SHOULDER INNOVATIONS, INC. (SI) Q1 2026 Earnings Report, Transcript and Summary

Welcome, ladies and gentlemen, to the first quarter 2026 earnings conference call for Shoulder Innovations. [Operator Instructions] Please note that this conference is being recorded and will be available on the company's website for replay shortly. I would now like to turn the call over to Sam Bentzinger, Investor Relations at Gilmartin Group, for a few introductory comments. Please go ahead.

Good afternoon, and thank you for participating in today's call. Joining me from Shoulder Innovations are Rob Ball, Chief Executive Officer; and Jeff Points, available on the Investor Relations section of the company's website. Before we begin, I'd like to remind you that management will make remarks during this call that constitute forward-looking statements within the meanings of federal securities laws and that these are being made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Any statements contained in this call that relate to expectations or predictions of future events, results or performance are forward-looking statements. These statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements. Accordingly, you should not place undue reliance on these statements. For a full list and description of the risks and uncertainties associated with our business, please refer to the Risk Factors section of our most recent annual report on Form 10-K and in our other filings with the Securities and Exchange Commission. Additionally, during this conference call, the company will discuss certain financial measures that have not been prepared in accordance with GAAP. This non-GAAP information should not be considered in isolation or as a substitute for or superior to results prepared in accordance with GAAP. Please refer to the tables in our earnings release for a reconciliation of these measures to the most directly comparable GAAP financial measure. This conference call contains time-sensitive information and is accurate only as of the live broadcast today, May 13, 2026. Shoulder Innovations disclaims any intention or obligation, except as required by law, to update or revise any financial projections or forward-looking statements, whether because of new information, future events or otherwise. With that, I'll turn the call over to Rob.

Thanks, Sam. Good afternoon, everyone, and welcome to our first quarter earnings call. I'm very pleased to report that 2026 is off to a strong start. Through the first few months of the year, we've rapidly onboarded new surgeons, deepened utilization within our existing customer base and achieved several important product milestones. This performance reflects intensifying momentum across our entire organization, which enabled us to deliver first quarter net revenue of $16.7 million, an increase of 65% year-over-year and 16% sequentially. First quarter gross margin also came in strong at 77.7%. And we see further opportunity for expansion as the organization continues to mature. Given the strength of these results, our growing scale and the efficiency of our commercial organization more broadly, we've increased conviction in the trajectory of our business. And as a result, we are raising our full year 2026 net revenue guidance today to a range of $65 million to $68 million, representing growth of 37% to 44% over 2025. This compares to our prior range of $62 million to $65 million or 31% to 37% growth. Jeff will provide additional color on our outlook shortly. Our ability to deliver this growth in 2026 is grounded in the same 3 strategic priorities we discussed on our last 2 calls, which include driving adoption among new surgeons, increasing penetration in our existing surgeon customer base to increase procedural volume, and adding products to our portfolio to address the remaining unmet needs of patients and surgeons. This includes both expanding indications and enabling technology. We've made meaningful progress on all 3 priorities in the first quarter, which I'll walk through now. Let me start with new surgeon adoption. Our W-2 commercial leadership organization remains laser-focused on the roughly 1,800 high-volume shoulder specialists in the U.S. And that targeted approach continues to translate into rapid growth in our customer base of core and contender surgeon customers. We are very pleased with the new surgeon adoption trends we're seeing through the early part of 2026. And we expect that momentum to be durable throughout the year. As a reminder, we ended 2025 with 134 core and contender surgeons, up 61% year-over-year and we'll update that figure on an annual cadence. Surgeon adoption continues to be driven by focused execution from our commercial leadership team, supported by our proprietary business intelligence platform. We are increasingly seeing the brand awareness we've built in the market over the past year compound that effort. Finally, we're benefiting from the accelerating productivity gains within the W-2 commercial leadership cohort hired in 2025. To capitalize on this growing momentum, we again added top talent to our commercial leadership team through Q1 to support further scaling of our business, particularly as we secure additional hospital approvals in key new territories. We are making progress with activating these markets and believe there is significant greenfield opportunity remaining across the U.S. for our team to target. We look forward to the contributions from these new commercial leaders as they ramp over the next couple of quarters and build deeper relationships within their territories. Meanwhile, we've continued to invest in terms of new surgeon adoption coming out of these sessions and increasingly view them as an integral part of our broader commercial strategy. Excluding industry meetings, our CEME team conducted 44 total SI-sponsored educational events in first quarter. And the peer-to-peer dynamic these events create generates organic advocacy that compounds across the Shoulder surgical community. Most recently, in April, we hosted our first National Symposium of 2026 in Napa Valley. Surgeon attendance was up over 70% versus last year's event, making it the largest symposium in SI's history since we launched the program 4 years ago. These symposiums combine digastric content, case-based discussion and hands-on experience with our InSet Shoulder arthroplasty portfolio and ProVoyance's preoperative planning platform with curriculum designed, written and proctored all by surgeons. The consistent positive feedback we received from attendees at these events validates the incredible work of our CEME team in creating a true differentiator in the marketplace that's generating tangible results, both in terms of generating interest among new surgeons and helping to drive our second key strategic priority of increasing utilization and procedural growth within our customer base. For example, of the attending surgeons at our NAPA course who are not already core or contender customers, more than 70% have already either performed their first case with our system, committed to their first case or committed to increasing volume. And that progression has occurred in just a few weeks since the meeting. When looking at the first quarter specifically, total implant volume across our core contender and prospect customers increased 51% year-over-year to 2,184 units. As has been the case in recent quarters, this volume growth reflected a combination of several additional compelling dynamics. First, surgeons are entering our new customer funnel faster. In fact, in the first quarter, we more than doubled the number of new customers entering our funnel as compared to the first quarter of 2025. Second, surgeons are scaling through the funnel from prospect to contender to core at a faster pace. And third, we're seeing increased volume from existing surgeons within their current prospect contender and core categories. Within these dynamics, the standout signal is that our highest growth surgeon category in the first quarter was core, both year-over-year and sequentially, which is the strongest possible signal of where our business is heading. The one category where growth has moderated is contender. And that's by design because we are losing those contenders to core status. Importantly, even as we rapidly added core surgeons, we've continued to see increases in units per surgeon, both year-over-year and sequentially in that category. This is particularly meaningful proof point. New entrants to the core category typically join at the lower end of the volume range, which would normally compress the average. But our highest volume core surgeons more than offset that dynamic, demonstrating that our existing core surgeons are continuing to grow their utilization even as the segment expands. To ensure we continually equip these surgeons and best-in-class product portfolio, we've also remained focused on our third strategic priority of developing and launching new technologies to address the remaining unmet needs of patients and surgeons, both through new indications and enabling technology. We've had an active few months on this front to start the year. And I want to highlight a couple of specific areas of progress. Starting with new indications. Consistent with our prior communicated timing, we initiated a limited user release of our I-135RFX products in early Q1. We recently expanded the indication to include more complex fractures. And 2 weeks ago, we announced the transition of our InSet 135RFX Humeral Stem from limited user release to full commercial launch following receipt of that expanded clearance from FDA. With this broader label, the I-135 now addresses primary revision and fracture total shoulder arthroplasty cases and equally important, its addition to our portfolio means that Shoulder Innovations can now nearly support the I-135 joins the smaller form factor I-195 and I-70 launched in 2024 and 2025, respectively, as the third addition to the I-Series humeral stem product line. Consistent with those earlier launches, the I-135 is built on our exclusive InSet lateral-lateral implant philosophy, which independent peer-reviewed research has shown reduces complications and maximizes postoperative range emotion. To date, surgeons have used the I-135 in both anatomic and reverse shoulder arthroplasty configurations and consistent feedback has highlighted its ease of use, straightforward surgical technique and seamless integration with our 2 tray surgical instrumentation system. Underpinning the clinical confidence behind the 135 and our entire implant portfolio is the real-world evidence we're building to our clinical data registry. We've now enrolled over 500 patients across both anatomic and reverse shoulder arthroplasty configurations. And we continue to believe this registry will generate a robust body of evidence that strengthens our position with surgeons, health systems and patients over time. Separately on the new product front, we initiated a limited user release of our N22 Glenosphere in the first quarter and have been pleased with this reception associated with allergic reactions for metal implants. We view this as an exciting incremental addressable market and look forward to providing further updates on our full launch plans in the months ahead. Turning now to enabling technology. Since announcing in December, our strategic partnership with Interventional Systems to introduce a shoulder-specific micro-robotic solution for shoulder arthroplasty. We've made tangible progress with respect to product development and remain incredibly excited with the mid- and longer-term economic and competitive opportunities associated with this technology. As a reminder, the solution is designed to integrate directly with our ProVoyance platform to deliver a seamless enabling technology experience from preoperative planning through intraoperative execution, allowing surgeons to plan in ProVoyance and deploy that plan in the operating room as a single connected workflow. In March, we performed yet another cadaver lab, which further reinforced our conviction that Interventional Systems' technology is indeed the right product for this robotic application in shoulder arthroplasty. This particular cadaveric session encompass the entire procedure, beginning with the CT scan through ProVoyance through operating the robot, placing the device in a cadaveric specimen as intended. Product development for the robotic solution is progressively slightly ahead of schedule. We are targeting 510(k) submission in 2027. We look forward to sharing additional updates regarding timing and product features on our future earnings call this year. As a final note and stepping back across everything we've discussed today, we are increasingly finding that focused shoulder-specific nature of our ecosystem is attracting interest from partners who see the value in reaching this market through us. And that excitement is only growing as we scale, whether through programs like our robotic development initiative or best-in-class implant portfolio or the strong clinical outcome surgeons are achieving with our products. As we look ahead, we are excited about a number of near-term opportunities we see to further expand the breadth of our Shoulder solutions we offer surgeons and patients, both through our own innovative vision through the relationships that market leadership attracts. We look forward to sharing more updates on these opportunities in coming quarters. With that, I'll now turn the call over to Jeff to review our first quarter results in more detail and provide an update on our outlook for 2026.

Thanks, Rob, and good afternoon, everyone. As Rob mentioned, net revenue for the first quarter of 2026 was $16.7 million, a 65% increase from $10.1 million in the prior year. Our unique commercial model and proprietary business intelligence capabilities drove continued commercial expansion in the first quarter, resulting in increased adoption of our implant systems across new and existing surgeons. Gross margin for the first quarter of 2026 was 77.7% compared to 76.9% in the prior year. The improvement was driven by improved ASPs, along with benefits from cost reduction programs. Selling, general and administrative expenses in the first quarter of 2026 were $18.2 million compared to $10.5 million in the prior year. The increase in SG&A expenses was primarily driven by increased headcount in the commercial organization, higher variable selling expense over the last few quarters, declining from 128% of revenue in Q3 of 2025 to 109% in Q1 of 2026, demonstrating our ability to drive operating leverage alongside our accelerated revenue growth. While this trend may not continue in every sequential quarter going forward, we're focused on balancing ongoing investments in our commercial organization with improving operating leverage and increasing productivity. Research and development expenses in the first quarter of 2026 were $3.8 million compared to $1.6 million in the prior year. The increase was primarily driven by investment in new product development efforts, including a second milestone payment and development costs related to the robotic platform strategic partnership. Net loss in the first quarter of 2026 was $8.4 million compared to a loss of $4.7 million in the prior year. The adjusted EBITDA loss in the first quarter of 2026 was $7.0 million compared to a loss of $3.5 million in the prior year. The increase in both net loss and the adjusted EBITDA loss were primarily related to the increase in the aforementioned operating expenses. Our cash and cash equivalents as of March 31, 2026, were $108.5 million. As mentioned in March, we are proactively increasing our inventory and asset purchases in the first half of the year to ensure preparedness for accelerated growth. This, combined with working capital changes contributed to our cash burn in the first quarter. Looking ahead, we expect to see significantly lower cash burn starting in Q2 and continuing through the balance of 2026. We continue to believe we are in a strong financial position to continue investing in growth while maintaining our ability to achieve cash flow breakeven with cash in hand. Turning now to our guidance and outlook for 2026. On the top line, we expect full year 2026 net revenue to range from $65 million to $68 million, representing growth of 37% to 44% year-over-year. This guidance reflects our continued high degree of conviction in our ability to deliver industry-leading growth by driving adoption among new surgeons, increasing penetration in our existing surgeon customer base and through commercial launches of new products. In addition, guidance accounts for seasonal dynamics that are typical in our industry, specifically lower sequential volumes in Q3 before a step-up in Q4. Regarding gross margins, we are very pleased with our progress on margin improvement and expect similar margins for the balance of 2026, noting there could be some quarter-to-quarter fluctuations based on product mix and ASP. Cost-down initiatives remain a significant focus and area of progress, and we're confident they will continue to drive further gross margin improvement as we further scale our business. At our current full year revenue guidance, we expect SG&A expenses as a percentage of revenue to increase slightly from Q1. As our conviction around business growth increases, we will continue to identify and invest in greenfield opportunities across new geographic areas for commercial team footprint expansion. Specifically, we expect this increase in SG&A expenses as a percentage of revenue will be more significant in Q2 and Q3 before declining in Q4. Finally, with currently contemplated innovation programs, we expect R&D expenses as a percentage of revenue to moderate late in 2026. With that, I'll turn the call back to Rob, for a few closing remarks.

Thanks, Jeff. In sum, the first quarter was a strong start to 2026 across every dimension of the business. We grew net revenue 65% year-over-year, expanded gross margin, rapidly onboarded new surgeons, deepened utilization within our existing base and advanced several meaningful product milestones, all while continuing to build the clinical, commercial and product foundation that we believe will drive durable above-market growth for years to come. The commercial organization we built is performing. The market opportunity in front of us remains large and underpenetrated. And the confidence we have in our team's ability to execute has never been higher. We believe Shoulder Innovations is still in the early stages of what we can accomplish in transforming shoulder surgical care. And we look forward to demonstrating that through our continued performance throughout 2026 and beyond. With that, I'll now turn the call over to the operator for Q&A. Operator?

[Operator Instructions] Your first question comes from David Roman with Goldman Sachs.

Maybe we could just dive into the results here for Q1 in a little bit more detail, and as you kind of reflect on the sequential and year-over-year improvement here in growth. Can you just maybe detail from your perspective, what you saw transpired throughout the quarter? And to what extent that is the result of product launches, commercial execution? I'm sure it's some combination of all of the above. But maybe you could just break down what you think helped to support such a significant inflection here on a sequential basis? And I had one follow-up on the outlook.

Yes, sure. Thanks, David. Appreciate the question. We certainly saw contributions in our growth in Q1 from all segments that you described. So obviously, the key priorities that I described in the call kind of are the key ones that are driving the growth. And so kind of we're executing as expected. New customer growth is obviously a meaningful contributor to what's driving growth and what drove growth in Q1. But that was also supported by kind of very nice volume increases from our existing customer base and some additional increase associated with average selling prices as well. So all of those were key components of growth. I'd characterize that that's all a function of just downright excellent execution across the entire organization, particularly in the commercial organization. And the way they worked together with the CEME team, kind of leveraging our business intelligence platform. We're identifying the right targets to invest and spend time on and that's just producing results, quite frankly.

Maybe if I kind of translate that into the outlook here, appreciating Jeff's comments on seasonality for Q3. But as I look at the number here in Q1 and try to kind of square that with the guidance you're given, even when considering the seasonality dynamic, it does look like a relatively conservative representation of the outlook. So maybe you could help us understand of the things that you saw go well in Q1? What have you translated to the balance of the year? What have you sort of risk-adjusted in your outlook? And how are you thinking about the risks and opportunities in the updated guidance here?

Yes. Thanks for the question, David. So obviously, we're really pleased with Q1. We had a great quarter. We're off to a great start for the year. The guidance that we're giving, obviously, it's an annual number. We're still very early in the year. And so as we set that annual guidance number, it's a number that we have high conviction around when we set that. And again, there's lots of variables and inputs that will go into that as far as what will drive annual results as far as like will ASPs stay where they're at, units, new customers, et cetera. And I think we've considered all those as we've kind of set the annual guidance number.

Maybe just if I could just push there just a little bit more. Is there anything here that you're -- it doesn't sound like you're seeing anything in the business that would contemplate a worsening of those metrics. It just happens to be early in the year, so you're taking a balanced approach. Is that a fair way to summarize the outlook?

I think that's very fair. I mean, I think we're providing guidance that we have a very, very high degree of conviction in. We obviously are kind of excited about the performance we were able to deliver in Q1. And we don't see -- we don't have any view of any perspectives in the marketplace today that kind of fundamentally change our view on the trajectory of the business.

Your next question comes from Ryan Zimmerman with BTIG.

Congrats on the quarter here. Kind of lifting off where David finished on the quarter. I'm just wondering, Rob, you're getting really good growth and you're getting really good conversion in your core contender segment of the business. But as you scale, I have to imagine and I appreciate your thoughts on this, that there is a bit of a broadening of the customer base. And so as I think about this kind of contribution from the prospects or the noncore contenders, how do you see that changing over time? Because I would imagine that it is, as numbers grow, a little harder to move into that core contender segment, but I may be wrong.

Well, I think, Ryan, your question -- I appreciate the question first. And it may be well received if we were a lot further ahead of where we are right now. I mean, so we've characterized the market as we're focused on high-volume surgeons. There's 1,800 of those. Obviously, we reported at the end of last year, 134 corn contender. And so we just perceive ourselves of having a long, long way to go. I'd also like just to characterize that we are focused on building a platform here. This isn't a product. And so we see that platform as a substantial foundation through which to continue to deliver both arthroplasty and other products. So not only do we see that opportunity for growth and continuing into that core and contender network in a meaningful way. We continue to -- we believe we'll be able to continue to drive additional revenues through that channel as time goes on. So hopefully, that's helpful.

The ASPs were ahead of where we thought they would be. Is that a reflection of new indications and higher ASPs per case? Is that a reflection of a higher mix of reverse shoulders? And what do you think about the durability of the ASP this quarter relative to the balance of the year?

Yes. I'll make a couple of comments here from a product perspective and let Jeff follow-up on his thoughts on durability based on the metrics. I think we -- I've shared in the last couple of calls that we have been focused on delivering improvement in average selling prices, and we've indeed focused there and have executed there. And that's through a function of identifying the right centers to spend time on where we can drive higher prices. I'd also say it's a function of our commercial organization becoming more skilled at navigating the negotiation with those centers and selling into the SKUs, if you will, with -- that augment price, I'll put it that way. And so that's been a really helpful dynamic as we've learned as an organization collectively on how to do that well. And so that's obviously resulted in a great outcome here. I think we are characterized as just ever so slightly ahead of schedule as it relates to new products in Q1. And I'd characterize, as I have before, that those products do have higher ASPs. And that contributed in a very small way in Q1 to the average selling prices. Now we're hopeful that can have a more meaningful contribution in out years, I'll put it that way, more so in '27, if you will. But it did play a very small role here in the quarter. Jeff, I'll let you...

Yes. I'll just say, Ryan, that I would expect there'll be some variation as we go forward in ASPs. Obviously, we saw a really nice increase here in Q1, which contributed to just gross margins as well. I mean the higher ASPs along with the cost down programs kind of starting to kick in, improve gross margins. But I would expect the ASPs to kind of stay in this neighborhood as we go throughout the rest of the year.

Your next question comes from Matt Taylor with Jefferies.

I just wanted to double-click on -- you made a lot of comments about the robotic system and the progress you're making there. Maybe you could just talk about how you're expecting that to start to contribute either to the stickiness of your business or your ability to drive even more share and give some thoughts on how it's really differentiated from some of the other solutions in the market.

Sure. So I appreciate the question, Matt. So I think kind of I'll start with the end of your question first. From a differentiation standpoint, we were focused on a number of things to deliver to the market with respect to robotic-enabling surgery. And indeed, I think we're accomplishing that. One is we wanted to develop a platform that was completely time transparent, leverage the exact same surgical techniques that surgeons use today. So there was no ambiguity about the fact that we could indeed drive optimized outcomes. And so that is a key differentiator for us. It's a very simple platform that indeed will be time transparent. The second differentiator we wanted to make sure that we delivered was the fact that the system was kind of able to provide a fundamentally different economic model to the marketplace. More thought of as robotics as a service instead of a capital acquisition. And so that requires that it be a portable platform. And indeed, that is indeed what we're delivering. We will provide the robotic on an event-by-event basis in a case about the size of a care use case. So I think those are 2 components of differentiation that are particularly special as it relates specifically to the shoulder arthroplasty market that's going to kind of provide a lot of traction. I'd characterize that as we have continued to do customer discovery with those differentiators in the marketplace, we have received a resounding yes as it relates to answering one of which has been engaging with our current surgeon customers about the excitement of that future and them being excited about. The another impact of that platform has been really, quite frankly, an entirely new innovation cycle that we consider built around robotics, which I think is going to be quite exciting. I've shared a little bit about that recently. And I'm planning here to share more here in the next couple of quarters in more detail.

Your next question comes from Matthew O'Brien with Piper Sandler.

I mean just to follow-up a little bit on both David and Ryan's question on the outlook for the year increase. And Jeff, based on what you're saying on the pricing side, it seems like most of the bump is just due to price over the next several quarters. But it seems like the volumes were, again, much better than we were modeling in Q1. So is there something else you're factoring into the guide? I don't know if it's the robotic competition or any sales churn or something else that we're just not thinking about that would potentially impact the outlook for the year? Or to David's point, is it, hey, it's just early in the year and we're just trying to be as conservative as possible.

Yes. Thanks, Matt, for the question. So in my prepared remarks, I talked about seasonality in Q3. That's obviously very common for our industry. We would expect Q3 to be lighter and then have a step-up in Q4. I will say as well that our ASP is somewhat dependent on the reverse percentage. So that obviously is a little bit lower as you get later in the year due to payer mix. We saw that in Q4 of 2025. We'd expect to see the same in 2026. So that could be a little variation that I mentioned earlier as we get later in the year. So -- but there's nothing else that I would specifically mention. Obviously, we expect to continue to drive units. ASP should kind of remain durable for the ongoing foreseeable future and we're feeling really good about the business.

Yes, for sure, we are feeling good about the business. I'll just double-click on something that Jeff said in the prepared remarks that we have deployed a fair amount of cash here in Q1 related to both kind of inventory and assets and leaning into the commercial organization. And I'd characterize that the purpose for that is being very prepared for above expectations growth and to find ourselves not in a circumstance where we can't support a business that continues to accelerate. So I'll just kind of emphasize that indeed, we prepared ourselves for the opportunity that things go a lot faster and to make sure that we aren't constrained in our ability to support even higher levels of growth.

Jeff, on the gross margin side and the update tonight, well above what we were modeling for gross margin here in Q1 and a stable outlook there. I don't want to go out too far. But just looking at that metric, looking at some of the leverage we saw in SG&A specifically in Q1 and then your commentary about R&D ramping down later this year. Is it -- are we getting to the point where we can start talking about Shoulder reaching EBITDA profitability maybe earlier than other orthopedic companies historically have or kind of TBD there?

Yes. Obviously, Matt, we're not providing any sort of threshold on that. But we're not providing a revenue threshold or a time line. But obviously, with the profile that we have, you've got a really strong margin profile. Obviously, we're starting to see leverage in kind of the SG&A line. We're demonstrating that. We believe we're on track for that. And we're balancing our investments that we're making with long-term profitability. And so you'll likely, over time, see continued progress in that area.

Yes. I'll just -- I'll lean into that a little bit harder. I'd say that I don't know, Matt, what compared to others means. And the natural consequence of building a business like that is above-market performance as it relates to EBITDA. So I mean that's by design. That's our intent here.

I mean I can be more specific, Rob. I mean it's like $200 million, $250 million historically, most of these companies turn profitable. I don't want to put you -- put a number out there for you. But it would seem like you're likely earlier than that.

We're not going to put a number on it either, Matt. But I'd say most particularly because to the extent that we are effectively deploying capital, we're going to continue to effectively deploy capital.

There are no further questions at this time. So I'll hand the floor back to Rob Ball for some concluding remarks. Thank you.

Thank you very much, operator. I just appreciate everyone engaging today. I appreciate the questions from the analysts. And I'm hopeful that we provided you some encouraging news around our trajectory. And we're excited to share again with you here in a couple of months. So everyone, have a great afternoon.

Thank you. And this concludes today's conference. You may disconnect your lines at this time. Thank you for your participation.