Xtant Medical (XTNT) 10-Q 11 May 21 2021 Q1 Quarterly report Financial data

Document and Entity Information

Document and Entity Information - shares	3 Months Ended
	Mar. 31, 2021	May 04, 2021
Cover [Abstract]
Entity Registrant Name	Xtant Medical Holdings, Inc.
Entity Central Index Key	0001453593
Document Type	10-Q
Document Period End Date	Mar. 31, 2021
Amendment Flag	false
Current Fiscal Year End Date	--12-31
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 Common Stock, Shares Outstanding		86,707,286
Document Fiscal Period Focus	Q1
Document Fiscal Year Focus	2021

Condensed Consolidated Balance

Condensed Consolidated Balance Sheets - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Current Assets:
Cash and cash equivalents	$ 18,643	$ 2,341
Trade accounts receivable, net of allowance for credit losses and doubtful accounts of $554 and $653, respectively	7,027	6,880
Inventories	21,641	21,408
Prepaid and other current assets	1,165	736
Total current assets	48,476	31,365
Property and equipment, net	4,666	4,347
Right-of-use asset, net	1,585	1,690
Goodwill	3,205	3,205
Intangible assets, net	443	457
Other assets	322	402
Total Assets	58,697	41,466
Current Liabilities:
Accounts payable	2,490	2,947
Accrued liabilities	4,569	5,462
Current portion of lease liability	431	423
Current portion of finance lease obligations	30	20
Current portion of long-term debt	16,490	16,797
Total current liabilities	24,010	25,649
Long-term Liabilities:
Lease liability, less current portion	1,192	1,303
Finance lease obligation, less current portion	129
Total Liabilities	25,331	26,952
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; 86,707,286 shares issued and outstanding as of March 31, 2021 and 77,573,680 shares issued and outstanding as of December 31, 2020
Additional paid-in capital	263,731	244,850
Accumulated deficit	(230,365)	(230,336)
Total Stockholders' Equity	33,366	14,514
Total Liabilities & Stockholders' Equity	$ 58,697	$ 41,466

Condensed Consolidated Balanc_2

Condensed Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Statement of Financial Position [Abstract]
Trade accounts receivable, allowance for credit losses	$ 554	$ 653
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	300,000,000
Common stock, shares issued	86,707,286	77,573,680
Common Stock, shares outstanding	86,707,286	77,573,680

Condensed Consolidated Statemen

Condensed Consolidated Statements of Operations (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Revenue
Orthopedic product sales	$ 12,509	$ 14,735
Other revenue	33	43
Total Revenue	12,542	14,778
Cost of sales	4,451	5,165
Gross Profit	8,091	9,613
Operating Expenses
General and administrative	3,027	4,318
Sales and marketing	4,855	6,413
Research and development	214	245
Total Operating Expenses	8,096	10,976
Loss from Operations	(5)	(1,363)
Other Expense
Interest expense	1	1,108
Total Other Expense	1	1,108
Net Loss Before Provision for Income Taxes	(6)	(2,471)
Provision for income taxes	(23)	(22)
Net Loss	$ (29)	$ (2,493)
Net loss per share:
Basic	$ 0	$ (0.19)
Dilutive	$ 0	$ (0.19)
Shares used in the computation:
Basic	81,248,875	13,175,345
Dilutive	81,248,875	13,175,345

Condensed Consolidated Statem_2

Condensed Consolidated Statements of Equity (Unaudited) - USD ($) $ in Thousands	Common Stock [Member]	Additional Paid-In Capital [Member]	Retained Deficit [Member]	Total
Beginning Balance at Dec. 31, 2019		$ 179,061	$ (223,266)	$ (44,205)
Beginning Balance, Shares at Dec. 31, 2019	13,161,762
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	61,803
Stock-based compensation		269		269
Net loss			(2,493)	(2,493)
Ending Balance at Mar. 31, 2020		179,330	(225,806)	(46,476)
Ending Balance, Shares at Mar. 31, 2020	13,223,565
Beginning Balance at Dec. 31, 2020		244,850	(230,336)	14,514
Beginning Balance, Shares at Dec. 31, 2020	77,573,680
ASU 2016-13 cumulative effect adjustment				(47)
Private placement of common stock, net of issuance costs of $1,926		12,831		12,831
Private placement of common stock, net of issuance costs of $1,926, shares	8,888,890
Warrants issued in connection with the private placement		5,243		5,243
Warrants issued in connection with the private placement to placement agents		351		351
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares	244,716
Stock-based compensation		456		456
Net loss			(29)	(29)
Ending Balance at Mar. 31, 2021		$ 263,731	$ (230,365)	$ 33,366
Ending Balance, Shares at Mar. 31, 2021	86,707,286

Condensed Consolidated Statem_3

Condensed Consolidated Statements of Equity (Unaudited) (Parenthetical) $ in Thousands	3 Months Ended
	Mar. 31, 2021USD ($)
Statement of Stockholders' Equity [Abstract]
Share issuance costs	$ 1,926

Condensed Consolidated Statem_4

Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Operating activities:
Net loss	$ (29)	$ (2,493)
Adjustments to reconcile net loss to net cash used in operating activities:
Depreciation and amortization	375	685
Gain on disposal of fixed assets	(32)	(105)
Non-cash interest		1,101
Non-cash rent	3	4
Stock-based compensation	456	269
Provision for reserve on accounts receivable	(63)	138
Provision for excess and obsolete inventory	150	31
Changes in operating assets and liabilities:
Accounts receivable	(83)	195
Inventories	(383)	(1,974)
Prepaid and other assets	(349)	(340)
Accounts payable	(459)	1,610
Accrued liabilities	(893)	(910)
Net cash used in operating activities	(1,307)	(1,789)
Investing activities:
Purchases of property and equipment and intangible assets	(542)	(258)
Proceeds from sale of fixed assets	59	83
Net cash used in investing activities	(483)	(175)
Financing activities:
Payments on financing leases	(25)	(34)
Payments on long-term debt	(308)
Proceeds from private placement, net of cash issuance costs	18,425
Net cash provided by (used in) financing activities	18,092	(34)
Net change in cash and cash equivalents	16,302	(1,998)
Cash and cash equivalents at beginning of period	2,341	5,237
Cash and cash equivalents at end of period	$ 18,643	$ 3,239

Business Description, Basis of

Business Description, Basis of Presentation and Summary of Significant Accounting Policies	3 Months Ended
	Mar. 31, 2021
Accounting Policies [Abstract]
Business Description, Basis of Presentation and Summary of Significant Accounting Policies	(1) Business Description, Basis of Presentation and Summary of Significant Accounting Policies Business Description and Basis of Presentation The accompanying condensed consolidated financial statements include the accounts of Xtant Medical Holdings, Inc. (“Xtant”), a Delaware corporation, and its wholly owned subsidiaries, Xtant Medical, Inc. (“Xtant Medical”), a Delaware corporation, Bacterin International, Inc. (“Bacterin”), a Nevada corporation, and X-spine Systems, Inc. (“X-spine”), an Ohio corporation (Xtant, Xtant Medical, Bacterin, and X-spine are jointly referred to herein as the “Company” or sometimes “we”, “our,” or “us”). All intercompany balances and transactions have been eliminated in consolidation. Xtant is a global medical technology company focused on the design, development, and commercialization of a comprehensive portfolio of orthobiologics and spinal implant systems to facilitate spinal fusion in complex spine, deformity, and degenerative procedures. 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. The accompanying condensed consolidated balance sheet as of December 31, 2020, which has been derived from audited financial statements, and the unaudited interim condensed consolidated financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America. They do not include all disclosures required by generally accepted accounting principles for annual consolidated financial statements, but in the opinion of management include all adjustments, consisting only of normal recurring items, necessary for a fair presentation. Interim results are not necessarily indicative of results that may be achieved in the future for the full year ending December 31, 2021. These condensed consolidated financial statements should be read in conjunction with the consolidated financial statements and notes thereto, which are included in Xtant’s Annual Report on Form 10-K for the year ended December 31, 2020. The accounting policies set forth in those annual consolidated financial statements are the same as the accounting policies utilized in the preparation of these condensed consolidated financial statements, except as modified for appropriate interim consolidated financial statement presentation. Private Placement On February 24, 2021, we issued in a private placement (the “Private Placement”) to a single healthcare-focused institutional accredited investor (the “Investor”) 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”). We received net cash proceeds of approximately $18.4 million, after deducting fees and other estimated offering expenses, from the Private Placement. The Investor Warrant, described in more detail in Note 10, “Warrants”, In connection with the Private Placement, we entered into a placement agent agreement with a placement agent (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 fee equal to 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, described in more detail in Note 10, “Warrants”, Use of Estimates The preparation of the condensed consolidated 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 condensed consolidated 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. Long-Lived Assets The Company reviews its long-lived assets for impairment whenever events or changes in circumstances indicate that the carrying amount of the asset may not be recovered. The Company looks primarily to estimated undiscounted future cash flows in its assessment of whether or not long-lived assets are recoverable. As a result of the revenue decline related to the COVID-19 pandemic, the Company evaluated whether the carrying values of the long-lived assets were recoverable. Based on these evaluations, the Company determined that the long-lived assets were still recoverable. No impairments of long-lived assets were recorded for the three months ended March 31, 2021 and 2020. 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. No impairments of goodwill were recorded for the three months ended March 31, 2021 and 2020. Net Loss Per Share Basic net income (loss) per share is computed by dividing net income (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 income (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 three months ended March 31, 2021 and 2020, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Our diluted earnings per share is the same as basic earnings per share, as the effects of including 11,982,139 and 4,363,089 outstanding stock options, restricted stock units and warrants for the three months ended March 31, 2021 and 2020, respectively, are anti-dilutive. Reclassification Certain prior year amounts have been reclassified to conform with current year presentation. 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.

Revenue

Revenue	3 Months Ended
	Mar. 31, 2021
Revenue from Contract with Customer [Abstract]
Revenue	(2) Revenue 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 control of the promised goods is transferred to the customer, in an amount that reflects the consideration we expect to collect in exchange for those goods or services The Company operates in one reportable segment with our net revenue derived primarily from the sale of orthobiologics and spinal implant products across North America, Europe, Asia Pacific, and Latin America. Sales are reported net of returns. The following table presents revenues from these product lines for the three months ended March 31, 2021 and 2020 (in thousands): Three Months Percentage of Three Months Percentage of March 31, 2021 Total Revenue March 31, 2020 Total Revenue Orthobiologics $ 9,011 72 % $ 10,755 73 % Spinal implant 3,498 28 % 3,980 27 % Other revenue 33 0 % 43 0 % Total revenue $ 12,542 100 % $ 14,778 100 %

Receivables

Receivables	3 Months Ended
	Mar. 31, 2021
Credit Loss [Abstract]
Receivables	(3) Receivables The Company’s provision for current expected credit loss (“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 the three months ended March 31, 2021 and 2020 (in thousands): March 31, 2021 March 31, 2020 Balance at January 1 $ 653 $ 547 Provision for expected credit losses (63 ) 138 Write-offs charged against allowance (36 ) (17 ) Balance at March 31 $ 554 $ 668

Inventories

Inventories	3 Months Ended
	Mar. 31, 2021
Inventory Disclosure [Abstract]
Inventories	(4) Inventories Inventories consist of the following (in thousands): March 31, 2021 December 31, 2020 Raw materials $ 3,758 $ 3,757 Work in process 1,537 1,733 Finished goods 16,346 15,918 $ 21,641 $ 21,408

Property and Equipment, Net

Property and Equipment, Net	3 Months Ended
	Mar. 31, 2021
Property, Plant and Equipment [Abstract]
Property and Equipment, Net	(5) Property and Equipment, Net Property and equipment, net are as follows (in thousands): March 31, 2021 December 31, 2020 Equipment $ 5,217 $ 4,950 Computer equipment 593 649 Computer software 517 570 Leasehold improvements 3,987 3,987 Surgical instruments 11,621 11,291 Total cost 21,935 21,447 Less: accumulated depreciation (17,269 ) (17,100 ) Property and equipment, net $ 4,666 $ 4,347 Depreciation expense related to property and equipment, including property under finance leases, for the first three months of 2021 and 2020 was $0.4 million and $0.7 million, respectively.

Intangible Assets

Intangible Assets	3 Months Ended
	Mar. 31, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible Assets	(6) Intangible Assets The following table sets forth information regarding intangible assets (in thousands): March 31, 2021 December 31, 2020 Patents $ 847 $ 847 Accumulated amortization (404 ) (390 ) Intangible assets, net $ 443 $ 457 The following is a summary of estimated future amortization expense for intangible assets as of March 31, 2021 (in thousands): Remainder of 2021 $ 41 2022 54 2023 53 2024 52 2025 52 Thereafter 191 Total $ 443

Accrued Liabilities

Accrued Liabilities	3 Months Ended
	Mar. 31, 2021
Payables and Accruals [Abstract]
Accrued Liabilities	(7) Accrued Liabilities Accrued liabilities consist of the following (in thousands): March 31, 2021 December 31, 2020 Cash compensation/commissions payable $ 3,183 $ 4,057 Other accrued liabilities 1,386 1,405 Accrued liabilities $ 4,569 $ 5,462

Debt

Debt	3 Months Ended
	Mar. 31, 2021
Debt Disclosure [Abstract]
Debt	(8) Debt The Company has a credit facility with OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) (the “Second A&R Credit Agreement”), which matures on December 31, 2021. As of March 31, 2021, the Company may request additional term loans from the Royalty Opportunities in an aggregate amount up to $5.0 million, subject to Royalty Opportunities’ discretion. As a result of our most recent amendment to the Second A&R Credit Agreement, 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. Long-term debt consists of the following (in thousands): March 31, 2021 December 31, 2020 Amounts due under the Second Amended and Restated Credit Agreement $ 15,556 $ 15,556 Premium related to Second Amendment 934 1,241 Less: current maturities (16,490 ) (16,797 ) Long-term debt $ — $ —

Stock-Based Compensation

Stock-Based Compensation	3 Months Ended
	Mar. 31, 2021
Share-based Payment Arrangement [Abstract]
Stock-Based Compensation	(9) Stock-Based Compensation Stock option activity, including options granted under the Xtant Medical Holdings, Inc. 2018 Equity Incentive Plan, as amended (the “2018 Plan”), and the Amended and Restated Xtant Medical Equity Incentive Plan and options granted to new hires to purchase shares of our common stock outside of any stockholder-approved plan, was as follows for the three months ended March 31, 2021 and 2020: 2021 2020 Shares Weighted Weighted Shares Weighted Weighted Outstanding at January 1 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Cancelled or expired (125 ) $ 372.00 $ 184.59 (76,299 ) $ 4.18 $ 2.96 Outstanding at March 31 2,190,767 $ 2.23 $ 1.64 526,667 $ 6.34 $ 4.14 Exercisable at March 31 122,614 $ 14.38 $ 8.77 48,764 $ 41.11 $ 23.34 Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the three months ended March 31, 2021 and 2020: 2021 2020 Shares Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 2,503,698 $ 1.54 499,914 $ 2.93 Granted - $ - 489,437 $ 1.45 Vested (244,716 ) $ 1.45 (61,803 ) $ 2.27 Outstanding at March 31 2,258,982 $ 1.54 927,548 $ 1.86

Warrants

Warrants	3 Months Ended
	Mar. 31, 2021
Warrants and Rights Note Disclosure [Abstract]
Warrants	(10) Warrants As noted in Note 1, “ Business Description, Basis of Presentation and Summary of Significant Accounting Policies in the same type or form of consideration that is being offered and paid to the holders of Company common stock in connection with the triggering transaction. While the Investor Warrants are classified as a component of equity, we were required to allocate the proceeds of the Private Placement between the shares of common stock and Investor Warrants issued based on their relative fair values. We utilized a lattice valuation model to determine the fair value of the Investor Warrants. The fair value of the Placement Agent Warrants issued in connection with the Private Placement was determined using a Black Scholes model. Significant assumptions in both models included contractual term (5 years) and the estimated volatility factor based on a weighted average of comparable published betas of peer companies (61%). Our warrant activity during the three months ended March 31, 2021 was as follows: Common Stock Warrants Weighted Average Exercise Price Outstanding at January 1, 2021 421,278 $ 10.80 Issued 7,111,112 2.29 Outstanding at March 31, 2021 7,532,390 $ 2.76

Commitments and Contingencies

Commitments and Contingencies	3 Months Ended
	Mar. 31, 2021
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies	(11) Commitments and Contingencies Operating Leases We lease three office facilities as of March 31, 2021 in Belgrade, Montana 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. Present Value of Long-term Leases (in thousands): March 31, 2021 Right-of-use assets, net $ 1,585 Current portion of lease liability 431 Lease liability, less current portion 1,192 Total lease liability $ 1,623 As of March 31, 2021, the weighted-average remaining lease term was 3.7 years. Future minimum payments for the next five years and thereafter as of March 31, 2021 under these long-term operating leases are as follows (in thousands): Remainder of 2021 $ 380 2022 521 2023 489 2024 224 2025 179 Total future minimum lease payments 1,793 Less amount representing interest (170 ) Present value of obligations under operating leases 1,623 Less current portion (431 ) Long-term operating lease obligations $ 1,192 Rent expense was $0.1 million for the three months ended March 31, 2021 and 2020. We have no contingent rent agreements. Financing Leases Future minimum payments under finance leases are as follows as of March 31, 2021 (in thousands): Remainder of 2021 $ 28 2022 37 2023 37 2024 37 2025 37 Thereafter 3 Total future minimum lease payments 179 Less amount representing interest (20 ) Present value of obligations under finance leases 159 Less current portion (30 ) Long-term operating lease obligations $ 129 Litigation 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 are subject to potential liabilities under government regulations and various claims and legal actions that are pending or may be asserted 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 indemnification 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 condensed 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	3 Months Ended
	Mar. 31, 2021
Income Tax Disclosure [Abstract]
Income Taxes	(12) Income Taxes In evaluating the realizability of the net deferred tax assets, we take into account a number of factors, primarily relating to the ability to generate taxable income. Where it is determined that it is likely that we will be unable to realize deferred tax assets, a valuation allowance is established against the portion of the deferred tax asset. Because it cannot be accurately determined when or if we will become profitable, a valuation allowance was provided against the entire deferred income tax asset balance. The Company did not recognize any interest or penalties related to income taxes for the three months ended March 31, 2021 and 2020.

Supplemental Disclosure of Cash

Supplemental Disclosure of Cash Flow Information	3 Months Ended
	Mar. 31, 2021
Supplemental Cash Flow Elements [Abstract]
Supplemental Disclosure of Cash Flow Information	(13) Supplemental Disclosure of Cash Flow Information Supplemental cash flow information is as follows (in thousands): Three Months Ended March 31, 2021 2020 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 1 $ 7 Non-cash activities: Fixed assets acquired under finance lease $ 163 $ — Warrants issued in connection with the Private Placement to placement agents $ 351 $ — ASU 2016-13 cumulative effect adjustment $ — $ 47

Related Party Transactions

Related Party Transactions	3 Months Ended
	Mar. 31, 2021
Related Party Transactions [Abstract]
Related Party Transactions	(14) Related Party Transactions Royalty Opportunities, which owns approximately 20% of the Company’s outstanding common stock, was the sole holder of our outstanding long-term debt and a party to the Second Amended and Restated Credit Agreement, which was terminated in connection with our debt refinancing described under Note 16. Business Description and Summary of Significant Accounting Policies 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	3 Months Ended
	Mar. 31, 2021
Segment Reporting [Abstract]
Segment and Geographic Information	(15) Segment and Geographic Information The Company’s management reviews financial results and manages the business on an aggregate basis. Therefore, financial results are reported in a single operating segment: the development, manufacture, and marketing of orthopedic medical products and devices. The Company attributes revenues to geographic areas based on the location of the customer. Approximately 98% and 96% of sales were in the United States for the nine months ended March 31, 2021 and 2020, respectively. Total revenue by major geographic area is as follows (in thousands): Three Months Ended 2021 2020 United States $ 12,293 $ 14,251 Rest of world 249 526 Total revenue $ 12,542 $ 14,777

Subsequent Event

Subsequent Event	3 Months Ended
	Mar. 31, 2021
Subsequent Events [Abstract]
Subsequent Event	(16) Subsequent Event On May 6, 2021 (the “Closing Date”), the Company, as guarantor, and its subsidiaries, as borrowers (collectively, the “Borrowers”), entered into a (i) Credit, Security and Guaranty Agreement (Term Loan) (the “Term Credit Agreement”) with MidCap Financial Trust, in its capacity as agent (the “Agent”), and a lender and the additional lenders from time to time party thereto and (ii) Credit, Security and Guaranty Agreement (Revolving Loan) (the “Revolving Credit Agreement,”, and, together with the Term Credit Agreement, the “Credit Agreements”), with the Agent and the lenders from time to time party thereto. The Term Credit Agreement provides for a secured term loan facility (the “Term Facility”) in an aggregate principal amount of $12,000,000 (the “Term Loan Commitment”), which was funded to the Borrowers on the Closing Date, and an additional $5,000,000 tranche available solely at the discretion of the Agent and the lenders, for the purposes agreed to between the Company, the Borrowers and the lenders in advance of the making of loans under such additional tranche. The Revolving Credit Agreement provides for a secured revolving credit facility (the “Revolving Facility,”, and, together with the Term Facility, the “Facilities”) under which the Borrowers may borrow up to $8,000,000 (such amount, the “Revolving Loan Commitment”) at any one time, the availability of which is determined based on a borrowing base equal to percentages of certain accounts receivable and inventory of the Borrowers in accordance with a formula set forth in the Revolving Credit Agreement. All borrowings under the Revolving Facility are subject to the satisfaction of customary conditions, including the absence of default, the accuracy of representations and warranties in all material respects and the delivery of an updated borrowing base certificate. The Facilities have a maturity date of May 1, 2026. The loans and other obligations pursuant to the Credit Agreements will bear interest at a per annum rate equal to the sum of the LIBOR rate, as such term is defined in the Credit Agreements, plus the applicable margin of 7.00% in the case of the Term Credit Agreement, and 4.50% in the case of the Revolving Credit Agreement, subject in each case to a LIBOR floor of 1.00%. The proceeds of the Term Facility were used to pay transaction fees in connection with the Facilities and to pay in full all outstanding indebtedness and accrued interest under the Company’s Second Amended and Restated Credit Agreement. The proceeds of the Revolving Facility may be used to pay transaction fees in connection with the Facilities, to pay in full all outstanding indebtedness and accrued interest under the Company’s prior credit facility, and for working capital and general corporate purposes. The Credit Agreements replaced the Company’s Second Amended and Restated Credit Agreement and the indebtedness incurred, and all other obligations of the Company and its subsidiaries owed, under the Second Amended and Restated Credit Agreement were repaid in full and terminated using proceeds of the loans received under the Credit Agreements.

Business Description, Basis o_2

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Policies)	3 Months Ended
	Mar. 31, 2021
Accounting Policies [Abstract]
Business Description and Basis of Presentation	Business Description and Basis of Presentation The accompanying condensed consolidated financial statements include the accounts of Xtant Medical Holdings, Inc. (“Xtant”), a Delaware corporation, and its wholly owned subsidiaries, Xtant Medical, Inc. (“Xtant Medical”), a Delaware corporation, Bacterin International, Inc. (“Bacterin”), a Nevada corporation, and X-spine Systems, Inc. (“X-spine”), an Ohio corporation (Xtant, Xtant Medical, Bacterin, and X-spine are jointly referred to herein as the “Company” or sometimes “we”, “our,” or “us”). All intercompany balances and transactions have been eliminated in consolidation. Xtant is a global medical technology company focused on the design, development, and commercialization of a comprehensive portfolio of orthobiologics and spinal implant systems to facilitate spinal fusion in complex spine, deformity, and degenerative procedures. 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. The accompanying condensed consolidated balance sheet as of December 31, 2020, which has been derived from audited financial statements, and the unaudited interim condensed consolidated financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America. They do not include all disclosures required by generally accepted accounting principles for annual consolidated financial statements, but in the opinion of management include all adjustments, consisting only of normal recurring items, necessary for a fair presentation. Interim results are not necessarily indicative of results that may be achieved in the future for the full year ending December 31, 2021. These condensed consolidated financial statements should be read in conjunction with the consolidated financial statements and notes thereto, which are included in Xtant’s Annual Report on Form 10-K for the year ended December 31, 2020. The accounting policies set forth in those annual consolidated financial statements are the same as the accounting policies utilized in the preparation of these condensed consolidated financial statements, except as modified for appropriate interim consolidated financial statement presentation.
Private Placement	Private Placement On February 24, 2021, we issued in a private placement (the “Private Placement”) to a single healthcare-focused institutional accredited investor (the “Investor”) 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”). We received net cash proceeds of approximately $18.4 million, after deducting fees and other estimated offering expenses, from the Private Placement. The Investor Warrant, described in more detail in Note 10, “Warrants”, In connection with the Private Placement, we entered into a placement agent agreement with a placement agent (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 fee equal to 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, described in more detail in Note 10, “Warrants”,
Use of Estimates	Use of Estimates The preparation of the condensed consolidated 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 condensed consolidated 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.
Long-Lived Assets	Long-Lived Assets The Company reviews its long-lived assets for impairment whenever events or changes in circumstances indicate that the carrying amount of the asset may not be recovered. The Company looks primarily to estimated undiscounted future cash flows in its assessment of whether or not long-lived assets are recoverable. As a result of the revenue decline related to the COVID-19 pandemic, the Company evaluated whether the carrying values of the long-lived assets were recoverable. Based on these evaluations, the Company determined that the long-lived assets were still recoverable. No impairments of long-lived assets were recorded for the three months ended March 31, 2021 and 2020.
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. No impairments of goodwill were recorded for the three months ended March 31, 2021 and 2020.
Net Loss Per Share	Net Loss Per Share Basic net income (loss) per share is computed by dividing net income (loss) by the weighted average number of 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 income (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 three months ended March 31, 2021 and 2020, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Our diluted earnings per share is the same as basic earnings per share, as the effects of including 11,982,139 and 4,363,089 outstanding stock options, restricted stock units and warrants for the three months ended March 31, 2021 and 2020, respectively, are anti-dilutive.
Reclassification	Reclassification Certain prior year amounts have been reclassified to conform with current year presentation.
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.

Revenue (Tables)

Revenue (Tables)	3 Months Ended
	Mar. 31, 2021
Revenue from Contract with Customer [Abstract]
Summary of Revenues from Product Lines	The following table presents revenues from these product lines for the three months ended March 31, 2021 and 2020 (in thousands): Three Months Percentage of Three Months Percentage of March 31, 2021 Total Revenue March 31, 2020 Total Revenue Orthobiologics $ 9,011 72 % $ 10,755 73 % Spinal implant 3,498 28 % 3,980 27 % Other revenue 33 0 % 43 0 % Total revenue $ 12,542 100 % $ 14,778 100 %

Receivables (Tables)

Receivables (Tables)	3 Months Ended
	Mar. 31, 2021
Credit Loss [Abstract]
Schedule of Allowance for Credit Losses	Activity within the allowance for credit losses was as follows for the three months ended March 31, 2021 and 2020 (in thousands): March 31, 2021 March 31, 2020 Balance at January 1 $ 653 $ 547 Provision for expected credit losses (63 ) 138 Write-offs charged against allowance (36 ) (17 ) Balance at March 31 $ 554 $ 668

Inventories (Tables)

Inventories (Tables)	3 Months Ended
	Mar. 31, 2021
Inventory Disclosure [Abstract]
Schedule of Inventories	Inventories consist of the following (in thousands): March 31, 2021 December 31, 2020 Raw materials $ 3,758 $ 3,757 Work in process 1,537 1,733 Finished goods 16,346 15,918 $ 21,641 $ 21,408

Property and Equipment, Net (Ta

Property and Equipment, Net (Tables)	3 Months Ended
	Mar. 31, 2021
Property, Plant and Equipment [Abstract]
Schedule of Property and Equipment, Net	Property and equipment, net are as follows (in thousands): March 31, 2021 December 31, 2020 Equipment $ 5,217 $ 4,950 Computer equipment 593 649 Computer software 517 570 Leasehold improvements 3,987 3,987 Surgical instruments 11,621 11,291 Total cost 21,935 21,447 Less: accumulated depreciation (17,269 ) (17,100 ) Property and equipment, net $ 4,666 $ 4,347

Intangible Assets (Tables)

Intangible Assets (Tables)	3 Months Ended
	Mar. 31, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Intangible Assets	The following table sets forth information regarding intangible assets (in thousands): March 31, 2021 December 31, 2020 Patents $ 847 $ 847 Accumulated amortization (404 ) (390 ) Intangible assets, net $ 443 $ 457
Summary of Future Amortization Expense for Intangible Assets	The following is a summary of estimated future amortization expense for intangible assets as of March 31, 2021 (in thousands): Remainder of 2021 $ 41 2022 54 2023 53 2024 52 2025 52 Thereafter 191 Total $ 443

Accrued Liabilities (Tables)

Accrued Liabilities (Tables)	3 Months Ended
	Mar. 31, 2021
Payables and Accruals [Abstract]
Schedule of Accrued Liabilities	Accrued liabilities consist of the following (in thousands): March 31, 2021 December 31, 2020 Cash compensation/commissions payable $ 3,183 $ 4,057 Other accrued liabilities 1,386 1,405 Accrued liabilities $ 4,569 $ 5,462

Debt (Tables)

Debt (Tables)	3 Months Ended
	Mar. 31, 2021
Debt Disclosure [Abstract]
Schedule of Long-term Debt	Long-term debt consists of the following (in thousands): March 31, 2021 December 31, 2020 Amounts due under the Second Amended and Restated Credit Agreement $ 15,556 $ 15,556 Premium related to Second Amendment 934 1,241 Less: current maturities (16,490 ) (16,797 ) Long-term debt $ — $ —

Stock-Based Compensation (Table

Stock-Based Compensation (Tables)	3 Months Ended
	Mar. 31, 2021
Share-based Payment Arrangement [Abstract]
Schedule of Share-based Compensation, Stock Options, Activity	Stock option activity, including options granted under the Xtant Medical Holdings, Inc. 2018 Equity Incentive Plan, as amended (the “2018 Plan”), and the Amended and Restated Xtant Medical Equity Incentive Plan and options granted to new hires to purchase shares of our common stock outside of any stockholder-approved plan, was as follows for the three months ended March 31, 2021 and 2020: 2021 2020 Shares Weighted Weighted Shares Weighted Weighted Outstanding at January 1 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Cancelled or expired (125 ) $ 372.00 $ 184.59 (76,299 ) $ 4.18 $ 2.96 Outstanding at March 31 2,190,767 $ 2.23 $ 1.64 526,667 $ 6.34 $ 4.14 Exercisable at March 31 122,614 $ 14.38 $ 8.77 48,764 $ 41.11 $ 23.34
Schedule of Restricted Stock Activity	Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the three months ended March 31, 2021 and 2020: 2021 2020 Shares Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 2,503,698 $ 1.54 499,914 $ 2.93 Granted - $ - 489,437 $ 1.45 Vested (244,716 ) $ 1.45 (61,803 ) $ 2.27 Outstanding at March 31 2,258,982 $ 1.54 927,548 $ 1.86

Warrants (Tables)

Warrants (Tables)	3 Months Ended
	Mar. 31, 2021
Warrants and Rights Note Disclosure [Abstract]
Schedule of Warrant Activity	Our warrant activity during the three months ended March 31, 2021 was as follows: Common Stock Warrants Weighted Average Exercise Price Outstanding at January 1, 2021 421,278 $ 10.80 Issued 7,111,112 2.29 Outstanding at March 31, 2021 7,532,390 $ 2.76

Commitments and Contingencies (

Commitments and Contingencies (Tables)	3 Months Ended
	Mar. 31, 2021
Commitments and Contingencies Disclosure [Abstract]
Schedule of Lease Liability	Present Value of Long-term Leases (in thousands): March 31, 2021 Right-of-use assets, net $ 1,585 Current portion of lease liability 431 Lease liability, less current portion 1,192 Total lease liability $ 1,623
Schedule of Future Minimum Rental Payments for Operating Leases	Future minimum payments for the next five years and thereafter as of March 31, 2021 under these long-term operating leases are as follows (in thousands): Remainder of 2021 $ 380 2022 521 2023 489 2024 224 2025 179 Total future minimum lease payments 1,793 Less amount representing interest (170 ) Present value of obligations under operating leases 1,623 Less current portion (431 ) Long-term operating lease obligations $ 1,192 Financing Leases Future minimum payments under finance leases are as follows as of March 31, 2021 (in thousands): Remainder of 2021 $ 28 2022 37 2023 37 2024 37 2025 37 Thereafter 3 Total future minimum lease payments 179 Less amount representing interest (20 ) Present value of obligations under finance leases 159 Less current portion (30 ) Long-term operating lease obligations $ 129

Supplemental Disclosure of Ca_2

Supplemental Disclosure of Cash Flow Information (Tables)	3 Months Ended
	Mar. 31, 2021
Supplemental Cash Flow Elements [Abstract]
Schedule of Supplemental Cash Flow Information	Supplemental cash flow information is as follows (in thousands): Three Months Ended March 31, 2021 2020 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 1 $ 7 Non-cash activities: Fixed assets acquired under finance lease $ 163 $ — Warrants issued in connection with the Private Placement to placement agents $ 351 $ — ASU 2016-13 cumulative effect adjustment $ — $ 47

Segment and Geographic Inform_2

Segment and Geographic Information (Tables)	3 Months Ended
	Mar. 31, 2021
Segment Reporting [Abstract]
Schedule of Revenues by Geographic Region	Total revenue by major geographic area is as follows (in thousands): Three Months Ended 2021 2020 United States $ 12,293 $ 14,251 Rest of world 249 526 Total revenue $ 12,542 $ 14,777

Business Description, Basis o_3

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	Feb. 24, 2021	Mar. 31, 2021	Mar. 31, 2020
Proceeds from private placement		$ 18,425
Impairments of long-lived assets
Impairments of goodwill
Antidilutive securities excluded from computation of earnings per share, amount		11,982,139	4,363,089
Private Placement [Member] | Investor [Member]
Stock issued during period, shares, new issues	8,888,890
Stock issued price per share	$ 2.25
Proceeds from private placement	$ 18,400
Private Placement [Member] | Investor [Member] | Placement Agent Agreement [Member]
Stock issued during period, shares, new issues	444,444
Private Placement [Member] | Investor [Member] | Placement Agent Agreement [Member] | Maximum [Member]
Warrants exercise price percentage	5.00%
Private Placement [Member] | Investor Warrant [Member]
Warrants to purchase common stock	6,666,668
Warrant exercise price	$ 2.25
Private Placement Warrant [Member] | Investor [Member] | Placement Agent Agreement [Member]
Warrant exercise price	$ 2.8125
Warrant term	5 years

Revenue - Summary of Revenues f

Revenue - Summary of Revenues from Product Lines (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Total revenue	$ 12,542	$ 14,778
Percentage of total revenue	100.00%	100.00%
Orthobiologics [Member]
Total revenue	$ 9,011	$ 10,755
Percentage of total revenue	72.00%	73.00%
Spinal Implant [Member]
Total revenue	$ 3,498	$ 3,980
Percentage of total revenue	28.00%	27.00%
Other Revenue [Member]
Total revenue	$ 33	$ 43
Percentage of total revenue	0.00%	0.00%

Receivables - Schedule of allow

Receivables - Schedule of allowance for credit losses (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Credit Loss [Abstract]
Beginning balance	$ 653	$ 547
Provision for expected credit losses	(63)	138
Write-offs charged against allowance	(36)	(17)
Ending balance	$ 554	$ 668

Inventories - Schedule of Inven

Inventories - Schedule of Inventories (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Inventory Disclosure [Abstract]
Raw materials	$ 3,758	$ 3,757
Work in process	1,537	1,733
Finished goods	16,346	15,918
Total	$ 21,641	$ 21,408

Property and Equipment, Net (De

Property and Equipment, Net (Details Narrative) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Property, Plant and Equipment [Abstract]
Depreciation expense	$ 400	$ 700

Property and Equipment, Net - S

Property and Equipment, Net - Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Total cost	$ 21,935	$ 21,447
Less: accumulated depreciation	(17,269)	(17,100)
Property and equipment, net	4,666	4,347
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	5,217	4,950
Computer Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	593	649
Computer Software [Member]
Property, Plant and Equipment [Line Items]
Total cost	517	570
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	3,987	3,987
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 11,621	$ 11,291

Intangible Assets - Schedule of

Intangible Assets - Schedule of Intangible Assets (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Patents	$ 847	$ 847
Accumulated amortization	(404)	(390)
Intangible assets, net	$ 443	$ 457

Intangible Assets - Schedule _2

Intangible Assets - Schedule of Estimated Amortization Expense for Intangible Assets (Details) $ in Thousands	Mar. 31, 2021USD ($)
Goodwill and Intangible Assets Disclosure [Abstract]
Remainder of 2021	$ 41
2022	54
2023	53
2024	52
2025	52
Thereafter	191
Total	$ 443

Accrued Liabilities - Schedule

Accrued Liabilities - Schedule of Accrued Liabilities (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Payables and Accruals [Abstract]
Cash compensation/commissions payable	$ 3,183	$ 4,057
Other accrued liabilities	1,386	1,405
Accrued liabilities	$ 4,569	$ 5,462

Debt (Details Narrative)

Debt (Details Narrative) - Second A&R Credit Agreement [Member] - OrbiMed Royalty Opportunities II, LP [Member] $ in Thousands	3 Months Ended
	Mar. 31, 2021USD ($)
Line of credit facility, maturity date	Dec. 31, 2021
Line of credit facility, maximum borrowing capacity	$ 5,000

Debt - Schedule of Long-term De

Debt - Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Debt Disclosure [Abstract]
Amounts due under the Second Amended and Restated Credit Agreement	$ 15,556	$ 15,556
Premium related to Second Amendment	934	1,241
Less: current maturities	(16,490)	(16,797)
Long-term debt

Stock-Based Compensation - Sche

Stock-Based Compensation - Schedule of Share-based Compensation, Stock Options, Activity (Details) - Equity Option [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Shares Outstanding, Beginning Balance	2,190,892	602,966
Shares Cancelled or expired	(125)	(76,299)
Shares Outstanding, Ending Balance	2,190,767	526,667
Shares Exercisable, Ending Balance	122,614	48,764
Weighted Average Exercise Price, Outstanding Beginning Balance	$ 2.25	$ 6.07
Weighted Average Exercise Price, Cancelled or expired	372	4.18
Weighted Average Exercise Price, Outstanding Ending Balance	2.23	6.34
Weighted Average Exercise Price, Exercisable Ending Balance	14.38	41.11
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	1.65	3.99
Weighted Average Fair Value at Grant Date, Cancelled or expired	184.59	2.96
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	1.64	4.14
Weighted Average Fair Value at Grant Date, Exercisable, Ending Balance	$ 8.77	$ 23.34

Stock-Based Compensation - Sc_2

Stock-Based Compensation - Schedule of Restricted Stock Activity (Details) - Restricted Stock Units (RSUs) [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Shares Outstanding, Beginning Balance	2,503,698	499,914
Shares Granted		489,437
Shares Vested	(244,716)	(61,803)
Shares Outstanding, Ending Balance	2,258,982	927,548
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 1.54	$ 2.93
Weighted Average Fair Value at Grant Date, Granted		1.45
Weighted Average Fair Value at Grant Date, Vested	1.45	2.27
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 1.54	$ 1.86

Warrants (Details Narrative)

Warrants (Details Narrative)	Mar. 31, 2021
Contractual Term [Member]
Class of Warrant or Right [Line Items]
Warrants contractual term	5 years
Volatility [Member]
Class of Warrant or Right [Line Items]
Warrants and rights outstanding, measurement input	61

Warrants - Schedule of Warrant

Warrants - Schedule of Warrant Activity (Details)	3 Months Ended
	Mar. 31, 2021$ / sharesshares
Warrants and Rights Note Disclosure [Abstract]
Common Stock Warrants Outstanding, Beginning Balance | shares	421,278
Common Stock Warrants, Issued | shares	7,111,112
Common Stock Warrants Outstanding, Ending Balance | shares	7,532,390
Weighted Average Exercise Price Outstanding Beginning Balance | $ / shares	$ 10.80
Weighted Average Exercise Price, Issued | $ / shares	2.29
Weighted Average Exercise Price Outstanding Ending Balance | $ / shares	$ 2.76

Commitments and Contingencies_2

Commitments and Contingencies (Details Narrative) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Operating lease expiration description	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.
Operating lease weighted-average remaining lease term	3 years 8 months 12 days
Rent expense	$ 100	$ 100

Commitments and Contingencies -

Commitments and Contingencies - Schedule of Future Minimum Rental Payments for Operating Leases (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Remainder of 2021	$ 380
2022	521
2023	489
2024	224
2025	179
Total future minimum lease payments	1,793
Less amount representing interest	(170)
Present value of obligations under operating leases	1,623
Less current portion	(431)	$ (423)
Long-term operating lease obligations	1,192	1,303
Remainder of 2021	28
2022	37
2023	37
2024	37
2025	37
Thereafter	3
Total future minimum lease payments	179
Less amount representing interest	(20)
Present value of obligations under operating leases	159
Less current portion	(30)	(20)
Long-term operating lease obligations	$ 129

Income Taxes (Details Narrative

Income Taxes (Details Narrative) - USD ($)	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Income Tax Disclosure [Abstract]
Interest or penalties related to income taxes

Supplemental Disclosure of Ca_3

Supplemental Disclosure of Cash Flow Information - Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Supplemental Cash Flow Elements [Abstract]
Interest	$ 1	$ 7
Fixed assets acquired under finance lease	163
Warrants issued in connection with the Private Placement to placement agents	351
ASU 2016-13 cumulative effect adjustment		$ 14

Related Party Transactions (Det

Related Party Transactions (Details Narrative)	Mar. 31, 2021
Sole Holders [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage	20.00%
OrbiMed Advisors LLC Member]
Related Party Transaction [Line Items]
Beneficially owned percentage	84.00%

Segment and Geographic Inform_3

Segment and Geographic Information (Details Narrative)	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
United States [Member] | Revenue [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	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Total revenue	$ 12,542	$ 14,778
United States [Member]
Total revenue	12,293	14,251
Rest of World [Member]
Total revenue	$ 249	$ 526

Subsequent Event (Details Narra

Subsequent Event (Details Narrative) - Subsequent Event [Member] $ in Thousands	May 06, 2021USD ($)
Line of credit facility, maturity date	May 1, 2026
Line of credit, interest rate	7.00%
Term Loan Commitment [Member]
Line of credit facility, maximum borrowing capacity	$ 12,000
Line of credit, interest rate	4.50%
Term Loan Commitment [Member] | Agent and Lenders [Member]
Line of credit facility, maximum borrowing capacity	$ 5,000
Revolving Loan Commitment [Member]
Line of credit facility, maximum borrowing capacity	$ 8,000
Revolving Loan Commitment [Member] | LIBOR [Member]
Line of credit, interest rate	1.00%