SI-BONE (SIBN) Q4 2025 Earnings Call Transcript

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Date

Monday, Feb. 23, 2026 at 4:30 p.m. ET

Call participants

• Chief Executive Officer — Laura A. Francis
• Chief Operating Officer and Chief Financial Officer — Anshul Maheshwari

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Takeaways

• Worldwide revenue -- $56.3 million for the quarter, up 15%.
• U.S. revenue -- $53.5 million, representing 13.9% growth against a challenging prior-year comparison.
• International revenue -- $2.9 million, up 38.8% with strong demand for iFuse TORQ.
• Full-year revenue -- $200.9 million, reflecting 20.2% growth.
• Gross profit (quarter) -- $44.5 million, an increase of 14.8%.
• Gross profit (full year) -- $159.9 million, up 21%.
• Gross margin -- 79% for the quarter and 79.6% for the full year, approximately 200 basis points above prior 2025 guidance.
• Operating expenses (quarter) -- $47 million, increasing 6.2% driven by revenue-generating activity and R&D investment.
• Operating expenses (full year) -- $182.2 million, up 8.9%.
• Net loss (quarter) -- $1.6 million, or $0.04 per diluted share, compared to $4.5 million, or $0.11, the year prior.
• Net loss (full year) -- $18.9 million, or $0.44 per diluted share, narrowed by 38.8%.
• Adjusted EBITDA (quarter) -- $5.1 million, representing a 176.2% improvement.
• Adjusted EBITDA margin (quarter) -- 9.1%.
• Adjusted EBITDA (full year) -- $8.9 million, swinging from a $5.1 million loss to positive EBITDA.
• Free cash flow (quarter) -- Nearly $500,000 generated, marking the first quarter of positive free cash flow, ahead of prior 2026 expectations.
• Cash and equivalents -- $147.8 million at year-end, increasing $2.1 million from the prior quarter.
• Physician adoption -- Record 1,640 physicians performed procedures in the quarter, an 18% increase.
• Territory manager force -- 89 quota-carrying managers; revenue per territory rose 18% to $2.1 million.
• Product launches -- Intra TI received FDA 510(k) clearance and began alpha launch; a third Breakthrough Device expected to submit for clearance in the third quarter and potentially commercialize late 2026.
• Reimbursement milestones -- Secured NTAP for iFuse TORQ TNT and TPT for iFuse Bedrock Granite, including CMS policy updates leading to a 17% increase in Medicare reimbursement for office-based labs and a new musculoskeletal APC with nearly $28 million payment for specific outpatient procedures.
• Smith+Nephew partnership -- Strategic arrangement signed to provide trauma market access at level 1 and level 2 trauma centers nationwide, effective beginning March with ramp-up expected through the year.
• 2026 outlook -- Revenue guidance of $228.5 million to $232.5 million, representing 14%-16% growth, with back-half weighting anticipated, annual gross margin of approximately 78%, and operating expense growth of 12.5% midpoint.
• ASC exposure -- 35% of SI joint fusion sales now occur in ambulatory surgery centers, up from negligible five years ago.

Summary

SI-BONE (NASDAQ:SIBN) reported double-digit revenue and profit growth, with positive adjusted EBITDA and free cash flow inflection, driven by expanding product adoption and favorable reimbursement gains. Management outlined major product launches, a new trauma segment partnership, and a broadened direct sales force as catalysts for future revenue growth. Guidance anticipates continued operating leverage and investment in innovation, with multiple tailwinds including policy shifts, commercial expansion, and new market entries positioned to support sustained profitability and addressable market expansion.

• The inclusion of the open SI joint fusion code in TPT calculation by CMS is expected to further improve reimbursement pathways.
• International launches for TNT are being brought forward to 2026 based on strong demand, advancing availability ahead of prior plans.
• Physician utilization data reveals that only 25% of SI joint fusion physicians have adopted additional procedures from the company, indicating material cross-sell opportunity.
• Leadership transitions place Nicholas Kerr as Chief Commercial Officer and Anshul Maheshwari as Chief Operating Officer; longstanding reimbursement expertise remains in-house with Jeff Ziegler’s promotion.

Industry glossary

• NTAP (New Technology Add-On Payment): Supplemental Medicare reimbursement for hospital inpatient cases using qualifying new technologies, enhancing payment for costly, innovative devices.
• TPT (Transitional Pass-Through payment): Additional Medicare reimbursement for outpatient procedures with new technologies meeting specific CMS criteria, temporarily increasing facility payments.
• 510(k) clearance: U.S. FDA process permitting marketing of a medical device shown to be substantially equivalent to an existing legally marketed device.
• APC (Ambulatory Payment Classification): CMS payment system grouping outpatient procedures into categories for facility reimbursement, updated to reflect procedural complexity.
• ASC (Ambulatory Surgery Center): Specialized healthcare facility focused on outpatient surgical care.
• OBL (Office-Based Lab): Medical practice setting where minimally invasive procedures are performed outside of hospital or ASC environments.

Full Conference Call Transcript

With that, I will turn the call over to Laura. Thanks, Saqib.

Laura A. Francis: Good afternoon, and thank you for joining us. Our strong fourth quarter and full year 2025 results validate that our innovation-led growth strategy is delivering meaningful real-world impact. We have built deep technical expertise to solve complex procedural challenges that historically led to poor outcomes for patients with compromised bone. That expertise has produced a differentiated platform of solutions including three products which have been granted FDA Breakthrough Device designation. We have consistently secured favorable reimbursement, including multiple New Technology Add-on Payments and a Transitional Pass-Through payment, confirming the superior outcomes, clinical value, and health economic benefits we deliver. Supported by world-class clinical evidence, and an industry-leading commercial team, our proprietary technologies have been used in over 140,000 procedures worldwide.

Looking at our execution in 2025, we achieved a series of major milestones that strengthened our foundation, and created powerful multiyear growth tailwinds. We generated record annual worldwide revenue of nearly $201,000,000, marking another year of over 20% growth. We reached new levels of customer engagement, with over 2,400 U.S. physicians performing nearly 22,000 procedures in 2025. The 22% increase in U.S. physicians who used our technologies in 2025 demonstrates the growing adoption, the expanded utilization, and the strength of our commercial engine. We meaningfully strengthened our reimbursement position, securing an NTAP for iFuse TORQ TNT, and a TPT for iFuse Bedrock Granite. These are critical catalysts that enhance our access, drive adoption, and reinforce platform leadership.

At the same time, we have made substantial progress on two highly compelling new products. The first product, Intra TI, was launched last week and we expect to commercialize our next Breakthrough Device in late 2026, further extending our growth runway. 2025 also marked a step change in our financial profile. We delivered our first full year of positive adjusted EBITDA, and achieved a 9% adjusted EBITDA margin in the fourth quarter. We capped the year by achieving positive free cash flow in the fourth quarter. Together, these results underscore a platform that is scaling, and is positioned to deliver sustained profitable growth.

We started this company by creating the sacroiliac joint fusion market, and we remain the undisputed market leader. Over the past five years, we have expanded in new adjacencies in the broader sacropelvic space, applying our biomechanical expertise and proprietary technology to achieve better patient outcomes. Looking ahead, the next five years represent an innovation super cycle for us, as we launch unique technologies targeting new clinical adjacencies. We are positioned to solve the largest unmet needs for patients with compromised bone, and we intend to lead this space for the long term. With a significant runway in our existing markets, and focused innovation aimed at sizable new opportunities, we are confident in the long-term growth potential of the business.

Now I will highlight the progress we have made on our four key priorities: innovation and market development, physician engagement, commercial execution, and operational excellence. Starting with innovation and market development, innovation to solve complex procedural challenges that historically led to poor outcomes for patients with compromised bone has been the primary driver of our industry-leading revenue growth of more than 20% since our IPO in 2018. We built a reputation for developing platform technologies to become category leaders in their respective markets. We offer the most comprehensive portfolio of solutions in SI joint fusion, purposefully designed to meet diverse patient needs and physician preferences.

As we continue to expand this robust offering, we are reinforcing our leadership position and deepening our commitment to innovation that addresses the needs of our orthopedic and neuro spine surgeons and a growing base of interventional spine physicians. Earlier this month, we received FDA 510(k) clearance for Intra TI, the newest addition to our SI joint fusion platform. Intra TI builds on the interventional spine physician’s posterior approach that Intra X uses, and is backed by established nationwide reimbursement. We are confident that Intra TI will improve the procedural efficiency of SI joint fusion at ambulatory surgery centers. This launch further advances our strategy to be the go-to partner across call points and sites of service.

We initiated our alpha launch last week, and expect adoption to ramp over the course of 2026 as we scale physician education and training. Intra X continues to gain momentum as the preferred percutaneous allograft solution in office-based labs. Effective 01/01/2026, Medicare reimbursement for the OBL site of care increased by 17%. The new reimbursement is nearly $14,000, reinforcing the economic attractiveness of minimally invasive SI joint fusion in this site of care. In the thoracolumbar market, iFuse Bedrock Granite has been one of our fastest-growing platforms and solidified our reputation as an innovator.

Since launch, Granite has significantly outpaced the overall deformity market growth rate, driven by new surgeon adoption and expanding use cases across both deformity and degenerative spine. The success of Granite in pelvic fixation underscores our ability to introduce true platform innovation, disrupt relatively mature markets, and establish new standards of care. Granite continues to benefit from TPT payment status, with a $0 device offset, resulting in a 100% reimbursement of facility-reported costs for Granite when used in outpatient and ASC settings. Also effective 01/01/2026, CMS approved the inclusion of the open SI joint fusion code in the TPT calculation, further expanding reimbursement path for these cases.

We are also encouraged by broader CMS policy signals that support outpatient migration in spine. Effective 01/01/2026, CMS created a new level seven musculoskeletal APC, paying nearly $28,000 for certain outpatient spine procedures. While higher acuity patients will continue to be treated inpatient, and clinical practice patterns will evolve over time, these changes reflect CMS’ continued efforts to move procedures to lower-cost settings. We believe Granite is well positioned in this environment as an objective solution to spinal fusion, particularly given the availability of the TPT. In the trauma market, iFuse TORQ TNT continues to gain momentum as highlighted by the 50% increase in physician adoption in the fourth quarter.

TNT addresses a longstanding procedural gap in sacral insufficiency fractures, where the majority of patients have low-density bone. With an intuitive workflow and up to 30% higher NTAP reimbursement in eligible cases, TNT is increasingly the preferred solution for sacral insufficiency fractures. Finally, an update on our third Breakthrough Device. We remain on track to file for 510(k) clearance in the third quarter. Subject to FDA review timeline, we could commercialize the unique product in late 2026. We believe this product will meaningfully expand our total addressable market and are excited about the clinical impact it can have and the growth opportunity it represents. Now let us move on to physician engagement.

In the fourth quarter, a record 1,640 physicians performed procedures using our solutions. The addition of 250 physicians in the quarter represents 18% growth compared to the prior-year period. This marked our twentieth consecutive quarter of double-digit growth in physician adoption. Notably, this growing physician interest spans all call points, as we observed double-digit growth across each of them in the fourth quarter.

Laura A. Francis: The number of physicians who performed procedures in 2025 as well as the prior year outpaced overall physician base growth. This substantiates that our expanded platform strategy is driving consistency. This cohort of physicians also performed more than three times the number of cases per physician compared to physicians who performed their first case with us in the current quarter. This highlights the long-term utilization potential as physicians integrate our solution into their practices and use our modalities with increasing intensity. Furthermore, only about 25% of physicians who performed an SI joint fusion procedure have adopted another procedure, highlighting a significant opportunity to further expand the use of our products.

We also expect future products to attract new physicians, while accelerating procedural density with this growing physician base. Now let us turn to commercial execution. We ended the quarter with 89 quota-carrying territory managers. Annual revenue per territory was $2,100,000 reflecting 18% year-over-year growth. This marked the thirteenth consecutive quarter of double-digit territory productivity growth. Our hybrid sales model, combining a direct sales force with over 300 third-party agents, has been instrumental in driving this productivity and enabling us to achieve strong operating leverage. In 2026, we plan to add 10 new territories while expanding strategic agent partnerships, to ensure we can fully capture the large market opportunity.

Given our success with the hybrid model, I am excited to announce that last week, we entered into a strategic partnership with Smith+Nephew, an orthopedics industry leader, to capitalize on the growing physician interest in our trauma solutions. This collaboration significantly expands our reach and accelerates our penetration into the trauma market. It will allow trauma surgeons across level 1 and level 2 trauma centers nationwide to gain access to TORQ and TNT in pelvic trauma. On the leadership front, following our announcement last August, we completed a smooth commercial transition. Nicholas Kerr has assumed the role of Chief Commercial Officer succeeding Tony Recupero, who has retired from his position as President of Commercial Operations.

Tony will remain in an advisory role for the next 12 months. Nick has been the architect of our product platform expansion, and his deep relationships with both the field and our customers positions our sales organization for continued success. Before I hand the call over to Anshul, I would like to share some additional updates. I am excited to announce that Anshul has assumed the role of Chief Operating Officer alongside his current position as Chief Financial Officer. Anshul has been leading our operations function for the past 18 months, and now in this expanded role, he will also be responsible for the IT and program management functions.

Over the past five years, Anshul has been instrumental in bringing operational excellence to SI-BONE, Inc., playing a pivotal role in driving strong and profitable top-line growth, and guiding us toward our goal of sustained free cash flow. His strategic vision, combined with his deep operational insights, uniquely position him to drive the company's next phase of growth. I am also pleased to announce the promotion of Jeff Ziegler to Senior Vice President of Market Access and Reimbursement. Jeff has developed our reimbursement strategy, playing a crucial role in securing favorable reimbursement, including NTAP and TPT for our solutions. He will continue to drive impactful results as we focus our reimbursement efforts on our new technologies we expect to launch.

With that, I will hand the call over to Anshul to provide an update on our fourth key priority, operational excellence, and discuss our fourth quarter results and 2026 outlook in more detail. Anshul?

Anshul Maheshwari: Thanks, Laura. Good afternoon, everyone. My comments today will cover fourth quarter and full year revenue growth, profitability and liquidity. And then I will walk through our full year guidance for 2026. All comparisons provided will be against the prior-year period unless noted otherwise. Starting with revenue growth, our fourth quarter worldwide revenue grew 15% to a record $56.3 million. U.S. revenue was $53.5 million, representing 13.9% growth, which was against a tough comparable prior-year quarter. On a two-year stack basis, U.S. revenue grew 20.7%, representing a 90 basis points acceleration compared to the third quarter’s two-year stacked revenue growth. International revenue in the fourth quarter was $2.9 million, growing 38.8%.

The strong international performance was driven by the stellar reception for iFuse TORQ. We are encouraged by the traction we are seeing with TORQ and are actively working to get TNT into these markets in late 2026, well ahead of our previously planned launch in 2027. For the full year 2025, we generated worldwide revenue of $200.9 million, reflecting 20.2% growth. Our U.S. revenue grew 20.6% to $191.1 million. U.S. revenue growth was driven by a 22% increase in procedure volume. International revenue for the full year 2025 was $9.8 million. Moving to profitability. Fourth quarter gross profit increased 14.8% to $44.5 million. For the full year, gross profit increased 21% to $159.9 million.

Gross margin was 79% for the quarter and 79.6% for the full year. The gross margin for the full year came in approximately 200 basis points above our original 2025 guidance. This outperformance was driven by stable ASP from a favorable procedure mix and supported by the positive impact of our ongoing operational initiatives, including improved supply chain efficiency and cost optimization. Operating expenses grew 6.2% in the fourth quarter to $47,000,000. For the full year 2025, operating expenses grew 8.9% to $182.2 million. The increase in operating expenses was mainly driven by revenue-generating activity including higher sales commission and increased R&D investment aimed at expanding our product pipeline.

Net loss narrowed to $1.6 million, or $0.04 per diluted share, compared to a net loss of $4.5 million, or $0.11 per diluted share, last year. For the full year 2025, net loss narrowed by 38.8% to $18.9 million, or $0.44 per diluted share. We delivered positive adjusted EBITDA of $5.1 million in the quarter, a 176.2% improvement over the prior year. Our 9.1% adjusted EBITDA margin in the fourth quarter highlights the scalability of our infrastructure. Adjusted EBITDA for the full year 2025 was positive $8.9 million compared to $5.1 million of adjusted EBITDA loss in 2024, representing approximately a $14 million improvement. Turning to liquidity. We exited 2025 with $147.8 million in cash and equivalents.

This was an increase of $2.1 million from the third quarter. The fourth quarter was our second consecutive quarter of positive cash flow from operating activities and the first quarter in which we generated free cash flow. We generated nearly $500,000 in net free cash flow in the fourth quarter. This was well ahead of our previously stated goal to achieve free cash flow at some point in 2026. For the full year 2025, our cash consumption was just $2.2 million compared to $16 million in cash consumption in 2024. This significant improvement, achieved while continuing to invest in surgical capacity, reflects our disciplined working capital management and our highly efficient asset-light business model.

Our robust liquidity position, consistent profitability, and recent cash flow inflection position us to self-fund revenue-accelerating investments in platform technologies targeting new addressable markets. Finally, moving to our outlook for 2026. In 2026, we expect worldwide revenue of $228.5 million to $232.5 million, implying year-over-year growth of 14% to 16%, driven by high-teens growth in U.S. procedure volume. Our guidance also assumes revenue growth to be weighted towards the second half of the year, as we expect the tailwinds that Laura highlighted to increasingly benefit the business as we progress through the year. Consistent with our guidance philosophy, we believe it is prudent to allow these tailwinds to materialize before we fully incorporate them into our expectations.

Based on the revenue assumptions, we expect 2026 annual gross margin to be approximately 78%. We expect annual operating expenses to grow 12.5% at the midpoint of the revenue range, allowing us to fund key growth initiatives including new product launch activity, planned sales force expansion, and pipeline development that we expect to commercialize in 2027 and beyond. Importantly, in 2026, based on the operating leverage inherent in our model, we will deliver increased adjusted EBITDA compared to the prior year, and remain firmly on track to deliver on our free cash flow commitments. With that, I will turn the call over to Laura.

Laura A. Francis: Thanks, Anshul. I want to congratulate my colleagues for record performance across revenue, physician engagement and profitability—you are our most valuable asset. I want to thank you for your commitment and contributions which have helped tens of thousands of patients this year improve their lives. As we look ahead, I am excited about the momentum we are carrying into 2026. With a strong foundation, a robust pipeline of innovative products, and expanding market opportunities, we are well positioned to deliver another impactful year. With that, happy to answer your questions.

Anshul Maheshwari: Operator?

Operator: Certainly. And our first question for today comes from the line of Patrick Wood from Morgan Stanley. Your question, please.

Patrick Wood: Amazing. Thanks so much for taking the questions. I will just do two quick ones. The first one on the Smith+Nephew partnership, how did that come about? How are you thinking about the potential contribution for that? And did we factor any of that into the guide?

Laura A. Francis: Patrick, it is Laura. Thank you so much for the question. We are really excited about the partnership with Smith+Nephew. And as you know, over the last few years, we have actually successfully deployed a hybrid sales model, and it has really been a key contributor as we expanded access to our solutions and it also translated into significant territory productivity gains as well. So what we did is building on that experience. We are announcing that partnership with Smith+Nephew, we understood that they had a very significant foot on the trauma side, and we have particular strengths and want to focus our team on spine and on interventional.

And so we had talked about this on our last couple of earnings calls that we were looking at large strategic distribution partnerships, and we are very excited that this one came to fruition. In terms of the partnership itself, it covers level 1, level 2 trauma centers. And it is going to allow trauma surgeons to get access to our trauma solutions and to treat these patients that have sacral insufficiency fractures. So really, for both of us, it is a win-win situation. It gives a large number of trauma surgeons working with Smith+Nephew access to our breakthrough technology.

And we do believe that it will become a standard of care for treating pelvic trauma similar to what we did with Granite in pelvic fixation. And as I said, it also frees up our direct sales force to focus more on market development and physician engagement with spine surgeons as well as interventionalists, especially given our march toward commercializing new products this year as well.

Anshul Maheshwari: And then Patrick, on your question on what is included in the guide, as we shared in our prepared remarks, trauma was a nice growth driver for us last year. It is still year one into its launch, and we saw a 50% increase in the number of physicians actually using our solution. So really excited about what this partnership can do in terms of expanding the access of our platform to these level 1, level 2 trauma sites. But it is too early. We just signed the agreement. We want to see how it seasons and matures as we go through the year.

And we will be sharing more as we go through the year on the impact it is having on the business.

Patrick Wood: Super helpful. And then just as a quick follow-up, you now have a clear clinical data set showing that the IPM physicians are getting very similar clinical outcomes to the direct surgeons on that side. Do you think that helps create more engagement on that side? Do you think the mix changes over time, or should we see a similar mix of physicians being onboarded?

Laura A. Francis: So I think what you are asking is the opportunity that we have with interventional in SI joint fusion. As you can see with the launch of our Intra product, it shows the dedication that we are making to the interventional physicians. Also, you mentioned clinical data. Our STACEY study was recently published, and showed the efficacy of our TORQ product used by interventionalists, and shows that they are able to perform these cases and have the same sorts of outcomes that we have seen in our other prospective studies as well as randomized controlled trials. But as you can tell, we are really leaning into our work with interventionalists.

We are seeing significant growth in our interventional business, and our Intra TI product really rounds out our SI joint fusion portfolio. It is going to allow physicians to use iFuse regardless of their preferred approach and implant type to fuse the SI joint. In this particular case, Intra TI is a post metal implant with piercing features. It qualifies for CPT 27279, which is clearly covered at all sites of service. And also, the posterior approach really aligns with interventional spine physicians’ workflow. And we have a streamlined single-use instrument kit, and it is going to allow us to drive procedural efficiencies, specifically in the ambulatory surgery center site of service.

So we are excited about the opportunity with interventional and with our suite of products, which includes TORQ and Intra X, as well as Intra TI.

Patrick Wood: Nice. Laura. Thanks, Hunter.

Laura A. Francis: Thanks, Patrick.

Operator: Thank you. And our next question comes from the line of Matthew Blackman from TD Cowen. Your question please.

Matthew Blackman: Good afternoon, everybody. Can you hear me okay?

Laura A. Francis: Yes.

Matthew Blackman: Great. Appreciate you taking my questions. Got two. Excuse me. Maybe, Anshul, starting with you, if I am backing into your adjusted EBITDA from some of the commentary, some assumptions on stock-based comp and maybe a little bit of math, it seems like you are guiding to somewhere north of $20,000,000 for EBITDA, adjusted EBITDA in 2026. So the first question is, is that right? Am I doing that math right? Any help there would be appreciated. And then I have got one follow-up.

Anshul Maheshwari: Yeah. Thanks for that question. So the way we have talked about it externally is if you look at our growth rate for the year from a guidance perspective, it is around between 14% to 16%, gross margins of 78% and OpEx growth of 12.5%. So rough math, that would imply operating leverage for 2026 being at 1.2 times. And there are three reasons for the operating leverage to be at 1.2 times this year. We have two new products that we want to look to commercialize this year. We are making investments in potentially putting out TNT in Europe as well in 2026.

You have a lot of training and commercial activity that goes on to drive the adoption of the technologies. That is number one. Number two is we are investing and expanding our commercial infrastructure. So as we have shared in our prepared remarks, we want to add 10 more territories. Part of that is in anticipation of these new product launches and making sure we can maximize the opportunity ahead of us. And then indexing on R&D again, growth remains a key priority for us. Laura has talked about a regular cadence of product launches that will happen between now and 2030. So we are really indexing heavily on the R&D side as well.

And on the adjusted EBITDA side, we have said we expect it to be an increase from prior year. We are not being very specific. But if you did the math, it would come not at $20,000,000, but a bit lighter than that.

Operator: Okay. I appreciate that. Then my follow-up is on Intra TI. And just thinking about its ASC-centric nature, how should we think about, or should we think about a possible halo effect from Intra TI that perhaps pulls through more of the portfolio in that setting?

Anshul Maheshwari: As the product, you know, ramps over the next couple of years? Thanks.

Laura A. Francis: Yeah. I think it is a good question that you are asking because it really is targeted toward the ambulatory surgery center. I did talk about how it really fits well with the interventional spine physician preferred workflow. And typically, those cases are done at the ambulatory surgery center. But it is also true that many of our spine surgeons also are working at ASCs too. And so we do think it is important in terms of continuing to see the growth that we would expect in our SI joint fusion part of the business. So just a little more information on it: it is a 3D-printed titanium solution. It has a similar workflow to our allograft solution.

And as I said previously, it is reimbursed under CPT 27279, which has nationwide coverage. So in terms of revenue impact, I would say that it expands the market in a couple of ways. It provides interventional spine physicians with a product similar to our Intra X workflow. But there are 22 states where allograft solutions are not reimbursed, and so we think that it is going to be an important solution for the physicians that are there. And then there is also a subset of interventionalists who prefer a non-allograft solution that is delivered in a posterior approach. So Intra TI is allowing us to serve those particular physicians.

But what is most important is that we have a full suite of products for SI joint fusion. So with TORQ, Intra X, iFuse 3D, and now Intra TI, we have a setup to continue to lead the market, both with spine surgeons as well as interventional physicians as well. And maybe the final thing I would say is that we still are in alpha launch right now, so we expect an adoption ramp, and we expect to see progress through the year and into the back half of 2026 for that particular product.

Operator: Alright. Much appreciated. Thank you.

Laura A. Francis: Thank you.

Operator: Thank you. And our next question comes from the line of Travis Steed from BofA Securities. Your question please.

Travis Steed: Thanks for taking the question. I wanted to ask more on the cadence on revenue. You mentioned second half a little bit more weighted. Any color on how you titrate Q1? And if you would quantify some of the tailwinds and benefit in the second half.

Anshul Maheshwari: Yeah. Travis, happy to take the question. So, coming into 2026, I think we have more tailwinds in the business than we have ever had before. If you look at the physician base that we entered the year with, we exited 2025 with over 1,640 active physicians. So that is a pretty formidable physician base. You have the improved reimbursement backdrop that Laura has talked about, whether it is the NTAP for TNT, the TPT for Granite, the increase in OBL fees for SI joint dysfunction. You have the Intra TI product that we just launched. You have the second BDD product that we are looking to commercialize potentially in late 2026.

And then you have the commercial expansion both direct as well as the strategic partnership. So a lot of tailwinds coming into the business. Now, we do think about our business on an annual basis and increasingly in a multiyear cycle basis. So we do not really provide quarterly guidance. And as you know, at our scale, the cadence can vary based on the timing and scale of new product launches and how they get commercialized, especially through this new hybrid commercial model. So for modeling purposes, we are expecting the revenue growth to be back-half weighted so we can see all of these tailwinds starting to materialize and incorporate them in our guidance.

Travis Steed: Okay. Helpful. And I think earlier in the prepared remarks, you mentioned innovation super cycle over the next five years. And should we think about that as sustaining the long-term growth rate, or is there a potential that this company is actually growing faster over the next five years than it has been over the last five years.

Laura A. Francis: Yeah. Thanks for that question, Travis. And if you think about since our IPO, we have been delivering average revenue growth of around 20%. And we have been doing that through developing these innovative solutions and addressing failures of incumbent standard of care. So as we look at applications in compromised bone, we are looking at markets that have these higher weighted average market growth rates because of these unmet clinical needs in the space. And our technologies have gone on to be category leaders. So whether it is SI joint fusion or pelvic fixation or now in pelvic trauma, it is allowing us to grow multiple times at the broader market growth rates in spine and interventional.

So as we think about developing these various platform technologies, they are meaningfully expanding the total addressable market across various new disease states, but very specifically targeted towards spine and interventional, which is really important to us in terms of focus. But looking ahead over the next five years, we have used that term innovation super cycle, and we think that is the right way to think about it. We are going to be regularly launching a cadence of products, but they are going to be these unique technologies, and they are going to be targeting these new clinical adjacencies that focus on spine and interventional.

And it really, first of all, takes these core competencies that we have developed in the business to address issues with compromised bone, but then also to lead the space for the long term.

Travis Steed: Great. Thanks a lot.

Operator: Thank you. And our next question comes from the line of Matthew O'Brien from Piper Sandler. Your question, please.

Anna (for Matthew O’Brien): Hi there. This is Anna on for Matt. Thanks for taking the question. I want to start with one on the guide. I mean, it seems like you have a ton of tailwinds throughout the year, but you are baking in sort of the 500 basis point sequential slowdown versus last year. Just wondering if there is anything specific to call out on areas for upside. It seems like there is a lot of areas for things to move higher. So yeah.

Anshul Maheshwari: Yeah. So happy to take that, Anna. In terms of potential areas for upside, you are right. We have a lot of tailwinds in the business. And the way I would categorize it is, our base guidance assumes high-teens growth in procedure volume and a degradation in ASP mostly driven by the mix in procedures. Some of the deformity and trauma procedures use fewer implants, so the ASP tends to be lower. And what we have been able to do in the last few years is actually offset that ASP pressure with continued growth on the deformity side and the SI joint dysfunction side as well.

So just simplistically maintaining that discipline and execution focus should provide some upside on the ASP. That is number one. And then you get into the potential ramp expectations of Intra TI, the continued acceleration of Intra X, and also this partnership with Smith+Nephew, which will continue to evolve as we progress through the first half of the year. So that also gives us a lot of confidence in the continued ramp in the business as we progress through the year.

And more importantly, that ramp continuing into 2027, especially when you incorporate the rollout of TNT in Europe at some point in 2026, the potential impact of our ability to commercialize the third Breakthrough Device in late 2026, which will be a material impact in 2027.

Anna (for Matthew O’Brien): Super helpful. And then, I guess, just again on the new Intra TI product for the ASC, I was wondering if you could give a bit more color on what your presence in the ASC is today, what you size that opportunity as, and how long it will take to really penetrate that market?

Laura A. Francis: Yeah, I can help out on that. So I have been the CEO for five years of the company. Five years ago, virtually none of our sales were in the ASC and today, around 35% of our SI joint fusion sales are in the ASC. So we do have a significant footprint there already. But I think the points you are trying to make is that with this new product, Intra TI, that it is going to provide another opportunity for us to grow the business overall and that a significant amount of that growth should be seen in the ASC.

And just given the nature of the product, the single-use system that we have, the simplicity of it, it is really set up perfectly in order to grow overall in the SI joint fusion market and to drive additional sales to the ASC.

Anna (for Matthew O’Brien): Great. Thanks so much.

Operator: Thank you. And our next question comes from the line of Caitlin Roberts from Canaccord Genuity. Your question please.

Caitlin Roberts: Hi. Thanks so much for taking the questions and congrats on the quarter. Just to talk about the commercial expansion, the direct commercial expansion. As you think about adding these new territories and the focus on growing the outpatient business and just touching on the ASC, how are you thinking about, strategically adding these territories?

Laura A. Francis: Yeah. I mean, what we do, obviously, we have quite a bit of information already on the opportunities that we have there. And so you identify where your targets actually are and where we are penetrated and where we are less penetrated. So what we are doing is we are looking across the United States and addressing those areas where we have a significant opportunity, and it could be on the spine side or it could be on the interventional side. And then you add accordingly in terms of territory managers in those particular locations.

In addition, in around half of our cases, we actually will split a territory, where the more junior territory rep is promoted to a territory manager. So on around 50% of the cases, we are typically promoting somebody into that level, and another 50% we are actually hiring from the outside. But we do have very significant opportunities across the portfolio to continue to grow and expand. We have gotten very significant leverage through our hybrid sales model with the addition of third-party agents. We have over 300 of them just in the U.S. alone.

But there is a balance between growing your direct sales force and then supplementing it with hybrid, and we think that we are striking the right balance by adding 10 more territories in 2026 to cap the opportunity.

Caitlin Roberts: That is great. And just a quick one on the patent extension. Seems like it applies to your original triangular iCS implant. How much of your business would you say is that legacy segment?

Anshul Maheshwari: Caitlin, happy to take that. The legacy Classic is barely any part of our business. I would say it is less than 0.1%. At this point, majority of our SI joint business comes from TORQ, 3D and now with going into interventional, allograft, and now we expect Intra TI to be a bigger contributor to the business as a portfolio.

Caitlin Roberts: Understood. Thank you so much.

Operator: Thank you. And our next question comes from the line of David Saxon from Needham & Company. Your question please.

David Saxon: Laura and Anshul, thanks for— I wanted to follow-up on the Smith+Nephew partnership. Maybe you can talk about the cadence of how that partnership ramps up in 2026. When do Smith+Nephew reps actually start carrying TORQ and TNT or those sets placed? And then is that a second-quarter dynamic? Or can that start as early as March?

Laura A. Francis: Yeah. I can at least start to answer that question. I mean, we just signed the agreement last week, but we are already in discussions to train and place implants as well as instrument trays into the field as well. So we are forming a joint steering committee between the two different companies. They are going to meet on a weekly basis and really get into a lot of the details of the relationship, but we do expect to start seeing some activity already in the month of March and then ramping up over the rest of the year.

Anshul Maheshwari: Yeah. And what I would say there, David, is just like when we put out a new product, we want to make sure we have the surgical capacity available to be able to support it. And the expectation is you should see the capacity ramp in Q2 and Q3, in preparation for Q4, which tends to be the biggest quarter.

David Saxon: That is helpful. Thanks for that. And then, Anshul, maybe sticking with you, so gross margin guidance, 78%. Looking back, you have seen expansion to varying degrees over the last couple of years. I understand there is this product mix dynamic that you might be considering, but would love to just understand the drivers of the 160 basis points of compression—mix, pricing, ramping product launches, etcetera? Thanks so much.

Anshul Maheshwari: Yeah. No, happy to take that. On the gross margin side, again, really proud of how we have been able to address our gross margin. We obviously started the year in 2025 at 77% to 78%. We did much better than that, about 200 basis points higher. And as we get bigger, as the business scales, we are actually more focused on top-line acceleration and operating profit dollars growth. So for 2026, as we look at our guidance of 78% gross margin, we exited the year at about 79%. So it is 100 basis points of gross margin impact. I would put most of that as non-cash impact from depreciation.

A lot of that is associated with the increase in surgical capacity. So for example, as we are building out this Smith+Nephew distributorship, we are going to be putting out TNT trays that support the volume of demand we see there. Granite continues to perform really well. We are going to be putting capacity out there for that. Potentially, the new product that we want to commercialize towards the tail end of 2026, there is going to be surgical capacity for that as well.

ASP does have some pressure on gross margins, but we are offsetting them by a lot of the operational initiatives that we have been working on over the last 12 to 18 months to bring our own cost down. So I would say, by and large, a lot of the impact is non-cash. And like we have seen over the last couple of years, the investment in surgical capacity and the new products does drive meaningful acceleration in our revenue growth. And while it is driving some de minimis pressure on the gross margin side, it has allowed us to get significant leverage and profitable dollar expansion over the subsequent period.

And so we feel really good about the setup and the balance we are striking.

David Saxon: Great. Appreciate that. Thanks so much.

Operator: Thank you. And our next question comes from the line of Richard Newitter from Truist Securities. Your question please.

Robbie (for Richard Newitter): Hi. This is Robbie here for Rich. Thanks for taking the questions. Congratulations on the promotions, everybody. I guess two on our end. First, on guidance. You are talking about high-teens U.S. volume growth. Procedure weighted. And that would represent a little bit of a step down versus what you did in 2025. And I would like to just understand the rationale behind that outlook given that you have a little bit more of a focused sales force coming in that is growing? You have this partnership with Smith+Nephew that should help lever each product set in the respective areas of the hospital. And you have a number of new product launches.

So just why was high-teens the right point, and then I have a follow-up.

Anshul Maheshwari: Yeah. So, Robbie, happy to take that. The first part of why it is high-teens, you have to think about it from a comp perspective. Some of the impact from new products is going to happen as we progress through the year. So if you look at 2025, Q1, Q2 continued to benefit from new product launches that had happened in late 2024. If you look at it on a stack basis, actually, you do see a much higher increase in procedure volume growth versus 2024. So I would say part of that is just the comps being the way they are. That is number one.

Number two is, whenever you are putting out new products or expanding the impact of reimbursement coverage or commercial footprint expansion, we want to see how those play out before we start incorporating them in our guidance. So as you look at the rest of the year, you will see that impact happen more pronounced. But we think it is prudent early in the year to be thoughtful.

Robbie (for Richard Newitter): Great. And then I guess on another question on the Smith+Nephew partnership. Can you help us understand what the incremental or the marginal profit looks like for each dollar of sale transferred over to Smith+Nephew. Thanks.

Anshul Maheshwari: Yeah. We are not going to break down what the relationship details are from that perspective. For us, what is important with the Smith+Nephew relationship is, number one, getting our product in level 1, level 2 trauma sites at a national level. Number two, being able to satisfy the demand that we are seeing from the trauma physicians. Number three, which is a natural offset of building this distribution partnership, is allowing our reps to be freed up to continue to go build relationships, engage surgeons and interventionalists, to drive that side of the business growth. So it is a multifaceted impact versus just one-off with what the impact with Smith+Nephew will have on the P&L.

Operator: Thank you. This does conclude the question-and-answer session of today’s program. I would like to hand the program back to Laura for any further remarks.

Laura A. Francis: I just want to say thanks to everybody for participating in the call and appreciate your interest in SI-BONE, Inc. And we look forward to seeing all of you at upcoming conferences. Thanks again. Goodbye.

Operator: Thank you, ladies and gentlemen, for your participation in today’s conference. This does conclude the program. You may now disconnect. Good day.

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