Xtant Medical (XTNT) 10-K 24 Feb 21 2020 FY Annual report Financial data

Document and Entity Information

Document and Entity Information - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Feb. 22, 2021	Jun. 30, 2020
Cover [Abstract]
Entity Registrant Name	Xtant Medical Holdings, Inc.
Entity Central Index Key	0001453593
Document Type	10-K
Document Period End Date	Dec. 31, 2020
Amendment Flag	false
Current Fiscal Year End Date	--12-31
Entity Well-known Seasoned Issuer	No
Entity Voluntary Filers	No
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Non-accelerated Filer
Entity Small Business Flag	true
Entity Emerging Growth Company	false
Entity Shell Company	false
Entity Public Float			$ 3,500
Entity Common Stock, Shares Outstanding		77,818,396
Document Fiscal Period Focus	FY
Document Fiscal Year Focus	2020

Consolidated Statements of Oper

Consolidated Statements of Operations - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Revenue
Orthopedic product sales	$ 53,188	$ 64,516
Other revenue	149	166
Total Revenue	53,337	64,682
Cost of Sales	18,945	22,166
Gross Profit	34,392	42,516
Operating Expenses
General and administrative	13,503	17,344
Sales and marketing	20,983	26,493
Research and development	657	932
Total Operating Expenses	35,143	44,769
Loss from Operations	(751)	(2,253)
Other Income (Expense)
Interest expense	(5,976)	(5,772)
Other expense		(98)
Total Other Expense	(5,976)	(5,870)
Net Loss from Operations Before Provision for Income Taxes	(6,727)	(8,123)
Provision for Income Taxes
Current and Deferred	(296)	(98)
Net Loss	$ (7,023)	$ (8,221)
Net loss per share:
Basic	$ (0.25)	$ (0.63)
Dilutive	$ (0.25)	$ (0.63)
Shares used in the computation:
Basic	28,499,847	13,163,931
Dilutive	28,499,847	13,163,931

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Current Assets:
Cash and cash equivalents	$ 2,341	$ 5,237
Trade accounts receivable, net of allowance for credit losses of $653 and $500, respectively	6,880	10,124
Inventories	21,408	16,101
Prepaid and other current assets	736	784
Total current assets	31,365	32,246
Property and equipment, net	4,347	4,695
Right of use asset, net	1,690	2,100
Goodwill	3,205	3,205
Intangible assets, net	457	515
Other assets	402	394
Total Assets	41,466	43,155
Current Liabilities:
Accounts payable	2,289	2,188
Accrued liabilities	6,120	6,632
Current portion of lease liability	423	394
Finance lease obligations	20	176
Current portion of long-term debt	16,797
Total current liabilities	25,649	9,390
Long-term Liabilities:
Lease obligation, net	1,303	1,726
Long-term debt, plus premium and less issuance costs		76,244
Total Liabilities	26,952	87,360
Commitments and Contingencies (note 11)
Stockholders' Equity (Deficit):
Preferred stock, $0.000001 par value; 10,000,000 shares authorized; no shares issued and outstanding
Common stock, $0.000001 par value; 300,000,000 shares authorized; 77,573,680 shares issued and outstanding as of December 31, 2020 and 75,000,000 shares authorized; 13,161,762 shares issued and outstanding as of December 31, 2019
Additional paid-in capital	244,850	179,061
Accumulated deficit	(230,336)	(223,266)
Total Stockholders' Equity (Deficit)	14,514	(44,205)
Total Liabilities & Stockholders' Equity (Deficit)	$ 41,466	$ 43,155

Consolidated Balance Sheets (Pa

Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Statement of Financial Position [Abstract]
Trade accounts receivable, allowance for credit losses	$ 653	$ 500
Preferred stock, par value	$ 0.000001	$ 0.000001
Preferred stock, shares authorized	10,000,000	10,000,000
Preferred stock, shares issued
Preferred stock, shares outstanding
Common stock, par value	$ 0.000001	$ 0.000001
Common stock, shares authorized	300,000,000	75,000,000
Common stock, shares issued	77,573,680	13,161,762
Common Stock, shares outstanding	77,573,680	13,161,762

Consolidated Statements of Chan

Consolidated Statements of Changes in Stockholders' Equity (Deficit) - USD ($) $ in Thousands	Common Stock [Member]	Additional Paid-In Capital [Member]	Accumulated Deficit [Member]	Total
Beginning Balance at Dec. 31, 2018		$ 171,273	$ (215,045)	$ (43,772)
Beginning Balance, Shares at Dec. 31, 2018	13,172,179
Stock-based compensation		515		515
Forfeiture of restricted stock
Forfeiture of restricted stock, shares	(10,417)
Debt extinguishment		$ 7,264		$ 7,264
Issuance of warrant		9		9
Net loss			(8,221)	(8,221)
Ending Balance at Dec. 31, 2019		179,061	(223,266)	(44,205)
Ending Balance, Shares at Dec. 31, 2019	13,161,762
Stock-based compensation		1,084		1,084
Issuance of warrant		1,862		1,862
ASU 2016-13 cumulative effect adjustment			(47)	(47)
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares	144,878
Debt exchange, net of exchange costs of $1,058		62,175		62,175
Debt exchange, net of exchange costs of $1,058, shares	58,754,394
Issuance of common shares, net of issuance costs of $143		620		620
Issuance of common shares, net of issuance costs of $143, shares	712,646
Exercise of warrants		48		48
Exercise of warrants, shares	4,800,000
Net loss			(7,023)	(7,023)
Ending Balance at Dec. 31, 2020		$ 244,850	$ (230,336)	$ 14,514
Ending Balance, Shares at Dec. 31, 2020	77,573,680

Consolidated Statements of Ch_2

Consolidated Statements of Changes in Stockholders' Equity (Deficit) (Parenthetical) $ in Thousands	Dec. 31, 2020USD ($)
Statement of Stockholders' Equity [Abstract]
Debt, exchange costs	$ 1,058
Share issuance costs	$ 143

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Operating activities:
Net loss	$ (7,023)	$ (8,221)
Adjustments to reconcile net loss to net cash used in operating activities:
Depreciation and amortization	2,079	3,143
Non-cash interest	5,963	5,726
Non-cash rent	16	20
Gain on sale of fixed assets	(369)	(61)
Stock-based compensation	1,084	515
Provision for reserve on accounts receivable	307	513
Provision for excess and obsolete inventory	485	509
Changes in operating assets and liabilities:
Trade accounts receivable	2,890	(647)
Inventories	(5,792)	692
Prepaid and other assets	40	204
Accounts payable	101	(4,278)
Accrued liabilities	(512)	1,472
Net cash used in operating activities	(731)	(413)
Investing activities:
Purchases of property and equipment	(1,545)	(879)
Proceeds from sale of fixed assets	241	335
Net cash used in investing activities	(1,304)	(544)
Financing activities:
Payments on financing leases	(156)	(455)
Payments on long-term debt	(315)
Costs associated with exchange of debt for common shares	(1,058)
Proceeds from issuance of common stock, net of issuance costs	620
Proceeds from exercise of common stock warrants	48
Costs associated with Second Amended and Restated Credit Agreement		(148)
Net cash used in financing activities	(861)	(603)
Net change in cash and cash equivalents	(2,896)	(1,560)
Cash and cash equivalents at beginning of year	5,237	6,797
Cash and cash equivalents at end of year	$ 2,341	$ 5,237

Business Description and Summar

Business Description and Summary of Significant Accounting Policies	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Business Description and Summary of Significant Accounting Policies	(1) Business Description and Summary of Significant Accounting Policies Business Description The accompanying consolidated financial statements include the accounts of Xtant Medical Holdings, Inc., formerly known as Bacterin International Holdings, Inc., a Delaware corporation, and its wholly owned subsidiaries, Xtant Medical, Inc., a Delaware corporation, Bacterin International, Inc., (“Bacterin”) a Nevada corporation, and X-Spine Systems, Inc. (“X-spine”), an Ohio corporation (Xtant Medical Inc., Bacterin and X-spine are jointly referred to herein as “Xtant” or the “Company”). The terms “we,” “us” and “our” also refer to Xtant. All intercompany balances and transactions have been eliminated in consolidation. 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 foot surgeries and the development, manufacturing and sale of medical devices for use in orthopedic spinal surgeries. Since March 2020, the COVID-19 pandemic has caused business closures, severe travel restrictions and implementation of social distancing measures. At the onset of the COVID-19 pandemic, hospitals and other medical facilities cancelled or deferred elective procedures, diverted resources to patients suffering from infections and limited access for non-patients, including our direct and indirect sales representatives. Because of the COVID-19 pandemic, surgeons and their patients have been, and may continue to be, required, or are choosing, to defer procedures in which our products otherwise would be used, and many facilities that specialize in the procedures in which our products otherwise would be used have experienced temporary closures or reduced operating hours. These circumstances have negatively impacted, and may continue to negatively impact, the ability of our employees, independent sales representatives and distributors to effectively market and sell our products, which has had and will likely continue to have a material adverse effect on our revenues. At December 31, 2020, the Company had cash and cash equivalents of $2.3 million, and an accumulated deficit of $230.3 million and has incurred significant losses in the current and prior periods. Management’s evaluation of going concern was conducted as part of its discussions with the Xtant Board of Directors’ review of the 2021 Annual Operating Plan. Management believes that we will be able to refinance the amounts outstanding under our credit agreement or extend the maturity date, based on communications with the lender, such that our $2.3 million of cash and cash equivalents as of December 31, 2020, together with the $5.0 million available at the lender’s sole discretion under our credit agreement, or comparable refinanced credit agreement, will be sufficient to meet our anticipated cash requirements and continue as a going concern through at least February 2022. Debt Restructuring On August 7, 2020, we entered into a Restructuring and Exchange Agreement (the “Restructuring Agreement”) with OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) and ROS Acquisition Offshore LP (“ROS”), pursuant to which the parties thereto agreed, subject to the terms and conditions set forth therein, to take certain actions as set forth therein and as described below (collectively, the “Restructuring Transactions”) in furtherance of a restructuring of the Company’s outstanding indebtedness under the Company’s Second Amended and Restated Credit Agreement with Royalty Opportunities and ROS, as amended (the “Second A&R Credit Agreement”). The primary purpose of the Restructuring Transactions was to improve our capital structure by reducing the amount of our indebtedness and cost to service our debt, which should make it easier for us to refinance or replace this debt in the future, as well as facilitate easier access to capital markets for investment in our growth initiatives. The Restructuring Transactions also allowed us to regain compliance with the NYSE American continued listing standards, which we achieved on October 5, 2020. The Restructuring Transactions included, among others: ● an amendment to the Company’s Amended and Restated Certificate of Incorporation, as amended (“Charter”), to increase the number of authorized shares of our common stock from 75 million to 300 million (the “Charter Amendment”), which occurred on October 1, 2020; ● the exchange by the Company of shares of our common stock for approximately $40.8 million of the aggregate outstanding principal amount under the Second A&R Credit Agreement, as well as, without duplication, approximately $21.1 million of the outstanding amount of PIK Interest (as defined in the Second A&R Credit Agreement) (such loans and PIK Interest, the “Exchanging Loans”), plus all other accrued and unpaid interest on the Exchanging Loans outstanding as of the closing date, at an exchange price of $1.07 per share, representing the average closing price of the common stock over the 10 trading days immediately prior to the parties entering into the Restructuring Agreement, and resulting in the issuance of approximately 57.8 million shares of common stock (the “Share Issuance”), which occurred on October 1, 2020 ● the execution of an amendment to the Second A&R Credit Agreement by the parties thereto to change certain provisions therein, including extinguishing loans in an aggregate principal amount equal to the Exchanging Loans outstanding thereunder together with all accrued and unpaid interest thereon, paying a portion of the prepayment fee payable thereunder in respect of the Exchanging Loans with proceeds of additional loans under the Second A&R Credit Agreement, with the remaining portion of the prepayment fee exchanged for an additional 0.9 million shares of our common stock, reducing the amount of credit availability thereunder, decreasing the interest rate and eliminating certain financial covenants, which occurred on October 1, 2020, as described in more detail under Note 7, “Debt” ● the launch by the Company of a rights offering to allow our stockholders to purchase up to an aggregate of $15 million of our common stock at the same price per share as the $1.07 per share exchange price used to exchange the Exchanging Loans into our common stock as part of the Share Issuance (the “Rights Offering”), which commenced on November 5, 2020 and expired on December 4, 2020 and resulted in the issuance of 712,646 shares of our common stock and gross proceeds of $0.8 million, as described in more detail under Note 8, “Equity” As a result of the completion of these Restructuring Transactions, Royalty Opportunities and ROS own, in the aggregate, approximately 93.9% of the outstanding common stock and all other existing stockholders of the Company own approximately 6.1% of the outstanding common stock as of December 31, 2020. Following completion of these Restructuring Transactions, the remaining principal balance of our outstanding debt totals $15.6 million. Investor Rights Agreement We are party to an Investor Rights Agreement with ROS and Royalty Opportunities, which are funds affiliated with OrbiMed Advisors LLC (“OrbiMed”). Under the Investor Rights Agreement, Royalty Opportunities and ROS are permitted to nominate a majority of the directors and designate the chairperson of our Board of Directors at subsequent annual meetings, as long as they maintain an ownership threshold in our Company of at least 40% of our then outstanding common stock (the “Ownership Threshold”). If Royalty Opportunities and ROS are unable to maintain the Ownership Threshold, the Investor Rights Agreement contemplates a reduction of nomination rights commensurate with our ownership interests. In addition, for so long as the Ownership Threshold is met, we must obtain the approval of a majority of our common stock held by Royalty Opportunities and ROS to proceed with the following actions: (i) issue new securities; (ii) incur over $250,000 of debt in a fiscal year; (iii) sell or transfer over $250,000 of our assets or businesses or our subsidiaries in a fiscal year; (iv) acquire over $250,000 of assets or properties in a fiscal year; (v) make capital expenditures over $125,000 individually, or $1.5 million in the aggregate during a fiscal year; (vi) approve our annual budget; (vii) hire or terminate our chief executive officer; (viii) appoint or remove the chairperson of our Board of Directors; and (ix) make, loans to, investments in, or purchase, or permit any subsidiary to purchase, any stock or other securities in another entity in excess of $250,000 in a fiscal year. As long as the Ownership Threshold is met, we may not increase the size of our Board or Directors beyond seven directors without the approval of a majority of the directors nominated by Royalty Opportunities and ROS. The Investor Rights Agreement grants Royalty Opportunities and ROS the right to purchase from us a pro rata amount of any new securities that we may propose to issue and sell. The Investor Rights Agreement may be terminated (a) upon the mutual written agreement of all the parties, (b) upon our written notice, ROS or Royalty Opportunities if the ownership percentage of our then outstanding common stock of ROS and Royalty Opportunities is less than 10%, or (c) upon written notice of ROS and Royalty Opportunities. Concentrations and Credit Risk The Company’s accounts receivables are from a variety of health care organizations and distributors throughout the world. No single customer accounted for more than 10% of our revenue or accounts receivable in the fiscal years 2020 or 2019. Management believes that all significant credit risks have been identified at December 31, 2020. 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; current and long-term lease obligations and corresponding right-of-use asset; and estimates for the fair value of long-term debt, stock option grants and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates. Cash and Cash Equivalents The Company considers all highly liquid investments purchased with an original maturity date of three months or less to be cash equivalents. Cash equivalents are recorded at cost, which approximates market value. At times, the Company maintains deposits in financial institutions in excess of federally insured limits. Trade Accounts Receivable Accounts receivable represents amounts due from customers for which revenue has been recognized. Normal terms on trade accounts receivable are net 30 days, and some customers are offered discounts for early pay. The Company performs credit evaluations when considered necessary, but generally does not require collateral to extend credit. In June 2016, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2016-13, Financial Instruments–Credit Losses: Measurement of Credit Losses on Financial Instruments to change the impairment model for most financial assets and certain other instruments. For trade and other receivables, held to maturity debt securities, loans, and other instruments, entities are required to use a new forward-looking “expected loss” model that generally will result in the earlier recognition of allowances for losses. The Company adopted the guidance on January 1, 2020 and recognized a cumulative effect adjustment of $47,000 to retained earnings and accounts receivable, net as a result of adoption. The Company has included the additional disclosures required by ASU 2016-13 in Note 2, “ Receivables .” The allowance for doubtful accounts is the Company’s best estimate of the amount of probable credit losses in the Company’s existing receivables. The Company determines the allowance based on factors such as historical collection experience, customers’ current creditworthiness, customer concentration, age of accounts receivable balance, general economic conditions that may affect a customer’s ability to pay, and management judgment. In addition, we include provision for current expected credit loss based on historical collection experience adjusted for current economic conditions affecting collectability. Actual customer collections could differ from estimates. Account balances are charged to the allowance after all means of collection have been exhausted and the potential for recovery is considered remote. Provisions to the allowance for doubtful accounts are charged to expense. The Company does not have any off-balance sheet credit exposure related to its customers. Inventories Inventories are stated at the lower of cost or net realizable value. Cost is determined using the specific identification method and includes materials, labor and overhead. The Company calculates an inventory reserve for estimated obsolescence and excess inventory based on historical usage and sales, as well as assumptions about future demand for its products. These estimates for excess and obsolete inventory are reviewed and updated on a quarterly basis. Increases in the inventory reserves result in a corresponding expense, which is recorded to cost of sales. Property and Equipment Property and equipment are stated at cost less accumulated depreciation. Depreciation is computed using the straight-line method over the estimated useful lives of the assets, generally three to seven years for computers and equipment and five years for surgical instruments. Leasehold improvements are depreciated over the shorter of their estimated useful life or the remaining term of the lease. Repairs and maintenance are expensed as incurred. Intangible Assets Intangible assets with estimable useful lives are amortized over their respective estimated useful lives to their estimated residual values and reviewed for impairment whenever events or circumstances indicate their carrying amount may not be recoverable. Intangible assets include trademarks and patents and include costs to acquire and protect Company patents. Intangible assets are carried at cost less accumulated amortization. The Company amortizes these assets on a straight-line basis over their estimated useful lives. Other Assets Other assets consist of the short-term and the long-term portion of prepaid expenses and security deposits. Long-Lived Asset Impairment Long-lived assets, including property and equipment and 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 undiscounted 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. 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 the asset may not be recoverable. The Company conducts its impairment test on an annual basis and reviews the analysis assumptions on a quarterly basis. We test goodwill for impairment at the reporting unit level, which is an operating segment or one level below an operating segment, referred to as a component. A component of an operating segment is a reporting unit if the component constitutes a business for which discrete financial information is available and segment management regularly reviews the operating results of that component. Revenue Recognition In the United States, we generate most of our revenue from independent commissioned sales agents. We consign our orthobiologics products to hospitals and consign or loan our spinal implant sets to the independent sales agents. The spinal implant sets typically contain the instruments, disposables, and spinal implants required to complete a surgery. Consigned sets are managed by the sales agent to service hospitals that are high volume users for multiple procedures. We ship replacement inventory to independent sales agents to replace the consigned inventory used in surgeries. Loaned sets are returned to the Company’s distribution center, replenished, and made available to sales agents for the next surgical procedure. For each surgical procedure, the sales agent reports use of the product by the hospital and, as soon as practicable thereafter, ensures that the hospital provides a purchase order to the Company. Upon receipt of the hospital purchase order, the Company invoices the hospital, and revenue is recognized in the proper period. Additionally, the Company sells product directly to domestic and international stocking resellers and private label resellers. Upon receipt and acceptance of a purchase order from a stocking reseller, the Company ships product and invoices the reseller. The Company recognizes revenue when the products are shipped, and the transfer of title and risk of loss occurs. There is generally no customer acceptance or other condition that prevents the Company from recognizing revenue in accordance with the delivery terms for these sales transactions. In the normal course of business, the Company accepts returns of product that have not been implanted. Product returns are not material to the Company’s consolidated statements of operations. The Company accounts for shipping and handling activities as a fulfillment cost rather than a separate performance obligation. The Company’s policy is to record revenue net of any applicable sales, use, or excise taxes. Payment terms are generally net 30 days from invoice date and some customers are offered discounts for early pay. Disaggregation of revenue The Company operates in one reportable segment with its net revenue derived primarily from the sale of orthobiologics and spinal implant products across North America, Asia Pacific and Latin America. Sales are reported net of returns. No rebates, group purchasing organization fees or other customer allowances are present, and so are not relevant to net revenue determination. The following table presents revenues from these product lines for the years ended December 31, 2020 and 2019 (dollars in thousands): Year Ended December 31, 2020 Percentage of Total Revenue Year Ended December 31, 2019 Percentage of Total Revenue Orthobiologics $ 39,308 74 % $ 46,663 72 % Spinal implant 13,880 26 % 17,872 28 % Other revenue 149 0 % 147 0 % Total revenue $ 53,337 100 % $ 64,682 100 % Research and Development Research and development costs, which are principally related to internal costs for the development of new products, are expensed as incurred. Net Loss Per Share Basic net loss per share is computed by dividing net loss by the weighted average number of shares of common stock 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 loss per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive shares of common stock 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 years ended December 31, 2020 and 2019, as shares issuable upon the exercise of stock options and warrants and settlement of restricted stock units were anti-dilutive as a result of the net losses incurred for those periods. Diluted net loss per share is not reported as the effects of including 5,115,868 and 4,011,754 outstanding stock options, warrants and restricted stock units for the years ended December 31, 2020 and 2019, respectively, are anti-dilutive. Fair Value of Financial Instruments The carrying values of financial instruments, including trade accounts receivable, accounts payable, accrued liabilities 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 fair value 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 years ended December 31, 2020 and 2019, there was no reclassification in financial assets or liabilities between Level 1, 2 or 3 categories. Reclassification Certain prior year amounts have been reclassified to conform with current year presentation.

Receivables

Receivables	12 Months Ended
	Dec. 31, 2020
Credit Loss [Abstract]
Receivables	(2) Receivables Concurrent with the adoption of ASU 2016-13, the Company’s allowance for doubtful accounts was expanded to include provision for current expected credit loss (“CECL”). The Company’s provision for CECL is determined based on historical collection experience adjusted for current economic conditions affecting collectability. Actual customer collections could differ from estimates. Account balances are charged to the allowance after all means of collection have been exhausted and the potential for recovery is considered remote. Provisions to the allowance for credit losses are charged to expense. Activity within the allowance for credit losses was as follows for year ended December 31, 2020 (in thousands): Balance at January 1, 2020 $ 547 Provision for expected credit losses 307 Write-offs charged against allowance (201 ) Balance at December 31, 2020 $ 653

Inventories

Inventories	12 Months Ended
	Dec. 31, 2020
Inventory Disclosure [Abstract]
Inventories	(3) Inventories Inventories consist of the following (in thousands): December 31, 2020 December 31, 2019 Raw materials $ 3,757 $ 3,386 Work in process 1,733 1,256 Finished goods 15,918 11,459 $ 21,408 $ 16,101

Property and Equipment, Net

Property and Equipment, Net	12 Months Ended
	Dec. 31, 2020
Property, Plant and Equipment [Abstract]
Property and Equipment, Net	(4) Property and Equipment, Net Property and equipment, net are as follows (in thousands): December 31, 2020 December 31, 2019 Equipment $ 4,807 $ 4,250 Computer equipment 649 455 Computer software 570 570 Furniture and fixtures 133 124 Leasehold improvements 3,987 3,980 Other 10 10 Surgical instruments 11,291 10,897 Total cost 21,447 20,286 Less: accumulated depreciation (17,100 ) (15,591 ) $ 4,347 $ 4,695 Depreciation expense related to property and equipment, including property under capital lease, for the years ended December 31, 2020 and 2019 was $2.0 million and $3.1 million, respectively. The Company leases certain equipment under finance leases. For financial reporting purposes, minimum lease payments relating to the assets have been capitalized. As of December 31, 2020 and 2019, the Company has recorded $0.5 million and $1.4 million, respectively, within Equipment, and $0.4 million and $1.0 million, respectively, of accumulated depreciation.

Goodwill and Intangible Assets

Goodwill and Intangible Assets	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Goodwill and Intangible Assets	(5) Goodwill and Intangible Assets The results of the Company’s annual goodwill impairment tests for the years ended December 31, 2020 and 2019 indicated that no goodwill impairment existed as of the test date. The following table sets forth information regarding intangible assets (in thousands): December 31, 2020 December 31, 2019 Patents $ 847 $ 847 Accumulated amortization (390 ) (332 ) Net carrying value $ 457 $ 515 Amortization expense was $0.1 million for both of the years ended December 31, 2020 and 2019. The following is a summary of estimated future amortization expense for intangible assets as of December 31, 2020 (in thousands): 2021 $ 56 2022 54 2023 53 2024 52 2025 52 Thereafter 190 Total $ 457

Accrued Liabilities

Accrued Liabilities	12 Months Ended
	Dec. 31, 2020
Payables and Accruals [Abstract]
Accrued Liabilities	(6) Accrued Liabilities Accrued liabilities consist of the following (in thousands): December 31, 2020 December 31, 2019 Wages/commissions payable $ 4,057 $ 3,902 Other accrued liabilities 2,063 2,730 Accrued liabilities $ 6,120 $ 6,632

Debt

Debt	12 Months Ended
	Dec. 31, 2020
Debt Disclosure [Abstract]
Debt	(7) Debt Second A&R Credit Agreement On March 29, 2019, the Company and ROS and Royalty Opportunities entered into a Second A&R Credit Agreement, which amended and restated the Amended and Restated Credit Agreement by and between Bacterin and ROS (collectively, the “Prior Credit Agreement” and the facility created under such agreement, the “Credit Facility”). Under the Second A&R Credit Agreement, some of which terms have been further amended: ● We may continue to make requests for term loans in amounts equal to the remaining commitment for additional delayed draw loans, which was approximately $2.2 million as of the date of the Second A&R Credit Agreement, and could request additional term loans with ROS and Royalty Opportunities in an aggregate amount of up to $10.0 million, with the amount of each loan draw to be subject to our production of a thirteen-week cash flow forecast that is approved by ROS and Royalty Opportunities and which shows a projected cash balance for the following two-week period of less than $1.5 million, as well as the satisfaction (or waiver in writing by ROS and Royalty Opportunities) of conditions precedent, including closing certificate, delivery of budget, and other satisfactory documents; ● no interest would accrue on the loans outstanding under the Second A&R Credit Agreement (the “Loans”) from and after January 1, 2019 until March 31, 2020; ● beginning April 1, 2020 through the maturity date of the Second A&R Credit Agreement, interest payable in cash would accrue on the Loans under the Credit Agreement at a rate per annum equal to the sum of (a) 10.00% plus (b) the higher of (x) the LIBO Rate (as such term is defined in the Second A&R Credit Agreement) and (y) 2.3125%; ● the maturity date of the Loans was March 31, 2021; ● the Consolidated Senior Leverage Ratio and Consolidated EBITDA (as such terms were defined in the Prior Credit Agreement) financial covenants were deleted, and a new Revenue Base (as such term is defined in the Second A&R Credit Agreement) financial covenant was added; and ● the key person event default provision was revised to refer specifically to certain then recently-hired executive officers of the Company. Long-term debt, less issuance costs consists of long-term debt due to the lenders under the Second A&R Credit Agreement as of December 31, 2019. The execution of the Second A&R Credit Agreement during the first quarter of 2019 and the changes to our credit facility reflected therein, including the interest rate relief and extended maturity, along with the additional availability, were determined to be and accounted for as a debt extinguishment under U.S. generally accepted accounting principles (“GAAP”), resulting in the write-off of the original loan and associated issuance costs. The present value of the new loan was determined to be $72.7 million as of March 31, 2019 with the Company recording an increase to additional paid-in capital of $7.3 million. Because of the related party affiliation between the Company and ROS and Royalty Opportunities, this debt extinguishment resulted in an increase in additional paid-in capital rather than flowing through our consolidated statements of operations as a gain on extinguishment. On April 1, 2019, we issued warrants to purchase an aggregate of 1.2 million shares of our common stock to ROS and Royalty Opportunities, with an exercise price of $0.01 per share and an expiration date of April 1, 2029 (collectively, the “2019 Warrants”). The issuance of the 2019 Warrants (see Note 9, “ Stock-Based Compensation On May 6, 2020, we entered into a First Amendment to the Second A&R Credit Agreement (the “First Amendment”) with ROS and Royalty Opportunities among other things, provided that: ● No interest would accrue on the Loans from and after March 31, 2020 until September 30, 2020; ● Beginning October 1, 2020 through the maturity date of the Second A&R Credit Agreement, interest payable in cash would accrue on the Loans under the Second A&R Credit Agreement at a rate per annum equal to the sum of (i) 10.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second A&R Credit Agreement) and (y) 2.3125%; ● The maturity date of the Loans is December 31, 2021; ● The Revenue Base (as such term is defined in the Second A&R Credit Agreement) financial covenant was revised through December 31, 2021; and ● The key person event default provision was revised to refer specifically to Sean Browne in lieu of a former executive. On May 6, 2020, we issued warrants to purchase an aggregate of 2.4 million shares of our common stock to ROS and Royalty Opportunities, with an exercise price of $0.01 per share and an expiration date of May 6, 2030 (collectively, the “2020 Warrants”). The issuance of the 2020 Warrants was a condition to the effectiveness of the First Amendment. The First Amendment was accounted for as a debt modification whereby the recorded debt balance was discounted for the fair value of the 2020 Warrants issued and interest expense is accrued through the maturity date of the Loans at the post-amendment effective interest rate of 10.02%. These 2020 Warrants were exercised in full in November 2020. On October 1, 2020, in connection with our recent debt restructuring transaction, we entered into a Second Amendment to the Second A&R Credit Agreement (the “Second Amendment”) with ROS and Royalty Opportunities, which among other things, provided for: ● Extinguishment by ROS and Royalty Opportunities of approximately $61.9 million of principal and paid-in-kind interest outstanding on the Loans in exchange for approximately 57.8 million shares of our common stock and the addition of a principal amount equal to prepayment fees associated with the Loans not paid in cash or exchanged for shares of our common stock; ● Exchange of approximately $0.9 million of prepayment fees associated with the Loans for approximately 0.9 million shares of our common stock (the “Prepayment Fee Shares”); ● Elimination of the availability of additional draw loan advances and reduction of available additional term loans to $5.0 million, the availability of which is in the sole and absolute discretion of the lender; ● Accrual of interest payable in cash for the remaining term of the Second A&R Credit Agreement at a rate per annum equal to the sum of (i) 7.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second A&R Credit Agreement) and (y) 1.00%; and ● Elimination of certain financial covenants. As a result of our recent debt restructuring, as previously described, we recorded a gain on restructuring totaling $15.1 million. The gain represents the excess of the carrying value of our outstanding loans under the Second A&R Credit Agreement prior to the extinguishment of such debt in the debt restructuring transaction, $80.3 million, over the sum of the fair value of the 57.8 million shares issued therewith, $48.2 million based on the closing price of our common stock on October 1, 2020, and $17.1 million of undiscounted future cash payments associated with the Second Amendment. Because of the related party affiliation between the Company and ROS and Royalty Opportunities, this debt extinguishment resulted in an increase in additional paid-in capital rather than flowing through our consolidated statements of operations as a gain on extinguishment. The carrying value of loans outstanding under the Second A&R Credit Agreement is equal to the undiscounted future cash payments associated with the Second Amendment and principal associated with loans thereunder. Cash interest payments in connection with the Second A&R Credit Agreement will reduce the carrying value of associated loans; and accordingly, no interest expense related to cash interest payments will be recorded for the duration of the Second A&R Credit Agreement. As a result of the Second Amendment, Royalty Opportunities became the sole holder of our outstanding long-term debt and the sole lender under the credit agreement. Long-term debt consists of the following (in thousands): December 31, 2020 December 31, 2019 Amounts due under the Credit Facility $ 15,556 $ 72,657 PIK interest payable related to the Credit Facility — 3,280 Plus: 2% exit fee on Credit Facility — 399 Gross long-term debt 15,556 76,336 Premium related to Second Amendment 1,241 — Less: current maturities (16,797 ) Less: total debt issuance costs — (92 ) Long-term debt, less issuance costs $ — $ 76,244 All gross long-term debt will mature December 31, 2021 and become payable at that time. Since the maturity date of the indebtedness outstanding under our credit facility is December 31, 2021, all outstanding indebtedness is classified as current as of December 31, 2020 on the accompanying consolidated balance sheet.

Equity

Equity	12 Months Ended
	Dec. 31, 2020
Equity [Abstract]
Equity	(8) Equity Charter Amendments On October 30, 2019, the Company’s stockholders, upon recommendation of the Board, approved an amendment to the Company’s Charter to increase the number of authorized shares of common stock from 50 million to 75 million. This Charter amendment was effective upon the filing of a Certificate of Amendment with the Office of the Secretary of State of the State of Delaware on October 30, 2019. On August 7, 2020, the Company’s stockholders, upon recommendation of the Board, approved an amendment to the Company’s Charter to increase the number of authorized shares of common stock from 75 million to 300 million. This Charter amendment was effective upon the filing of a Certificate of Amendment with the Office of the Secretary of State of the State of Delaware on October 1, 2020. Debt Restructuring On October 1, 2020, we issued 58.7 million shares of our common stock in connection with our recent debt restructuring. See Note (1) Business Description and Summary of Significant Accounting Policies – Debt Restructuring. Rights Offering On November 6, 2020, we distributed to holders of our common stock, at no charge, non-transferable subscription rights to purchase up to an aggregate of 14,018,690 shares of our common stock (the “Rights Offering”). In the Rights Offering, holders received 0.194539 subscription rights for each share of common stock held on the record date, November 5, 2020. Each whole subscription right entitled the holder to purchase one share of our common stock for $1.07 in cash. The Rights Offering was commenced on November 6, 2020 and expired on December 4, 2020, at which time the rights were no longer exercisable. We issued 712,646 shares of our common stock in the Rights Offering, resulting in $0.8 million in gross proceeds to us. Warrant Exercises On November 17, 2020, ROS and Royalty Opportunities exercised warrants representing an aggregate of 4.8 million shares of our common stock and in connection therewith we received aggregate proceeds of $48,000. See Note (10) Warrants.

Stock-Based Compensation

Stock-Based Compensation	12 Months Ended
	Dec. 31, 2020
Share-based Payment Arrangement [Abstract]
Stock-Based Compensation	(9) Stock-Based Compensation Xtant Medical Holdings, Inc. 2018 Equity Incentive Plan On August 1, 2018, our stockholders approved the Xtant Medical Holdings, Inc. 2018 Equity Incentive Plan at the 2018 annual meeting of stockholders of Xtant and on October 30, 2019 at our 2019 annual meeting of stockholders, our stockholders approved an amendment to increase the number of shares of common stock available thereunder by 1,500,000 shares. On October 27, 2020, at our 2020 annual meeting of stockholders, our stockholders approved an amendment to further increase the number of shares of our common stock available for issuance under the 2018 Plan by an additional 5,550,308 shares Stock options granted under the 2018 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 exercise price of all stock options granted under the 2018 Plan must be at least equal to the fair market value of the shares of common stock on the date of the grant. The 2018 Plan is administered by the Board. Stock options granted under the 2018 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 the optionee. Stock option activity, including options granted under the 2018 Plan and the Prior Plan was as follows: 2020 2019 Weighted Weighted Weighted Average Weighted Average Average Value at Average Value at Shares Price Date Shares Price Date Outstanding at January 1 602,966 $ 6.07 $ 3.99 496,958 $ 9.90 $ 6.62 Granted 1,708,743 1.24 1.01 554,825 2.55 2.01 Cancelled or expired (120,817 ) 6.95 4.31 (448,817 ) 5.96 4.45 Outstanding at December 31 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Exercisable at December 31 122,739 $ 14.74 $ 8.95 25,063 $ 83.78 $ 46.66 The estimated fair value of stock options granted is determined using the Black-Scholes-Merton method applied to individual grants. Key assumptions used to estimate the fair value of stock awards are as follows: Year Ended December 31, 2020 2019 Risk free interest rate 0.54 % 1.82 % Dividend yield 0 % 0 % Expected term 6.2 years 7.1 years Expected volatility 105 % 92 % Restricted stock unit activity for awards granted under the 2018 Plan was as follows: 2020 2019 Shares Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 499,914 $ 2.87 40,000 $ 6.20 Granted 2,148,662 $ 1.29 459,914 $ 2.65 Vested (144,878 ) $ 2.52 - $ - Outstanding at December 31 2,503,698 $ 1.54 499,914 $ 2.87 Total stock-based compensation expense recognized for employees and directors was $1.1 million and $0.5 million for the years ended December 31, 2020 and 2019, respectively, and was recognized as general and administrative expense. The aggregate intrinsic value of options outstanding as of December 31, 2019 was $16,000. As of December 31, 2020, total compensation expense related to unvested employee stock options not yet recognized was $2.3 million, which is expected to be allocated to expenses over a weighted-average period of 3.7 years. Total compensation expense related to unvested restricted stock units not yet recognized was $3.2 million as of December 31, 2020, which is expected to be allocated to expenses over a weighted-average period of 3.4 years.

Warrants

Warrants	12 Months Ended
	Dec. 31, 2020
Warrants and Rights Note Disclosure [Abstract]
Warrants	(10) Warrants 2020 Warrants As noted in Note 7, “ Debt 2019 Warrants On April 1, 2019, we issued warrants to purchase an aggregate of 1.2 million shares of our common stock to ROS and Royalty Opportunities with an exercise price of $0.01 per share and an expiration date of April 1, 2029. The issuance of the 2019 Warrants was a condition to the effectiveness of the Second A&R Credit Agreement. The fair value of the 2019 Warrants upon issuance was determined to be $9,000. The 2019 Warrants met all the requirements to be classified as equity awards in accordance with ASC No. 815-40. The number of shares of our common stock issuable upon exercise of the 2019 Warrants was subject to standard and customary anti-dilution provisions for stock splits, stock dividends, or similar transactions. The 2019 Warrants were exercised in full on November 17, 2020. The following table summarizes our warrant activities for the years ended December 31, 2020 and 2019: Weighted Common Average Stock Exercise Warrants Price Outstanding as of January 1, 2019 1,710,609 $ 7.33 Issued 1,200,000 0.01 Expired (1,735 ) 259.60 Outstanding as of December 31, 2019 2,908,874 $ 4.16 Issued 2,400,000 0.01 Exercised (4,800,000 ) 0.01 Expired (87,596 ) 85.92 Outstanding at December 31, 2020 421,278 $ 10.80 The following table summarizes our activities related to warrants accounted for as a derivative liability for the years ended December 31, 2020 and 2019: 2020 2019 Balance at January 1 87,509 87,509 Derivative warrants expired (87,509 ) — Balance at December 31 — 87,509

Commitments and Contingencies

Commitments and Contingencies	12 Months Ended
	Dec. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies	(11) Commitments and Contingencies In 2019, we adopted ASU No. 2016-02, Leases (Topic 842), which requires lessees to recognize a right-of-use (“ROU”) asset and lease liability on their balance sheet for all leases with terms beyond 12 months. The new standard also requires enhanced disclosures intended to provide more transparency and information to financial statement users about lease portfolios. The distinction between operating and finance leases will continue to exist under the new standard. Additionally, the recognition and measurement of operating and finance lease expenses and cash flows will not change significantly from current treatment. For finance leases, lessees will continue to recognize interest expense on the lease liability using the effective yield method, while the right-of-use asset will be amortized on a straight-line basis. For operating leases, expense will be recognized on a straight-line basis, consistent with the previous standard. Operating Leases We currently lease four office facilities. These leases are under non-cancelable operating lease agreements with expiration dates between 2023 and 2025. We have the option to extend certain leases to five or ten-year term(s) and we have the right of first refusal on any sale. The Company records lease liabilities within current liabilities or long-term liabilities based upon the length of time associated with the lease payments. The Company records its long-term operating leases as right-of-use assets. Upon initial adoption, using the modified retrospective transition approach, no leases with terms less than 12 months have been capitalized to the consolidated balance sheet consistent with ASC 842. Instead, these leases are recognized in the consolidated statement of operations on a straight-line expense throughout the lives of the leases. No Company leases contain common area maintenance or security agreements. We have made certain assumptions and judgments when applying ASC 842, the most significant of which is that we elected the package of practical expedients available for transition, which allow us to not reassess whether expired or existing contracts contain leases under the new definition of a lease, lease classification for expired or existing leases, and whether previously capitalized initial direct costs would qualify for capitalization under ASC 842. Additionally, we did not elect to use hindsight when considering judgments and estimates such as assessments of lessee options to extend or terminate a lease or purchase the underlying asset. As of December 31, 2020, the weighted-average remaining lease term was 4 years. Lease expense related to operating leases was $0.6 million for both of the years ended December 31, 2020 and 2019, respectively. The Company’s lease agreements do not provide a readily determinable implicit rate nor is it available to the Company from its lessors. Instead, as of December 31, 2020, the Company estimates the weighted-average discount rate for its operating leases to be 5.2% to present value based on the incremental borrowing rate. Future minimum payments for the next five years and thereafter as of December 31, 2020 under these long-term operating leases are as follows (in thousands): 2021 $ 507 2022 521 2023 489 2024 224 Thereafter 180 Total future minimum lease payments 1,921 Less amount representing interest (195 ) Present value of obligations under operating leases 1,726 Less current portion (423 ) Long-term operating lease obligations $ 1,303 Finance Leases During the years ended December 31, 2020 and 2019, we incurred lease interest cost of $13,000 and $0.1 million, respectively, and amortization expense of $0.1 million and $0.2 million, respectively Litigation On December 13, 2018, a complaint was filed by RSB Spine, LLC, against Xtant Medical Holdings, Inc., which claimed that some of our products, including the Irix-A Lumbar Integrated Fusion System and the Irix-C Cervical Integrated Fusion System, infringe certain of RSB Spine’s patents. On February 28, 2020, we entered into a confidential settlement and patent license agreement with RSB Spine pursuant to which we agreed to make an undisclosed settlement payment to RSB Spine and pay royalties on future sales of the two products through the expiration of the asserted patents. The settlement payment was included in accrued expenses as of December 31, 2019. In November 2020, we received a letter from a third party’s legal counsel claiming that some of our products, including the Butrex Plating System, Spider Plating System, Aranax Plating System and Irix Fusion System, infringe a patent held by the third party and offering to discuss settlement terms. Because this matter is in early stages and because of the complexity of the claims, we cannot estimate the possible loss or range of loss, if any, associated with its resolution. However, there can be no assurance that the ultimate resolution of this matter will not result in a material adverse effect on our business, financial condition or results of operations. In addition, we may be subject to potential liabilities under government regulations and various claims and legal actions that are pending but we believe are immaterial at this time or may be asserted in the future from time to time. These matters arise in the ordinary course and conduct of our business and may include, for example, commercial, product liability, intellectual property, and employment matters. We intend to continue to defend the Company vigorously in such matters and when warranted, take legal action against others. Furthermore, we regularly assess contingencies to determine the degree of probability and range of possible loss for potential accrual in our financial statements. An estimated loss contingency is accrued in our financial statements if it is probable that a liability has been incurred and the amount of the loss can be reasonably estimated. Based on our assessment, we have adequately accrued an amount for contingent liabilities currently in existence. We do not accrue amounts for liabilities that we do not believe are probable or that we consider immaterial to our overall financial position. Litigation is inherently unpredictable, and unfavorable resolutions could occur. As a result, assessing contingencies is highly subjective and requires judgment about future events. The amount of ultimate loss may exceed the Company’s current accruals, and it is possible that its cash flows or results of operations could be materially affected in any particular period by the unfavorable resolution of one or more of these contingencies. 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 consolidated 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.

Income Taxes

Income Taxes	12 Months Ended
	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Income Taxes	(12) Income Taxes The Company’s provision for income taxes differs from applying the statutory U.S. Federal income tax rate to income before taxes. The primary difference results from providing for state income taxes and from deducting certain expenses for financial statement purposes but not for federal income tax purposes. The components of income (loss) before provision for income taxes consist of the following (in thousands): Year Ended December 31, 2020 2019 United States $ (6,727 ) $ (8,123 ) Total $ (6,727 ) $ (8,123 ) The components of the income tax provision are as follows (in thousands): Year Ended December 31, 2019 2019 Current: Federal $ 51 $ — State 245 98 Total current 296 98 Deferred: Federal — — State — — Total deferred — — Total Provision for Income Taxes $ 296 $ 98 The reconciliation of income tax attributable to operations computed at the U.S. Federal statutory income tax rate of 21% to income tax expense is as follows (in thousands): Year Ended December 31, 2020 2019 Statutory Federal tax rate $ (1,413 ) $ (1,706 ) Valuation allowance (10,968 ) 73 State income taxes, net of Federal benefit 619 34 Attribute reduction related to Sec. 382 8,607 — Change in state income tax rate (61 ) (136 ) Gain on extinguishment of debt 3,488 1,534 Stock compensation adjustment and other reconciling items 14 282 Nondeductible meals and entertainment expense 10 17 Total Provision for Income Taxes $ 296 $ 98 Deferred tax components are as follows (in thousands): At December 31, 2020 2019 Deferred tax assets: Accrued liability for vacation $ 123 $ 111 Accrued commissions and bonuses / compensation 565 298 Accrued contingencies 42 132 Amortization 32 36 Depreciation — 157 Bad debt reserve 174 133 Charitable contributions carryforward — 8 Lease liability 459 564 Interest expense 2,342 3,407 Inventory reserve 2,975 3,058 Net operating loss carryovers 12,114 22,009 Stock option compensation 653 476 Other 109 102 Total deferred tax assets 19,588 30,491 Deferred tax liabilities: Right of use asset (450 ) (558 ) Prepaids (73 ) Depreciation (100 ) — Total deferred tax liabilities (623 ) (558 ) Valuation allowance (18,965 ) (29,933 ) Net deferred tax assets $ — $ — The ultimate realization of deferred tax assets is dependent upon the existence, or generation, of taxable income in the periods when those temporary differences and net operating loss carryovers are deductible. Management considers the scheduled reversal of deferred tax liabilities, taxes paid in carryover years, projected future taxable income, available tax planning strategies, and other factors in making this assessment. Based on available evidence, management does not believe it is more likely than not that all of the deferred tax assets will be realized. Accordingly, the Company has established a valuation allowance equal to the net realizable deferred tax assets. The valuation allowance decreased by $11.0 million in 2020 and increased by $0.1 million in 2019. At December 31, 2020 and 2019, the Company had total domestic Federal and state net operating loss carryovers of approximately $97.0 million and $149.8 million, respectively. Federal net operating losses generated prior to 2018 and State net operating loss carryovers expire at various dates between 2024 and 2040. Federal net operating losses generated after 2017 have an indefinite carryforward and are only available to offset 80% taxable income beginning in 2021. On March 27, 2020 the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) was signed into law. The CARES Act provided for an increased interest deduction for tax years 2019 and 2020, as well as the deferral of the employer portion of social security taxes. The Company has completed a study to assess whether an ownership change, as defined by Section 382 of the Internal Revenue Code, had occurred from the Company’s formation through December 31, 2020. Based upon this study, the Company determined that an ownership change occurred during 2018. Accordingly, the Company reduced its deferred tax assets related to the federal net operating loss carryforwards that are anticipated to expire unused as a result of these ownership changes. These tax attributes were excluded from deferred tax assets with a corresponding reduction of the valuation allowance with no net effect on income tax expense or the effective tax rate. Future ownership changes may further limit the Company’s ability to utilize its remaining tax attributes. The 2017 through 2019 tax years remain open to examination by the Internal Revenue Service and various other state tax agencies. These taxing authorities have the authority to examine those tax years until the applicable statute of limitations expire. The Company did not recognize any material interest or penalties related to income taxes for the years ended December 31, 2020 and 2019.

Employee Benefit Plans

Employee Benefit Plans	12 Months Ended
	Dec. 31, 2020
Retirement Benefits [Abstract]
Employee Benefit Plans	(13) Employee Benefit Plans We have a 401(k) plan for our employees. The 401(k) plan is a defined contribution plan covering substantially all of our employees. Employees are eligible to participate in the plan on the first day of any month after starting employment. Employees are allowed to contribute a percentage of their wages to the 401(k) plan, subject to statutorily prescribed limits and are subject to a discretionary employer match of 100% of their wage deferrals not in excess of 4% of their wages. The 401(k) plan matching contributions by the Company were temporarily suspended at the onset of the COVID-19 pandemic, but future plan matching contributions were subsequently restored effective July 1, 2020. The Company contributed $0.2 million as part of the employer match program for each of the years ended December 31, 2020 and 2019

Supplemental Disclosure of Cash

Supplemental Disclosure of Cash Flow Information	12 Months Ended
	Dec. 31, 2020
Supplemental Cash Flow Elements [Abstract]
Supplemental Disclosure of Cash Flow Information	(14) Supplemental Disclosure of Cash Flow Information Supplemental cash flow information is as follows (in thousands): Year Ended December 31, 2020 2019 Cash paid during the period for: Interest $ 13 $ 51 Non-cash activities: ASU 2016-13 cumulative effect adjustment $ 47 $ — Recognition of 2020 Warrants $ 1,862 $ — Partial extinguishment of Second Amended and Restated Credit Agreement (including debt issuance costs) $ 63,233 $ — Lease liability from right-of-use assets $ — $ 2,296 Extinguishment of the Company’s Prior Credit Agreement (including debt issuance costs) $ — $ 79,624 Recognition of Second Amended and Restated Credit Agreement $ — $ 72,657 Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees $ — $ 307 Recognition of 2019 Warrants $ — $ 9

Related Party Transactions

Related Party Transactions	12 Months Ended
	Dec. 31, 2020
Related Party Transactions [Abstract]
Related Party Transactions	(15) Related Party Transactions Royalty Opportunities, owning approximately 22% of the Company’s outstanding common stock, is the sole holder of our outstanding long-term debt. In addition, as described in more detail under Note 1, “ Business Description and Summary of Significant Accounting Policies On April 5, 2019, the Company entered into a Sublease Agreement wherein the Company leases from Cardialen, Inc., a portion of Cardialen’s office space commencing April 2019 on a month-to-month basis until January 2024, unless terminated earlier upon notice of 60 days. The rent is approximately $1,000 per month. Because Jeffrey Peters is both a member of our Board of Directors and the Chief Executive Officer, President, and a director of Cardialen, this transaction qualifies as a related party transaction. All related party transactions are reviewed and approved by the Audit Committee or the disinterested members of the full Board.

Segment and Geographic Informat

Segment and Geographic Information	12 Months Ended
	Dec. 31, 2020
Segment Reporting [Abstract]
Segment and Geographic Information	(16) Segment and Geographic Information The Company’s management reviews our 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. Approximately 98% and 96% of revenue was in the United States for the years ended December 31, 2020 and 2019, respectively. Total revenue by major geographic area is as follows (in thousands): Year Ended 2020 2019 United States $ 52,147 $ 62,377 Rest of World 1,190 2,305 Total $ 53,337 $ 64,682

Subsequent Event

Subsequent Event	12 Months Ended
	Dec. 31, 2020
Subsequent Events [Abstract]
Subsequent Event	(17) Subsequent Event On February 22, 2021, the Company entered into a securities purchase agreement with a single healthcare-focused institutional investor (the “Investor”) pursuant to which we agreed to issue 8,888,890 shares of our common stock at a purchase price of $2.25 per share, and warrants to purchase up to 6,666,668 shares of our common stock (the “Investor Warrant”) in a private placement (the “Private Placement”). The closing of the Private Placement is expected to occur on February 24, 2021, subject to the satisfaction of customary closing conditions. We expect to receive gross proceeds of approximately $20 million before deducting fees and other estimated offering expenses from the Private Placement. We expect to use the net proceeds from the Private Placement for working capital and other general corporate purposes. The Investor Warrant will have an exercise price of $2.25 per share, subject to customary anti-dilution, but not price protection, adjustments, and will be immediately exercisable and expire on the five-year anniversary of the date of issuance. Under the terms of the Securities Purchase Agreement, we agreed that in the event we propose to offer and sell shares of our common stock or certain common stock equivalents to non-strategic investors primarily for capital raising purposes, we would provide the Investor the right, but not the obligation, to participate in such offering in an amount of up to 25% of the securities offered in such offering. This participation right will expire upon the earlier of 12 months after the closing of the Private Placement or upon the occurrence of certain change in control events. We also agreed, under the terms of the Securities Purchase Agreement, to enter into a registration rights agreement (the “Registration Rights Agreement”) with the Investor pursuant to which we will agree to prepare and file a registration statement (the “Resale Registration Statement”) with the SEC within 45 days of the closing date for purposes of registering the resale of the shares of common stock issued to the Investor and the shares of common stock issuable upon exercise of the Investor Warrant. We will also agree to use our reasonable best efforts to cause the Resale Registration Statement to be declared effective by the SEC within 60 calendar days of the closing of the Private Placement (75 calendar days in the event the registration statement is reviewed by the SEC). If we fail to meet the specified filing deadlines or keep the Resale Registration Statement effective, subject to certain permitted exceptions, we will be required to pay liquidated damages to the Investor. In connection with the Private Placement, we entered into a placement agent agreement with A.G.P./Alliance Global Partners (the “Placement Agent”) pursuant to which the Placement Agent is serving as our exclusive placement agent in connection with the Private Placement (the “Placement Agent Agreement”). Pursuant to the Placement Agent Agreement, we agreed to pay the Placement Agent a certain percentage of the aggregate gross proceeds from the Private Placement. In addition to the cash fee, we agreed to issue to the Placement Agent a warrant to purchase up to 5.0% of the shares sold to the Investor in the Private Placement, or 444,444 shares of our common stock (the “Placement Agent Warrant”). The Placement Agent Warrant will have an exercise price of $2.8125 per share, subject to customary anti-dilution, but not price protection, adjustments and will be immediately exercisable and expire on the five-year anniversary of the date of issuance.

Business Description and Summ_2

Business Description and Summary of Significant Accounting Policies (Policies)	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Business Description	Business Description The accompanying consolidated financial statements include the accounts of Xtant Medical Holdings, Inc., formerly known as Bacterin International Holdings, Inc., a Delaware corporation, and its wholly owned subsidiaries, Xtant Medical, Inc., a Delaware corporation, Bacterin International, Inc., (“Bacterin”) a Nevada corporation, and X-Spine Systems, Inc. (“X-spine”), an Ohio corporation (Xtant Medical Inc., Bacterin and X-spine are jointly referred to herein as “Xtant” or the “Company”). The terms “we,” “us” and “our” also refer to Xtant. All intercompany balances and transactions have been eliminated in consolidation. 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 foot surgeries and the development, manufacturing and sale of medical devices for use in orthopedic spinal surgeries. Since March 2020, the COVID-19 pandemic has caused business closures, severe travel restrictions and implementation of social distancing measures. At the onset of the COVID-19 pandemic, hospitals and other medical facilities cancelled or deferred elective procedures, diverted resources to patients suffering from infections and limited access for non-patients, including our direct and indirect sales representatives. Because of the COVID-19 pandemic, surgeons and their patients have been, and may continue to be, required, or are choosing, to defer procedures in which our products otherwise would be used, and many facilities that specialize in the procedures in which our products otherwise would be used have experienced temporary closures or reduced operating hours. These circumstances have negatively impacted, and may continue to negatively impact, the ability of our employees, independent sales representatives and distributors to effectively market and sell our products, which has had and will likely continue to have a material adverse effect on our revenues. At December 31, 2020, the Company had cash and cash equivalents of $2.3 million, and an accumulated deficit of $230.3 million and has incurred significant losses in the current and prior periods. Management’s evaluation of going concern was conducted as part of its discussions with the Xtant Board of Directors’ review of the 2021 Annual Operating Plan. Management believes that we will be able to refinance the amounts outstanding under our credit agreement or extend the maturity date, based on communications with the lender, such that our $2.3 million of cash and cash equivalents as of December 31, 2020, together with the $5.0 million available at the lender’s sole discretion under our credit agreement, or comparable refinanced credit agreement, will be sufficient to meet our anticipated cash requirements and continue as a going concern through at least February 2022.
Debt Restructuring	Debt Restructuring On August 7, 2020, we entered into a Restructuring and Exchange Agreement (the “Restructuring Agreement”) with OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) and ROS Acquisition Offshore LP (“ROS”), pursuant to which the parties thereto agreed, subject to the terms and conditions set forth therein, to take certain actions as set forth therein and as described below (collectively, the “Restructuring Transactions”) in furtherance of a restructuring of the Company’s outstanding indebtedness under the Company’s Second Amended and Restated Credit Agreement with Royalty Opportunities and ROS, as amended (the “Second A&R Credit Agreement”). The primary purpose of the Restructuring Transactions was to improve our capital structure by reducing the amount of our indebtedness and cost to service our debt, which should make it easier for us to refinance or replace this debt in the future, as well as facilitate easier access to capital markets for investment in our growth initiatives. The Restructuring Transactions also allowed us to regain compliance with the NYSE American continued listing standards, which we achieved on October 5, 2020. The Restructuring Transactions included, among others: ● an amendment to the Company’s Amended and Restated Certificate of Incorporation, as amended (“Charter”), to increase the number of authorized shares of our common stock from 75 million to 300 million (the “Charter Amendment”), which occurred on October 1, 2020; ● the exchange by the Company of shares of our common stock for approximately $40.8 million of the aggregate outstanding principal amount under the Second A&R Credit Agreement, as well as, without duplication, approximately $21.1 million of the outstanding amount of PIK Interest (as defined in the Second A&R Credit Agreement) (such loans and PIK Interest, the “Exchanging Loans”), plus all other accrued and unpaid interest on the Exchanging Loans outstanding as of the closing date, at an exchange price of $1.07 per share, representing the average closing price of the common stock over the 10 trading days immediately prior to the parties entering into the Restructuring Agreement, and resulting in the issuance of approximately 57.8 million shares of common stock (the “Share Issuance”), which occurred on October 1, 2020 ● the execution of an amendment to the Second A&R Credit Agreement by the parties thereto to change certain provisions therein, including extinguishing loans in an aggregate principal amount equal to the Exchanging Loans outstanding thereunder together with all accrued and unpaid interest thereon, paying a portion of the prepayment fee payable thereunder in respect of the Exchanging Loans with proceeds of additional loans under the Second A&R Credit Agreement, with the remaining portion of the prepayment fee exchanged for an additional 0.9 million shares of our common stock, reducing the amount of credit availability thereunder, decreasing the interest rate and eliminating certain financial covenants, which occurred on October 1, 2020, as described in more detail under Note 7, “Debt” ● the launch by the Company of a rights offering to allow our stockholders to purchase up to an aggregate of $15 million of our common stock at the same price per share as the $1.07 per share exchange price used to exchange the Exchanging Loans into our common stock as part of the Share Issuance (the “Rights Offering”), which commenced on November 5, 2020 and expired on December 4, 2020 and resulted in the issuance of 712,646 shares of our common stock and gross proceeds of $0.8 million, as described in more detail under Note 8, “Equity” As a result of the completion of these Restructuring Transactions, Royalty Opportunities and ROS own, in the aggregate, approximately 93.9% of the outstanding common stock and all other existing stockholders of the Company own approximately 6.1% of the outstanding common stock as of December 31, 2020. Following completion of these Restructuring Transactions, the remaining principal balance of our outstanding debt totals $15.6 million.
Investor Rights Agreement	Investor Rights Agreement We are party to an Investor Rights Agreement with ROS and Royalty Opportunities, which are funds affiliated with OrbiMed Advisors LLC (“OrbiMed”). Under the Investor Rights Agreement, Royalty Opportunities and ROS are permitted to nominate a majority of the directors and designate the chairperson of our Board of Directors at subsequent annual meetings, as long as they maintain an ownership threshold in our Company of at least 40% of our then outstanding common stock (the “Ownership Threshold”). If Royalty Opportunities and ROS are unable to maintain the Ownership Threshold, the Investor Rights Agreement contemplates a reduction of nomination rights commensurate with our ownership interests. In addition, for so long as the Ownership Threshold is met, we must obtain the approval of a majority of our common stock held by Royalty Opportunities and ROS to proceed with the following actions: (i) issue new securities; (ii) incur over $250,000 of debt in a fiscal year; (iii) sell or transfer over $250,000 of our assets or businesses or our subsidiaries in a fiscal year; (iv) acquire over $250,000 of assets or properties in a fiscal year; (v) make capital expenditures over $125,000 individually, or $1.5 million in the aggregate during a fiscal year; (vi) approve our annual budget; (vii) hire or terminate our chief executive officer; (viii) appoint or remove the chairperson of our Board of Directors; and (ix) make, loans to, investments in, or purchase, or permit any subsidiary to purchase, any stock or other securities in another entity in excess of $250,000 in a fiscal year. As long as the Ownership Threshold is met, we may not increase the size of our Board or Directors beyond seven directors without the approval of a majority of the directors nominated by Royalty Opportunities and ROS. The Investor Rights Agreement grants Royalty Opportunities and ROS the right to purchase from us a pro rata amount of any new securities that we may propose to issue and sell. The Investor Rights Agreement may be terminated (a) upon the mutual written agreement of all the parties, (b) upon our written notice, ROS or Royalty Opportunities if the ownership percentage of our then outstanding common stock of ROS and Royalty Opportunities is less than 10%, or (c) upon written notice of ROS and Royalty Opportunities.
Concentrations and Credit Risk	Concentrations and Credit Risk The Company’s accounts receivables are from a variety of health care organizations and distributors throughout the world. No single customer accounted for more than 10% of our revenue or accounts receivable in the fiscal years 2020 or 2019. Management believes that all significant credit risks have been identified at December 31, 2020.
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; current and long-term lease obligations and corresponding right-of-use asset; and estimates for the fair value of long-term debt, stock option grants and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates.
Cash and Cash Equivalents	Cash and Cash Equivalents The Company considers all highly liquid investments purchased with an original maturity date of three months or less to be cash equivalents. Cash equivalents are recorded at cost, which approximates market value. At times, the Company maintains deposits in financial institutions in excess of federally insured limits.
Trade Accounts Receivable	Trade Accounts Receivable Accounts receivable represents amounts due from customers for which revenue has been recognized. Normal terms on trade accounts receivable are net 30 days, and some customers are offered discounts for early pay. The Company performs credit evaluations when considered necessary, but generally does not require collateral to extend credit. In June 2016, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2016-13, Financial Instruments–Credit Losses: Measurement of Credit Losses on Financial Instruments to change the impairment model for most financial assets and certain other instruments. For trade and other receivables, held to maturity debt securities, loans, and other instruments, entities are required to use a new forward-looking “expected loss” model that generally will result in the earlier recognition of allowances for losses. The Company adopted the guidance on January 1, 2020 and recognized a cumulative effect adjustment of $47,000 to retained earnings and accounts receivable, net as a result of adoption. The Company has included the additional disclosures required by ASU 2016-13 in Note 2, “ Receivables .” The allowance for doubtful accounts is the Company’s best estimate of the amount of probable credit losses in the Company’s existing receivables. The Company determines the allowance based on factors such as historical collection experience, customers’ current creditworthiness, customer concentration, age of accounts receivable balance, general economic conditions that may affect a customer’s ability to pay, and management judgment. In addition, we include provision for current expected credit loss based on historical collection experience adjusted for current economic conditions affecting collectability. Actual customer collections could differ from estimates. Account balances are charged to the allowance after all means of collection have been exhausted and the potential for recovery is considered remote. Provisions to the allowance for doubtful accounts are charged to expense. The Company does not have any off-balance sheet credit exposure related to its customers.
Inventories	Inventories Inventories are stated at the lower of cost or net realizable value. Cost is determined using the specific identification method and includes materials, labor and overhead. The Company calculates an inventory reserve for estimated obsolescence and excess inventory based on historical usage and sales, as well as assumptions about future demand for its products. These estimates for excess and obsolete inventory are reviewed and updated on a quarterly basis. Increases in the inventory reserves result in a corresponding expense, which is recorded to cost of sales.
Property and Equipment	Property and Equipment Property and equipment are stated at cost less accumulated depreciation. Depreciation is computed using the straight-line method over the estimated useful lives of the assets, generally three to seven years for computers and equipment and five years for surgical instruments. Leasehold improvements are depreciated over the shorter of their estimated useful life or the remaining term of the lease. Repairs and maintenance are expensed as incurred.
Intangible Assets	Intangible Assets Intangible assets with estimable useful lives are amortized over their respective estimated useful lives to their estimated residual values and reviewed for impairment whenever events or circumstances indicate their carrying amount may not be recoverable. Intangible assets include trademarks and patents and include costs to acquire and protect Company patents. Intangible assets are carried at cost less accumulated amortization. The Company amortizes these assets on a straight-line basis over their estimated useful lives.
Other Assets	Other Assets Other assets consist of the short-term and the long-term portion of prepaid expenses and security deposits.
Long-Lived Asset Impairment	Long-Lived Asset Impairment Long-lived assets, including property and equipment and 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 undiscounted 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.
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 the asset may not be recoverable. The Company conducts its impairment test on an annual basis and reviews the analysis assumptions on a quarterly basis. We test goodwill for impairment at the reporting unit level, which is an operating segment or one level below an operating segment, referred to as a component. A component of an operating segment is a reporting unit if the component constitutes a business for which discrete financial information is available and segment management regularly reviews the operating results of that component.
Revenue Recognition	Revenue Recognition In the United States, we generate most of our revenue from independent commissioned sales agents. We consign our orthobiologics products to hospitals and consign or loan our spinal implant sets to the independent sales agents. The spinal implant sets typically contain the instruments, disposables, and spinal implants required to complete a surgery. Consigned sets are managed by the sales agent to service hospitals that are high volume users for multiple procedures. We ship replacement inventory to independent sales agents to replace the consigned inventory used in surgeries. Loaned sets are returned to the Company’s distribution center, replenished, and made available to sales agents for the next surgical procedure. For each surgical procedure, the sales agent reports use of the product by the hospital and, as soon as practicable thereafter, ensures that the hospital provides a purchase order to the Company. Upon receipt of the hospital purchase order, the Company invoices the hospital, and revenue is recognized in the proper period. Additionally, the Company sells product directly to domestic and international stocking resellers and private label resellers. Upon receipt and acceptance of a purchase order from a stocking reseller, the Company ships product and invoices the reseller. The Company recognizes revenue when the products are shipped, and the transfer of title and risk of loss occurs. There is generally no customer acceptance or other condition that prevents the Company from recognizing revenue in accordance with the delivery terms for these sales transactions. In the normal course of business, the Company accepts returns of product that have not been implanted. Product returns are not material to the Company’s consolidated statements of operations. The Company accounts for shipping and handling activities as a fulfillment cost rather than a separate performance obligation. The Company’s policy is to record revenue net of any applicable sales, use, or excise taxes. Payment terms are generally net 30 days from invoice date and some customers are offered discounts for early pay. Disaggregation of revenue The Company operates in one reportable segment with its net revenue derived primarily from the sale of orthobiologics and spinal implant products across North America, Asia Pacific and Latin America. Sales are reported net of returns. No rebates, group purchasing organization fees or other customer allowances are present, and so are not relevant to net revenue determination. The following table presents revenues from these product lines for the years ended December 31, 2020 and 2019 (dollars in thousands): Year Ended December 31, 2020 Percentage of Total Revenue Year Ended December 31, 2019 Percentage of Total Revenue Orthobiologics $ 39,308 74 % $ 46,663 72 % Spinal implant 13,880 26 % 17,872 28 % Other revenue 149 0 % 147 0 % Total revenue $ 53,337 100 % $ 64,682 100 %
Research and Development	Research and Development Research and development costs, which are principally related to internal costs for the development of new products, are expensed as incurred.
Net Loss Per Share	Net Loss Per Share Basic net loss per share is computed by dividing net loss by the weighted average number of shares of common stock 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 loss per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive shares of common stock 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 years ended December 31, 2020 and 2019, as shares issuable upon the exercise of stock options and warrants and settlement of restricted stock units were anti-dilutive as a result of the net losses incurred for those periods. Diluted net loss per share is not reported as the effects of including 5,115,868 and 4,011,754 outstanding stock options, warrants and restricted stock units for the years ended December 31, 2020 and 2019, respectively, are anti-dilutive.
Fair Value of Financial Instruments	Fair Value of Financial Instruments The carrying values of financial instruments, including trade accounts receivable, accounts payable, accrued liabilities 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 fair value 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 years ended December 31, 2020 and 2019, there was no reclassification in financial assets or liabilities between Level 1, 2 or 3 categories.
Reclassifications	Reclassification Certain prior year amounts have been reclassified to conform with current year presentation.

Business Description and Summ_3

Business Description and Summary of Significant Accounting Policies (Tables)	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Summary of Revenues from Product Lines	The following table presents revenues from these product lines for the years ended December 31, 2020 and 2019 (dollars in thousands): Year Ended December 31, 2020 Percentage of Total Revenue Year Ended December 31, 2019 Percentage of Total Revenue Orthobiologics $ 39,308 74 % $ 46,663 72 % Spinal implant 13,880 26 % 17,872 28 % Other revenue 149 0 % 147 0 % Total revenue $ 53,337 100 % $ 64,682 100 %

Receivables (Tables)

Receivables (Tables)	12 Months Ended
	Dec. 31, 2020
Credit Loss [Abstract]
Schedule of Allowance for Credit Losses	Provisions to the allowance for credit losses are charged to expense. Activity within the allowance for credit losses was as follows for year ended December 31, 2020 (in thousands): Balance at January 1, 2020 $ 547 Provision for expected credit losses 307 Write-offs charged against allowance (201 ) Balance at December 31, 2020 $ 653

Inventories (Tables)

Inventories (Tables)	12 Months Ended
	Dec. 31, 2020
Inventory Disclosure [Abstract]
Schedule of Inventories	Inventories consist of the following (in thousands): December 31, 2020 December 31, 2019 Raw materials $ 3,757 $ 3,386 Work in process 1,733 1,256 Finished goods 15,918 11,459 $ 21,408 $ 16,101

Property and Equipment, Net (Ta

Property and Equipment, Net (Tables)	12 Months Ended
	Dec. 31, 2020
Property, Plant and Equipment [Abstract]
Schedule of Property and Equipment, Net	Property and equipment, net are as follows (in thousands): December 31, 2020 December 31, 2019 Equipment $ 4,807 $ 4,250 Computer equipment 649 455 Computer software 570 570 Furniture and fixtures 133 124 Leasehold improvements 3,987 3,980 Other 10 10 Surgical instruments 11,291 10,897 Total cost 21,447 20,286 Less: accumulated depreciation (17,100 ) (15,591 ) $ 4,347 $ 4,695

Goodwill and Intangible Assets

Goodwill and Intangible Assets (Tables)	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Goodwill and Intangible Assets	The following table sets forth information regarding intangible assets (in thousands): December 31, 2020 December 31, 2019 Patents $ 847 $ 847 Accumulated amortization (390 ) (332 ) Net carrying value $ 457 $ 515
Summary of Future Amortization Expense for Intangible Assets	The following is a summary of estimated future amortization expense for intangible assets as of December 31, 2020 (in thousands): 2021 $ 56 2022 54 2023 53 2024 52 2025 52 Thereafter 190 Total $ 457

Accrued Liabilities (Tables)

Accrued Liabilities (Tables)	12 Months Ended
	Dec. 31, 2020
Payables and Accruals [Abstract]
Schedule of Accrued Liabilities	Accrued liabilities consist of the following (in thousands): December 31, 2020 December 31, 2019 Wages/commissions payable $ 4,057 $ 3,902 Other accrued liabilities 2,063 2,730 Accrued liabilities $ 6,120 $ 6,632

Debt (Tables)

Debt (Tables)	12 Months Ended
	Dec. 31, 2020
Debt Disclosure [Abstract]
Schedule of Long-term Debt	Long-term debt consists of the following (in thousands): December 31, 2020 December 31, 2019 Amounts due under the Credit Facility $ 15,556 $ 72,657 PIK interest payable related to the Credit Facility — 3,280 Plus: 2% exit fee on Credit Facility — 399 Gross long-term debt 15,556 76,336 Premium related to Second Amendment 1,241 — Less: current maturities (16,797 ) Less: total debt issuance costs — (92 ) Long-term debt, less issuance costs $ — $ 76,244

Stock-Based Compensation (Table

Stock-Based Compensation (Tables)	12 Months Ended
	Dec. 31, 2020
Share-based Payment Arrangement [Abstract]
Schedule of Share-based Compensation, Stock Options, Activity	Stock option activity, including options granted under the 2018 Plan and the Prior Plan was as follows: 2020 2019 Weighted Weighted Weighted Average Weighted Average Average Value at Average Value at Shares Price Date Shares Price Date Outstanding at January 1 602,966 $ 6.07 $ 3.99 496,958 $ 9.90 $ 6.62 Granted 1,708,743 1.24 1.01 554,825 2.55 2.01 Cancelled or expired (120,817 ) 6.95 4.31 (448,817 ) 5.96 4.45 Outstanding at December 31 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Exercisable at December 31 122,739 $ 14.74 $ 8.95 25,063 $ 83.78 $ 46.66
Schedule of Assumptions of Stock Option Granted	The estimated fair value of stock options granted is determined using the Black-Scholes-Merton method applied to individual grants. Key assumptions used to estimate the fair value of stock awards are as follows: Year Ended December 31, 2020 2019 Risk free interest rate 0.54 % 1.82 % Dividend yield 0 % 0 % Expected term 6.2 years 7.1 years Expected volatility 105 % 92 %
Schedule of Restricted Stock Activity	Restricted stock unit activity for awards granted under the 2018 Plan was as follows: 2020 2019 Shares Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 499,914 $ 2.87 40,000 $ 6.20 Granted 2,148,662 $ 1.29 459,914 $ 2.65 Vested (144,878 ) $ 2.52 - $ - Outstanding at December 31 2,503,698 $ 1.54 499,914 $ 2.87

Warrants (Tables)

Warrants (Tables)	12 Months Ended
	Dec. 31, 2020
Warrants and Rights Note Disclosure [Abstract]
Schedule of Warrant Activity	The following table summarizes our warrant activities for the years ended December 31, 2020 and 2019: Weighted Common Average Stock Exercise Warrants Price Outstanding as of January 1, 2019 1,710,609 $ 7.33 Issued 1,200,000 0.01 Expired (1,735 ) 259.60 Outstanding as of December 31, 2019 2,908,874 $ 4.16 Issued 2,400,000 0.01 Exercised (4,800,000 ) 0.01 Expired (87,596 ) 85.92 Outstanding at December 31, 2020 421,278 $ 10.80
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 years ended December 31, 2020 and 2019: 2020 2019 Balance at January 1 87,509 87,509 Derivative warrants expired (87,509 ) — Balance at December 31 — 87,509

Commitments and Contingencies (

Commitments and Contingencies (Tables)	12 Months Ended
	Dec. 31, 2020
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 December 31, 2020 under these long-term operating leases are as follows (in thousands): 2021 $ 507 2022 521 2023 489 2024 224 Thereafter 180 Total future minimum lease payments 1,921 Less amount representing interest (195 ) Present value of obligations under operating leases 1,726 Less current portion (423 ) Long-term operating lease obligations $ 1,303

Income Taxes (Tables)

Income Taxes (Tables)	12 Months Ended
	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Schedule of Components of Income Loss Before Provision for Income Taxes	The components of income (loss) before provision for income taxes consist of the following (in thousands): Year Ended December 31, 2020 2019 United States $ (6,727 ) $ (8,123 ) Total $ (6,727 ) $ (8,123 )
Schedule of Components of Income Tax Provision	The components of the income tax provision are as follows (in thousands): Year Ended December 31, 2019 2019 Current: Federal $ 51 $ — State 245 98 Total current 296 98 Deferred: Federal — — State — — Total deferred — — Total Provision for Income Taxes $ 296 $ 98
Schedule of Effective Income Tax Rate Reconciliation	The reconciliation of income tax attributable to operations computed at the U.S. Federal statutory income tax rate of 21% to income tax expense is as follows (in thousands): Year Ended December 31, 2020 2019 Statutory Federal tax rate $ (1,413 ) $ (1,706 ) Valuation allowance (10,968 ) 73 State income taxes, net of Federal benefit 619 34 Attribute reduction related to Sec. 382 8,607 — Change in state income tax rate (61 ) (136 ) Gain on extinguishment of debt 3,488 1,534 Stock compensation adjustment and other reconciling items 14 282 Nondeductible meals and entertainment expense 10 17 Total Provision for Income Taxes $ 296 $ 98
Schedule of Deferred Tax Assets and Liabilities	Deferred tax components are as follows (in thousands): At December 31, 2020 2019 Deferred tax assets: Accrued liability for vacation $ 123 $ 111 Accrued commissions and bonuses / compensation 565 298 Accrued contingencies 42 132 Amortization 32 36 Depreciation — 157 Bad debt reserve 174 133 Charitable contributions carryforward — 8 Lease liability 459 564 Interest expense 2,342 3,407 Inventory reserve 2,975 3,058 Net operating loss carryovers 12,114 22,009 Stock option compensation 653 476 Other 109 102 Total deferred tax assets 19,588 30,491 Deferred tax liabilities: Right of use asset (450 ) (558 ) Prepaids (73 ) Depreciation (100 ) — Total deferred tax liabilities (623 ) (558 ) Valuation allowance (18,965 ) (29,933 ) Net deferred tax assets $ — $ —

Supplemental Disclosure of Ca_2

Supplemental Disclosure of Cash Flow Information (Tables)	12 Months Ended
	Dec. 31, 2020
Supplemental Cash Flow Elements [Abstract]
Schedule of Supplemental Cash Flow Information	Supplemental cash flow information is as follows (in thousands): Year Ended December 31, 2020 2019 Cash paid during the period for: Interest $ 13 $ 51 Non-cash activities: ASU 2016-13 cumulative effect adjustment $ 47 $ — Recognition of 2020 Warrants $ 1,862 $ — Partial extinguishment of Second Amended and Restated Credit Agreement (including debt issuance costs) $ 63,233 $ — Lease liability from right-of-use assets $ — $ 2,296 Extinguishment of the Company’s Prior Credit Agreement (including debt issuance costs) $ — $ 79,624 Recognition of Second Amended and Restated Credit Agreement $ — $ 72,657 Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees $ — $ 307 Recognition of 2019 Warrants $ — $ 9

Segment and Geographic Inform_2

Segment and Geographic Information (Tables)	12 Months Ended
	Dec. 31, 2020
Segment Reporting [Abstract]
Schedule of Revenues by Geographic Region	Total revenue by major geographic area is as follows (in thousands): Year Ended 2020 2019 United States $ 52,147 $ 62,377 Rest of World 1,190 2,305 Total $ 53,337 $ 64,682

Business Description and Summ_4

Business Description and Summary of Significant Accounting Policies (Details Narrative) $ / shares in Units, $ in Thousands

Dec. 04, 2020USD ($)shares

Nov. 06, 2020shares

Oct. 02, 2020USD ($)days$ / sharesshares

Oct. 01, 2020shares

Jan. 02, 2020USD ($)

Dec. 31, 2020USD ($)shares

Dec. 31, 2019USD ($)shares

Sep. 30, 2020shares

Aug. 07, 2020shares

Aug. 06, 2020shares

Oct. 30, 2019shares

Oct. 29, 2019shares

Cash and cash equivalents

$ 2,341

$ 5,237

Accumulated deficit

$ (230,336)

$ (223,266)

Common stock, shares authorized | shares

300,000,000

300,000,000

75,000,000

75,000,000

300,000,000

75,000,000

75,000,000

50,000,000

Number of shares issued during period | shares

712,646

Proceeds from issuance of common stock

$ 620

Outstanding debt

$ 76,244

Cumulative effect adjustment

$ (47)

Antidilutive securities excluded from computation of earnings per share, amount | shares

5,115,868

4,011,754

Maximum [Member]

Number of shares issued during period | shares

14,018,690

Computers and Equipment [Member] | Minimum [Member]

Property and equipment, estimated useful lives

3 years

Computers and Equipment [Member] | Maximum [Member]

Property and equipment, estimated useful lives

7 years

Surgical Instruments [Member]

Property and equipment, estimated useful lives

5 years

Accounting Standards Update 2016-13 [Member]

Cumulative effect adjustment

$ 47

Revenue [Member]

Concentration risk, percentage

10.00%

10.00%

Accounts Receivable [Member]

Concentration risk, percentage

10.00%

10.00%

Royalty Opportunities and ROS [Member]

Beneficially owned percentage

93.90%

Other Existing Stockholders [Member]

Beneficially owned percentage

6.10%

Credit Agreement [Member] | Lender [Member]

Debt capital

$ 5,000

Restructuring Agreement [Member] | Rights Offering [Member]

Shares issued in exchange of principal and paid-in-kind interest outstanding

$ 15,000

Exchange price per share | $ / shares

$ 1.07

Number of shares issued during period | shares

712,646

Proceeds from issuance of common stock

$ 800

Restructuring Agreement [Member] | Royalty Opportunities and ROS [Member]

Exchange price per share | $ / shares

$ 1.07

Trading days | days

10

Shares issued in exchange of loans outstanding | shares

57,800,000

58,700,000

Outstanding debt

$ 15,600

Restructuring Agreement [Member] | Royalty Opportunities and ROS [Member] | Loans Payable [Member]

Shares issued in exchange of principal and paid-in-kind interest outstanding

$ 40,800

Restructuring Agreement [Member] | Royalty Opportunities and ROS [Member] | PIK Interest [Member]

Shares issued in exchange of principal and paid-in-kind interest outstanding

$ 21,100

Second A & R Credit Agreement [Member] | Royalty Opportunities and ROS [Member]

Shares issued in exchange of loans outstanding | shares

900,000

Investor Rights Agreement [Member]

Invester rights agreement, description

In addition, for so long as the Ownership Threshold is met, we must obtain the approval of a majority of our common stock held by Royalty Opportunities and ROS to proceed with the following actions: (i) issue new securities; (ii) incur over $250,000 of debt in a fiscal year; (iii) sell or transfer over $250,000 of our assets or businesses or our subsidiaries in a fiscal year; (iv) acquire over $250,000 of assets or properties in a fiscal year; (v) make capital expenditures over $125,000 individually, or $1.5 million in the aggregate during a fiscal year; (vi) approve our annual budget; (vii) hire or terminate our chief executive officer; (viii) appoint or remove the chairperson of our Board of Directors; and (ix) make, loans to, investments in, or purchase, or permit any subsidiary to purchase, any stock or other securities in another entity in excess of $250,000 in a fiscal year. As long as the Ownership Threshold is met, we may not increase the size of our Board or Directors beyond seven directors without the approval of a majority of the directors nominated by Royalty Opportunities and ROS. The Investor Rights Agreement may be terminated (a) upon the mutual written agreement of all the parties, (b) upon our written notice, ROS or Royalty Opportunities if the ownership percentage of our then outstanding common stock of ROS and Royalty Opportunities is less than 10%, or (c) upon written notice of ROS and Royalty Opportunities.

Business Description and Summ_5

Business Description and Summary of Significant Accounting Policies - Summary of Revenues from Product Lines (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Total revenue	$ 53,337	$ 64,682
Percentage of total revenue	100.00%	100.00%
Orthobiologics [Member]
Total revenue	$ 39,308	$ 46,663
Percentage of total revenue	74.00%	72.00%
Spinal Implant [Member]
Total revenue	$ 13,880	$ 17,872
Percentage of total revenue	26.00%	28.00%
Other Revenue [Member]
Total revenue	$ 149	$ 147
Percentage of total revenue	0.00%	0.00%

Receivables -Schedule of allowa

Receivables -Schedule of allowance for credit losses (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Credit Loss [Abstract]
Beginning balance	$ 547
Provision for expected credit losses	307	$ 513
Write-offs charged against allowance	(201)
Ending balance	$ 653	$ 547

Inventories - Schedule of Inven

Inventories - Schedule of Inventories (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Inventory Disclosure [Abstract]
Raw materials	$ 3,757	$ 3,386
Work in process	1,733	1,256
Finished goods	15,918	11,459
Total	$ 21,408	$ 16,101

Property and Equipment, Net (De

Property and Equipment, Net (Details Narrative) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Property, Plant and Equipment [Abstract]
Depreciation expense	$ 2,000	$ 3,100
Gross assets	500	1,400
Accumulated depreciation	$ 400	$ 1,000

Property and Equipment, Net - S

Property and Equipment, Net - Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Property, Plant and Equipment [Line Items]
Total cost	$ 21,447	$ 20,286
Less: accumulated depreciation	(17,100)	(15,591)
Property and equipment, net	4,347	4,695
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	4,807	4,250
Computer Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	649	455
Computer Software [Member]
Property, Plant and Equipment [Line Items]
Total cost	570	570
Furniture and Fixtures [Member]
Property, Plant and Equipment [Line Items]
Total cost	133	124
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	3,987	3,980
Other [Member]
Property, Plant and Equipment [Line Items]
Total cost	10
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 11,291	10,897
Vehicles [Member]
Property, Plant and Equipment [Line Items]
Total cost		$ 10

Goodwill and Intangible Asset_2

Goodwill and Intangible Assets (Details Narrative) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract]
Amortization expense	$ 100	$ 100

Goodwill and Intangible Asset_3

Goodwill and Intangible Assets - Schedule of Intangible Assets (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract]
Patents	$ 847	$ 847
Accumulated amortization	(390)	(332)
Intangible assets, net	$ 457	$ 515

Goodwill and Intangible Asset_4

Goodwill and Intangible Assets - Schedule of Estimated Amortization Expense for Intangible Assets (Details) $ in Thousands	Dec. 31, 2020USD ($)
Goodwill and Intangible Assets Disclosure [Abstract]
2021	$ 56
2022	54
2023	53
2024	52
2025	52
Thereafter	190
Total	$ 457

Accrued Liabilities - Schedule

Accrued Liabilities - Schedule of Accrued Liabilities (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Payables and Accruals [Abstract]
Wages/commissions payable	$ 4,057	$ 3,902
Other accrued liabilities	2,063	2,730
Accrued liabilities	$ 6,120	$ 6,632

Debt (Details Narrative)

Debt (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	Oct. 01, 2020	May 06, 2020	Mar. 29, 2019	Mar. 31, 2019	Dec. 31, 2020	Nov. 17, 2020	Dec. 31, 2019	Apr. 02, 2019
Debt instrument maturity date					Dec. 31, 2021
Long-term debt							$ 76,244
ROS and Royalty Opportunities [Member]
Issuance of warrants to purchase a common stock						4,800,000
2019 Warrants [Member] | ROS and Royalty Opportunities [Member]
Issuance of warrants to purchase a common stock								1,200,000
Exercise price of warrants								$ 0.01
Warrants expiration date								Apr. 1, 2029
2020 Warrants [Member] | ROS and Royalty Opportunities [Member]
Issuance of warrants to purchase a common stock		2,400,000
Exercise price of warrants		$ 0.01
Warrants expiration date		May 6, 2030
New effective interest rate		10.02%
Second A&R Credit Agreement [Member]
Debt instrument face amount	$ 80,300		$ 2,200
Debt instrument maturity date			Mar. 31, 2021
Debt instrument description			No interest would accrue on the loans outstanding under the Second A&R Credit Agreement (the “Loans”) from and after January 1, 2019 until March 31, 2020; beginning April 1, 2020 through the maturity date of the Second A&R Credit Agreement, interest payable in cash would accrue on the Loans under the Credit Agreement at a rate per annum equal to the sum of (a) 10.00% plus (b) the higher of (x) the LIBO Rate (as such term is defined in the Second A&R Credit Agreement) and (y) 2.3125%;
Long-term debt				$ 72,700
Increase in additional paid-in capital				$ 7,300
Gain on restructuring of debt	15,100
Fair value of debt instrument	57,800
Second A&R Credit Agreement [Member] | Forecast [Member]
Cash balance			$ 1,500
Second A&R Credit Agreement [Member] | Investors [Member]
Debt instrument face amount			$ 10,000
First Amendment [Member] | ROS and Royalty Opportunities [Member]
Debt instrument maturity date		Dec. 31, 2021
Debt instrument description		No interest would accrue on the Loans from and after March 31, 2020 until September 30, 2020; Beginning October 1, 2020 through the maturity date of the Second A&R Credit Agreement, interest payable in cash would accrue on the Loans under the Second A&R Credit Agreement at a rate per annum equal to the sum of (i) 10.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second A&R Credit Agreement) and (y) 2.3125%;
Second Amendment [Member] | ROS and Royalty Opportunities [Member]
Shares issued in exchange of principal and paid-in-kind interest outstanding	$ 61,900
Shares issued in exchange of loans outstanding	57,800,000
Prepayment fees	$ 900
Available additional term loans	$ 5,000
Interest rate	7.00%
Debt instrument, basis spread on variable rate	1.00%
Undiscounted future cash payments	$ 17,100
Second Amendment [Member] | ROS and Royalty Opportunities [Member] | Prepayment Fee Shares [Member]
Shares issued in exchange of loans outstanding	900,000

Debt - Schedule of Long-term De

Debt - Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Debt Disclosure [Abstract]
Amounts due under the Credit Facility	$ 15,556	$ 72,657
PIK interest payable related to the Credit Facility		3,280
Plus: 2% exit fee on Credit Facility		399
Gross long-term debt	15,556	76,336
Premium related to Second Amendment	1,241
Less: current maturities	(16,797)
Less: total debt issuance costs		(92)
Long-term debt, less issuance costs		$ 76,244

Equity (Details Narrative)

Equity (Details Narrative) - USD ($)	Nov. 17, 2020	Nov. 06, 2020	Oct. 02, 2020	Oct. 01, 2020	Dec. 31, 2020	Sep. 30, 2020	Aug. 07, 2020	Aug. 06, 2020	Dec. 31, 2019	Oct. 30, 2019	Oct. 29, 2019
Schedule of Equity Method Investments [Line Items]
Common stock, shares authorized			300,000,000		300,000,000	75,000,000	300,000,000	75,000,000	75,000,000	75,000,000	50,000,000
Stock issued during period, shares, new issues		712,646
Shares issued, price per share		$ 0.194539
Share price		$ 1.07
Stock issued during period, value, new issues		$ 800,000			$ 620,000
Right offering expired date		Nov. 6, 2020
Maximum [Member]
Schedule of Equity Method Investments [Line Items]
Stock issued during period, shares, new issues		14,018,690
ROS and Royalty Opportunities [Member]
Schedule of Equity Method Investments [Line Items]
Number of securities called by warrants	4,800,000
Proceeds from warrant exercise	$ 48,000
Restructuring Agreement [Member] | Royalty Opportunities and ROS [Member]
Schedule of Equity Method Investments [Line Items]
Shares issued in exchange of loans outstanding			57,800,000	58,700,000

Stock-Based Compensation (Detai

Stock-Based Compensation (Details Narrative) - USD ($) $ in Thousands	Aug. 01, 2018	Dec. 31, 2020	Dec. 31, 2019	Oct. 27, 2018
Intrinsic value of options outstanding			$ 16
Unvested employee stock options not yet recognized		$ 3,200	$ 2,300
Stock option vested weighted average period		3 years 4 months 24 days	3 years 8 months 12 days
Employees and Directors [Member]
Allocated share-based compensation expense		$ 1,100	$ 500
2018 Equity Incentive Plan [Member]
Number of shares available for issuance		8,358,055
Term of plan, description	The 2018 Plan became effective immediately upon initial approval of the plan by our stockholders on August 1, 2018 and will expire on July 31, 2028, unless terminated earlier.
Number of common stock shares remaining available		3,507,165
2018 Equity Incentive Plan [Member] | Maximum [Member]
Number of shares available for issuance	1,500,000			5,550,308

Stock-Based Compensation - Sche

Stock-Based Compensation - Schedule of Share-based Compensation, Stock Options, Activity (Details) - Equity Option [Member] - $ / shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Shares Outstanding, Beginning Balance	602,966	496,958
Shares Granted	1,708,743	554,825
Shares Cancelled or expired	(120,817)	(448,817)
Shares Outstanding, Ending Balance	2,190,892	602,966
Shares Exercisable, Ending Balance	122,739	25,063
Weighted Average Exercise Price, Outstanding Beginning Balance	$ 6.07	$ 9.90
Weighted Average Exercise Price, Granted	1.24	2.55
Weighted Average Exercise Price, Cancelled or expired	6.95	5.96
Weighted Average Exercise Price, Outstanding Ending Balance	2.25	6.07
Weighted Average Exercise Price, Exercisable Ending Balance	14.74	83.78
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	3.99	6.62
Weighted Average Fair Value at Grant Date, Granted	1.01	2.01
Weighted Average Fair Value at Grant Date, Cancelled or expired	4.31	4.45
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	1.65	3.99
Weighted Average Fair Value at Grant Date, Exercisable, Ending Balance	$ 8.95	$ 46.66

Stock-Based Compensation - Sc_2

Stock-Based Compensation - Schedule of Assumptions of Stock Option Granted (Details)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Share-based Payment Arrangement [Abstract]
Risk free interest rate	0.54%	1.82%
Dividend yield	0.00%	0.00%
Expected term	6 years 2 months 12 days	7 years 1 month 6 days
Expected volatility	105.00%	92.00%

Stock-Based Compensation - Sc_3

Stock-Based Compensation - Schedule of Restricted Stock Activity (Details) - Restricted Stock Units (RSUs) [Member] - $ / shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Shares Outstanding, Beginning Balance	499,914	40,000
Shares Granted	2,148,662	459,914
Shares Vested	(144,878)
Shares Outstanding, Ending Balance	2,503,698	499,914
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 2.87	$ 6.20
Weighted Average Fair Value at Grant Date, Granted	1.29	2.65
Weighted Average Fair Value at Grant Date, Vested	2.52
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 1.54	$ 2.87

Warrants (Details Narrative)

Warrants (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	May 06, 2020	Apr. 02, 2019
2020 Warrant [Member]
Class of Warrant or Right [Line Items]
Issuance of warrants to purchase a common stock	2,400,000
Exercise price of warrants	$ 0.01
Fair value of warrants	$ 1,900	$ 9
Warrants expiration date	May 6, 2030
2019 Warrant [Member]
Class of Warrant or Right [Line Items]
Issuance of warrants to purchase a common stock		1,200,000
Exercise price of warrants		$ 0.01
Warrants expiration date		Apr. 1, 2029

Warrants - Schedule of Warrant

Warrants - Schedule of Warrant Activity (Details) - $ / shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Warrants and Rights Note Disclosure [Abstract]
Common Stock Warrants Outstanding, Beginning Balance	2,908,874	1,710,609
Common Stock Warrants, Issued	2,400,000	1,200,000
Common Stock Warrants, Exercised	(4,800,000)
Common Stock Warrants, Expired	(87,596)	(1,735)
Common Stock Warrants Outstanding, Ending Balance	421,278	2,908,874
Weighted Average Exercise Price Outstanding Beginning Balance	$ 4.16	$ 7.33
Weighted Average Exercise Price, Issued	0.01	0.01
Weighted Average Exercise Price, Exercised	0.01
Weighted Average Exercise Price, Expired	85.92	259.60
Weighted Average Exercise Price Outstanding Ending Balance	$ 10.80	$ 4.16

Warrants - Schedule of Warrants

Warrants - Schedule of Warrants Activities Used in Derivative Liability (Details) - Warrant [Member] - shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Class of Warrant or Right [Line Items]
Common Stock Warrants Outstanding, Beginning Balance	87,509	87,509
Derivative warrants expired	(87,509)
Common Stock Warrants Outstanding, Ending Balance		87,509

Commitments and Contingencies_2

Commitments and Contingencies (Details Narrative) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Commitments and Contingencies Disclosure [Abstract]
Operating lease expiration description	Expiration dates between 2023 and 2025
Operating lease weighted-average remaining lease term	4 years
Lease expense related to operating leases	$ 600	$ 600
Operating lease weighted-average discount rate	5.20%
Lease interest cost	$ 13	100
Amortization expense	$ 100	$ 200

Commitments and Contingencies -

Commitments and Contingencies - Schedule of Future Minimum Rental Payments for Operating Leases (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Commitments and Contingencies Disclosure [Abstract]
2021	$ 507
2022	521
2023	489
2024	224
Thereafter	180
Total future minimum lease payments	1,921
Less amount representing interest	(195)
Present value of obligations under operating leases	1,726
Less current portion	(423)	$ (394)
Long-term operating lease obligations	$ 1,303	$ 1,726

Income Taxes (Details Narrative

Income Taxes (Details Narrative) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Income Tax Disclosure [Abstract]
Federal statutory income tax rate	21.00%
(Decrease) increase in valuation allowance	$ (11,000)	$ 1,000
Operating loss carryforwards	$ 97,000	149,800
Operating loss carryforwards expiration period	Between 2024 and 2040
Indefinite carryforward available to offset taxable income percentage	80.00%
Interest or penalties related to income taxes

Income Taxes - Schedule of Comp

Income Taxes - Schedule of Components of Income Loss Before Provision for Income Taxes (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Income (loss) before provision for income taxes	$ (6,727)	$ (8,123)
United States [Member]
Income (loss) before provision for income taxes	$ (6,727)	$ (8,123)

Income Taxes - Schedule of Co_2

Income Taxes - Schedule of Components of Income Tax Provision (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Income Tax Disclosure [Abstract]
Current: Federal	$ 51
Current: State	245	98
Total current	296	98
Deferred: Federal
Deferred: State
Total deferred
Total Provision for Income Taxes	$ (296)	$ (98)

Income Taxes - Schedule of Effe

Income Taxes - Schedule of Effective Income Tax Rate Reconciliation (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Income Tax Disclosure [Abstract]
Statutory Federal tax rate	$ (1,413)	$ (1,706)
Valuation allowance	(10,968)	73
State income taxes, net of Federal benefit	619	34
Attribute reduction related to Sec. 382	8,607
Change in state income tax rate	(61)	(136)
Gain on extinguishment of debt	3,488	1,534
Stock compensation adjustment and other reconciling items	14	282
Nondeductible meals and entertainment expense	10	17
Total Provision for Income Taxes	$ (296)	$ (98)

Income Taxes - Schedule of Defe

Income Taxes - Schedule of Deferred Tax Assets and Liabilities (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Income Tax Disclosure [Abstract]
Accrued liability for vacation	$ 123	$ 111
Accrued commissions and bonuses / compensation	565	298
Accrued contingencies	42	132
Amortization	32	36
Depreciation		157
Bad debt reserve	174	133
Charitable contributions carryforward		8
Lease liability	459	564
Interest expense	2,342	3,407
Inventory reserve	2,975	3,058
Net operating loss carryovers	12,114	22,009
Stock option compensation	653	476
Other	109	102
Total deferred tax assets	19,588	30,491
Right of use asset	(450)	(558)
Prepaids	(73)
Depreciation	(100)
Total deferred tax liabilities	(623)	(558)
Valuation allowance	$ (18,965)	(29,933)
Net deferred tax assets

Employee Benefit Plans (Details

Employee Benefit Plans (Details Narrative) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Retirement Benefits [Abstract]
Discretionary match	100.00%
Contribution limit, description	Wage deferrals not in excess of 4% of their wages.
Employer contributed amount	$ 2,000	$ 2,000

Supplemental Disclosure of Ca_3

Supplemental Disclosure of Cash Flow Information - Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Supplemental Cash Flow Elements [Abstract]
Interest	$ 13	$ 51
ASU 2016-13 cumulative effect adjustment	47
Recognition of 2020 Warrants	1,862
Partial extinguishment of Second Amended and Restated Credit Agreement (including debt issuance costs)	63,233
Lease liability from right-of-use assets		2,296
Extinguishment of the Company's Prior Credit Agreement (including debt issuance costs)		79,624
Recognition of Second Amended and Restated Credit Agreement		72,657
Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees		307
Recognition of 2019 Warrants		$ 9

Related Party Transactions (Det

Related Party Transactions (Details Narrative) - USD ($)	Jan. 22, 2020	Apr. 05, 2019	Dec. 31, 2020
Related Party Transaction [Line Items]
Operating lease description			Expiration dates between 2023 and 2025
Sole Holders [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage			22.00%
Sublease Agreement [Member] | Cardialen, Inc., [Member]
Related Party Transaction [Line Items]
Operating lease description		Portion of Cardialen's office space commencing April 2019 on a month-to-month basis until January 2024, unless terminated earlier upon notice of 60 days
Rent expense	$ 1,000

Segment and Geographic Inform_3

Segment and Geographic Information (Details Narrative) - Revenue [Member]	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Concentration risk, percentage	10.00%	10.00%
United States [Member] | Geographic Concentration Risk [Member]
Concentration risk, percentage	98.00%	96.00%

Segment and Geographic Inform_4

Segment and Geographic Information - Schedule of Revenues by Geographic Region (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Total revenue	$ 53,337	$ 64,682
United States [Member]
Total revenue	52,147	62,377
Rest of World [Member]
Total revenue	$ 1,190	$ 2,305

Subsequent Event (Details Narra

Subsequent Event (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	Feb. 24, 2021	Feb. 22, 2021	Nov. 06, 2020
Stock issued during period, shares, new issues			712,646
Stock issued price per share			$ 0.194539
Maximum [Member]
Stock issued during period, shares, new issues			14,018,690
Subsequent Event [Member] | Private Placement [Member]
Proceeds from private placement	$ 20,000
Subsequent Event [Member] | Investor Warrants [Member]
Warrant exercise price		$ 2.25
Warrant term		5 years
Subsequent Event [Member] | Securities Purchase Agreement [Member]
Agreement description		We would provide the Investor the right, but not the obligation, to participate in such offering in an amount of up to 25% of the securities offered in such offering. This participation right will expire upon the earlier of 12 months after the closing of the Private Placement or upon the occurrence of certain change in control events.
Subsequent Event [Member] | Securities Purchase Agreement [Member] | Investor Warrants [Member] | Maximum [Member]
Purchase of warrants		6,666,668
Subsequent Event [Member] | Securities Purchase Agreement [Member] | Investor [Member]
Stock issued during period, shares, new issues		8,888,890
Stock issued price per share		$ 2.25
Subsequent Event [Member] | Placement Agent Agreement [Member] | Investor [Member] | Private Placement [Member]
Stock issued during period, shares, new issues		444,444
Warrant exercise price		$ 2.8125
Warrant term		5 years
Subsequent Event [Member] | Placement Agent Agreement [Member] | Investor [Member] | Maximum [Member] | Private Placement [Member]
Warrants exercise price percentage		5.00%