated ASP from a favorable procedure mix, alongside the sustained impact of our operational efficiency initiatives contributed to the strong gross margins in the quarter. Operating expenses were $47 million, representing 4.1% growth. The modest increase was driven by higher commissions tied to revenue growth as well as targeted investments in training, marketing investment to support INTRA Ti launch and ongoing investment in the product pipeline. The combination of strong revenue growth and operating discipline continues to drive meaningful operating leverage in the business. Our net loss narrowed to $4.3 million or $0.10 per diluted share compared to a net loss of $6.5 million or $0.15 per diluted share, representing strong year-over-year progress. Adjusted EBITDA was $2.5 million in the quarter, representing over 440% improvement compared to $0.5 million in the first quarter of 2025. We're pleased with the expanding profitability even as we prioritize investments in innovation and commercial expansion. Turning to liquidity. We exited the quarter with $144.7 million in cash and marketable securities, providing us with significant financial flexibility. Free cash flow in the first quarter was only negative $3.4 million, representing a 50.7% improvement compared to the prior year period. As a reminder, first quarter cash usage reflects the seasonal impact of fourth quarter commission true-ups and annual bonus payouts. We do expect to see higher-than-normal cash flow variability in the second and the third quarter, driven by the timing of payments from build-out of our new headquarters, which is expected in the second quarter and the timing of tenant improvement allowance reimbursements. Our balance sheet, combined with the progress towards free cash flow breakeven positions us well to both invest and scale profitably. We have the liquidity to accelerate R&D investments and expand the commercial infrastructure to support multiple product launches over the next 5 years. Now turning to our updated outlook for 2026. We are increasing our full year revenue guidance to a range of $230 million to $233 million. The updated guidance implies year-over-year growth of approximately 14% to 16%. We expect quarterly year-over-year revenue growth to accelerate as we progress through the year, driven by the impact of the strategic innovation, commercial expansion and geographic initiatives we highlighted today. We are still in the early stages of realizing the full benefit of these efforts, which we believe could represent a meaningful source of potential outperformance in the second half of 2026 and going into 2027. As their impact increases, we will appropriately reflect that upside in our guidance. We're also raising our annual gross margin expectations to approximately 79%, up 100 basis points from our prior guidance. This reflects the favorable procedure mix and the sustained impact of our operational efficiency initiative. Taken together, both raises reinforce our conviction that the business is performing at a high level and that our path to expanding profitability is on track. We expect full year operating expenses to grow approximately 12.5% at the midpoint of our revenue guidance. We believe this disciplined investment will further strengthen our competitive position and facilitate sustained long-term growth. With that, I will turn the call over to Laura.
Laura Francis: Thanks, Anshul. Before we go to Q&A, let me leave you with a few proof points that define our stellar execution track record. 20 consecutive quarters of double-digit physician growth and a record 1,650 active physicians in the first quarter, 14 consecutive quarters of double-digit territory productivity growth, improving profitability and free cash flow trajectory. Guidance raised after the first quarter with revenue growth accelerating as we progress through the year and a third breakthrough device on track for launch in the fourth quarter. We've built something durable and scalable here, and we're excited about what comes next. With that, we're happy to answer your questions. Operator?
Operator: [Operator Instructions] And our first question comes from Matthew O'Brien with Piper Sandler.
Matthew O'Brien: Just, Anshul, can you quantify the weather impact in the quarter? And then I guess the top end of the guide was only raised by about $500,000. The bottom end came up by $1.5 million. Why not take it up a little bit more? Just -- is there anything to read into that? And then I do have a follow-up.
Anshul Maheshwari: Matt, yes, happy to take that question. One, we're really pleased with how the business performed in the quarter. We saw, like I said in my prepared remarks, sort of the acceleration in revenue as we progress through the quarter, and that trend continued into April. So very, very encouraged there. In terms of the weather-related impact in January, I would say it's circa in the $0.5 million range, but a lot of that gets recaptured. If you go back in time, even during the pandemic or other disruptions, it generally takes about 60 days or so for the procedures to get rescheduled. So I'd say the impact for the quarter was pretty muted. It was just timing between month 1 and later. So that's there. In terms of our guidance, look, again, we raised the lower end of the guide by $1.5 million, the upper end by half. So the midpoint is going up about $1 million. That's pretty consistent with our disciplined approach to guidance, especially this early in the year. Laura highlighted several of the initiatives that we've been focused on in Q1, and we know that there is potential upside there, especially when you think about the potential opportunity for our INTRA Ti product as we expand into interventional, the potential for Smith+Nephew partnership as it gets seasoned in the back half of the year. And then you've got a couple of other nice tailwinds around the potential higher DRG reimbursement that could go into effect on October 1. That could be a really nice tailwind for our Granite business, which has been scaling really well. And then you've got our fourth -- third BDD product that we're going to launch out in the fourth quarter. So there's a lot of tailwinds in the business. But given that we're early in the year, a lot of these tailwinds are still preliminary. We want to grow into those and then reflect that upside in our updated guidance as we go through the year.
Matthew O'Brien: Got it. Appreciate that. And then, Laura, thanks for the update on the new product that's coming out relatively soon that has breakthrough device designation. You said Q2 filing. Is it too aggressive to think that we may be able to see that at NASS this year or NASS/[indiscernible]/ launch it? Or should we really expect more of a launch in '27?
Laura Francis: Yes, Matt, thanks for the question. So what we said is that we will have a Q3 filing and that we expect for the product to launch sometime in the fourth quarter based on that timing. So as soon as we have a product, we will be bringing that product to various conferences on NASS, maybe a little bit early in the year for us to talk about it. But regardless, we're very excited. It is our third breakthrough device. We believe that we're addressing the largest unmet clinical need with our spine surgeons. And so we really think that we're on a good trajectory with that product. Also, we think it's going to provide a really nice opportunity for us to increase surgeon density as well. Last year, we had over 2,400 physicians who did at least one case with us. And so we have a very significant-sized customer base in order to utilize that product. And we believe that, that product may be used in the same cases as Granite as well. So -- and given the new DRG as well and that product being used in those cases, it provides this opportunity not just to open up a new TAM for us, but also to increase our surgeon density in a significant way. So as soon as we have a clearance, you're going to know about it and you're going to see the product, but we're incredibly excited about it and what it can bring to us late this year and certainly into 2027.
Operator: Our next question comes from Young Li with Jefferies.
Young Li: I guess to start, just kind of curious, I mean, there's a lot of momentum in the business. There's going to be a new product launching that's going to be impacting growth next year. There's reimbursement tailwinds, you're adding new territories and expanding commercial scale. I guess the question is, can '27 growth be higher than '26 growth or exit rate growth?
Anshul Maheshwari: Young, thanks for that question. Happy to take that. Just even thinking about how we set expectations for the rest of the year 2026, we do believe there is potential for significant upside as those tailwinds start having a more meaningful impact as we progress through the year. And that's embedded in our statement around year-over-year growth acceleration in each of the subsequent quarters. So we feel very good about that. Now in terms of talking about exit growth rates, again, as revenue growth accelerates, I think that will be a nice off-ramp for 2027. And that's just seeing the initial impact of these tailwinds. So I'm not going to provide context on where 2027 could go, but let me just provide some quantitative color that will help you understand sort of the secular tailwinds in the business, which are actually long term, not specific to just 2026. Within SI joint fusion, our interventional strategy is in the early innings. With the increase in reimbursement for OBL, our Intra X product is doing really well there. INTRA Ti just launched, and we're seeing rapid pace of adoption across our INTRA family and which should only accelerate going into 2027. On the pelvic fixation side, Granite has scaled up really well with the potential for the new DRGs going into effect on October 1. You obviously will have an impact in the fourth quarter, but a more pronounced impact as you go into next year as well. And then when you layer on that new product Laura just talked about, it also provides an opportunity for a higher procedure ASP because that new product alongside Granite can go into the same product. And then on the pelvic trauma side, with Smith+Nephew as we go through the year and we start seeing that relationship mature, we're going to continue to put surgical capacity out there in 2027 as well given the breadth of trauma, Level 1, Level 2 trauma sites we're targeting. So I think that should be a nice tailwind, too. And then there's international. You've got TNT that just got commercialized in Europe. That's about, I'd say, 9 months ahead of schedule. We were hoping to commercialize it in 2027. So as that gets seasoned, that will be a nice tailwind as well. So I think there's a lot of positive long-term secular tailwinds in the business that extend beyond '26 into '27. But again, consistent with how we think about the business, we want to execute through 2026, grow into those tailwinds and then be able to articulate what that exit ramp translates into 2027 growth.
Young Li: All right. That's very helpful. And then just on the revenue per rep or trailing 12 months, still seeing pretty solid double-digit growth there. Just kind of curious, where do you think that can continue to grow to? Where does it sort of cap out at, especially with the contributions from the Smith+Nephew relationship as well as new territories you are adding?
Laura Francis: You're right. We have continued to see those productivity gains over the last 3 years. I think that we've doubled in terms of sales rep productivity. And a lot of that did come from the hybrid model that we have in place, where it's the territory managers that carry the quota, those 89 people that we ended with at the end of Q1, supported by our more junior territory reps, but then also the over 300 third-party agents that we're working with. With that said, the $2.2 million, I do not think that, that's a cap. Our largest territories are more than double that size. So we have examples where we have much higher productivity in the field. So those are the examples that we're using for best practices. With that said, we do target to get to nearly 100 territories over the next 12 months. We want to capitalize on the current demand that we have and also all of the discussion that we just had around upcoming launches at the end of 2026 and into 2027 is really important. So -- but you're also right that the growth is not solely dependent on the territory count. The expected ramp with Smith+Nephew, that partnership there is going to provide an opportunity for us, specifically in trauma while allowing our sales reps to focus on spine and interventional. So overall, I think the way that we're growing the territories, as you can see, we've gotten significant operating leverage, but our goal is to continue to drive growth and penetration with our current customers and potential new customers.
Operator: Our next question comes from Matt Blackman with TD Cowen.
Unknown Analyst: Anshul, it's Drew on for Matt tonight. Laura, maybe just for you to start. I think in your prepared remarks, you said the spinal pelvic fusion market or opportunity could be your largest contributor over the next few years. Can you maybe dive into that a little bit more? Do you need the breakthrough designated device the third one to really drive the bulk of that aspiration? Or is there more in the pipeline that's really needed for that to occur? And maybe just help us size the Granite revenue contribution today, so we might be able to better appreciate the opportunity ahead.
Laura Francis: Yes, Drew, thanks for the question. So yes, we are pretty excited about the opportunity in spinal pelvic. As I mentioned, we worked with over 2,400 physicians last year, most of those spine surgeons, and they're doing SI joint fusion procedures and more and more often, they're doing Granite procedures. So in terms of the comment that was made that this could be our largest market, it does take into consideration the continued growth opportunity with Granite, especially supported by the new DRGs effective in October of this year. We think that, that's going to have a significant impact, taking cost away from the conversation that we have with hospitals and really helping to support Granite as the standard of care in spinal pelvic fixation. So that's number one. But number two is also that breakthrough device as well. I did mention that, that's targeted towards spine surgeons as well. It does fall into the spinal pelvic market category as well. And it is a procedure that they're doing already. It is a product that they may use in the same cases as they're using Granite. So it provides an opportunity for -- to engage new physicians, but also to significantly increase density with our existing physicians, whether it's using that product on its own or whether it's in combination with Granite where it's going to increase the ASP for that particular case.
Anshul Maheshwari: Yes. The other thing I would say, Drew, is we have a pretty active R&D pipeline right now. Laura has talked about it in the past, where we want to get into a regular cadence of launching products. And the strategy has been on ensuring that we're going after large unmet markets, but that are also synergistic both at a procedure level and a call point level. So that's what gives us confidence, not just these 2 products, but the other products that are in the hopper, which we're not going to talk about right now, but we will start talking about as we get closer to FDA clearance or submissions or things like that, consistent with what we've done in the past.
Unknown Analyst: Got it. I'm guessing you don't want to give the revenue contribution for Granite today. All right. Well, next question, actually, Anshul, for you. Just you were talking a bit about capital spending in the second and third quarter. It looked like first quarter was, kind of, the lowest CapEx that you've had over the past several quarters. Just how do we kind of balance that with your commentary about putting more surgical capacity in the field for Smith+Nephew and these more -- and more product launches coming throughout the year and into next year?
Anshul Maheshwari: Yes. That's a good question. So in terms of CapEx in the business, Drew, I would think the run rate CapEx just from an instrument tray surgical capacity standpoint, sort of that $9 million, $10 million. We've sort of been in that $8 million to $10 million range given the year when you launch a product. So we believe that, that's going to be the right range. There's 2 offsets to that. One is new products. Yes, we're putting up more capacity for Smith+Nephew. We're going to put out more surgical capacity for the new products that we want to commercialize. But the offset to that also is we're making sure we're driving utilization higher of existing surgical capacity. So you're going to see leverage there. That's number one. Number two is now that we have a broad expertise in terms of launching multiple products, we're taking a lot of those learnings and making sure we drive the cost of these instrument trays lower as we launch new products. So even though we'll put up more products, those 2 things will be allowing us to offset some of the capital footprint that we need to grow. So that's one. Now we do have our new headquarters being built. It's an 8-year lease. So we're in the midst of doing the construction there. So you'll have a bit of onetime spend between Q2 and Q3. But even with that, even the investment we want to make in the business, we feel very good about our target to get to free cash flow breakeven.
Operator: Our next question comes from Travis Steed with Bank of America Securities.
Travis Steed: With maybe ask a little bit more about the Smith+Nephew partnership, how that's ramping? And maybe any -- you've given a lot of qualitative color, but any way to think about the quantitative contribution to growth in 2026 and assumptions in that guide raise?
Laura Francis: Thanks for that question. We're really excited about the partnership with Smith+Nephew. So it covers Level 1 and Level 2 trauma centers, and it's going to allow our trauma surgeons to gain access to our TNT product as well as TORQ to treat sacral insufficiency fractures. We actually have the Smith+Nephew trauma leadership team here last week in our offices. So talking about moving forward our collaboration. The excitement is clear, the commitment is clear, and that's in the field as well as with physicians as well. So we think that our TNT solution is very synergistic with their portfolio, and we're still working through rep training and the rollout should be complete by the end of the second quarter. So given a normal ramp time line, it would be a few months between training and first case, but we should start to see the revenue contribution here coming in the second half of the year. In terms of providing more information on the opportunity, if you think about the TAM, it's around 60,000 patients in total. It's around $300 million per year is the opportunity that we're targeting here. And so we'll give more information as the relationship develops, and we'll bake more into our guidance as we see that momentum.
Travis Steed: That's helpful. And then just a quick follow-up. Maybe what you're seeing in the second quarter already in terms of procedure volumes or trends in the spine market more broadly?
Anshul Maheshwari: Yes. So we're not going to provide specific context on what we're seeing in the quarter. We did talk about in our prepared remarks around acceleration as we progress through the first quarter trend we saw in April. The way we are thinking about our business is not even on a quarterly basis, but on an annual, multiannual, multiyear basis because a lot of the tailwinds that we've talked about on this call are indeed secular. They're going to be over a couple -- a few years. You're going to continue to see the impact of that. And that confidence is reflecting in our guidance.
Operator: Our next question comes from Caitlin Roberts with Canaccord Genuity.
Caitlin Cronin: Congrats. Just to start with Europe and the U.S. It seems like TNT that you noted was launched earlier than expected in Europe. And then along with the Australian launch of TORQ, do you see these changes as changing the potential OUS growth expectations for this year?
Anshul Maheshwari: Yes. Happy to take that, Caitlin. So on the international side, yes, really pleased with how the business did, both in Q4, which was the first full quarter of TORQ being available in Europe, but also what we're seeing in Q1 with TORQ and then the early commercialization of TORQ in Australia and also TNT in broader Europe. It is still 5% or 6% of our business, but it's tracking really well. And given that we're in the early stages of launch, we want to be very thoughtful about how those 2 markets scale for us before we start incorporating upside there. But we are very confident that Europe with these 2 new products continued with the strength of our SI joint business with the Triangle product, which is what they've had for the longest time, should actually be accretive to worldwide growth, which it hasn't been for the last few years. So we like the trajectory of the business, and we like what potential upside could come from it. And we are also looking at other international markets where we're seeing physician interest to be able to deploy TNT TORQ and potentially even Granite.
Caitlin Cronin: That's great. And then just on the S&N partnership, Smith+Nephew is continuing to go through its own efforts in the U.S., particularly as it works to launch its NexGen Knee later this year. I mean, any risk for the ramp for you guys to be slower given the focus for Smith+Nephew? Or are these areas mainly separate?
Laura Francis: For the most part, these are actually separate areas. So we're working specifically with the trauma team there at Smith+Nephew. And as I said, the products are very synergistic with one another. They are focusing on the pelvis later this year, and this product is supportive of that. The fact that it's a breakthrough device, the fact that it has an NTAP of over $4,000, the typical ASP is significantly higher than what Smith+Nephew is used to seeing in their own portfolio. All of these things, I think, bode very well for the product and for the uptake with the folks at Smith+Nephew. As I said, we are working with them from a training perspective right now. We're deploying assets into the field with them. And also, it's getting some of these trauma hospitals on the approved list, too. So there's a number of things that are more administrative in nature that are going on right now. But we feel that Smith+Nephew is going to be a great partner for us and we're seeing that commitment from them.
Operator: Our next question comes from David Saxon with Needham & Company.
David Saxon: Congrats on the quarter. I wanted to ask on just the path to 100 territories over the next year. So just looking back, I mean, that would represent the fastest pace of hiring you've seen since, I believe, 2021. So I guess, like what's the confidence in getting there? And how important is it to the organization in the context of this upcoming BDD launch?
Laura Francis: Yes. I think actually the last part of your question was the most important part. So since 2021, a lot of our focus in terms of expanding the sales force has been utilizing our hybrid model. And we grew from a very small number of third-party agents in 2021 and up until today, where we're over 300 at this point. So that has been a very significant way that we've grown the business and gained significant operating leverage on the business. And the Smith+Nephew relationship is another part of that particular strategy. So why do we think it's important to grow to those nearly 100 territories over the next 12 months? It does get it this next product that we're going to be launching a breakthrough device that we think that has very significant potential to gather yet more surgeons as customers beyond the record that we had this last quarter of 1,650 over 17% growth. And typically, we even see a little bit of a fallback between Q4 and Q1 in terms of the number of surgeons that are using the product, but that was not the case for us in Q1. So it is important for us to ramp to get to those 100 territories to be prepared for the launch of this next product from the perspective of adding surgeons, but also I mentioned the surgeon density that we think is incredibly important. We have a tremendous asset in our customer base. And this product will give us the ability to meet the needs of those physicians, whether it's in SI joint fusion, pelvic fixation or the new indication that we're working on with the next product.
Anshul Maheshwari: And then, David, you brought up a really good point on going back to 2021. If you look at what our strategy has been and you look at what the performance was since 2021 once we built out the sales force, it was very quickly followed by 4 new product launches. You launched TORQ, you launched Granite, you launched TNT and then you launched the INTRA family. And what you saw between 2021 and 2025 is growth really inflect in the 22% range on a cumulative -- on a CAGR basis. Right? So what you're seeing is a similar playbook now, except we're at a much larger scale. We still expect to launch new products. We still expect to get a lot more operating scale on the business or operating leverage on the business. But this is in anticipation of what we know is going to be a pretty aggressive innovation cycle for us over the next 5 years.
David Saxon: Okay. That was super helpful. Maybe for my second question, Anshul, just on gross margins, obviously, really strong performance here in the first quarter. So like what's driving that? Is that just kind of better leverage on higher revenue or anything from an operational perspective? And then, Anshul, can you just remind us what the latest assumption is in terms of pricing on guidance?
Anshul Maheshwari: Sure. On the gross margin side, David, again, really pleased with the nearly 80% margins at 79.8%, but nearly 80% margin, which, look, we're really proud of. They are industry-leading, and they're ahead of our expectations. And that's why we reflected that in our increased guidance by increasing gross margins by 100 basis points for the year. A lot of that is driven by the better-than-expected execution, both on the procedure mix side, so the ASP came in a bit better, but also we are seeing the incremental impact of the supply chain efficiencies and cost optimization initiatives that we've put in place. So we feel really good about the trend there. Now as we launch new products, including the rollout of additional surgical capacity to support Smith+Nephew, we do expect some noncash impact, i.e., depreciation of those instrument trays in the back half of the year, and that's incorporated in our updated guidance of 79% for the year. In terms of ASP, we're still maintaining a conservative position on ASP. We sort of started the year at mid-single-digit ASP decline. Now we've done better than that. Granite has been a big contributor to that because of more 4 implant cases than we had in our initial guidance. We're still assuming low single-digit ASP degradation. Now we think we can do better than that. But the reason for that assumption is -- for our interventional with the INTRA family, you generally have fewer implants used. And within trauma, again, you might have anywhere between 1 and 2 implants used in a procedure. So we're embedding that as potential pressure on ASP. What we're still not incorporating is the upside of Granite continuing to see more 4 implant cases and the continued strength in the SI joint business where you use 3 implants.
Operator: Our next question comes from David Turkaly with Citizens.
David Turkaly: Just quickly Anshul, I know you mentioned the headquarters. Did you put a dollar amount on that? And then I just wanted to check sort of from a capital allocation standpoint, you have a lot of cash, sort of your priorities there? And has the buyback ever been considered?
Anshul Maheshwari: Yes. So from a CapEx perspective, like I said, on this traditional surgical capacity, it's around $9 million to $10 million for the year, and then you've got another $4-plus million on CapEx for the new headquarters. Now some of that will get reimbursed as part of the Ti launch, it's just the timing of CBD based on the way the contract is structured. So that's where the CapEx sits. And then your next question was around buybacks. Yes, look, when I think -- when we think about capital allocation, our focus remains on making investments in R&D in new product innovation on clinical data, especially as we look at the number of products that we have in the hopper that we want to commercialize. Supporting that will be surgical capacity. And then the last piece is building the commercial infrastructure to continue to support that growth. Now we do like the way the business is positioned with the growth in gross margin dollars, the continued inflection on operating leverage, but our focus remains on growth and investing in growth accretive opportunities within the business.
Operator: Our next question comes from Richard Newitter with Truist Securities.
Richard Newitter: Maybe just on the cadence of the revenue guide. I know you said you expect acceleration moving through the year. It looks like consensus is right around 15% to 16% growth for 2Q or about $55 million. I guess that would imply maybe something like 2.5% year-over-year acceleration in year-over-year increases moving through the year. Is that about right? And can you comment on that cadence in the 2Q number at all? And then just on that topic as well, just you maintained your operating expense growth guidance. I guess you're coming out of the gate here at almost 3x your top line growth versus your OpEx growth. And I'm just curious to know kind of is there -- what's behind that? Where are the expenses getting pushed out, if that's the case? Or is that just kind of conservatism right now?
Anshul Maheshwari: Yes. So happy to take both those questions, Richard. In terms of trending by quarters, as you know, we don't provide quarterly guidance, and we like to manage the business on a full year multiyear basis. And we do expect year-over-year growth to accelerate. Now our current assumption is the acceleration is going to be more pronounced in the second half of the year. Part of that is just timing of scaling up this new product within interventional. But also, as Laura talked about, the Smith+Nephew partnership, the expectation that you really start seeing a meaningful contribution in the third and the fourth quarter. So you might see some timing shift between Q2 and Q3, mostly because of the Smith+Nephew partnership. But for the year, we feel really good about where the growth is going and more importantly, the exit ramp from fourth quarter going into 2027. So that's there. On the spend side, you're right. We like the operating leverage we saw in the business. Now from an expense standpoint, when you are at our scale, timing can have a big impact. So we are in the second and third quarter, right in the midst of our V&V testing and a lot of our work on FDA regulatory submissions as well as marketing activities, both for INTRA Ti, which was launched, but also for this new product we want to commercialize in the fourth quarter. So you're going to see a bulk of that spend there. We're also embedding R&D spend that is going to have an impact on products we want to launch in 2027. So you're seeing an OpEx expense growth rate embedding a lot of the spend that could contribute to revenue upside as we progress through the back half of the year. So that might mean there's some upside on the operating leverage, too. But we believe it's better to be conservative, incorporate the spend and then let the growth speak for itself as we progress through the year.
Richard Newitter: That's really helpful. And then maybe just on the DRG proposal or the Upcode tailwind. This seems like a really big potential tailwind for you. I guess, one, is this something that you were expecting that you've been lobbying for or not lobbying, but the kind of -- you were expecting this outcome? And then why wouldn't this just be a really enormous tailwind for you next year?
Laura Francis: Richard, it's a great question, and we, quite frankly, do think this is a very significant and underappreciated tailwind. Granite, first of all, has been one of our fastest scaling products in the history of the company. We addressed this unmet clinical need in terms of fixation failure and multilevel construct. We have a fair amount of clinical data that actually shows the benefit of the technology and it really should become the standard of care in 130,000 cases per year in the United States. So I think number one is just the product itself is an incredibly important product to these patients and surgeons who are working with patients that need multilevel constructs. Now when you get into the rule itself, so the inpatient rule created a new DRG group for complex and extensive spine surgeries. And under the proposal, Granite is 1 of only 2 technologies for which those procedures automatically map to the new DRG. So the proposal is actually significantly better than what we had requested from CMS. We've been in discussions with CMS for not 1 year, but 2 years. And our initial request was a reassignment of Granite cases to higher severity levels within the existing DRGs. So when CMS actually looked at the data, they concluded that the reassignment actually wouldn't fully address the cost differential. And so instead of moving cases around within the existing structure, they created the new DRG family. And the improvement in the hospital payment under the proposed new DRGs could be as high as $50,000. I mentioned that in my preprepared remarks. And although it depends on the specifics of the patient diagnosis and severity. What's interesting about this, too, is that these new DRGs are more durable than an NTAP. They're not a temporary fix. The NTAP also was only limited to Medicare patients. And if finalized, we expect commercial payers to broadly adopt the new DRGs alongside CMS. So in summary, we do strongly believe the new DRGs are going to have a positive impact on the spinal pelvic market opportunity that we're going after with Granite, assuming that they're finalized as proposed. We think the incremental reimbursement is going to support the adoption of our Granite technology, and it's going to remove cost as a potential objection. I hope that helps.
Operator: I'm showing no further questions at this time. I would now like to turn it back to Laura Francis for closing remarks.
Laura Francis: Yes. I just wanted to say thank you to everybody for participating in today's call. We really appreciate your interest in SI-BONE, and we look forward to seeing you all at upcoming conferences as well as non-deal roadshows. Goodbye.
Operator: This concludes today's conference call. Thank you for participating. You may now disconnect.