NOT PRECEDENTIAL

         UNITED STATES COURT OF APPEALS
              FOR THE THIRD CIRCUIT
                   ____________

                        No. 09-2105
                       ____________

              RICHARD H. MCCULLOUGH;
               HOLLY A. MCCULLOUGH,

                                      Appellants

                             v.

       ZIMMER, INC.; ZIMMER HOLDINGS, INC.;
     STRYKER ORTHOPEDICS, INC; STRYKER, INC;
        ZIMMER-RANDALL ASSOCIATES, INC.


                       ____________

       On Appeal from the United States District Court
          for the Western District of Pennsylvania
                    (D.C. No. 08-01123)
        District Judge: Honorable Arthur J. Schwab
                       ____________

         Submitted Under Third Circuit LAR 34.1(a)
                      May 19, 2010

Before: FUENTES, HARDIMAN and NYGAARD, Circuit Judges.

                    (Filed:June 1, 2010)

                       ____________

                OPINION OF THE COURT
                     ____________
HARDIMAN, Circuit Judge.

       Richard and Holly McCullough, husband and wife, sued five of the nation’s largest

manufacturers of orthopedic devices, alleging violations of federal and state law. The

McCulloughs appeal from an order of the District Court dismissing their amended

complaint for failure to state a claim. We will affirm, largely for the reasons articulated

by the District Court in its thorough opinion.

                                              I.

       Because we write for the parties, we recount only the essential facts.

                                             A.

       Defendants Zimmer, Inc., Depuy Orthopaedics, Inc., Biomet, Inc., Smith &

Nephew, Inc., and Stryker Orthopedics, Inc. are competing manufacturers of surgical

orthopedic devices that together account for approximately 95% of the United States

market in such products. In 2007, a Department of Justice investigation revealed that

from at least 2002 until 2006, each defendant individually paid kickbacks and bribes to

orthopedic surgeons to induce them to use its products. Although the companies engaged

in similar schemes, the investigation did not suggest that they had colluded or otherwise

coordinated their illicit conduct. Defendants avoided criminal liability by agreeing to

implement new corporate compliance procedures and to submit to federal monitoring.

Four of the companies also agreed to pay a total of $311 million in fines.




                                              2
       The McCulloughs averred that they competed directly with Defendants beginning

in 1988. The source of this competition, according to the McCulloughs, was the fact that

they possessed exclusive contracts with Defendants’ competitors, including Sulzer-

Medica, Inc. (Sulzer), to demonstrate, distribute, and service surgical orthopedic devices

in western Pennsylvania, eastern Ohio, and West Virginia. The McCulloughs alleged that

the bribes and kickbacks paid by Defendants harmed their business and eventually

excluded them from the surgical orthopedic device market in their sales territory in

violation of the federal antitrust laws. Specifically, they alleged that Defendants violated

§ 1 of the Sherman Act, 15 U.S.C. § 1, and § 2(a) of the Robinson-Patman Act, 15 U.S.C.

§ 13(a), which gave them a private right of action under § 4 of the Clayton Act, 15 U.S.C.

§ 15(a). The McCulloughs also alleged that Defendants violated the civil aspect of the

Racketeer Influenced and Corrupt Organizations Act (RICO), 18 U.S.C. §§ 1962, 1964.

Finally, their complaint included several Pennsylvania state law claims.

                                             B.

       After its initial review of the complaint, the District Court ordered the

McCulloughs to amplify their RICO allegations by filing a detailed “RICO case

statement.” Defendants subsequently filed a motion to dismiss pursuant to Federal Rule

of Civil Procedure 12(b)(6) for failure to state a claim. After hearing oral argument, the

District Court granted Defendants’ motion but allowed the McCulloughs leave to amend

their complaint. In doing so, the District Court candidly explained that the McCulloughs



                                              3
had not adequately alleged standing under either the Clayton Act or RICO. The District

Court also explained that the complaint was deficient in regard to the existence of a RICO

enterprise.1

       Following the District Court’s initial decision, the McCulloughs filed an amended

complaint. Defendants filed a second motion to dismiss under Rule 12(b)(6), which the

District Court again granted. The District Court held the McCulloughs lacked standing

because they had not suffered a cognizable antitrust injury attributable to Defendants’

alleged conduct. The District Court also held that the relevant factors identified by the

Supreme Court in Associated General Contractors of California v. California State

Council of Carpenters, 

, 537-545 (1983), militated against finding antitrust

standing on these facts.2

       1
        After the District Court dismissed the McCulloughs’ initial complaint, defendants
Depuy Orthopaedics, Inc., Biomet, Inc., and Smith & Nephew, Inc. settled with the
McCulloughs. Only Zimmer, Inc., Stryker Orthopedics, Inc. and their associated entities
remain as defendants.
       2
           We have described these factors as:

       (1) the causal connection between the antitrust violation and the harm to the
       plaintiff and the intent by the defendant to cause that harm, with neither
       factor alone conferring standing; (2) whether the plaintiff's alleged injury is
       of the type for which the antitrust laws were intended to provide redress; (3)
       the directness of the injury, which addresses the concerns that liberal
       application of standing principles might produce speculative claims; (4) the
       existence of more direct victims of the alleged antitrust violations; and (5)
       the potential for duplicative recovery or complex apportionment of
       damages.

In re Lower Lake Erie Iron Ore Antitrust Litig., 

, 1165-66 (3d Cir. 1993)

                                                 4
       The District Court also identified numerous problems with the substance of the

McCulloughs’ antitrust allegations. Explaining that the “essence of a Section 1 claim

[under the Sherman Act] is the existence of an agreement[,]” the District Court observed

that the McCulloughs “have not alleged that Defendants acted in concert.” The District

Court further found that the McCulloughs not only failed to plead any “anticompetitive

effects on the relevant market[,]” as the Sherman Act requires, but also neglected to

define the relevant market properly in the first instance. The District Court also dismissed

the McCulloughs’ Robinson-Patman Act claim, finding that although the couple argued

they had properly pled a commercial bribery claim under Section 2(c), their amended

complaint alleged only illegal price discrimination under Section 2(a).

       The McCulloughs’ RICO allegations were deficient as well. The District Court

held the McCulloughs failed to allege the existence of a RICO enterprise with sufficient

specificity because neither their amended complaint nor their RICO case statement

explained how Defendants “are organized into a cohesive unit involved in group action.”

Furthermore, the McCulloughs did not aver that the supposed enterprise existed

independent of the alleged racketeering activity.

       After dismissing all federal claims, the District Court declined supplemental

jurisdiction over the couple’s remaining state law claims. This appeal followed.3


(citing Associated 

).
       3
       The District Court had jurisdiction over the antitrust and RICO claims pursuant to
28 U.S.C. § 1331 and supplemental jurisdiction over the state law claims under 28 U.S.C.

                                             5
                                              II.

       The McCulloughs claim the District Court erred in various respects when it

dismissed their antitrust and RICO claims. We review de novo the District Court’s

dismissal of plaintiffs’ amended complaint for failure to state a claim pursuant to Rule

12(b)(6). Phillips v. County of Allegheny, 

, 233 (3d Cir. 2008).

                                              A.

       The doctrine of antitrust standing ensures that a “plaintiff is a proper party to bring

a private antitrust action.” Gulfstream III Associates, Inc. v. Gulfstream Aerospace Corp.,

, 429 (3d Cir. 1993) (quoting Associated 

n.31)

(internal quotation marks omitted). Because it is a threshold requirement to bring suit

under the Clayton Act, see City of Pittsburgh v. W. Penn Power Co., 

, 264-

65 (3d Cir. 1998), we turn first to the McCulloughs’ contention that the District Court

erred when it held they lacked standing to pursue their antitrust claims.

       As we did in City of Pittsburgh, 

, the District Court first

considered whether the McCulloughs had alleged an “antitrust injury” that was causally

connected to Defendants’ alleged anticompetitive conduct. In doing so, the District Court



§ 1367. We have appellate jurisdiction under 28 U.S.C. § 1291. The McCulloughs argue
that the District Court erred by dismissing their state law claims because it also had
diversity jurisdiction. They are mistaken. Diversity jurisdiction “under 28 U.S.C. § 1332
. . . requires complete diversity of the parties; that is, no plaintiff can be a citizen of the
same state as any of the defendants.” Grand Union Supermarkets v. H.E. Lockhart
Mgmt., 

, 410 (3d Cir. 2003). The amended complaint, however, alleges that
the McCulloughs and Zimmer-Randall Associates, Inc. are both Pennsylvania residents.

                                               6
recognized that typically, a “plaintiff who is neither a competitor nor a consumer in the

relevant market does not suffer antitrust injury” and therefore lacks standing to bring suit

under the antitrust laws. Schuylkill Energy Res., Inc. v. Pa. Power & Light Co., 

, 415 (3d Cir. 1997) (quoting Vinci v. Waste Mgmt., Inc., 

, 1376 (9th Cir.

1996)).

       The McCulloughs argue that because they sometimes purchased products from

competitors of Defendants for demonstration and resale purposes, they were both

competitors and consumers in the relevant market. We agree with the District Court,

however, that the balance of their allegations established the couple only as commission-

based sales representatives who did business with competitors and consumers in the

market for surgical orthopedic devices, not as competitors or consumers themselves. As

mere intermediaries in the supply chain, the McCulloughs suffered no cognizable antitrust

injury as a result of Defendants’ alleged anticompetitive conduct. See Barton & Pittinos,

Inc. v. Smithkline Beecham Corp., 

, 184 (3d Cir. 1997); Gregory Mktg.

Corp. v. Wakefern Food Corp., 

, 95-97 (3d Cir. 1986).4




       4
         The McCulloughs claim standing based merely upon the alleged link between
their lost profits, sales, and market share and Defendants’ illegal conduct. They also
contend Defendants’ antitrust violations were intended to drive businesses like theirs
from the market. We have emphasized that “neither causation in this but-for sense nor an
allegation of improper motive is sufficient to ‘enable any complaint to withstand a motion
to dismiss.’” Gregory 

(quoting Associated 

).

                                             7
       The McCulloughs also cite several cases holding that plaintiffs who were neither

competitors nor consumers in the relevant market nonetheless had antitrust standing

because their injuries were “inextricably intertwined” with alleged antitrust violations.

See, e.g., Carpet Group Int’l v. Oriental Rug Imp. Ass’n, 

, 77 (3d Cir. 2000).

In those cases, however, the harm suffered by the plaintiff was typically an “integral” or

otherwise “necessary step in effecting the ends of the alleged” anticompetitive conduct.

Blue Shield of Virginia v. McCready, 

, 479 (1982). Thus, in Steamfitters

Local Union No. 420 Welfare Fund v. Phillip Morris, Inc., we rejected a claim by several

union healthcare funds that they had standing to bring antitrust claims against tobacco

companies for withholding safer products from the market, which included workers

covered by the funds. 

, 923 (3d Cir. 1999). Though the funds were

tangentially harmed by the scheme because the workers’ healthcare costs were higher

over time, their injuries were not inextricably intertwined with the antitrust violations

because “the tobacco companies . . . could have achieved their alleged aims without the

existence of the Funds or the relationship between the Funds and smokers.” 

here, where the injury suffered by the McCulloughs was not an integral

aspect of Defendants’ alleged scheme. Rather, as the District Court recognized, any harm

to the couple’s business was a byproduct of the illegal kickbacks and bribes paid by

Defendants to numerous doctors and hospitals. Accordingly, we agree with the District




                                              8
Court that the McCulloughs’ injury was not so inextricably intertwined with Defendants’

anticompetitive conduct that they had standing to bring an antitrust claim.

       Finally, the McCulloughs contend that they had antitrust standing because two of

the five Associated General factors supported such a finding. Specifically, the couple

argues that there are no more direct victims of Defendants’ anticompetitive conduct and

that their suit raises little risk of complex apportionment of damages or duplicative

recovery. See Associated 

.

       We have made it abundantly clear, however, that a cognizable antitrust injury is a

necessary precursor to antitrust standing, regardless of whether other Associated General

factors support such a finding. See Barton & 

n.9 (“Because

[plaintiff] fails the antitrust injury requirement, it would lack standing even if the other

[Associated General] factors favored it.”). Indeed, we have directed district courts to

consider the threshold issue of antitrust injury at the outset, because “[i]f antitrust injury is

not found, further inquiry is unnecessary.” City of 

.

       As noted above, the McCulloughs failed to plead a redressable antitrust injury

because they were neither competitors nor consumers in the pertinent market. Nor was

any harm to their business inextricably intertwined with Defendants’ alleged conduct.




                                               9
Because they have failed to allege antitrust injury ab initio, the remaining Associated

General factors are irrelevant.5

       For these reasons, we will affirm the District Court’s finding that the McCulloughs

lacked standing to sue under the Clayton Act for Defendants’ alleged violations of the

Sherman and Robinson-Patman Acts.6




       5
        Furthermore, as the District Court found, the Associated General factors cited by
the McCulloughs offer them no real support. The manufacturers who competed directly
with Defendants and lost market share as a result of their alleged anticompetitive
conduct— such as Sulzer—undoubtedly suffered harm that was more direct than the
couple’s lost commissions. Moreover, allowing both Defendants’ competitors and those
competitors’ salespeople to bring separate antitrust claims would present a substantial risk
of duplicative recovery and require an unduly complex apportionment of damages.
       6
         Even if they had established antitrust standing, the McCulloughs’ antitrust claims
would fail on the merits. Although the “essence” of a claim under § 1 of the Sherman Act
“is the existence of an agreement[,]” Gordon v. Lewiston Hosp., 

, 207 (3d
Cir. 2005) (citations omitted), the McCulloughs have alleged no facts suggesting that
Defendants agreed to act in concert. See Bell Atlantic Corp. v. Twombly, 

,
565 n.10. (2007) (explaining that a complaint which “mentioned no specific time, place,
or person involved in the alleged conspiracies” was deficient because it did not allege
who “supposedly agreed, or when and where the illicit agreement took place”). Nor have
the McCulloughs defined the relevant market with any reference to the rule of reasonable
interchangeability or cross-elasticity of demand, as a § 1 claim requires. See Queen City
Pizza, Inc. v. Domino’s Pizza, Inc., 

, 436 (3d Cir. 1997). Finally, though the
couple argue on appeal that they pled a commercial bribery claim under Section 2(c) of
the Robinson-Patman Act, their amended complaint actually alleged illegal price
discrimination under Section 2(a), a claim they have now abandoned. We thus agree with
the District Court that the amended complaint would fall well short of stating a plausible
claim for relief on the merits even if the McCulloughs had standing to bring a private
antitrust action under the Clayton Act.

                                             10
                                               B.

       The McCulloughs next claim the District Court erred in dismissing their RICO

claims. We agree with the District Court, however, that the McCulloughs’ amended

complaint failed to allege certain essential elements of a RICO cause of action.7

       The McCulloughs acknowledge that they must plead the existence of an

“enterprise” to state a claim under § 1962(c) of RICO. An “enterprise is an entity, . . . a

group of persons associated together for a common purpose of engaging in a course of

conduct.” United States v. Turkette, 

, 583 (1981). Instead of claiming that

Defendants qualify as an enterprise, the McCulloughs argue that the surgeons, hospital

administrators, and other entities that allegedly received bribes and kickbacks from

Defendants are the relevant enterprise for RICO purposes. Because Defendants

“participate[d] . . . in the conduct of [this] enterprise’s affairs through a pattern of




       7
         The McCulloughs’ lack of standing to bring an antitrust action likewise prevents
them from pursuing their RICO claims. The Supreme Court has extended much of the
Associated General analysis for antitrust standing to RICO cases. See Holmes v. Sec.
Investor Prot. Corp., 

, 267-70 (1992); 

. A
plaintiff lacks standing to sue under RICO where, as here, he suffers injury that is only
indirectly related to a defendant’s alleged misconduct. See 

;

-33. Accordingly, even if the McCulloughs had properly
alleged the essential elements of a RICO claim, they would lack standing to sue under
RICO for the same reasons they lack standing to sue under the Clayton Act. See

(“[M]uch, (if not all) of what we have said . . . in our
discussion of antitrust standing applies to the [plaintiff’s] RICO claims.”). Although the
District Court did not consider whether the McCulloughs had standing to bring a RICO
claim, we may affirm for any reason supported by the record. Donahue v. Gavin, 

, 372 n.2 (3d Cir. 2002).

                                               11
racketeering activity”—i.e., regularly paying bribes—the McCulloughs seek to hold them

liable under § 1962(c).

       To prove the existence of a RICO enterprise, a plaintiff must show: “(1) that the

enterprise is an ongoing organization with some sort of framework for making or carrying

out decisions; (2) that the various associates function as a continuing unit; and (3) that the

enterprise be separate and apart from the pattern of activity in which it engages.” United

States v. Irizarry, 

(3d Cir, 2003) (quoting United States v. Riccobene, 

, 222 (3d Cir. 1983)). Simply listing a string of individuals or entities that

engaged in illegal conduct, without more, is insufficient to allege the existence of a RICO

enterprise. See Richmond v. Nationwide Cassel, L.P., 

, 646 (7th Cir. 1995).8

       Here, the McCulloughs’ RICO allegations suggest at most that numerous surgeons

throughout their sales territory regularly and individually received illegal payments from




       8
         The McCulloughs cite Seville Industrial Machinery Corp. v. Southmost
Machinery Corp., where we held that the plaintiff need not affirmatively plead the three
essential attributes of a RICO enterprise as long as it alleged that an enterprise existed.

, 790 (3d Cir. 1984). We doubt that the conclusory allegation of enterprise
that we accepted in Seville would pass muster under the pleading requirements articulated
by the Supreme Court in 

, and Ashcroft v. Iqbal, 

, 1949-50 (2009). Under today’s pleading standards, the “formulaic recitation of the
elements of a” RICO claim that we allowed in Seville likely would be insufficient to
“state a claim to relief that is plausible on its face.” 

, 570.
Moreover, the alleged RICO enterprise in Seville involved two existing corporate entities,

, which indicated that the putative organization was ongoing and had
both a decisionmaking hierarchy and an existence separate and apart from any illegal
activity. Here, by contrast, the McCulloughs implausibly allege that competing doctors in
three different states qualify as an enterprise.

                                             12
Defendants. However, nothing in their amended complaint or RICO case statement

plausibly suggests that these doctors combined as a unit with any semblance of an

organizational framework or common purpose. Nor have they alleged facts that would

support an inference that this alleged enterprise had any structure or existence separate

and apart from Defendants’ alleged criminal conduct. To the contrary, the McCulloughs’

allegations indicate that the doctors and hospitals who supposedly comprised the RICO

enterprise in fact competed against one another in the market for surgical orthopedic

services. Accordingly, we agree with the District Court that the McCulloughs’ amended

complaint failed to state a claim under § 1962(c) of RICO.9

                                            III.

       Anticipating the possibility that we might agree with the District Court, the

McCulloughs ask us to remand their case to allow additional amendments. We decline

this invitation because the McCulloughs’ failure to remedy the significant legal and

factual deficiencies that plague their allegations—especially after receiving detailed

guidance from the District Court—convinces us that any further amendments would be

futile. See Foman v. Davis, 

, 182 (1962) (explaining that “repeated failure to

cure deficiencies by amendments previously allowed” supports a denial of leave to

amend). Accordingly, we will affirm the District Court’s judgment in all respects.


       9
         The McCulloughs also contend that they properly alleged a RICO conspiracy in
violation of § 1962(d). Because their conspiracy claim under § 1962(d) is predicated
solely on Defendants’ alleged violation of § 1962(c), it likewise fails.

                                             13