Xtant Medical (XTNT) 10-Q 10 Nov 16 2016 Q3 Quarterly report Financial data

Document And Entity Information

Document And Entity Information - shares	9 Months Ended
	Sep. 30, 2016	Nov. 08, 2016
Document Information [Line Items]
Document Type	10-Q
Amendment Flag	false
Document Period End Date	Sep. 30, 2016
Document Fiscal Year Focus	2,016
Document Fiscal Period Focus	Q3
Entity Registrant Name	Xtant Medical Holdings, Inc.
Entity Central Index Key	1,453,593
Current Fiscal Year End Date	--12-31
Entity Filer Category	Smaller Reporting Company
Trading Symbol	XTNT
Entity Common Stock, Shares Outstanding		12,193,970

CONDENSED CONSOLIDATED BALANCE

CONDENSED CONSOLIDATED BALANCE SHEETS - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Current Assets:
Cash and cash equivalents	$ 1,408,608	$ 6,368,016
Trade accounts receivable, net of allowance for doubtful accounts of $2,997,747 and $2,579,634, respectively	15,826,130	15,385,218
Current inventories, net	26,499,085	22,684,716
Prepaid and other current assets	2,034,127	601,697
Total current assets	45,767,950	45,039,647
Non-current inventories, net	1,271,425	1,607,915
Property and equipment, net	16,012,138	11,816,629
Goodwill	41,534,626	41,534,626
Intangible assets, net	37,021,472	40,237,289
Other assets	841,354	791,221
Total Assets	142,448,965	141,027,327
Current Liabilities:
Accounts payable	12,889,056	9,386,531
Accounts payable - related party (Note 15)	1,060,200	1,406,763
Revolving line of credit	8,353,117	0
Accrued liabilities	5,623,574	9,595,851
Warrant derivative liability	333,613	1,050,351
Current portion of capital lease obligations	209,826	35,139
Total current liabilities	28,469,386	21,474,635
Long-term Liabilities:
Capital lease obligation, less current portion	720,265	7,800
Long-term convertible debt, less issuance costs	68,864,974	66,436,647
Long-term debt, less issuance costs	49,493,259	44,231,718
Total Liabilities	147,547,884	132,150,800
Commitments and Contingencies (Note 12)
Stockholders' equity:
Preferred stock, $0.000001 par value; 5,000,000 shares authorized; no shares issued and outstanding	0	0
Common stock, $0.000001 par value; 95,000,000 shares authorized; shares issued and outstanding as of September 30, 2016 12,193,970 and shares issued and outstanding as of December 31, 2015 11,897,601	11	11
Additional paid-in capital	82,898,754	81,917,488
Accumulated deficit	(87,997,684)	(73,040,972)
Total stockholders’ (deficit) equity	(5,098,919)	8,876,527
Total liabilities & stockholders’ (deficit) equity	$ 142,448,965	$ 141,027,327

CONDENSED CONSOLIDATED BALANCE3

CONDENSED CONSOLIDATED BALANCE SHEETS [Parenthetical] - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Trade accounts receivable, allowance for doubtful accounts (in dollars)	$ 2,997,747	$ 2,579,634
Preferred stock, par value (in dollars per share)	$ 0.000001	$ 0.000001
Preferred stock, shares authorized	5,000,000	5,000,000
Preferred stock, shares issued	0	0
Preferred stock, shares outstanding	0	0
Common stock, par value (in dollars per share)	$ 0.000001	$ 0.000001
Common stock, shares authorized	95,000,000	95,000,000
Common stock, shares issued	12,193,970	11,897,601
Common Stock, shares outstanding	12,193,970	11,897,601

CONDENSED CONSOLIDATED STATEMEN

CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015	Sep. 30, 2016	Sep. 30, 2015
Revenue
Orthopedic product sales	$ 22,907,717	$ 17,421,397	$ 65,025,908	$ 36,431,354
Other revenue	186,423	271,623	505,971	657,395
Total Revenue	23,094,140	17,693,020	65,531,879	37,088,749
Cost of Sales	7,114,041	6,035,673	20,749,381	12,883,439
Gross Profit	15,980,099	11,657,347	44,782,498	24,205,310
Operating Expenses
General and administrative	3,773,236	3,980,805	11,216,112	8,805,104
Sales and marketing	11,242,820	8,430,303	32,115,763	18,179,552
Research and development	928,930	794,464	2,612,402	1,519,196
Depreciation and amortization	1,265,490	1,541,220	3,690,519	1,765,994
Acquisition and integration related expenses (Note 2)	517,083	3,856,519	1,269,613	3,856,519
Extinguishment of debt	0	(2,345,019)	0	(2,345,019)
Impairment of assets	0	233,748	0	233,748
Non-cash consulting expense	156,129	50,000	266,721	190,869
Total Operating Expenses	17,883,688	16,542,040	51,171,130	32,205,963
Loss from Operations	(1,903,589)	(4,884,693)	(6,388,632)	(8,000,653)
Other Income (Expense)
Interest expense	(3,163,534)	(2,111,721)	(8,974,895)	(4,930,941)
Change in warrant derivative liability	220,409	397,366	716,738	(78,923)
Non-cash consideration associated with stock purchase agreement	0	0	0	(558,185)
Other income (expense)	(51,350)	(89,926)	(309,924)	(193,052)
Total Other Income (Expense)	(2,994,475)	(1,804,281)	(8,568,081)	(5,761,101)
Net Loss from Operations	$ (4,898,064)	$ (6,688,974)	$ (14,956,713)	$ (13,761,754)
Net loss per share:
Basic (in dollars per share)	$ (0.40)	$ (0.64)	$ (1.24)	$ (1.7)
Dilutive (in dollars per share)	$ (0.40)	$ (0.64)	$ (1.24)	$ (1.7)
Shares used in the computation:
Basic (in shares)	12,193,970	10,432,622	12,064,782	8,100,226
Dilutive (in shares)	12,193,970	10,432,622	12,064,782	8,100,226

CONDENSED CONSOLIDATED STATEME5

CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($)	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Operating activities:
Net loss	$ (14,956,713)	$ (13,761,754)
Adjustments to reconcile net loss to net cash used in operating activities:
Depreciation and amortization	5,551,854	2,403,934
Non-cash interest	4,477,148	1,665,172
Extinguishment of debt	0	(2,345,019)
Non-cash consideration associated with stock purchase agreement	0	558,185
Impairment of Assets	0	233,748
Amortization of debt discount	0	707,281
(Gain) Loss on sale of fixed assets	(14,149)	11,377
Non-cash consulting expense/stock option expense	522,987	881,681
Provision for losses on accounts receivable and inventory	898,285	805,684
Change in derivative warrant liability	(716,738)	78,923
Changes in operating assets and liabilities:
Accounts receivable	(859,026)	(2,801,124)
Inventories	(3,958,050)	477,818
Prepaid and other assets	(1,482,561)	(325,976)
Accounts payable	3,155,962	694,326
Accrued liabilities	(3,813,998)	1,688,664
Net cash used in operating activities	(11,194,999)	(9,027,080)
Investing activities:
Acquisition of X-spine Systems, Inc.	0	(73,033,049)
Purchases of property and equipment and intangible assets	(5,566,569)	(444,312)
Proceeds from sale of fixed assets	16,400	102,587
Net cash used in investing activities	(5,550,169)	(73,374,774)
Financing activities:
Payments on long-term debt	0	(38,668)
Net proceeds from equity private placement	0	515,395
Payment on royalty obligation	0	(542,905)
Proceeds from the issuance of capital leases	0	70,921
Payments on capital leases	(80,071)	(78,490)
Net proceeds from issuance of long-term debt	1,000,000	17,479,159
Net proceeds from the issuance of convertible debt	2,212,718	66,322,366
Net proceeds from the revolving line of credit	8,353,113	0
Net proceeds from issuance of stock	300,000	2,118,483
Net cash provided by financing activities	11,785,760	85,846,261
Net change in cash and cash equivalents	(4,959,408)	3,444,407
Cash and cash equivalents at beginning of period	6,368,016	4,526,026
Cash and cash equivalents at end of period	$ 1,408,608	$ 7,970,433

Business Description and Summar

Business Description and Summary of Significant Accounting Policies	9 Months Ended
	Sep. 30, 2016
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Business Description and Summary of Significant Accounting Policies	(1) Business Description and Summary of Significant Accounting Policies The accompanying condensed consolidated financial statements include the accounts of Xtant Medical Holdings, Inc. (“Xtant”), formerly known as Bacterin International Holdings, Inc., a Delaware corporation, and its wholly owned subsidiaries, Bacterin International, Inc., (“Bacterin”) a Nevada corporation, Xtant Medical, Inc. (“Xtant Medical”), a Delaware corporation, and X-spine Systems, Inc. (“X-spine”), an Ohio corporation, (Xtant, Xtant Medical, Bacterin and X-spine are jointly referred to herein as the “Company”). All intercompany balances and transactions have been eliminated in consolidation. Xtant develops, manufactures and markets orthopedic products for domestic and international markets. Xtant products serve the combined specialized needs of orthopedic and neurological surgeons, including orthobiologics for the promotion of bone healing, implants and instrumentation for the treatment of spinal disease, tissue grafts for the treatment of orthopedic disorders to promote healing following spine, cranial and surgeries and the development, manufacturing and sale of medical devices for use in orthopedic spinal surgeries. The Company also previously developed and licensed coatings for various medical device applications. On July 31, 2015, Xtant acquired all of the outstanding capital stock of X-spine Systems, Inc. for approximately $ 60 13 4.24 The markets in which the Company competes are highly competitive and rapidly changing. Significant technological advances, changes in customer requirements, or the emergence of competitive products with new capabilities or technologies could adversely affect the Company’s operating results. The Company’s business could be harmed by a decline in demand for, or in the prices of, its products or as a result of, among other factors, any change in pricing or distribution methods, increased price competition, changes in government regulations or a failure by the Company to keep up with technological change. Further, a decline in available donors could have an adverse impact on our business. The accompanying interim condensed consolidated financial statements of Xtant for the three and nine months ended September 30, 2016 and 2015 are unaudited and are prepared in accordance with accounting principles generally accepted in the United States of America. They do not include all disclosures required by generally accepted accounting principles for annual financial statements, but in the opinion of management, include all adjustments, consisting only of normal recurring items, necessary for a fair presentation. Interim results are not necessarily indicative of results which may be achieved in the future for the full year ending December 31, 2016. These financial statements should be read in conjunction with the financial statements and notes thereto which are included in Xtant’s Annual Report on Form 10-K for the year ended December 31, 2015. The accounting policies set forth in those annual financial statements are the same as the accounting policies utilized in the preparation of these financial statements, except as modified for appropriate interim financial statement presentation. The Company’s accounts receivable are due from a variety of health care organizations and distributors throughout the world. Approximately 95 In the nine months ended September 30, 2016, Xtant purchased from Norwood Medical approximately 12 Nine Months Ended 2016 2015 United States $ 62,253,220 $ 35,419,434 Rest of world 3,278,659 1,669,315 Total revenue $ 65,531,879 $ 37,088,749 The preparation of the financial statements requires management of the Company to make a number of estimates and assumptions relating to the reported amount of assets and liabilities and the disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenue and expenses during the period. Significant estimates include the carrying amount of property and equipment, goodwill, and intangible assets and liabilities; valuation allowances for trade receivables, inventory, and deferred income tax assets and liabilities; valuation of the warrant derivative liability, inventory and estimates for the fair value of stock options grants and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates. Long-lived assets, including intangible assets, are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of assets to be held and used is measured by a comparison of the carrying amount of an asset to future net cash flows expected to be generated by the asset. If such assets are considered to be impaired, the impairment to be recognized is measured by the amount by which the carrying amount of the assets exceeds the estimated fair value of the assets. (See Note 5, “Impairment of Assets” below.) Goodwill represents the excess of costs over fair value of assets of businesses acquired. Goodwill and intangible assets acquired in a purchase business combination and determined to have indefinite useful lives are not amortized, instead they are tested for impairment at least annually and whenever events or circumstances indicate the carrying amount of such asset may not be recoverable. In its evaluation of goodwill, the Company performs an assessment of qualitative factors to determine if it is more-likely-than-not that goodwill might be impaired and whether it is necessary to perform the two-step goodwill impairment. The Company conducts its annual impairment test on December 31 of each year. Revenue is recognized when all of the following criteria are met: a) the Company has entered into a legally binding agreement with the customer; b) the products or services have been delivered; c) the Company’s fee for providing the products and services is fixed or determinable; and d) collection of the Company’s fee is probable. The Company’s policy is to record revenue net of any applicable sales, use, or excise taxes. If an arrangement includes a right of acceptance or a right to cancel, revenue is recognized when acceptance is received or the right to cancel has expired. The Company ships to certain customers under consignment arrangements whereby the Company’s product is stored by the customer. The customer is required to report the use to the Company and upon such notice, the Company invoices the customer and revenue is recognized when above criteria have been met. The Company expenses advertising costs as incurred. The Company had advertising expense of $ 140,049 93,854 Research and development costs, which are principally related to internal costs for the development of new devices and biologics and processes are expensed as incurred. Other income (expense) primarily consists of non-recurring items that are outside of the normal Company’s operations such as other related legal expenses, gain or loss on the sale of fixed assets and miscellaneous minor adjustments to account balances. Basic net income (loss) per share is computed by dividing net income (loss) by the weighted average number of common shares outstanding. Shares issued during the period and shares reacquired during the period are weighted for the portion of the period that they were outstanding. Diluted net income (loss) per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive common shares outstanding during the period, which include the assumed exercise of stock options and warrants using the treasury stock method. Diluted net loss per share was the same as basic net loss per share for the three and nine months ended September 30, 2016 and 2015, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Dilutive earnings per share are not reported as their effects of including 1,794,792 1,896,253 The carrying values of financial instruments, including trade accounts receivable, accounts payable, other accrued expenses and long-term debt, approximate their fair values based on terms and related interest rates. The Company follows a framework for measuring fair value. The framework provides a hierarchy that prioritizes the inputs to valuation techniques used to measure fair value. The hierarchy gives the highest priority to unadjusted quoted prices in active markets for identical assets or liabilities (Level 1) and the lowest priority to unobservable inputs (Level 3). The three levels of the fair value hierarchy are described below: Level 1: Inputs to the valuation methodology are unadjusted quoted prices for identical assets or liabilities in active markets. Level 2: Inputs to the valuation methodology include quoted prices for similar assets and liabilities in active markets, and inputs that are observable for the asset or liability, either directly or indirectly, for substantially the full term of the financial instrument. Level 3: Inputs to the valuation methodology are unobservable and significant to the fair value measurement. A financial instrument’s level within the fair value hierarchy is based on the lowest level of any input that is significant to the fair value measurement. During the three and nine months ended September 30, 2016 and 2015, there was no reclassification in financial assets or liabilities between Level 1, 2 or 3 categories. Warrant derivative liability As of As of Level 1 - - Level 2 - - Level 3 $ 333,613 $ 1,050,351 The valuation technique used to measure fair value of the warrant liability is based on a valuation model and significant assumptions and inputs determined by us (See Note 11, “Warrants” below). Level 3 Changes Warrant derivative liability Balance at January 1, 2016 $ 1,050,351 Gain recognized in earnings in first six months of 2016 (496,329) Balance at June 30, 2016 554,022 Gain recognized in earnings in third quarter of 2016 (220,409) Balance at September 30, 2016 $ 333,613 During the three and nine months ended September 30, 2016, the Company did not change any of the valuation techniques used to measure its liabilities at fair value.

Business Combination

Business Combination	9 Months Ended
	Sep. 30, 2016
Business Combinations [Abstract]
Business Combination	(2) Business Combination On July 31, 2015 (the “Acquisition Date”), the Company completed its acquisition of 100 1,269,613 3,325,048 Unaudited Supplemental Pro Forma Financial Information The unaudited pro forma results presented below for the three and nine months ending September 30, 2016 include the combined results of both entities as if the acquisition had been consummated as of January 1, 2015. Certain pro forma adjustments have been made to reflect the impact of the purchase transaction, primarily consisting of amortization of intangible assets with determinable lives and interest expense on long-term debt. In addition, certain historical expenses, such as warrant expense and interest expense associated with debt that was immediately repaid, were eliminated from these pro-forma results. The pro forma information does not necessarily reflect the actual results of operations had the acquisition been consummated at the beginning of the fiscal reporting period indicated nor is it indicative of future operating results. The pro forma information does not include any adjustment for potential revenue enhancements, cost synergies or other operating efficiencies that could result from the acquisition. Three Months Ended September 30, Nine Months Ended September 30, 2016 2015 2016 2015 Revenue $ 23,094,140 $ 20,901,292 $ 65,531,879 $ 64,401,225 Net loss $ (4,898,064) $ (5,357,091) $ (14,981,713) $ (16,061,103)

Equity

Equity	9 Months Ended
	Sep. 30, 2016
Equity [Abstract]
Equity	(3) Equity We entered into the Purchase Agreement on March 16, 2015, as amended and restated on April 17, 2015, with Aspire Capital, which provides that, upon the terms and subject to the conditions and limitations set forth therein, Aspire Capital is committed to purchase up to an aggregate of $ 10.0 207,182 750,000 154,189 3.62 558,185 150,000 300,000 417,000 1,366,941 Under the Purchase Agreement, we have the right, at our sole discretion, to present Aspire Capital with purchase notices, directing Aspire Capital (as principal) to purchase up to 50,000 500,000 · the lowest sale price of our common stock on the purchase date; or · the arithmetic average of the three lowest closing sale prices for our common stock during the ten consecutive trading days ending on the trading day immediately preceding the purchase date. In addition, we also have the right to present Aspire Capital with volume-weighted average price purchase notices directing Aspire Capital to purchase an amount of our common stock equal to up to 30 The Purchase Agreement may be terminated by us at any time, at our discretion, without any penalty or cost to us. The Purchase Agreement also provides for customary events of default, upon the occurrence of which Aspire Capital may terminate the Purchase Agreement. Aspire Capital has agreed that neither it nor any of its agents, representatives or affiliates shall engage in any direct or indirect short-selling or hedging of our common stock during any time prior to the termination of the Purchase Agreement. Any proceeds we receive under the Purchase Agreement are expected to be used for working capital and general corporate purposes. On July 31, 2015, the Company acquired all of the outstanding capital stock of X-spine for approximately $ 60 13 4,242,655 Related to the acquisition, on October 8, 2015 the Company granted 78,510 3.19 250,447 On September 4, 2015, the Company sold an aggregate of 140,053 515,395

Inventories, Net

Inventories, Net	9 Months Ended
	Sep. 30, 2016
Inventory Disclosure [Abstract]
Inventories, Net	(4) Inventories, Net September 30, December 31, 2016 2015 Current inventories Raw materials $ 5,508,685 $ 4,860,914 Work in process 2,258,138 2,720,707 Finished goods 22,399,012 18,289,674 Gross current inventories 30,165,835 25,871,295 Reserve for obsolescence (3,666,750) (3,186,579) Current inventories, net 26,499,085 22,684,716 Non-current inventories Finished goods 1,684,588 2,021,077 Reserve for obsolescence (413,163) (413,162) Non-current inventories, net 1,271,425 1,607,915 Total inventories, net $ 27,770,510 $ 24,292,631

Impairment of Assets

Impairment of Assets	9 Months Ended
	Sep. 30, 2016
Impairment or Disposal of Tangible Assets Disclosure [Abstract]
Impairment of Assets	(5) Impairment of Assets During the third quarter of 2015, Intangible Assets were reviewed and found to be impaired. The impact, net of amortization, was $ 285,224

Property and Equipment, Net

Property and Equipment, Net	9 Months Ended
	Sep. 30, 2016
Property, Plant and Equipment [Abstract]
Property and Equipment, Net	(6) Property and Equipment, Net September 30, December 31, 2016 2015 Equipment $ 5,148,782 $ 5,368,567 Computer equipment 358,560 348,404 Computer software 551,851 503,587 Furniture and fixtures 164,216 174,215 Leasehold improvements 4,042,311 2,661,802 Vehicles 10,000 10,000 Surgical instruments 13,196,895 8,175,578 Total cost 23,472,615 17,242,153 Less: accumulated depreciation (7,460,477) (5,425,524) Property and equipment, net $ 16,012,138 $ 11,816,629 The Company provides surgical instruments to surgeons to use during surgical procedures. Instruments are classified as non-current assets and are recorded as property, plant and equipment. Instruments are carried at cost and are held at book value (cost less accumulated depreciation). Depreciation is calculated using the straight-line method using a five year useful life. The Company leases certain equipment under capital leases. For financial reporting purposes, minimum lease payments relating to the assets have been capitalized. As of September 30, 2016, the Company has recorded $ 1,316,383 261,574 Maintenance and repairs expense for the nine months of 2016 and 2015 was $ 427,575 272,811 2,181,541 563,790

Intangible Assets

Intangible Assets	9 Months Ended
	Sep. 30, 2016
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible Assets	(7) Intangible Assets Intangible assets consist of various patents with regard to processes for its products and intangible assets associated with the acquisition of X-spine. September 30, December 31, Patents $ 719,210 $ 564,717 Acquisition related intangibles: Technology 28,698,700 28,698,700 Customer relationships 9,911,000 9,911,000 Tradename 4,543,300 4,543,300 Non-compete 40,500 40,500 Accumulated amortization (6,891,238) (3,520,928) Intangible assets, net $ 37,021,472 $ 40,237,289 Aggregate amortization expense: $ 3,370,309 $ 3,438,596 Remainder of 2016 $ 1,119,779 2017 4,637,474 2018 4,652,587 2019 4,543,386 2020 4,461,092 Thereafter 17,607,154 Total $ 37,021,472

Accrued Liabilities

Accrued Liabilities	9 Months Ended
	Sep. 30, 2016
Payables and Accruals [Abstract]
Accrued Liabilities	(8) Accrued Liabilities September 30, December 31, 2016 2015 Accrued stock compensation $ 213,758 $ 147,037 Wages/commissions payable 2,736,925 5,272,241 Accrued integration expense 358,989 731,645 Accrued interest payable 889,683 1,716,167 Other accrued expenses 1,424,219 1,728,761 Accrued liabilities $ 5,623,574 $ 9,595,851

Debt

Debt	9 Months Ended
	Sep. 30, 2016
Debt Disclosure [Abstract]
Debt Disclosure [Text Block]	(9) Debt On July 31, 2015, concurrent with the acquisition of X-spine, we completed an offering of $ 65.0 6.00 52.0 3 The Notes bear interest at a rate equal to 6.00 July 15, 2021 At any time prior to the close of business on the second business day immediately preceding the maturity date, holders may convert their Notes into shares of Xtant common stock (together with cash in lieu of fractional shares) at an initial conversion rate of 257.5163 1,000 3.88 9.99 ⋅ the issuance of certain share and cash dividends on our common stock; ⋅ the issuance of certain rights or warrants; ⋅ certain subdivisions and combinations of our capital stock; ⋅ certain distributions of capital stock, indebtedness or assets; and ⋅ certain tender or exchange offers. We will not adjust the conversion rate for other events, such as for an issuance of our common stock for cash or in connection with an acquisition that may dilute our common stock thereby adversely affecting its market price. In addition, Xtant will, in certain circumstances, increase the conversion rate for holders who convert their Notes in connection with a “make-whole fundamental change” (as defined in the Indenture). No sinking fund is provided for the Notes. Xtant may not redeem the Notes at its option prior to their maturity. If a “fundamental change” (as defined in the Indenture) occurs, holders will have the right, at their option, to require us to repurchase their Notes at a cash price equal to 100 The Notes are Xtant’s senior, unsecured obligations, rank equal in right of payment with its existing and future unsecured indebtedness that is not junior to the Notes, are senior in right of payment to any of its existing and future indebtedness that is expressly subordinated to the Notes, and are structurally subordinated to all existing and future indebtedness and other liabilities, including trade payables, and (to the extent Xtant is not a holder thereof) preferred equity, if any, of its subsidiaries. Amended and Restated Credit Agreement On July 31, 2015, we refinanced approximately $ 24 18 July 31, 2020 9 14 1 9 14 1 12 14 1 12 7.5 We accounted for the Notes and for the New Facility with ROS in accordance with ASC Subtopic 470-50, Debt Modifications and Extinguishments, and ASC Subtopic 470-60, Troubled Debt Restructurings by Debtors. Based on the facts and circumstances surrounding the changes to the loan and applying the calculation methodology per the above mentioned ASC Subtopics, the Company recognized a gain from the extinguishment of debt of $ 2,345,019 In addition, the Company calculated a fair value of the New Facility on a non-recurring basis by taking the five year cash flow and discounting it at a market interest rate. There was no significant difference between the calculated value and the stated value of the New Facility. Approximately $ 4.7 2.2 2.5 In April 2015, the FASB issued ASU 2015-3 to simplify the presentation of debt issuance costs. This update required that debt issuance costs be presented in the balance sheet as a direct deduction from the carrying amount of the associated debt liability, consistent with the required presentation for debt discounts. As required, the update was adopted and effective for interim and annual periods beginning after December 15, 2015. ASU 2015-3 did not have a material impact. Prior to the issuance of the New Facility, the Company was required to pay a royalty of 1.75% on the first $45,000,000 of net sales, plus 1.0% of net sales in excess of $45,000,000 7.4 12.3 2.3 On March 31, 2016, we entered into an amendment of the New Facility. The amendment modifies the New Facility by extending the time frame during which the Company may elect to allow interest to accrue on its loan in lieu of making interest payments, from December 31, 2015 to March 31, 2016. The amendment also lowers the minimum liquidity requirements of the Company, by allowing the Company to maintain a liquidity amount of $500,000 or greater through June 30, 2016. The lower minimum liquidity requirement of $ 500,000 On April 14, 2016, we issued $ 2,238,166.45 Both the Additional Notes and the Notes bear interest at a rate equal to 6.00 The Additional Notes may be converted into shares of our common stock (together with cash in lieu of fractional shares) at an initial conversion rate of 344.8276 1,000 2.90 On July 29, 2016 we entered into the fourth amendment to the New Facility. The amendment modified the New Facility by including an additional “Tranche A Commitment” in an amount up to $ 1,000,000 On August 12, 2016, we entered into the fifth amendment to the New Facility, which amended one of the negative covenants under the New Facility to take into account the Modification Agreement. On September 27, 2016, we entered into the sixth amendment to the New Facility. The sixth amendment modifies the New Facility by increasing this fee on any amounts paid under the New Facility from 7.5 9.0 9.0 Loan and Security Agreement On May 25, 2016, we entered into a Loan and Security Agreement (the “LSA”) with Silicon Valley Bank, a California corporation (the “Bank”), pursuant to which the Bank agreed to provide us with a revolving line of credit in the aggregate principal amount of $ 6,000,000 1.00 As a condition to the extension of credit under the LSA, we agreed to enter into an Intellectual Property Security Agreement with the Bank, dated May 25, 2016, and to take such other actions as the Bank may request in its good faith business judgment to perfect and maintain a perfected security interest in favor of the Bank in our intellectual property. On August 12, 2016, we entered into a First Loan Modification Agreement (the “Modification Agreement”) with the Bank, which amended certain provisions of the LSA. Pursuant to the terms of the Modification Agreement, the Bank increased the aggregate principal amount of the revolving line of credit to $ 11,000,000 4.00 September 30, December 31, 2016 2015 Loan payable to ROS Acquisition Offshore (See details above) $ 43,000,000 $ 42,000,000 PIK Interest payable to ROS 6,883,890 2,700,476 6% convertible senior unsecured notes due 2021 (See details above) 70,238,167 68,000,000 Gross long-term debt 120,122,057 112,700,476 Less: capitalized debt issuance costs (1,763,824) $ (1,563,353) Long-term debt, less issuance costs $ 118,358,233 $ 111,137,123 Remainder of 2016 $ - 2017 - 2018 - 2019 - 2020 49,883,889 Thereafter 70,238,168 Total gross long-term debt $ 120,122,057

Stock-Based Compensation

Stock-Based Compensation	9 Months Ended
	Sep. 30, 2016
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]
Stock-Based Compensation	(10) Stock-Based Compensation The Amended and Restated Xtant Medical Equity Incentive Plan (the “Plan”) provides for stock awards, including options and performance stock awards, to be granted to employees, consultants, independent contractors, officers and directors. The purpose of the Plan is to enable us to attract, retain and motivate key employees, directors and, on occasion, independent consultants, by providing them with stock options and restricted stock grants. Stock options granted under the Plan may be either incentive stock options to employees, as defined in Section 422A of the Internal Revenue Code of 1986, or non-qualified stock options. The Plan is administered by the compensation committee of our Board of Directors. Stock options granted under the Plan are generally not transferable, vest in installments over the requisite service period and are exercisable during the stated contractual term of the option only by such optionee. The exercise price of all incentive stock options granted under the Plan must be at least equal to the fair market value of the shares of common stock on the date of the grant. 1,900,000 530,000 Stock compensation expense recognized in the condensed consolidated statements of operations for the nine months ended September 30, 2016 and 2015 is based on awards ultimately expected to vest and reflects an estimate of awards that will be forfeited. ASC 718 requires forfeitures to be estimated at the time of grant and revised, if necessary, in subsequent periods if actual forfeitures differ from those estimates. Nine Months Nine Months September 30, September 30, Risk-free interest rate 2.21 % 1.30 % Expected volatility 79 % 75 % Expected term (Years) 6.0 6.0 Expected forfeiture rate 20 % 20 % Dividend yield 0 % 0 % 2016 2015 Shares Weighted Weighted Shares Weighted Weighted Outstanding at January 1 664,081 $ 10.64 $ 5.32 695,336 $ 11.09 $ 5.35 Granted - - - 45,000 4.00 2.81 Exercised - - - - - - Cancelled or expired (105,275) 9.48 4.50 (31,604) 12.71 6.02 Outstanding at September 30 558,806 $ 10.85 $ 5.42 708,732 $ 10.54 $ 5.29 Exercisable at September 30 409,179 $ 12.67 $ 6.15 388,498 $ 13.53 $ 6.43 The aggregate intrinsic value of options outstanding as of September 30, 2016 was zero because the closing price of the stock at September 30, 2016 was less than the strike price of all options outstanding. As of September 30, 2016, there were 409,179 12.67 700,000 From time to time we may grant stock options and stock grants to consultants. We account for consultant stock options in accordance with ASC 505-50. Consulting expense for the grant of stock options to consultants is determined based on the estimated fair value of the stock options at the measurement date as defined in ASC 505-50 and is recognized over the vesting period. The Company recognized expenses for the nine months ended September 30, 2016 and 2015 of zero and $ 140,869 Total share based compensation recognized for employees, directors and consultants was $ 479,289 444,352 On July 1, 2015, the 39,312 4.07 160,000 On July 1, 2015, the Company granted 58,820 3.40 200,000 100,000 On October 8, 2015 the Company granted 78,510 3.19 250,447 55,995 Also, on October 8, 2015, the Company granted 20,000 3.19 65,550 15,888 On , July 20 2016, the Company granted 300,000 1.77 531,000 83,833 On July 5, 2016, the Company granted 80,404 1.99 160,004 42,000 On July 5, 2016, the Company granted 59,400 1.99 118,206 10,000 On October 6, 2016, we issued an option to purchase 300,000 1.11

Warrants

Warrants	9 Months Ended
	Sep. 30, 2016
Warrants and Rights Note Disclosure [Abstract]
Warrants	(11) Warrants Weighted Common Average Stock Exercise Warrants Price Outstanding as of January 1, 2015 1,655,320 $ 13.06 Issued - - Expired (376,754) 22.87 Outstanding at January 1, 2016 1,278,566 $ 8.45 Issued - - Expired (42,580) 31.73 Outstanding at September 30, 2016 1,235,986 $ 7.65 We utilize a valuation model to determine the fair market value of the warrants accounted for as liabilities. The valuation model accommodates the probability of exercise price adjustment features as outlined in the warrant agreements. We recorded an unrealized gain of $ 716,738 Nine Months Ended September 30, 2016 2015 Value of underlying common stock (per share) $ 1.13 $ 3.26 Risk free interest rate 2.21 % 1.37 % Expected term (years) 3.25 4.25 Volatility 79 % 75 % Dividend yield 0 % 0 % 2016 2015 Balance at January 1, 1,125,119 1,171,692 Derivative warrants issued - - Derivative warrants exercised - - Expired - - Balance at September 30, 1,125,119 1,171,692

Commitments and Contingencies

Commitments and Contingencies	9 Months Ended
	Sep. 30, 2016
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies	(12) Commitments and Contingencies Operating Leases We lease four office facilities under non-cancelable operating lease agreements with expiration dates in 2016, 2019, 2023 and 2025. We have the option to extend the four leases for up to another ten year term and for one facility, we have the right of first refusal on any sale. We lease additional office space under a month-to-month arrangement. On October 23, 2015, the Company entered into a sale-leaseback transaction for the property located at 664 Cruiser Lane, Belgrade, Montana, 59714 which formerly secured the 6 Remainder of 2016 $ 195,218 2017 794,437 2018 806,747 2019 668,807 2020 396,263 2021 375,289 Thereafter 1,038,416 Total $ 4,275,177 Rent expense was $ 661,219 458,814 Indemnifications Our arrangements generally include limited warranties and certain provisions for indemnifying customers against liabilities if our products or services infringe a third-party’s intellectual property rights. To date, we have not incurred any material costs as a result of such warranties or indemnification provisions and have not accrued any liabilities related to such obligations in the accompanying financial statements. We have also agreed to indemnify our directors and executive officers for costs associated with any fees, expenses, judgments, fines and settlement amounts incurred by any of these persons in any action or proceeding to which any of those persons is, or is threatened to be, made a party by reason of the person’s service as a director or officer, including any action by us, arising out of that person’s services as our director or officer or that person’s services provided to any other company or enterprise at our request. Litigation On March 17, 2014, a complaint was served on the Company in the following state court action in the District Court for the County of Arapahoe, State of Colorado: Robert Taggart v. Guy Cook, Bacterin International, Inc., a Nevada Corporation and Bacterin International Holdings, Inc., a Delaware corporation, Civil Action No. 14CV30401. The complaint involves claims under an employment agreement between plaintiff and the Company seeking commissions on Company sales, a commission on funds obtained by the Company as a result of a reverse merger and vesting of certain stock options and was settled in the quarter ending March 31, 2016. We are also engaged in ordinary routine litigation incidental to our business, including product liability disputes.

Income Taxes

Income Taxes	9 Months Ended
	Sep. 30, 2016
Income Tax Disclosure [Abstract]
Income Taxes	(13) Income Taxes In evaluating the realizability of the net deferred tax assets, we take into account a number of factors, primarily relating to the ability to generate taxable income. Where it is determined that it is likely that we will be unable to realize deferred tax assets, a valuation allowance is established against the portion of the deferred tax asset. Because it cannot be accurately determined when or if we will become profitable, a valuation allowance was provided against the entire deferred income tax asset balance. The Company did not recognize any interest or penalties related to income taxes for the nine months ended September 30, 2016 and 2015.

Supplemental Disclosure of Cash

Supplemental Disclosure of Cash Flow Information	9 Months Ended
	Sep. 30, 2016
Supplemental Cash Flow Elements [Abstract]
Supplemental Disclosure of Cash Flow Information	(14) Supplemental Disclosure of Cash Flow Information Nine Months Ended September 30, 2016 2015 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 4,530,170 $ 2,372,453 Non-cash activities: Issuance of capital leases $ 967,221 $ 70,020 Issuance of shares associated with legal settlement $ 225,000 $ - Issuance of share for non-cash consulting expense $ - $ 190,869 Issuance of restricted stock to employees $ - $ 41,741 Issuance of shares in conjunction with the acquisition of X-spine $ - $ 14,934,146

Related Party Transactions

Related Party Transactions	9 Months Ended
	Sep. 30, 2016
Related Party Transactions [Abstract]
Related Party Transactions	(15) Related Party Transactions Darrel Holmes, our former Chief Operating Officer of our Bacterin subsidiary, serves on the board of American Donor Services Inc. (“ADS”). Mr. Holmes receives $ 5,000 844,643 1,367,487 Certain of X-spine’s former shareholders now own over 10% of our common stock as of the Acquisition Date, and have owned a controlling interest of X-spine’s largest supplier, Norwood Tool Company d/b/a Norwood Medical. In the first nine months of 2016, Xtant purchased from Norwood Medical approximately 12 Unless delegated to the Compensation Committee by the Board of Directors, the Audit Committee or the disinterested members of the full Board of Directors reviews and approves all related party transactions.

Segment and Geographic Informat

Segment and Geographic Information	9 Months Ended
	Sep. 30, 2016
Segment Reporting [Abstract]
Segment and Geographic Information	(16) Segment and Geographic Information The Company’s management reviews financial results and manages the business on an aggregate basis. Therefore, financial results are reported in a single operating segment: the development, manufacture and marketing of orthopedic medical products and devices. The Company attributes revenues to geographic areas based on the location of the customer. Total revenue by major geographic area is reported in Note 1, “Business Description and Summary of Significant Accounting Policies” above.

Subsequent Events

Subsequent Events	9 Months Ended
	Sep. 30, 2016
Subsequent Events [Abstract]
Subsequent Events	(17) Subsequent Events On October 6, 2016, our board of directors appointed Carl D. O’Connell to serve as the President of the Company. His appointment became effective October 6, 2016. In connection with the hiring of Mr. O’Connell, we issued him an option to purchase 300,000 1.11 On October 31, 2016, the Company distributed to holders of its Common Stock and to holders of its convertible notes, at no charge, non-transferable subscription rights to purchase units. Each unit consisted of one share of Common Stock and one tradable warrant representing the right to purchase one share of Common Stock (“Tradeable Warrants”). The offering of units pursuant to the subscription rights is referred to as the “Rights Offering.” On October 31, 2016, the Company entered into a dealer-manager agreement (the “Dealer-Manager Agreement”) with Maxim Group LLC (“Maxim”), to engage Maxim as dealer-manager for the Rights Offering. In the Rights Offering, holders received two subscription rights for each share of Common Stock, or each share of Common Stock underlying our convertible notes owned on the record date, October 21, 2016. Subscribers whose subscriptions otherwise would have resulted in their beneficial ownership of more than 4.99 0.01 0.01 The Rights Offering commenced on October 31, 2016 and the subscription rights are expected to expire on November 14, 2016, unless extended. The units were initially priced at $ 0.90 per unit. On November 9, 2016, the Company reduced the subscription price to $ 0.75 11.3 10.2 0.75 0.90 After the one-year anniversary of issuance, we may redeem the Tradable Warrants for $0.01 per Tradable Warrant if the volume weighted average price of our Common Stock is above $2.25 for each of 10 consecutive trading days. In connection with the Rights Offering, the Company will pay to Maxim a cash fee equal to 7 75,000 Under the terms and subject to the conditions contained in the Dealer-Manager Agreement, the Company has agreed not to issue, agree to issue or announce the issuance of any shares of Common Stock or Common Stock equivalents until 90 days after the closing date of the Rights Offering, without the consent of Maxim, subject to certain exceptions including a pre-existing agreement, equity awards, conversion of derivative securities and in connection with any acquisitions, partnerships or strategic transactions. A registration statement on Form S-1, as amended (File No. 333-213350), relating to the securities being offered and sold in connection with the Rights Offering was declared effective by the U.S. Securities and Exchange Commission (“SEC”) on October 31, 2016. A prospectus and prospectus supplement relating to and describing the terms of the Rights Offering has been filed with the SEC as a part of the registration statement and is available on the SEC’s web site at http://www.sec.gov.

Business Description and Summ23

Business Description and Summary of Significant Accounting Policies (Policies)	9 Months Ended
	Sep. 30, 2016
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Business Description	Business Description The accompanying condensed consolidated financial statements include the accounts of Xtant Medical Holdings, Inc. (“Xtant”), formerly known as Bacterin International Holdings, Inc., a Delaware corporation, and its wholly owned subsidiaries, Bacterin International, Inc., (“Bacterin”) a Nevada corporation, Xtant Medical, Inc. (“Xtant Medical”), a Delaware corporation, and X-spine Systems, Inc. (“X-spine”), an Ohio corporation, (Xtant, Xtant Medical, Bacterin and X-spine are jointly referred to herein as the “Company”). All intercompany balances and transactions have been eliminated in consolidation. Xtant develops, manufactures and markets orthopedic products for domestic and international markets. Xtant products serve the combined specialized needs of orthopedic and neurological surgeons, including orthobiologics for the promotion of bone healing, implants and instrumentation for the treatment of spinal disease, tissue grafts for the treatment of orthopedic disorders to promote healing following spine, cranial and surgeries and the development, manufacturing and sale of medical devices for use in orthopedic spinal surgeries. The Company also previously developed and licensed coatings for various medical device applications. On July 31, 2015, Xtant acquired all of the outstanding capital stock of X-spine Systems, Inc. for approximately $ 60 13 4.24 The markets in which the Company competes are highly competitive and rapidly changing. Significant technological advances, changes in customer requirements, or the emergence of competitive products with new capabilities or technologies could adversely affect the Company’s operating results. The Company’s business could be harmed by a decline in demand for, or in the prices of, its products or as a result of, among other factors, any change in pricing or distribution methods, increased price competition, changes in government regulations or a failure by the Company to keep up with technological change. Further, a decline in available donors could have an adverse impact on our business. The accompanying interim condensed consolidated financial statements of Xtant for the three and nine months ended September 30, 2016 and 2015 are unaudited and are prepared in accordance with accounting principles generally accepted in the United States of America. They do not include all disclosures required by generally accepted accounting principles for annual financial statements, but in the opinion of management, include all adjustments, consisting only of normal recurring items, necessary for a fair presentation. Interim results are not necessarily indicative of results which may be achieved in the future for the full year ending December 31, 2016. These financial statements should be read in conjunction with the financial statements and notes thereto which are included in Xtant’s Annual Report on Form 10-K for the year ended December 31, 2015. The accounting policies set forth in those annual financial statements are the same as the accounting policies utilized in the preparation of these financial statements, except as modified for appropriate interim financial statement presentation.
Concentrations and Credit Risk	Concentrations and Credit Risk The Company’s accounts receivable are due from a variety of health care organizations and distributors throughout the world. Approximately 95 In the nine months ended September 30, 2016, Xtant purchased from Norwood Medical approximately 12 Nine Months Ended 2016 2015 United States $ 62,253,220 $ 35,419,434 Rest of world 3,278,659 1,669,315 Total revenue $ 65,531,879 $ 37,088,749
Use of Estimates	Use of Estimates The preparation of the financial statements requires management of the Company to make a number of estimates and assumptions relating to the reported amount of assets and liabilities and the disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenue and expenses during the period. Significant estimates include the carrying amount of property and equipment, goodwill, and intangible assets and liabilities; valuation allowances for trade receivables, inventory, and deferred income tax assets and liabilities; valuation of the warrant derivative liability, inventory and estimates for the fair value of stock options grants and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates.
Long-Lived Assets	Long-Lived Assets Long-lived assets, including intangible assets, are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of assets to be held and used is measured by a comparison of the carrying amount of an asset to future net cash flows expected to be generated by the asset. If such assets are considered to be impaired, the impairment to be recognized is measured by the amount by which the carrying amount of the assets exceeds the estimated fair value of the assets. (See Note 5, “Impairment of Assets” below.)
Goodwill	Goodwill Goodwill represents the excess of costs over fair value of assets of businesses acquired. Goodwill and intangible assets acquired in a purchase business combination and determined to have indefinite useful lives are not amortized, instead they are tested for impairment at least annually and whenever events or circumstances indicate the carrying amount of such asset may not be recoverable. In its evaluation of goodwill, the Company performs an assessment of qualitative factors to determine if it is more-likely-than-not that goodwill might be impaired and whether it is necessary to perform the two-step goodwill impairment. The Company conducts its annual impairment test on December 31 of each year.
Revenue Recognition	Revenue Recognition Revenue is recognized when all of the following criteria are met: a) the Company has entered into a legally binding agreement with the customer; b) the products or services have been delivered; c) the Company’s fee for providing the products and services is fixed or determinable; and d) collection of the Company’s fee is probable. The Company’s policy is to record revenue net of any applicable sales, use, or excise taxes. If an arrangement includes a right of acceptance or a right to cancel, revenue is recognized when acceptance is received or the right to cancel has expired. The Company ships to certain customers under consignment arrangements whereby the Company’s product is stored by the customer. The customer is required to report the use to the Company and upon such notice, the Company invoices the customer and revenue is recognized when above criteria have been met.
Advertising Costs	Advertising Costs The Company expenses advertising costs as incurred. The Company had advertising expense of $ 140,049 93,854
Research and Development	Research and Development Research and development costs, which are principally related to internal costs for the development of new devices and biologics and processes are expensed as incurred.
Other Income (Expense)	Other Income (Expense) Other income (expense) primarily consists of non-recurring items that are outside of the normal Company’s operations such as other related legal expenses, gain or loss on the sale of fixed assets and miscellaneous minor adjustments to account balances.
Net Loss Per Share	Net Loss Per Share Basic net income (loss) per share is computed by dividing net income (loss) by the weighted average number of common shares outstanding. Shares issued during the period and shares reacquired during the period are weighted for the portion of the period that they were outstanding. Diluted net income (loss) per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive common shares outstanding during the period, which include the assumed exercise of stock options and warrants using the treasury stock method. Diluted net loss per share was the same as basic net loss per share for the three and nine months ended September 30, 2016 and 2015, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Dilutive earnings per share are not reported as their effects of including 1,794,792 1,896,253
Fair Value of Financial Instruments	Fair Value of Financial Instruments The carrying values of financial instruments, including trade accounts receivable, accounts payable, other accrued expenses and long-term debt, approximate their fair values based on terms and related interest rates. The Company follows a framework for measuring fair value. The framework provides a hierarchy that prioritizes the inputs to valuation techniques used to measure fair value. The hierarchy gives the highest priority to unadjusted quoted prices in active markets for identical assets or liabilities (Level 1) and the lowest priority to unobservable inputs (Level 3). The three levels of the fair value hierarchy are described below: Level 1: Inputs to the valuation methodology are unadjusted quoted prices for identical assets or liabilities in active markets. Level 2: Inputs to the valuation methodology include quoted prices for similar assets and liabilities in active markets, and inputs that are observable for the asset or liability, either directly or indirectly, for substantially the full term of the financial instrument. Level 3: Inputs to the valuation methodology are unobservable and significant to the fair value measurement. A financial instrument’s level within the fair value hierarchy is based on the lowest level of any input that is significant to the fair value measurement. During the three and nine months ended September 30, 2016 and 2015, there was no reclassification in financial assets or liabilities between Level 1, 2 or 3 categories. Warrant derivative liability As of As of Level 1 - - Level 2 - - Level 3 $ 333,613 $ 1,050,351 The valuation technique used to measure fair value of the warrant liability is based on a valuation model and significant assumptions and inputs determined by us (See Note 11, “Warrants” below). Level 3 Changes Warrant derivative liability Balance at January 1, 2016 $ 1,050,351 Gain recognized in earnings in first six months of 2016 (496,329) Balance at June 30, 2016 554,022 Gain recognized in earnings in third quarter of 2016 (220,409) Balance at September 30, 2016 $ 333,613 During the three and nine months ended September 30, 2016, the Company did not change any of the valuation techniques used to measure its liabilities at fair value.

Business Description and Summ24

Business Description and Summary of Significant Accounting Policies (Tables)	9 Months Ended
	Sep. 30, 2016
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Schedule of Revenues by Geographic Region	Revenue by geographical region is as follows: Nine Months Ended 2016 2015 United States $ 62,253,220 $ 35,419,434 Rest of world 3,278,659 1,669,315 Total revenue $ 65,531,879 $ 37,088,749
Schedule of Assets and Liabilities Measured on Recurring Basis	The following table sets forth by level, within the fair value hierarchy, our liabilities as of September 30, 2016 and December 31, 2015, that are measured at fair value on a recurring basis: Warrant derivative liability As of As of Level 1 - - Level 2 - - Level 3 $ 333,613 $ 1,050,351
Schedule of Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation	The following is a reconciliation of the beginning and ending balances for liabilities measured at fair value on a recurring basis using significant unobservable inputs (Level 3) during the nine months ended September 30, 2016: Warrant derivative liability Balance at January 1, 2016 $ 1,050,351 Gain recognized in earnings in first six months of 2016 (496,329) Balance at June 30, 2016 554,022 Gain recognized in earnings in third quarter of 2016 (220,409) Balance at September 30, 2016 $ 333,613

Business Combination (Tables)

Business Combination (Tables)	9 Months Ended
	Sep. 30, 2016
Business Combinations [Abstract]
Business Acquisition, Pro Forma Information	Three Months Ended September 30, Nine Months Ended September 30, 2016 2015 2016 2015 Revenue $ 23,094,140 $ 20,901,292 $ 65,531,879 $ 64,401,225 Net loss $ (4,898,064) $ (5,357,091) $ (14,981,713) $ (16,061,103)

Inventories, Net (Tables)

Inventories, Net (Tables)	9 Months Ended
	Sep. 30, 2016
Inventory Disclosure [Abstract]
Schedule of Inventories	Inventories consist of the following: September 30, December 31, 2016 2015 Current inventories Raw materials $ 5,508,685 $ 4,860,914 Work in process 2,258,138 2,720,707 Finished goods 22,399,012 18,289,674 Gross current inventories 30,165,835 25,871,295 Reserve for obsolescence (3,666,750) (3,186,579) Current inventories, net 26,499,085 22,684,716 Non-current inventories Finished goods 1,684,588 2,021,077 Reserve for obsolescence (413,163) (413,162) Non-current inventories, net 1,271,425 1,607,915 Total inventories, net $ 27,770,510 $ 24,292,631

Property and Equipment, Net (Ta

Property and Equipment, Net (Tables)	9 Months Ended
	Sep. 30, 2016
Property, Plant and Equipment [Abstract]
Schedule of Property and Equipment, Net	Property and equipment, net are as follows: September 30, December 31, 2016 2015 Equipment $ 5,148,782 $ 5,368,567 Computer equipment 358,560 348,404 Computer software 551,851 503,587 Furniture and fixtures 164,216 174,215 Leasehold improvements 4,042,311 2,661,802 Vehicles 10,000 10,000 Surgical instruments 13,196,895 8,175,578 Total cost 23,472,615 17,242,153 Less: accumulated depreciation (7,460,477) (5,425,524) Property and equipment, net $ 16,012,138 $ 11,816,629

Intangible Assets (Tables)

Intangible Assets (Tables)	9 Months Ended
	Sep. 30, 2016
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Intangible Assets	The following table sets forth information regarding intangible assets: September 30, December 31, Patents $ 719,210 $ 564,717 Acquisition related intangibles: Technology 28,698,700 28,698,700 Customer relationships 9,911,000 9,911,000 Tradename 4,543,300 4,543,300 Non-compete 40,500 40,500 Accumulated amortization (6,891,238) (3,520,928) Intangible assets, net $ 37,021,472 $ 40,237,289 Aggregate amortization expense: $ 3,370,309 $ 3,438,596
Schedule of Estimated Amortization Expense for Intangible Assets	The following is a summary of estimated future amortization expense for intangible assets as of September 30, 2016: Remainder of 2016 $ 1,119,779 2017 4,637,474 2018 4,652,587 2019 4,543,386 2020 4,461,092 Thereafter 17,607,154 Total $ 37,021,472

Accrued Liabilities (Tables)

Accrued Liabilities (Tables)	9 Months Ended
	Sep. 30, 2016
Payables and Accruals [Abstract]
Schedule of Accrued Liabilities	Accrued liabilities consist of the following: September 30, December 31, 2016 2015 Accrued stock compensation $ 213,758 $ 147,037 Wages/commissions payable 2,736,925 5,272,241 Accrued integration expense 358,989 731,645 Accrued interest payable 889,683 1,716,167 Other accrued expenses 1,424,219 1,728,761 Accrued liabilities $ 5,623,574 $ 9,595,851

Debt (Tables)

Debt (Tables)	9 Months Ended
	Sep. 30, 2016
Debt Disclosure [Abstract]
Schedule of Long-term Debt	Long-term debt consists of the following: September 30, December 31, 2016 2015 Loan payable to ROS Acquisition Offshore (See details above) $ 43,000,000 $ 42,000,000 PIK Interest payable to ROS 6,883,890 2,700,476 6% convertible senior unsecured notes due 2021 (See details above) 70,238,167 68,000,000 Gross long-term debt 120,122,057 112,700,476 Less: capitalized debt issuance costs (1,763,824) $ (1,563,353) Long-term debt, less issuance costs $ 118,358,233 $ 111,137,123
Schedule of Maturities of Long-term Debt	The following is a summary of maturities due on the debt as of September 30, 2016: Remainder of 2016 $ - 2017 - 2018 - 2019 - 2020 49,883,889 Thereafter 70,238,168 Total gross long-term debt $ 120,122,057

Stock-Based Compensation (Table

Stock-Based Compensation (Tables)	9 Months Ended
	Sep. 30, 2016
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]
Schedule of Share-based Payment Award, Stock Options, Valuation Assumptions	The estimated fair value of stock options granted is done using the Black-Scholes-Merton method applied to individual grants. Key assumptions used to estimate the fair value of stock awards are as follows: Nine Months Nine Months September 30, September 30, Risk-free interest rate 2.21 % 1.30 % Expected volatility 79 % 75 % Expected term (Years) 6.0 6.0 Expected forfeiture rate 20 % 20 % Dividend yield 0 % 0 %
Schedule of Share-based Compensation, Stock Options, Activity	Stock option activity, including options granted under the Plan and the Non-Plan Grants, was as follows: 2016 2015 Shares Weighted Weighted Shares Weighted Weighted Outstanding at January 1 664,081 $ 10.64 $ 5.32 695,336 $ 11.09 $ 5.35 Granted - - - 45,000 4.00 2.81 Exercised - - - - - - Cancelled or expired (105,275) 9.48 4.50 (31,604) 12.71 6.02 Outstanding at September 30 558,806 $ 10.85 $ 5.42 708,732 $ 10.54 $ 5.29 Exercisable at September 30 409,179 $ 12.67 $ 6.15 388,498 $ 13.53 $ 6.43

Warrants (Tables)

Warrants (Tables)	9 Months Ended
	Sep. 30, 2016
Warrants and Rights Note Disclosure [Abstract]
Schedule of Warrant Activity	The following table summarizes our warrant activities for the quarter ended September 30, 2016: Weighted Common Average Stock Exercise Warrants Price Outstanding as of January 1, 2015 1,655,320 $ 13.06 Issued - - Expired (376,754) 22.87 Outstanding at January 1, 2016 1,278,566 $ 8.45 Issued - - Expired (42,580) 31.73 Outstanding at September 30, 2016 1,235,986 $ 7.65
Schedule of Warrant Valuation Assumptions	The estimated fair value was derived using a valuation model with the following weighted-average assumptions: Nine Months Ended September 30, 2016 2015 Value of underlying common stock (per share) $ 1.13 $ 3.26 Risk free interest rate 2.21 % 1.37 % Expected term (years) 3.25 4.25 Volatility 79 % 75 % Dividend yield 0 % 0 %
Schedule of Warrants Activities Used In Derivative Liability	The following table summarizes our activities related to warrants accounted for as a derivative liability for the nine months ended September 30, 2016 and 2015: 2016 2015 Balance at January 1, 1,125,119 1,171,692 Derivative warrants issued - - Derivative warrants exercised - - Expired - - Balance at September 30, 1,125,119 1,171,692

Commitments and Contingencies (

Commitments and Contingencies (Tables)	9 Months Ended
	Sep. 30, 2016
Commitments and Contingencies Disclosure [Abstract]
Schedule of Future Minimum Rental Payments for Operating Leases	Future minimum payments for the next five years and thereafter as of September 30, 2016, under these leases, are as follows: Remainder of 2016 $ 195,218 2017 794,437 2018 806,747 2019 668,807 2020 396,263 2021 375,289 Thereafter 1,038,416 Total $ 4,275,177

Supplemental Disclosure of Ca34

Supplemental Disclosure of Cash Flow Information (Tables)	9 Months Ended
	Sep. 30, 2016
Supplemental Cash Flow Elements [Abstract]
Supplemental Disclosure of Cash Flow Information	Supplemental cash flow information is as follows: Nine Months Ended September 30, 2016 2015 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 4,530,170 $ 2,372,453 Non-cash activities: Issuance of capital leases $ 967,221 $ 70,020 Issuance of shares associated with legal settlement $ 225,000 $ - Issuance of share for non-cash consulting expense $ - $ 190,869 Issuance of restricted stock to employees $ - $ 41,741 Issuance of shares in conjunction with the acquisition of X-spine $ - $ 14,934,146

Business Description and Summ35

Business Description and Summary of Significant Accounting Policies (Details) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015	Sep. 30, 2016	Sep. 30, 2015
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total revenue	$ 23,094,140	$ 17,693,020	$ 65,531,879	$ 37,088,749
US [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total revenue			62,253,220	35,419,434
Rest of world [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Total revenue			$ 3,278,659	$ 1,669,315

Business Description and Summ36

Business Description and Summary of Significant Accounting Policies (Details 1) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Warrant derivative liability	$ 333,613	$ 1,050,351
Fair Value, Inputs, Level 1 [Member] | Fair Value, Measurements, Recurring [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Warrant derivative liability	0	0
Fair Value, Inputs, Level 2 [Member] | Fair Value, Measurements, Recurring [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Warrant derivative liability	0	0
Fair Value, Inputs, Level 3 [Member] | Fair Value, Measurements, Recurring [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Warrant derivative liability	$ 333,613	$ 1,050,351

Business Description and Summ37

Business Description and Summary of Significant Accounting Policies (Details 2) - USD ($)	3 Months Ended	6 Months Ended
	Sep. 30, 2016	Jun. 30, 2016
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Balance	$ 554,022	$ 1,050,351
Gain recognized in earnings	(220,409)	(496,329)
Balance	$ 333,613	$ 554,022

Business Description and Summ38

Business Description and Summary of Significant Accounting Policies (Details Textual) - USD ($)	1 Months Ended	9 Months Ended
	Jul. 31, 2015	Sep. 30, 2016	Sep. 30, 2015
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Advertising Expense		$ 140,049	$ 93,854
Antidilutive Securities Excluded from Computation of Earnings Per Share, Amount		1,794,792	1,896,253
Business Combination, Consideration Transferred	$ 60,000,000
Debt [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Other Payments to Acquire Businesses	$ 13,000,000
Common Stock [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Business Acquisition Number Of Shares Acquired	4,240,000
Sales Revenue, Net [Member] | One Vendor [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Concentration Risk, Percentage		12.00%
Geographic Concentration Risk [Member] | Sales Revenue, Net [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Concentration Risk, Percentage			95.00%
Geographic Concentration Risk [Member] | Sales Revenue, Net [Member] | US [Member]
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Concentration Risk, Percentage		95.00%

Business Combination (Details)

Business Combination (Details) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015	Sep. 30, 2016	Sep. 30, 2015
Revenue	$ 23,094,140	$ 20,901,292	$ 65,531,879	$ 64,401,225
Net loss	$ (4,898,064)	$ (5,357,091)	$ (14,981,713)	$ (16,061,103)

Business Combination (Details T

Business Combination (Details Textual) - USD ($)	9 Months Ended
	Sep. 30, 2016	Jul. 31, 2015
Business Acquisition, Percentage of Voting Interests Acquired		100.00%
Xspine [Member]
Business Acquisition, Percentage of Voting Interests Acquired		100.00%
Business Combination, Integration Related Costs	$ 1,269,613
Amortization of Acquisition Costs	$ 3,325,048

Equity (Details Textual)

Equity (Details Textual) - USD ($)	Oct. 08, 2015	Sep. 04, 2015	Jul. 20, 2016	Jul. 31, 2015	Mar. 16, 2015	Sep. 30, 2016	Sep. 30, 2015	Mar. 31, 2015	Sep. 30, 2016	Sep. 30, 2015
Schedule of Equity Method Investments [Line Items]
Shares Issued, Price Per Share	$ 3.19
Other Non Cash Expense Associated With Stock Purchase Agreement						$ 0	$ 0		$ 0	$ 558,185
Business Combination, Consideration Transferred, Total				$ 60,000,000
Stock Issued During Period, Shares, Restricted Stock Award, Gross	20,000		300,000
Stock Issued During Period, Value, Restricted Stock Award, Gross	$ 65,550
Acquisition of X-spine Systems, Inc. [Member]
Schedule of Equity Method Investments [Line Items]
Stock Issued During Period, Shares, Acquisitions				4,242,655
Business Combination, Consideration Transferred, Total				$ 60,000,000
Other Payments to Acquire Businesses				$ 13,000,000
Restricted Stock [Member]
Schedule of Equity Method Investments [Line Items]
Stock Issued During Period, Shares, New Issues	78,510
Shares Issued, Price Per Share				$ 3.40
Stock Issued During Period, Value, New Issues	$ 250,447
Private Placement [Member] | Common Stock [Member] | Board Of Directors [Member]
Schedule of Equity Method Investments [Line Items]
Stock Issued During Period, Shares, New Issues		140,053
Stock Issued During Period, Value, New Issues		$ 515,395
Aspire Capital Fund LLC [Member]
Schedule of Equity Method Investments [Line Items]
Stock Issued During Period, Shares, New Issues								207,182	150,000	417,000
Common Stock, Shares Subscribed but Unissued					10,000,000
Stock Issued During Period, Value, New Issues								$ 750,000	$ 300,000	$ 1,366,941
Common Stock To Be Issued For Commitment Fee								154,189
Maximum Common Stock To Be Issued Per Trading Day					50,000
Maximum Common Stock Value To Be Issued Per Trading Day					$ 500,000
Maximum Percentage Of Common Stock Weighted Average Price					30.00%
Other Non Cash Expense Associated With Stock Purchase Agreement								$ 558,185
Share Price								$ 3.62
Five X-spine Employees [Member] | Restricted Stock [Member]
Schedule of Equity Method Investments [Line Items]
Shares Issued, Price Per Share	$ 3.19
Stock Issued During Period, Shares, Restricted Stock Award, Gross	78,510
Stock Issued During Period, Value, Restricted Stock Award, Gross	$ 250,447

Inventories, Net (Details)

Inventories, Net (Details) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Current inventories
Raw materials	$ 5,508,685	$ 4,860,914
Work in process	2,258,138	2,720,707
Finished goods	22,399,012	18,289,674
Gross current inventories	30,165,835	25,871,295
Reserve for obsolescence	(3,666,750)	(3,186,579)
Current inventories, net	26,499,085	22,684,716
Non-current inventories
Finished goods	1,684,588	2,021,077
Reserve for obsolescence	(413,163)	(413,162)
Non-current inventories, net	1,271,425	1,607,915
Total inventories, net	$ 27,770,510	$ 24,292,631

Impairment of Assets (Details T

Impairment of Assets (Details Textual)	3 Months Ended
	Sep. 30, 2015USD ($)
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Depreciation, Amortization and Accretion, Net, Total	$ 285,224

Property and Equipment, Net (De

Property and Equipment, Net (Details) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Property, Plant and Equipment [Line Items]
Total cost	$ 23,472,615	$ 17,242,153
Less: accumulated depreciation	(7,460,477)	(5,425,524)
Property and equipment, net	16,012,138	11,816,629
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	5,148,782	5,368,567
Computer equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	358,560	348,404
Computer software[Member]
Property, Plant and Equipment [Line Items]
Total cost	551,851	503,587
Furniture and fixtures [Member]
Property, Plant and Equipment [Line Items]
Total cost	164,216	174,215
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	4,042,311	2,661,802
Vehicles [Member]
Property, Plant and Equipment [Line Items]
Total cost	10,000	10,000
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 13,196,895	$ 8,175,578

Property and Equipment, Net (45

Property and Equipment, Net (Details Textual) - USD ($)	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Property, Plant and Equipment [Line Items]
Capital Leased Assets, Gross	$ 1,316,383
Capital Leases, Lessee Balance Sheet, Assets by Major Class, Accumulated Depreciation	261,574
Cost of Property Repairs and Maintenance	427,575	$ 272,811
Depreciation	$ 2,181,541	$ 563,790
Property, Plant and Equipment, Useful Life	5 years

Intangible Assets (Details)

Intangible Assets (Details) - USD ($)	9 Months Ended	12 Months Ended
	Sep. 30, 2016	Dec. 31, 2015
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Accumulated amortization	$ (6,891,238)	$ (3,520,928)
Intangible assets, net	37,021,472	40,237,289
Aggregate amortization expense:	3,370,309	3,438,596
Patents [Member]
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Gross carrying value	719,210	564,717
Technology [Member]
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Gross carrying value	28,698,700	28,698,700
Customer relationships [Member]
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Gross carrying value	9,911,000	9,911,000
Tradename [Member]
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Gross carrying value	4,543,300	4,543,300
Non-compete [Member]
Finite Lived Intangible Assets Future Amortization Expense [Line Items]
Gross carrying value	$ 40,500	$ 40,500

Intangible Assets (Details 1)

Intangible Assets (Details 1) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Estimated amortization expense:
Remainder of 2016	$ 1,119,779
2,017	4,637,474
2,018	4,652,587
2,019	4,543,386
2,020	4,461,092
Thereafter	17,607,154
Total	$ 37,021,472	$ 40,237,289

Accrued Liabilities (Details)

Accrued Liabilities (Details) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Accrued Liabilities [Line Items]
Accrued stock compensation	$ 213,758	$ 147,037
Wages/commissions payable	2,736,925	5,272,241
Accrued integration expense	358,989	731,645
Accrued interest payable	889,683	1,716,167
Other accrued expenses	1,424,219	1,728,761
Accrued liabilities	$ 5,623,574	$ 9,595,851

Debt (Details)

Debt (Details) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Debt Instrument [Line Items]
Loan payable to ROS Acquisition Offshore (See details above)	$ 43,000,000	$ 42,000,000
PIK Interest payable to ROS	6,883,890	2,700,476
6% convertible senior unsecured notes due 2021 (See details above)	70,238,167	68,000,000
Total	120,122,057	112,700,476
Less: capitalized debt issuance costs	(1,763,824)	(1,563,353)
Long-term debt, less issuance costs	$ 118,358,233	$ 111,137,123

Debt (Details 1)

Debt (Details 1) - USD ($)	Sep. 30, 2016	Dec. 31, 2015
Schedule of maturities due on debt [Line Items]
Remainder of 2016	$ 0
2,017	0
2,018	0
2,019	0
2,020	49,883,889
Thereafter	70,238,168
Total	$ 120,122,057	$ 112,700,476

Debt (Details Textual)

Debt (Details Textual) - USD ($)

Aug. 12, 2016

May 25, 2016

Aug. 10, 2015

Apr. 14, 2016

Jul. 31, 2015

Sep. 30, 2016

Sep. 30, 2015

Sep. 30, 2016

Sep. 30, 2015

Sep. 27, 2016

Jul. 29, 2016

Dec. 31, 2015

Debt Instrument [Line Items]

Royalty Expenses Description

royalty of 1.75% on the first $45,000,000 of net sales, plus 1.0% of net sales in excess of $45,000,000

Debt Instrument, Face Amount

$ 65,000,000

Business Acquisition, Percentage of Voting Interests Acquired

100.00%

Business Combination Conjunction Related Expenses

$ 4,700,000

Payments of Debt Issuance Costs

$ 2,200,000

Business Combination Expenses Related To Future Acquisition

$ 2,500,000

Line of Credit Facility, Expiration Date

Jul. 15, 2021

Gains (Losses) on Extinguishment of Debt, Total

$ 0

$ 2,345,019

$ 0

$ 2,345,019

Debt Instrument, Convertible, Extent Not Convertible, Beneficial Ownership Percentage

9.99%

9.99%

Acquisition Of X Spine Systems Inc [Member]

Debt Instrument [Line Items]

Payments of Debt Issuance Costs

$ 2,300,000

Extinguishment of Debt, Amount

$ 12,300,000

Accrued Royalties

$ 7,400,000

Xspine [Member]

Debt Instrument [Line Items]

Debt Instrument, Interest Rate During Period

6.00%

New Facility [Member]

Debt Instrument [Line Items]

Line of Credit Facility, Current Borrowing Capacity

$ 18,000,000

Line of Credit Facility, Expiration Date

Jul. 31, 2020

Gains (Losses) on Extinguishment of Debt, Total

$ 2,345,019

Line Of Credit Facility Loans Outstanding Payment Fee

7.50%

New Facility [Member] | First Period [Member]

Debt Instrument [Line Items]

Debt Instrument, Interest Rate, Portion Payable in Cash

9.00%

Debt Instrument, Interest Rate, Portion Payable in Kind

14.00%

Debt Instrument, Interest Rate, Addition to PIK Portion

1.00%

Debt Instrument, Interest Rate, PIK Portion, Subtraction

9.00%

New Facility [Member] | Optional Pik Period [Member]

Debt Instrument [Line Items]

Debt Instrument, Interest Rate, Portion Payable in Kind

14.00%

Debt Instrument, Interest Rate, Addition to PIK Portion

1.00%

New Facility [Member] | Second Period [Member]

Debt Instrument [Line Items]

Debt Instrument, Interest Rate, Portion Payable in Cash

12.00%

Debt Instrument, Interest Rate, Portion Payable in Kind

14.00%

Debt Instrument, Interest Rate, Addition to PIK Portion

1.00%

Debt Instrument, Interest Rate, PIK Portion, Subtraction

12.00%

Amendment to the New Facility [Member]

Debt Instrument [Line Items]

Line Of Credit Facility Minimum Liquidity Through Januray 1 2017

$ 500,000

$ 500,000

Fourth Amendment to Amended and Restated Credit Agreement [Member] | OrbiMed and ROS [Member]

Debt Instrument [Line Items]

Debt Instrument Additional Tranche A Commitment

$ 1,000,000

Sixth Amendement To The Restated New Credit Faciltiy [Member]

Debt Instrument [Line Items]

Line Of Credit Facility Loans Paid In Kind Interest Percentage

9.00%

Sixth Amendement To The Restated New Credit Faciltiy [Member] | Minimum [Member]

Debt Instrument [Line Items]

Line Of Credit Facility Loans Outstanding Payment Fee Percentage

7.50%

Sixth Amendement To The Restated New Credit Faciltiy [Member] | Maximum [Member]

Debt Instrument [Line Items]

Line Of Credit Facility Loans Outstanding Payment Fee Percentage

9.00%

Convertible Notes Payable [Member]

Debt Instrument [Line Items]

Debt Instrument, Face Amount

$ 52,000,000

Debt Instrument, Interest Rate During Period

6.00%

Debt Instrument Purchase Of Additional Notes

$ 3,000,000

Conversion of Stock, Shares Converted

257.5163

Conversion of Stock, Amount Converted

$ 1,000

Debt Instrument, Convertible, Conversion Price

$ 3.88

Term Loan [Member]

Debt Instrument [Line Items]

Line of Credit Facility, Current Borrowing Capacity

$ 24,000,000

Silicon Valley Bank [Member] | Revolving Credit Facility [Member]

Debt Instrument [Line Items]

Line of Credit Facility, Maximum Borrowing Capacity

$ 6,000,000

Debt Instrument, Basis Spread on Variable Rate

1.00%

Silicon Valley Bank [Member] | First Loan Modification Agreement [Member]

Debt Instrument [Line Items]

Line of Credit Facility, Maximum Borrowing Capacity

$ 11,000,000

Debt Instrument, Basis Spread on Variable Rate

4.00%

Convertible Senior Unsecured Notes [Member]

Debt Instrument [Line Items]

Debt Instrument, Face Amount

$ 2,238,166.45

Debt Instrument, Interest Rate During Period

6.00%

Conversion of Stock, Shares Converted

344.8276

Conversion of Stock, Amount Converted

$ 1,000

Debt Instrument, Convertible, Conversion Price

$ 2.90

Stock-Based Compensation (Detai

Stock-Based Compensation (Details)	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Risk-free interest rate	2.21%	1.30%
Expected volatility	79.00%	75.00%
Expected term (Years)	6 years	6 years
Expected forfeiture rate	20.00%	20.00%
Dividend yield	0.00%	0.00%

Stock-Based Compensation (Det53

Stock-Based Compensation (Details 1) - Stock Option - $ / shares	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Schedule of activity under stock option plans [Line Items]
Outstanding at January 1, 2016, Shares	664,081	695,336
Granted, Shares	0	45,000
Exercised, Shares	0	0
Cancelled or expired, Shares	(105,275)	(31,604)
Outstanding at September 30, 2016, Shares	558,806	708,732
Exercisable at September 30, 2016, Shares	409,179	388,498
Outstanding at January 1, 2016, Weighted Average Exercise Price	$ 10.64	$ 11.09
Granted, Weighted Average Exercise Price	0	4
Exercised, Weighted Average Exercise Price	0	0
Cancelled or expired, Weighted Average Exercise Price	9.48	12.71
Outstanding at September 30, 2016, Weighted Average Exercise Price	10.85	10.54
Exercisable at September 30, 2016, Weighted Average Exercise Price	12.67	13.53
Outstanding at January 1, 2016, Weighted Average Fair Value at Grant Date	5.32	5.35
Granted, Weighted Average Fair Value at Grant Date	0	2.81
Exercised, Weighted Average Fair Value at Grant Date	0	0
Cancelled or expired, Weighted Average Fair Value at Grant Date	4.5	6.02
Outstanding at September 30, 2016, Weighted Average Fair Value at Grant Date	5.42	5.29
Exercisable at September 30, 2016, Weighted Average Fair Value at Grant Date	$ 6.15	$ 6.43

Stock-Based Compensation (Det54

Stock-Based Compensation (Details Textual) - USD ($)	Nov. 14, 2016	Oct. 06, 2016	Jul. 05, 2016	Oct. 08, 2015	Nov. 10, 2014	Jul. 20, 2016	Jul. 31, 2015	Sep. 30, 2016	Sep. 30, 2015	Sep. 30, 2016	Sep. 30, 2015
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Shares authorized under the Plan								1,900,000		1,900,000
Aggregate intrinsic value of options outstanding								530,000		530,000
Shares Issued, Price Per Share				$ 3.19
Stock Issued During Period, Shares, Restricted Stock Award, Gross				20,000		300,000
Stock Issued During Period, Value, Restricted Stock Award, Gross				$ 65,550
General and Administrative Expense, Total								$ 3,773,236	$ 3,980,805	$ 11,216,112	$ 8,805,104
Share-based Compensation, Total										522,987	881,681
Other Noncash Expense								156,129	50,000	266,721	190,869
General and Administrative Expense [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Allocated Share-based Compensation Expense										15,888
Subsequent Event [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Stock Issued During Period, Shares, New Issues	0
President [Member] | Subsequent Event [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Share Price		$ 1.11
Share-Based Compensation Arrangement By Share-Based Payment Award, Options, Grants In Period, Gross		300,000
Messrs Lopach, Swanson, Deedrick And Buckman [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Share-Based Compensation Arrangement By Share-Based Payment Award, Equity Instruments Other Than Options, Grants In Period			80,404
Share Price			$ 1.99
Share-based Compensation, Total			$ 160,004
Other Noncash Expense										42,000
Messrs Mazzocchi And Timko [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Share-based Compensation, Total			$ 118,206
Other Noncash Expense										10,000
Share-Based Compensation Arrangement By Share-Based Payment Award, Options, Grants In Period, Gross			59,400
Share-based Compensation Arrangement by Share-based Payment Award, Options, Vested and Expected to Vest, Exercisable, Weighted Average Exercise Price			$ 1.99
Vice President [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
General and Administrative Expense, Total										83,833
Share-based Compensation, Total						$ 531,000
Share-based Compensation Arrangements by Share-based Payment Award, Options, Grants in Period, Weighted Average Exercise Price						$ 1.77
Employees and Consultants [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Share-based Compensation, Total								479,289	$ 444,352
Employee Stock Option [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Stock Options								$ 409,179		$ 409,179
Share-Based Compensation Arrangement By Share-Based Payment Award, Options, Exercisable, Weighted Average Exercise Price								$ 12.67		$ 12.67
Employee Service Share-based Compensation, Tax Benefit from Compensation Expense										$ 700,000
Restricted Stock [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Share-Based Compensation Arrangement By Share-Based Payment Award, Equity Instruments Other Than Options, Grants In Period					39,312		58,820
Employee Service Share-based Compensation, Nonvested Awards, Compensation Not yet Recognized, Share-based Awards Other than Options					$ 160,000		$ 200,000	$ 55,995		55,995
Share Based Compensation Arrangement By Share Based Payment Award Equity Instruments Other Than Options Issue Price On Grand Date					$ 4.07
Shares Issued, Price Per Share							$ 3.40
Stock Issued During Period, Value, New Issues				$ 250,447
Stock Issued During Period, Shares, New Issues				78,510
Stock Issued During Period, Price Per Share				$ 3.19
Share-based Compensation, Total											$ 140,869
Restricted Stock [Member] | General and Administrative Expense [Member]
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Allocated Share-based Compensation Expense										$ 100,000

Warrants (Details)

Warrants (Details) - $ / shares	9 Months Ended	12 Months Ended
	Sep. 30, 2016	Dec. 31, 2015
Warrant activity [Line Items]
Outstanding	1,278,566	1,655,320
Issued, Common Stock Warrants	0	0
Expired, Common Stock Warrants	(42,580)	(376,754)
Outstanding	1,235,986	1,278,566
Outstanding, Weighted Average Exercise Price	$ 8.45	$ 13.06
Issued, Weighted Average Exercise Price	0	0
Expired, Weighted Average Exercise Price	31.73	22.87
Outstanding, Weighted Average Exercise Price	$ 7.65	$ 8.45

Warrants (Details 1)

Warrants (Details 1) - Warrant [Member] - $ / shares	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Value of underlying common stock (per share)	$ 1.13	$ 3.26
Risk free interest rate	2.21%	1.37%
Expected term (years)	3 years 3 months	4 years 3 months
Volatility	79.00%	75.00%
Dividend yield	0.00%	0.00%

Warrants (Details 2)

Warrants (Details 2) - shares	9 Months Ended		12 Months Ended
	Sep. 30, 2016	Sep. 30, 2015	Dec. 31, 2015
Class of Warrant or Right [Line Items]
Outstanding	1,278,566	1,655,320	1,655,320
Derivative warrants issued	0		0
Outstanding	1,235,986		1,278,566
Warrant [Member]
Class of Warrant or Right [Line Items]
Outstanding	1,125,119	1,171,692	1,171,692
Derivative warrants issued	0	0
Derivative warrants exercised	0	0
Expired	0	0
Outstanding	1,125,119	1,171,692	1,125,119

Warrants (Details Textual)

Warrants (Details Textual)	9 Months Ended
	Sep. 30, 2016USD ($)
Class of Warrant or Right [Line Items]
Unrealized Loss On Warranty Derivative Liability	$ 716,738

Commitments and Contingencies59

Commitments and Contingencies (Details)	Sep. 30, 2016USD ($)
Schedule of future minimum payments by operating lease [Line Items]
Remainder of 2016	$ 195,218
2,017	794,437
2,018	806,747
2,019	668,807
2,020	396,263
2,021	375,289
Thereafter	1,038,416
Total	$ 4,275,177

Commitments and Contingencies60

Commitments and Contingencies (Details Textual)	1 Months Ended	9 Months Ended
	Oct. 23, 2015	Sep. 30, 2016USD ($)	Sep. 30, 2015USD ($)
Sale-leaseback Transaction for the Property Located at 664 Cruiser Lane, Belgrade, Montana [Member]
Schedule of commitment and contingencies [Line Items]
Operating Leases, Rent Expense, Net		$ 661,219	$ 458,814
Lessee Leasing Arrangements, Operating Leases, Renewal Term	10 years	10 years
Lessee Leasing Arrangements, Operating Leases, Term of Contract	10 years
Lessee Leasing Arrangements, Operating Leases, Term Of Contract, Number Of Options To Extend	2
Lessee Leasing Arrangements, Operating Leases, Term of Each Option to Extend	5 years
Lessee Leasing Arrangements, Operating Leases, Number of Office Facilities Leased Under Non-cancelable Operating Lease Agreements		4
Lessee Leasing Arrangements, Operating Leases, Number of Facilities With Right of First Refusal on Any Sale		1
Loans Payable [Member]
Schedule of commitment and contingencies [Line Items]
Debt Instrument, Interest Rate, Stated Percentage	6.00%

Income Taxes (Details Textual)

Income Taxes (Details Textual) - USD ($)	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
Income Tax Disclosure [Line Items]
Income Tax Examination, Penalties and Interest Expense	$ 0	$ 0

Supplemental Disclosure of Ca62

Supplemental Disclosure of Cash Flow Information (Details) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015	Sep. 30, 2016	Sep. 30, 2015
Cash paid during the period for:
Interest			$ 4,530,170	$ 2,372,453
Non-cash activities:
Issuance of capital leases			967,221	70,020
Issuance of shares associated with legal settlement			225,000	0
Issuance of share for non-cash consulting expense	$ 156,129	$ 50,000	266,721	190,869
Issuance of restricted stock to employees			0	41,741
Issuance of shares in conjunction with the acquisition of X-spine			$ 0	$ 14,934,146

Related Party Transactions (Det

Related Party Transactions (Details Textual) - USD ($)	9 Months Ended
	Sep. 30, 2016	Sep. 30, 2015
One Vendor [Member] | Sales Revenue, Net [Member]
Related Party Transaction [Line Items]
Concentration Risk, Percentage	12.00%
Chief Operating Officer [Member]
Related Party Transaction [Line Items]
Amount of related party transaction	$ 5,000
American Donor Services [Member]
Related Party Transaction [Line Items]
Amount of related party transaction	$ 844,643	$ 1,367,487

Subsequent Events (Details Text

Subsequent Events (Details Textual) - USD ($)	Nov. 14, 2016	Oct. 06, 2016	Nov. 09, 2016	Oct. 31, 2016	Oct. 21, 2016	Sep. 30, 2016	Dec. 31, 2015	Sep. 30, 2015	Dec. 31, 2014
Subsequent Event [Line Items]
Class of Warrant or Right, Exercise Price of Warrants or Rights						$ 7.65	$ 8.45		$ 13.06
Cash and Cash Equivalents, at Carrying Value, Total						$ 1,408,608	$ 6,368,016	$ 7,970,433	$ 4,526,026
Subsequent Event [Member]
Subsequent Event [Line Items]
Equity Method Investment, Ownership Percentage					4.99%
Class of Warrant or Right, Exercise Price of Warrants or Rights	$ 0.90				$ 0.01
Rights Offering Offering Price Per Unit	$ 0.75		$ 0.75	$ 0.90
Gross Proceeds From Issuance Of Rights Shares	$ 11,300,000
Rights Offering, Number Units Issued	0
Net Proceeds From Issuance Of Rights Shares	$ 10,200,000
Cash and Cash Equivalents, at Carrying Value, Total	$ 0
Stock Issued During Period, Shares, New Issues	0
Share-based Compensation Arrangement by Share-based Payment Award, Award Vesting Rights		In connection with the hiring of Mr. O’Connell, we issued him an option to purchase 300,000 shares of our common stock at $1.11 per share which start vesting 60,000 shares on October 6, 2017 and then vest 15,000 shares per quarter on January 6, 2018 until October 6, 2021.
Subsequent Event [Member] | President [Member]
Subsequent Event [Line Items]
Share-Based Compensation Arrangement By Share-Based Payment Award, Options, Grants In Period, Gross		300,000
Share Price		$ 1.11
Subsequent Event [Member] | Prefunded Warrant [Member]
Subsequent Event [Line Items]
Class of Warrant or Right, Exercise Price of Warrants or Rights					$ 0.01
Class of Warrant or Right, Number Of Warrants Issued	0
Subsequent Event [Member] | Tradable Warrants [Member]
Subsequent Event [Line Items]
Class of Warrant or Right, Number Of Warrants Issued	0
Class of Warrant or Right, Warrant Redemption Terms	After the one-year anniversary of issuance, we may redeem the Tradable Warrants for $0.01 per Tradable Warrant if the volume weighted average price of our Common Stock is above $2.25 for each of 10 consecutive trading days.
Maxim Group LLC [Member] | Subsequent Event [Member]
Subsequent Event [Line Items]
Rights Offering Cash Fee Percentage Paid To Gross Proceeds	7.00%
Rights Offering, Cash Fee Reimbursed	$ 75,000