You are given a text that consists of multiple sentences. Your task is to perform abstractive summarization on this text. Use your understanding of the content to express the main ideas and crucial details in a shorter, coherent, and natural sounding text. 
Text: I hope you are all well and safe.
Let me just start with the things that I'm happy about when it comes to Q3.
First of all, I'm happy on our progress with our new product introductions that they're going quite well.
Our execution on recent M&A is going as planned, if not better.
Our commercial focus and our discipline is as good as I've seen it.
And I'm very happy with our growth versus our key competitors in both large joints and set, particularly when it comes to the U.S. For the team, in my view, continues to drive results in the areas under our control.
And as a result, I continue to be proud of them for doing so.
Alternatively, Q3 was also a quarter with unexpected negative environmental impacts that are, for the most part, out of our control.
Q3 brought greater COVID pressure than I think anybody expected.
More customer staffing shortages certainly than we expected and an earlier China VBP impact than we anticipated.
And this resulted in Q3 revenues that were lower than we had projected.
And unfortunately, we expect these pressure points to continue into Q4.
And as a result, we need to update our 2021 financial guidance and really the view we have of the fourth quarter.
As we look forward, until we see a fundamental shift in these trends, we're just going to assume that these pressure points aren't going away, but will be with us into Q4 and possibly into early 2022.
Let's just start by taking a look at COVID and staffing concerns kind of together because I believe they're somewhat related.
As I think most of us know by now that there was a significant delta variance surge in Q3 that drove more COVID pressure than, again, I think anybody expected.
We previously thought COVID pressure would lessen through the back half of the year, but instead, while procedures did seasonally step up in September, it wasn't by as much as we expected, again, due to the enhanced COVID and staffing pressures.
And as a result, September was our least attractive month relative to growth.
And until we see a real shift in COVID and staffing-related recovery, we're projecting that the pressure we saw in September will continue through the end of the year, that's in the view of COVID.
If we think about the China VBP, the process in China is moving forward.
And although it's still fluid, we are getting more clarity on what it will mean this year and in 2022.
And our assumption going into the process was that VBP would pose no more than a 1% risk in terms of impact to ZB's overall revenue.
And although for a number of reasons, the overall impact will likely be greater than what we originally anticipated.
We do believe that sizing this at around 1% of revenue impact is still accurate, that is the right way to size it.
With that said, the timing of the revenue impact as definitely shifted forward, and we now expect that much of this impact will be felt in 2021.
And there are a few factors that are driving this shift into 2021.
First one is around current year inventory reductions by distributors.
The second is around just ongoing negotiations we have with our distributor partners that are beginning to include price concessions on existing inventory.
And then unfortunately, we're now seeing patients defer their surgeries until after the lower VBP pricing is in effect.
Apparently, even though China achieves near universal public medical coverage, there are out-of-pocket expenses that increase or decrease based on implant pricing, and this is substantial enough for patients to defer their procedures.
So clearly, in summary, although we feel very good about our execution in the areas we can control, these macro environmental issues continue to mute our overall performance, and these are fluid.
These issues for sure, they're fluid, but we've done our best to incorporate our current view of their impact in our revised guidance.
I'm going to briefly discuss our Q3 results and updates that we made to our full year 2021 financial guidance.
We've also provided comparisons to the third quarter of 2019 as we feel that performance to pre-pandemic results is an important comparator.
Net sales in the third quarter were $1.924 billion, a reported decrease of 0.3% and a decrease of 0.8% on a constant currency basis.
When compared to 2019, net sales increased 0.4%.
On a consolidated basis, as Bryan mentioned, we were growing through August, but then declined in September as we saw delta variant cases and staffing shortage increases.
In short, there was a seasonal step-up in procedure volumes for the quarter, but the recovery has not taken hold as fast as we thought it would, especially in our hip and knee businesses.
The Americas declined 3.2% or flat versus 2019.
The U.S. declined 4.4% or up 0.1% versus 2019.
Lower U.S. performance in September was the key driver to lower consolidated results.
EMEA grew 5.9% or up 0.3% versus 2019.
This is the first time the region posted positive growth since the start of the pandemic.
In the quarter, we saw an improving trend across a number of markets.
However, the U.K., France, Spain and most emerging markets continue to be challenged despite higher vaccination rates.
Lastly, Asia Pacific grew 0.5% or up 1.5% versus 2019.
While we did see growth versus 2019, it decelerated versus what we observed in the first half of the year.
This was driven in part by pricing adjustments on channel inventory as we continue to negotiate with our distributor partners ahead of VBP implementation.
In tandem with continuing COVID pressure throughout the region, especially in Japan and Australia and New Zealand.
Turning to business performance in the third quarter.
The global knee business declined 0.7% or down 1% versus 2019.
In the U.S., knee is declined 5.3% or down 0.7% versus '19.
Our global hip business declined 6.6% or down 2.4% versus 2019.
In the U.S., hips declined 11.3% or down 2.4% versus '19.
The sports extremity and trauma category increased 4.2% or 7.7% versus '19, driven by continuing commercial specialization, new product introductions and the contribution from strategic acquisitions we added to this portfolio in 2020.
Our dental and spine category declined 6.1% or down 2% versus 2019.
The dental business posted good growth in the quarter and continued to benefit from strong execution and market recovery, while the spine business declined when compared to 2020 and 2019 due to increasing COVID pressure throughout the quarter.
Finally, our other category grew 15.4% or down 1.1% versus 2019.
Inside this category, we saw ongoing demand for ROSA Knee as well as increased revenues from the launch of our ROSA partial knee and hip applications.
Moving to the P&L.
For the quarter, we reported GAAP diluted earnings per share of $0.69, lower than our GAAP diluted earnings per share of $1.16 in the third quarter of 2020.
This decrease was driven primarily by cost of goods and higher spending related to litigation, our spin-off and R&D.
In addition, our share count was up versus the prior year.
On an adjusted basis, diluted earnings per share of $1.81 was flat compared to the prior year, even though sales were down.
We implemented targeted reductions in SG&A, which in tandem with a slightly lower tax rate helped offset higher investments in R&D and a higher share count.
Adjusted gross margin of 70.3% was just below the prior year, and the results were slightly below our expectations due to lower volumes in tandem with less favorable product and geographic mix.
Our adjusted operating expenses of $852 million were in line with the prior year and stepped down sequentially versus the second quarter.
Inside of that, we continue to ramp up investment in R&D and commercial infrastructure across priority growth areas like S.E.T., robotics and data and informatics.
And we are offsetting those increases with improvements in efficiency across other areas of SG&A.
Our adjusted operating margin for the quarter was 26.1%, largely in line with the prior year and prior quarter.
The adjusted tax rate of 15.8% in the quarter was in line with our expectations.
Turning to cash and liquidity.
We had operating cash flows of $433 million and free cash flow totaled $307 million with an ending cash and cash equivalents balance of just over $900 million.
We continue to make good progress on deleveraging the balance sheet and pay down another $300 million of debt totaling $500 million of debt paydown for 2021 to date.
Moving to our financial guidance.
We've updated our full year 2021 outlook based on two factors: first, COVID and customer staffing pressures continuing at levels higher than previously expected.
And while we expect procedure volumes to seasonally improve in the fourth quarter, we are taking a cautious approach and currently assuming that the more acute pressure we saw in September will continue through the fourth quarter.
And second, as Bryan mentioned, we now know more about the dynamics leading up to the implementation of the China VBP and project that it will have a bigger impact in the fourth quarter than originally assumed.
The impact across inventory reductions, price write-downs on existing inventory and a new factor, which is patients deferring their procedures have increased the impact of VBP and the timing of that impact.
As a result, our current projection for Q4 VBP impact is about 300 basis points of headwind to our consolidated results, but the situation remains fluid, and we will continue to update you as the implementation of VBP unfolds.
For the full year, we now expect reported revenue growth to be 11.3% to 12.5% versus 2020 with an FX impact of about 140 basis points of tailwind for the year.
While we are taking steps to further reduce spending in the fourth quarter as a response to our lower revenue outlook, we are reducing our adjusted operating margin projections to be 26% to 26.5% for the full year.
Our updated full year adjusted diluted earnings per share guidance is now in the range of $7.32 to $7.47.
Our adjusted tax rate projection is unchanged at 16% to 16.5%.
And finally, our free cash flow estimates remain in the range of $900 million to $1.1 billion.
This updated full year 2021 guidance range implies that Q4 constant currency revenue growth will be between negative 2.3% and positive 1.8% versus Q4 2020.
And we project Q4 adjusted earnings per share to be between $1.90 to $2.05.
We kept a wider range of potential Q4 outcomes in our guidance to account for the uncertainty around COVID surges, customer staffing pressure and VBP implementation.
As a note, we do believe that COVID pressure, including the related staffing shortages will continue to mute pandemic recovery as we move into 2022.
Additionally, as we mentioned earlier, VBP is expected to reduce 2022 consolidated revenues by about 100 basis points.
That impact will be felt in our large joint segment and will negatively impact gross margins as we move forward.
To respond to this, we are accelerating transformation and efficiency efforts to help offset these headwinds.
In summary, the macro environment presents challenges, but our underlying business fundamentals remain strong as we continue to execute successfully against what we can control.
And that's why I have such confidence in our long-term growth projections.
The ZB team remains intensely focused on creating value and most importantly, delivering on our mission.
Our underlying business is strong.
And overall, we're pleased with our performance in large joints and set versus market.
This is a significant shift for ZB versus where we were just a few years ago and an important driver of our ongoing growth.
Our innovation is in full stride, and that's a big part of this.
We're going to enter 2022 with a new product pipeline of more than 20 anticipated product launches across the next two years.
And of course, this is incremental to a number of new products we recently launched, including, but certainly not limited to, ROSA partial knee, ROSA Hip and Persona IQ, which is the first smart knee implant in the world.
We're very excited about this launch.
And we continue to see strong ROSA placements, increased robotic penetration into our accounts.
I think most importantly, just more robotic procedures as a percentage of our overall procedure base.
And ROSA is even more attractive because it's a key component of our ZBEdge suite of truly integrated solutions.
And that really does help to tie pre-intra and post-op data together with the goal of changing patient care.
And finally, we are accelerating our corporate transformation.
We're making great progress on the planned spin-off of our spine and dental business.
We just recently appointed a new CFO and other key leadership team members for Zimby.
We continue to be strategic and selective in our active portfolio management process and have added key assets over the past year that have helped us to better compete and more importantly to win across robotics and data, dental, set, CMFT and the broader ASC market.
We're reinvesting in our business for sure, but we're also advancing efficiency programs designed to streamline and improve how we operate and very importantly drive savings.
All of this forward momentum plus ZB's differentiated portfolio, the expected value creation of our planned spin transaction and our ability to execute really does give us continued confidence in our path to grow revenue in the mid-single digits and to deliver a 30% operating margin by the end of 2023.
And I can tell you that this is clearly a time of significant challenge in market pressures, particularly given the fact that we have such a dependence on elective procedures.
So there's no doubt about that.
But this is also a time of significant opportunity for Zimmer Biomet.
We look forward to delivering for our team members, delivering for our shareholders and most importantly, the customers and patients that we serve.
[Operator Instructions] With that, operator, may we have the first question, please?

user
q3 adjusted earnings per share $1.81.
q3 earnings per share $0.69.
q3 sales fell 0.3 percent to $1.924 billion.
sees fy 2021 adjusted earnings per share $7.32 - $7.47.

assistant