Participants

Matthew Brinckman; SVP of Strategy & IR; Paragon 28 Inc (Pre-Reincorporation)

Albert DaCosta; Chairman of the Board, President, Chief Executive Officer; Paragon 28 Inc (Pre-Reincorporation)

Krissy Wright; Interim CEO; Paragon 28 Inc (Pre-Reincorporation)

Matthew O'Brien; Analyst; Piper Sandler & Co.

George Sellers; Analyst; Stephens Inc.

Craig Bijou; Analyst; BofA Securities

Mike Matson; Analyst; Needham & Company, LLC

Justin Lin; Analyst; William Blair & Company LLC

Dave Turkaly; Analyst; Citizens Financial Group

Caitlin Cronin; Analyst; Canaccord Genuity

Presentation

Operator

Good afternoon, and welcome to Paragon 28 first quarter 2024 earnings conference call. (Operator Instructions) As a reminder, this call is being recorded for replay purposes.
I would now like to hand the conference over to your host today, Mr. Matthew Brinckman, SVP Strategy, Investor Relations. Mr. Brinckman, please go ahead.

Matthew Brinckman

Good afternoon, and thank you for joining Paragon 28 first quarter 2024 financial results and earnings call.
Presenting on today's call are Albert DaCosta, Chairman and Chief Executive Officer; and Krissy Wright, Interim Chief Financial Officer.
Before we begin, I would like to remind you that management will make statements during this call that 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.
Forward-looking statements include statements made as to the Company's or management's intentions, hopes, beliefs, expectations or predictions of future events, results or performance. These forward-looking statements are subject to a number of risks, uncertainties, estimates and assumptions that may cause actual results to differ materially from these forward looking statements. All forward-looking statements are based upon current available information and Paragon 28 assumes no obligation except as required by law to update these data.
Additional information concerning certain risks and uncertainties that may impact these forward-looking statements is contained from time to time in the Company's SEC filings and in the press release that was issued earlier today.
During this presentation, we will refer to the non-GAAP financial measure of adjusted EBITDA and constant currency net revenue growth. A reconciliation to the most comparable GAAP financial measure, net income and reported net revenue growth is contained in our press release issued earlier today and with that.
I will turn the call over to Albert.

Albert DaCosta

Thanks, Matt. Good afternoon and thank you for joining us for our first quarter 2024 earnings call. I am pleased to have our Interim CFO, Chris Wright, joined us for today's call, Chris. He has been an incredible partner on our Board since 2021, serving as our Audit Committee Chair and as a member of our Nominating and Governance Committee.
I'm now going to kick things off with a review of our first quarter performance, followed by recent highlights. After that, I'll pass it over to Christie to provide further details on our first quarter financial results and guidance.
Global revenue for the first quarter of '24 was a record $61.1 million, representing 17.4% reported and constant currency growth in line with the top end of our preliminary revenue results reported on April 4. Overall, we are pleased with our growth through the first quarter of '24 compared to our strong growth comps in the first quarter of '23.
Despite one less billing day this year, we also saw a modest step up from the fourth quarter of 2023, which is typically the seasonally highest revenue contribution of any quarter each year. Importantly, we continue to see balanced top-line performance across all five foot and ankle subsegments.
Looking at the U.S. business performance, net revenue for the first quarter of '24 was $51.1 million, representing 13.5% reported growth during the quarter. We increased our US producing sales rep roster by 6% to 261 reps compared to the first quarter of '23 and saw an 8% increase in productivity across our rep base.
Over the same period, we grew our surgeon customer base by 12% to a record 2,275 surgeons. Medical education remains a core part of our commercial strategy, and our two mobile labs have been important drivers of surgeon adoption to start the year. We are excited to see solid growth in these leading commercial indicators and expect to see continued momentum in these areas throughout the year.
In line with our typical seasonal trends, first quarter international net revenue was $10 million, representing 42.2% and 42.5% reported and constant currency growth, respectively. International growth was driven primarily by the United Kingdom and Australia. Overall, I am thrilled with our international momentum. Our foundation is set for sustainable growth as we drive further investments to clear and launch additional products and new markets outside of the United States.
Turning next to our product portfolio, 2024 is off to an incredible start with six four product launches and one limited market release in the first quarter of '24. We remain focused on innovating across all segments, but it's important to note that all products launched so far in '24 are in high-growth Foot and Ankle segments like bunion, soft tissue and minimally invasive surgery.
Ultimately, these most recent launches will help advance Paragon 28's portfolio in the fastest growing subsegments in our market and position the Company well for sustainable long-term growth. Most recently, we launched the granular reinforced repair system, adding to our suite of novel centers, most U.S. repair solutions and broadening our rapidly growing soft tissue portfolio.
As a reminder, early in the first quarter, we launched three other soft tissue solutions with the granular knotless anchor fringe line Tate and Mr. Tennant Harvester, all of which will typically be used in conjunction with other products and are highly complementary to our existing plating and screw systems.
Another solution is our FJ. 2000 power console and burner system designed specifically for the extremities and MIS surgery.
Lastly, we launched the precision MIS. bunion system and have our new Lapidus plant by pneumatic, which is on limited market release with full release expected later this year. We continue to see strong momentum from our 2022 and 2023 product launches, which have continued to be significant drivers of growth for the first quarter of this year, especially in areas of external fixation and hindfoot fusion, where we launched our monkey rings monkey bars in Fantom hindfoot.
Now and 2022. Our product launches in 2024 are still relatively fresh and have not yet contributed materially to the revenue in the first quarter, but they've been generating a ton of buzz with our rep base and within the surgeon community. These launches give us confidence in our guidance for 2024 and P. 20 eight's ability to drive further growth later this year and beyond.
As we look further into 2024, we expect to continue investing in our commercial and educational opportunities to enable P. 28 to realize the full potential of our new product launches as well as legacy products, both in the US and internationally.
In closing, when we founded Paragon 28 and 2011, we set out with the mission to continuously improve the outcomes and experiences of patients suffering from Foot and Ankle conditions that remained our mission through our IPO in 2021 and continues to be our top priority today. Everything we do and every decision we make is to advance P. 28 along that mission and I attribute our success to the team's dedication to that unified goal. This is a long-term journey. And while I am incredibly proud of what we've achieved in the past several years, I could not be more excited about the Company's future.
With that, I will now turn it over to Krissy.

Krissy Wright

Thank you, Albert. Turning to the rest of the P&L, beginning with gross margin, gross profit margin for the quarter was 80% compared to 82.9% in the first quarter of 2023. The decrease in gross profit margin is primarily the result of higher prices from suppliers as well as product and geographic mix shift.
First quarter research and development expenses were $7.6 million or 12.4% of net revenue compared to $7 million or 13.5% of net revenue in the prior year period. We continue to invest in new product development to improve patient lives through our product pipeline, which remains robust with over 25 active projects in development, including several tied to smart 28.
Selling, general and administrative expenses in the quarter were $54.2 million a $10.4 million or 23.7% increase from $43.8 million in the first quarter of 2023. As a percentage of net revenue, SG&A was 88.8% compared to 84.2% in the prior year period. The increase in SG&A was primarily driven by increased head count annual merit increases. Investments in the commercial team, increased variable sales.
Representative commission expenses related to net revenue growth, an increase in professional services fees and an increase in depreciation expense. Adjusted EBITDA for the first quarter of 2024 was a $5.5 million loss compared to a $1.4 million loss in the prior year period. The decrease in adjusted EBITDA is primarily attributable to an increase in operating expenses.
While we remain laser focused on driving operating leverage across the P&L in the months and quarters ahead, the impact of investments made in Q1 has slightly pushed out our expectation for EBITDA breakeven in 2024. Importantly, we are prioritizing initiatives directly associated with our growth strategies and top line performance.
Operating cash flow for the first quarter of 2024 was negative $11 million compared to negative $5 million in the prior year period. After adjusting for the $9 million legal settlement payments made in Q1 2023. Increase in cash used is attributed to higher operating costs and net changes in working capital items. We ended the first quarter 2024 with $108 million of total liquidity, consisting of $58 million of cash on the balance sheet and $50 million available through our credit facility.
Now turning to our 2024 revenue guidance for the full year 2024, we are reaffirming our previous net revenue guidance of $249 million to $259 million, representing reported growth of 15.1% to 19.7% through the rest of 2024. On a quarterly basis and anticipate the impacts of seasonality to be consistent with 2023. Our net revenue guidance assumes foreign currency translation rates remain consistent with current translation rates. That is the end of our prepared remark.

Question and Answer Session

Operator

Matthew O'Brien, Piper Sandler.

Matthew O'Brien

Great. Thanks for taking my questions. Maybe just for starters here, Albert or proceeds, just the revenue that you generated in Q1 was was good. Actually that acceleration on a two year stack basis, but as I look at the rest of the year here, you're getting easier comps that you're kind of keeping the growth outlook is static. And so I'm just wondering what is it is there something specifically domestically or internationally that you're hesitant about? Or is competition getting more challenging? And then the split between the two, should we expect more international to drive most of the growth or more of the growth this year and next? And then I do have a follow-up.

Albert DaCosta

Hey, Matt, it's Robert. Thanks for the question. But maybe for starters, I'll say we have a we've got a lot of confidence in the numbers that we set out in February, and we expect net revenue to be $249 million to $259 million. That's that's around 15.1% on the low end to 19.7%. On the high end, the assumptions haven't changed. I'm going into that number and are we are definitely thrilled with the performance for Q1. It's always really nice to see an uptick in Q1 versus Q4, and we have a lot of our KPI.'s hit, and we have a lot of confidence in the range that we set out in February. So one thing I'll say is we're going to keep analyzing that and and report back as there are changes to be made.
On the international question, the one thing that I'll tell you, I actually couldn't be more thrilled about the performance of the business overall. But the international business in particular, we set out as our mission to improve outcomes for foot and ankle patients and to really put a mark on this on this market and you can't do that as a domestic-only company.
You really have to be global and our international reception has been phenomenal. We've made a lot of investments in the international business. And so you're seeing a lot of those paying off. It's on a smaller scale, obviously than the US. So the growth rate is higher there. And we expect that to continue, but the ability to participate with global KOLs and really help craft the message about where this market is going and how it's going to get there is on it's thrilling for us.

Matthew O'Brien

Got it. Appreciate that. And then the follow-up is around the EBITDA commentary, the pushout, is that just for pushing it up to 25 and then the investments that you're making? Are those investments to help you grow faster? Or do you have to spend more to kind of grow at these rates? Thank you.

Albert DaCosta

Yes, thanks again, for the question up, definitely those investments for to help us grow, right? We took some opportunities to invest in the commercial team and we had some R&D investments that we took in Q1. One thing that we've always been really passionate and committed to is we want to make sure that we're spending every dollar to improve this business and to help us get to where we're going.
The one thing we want to do is I'd look at efficiencies and really look across the P&L to find operating leverage as we grow this thing. So that we continue to build the best business we can. So yes, we took some we took some opportunities to invest in additional opportunities to grow. We think those investments are really going to support us moving forward. And on the other side of it, as we're always looking for leverage, we're always looking for efficiencies to drive better management of the capital. The precious capital that we've got.

Matthew O'Brien

Okay. And sorry to push a little bit over, just is that investment to grow faster or investment just to keep growing it better, still elevated level.

Albert DaCosta

Investments to grow faster.

Matthew O'Brien

Got it. Thank you.

Albert DaCosta

Of course. Thank you.

Operator

George Sellers, Stephens.

George Sellers

Good afternoon. Thanks for taking the question. Maybe to shift back to the guidance, I'm just curious, what does that assume from contribution from some of the new devices you launched in the first quarter and towards the end of last year? And also what does that assume in terms of the underlying market and the competitive dynamics there and some others in the market as commented on recently?

Albert DaCosta

Yes. Hey, George, thanks for the question. And maybe to start, you know, this is a topical point for me, but on the products we've launched, honestly, really since the beginning, but more importantly, this class of launches and the ones you're referencing late last year and early this year, generating so much excitement there and really high value, high growth segments of the market and the reception we're getting is phenomenal.
Now modeling that and I will tell you products we launch in Q1. We don't expect to be as material early on, we would expect maybe in the latter half of the year and into next year to see some meaningful contribution from those products. But the reception that we've gotten so far has exceeded our of expectations, and we're thrilled. We just keep our goal in this market is learning so much every day and we take that information and we go back and we see how we can improve these outcomes and refine systems and improve the offering out there.
And and the reception that the products have received tells us that we are definitely hitting the mark there that this market is young. There's a lot of room for improved outcomes, and we feel like we're the company on the front of that mission to do that. And so I just to put that there, I'll tell you those new products are already generating some momentum for us earlier than expected.
And we do have a lot of excitement too about what's coming in the second half of the year. We got a lot of good products and one that I had mentioned on several calls is this our 28 launch is still on plan. And so we're just we think there's going to be a really good year for that.

George Sellers

Okay. That's great to hear.

Albert DaCosta

And mean one thing. I wanted to say that. Yes, I'm sorry, George, one thing I was going to say I don't mean to minimize the excitement around the sales force expansion that we also are pretty excited about this year. We've got some great new sales folks that we expect to start contributing later in the year. And and so I didn't mean to emphasize everything on product, but we think there's a lot of KPI.s that are that are going to contribute nicely this year.

George Sellers

Okay. That's that's helpful to hear. And then maybe digging into that sales commentary and some of the adjusted EBITDA commentary a little bit the SG&A line really reaccelerated on a year-over-year growth basis this quarter. I'm just curious how we should think about the cadence for growth through the remainder of the year.
And maybe to follow up on a prior question, how far out did and this quarter sort of pushed that adjusted EBITDA breakeven plant one?

Albert DaCosta

Yes. Again, thanks for the question. We don't typically comment on it the exact time line for EBITDA. I could say it was a slight push some so not terribly significant. The one thing I will say is the SG&A increase. We absolutely expect to start leveraging those investments. And so that that increase, we took advantage of some opportunities to invest in the business there and we did. But we fully expect to start leveraging that and to see a much different profile for SG&A moving forward.

George Sellers

Okay. Thanks for the time.

Albert DaCosta

Thank you, George, for your question.

Operator

Craig Bijou, Bank of America.

Craig Bijou

Good afternoon. Thanks for taking the question from Albert, maybe following up on some of the sales force investment that you're making, I'd love to hear what you're seeing in the market and kind of what's what's driving or I guess the opportunity that you see there, the rationale for making the investments was their talent available. Did you see was that a competitive dynamic that maybe you could take advantage of it would just love maybe a little bit more color on the opportunity and have the push or why you thought it was time to invest like you have. So maybe what you see over the next entrepreneurs?

Albert DaCosta

Absolutely. I'm great to hear from you, Craig, and thanks for the question. And I will say every time we launch new technology. It generates a real nice buzz in the market and that brings some opportunities forward. I don't want that to sound like we're pretty flippant about who we bring on we are very clinically oriented organization, our products and systems, the way we service that we take deep pride in being a real resource to our surgeon customers and ultimately impacting that patient on the table.
So when we're presented with those opportunities, what we're really evaluating is the clinical approach to and the sales force and making sure we get not only the geography covered, but get the right partners in place so that all of these things kind of feed together.
One thing that Paragon has always been blessed with is we have just a phenomenal culture around developing better solutions were not bag fillers. And when we launch these systems to the market, it means so much to sales people, it means so much to surgeons. It generates a buzz around medical education, those opportunities all connect and we are one part product development and an equal part sales force, right?
And we really have a sales culture here with most of us came from selling not only medical devices but selling foot and ankle products. We have a deep passion for the procedures themselves above and beyond the implants. And so that connection just is a really good recipe for us. And so windows opportunities present, and it's the right fit. We have to take advantage of those.
We have to be committed to investing in the things that matter. And we can look at efficiencies and the things that don't drive top line and don't improved our organization. That was a long answer for that, Craig, I apologize, but that's some it's a real sweet spot for Paragon 28. We happen to be a spot that a lot of people aspire to go to.

Craig Bijou

No, I think that was great, Albert, thank you for that. And maybe just following up with a couple quick ones on the P&L side with your comments with with the with the script, you talked about just against a higher variable sales commission. So wanted to get and just a little bit more color on that. Is that something that's being driven by maybe competitive hires or or competitive hiring in the market? And then secondly, and sorry if I missed this, but the cadence for your EBITDA during the year, I mean should we think of Q1 and the investments that you made should should the cadence improve sequentially throughout the year?

Albert DaCosta

It absolutely. On the last part, there was an increase due to the variable commission piece of it, just the increased sales driving that there were some investments in bringing on new sales folks that also reflected in that number. We had some R&D spend, we had some additional headcount and we had some external professional services fees that that also impacted SG&A. Did I answer the EBITDA part of it? We are 100% expect the year sequentially to improve over Q1.

Craig Bijou

Okay. Thanks for taking the questions.

Albert DaCosta

Yes, of course. Thank you.

Operator

Mike Matson, Needham & Co.

Mike Matson

But I guess what I'm wondering is you're mentioning that you expect to leverage it, but does that just mean it will kind of stay flat and new sales will increase or were there because of these rep hires? Were there any Kinosis come one timers in there like Keno upfront payments or something like that, that caused the dollar amount to actually be higher of this quarter that it will be in future quarters?

Albert DaCosta

Yes. Thanks for the question. Mike. Maybe I'll pass that one to Chris.

Krissy Wright

Yes, absolutely. Hi, Mike. Nice to meet you. In terms of our total OpEx spend as a percent of revenue. We do expect that to of our sequential quarters from what we see in Q1, both as a result of an increase in revenue and as a result of leveraging our operating expense investments we've made in Q1 and prior quarters over the remaining quarters for 2024.

Mike Matson

Okay. So my interpretation of what you're saying is that don't expect the dollar amount of OpEx to go down, but the it should at least be stable, stable, it has high test and the revenue grows. And so then you get leverage is that kind of what you're saying? I mean that the run rate of OpEx stays in kind of the low 60s. Is that a reasonable assumption there.

Krissy Wright

But that's a reasonable assumption we get leverage as the growth on that operating expenses is a slower growth rate than the growth rate on revenue.

Mike Matson

Okay. Got it. And then you did launch a number of products kind of in that the funny end market on I think you're saying that, you know, those products along with some of the other products you introduced. So the buyer part of last year and early part of this year haven't really contributed yet. But I just wanted to see if you're seeing any kind of share gains or anything like that funding category as a result of that fund pneumatic and some of these other products?

Albert DaCosta

Yes, absolutely. I'll tell you, our forefoot franchise continues to grow nicely and on those products in particular, we believe we are definitely taking some share with some of the newer entrants like the MIS. A bunion portfolio has just been received really, really well. I think we we really hit a sweet spot with patients' interest rate, what patients are looking for. And so that product is doing really well. It's exceeding our expectations.
Combination of that with the FJ. 2000, the power console that really delivers the perfect torque and speed for the bird to do those MIS procedures. That tandem has just been really well received it is early in the cycle. We launched that really in Q1. And so the normal ramp-up of a product, we would expect more meaningful contribution at the end of the year.
But I wouldn't underestimate to the power of the excitement around those products, bringing surgeons to medical education right now and reminding them of other products that they might not have either been aware of or they wasn't top of mind. And so that the power of new products and the energy it generates has always been really good for us.

Mike Matson

Okay. Got it.

Albert DaCosta

You've got it. Thanks.

Operator

Brandon Vazquez, William Blair.

Justin Lin

Hi, good afternoon. Guys. This is actually Justin Lin on for Brandon. I'm thinking kind of beyond your short term EBITDA commentary here longer term, what are some of the levers you can pull to maybe make the business more profitable? Is that as simple as kind of increasing volume and naturally growing into that fixed cost infrastructure or is it more nuanced?

Albert DaCosta

Justin, I'll pass that one to Christi as well.

Krissy Wright

Kathryn, nice to meet you. I think you're on the right track as it relates to leveraging our operating investments that we've made historically in G&A as the Company became public. We had to make significant investments to upgrade our systems and processes. And over time, we'll be able to leverage those investments to a greater degree selling and marketing obviously has some opportunity for leverage as well. But as we grow, we'll look for those opportunities to be as efficient in the fixed cost structure there.
And as Albert has mentioned multiple times. Our focus on investing appropriately in innovation and technology will continue to be a focus for us. And I would expect us to have consistent investment as a percentage of revenue on R&D for the foreseeable future.

Justin Lin

Got it. That's helpful. And I guess, can you maybe talk about your hiring plans for 2024 in the U.S.? So the accelerated investments that you talked about. Does that include maybe hiring more reps than you were originally thinking? I think the Street models have you adding a little more a little bit more than I think, 20 reps this year. Curious to hear your thinking behind that INPUT?

Albert DaCosta

Yes. The one thing we don't normally communicate is the number of reps that we're anticipating bringing on, if you remember the the report, the reported information that we give is the producing rep count and then there can be some seasonal fluctuation in that number. But that's really where we see the impact. Sometimes when you bring new folks on, there's a period of no productivity as they're getting situated, they're learning the products they're getting familiar with the hospital systems.
And so we really look at when people start becoming producing reps. And that number, if you remember, is a person who sells a product in each month of a quarter. And that's the number that you see that we measure and we communicate out that we think is really meaningful to a direction about where we're going. And there's still a lot of room for us to increase that number. I wouldn't say doubling where we are today. It's short of that likely, but we still have a lot of opportunity to keep expanding our sales force in the U.S. And honestly, geographically and internationally as well.

Justin Lin

Understood. Thank you.

Operator

Dave Turkaly, Citizen's JMP.

Dave Turkaly

Albert, maybe just to push a little bit on the bundling commentary. I know you don't typically speak a lot about the subsectors specifically, but I'm just curious if you think yes, market is still that one of the highest growth of the five, let's say, subsectors. And I was wondering if you might be able to comment like we have had was that a double digit grower for you in the quarter?

Albert DaCosta

Yes. Hey, Dave, and thanks for the question and maybe the best way to answer this. I think kind of going back if one of the things we're really becoming sensitized to more than ever is the pathway to bunion is pretty unique. There's a lot of different pathways that lead to a bunion, right? So some people are born with them. Some people develop them later in life from Wayne, around shoes, some people or a flat foot derivative of a bunion.
You've got a what's called a medic that this category of bunion people who are born with Club fee. And so there's those pathways each have very different considerations and honestly, very different deformity patterns, right? And so Paragon's approach to bunion solutions has always been it's not one size fits all, but it's really tailoring solutions to the needs of each of those unique pathways. I think there's probably no one better than Paragon 28 in that particular sense.
And I think that concept is working and has worked for us really well in the absence of reporting the exact growth for us. I could say all of our subsector segments continued to see really strong growth in all of our investments in R & D, still our blended across all of the subsegments of foot and ankle. That's one of our proudest moments, right?
The bunion market happens to be a really complicated and a very big market that is growing nicely on the ankle market is also a really nice growing market. You know, flat flip in the PCFD. So I none of my babies, I don't call any of my children have favorites. And it just so happens that we've launched a really nice cluster around the bunion and forefoot segment over the last few months, and we happen to be and feel a lot of great energy around that.

Dave Turkaly

Thank you for that. And then I have two quick follow ups. I think for Christie beta and any other days changes that we should be aware of two three and four Q. And interest expense of $2.6 million, is that kind of what we should expect as we move throughout the year? Thank you.

Krissy Wright

Do you mind repeating the first part of your question? I think I missed one of the words while you're thinking of perhaps what it is? I'll answer the second part of your question first on. Yes, I would model interest expense consistent with Q1 in terms of our outstanding debt for the remainder of the year.

Dave Turkaly

Do you have heard from me is just on the number of days, like I think you said there was one fewer in 1Q and I'm curious, it is any other deltas into three or 4Q that we should be aware of in terms of selling days in Q2?

Krissy Wright

Yes. Thank you so much. I was curious of whether it was days sales outstanding or days of inventory, but billing days as it relates to Q2, there are two billing day difference between 2024 and 2023. And for the remainder of the year, it's pretty consistent year over year.

Dave Turkaly

2Q has two more to that days two more.

Albert DaCosta

We added a headwind in Q1 of about 200 basis points and we expect a tailwind for the remainder of the year.

Dave Turkaly

Thank you for that, of course.

Operator

Caitlin Cronin, Canaccord.

Caitlin Cronin

Hi. Thanks for taking my questions. And just a quick one to start off. You noted that the lab has client base currently in limited release, when do you expect full launch product?

Albert DaCosta

Yes. Hey, Caitlin, and thanks for the question. I just want to point out that I'm actually wearing a shirt that says buy Nomadik. So I'm supporting the product and that product has been written. And I feel like I'm saying this about everything, but that product has been really well received. I think we really addressed some limitations that existed out there and the reproducibility of that system is phenomenal. So one generating a lot of excitement. Two, we're expecting a more fulsome launch coming up here in the next few months, and I'd likely target mid midyear to see that.
And we have Hi, high aspirations about what that's going to do.

Caitlin Cronin

As some of you know, U.S. revs were up just a little light, even considering the selling day and the comp impact in Q1 anyway, dynamics call out there?

Albert DaCosta

I don't know that I could call out any unusual situations in the quarter. It was really, really nice for us to see that sequential step-up from again, that's a little bit uncommon for Q1 versus Q4. There is some fluctuation typically around Q. one can see some some fluctuations around the fracture fixation market in particular. And but given given the headwinds of the fewer selling days and the sequential growth. I think we're pretty thrilled about that performance there.

Caitlin Cronin

Thanks much.

Albert DaCosta

And one thing to point out. Yes, I think I think we mentioned that in the prepared remarks, but Q1 of '23 was our toughest comp. I mean, we we grew it was at 27% constant currency in '23 Q1. So to see the growth that we achieved in Q1 this year was really and really powerful piece for us.

Caitlin Cronin

Okay. Yes. Thank you.

Operator

Thank you for your question. There are no additional questions waiting at this time. I would now like to pass the call back to management team for any further remarks.

Albert DaCosta

Yes. Thank you all again for your time today. And if you have any further questions please reach out Otherwise, we look forward to seeing many of you at future investor conferences and industry conferences. This concludes our call. A great day. Thank you.

Operator

That concludes today's call. Thank you for your participation, and you may now disconnect your lines.