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OrthoPediatrics Corp. (KIDS -4.04%)
Q3Â 2020 Earnings Call
Nov 6, 2020, 8:00 p.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Welcome to the Quarter Three 2020 OrthoPediatrics Corporation Earnings Conference Call. My name is Holly, and I'll be your conference operator today. After the speakers' remarks, we will have a question-and-answer session. [Operator Instructions] Please note that this conference is being recorded. I will now turn the call over to Jan Medina. Jan, you may begin.
Jan Medina -- Senior Vice President
Thank you, Holly, and thank you everyone for joining today's call. With me from the Company are Mark Throdahl, Chief Executive Officer; Fred Hite, Chief Operating Officer and Chief Financial Officer; and David Bailey, President.
Before we begin, I would like to caution listeners that comments made by management during this conference call will include forward-looking statements within the meaning of federal securities laws, including the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements involve material risks and uncertainties, and the Company's actual results may differ materially. For a discussion of risk factors, including among others, the risks related to COVID-19, the impact such pandemic may have on the demand for the Company's products and the Company's ability to respond to the related challenges, I encourage you to review the Company's most recent quarterly report on Form 10-Q, which will be filed with the Securities and Exchange Commission soon.
During the call today, management will also discuss certain non-GAAP financial measures, which are used as supplemental measures of performance. The Company believes these measures provide useful information for investors in evaluating its operations period over period. For each non-GAAP financial measure referenced on this call, the Company has included a reconciliation of the non-GAAP financial measures to the most directly comparable GAAP financial measures in its earnings release. Please note that non-GAAP financial measures have limitations as analytical tools and should not be considered in isolation or as a substitute for OrthoPediatrics' financial results prepared in accordance with GAAP.
In addition, the content of this conference call contains time-sensitive information that is accurate only as of the date of the live broadcast, November 5, 2020. Except as required by law, the Company undertakes no obligation to revise or update any statements to reflect events or circumstances that take place after the date of this call.
With that said, I'd like to turn the call over to Mark.
Mark Throdahl -- Chief Executive Officer
Good morning, everyone, and thank you for joining us today on our third quarter 2020 earnings conference call. I'd like to begin by recognizing all our OrthoPediatrics associates for their tremendous effort, which has produced the strong results during the recent quarter, including record revenue and improved EBITDA. The pandemic continues to pose challenges, particularly in some overseas markets, but our associates have been able to excel during these times of unprecedented difficulty. While the operating environment remains highly uncertain, the positive momentum we have seen since May accelerated during the recent quarter and has continued into October. We delivered accelerating growth in United States, improved our gross margin, and produced improved EBITDA and positive adjusted EBITDA.
This morning, I will begin by providing an overview of our results by geography and product line, including our thinking on procedure recovery rates in the U.S. and abroad. I will then discuss our recent acquisitions, following which I'll comment on additional progress and factors driving our business. I'll then turn things over to Fred for a detailed financial review and the guidance for the fourth quarter, and we'll then open the call up to your questions.
The U.S. recovery, which began in the second quarter, continued to accelerate in the third, and we achieved domestic growth of 17% year-over-year with Trauma & Deformity and Scoliosis growing in line with total domestic sales, and Scoliosis increasing total users 33% on a year-to-date basis over third quarter 2019. This was a tremendous improvement over the 12% decline seen during the previous quarter. Moreover, U.S. sales continued to accelerate monthly during the third quarter, and we have seen consistent increases in domestic sales every month since April's sharp decline. October domestic sales continued strong, and we -- and confirm that we are clearly on an upward although choppy trajectory. However, we are concerned by the recent spike in COVID-19 cases nationally and cannot predict whether there will be another deferral of elective surgeries in this country. As we consider the final quarter of 2020, we believe we remain on a solid footing for continued strong domestic growth, which will be slightly improved over Q3's performance.
The recovery overseas continues to lag that in the U.S. Most pediatric surgery abroad occurs in general hospitals, many of which also treat COVID cases. There remains a high-degree of last minute case cancellations, which may be due to parental concerns over bringing their children to these hospitals. Additionally, given the low procedures, our stocking distributors have made little to no set purchases in Q3, and we expect the same in Q4. While international sales declined 34% year-over-year, EMEA and APAC were relative bright spots. Sales in EMEA grew 5% during Q3, driven in part by agency sales growth, while APAC was up 7%, driven in part by strong agency performance in Australia. Overall, agency sales grew 26% and accounted for half of third quarter international sales compared to 25% historically. This helped drive strong gross profit performance in Q3. Despite the recent growth of COVID cases in many countries, so far, we have seen only localized impact on elective surgeries. In addition to lagging the U.S. recovery, trends overseas are also more variable geography-by-geography, notably in Latin America, which was the Company's sole disappointing region in Q3. Continued challenges notwithstanding, we remain committed to the region, and we are continuing our aggressive training programs and surgical society support.
Moving on to revenue contribution by business. Trauma & Deformity sales increased 8% for the third quarter. Domestic sales were driven by very strong trauma growth and encouraging signs of recovery in elective deformity correction surgery. PNP Femur, Cannulated Screws, and Orthex all contributed substantially to domestic sales growth as well. Worldwide Scoliosis sales increased 1%, with domestic growth in line with overall U.S. sales growth, driven by RESPONSE and FIREFLY as well as a 33% increase in total users year-to-date compared to prior year. Sports Medicine & Other grew 56%, reflecting contributions from Telos Partners.
Turning to acquisitions. While representing a small percentage of our sales, we remain pleased with the revenue impact of Telos, which won several multi-year consulting contracts with new medical technology clients. We acquired Telos in March to bring into the Company state-of-the-art expertise on regulatory trends and clinical trials management. And this expertise is highly sought after in the COVID-19 environment. While we manage Telos on an arm's length basis, so its clients can be assured of confidentiality, we have benefited from Telos' knowledge that enables OrthoPediatrics to gather clinical data on our surgical systems, and anticipate future regulations in a sure-footed manner.
Orthex continue to deliver strong growth with a number of new users and sales agencies performing their first cases 50% of our U.S. sales force is now actively supporting complex external fixation surgery. Orthex was recently approved in Australia, where we're now booking cases. We anticipate launching Orthex in Europe with the CE Mark in Q1 2021, and in preparation, are hiring a European Orthex Sales Director to handle the strong demand we are already seeing. It is clear that the Orthex acquisition, our first, is producing synergy with the extensive line of internally developed surgical systems we have launched since the IPO, thus increasing our credibility as the supplier of choice to pediatric hospitals.
Acquired in April, ApiFix represents another selective technology acquisition that can increase the scale of our Scoliosis franchise, which has grown between 20% and 40% annually over the past years. ApiFix is one of two recently approved non-fusion technologies and represents a revolutionary approach to how Scoliosis is treated. As a reminder, earlier this year, we received FDA approval to expand the label to 35 degrees to 60 degrees or progressive curves from 40 degrees to 60 degrees previously. This allows the ApiFix system to compete head-to-head with spinal tethering, the only other non-fusion technology approved for use in skeletally immature patients. However, ApiFix is a much simpler surgery than spinal tethering, which comes with a significant learning curve.
As with Orthex, from a return on capital perspective, we anticipate benefiting from very high revenue contribution per dollar of set inventory. To date, ApiFix sales have not been material for the Company, but we anticipate this changing next year. ApiFix has achieved significant milestones in its short time with OrthoPediatrics. The system is now in various phases of IRB approval at 20 sites in the U.S. Of these 20 IRB sites, seven are now fully approved to conduct surgery having received both IRB and registry approvals. We anticipate that the balance of the sites will be fully approved by year-end or early 2021. Nine surgeries have occurred at four sites and each case has been an unqualified success. The other three recently approved sites have scheduled cases, which will be completed very soon. Surgeons are responding enthusiastically to the results they can achieve with ApiFix. Correction is comparable to fusion, but with a much simpler surgery and reduced procedure times. Cases are completed within several hours or less. Surgeons also like the short hospital stays for patients, which range from 24 hours to 48 hours, as well as the fast post-op recovery times. We expect IRB sites to continue their internal approval process with surgeries commencing in most of the 20 hospitals by year-end or early 2021. We have agreed with FDA that the first 200 patients in the U.S. will be included in a registry, and we anticipate that these cases will be completed by mid- to late-2021.
Switching gears to factors enhancing our competitive advantage, the pandemic has thus far proven to be an excellent opportunity for strengthening our industry-leading position in pediatric orthopedics. The Company has remained committed to supporting our patients and surgeons with no reductions in financial support of important surgical societies, in stark contrast to other industry sponsors. In Q3, this included maintaining our Gold Level support of the Scoliosis Research Society, our Platinum Level support of the American Academy for Cerebral Palsy and Developmental Medicine, and our Diamond Level sponsorship of the 30th Annual Baltimore Limb Deformity Course. We grew the domestic sales organization headcount by 5% over the third quarter 2019 to 166 sales representatives. Given the uncertain environment, we are proud that our domestic sales agencies continue to make personnel investments that will drive future growth, a tangible indicator of their confidence in OrthoPediatrics and of the market we serve. As the U.S. market continues to normalize, we expect an increased number of new sales associates to be hired in Q4.
While our international business remains more significantly affected by the pandemic and we cannot predict win consistent OUS growth will return, there are a number of tailwinds that can significantly impact growth in 2021. These include significant numbers of new regulatory approvals completed in foreign jurisdictions; the launch of Orthex with the CE Mark in Europe, the launch of individually packaged sterile configurations of most OrthoPediatrics products that are now in demand by many European hospitals, and the upcoming conversion of multiple stocking distributors to sales agencies. Distributor conversion discussions are in an advanced stage in three EMEA markets, and conversion should be completed by year-end 2020 or the first quarter 2021. As a reminder, our sales agencies here and abroad -- and around the world do not take title to product, instead they are paid a commission on sales generated, but OrthoPediatrics decides on the pace of consignment of set inventories, which remain on our books. Converting a stocking distributor to a sales agency allows us to build customers directly at full hospital prices, thus doubling our revenues and gross margins. More importantly, it allows us to accelerate the pace of organic growth in the market.
Regarding inventory investment and operations, we largely maintained instrument implant set deployments with $13.1 million in investments during the first nine months of 2020 versus $13.7 million in the same period last year. We have made significant progress consolidating the number of our contract manufacturing suppliers. Several years ago, we embarked on a strategy to consolidate 80% of our implant volume in the hands of a single supplier in Northern Indiana that was equally dependent on OrthoPediatrics. This strategy has largely been implemented in 2020 giving us lower costs, greater control over quality, and increased responsiveness.
Here in Warsaw, we are now constructing a 20,000 square foot warehouse, nearly 3 times the size of the warehouse expansion completed only 18 months ago. We anticipate that the new facility will be completed in Q1 of 2021. Longer term, the current warehouse will be converted to office space for new personnel. We also expect the beta launch this year of a new mobile app that is now well along in development. This app will allow surgeons and sales consultants to access all OP's training videos, surgeon technique guides, and other information on the Company's 35 surgical systems, both before and during surgery.
We view ourselves as the market leader in pediatric orthopedics. We have recently seen a few companies announced initiatives in our market, and we welcome the wider commitment of industry to the well-being of children. However, being the market leader is more than just cherry-picking one or two lucrative pediatric products. It is more than just bundling several old products together under a new marketing banner. It is more than so-called entrepreneurial initiatives to cobble together a company that seeks a quick sale to a strategic or financial buyer. Being the market leader requires a long-term multi-dimensional commitment to innovative product development, selective acquisition of complementary technologies, investing in non-commercial clinical education, and leading the financial support of pediatric orthopedic surgical societies. Being the market leader requires a built to last strategy of steady execution that balances growth with profitability. We believe that OrthoPediatrics has continued to exercise market leadership and resiliency even in the pandemic environment, both during its shutdown earlier this year and during the improved operating environment that's followed. In the process, nearly all of our 2020 corporate objectives have tracked to plan thus far. As we consider the last quarter of the year and prospects for 2021, we believe that our market leadership and resiliency will continue to benefit our customers and our shareholders.
With that, let me now turn the call over to Fred to review our financial results and provide an outlook for Q4. Fred?
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Thanks, Mark. Total revenue for the third quarter of 2020 was a record-setting $22.2 million and a 7% increase compared to $20.7 million for the same period last year. U.S. revenue for the third quarter of 2020 was $19.6 million, a 17% increase, compared to $16.8 million for the same period last year, representing 88% of total revenue. International revenue for the third quarter of 2020 was $2.6 million, a 34% decrease, compared to $4.0 million for the same period last year, representing 12% of total revenue. With domestic sales growth accelerating during the third quarter, we are very encouraged that we could build on the momentum we carry from earlier in the summer. Outside of the U.S., as Mark mentioned, with fewer stand-alone pediatric hospitals, the ex-U.S. procedure trends are taking longer to normalize and recovery in the international market continues to lag the recovery we've seen in the U.S., which also has resulted in little to no set sales to our stocking distributors outside of U.S. That being said, international performance was strongest in EMEA and Asia Pacific, particularly with the sales of our sales agencies. The recovery overseas is also more variable with Latin America a lagging performer for OP during the third quarter.
Our third quarter revenue breakdown by product category was as follows: Trauma & Deformity revenue was $15.0 million, an 8% increase compared to $13.8 million in the same period last year. Strong growth in trauma continued to drive domestic sales, with encouraging signs of recovery seen in elective deformity surgeries. Scoliosis revenue in the third quarter of 2020 was $6.6 million, a 1.3% increase, compared to $6.5 million in the same period last year. And as Mark mentioned, our domestic Scoliosis business showed improvement during the latest quarter. Lastly, Sports Medicine/Other revenue in the third quarter of 2020 was $0.7 million, representing a 56% increase over the $0.4 million in the same period last year. Telos continues to perform very strongly. As mentioned earlier, the U.S. growth rate of Trauma & Deformity and Scoliosis grew in line with our overall domestic growth of 17%.
Moving down the income statement, gross profit for the third quarter of 2020 was $17.6 million, an 11% increase compared to $15.9 million for the same period last year. Gross profit margin for the third quarter of 2020 was 79.4%, compared to 76.6% for the same period last year. The strength in gross margin was driven by a large percentage of domestic and OUS agency sales with little to no set sales to our OUS stocking distributors as a result of COVID. Sales and marketing expenses in the third quarter of 2020 increased 5% to $9.2 million, compared to $8.8 million in the same period last year. This was driven by an increase in unit volumes sold and associated commissions in the U.S. and international markets with sales agencies. General and administrative expenses in the third quarter of 2020 were $9.8 million, an increase of 35% over $7.3 million in the third quarter of 2019. The increase in expense was primarily driven by the increased non-cash stock compensation, depreciation and amortization expenses, as well as the addition of ApiFix and Telos G&A. Research and development expense of $1.1 million in the third quarter of 2020, a decrease of 23% from $1.4 million in the third quarter of 2019. Total operating expenses in the third quarter of 2020 were $20.1 million, compared to $17.4 million for the same period last year. Operating loss in the third quarter of 2020 was $2.5 million compared to a loss of $1.5 million in the third quarter of 2019.
Adjusted EBITDA for the third quarter of 2020 was a record-setting $1.1 million, compared to $0.7 million for the third quarter of 2019. This performance was achieved in the middle of a global pandemic, with single-digit overall sales growth, and was the result of effective cost containment across all aspects of our business combined with continued strategic investments in the business, which will drive future growth. Interest expense in the third quarter was $1.0 million, compared to $1.3 million in the same period last year. $1 million expense in the current quarter includes $0.8 million for the accretion of the ApiFix acquisition instalment payments. Effectively, this is the difference between the net present value of the liability and the total anticipated value expected to be paid in the future. Separately, from interest expense, we also had a non-cash charge and other expense for the fair value adjustments of contingent considerations of $900,000 associated with the ApiFix year four payment, which is based on sales performance.
Net loss from continued operations for the third quarter of 2020 was $4.5 million, compared to a net loss of $2.9 million in the same period last year. Net loss per share in the third quarter of 2020 was $0.24 per basic and diluted share, compared to $0.18 per basic and diluted share in the same period last year.
Turning to our balance sheet, as of September 30, 2020, our cash and restricted cash was $89.7 million, compared to $114.4 million as of June 30, 2020. Related to our debt on July 15, 2020, we repaid our $20 million principal amount outstanding under our term loan agreement together with all unpaid interest and other related amounts payable. And currently, we have no outstanding long-term debt. We also expanded our $15 million revolving credit facility up to $25 million, and extended the expiration date from January of 2023 to January of 2024 at a 10% interest rate with the full $25 million currently available to us. The change in property and equipment during the third quarter of 2020 was $1.3 million, which compares to $2.0 million during the same period last year, reflecting a decrease in construction and process, which includes partial sets waiting to be deployed. Including implants, $4.0 million of consigned sets were deployed during the quarter, compared to $1.7 million during the third quarter of 2019. Year to date, we have now deployed $13.1 million of sets, compared to $13.7 million in 2019.
We now turn to our outlook. Regarding our performance during the last quarter of 2020, the Company expects overall sales growth in the fourth quarter to be similar to the third quarter of 2020. Fourth quarter sales growth in the U.S. is expected to accelerate slightly, while the international sales decline in the fourth quarter should be similar to that of the third quarter. As we discussed, the recovery overseas is lagging the domestic market, and performance by geography is uneven, particularly in Latin America. As we continue into the remainder of the fall and eye the winter months, there is also the continued dynamic of the pandemic to consider both in the U.S. and abroad.
As we continue to advance our strategic review and planning sessions, we see a number of tailwinds benefiting growth in 2021. These include robust ApiFix growth that will start to have a significant impact on our revenue. We expect Orthex conversions will continue to accelerate, both here and in Europe. Individually packaged sterile products will be launched in Europe. We will convert at least three EMEA stocking distributors to sales agencies with a doubling of revenue and gross margins in those countries. And the Company expects to continue to gain share OUS as well as within the major pediatric centers in the U.S. Consequently, while the pandemic environment will continue to evolve and potentially in unexpected ways, our proven business model, consistent and strong execution, continued focus on cost containment and our strong balance sheet all combined to provide us confidence in the future.
Let me now turn the call over to Mark for some final comments.
Mark Throdahl -- Chief Executive Officer
Thanks, Fred. In conclusion, the past nine months have been a strong reminder of how fortunate we are to serve the surgeons and healthcare providers we are proud to call our customers. We have unbounded admiration for their sacrifices as they put their lives on the line to improve the lives of children. I would also like to thank our associates throughout the world for their personal leadership that is allowed us to treat more than 188,000 children since 2008. I'm confident that our consistent execution will continue strengthening OrthoPediatrics' leading market position in pediatric orthopedics, and I'm confident that we will emerge from the COVID pandemic even stronger than when we entered it.
With that, let's turn the call over to your questions, please.
Questions and Answers:
Operator
Thank you. [Operator Instructions] And our first question is going to come from the line of Ryan Zimmerman, BTIG.
Ryan Zimmerman -- BTIG -- Analyst
Thank you. Good morning, everyone.
Mark Throdahl -- Chief Executive Officer
Hey, Ryan, how are you doing?
Ryan Zimmerman -- BTIG -- Analyst
Good, thank you. I just want to follow-up on a couple of dynamics that you've talked about. One, I think at our recent investor meetings, you talked about the dynamic in the fall, where the Scoliosis season was extended into the fall a little bit, typically done in summer, and so, I'm wondering, Mark, if you can give some commentary and thoughts around how that is playing out and what that says, maybe, about the durability or the seasonality you expect going forward here and what it could suggest for fourth quarter around Scoliosis, and then I have a follow-up.
Mark Throdahl -- Chief Executive Officer
Certainly, Ryan. Dave Bailey has actually been talking to a number of our Scoliosis surgeons personally on this issue. Dave?
David Bailey -- President
Hey, Ryan, how are you? I think what we are seeing is a bit of a tail on the summer Scoliosis season. We started to see that tail kind of continue to pick up through the balance of the end of summer and early into the fall. While it's too early to determine what the long-term ramifications are of COVID in terms of the seasonality of our business, I think what we can say is that we're very pleased with the rate of surgeon adoption of our products in the Scoliosis space, and we are starting to see a bit of a ramp into the back few months of the year here that would probably signal that we're picking up some of those cases that weren't done during the normal Scoliosis season in the summer.
Ryan Zimmerman -- BTIG -- Analyst
That's helpful. And then on this initiative to offer individually packed sterile products, is there something competitively that changed, that triggered your interest in pursuing kind of that individual packaged sterile product portfolio? I'm just curious kind of -- you've -- we've seen that in some other markets, we've seen that with some other competitors. I'm just wondering if that's something you're now pursuing more aggressively, particularly in the European market and maybe what the driving forces behind that.
Mark Throdahl -- Chief Executive Officer
I think Dave and I can both comment on that. Very quickly, my observation has been this is something we've been working on three years and has been an enormous undertaking in terms of finding the appropriate people who have been sterilized and configuring products and gaining regulatory approval to make that happen. This has been something that has been in demand in Europe for some time.
David Bailey -- President
Yeah. Ryan, this is at least at this stage is an entirely European phenomenon for us. And as Mark said, it's something we've been working on for a number of years, number of accounts and even in some countries right now that are demanding our products. One thing our products require are the products to be individually sterile packed. And while I'm not certain that the surgeons specifically are interested in that, I do believe the regulations are mandating that in the future. And so we wanted to be ahead of that curve when it was demanded of us in Europe. And so that's why we've invested in that and we're very pleased with the fact that we're near the completion of our capacity to sterilize these products and get them to our customers in Europe.
We see no demand in the United States for individually sterile packaged product beyond the fact that in certain ones of our systems, we will probably benefit in terms of our asset utilization metrics with the ability to have just the implants sterile for certain of our larger kits. And so, you may see over the coming years diversification of the portfolio, whereby some of our instrument sets might be non-sterile, but some of the implants might be sterile, which is very common in an industry, and -- but certainly internationally, we see a demand. Domestically, we see little to no demand for that within the children's hospitals.
Ryan Zimmerman -- BTIG -- Analyst
Got it, OK. And then just one -- squeeze in one more for Fred, I don't want to leave him out. The gross margins certainly were driven, it's very clear on the lack of set purchases internationally, and it sounds like that should continue at least into the fourth quarter, but following that, Fred, should we expect gross margins to revert back to maybe more normalized levels closer to the mid-seven days in '21 as you do expect stocking distributors to purchase sets potentially at lower margins into '21. Thanks for taking the questions, guys.
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Yeah, Ryan, thanks for including me. The third quarter is always our highest gross margin when you look back in history because the revenue is always the highest in the third quarter, and then traditionally, the fourth quarter revenue is always a little softer and so the margins will come down a little bit in the fourth quarter. With that being said, we do anticipate that in 2021, we will get the benefit of the more sales coming from our agencies outside of the U.S. So while 2020 has been a little unusual with the limited set sales, we do think that we can continue kind of the 76%-ish, plus or minus, gross margin next year, which is similar to what we're going to see this year as we do increase agency sales and at the same time start to sell sets at the zero margin that we've done historically.
Ryan Zimmerman -- BTIG -- Analyst
Understood. Thank you.
Mark Throdahl -- Chief Executive Officer
Thank you, Ryan.
Operator
And our next question will come from the line of Dave Turkaly, JMP Securities.
Dave Turkaly -- JMP Securities -- Analyst
Great. Good morning, guys. Congrats on the domestic rebound. I just wanted to get your thoughts quickly, obviously, you did mention some concern over some COVID hotspots. Are you seeing anything recently that gives you any more pause domestically? What are your sort of assumptions as we move in 4Q about -- do you think elective procedures and hospital shutdowns may occur again or any areas where that might be happening?
Mark Throdahl -- Chief Executive Officer
So far we're not seeing that occurring and I think that we're simply guarded as to what the future might bring. I think we would agree with others who observed that hospital stays generally are now shorter, treatment is more robust for COVID patients, and we continue to, of course, see the majority of our business occurring in pediatric hospitals that would be unaffected.
Internationally, it is a different story. In the U.K., there has begun yesterday a lockdown, a circuit breaker for the situation and that will impact the surgeries in non-pediatric centers. Italy, France, Spain are not quite as bad, but that is occurring there as well. So, internationally, we're much more guarded with regard to the impact of deferral of elective surgeries.
Dave Turkaly -- JMP Securities -- Analyst
Got it. And you mentioned the three conversions that are likely to happen. I was just wondering if you could comment on how many others are there that you could look to do, let's say, over the next couple of years.
David Bailey -- President
Yeah, Dave, it's Dave Bailey. I think that there are others. I think these three are probably the big ones for us at the moment, and so, we've really focused our attention on ensuring that we can get these accomplished, have been in the works all year. And as you can imagine, this isn't a simple process and it isn't aided frankly by COVID environment or traveling to outside of the United States has been very difficult. So the great majority of our focus has been on getting these three done, and I think we'll be very, very pleased to have that accomplished here by year-end or end of the first quarter. And I think those three markets will have a substantially larger impact than any of the other markets at least in the short term that we may choose to take toward the agency model.
That said, there are others, those would primarily be other substantial markets in Western Europe, and we are in early discussions with a few others. We may see the opportunity to do this with one or two Middle Eastern markets, but at this time, our heavy focus is really on these three markets in Europe that I think will substantially benefit us in 2021.
Dave Turkaly -- JMP Securities -- Analyst
Thank you.
Mark Throdahl -- Chief Executive Officer
Thanks, Dave.
Operator
Thank you. Our next question is going to come from the line of Mike Matson with Needham & Company.
Mike Matson -- Needham & Company -- Analyst
Good morning. Thanks for taking my questions. I guess I wanted to start with the international business, the decline that you saw there. Obviously, there is some procedural impact, but I was wondering if you could quantify or have a feel for the difference in the kind of destocking/set sales impact versus the actual procedure decline that happened there or maybe just visibility of that.
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Yeah. I think what I would say is we're very pleased by the growth that we did see in our agency sales. So those that are selling directly to the hospital up 26% is very encouraging for us, and really the large majority of the reduction year-over-year came from the lack of set sales that we have traditionally experienced as our small independent stocking distributors historically would be purchasing those sets to grow and continue to expand their marketplace. And given COVID, they are still trying to get their feet underneath them and catch up on a cash basis before they're willing to reinvest more cash into their overall business.
So the demand -- we do think that overall demand is less than what we're seeing in the U.S. because there are so many hotspots where things have slowed down, but clearly the reduction year-over-year is driven by the lack of set sales. In addition to that, I would point out that the currency fluctuations in Brazil has continued to have an impact on the business. The real is about BRL5.7, BRL5.5, in that range. It was about BRL3.5 about this time last year. So it's had a significant change in the overall cost of U.S. products being sold into Brazil.
Mike Matson -- Needham & Company -- Analyst
Okay, thanks, that's helpful. And then this move to this supplier, the 80% of your manufacturing, can you -- has that helped your gross margin or do you expect to help your gross margins and can you quantify what the impact of that is expected to be?
Mark Throdahl -- Chief Executive Officer
I think it'd be my perspective that we are not doing this to improve gross margin as much as we're doing this to improve responsiveness and the control over quality, because this is a supplier just 40 minutes from our facility here in Warsaw, Indiana. Fred, do you have any sense as to whether there is a material gross margin impact here?
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Yes. I completely agree. The main focus here is speed and getting product, particularly around our launches. But with that being said, our overall dramatic increase in volume to where we were three years ago has earned us volume discounts, particularly with this one supplier, which has helped our gross margin a little bit, but more importantly, it's reduced the amount of capital needed to deploy new sets into the marketplace. So, for example, that $13 million that we deployed this year maybe cost us $14 million three years ago, if you look at the cost we're paying today to what we paid historically.
Mike Matson -- Needham & Company -- Analyst
Okay. That makes sense. And then just in terms of the M&A pipeline, I didn't hear as much commentary on that. I know you've got a few deals. So maybe you're going to digest those, but what's the outlook there? And did the pandemic helped or hurt the M&A prospects, companies out there that are willing to sell and pricing, things like that? Thanks.
David Bailey -- President
Yeah, Mike. So I think it would be a good assessment that you made that we are going to have to digest some of the technologies that we've acquired here over the last few years. Obviously, we had a huge ramp in the Orthex business and we're aggressively still launching and deploying sets and training the sales force. On the ApiFix side, we're just -- we're not even in -- we've barely started in the first inning here on ApiFix. While the ApiFix acquisition isn't complicated -- wasn't complicated in terms of joining the organizations, certainly launching that product in the United States and around the world is consuming a lot of energy.
So I don't expect that you -- you can expect not to see anything major on the horizon at least short-term. You might see some small bolt-on stuff, particularly in the external fixation area. We really like our position with the Orthex Hexapod but there are some add-on technologies and products there that I think could strengthen our market position, but those would be very small. And we continue to be interested in partnerships, as we've said in the past, around digitization of the OR intraoperative navigation solutions, preoperative planning solutions. And so, we are always in discussions there with how we track our strategy in pediatrics, which we feel is frankly very different than how the ORs is being digitized in the adult space. But nothing major on the horizon at least in the near term.
Mike Matson -- Needham & Company -- Analyst
Okay, thank you.
Mark Throdahl -- Chief Executive Officer
Thanks, Mike.
Operator
Thank you. Our next question will come from the line of Matt O'Brien with Piper Sandler.
Matt O'Brien -- Piper Sandler -- Analyst
Thanks. Good morning. Thanks for taking the questions. And I'll start with Fred to make sure he doesn't feel left out at all.
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Excellent, thank you.
Matt O'Brien -- Piper Sandler -- Analyst
Of course, of course. Fred, so you made a lot of comments about your confidence in '21 with the set deployments and new products and ApiFix and conversions of distributors to direct. As I look at the Street numbers for next year, essentially, we're assuming that you get all the revenue you lost [Phonetic] this year back next year and then you also grow again around that 20% level for next year. So, just not wanting to get too much in the guidance for next year right now, but just from a set perspective and from a personnel perspective, can you deliver that type of performance next year where you're getting close to $100 million in sales?
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Yeah. I think the message was just relaying how strong we feel about the confidence in our business and our business model. Obviously, we have to react and our results will be based on COVID, both domestically and outside of the U.S. and we can't predict that; nobody can. But regardless of COVID, we're very confident in our ability to continue to grow the business. We have many, many really positive growth drivers that we're going to be coming online here next year and we're going to do very well to continue to take share both domestically and outside of the U.S. You're right, I don't want to get into predicting next year's revenue at this time, but I think the message is just clear that we're very, very confident, we're very pleased with the progress we've made this year in moving the business forward, in strengthening the business model, and that's going to continue to benefit us in the long term and we'll really start to see some of that kick in next year in 2021.
Matt O'Brien -- Piper Sandler -- Analyst
Got it. Okay. And then just I guess another one for you, Fred, on the instrument set side, you seem to be the zar as far as the sets go, what are your thoughts as far as set deployments are looking like into the future? Because I think -- I know in Q3, you're up at time, but I think year-to-date you're roughly flat. So should we see -- are we expecting an acceleration in set deployment here in Q4 and then into next year versus what we've seen here in 2020? And then can you talk at all about the productivity of those sets? And then I do have one more follow-up for either Mark or Dave. Thanks.
Fred Hite -- Chief Financial Officer & Chief Operating Officer
Absolutely. Yeah, so it's $13.1 million versus $13.7 million. So it's similar to what it was at this time last year. We do anticipate to continue to roll out more sets here in the fourth quarter as we continue to invest in these sets. A lot of it is focused on new products, products that have been developed or launched in the last couple of years and continuing to get more of those sets out there, which is very encouraging to see. Some of that is to our agency countries outside of the U.S. So we're investing and growing those locations as well. And we would fully expect that that will continue into next year at a similar pace.
The really encouraging part is that we talk about ApiFix, for example, or Orthex, those systems are very, very capital efficient. And so, as those two systems become larger and larger percentage of our sales, the need for capital deployment will go down, and that we're encouraged by that and think that will continue to benefit from that starting next year a little bit, but definitely beyond that point. The returns we're seeing obviously will skew because of -- we look at it on a trailing 12-month sales basis, and so with this second quarter sales softness, it skews the overall return. But the bottom line is, we are absolutely pleased with the return we're getting on all the sets and particularly the new products that are being deployed in the adoption of those new products. Mark mentioned, the PNP, Cannulated Screw, PediFoots, all those systems are really, really having strong adoption and so it's driving demand for more sets, which will continue to deploy here this year and next year.
Matt O'Brien -- Piper Sandler -- Analyst
Okay. Well, that's really encouraging. And then I guess the last one, again, for either Mark or Dave, on those -- on ApiFix, specifically, given how excited you are about that product, can you talk about those 20 IRB sites? Are they all existing customers or any of them new customers to OrthoPediatrics because of ApiFix? And then if they're not, if they're all existing customers, are any of those -- historically, they've been smaller customers but because of ApiFix and the opportunity there, they could be much, much bigger customers for OrthoPediatrics going forward? Thanks.
Mark Throdahl -- Chief Executive Officer
It's a mix, Matt. There are some existing customers, there are number of new customers. Most interesting to me is there are a number of new surgeons who have never used OrthoPediatrics response system. And so we would expect over time that there would be a pull-through of our conventional Scoliosis fusion technology as these surgeons get to know us as a supplier and they see the outstanding service that our sales representatives might provide them. Do you have any other comments, Dave, more specifically?
David Bailey -- President
Yeah, Matt, so I think we are really bullish about the opportunity to pull through a number of response cases in the next few years from these accounts. I would say more than half of these accounts are not active users of the response system. So -- and there are, as you know, a very substantial accounts with very substantial well-known key opinion leaders. So while they may be using our trauma and limb deformity products, they haven't historically been active users of the response system.
And even in some of these accounts, Matt, we have struggled historically to get our product or the response product approved, because the potential contracting obligations they have with another supplier like a Medtronic or DePuy. And we're in a good spot now in that circumstance, because if you remember correctly, the ApiFix device requires the use of two response screws. And so, to use the ApiFix device within an IRB site, that site is also required to approve for use on contract the response system. And so this gives our sales force a very nice hunting license into some substantially large key accounts that have historically not -- we've historically been shut out due to contracting. And so that was one, well, really a -- one of the drivers short term for the acquisition of ApiFix beyond how it's going to impact the lives of children through a non-fusion technique.
Matt O'Brien -- Piper Sandler -- Analyst
That's very helpful. Thank you so much.
Mark Throdahl -- Chief Executive Officer
Thanks, Matt.
Operator
Thank you. And our next question will come from the line of Kaila Krum with Truist Securities.
Kaila Krum -- Truist Securities -- Analyst
Hi guys, thanks for taking my questions. So, you guys mentioned really strong growth in Scoliosis users. So I love to just to get your sense as to whether or not you're seeing new users grow due to excitement around MID-C or what specifically is driving that, and then just how you're thinking about that translating into stronger revenue growth in the coming quarters.
Mark Throdahl -- Chief Executive Officer
Yeah. So that's a great question. I think that it's a combination of things here. Certainly, we are tracking new users of our Scoliosis system and the response system as a result of their exposure to the spine portfolio through the MID-C. We are definitely seeing that. But I think what we are really seeing probably more broadly is just the permanence of OrthoPediatrics in the marketplace. As you know, this is really, I believe, are only our sixth Scoliosis season with the product, and we compete against companies that have been in the marketplace selling pedicle screws and these accounts for 20, 30 years. And so the fact that I think these accounts consistently see sales reps, they have extremely low turnover within our selling organization, they're being serviced across multiple different products by the same sales force, I think the trust that we're ultimately building with our customers now for six years of Scoliosis sales and 12 years of product sales with these accounts is a bit of a title wave that is every quarter, every year attracting more and more customers to our Company more broadly.
And we have good technologies on the Scoliosis side and I think it's bolstered by the add-on of technologies like FIREFLY as well as technologies like the MID-C. And we are just -- we are seeing kind of all of those influences move customers to give our Scoliosis systems a try and when they do, I think that we're seeing a lot of stickiness in people adopting the product once they give it a go. So we -- as we think about primary demand long-term, I know no other way to determine what things are going to look like in the future by just -- other than to look at the total number of people who are using your product, which are well in excess of 100 at this stage and growing rapidly and to say that when we return to a completely normal or more normal environment post-COVID, having dramatically more customers I think points to substantially increasing growth number or revenue number over the course of the long-term.
Kaila Krum -- Truist Securities -- Analyst
Great. No, that makes a ton of sense. And then I guess just on MID-C, I think you guys mentioned that you've now done nine surgeries at seven centers. Can you just give us a little bit more anecdotal commentary what you're hearing from those cases? Did those happen kind of in the last month or two? Just would love to hear a little bit more detail there. Thank you.
Mark Throdahl -- Chief Executive Officer
Sure. So, yes, those cases have really happened over the last few months and we're seeing an accelerating scheduling trend. So I believe we have that many cases, if not more scheduled between now and end of the year already. And so as we see surgeons complete their first procedure, get comfortable with the procedure, see that patient and their post-operative outcomes of that patient after a few weeks, obviously, you start to see those customers who are trying a new thing for the first time, those customers start to get more comfortable and we're starting to see booking patterns reflect that. So the outcomes here have been fantastic. We've been able to -- and again, very short term, but we've been able to get great correction with surgeries that I would say right now are averaging less than two hours, which is drastically different than a tethering procedure and even more drastically different than a fusion procedure. And we have some of our first patients now that are a few months out, completely returning to normal activities. So the feedback from the customers has been extremely positive.
More recently, we had a first user group discussion, where we had a number of the surgeons in the IRB sites that are waiting approval and that was led by one of the surgeons who has done a few of these procedures and there was very good strong participation, and the surgeon -- surgeons were very proud to share the results and their experiences with the product after the first few months.
Kaila Krum -- Truist Securities -- Analyst
Thank you, guys.
Mark Throdahl -- Chief Executive Officer
Thanks, Kaila.
Operator
Thank you. And at this time, we have no further questions at this time.
Mark Throdahl -- Chief Executive Officer
Okay. Very good. Well, let me just close by thanking all of you for joining us today. We appreciate your interest in OrthoPediatrics and of course your support for the cause of helping kids throughout the world. So we hope everyone has a safe and healthy holiday season and we're looking very much forward to updating you on our future progress. So, everyone, please have a good day.
Operator
[Operator Closing Remarks]
Duration: 57 minutes
Call participants:
Jan Medina -- Senior Vice President
Mark Throdahl -- Chief Executive Officer
Fred Hite -- Chief Financial Officer & Chief Operating Officer
David Bailey -- President
Ryan Zimmerman -- BTIG -- Analyst
Dave Turkaly -- JMP Securities -- Analyst
Mike Matson -- Needham & Company -- Analyst
Matt O'Brien -- Piper Sandler -- Analyst
Kaila Krum -- Truist Securities -- Analyst
