Xtant Medical (XTNT) 10-Q 12 Nov 21 2021 Q3 Quarterly report Financial data

Cover

Cover - shares	9 Months Ended
	Sep. 30, 2021	Nov. 09, 2021
Cover [Abstract]
Document Type	10-Q
Amendment Flag	false
Document Quarterly Report	true
Document Transition Report	false
Document Period End Date	Sep. 30, 2021
Document Fiscal Period Focus	Q3
Document Fiscal Year Focus	2021
Current Fiscal Year End Date	--12-31
Entity File Number	001-34951
Entity Registrant Name	XTANT MEDICAL HOLDINGS, INC.
Entity Central Index Key	0001453593
Entity Tax Identification Number	20-5313323
Entity Incorporation, State or Country Code	DE
Entity Address, Address Line One	664 Cruiser Lane
Entity Address, City or Town	Belgrade
Entity Address, State or Province	MT
Entity Address, Postal Zip Code	59714
City Area Code	(406)
Local Phone Number	388-0480
Title of 12(b) Security	Common stock, par value $0.000001 per share
Trading Symbol	XTNT
Security Exchange Name	NYSE
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Non-accelerated Filer
Entity Small Business	true
Entity Emerging Growth Company	false
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		86,796,175

Condensed Consolidated Balance

Condensed Consolidated Balance Sheets - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Current Assets:
Cash and cash equivalents	$ 18,175	$ 2,341
Restricted cash	439
Trade accounts receivable, net of allowance for credit losses and doubtful accounts of $576 and $653, respectively	6,321	6,880
Inventories	19,708	21,408
Prepaid and other current assets	945	736
Total current assets	45,588	31,365
Property and equipment, net	4,971	4,347
Right-of-use asset, net	1,369	1,690
Goodwill	3,205	3,205
Intangible assets, net	414	457
Other assets	244	402
Total Assets	55,791	41,466
Current Liabilities:
Accounts payable	2,355	2,947
Accrued liabilities	4,079	5,462
Current portion of lease liability	451	423
Current portion of finance lease obligations	31	20
Line of credit	3,488
Current portion of long-term debt		16,797
Total current liabilities	10,404	25,649
Long-term Liabilities:
Lease liability, less current portion	961	1,303
Finance lease obligation, less current portion	111
Long-term debt, less issuance costs	11,678
Total Liabilities	23,154	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; 86,796,175 shares issued and outstanding as of September 30, 2021 and 77,573,680 shares issued and outstanding as of December 31, 2020
Additional paid-in capital	265,539	244,850
Accumulated deficit	(232,902)	(230,336)
Total Stockholders’ Equity	32,637	14,514
Total Liabilities & Stockholders’ Equity	$ 55,791	$ 41,466

Condensed Consolidated Balanc_2

Condensed Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Statement of Financial Position [Abstract]
Trade accounts receivable, allowance for credit losses	$ 576	$ 653
Preferred stock, par value	$ 0.000001	$ 0.000001
Preferred stock, shares authorized	10,000,000	10,000,000
Preferred stock, shares issued	0	0
Preferred stock, shares outstanding	0	0
Common stock, par value	$ 0.000001	$ 0.000001
Common stock, shares authorized	300,000,000	300,000,000
Common stock, shares issued	86,796,175	77,573,680
Common Stock, shares outstanding	86,796,175	77,573,680

Condensed Consolidated Statemen

Condensed Consolidated Statements of Operations (Unaudited) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Revenue
Orthopedic product sales	$ 13,743	$ 13,980	$ 41,193	$ 39,207
Other revenue	34	36	100	115
Total Revenue	13,777	14,016	41,293	39,322
Cost of sales	6,586	4,768	16,498	13,913
Gross Profit	7,191	9,248	24,795	25,409
Operating Expenses
General and administrative	3,107	3,042	10,307	10,293
Sales and marketing	5,267	5,270	15,712	15,578
Research and development	262	176	719	529
Total Operating Expenses	8,636	8,488	26,738	26,400
(Loss) Income from Operations	(1,445)	760	(1,943)	(991)
Other Expense
Interest expense	(329)	(2,097)	(529)	(5,258)
Total Other Expense	(329)	(2,097)	(529)	(5,258)
Net Loss Before Provision for Income Taxes	(1,774)	(1,337)	(2,472)	(6,249)
Provision for income taxes	(30)	(23)	(94)	(68)
Net Loss	$ (1,804)	$ (1,360)	$ (2,566)	$ (6,317)
Net loss per share:
Basic	$ (0.02)	$ (0.10)	$ (0.03)	$ (0.48)
Dilutive	$ (0.02)	$ (0.10)	$ (0.03)	$ (0.48)
Shares used in the computation:
Basic	86,763,210	13,231,823	84,926,656	13,210,386
Dilutive	86,763,210	13,231,823	84,926,656	13,210,386

Condensed Consolidated Statem_2

Condensed Consolidated Statements of Equity (Unaudited) - USD ($) $ in Thousands	Total	Common Stock [Member]	Additional Paid-in Capital [Member]	Retained Earnings [Member]
Balance at Dec. 31, 2019	$ (44,205)		$ 179,061	$ (223,266)
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)
Balance at Mar. 31, 2020	(46,476)		179,330	(225,806)
Ending balance, shares at Mar. 31, 2020		13,223,565
Balance at Dec. 31, 2019	(44,205)		179,061	(223,266)
Beginning balance, shares at Dec. 31, 2019		13,161,762
Net loss	(6,317)
Balance at Sep. 30, 2020	47,981		181,649	(230,630)
Ending balance, shares at Sep. 30, 2020		13,240,831
Balance at Mar. 31, 2020	(46,476)		179,330	(225,806)
Beginning balance, shares at Mar. 31, 2020		13,223,565
Stock-based compensation	220		220
Issuance of warrant	1,862		1,862
Net loss	(2,464)			(2,464)
Balance at Jun. 30, 2020	(46,858)		181,412	(228,270)
Ending balance, shares at Jun. 30, 2020		13,223,565
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares		17,266
Stock-based compensation	237		237
Net loss	(1,360)			(1,360)
Balance at Sep. 30, 2020	47,981		181,649	(230,630)
Ending balance, shares at Sep. 30, 2020		13,240,831
Balance at Dec. 31, 2020	14,514		244,850	(230,336)
Beginning balance, shares at Dec. 31, 2020		77,573,680
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)
Balance at Mar. 31, 2021	33,366		263,731	(230,365)
Ending balance, shares at Mar. 31, 2021		86,707,286
Balance at Dec. 31, 2020	14,514		244,850	(230,336)
Beginning balance, shares at Dec. 31, 2020		77,573,680
Net loss	(2,566)
Balance at Sep. 30, 2021	32,637		265,539	(232,902)
Ending balance, shares at Sep. 30, 2021		86,796,175
Balance at Mar. 31, 2021	33,366		263,731	(230,365)
Beginning balance, shares at Mar. 31, 2021		86,707,286
Stock-based compensation	465		465
Gain on debt extinguishment	786		786
Net loss	(733)			(733)
Balance at Jun. 30, 2021	33,884		264,982	(231,098)
Ending balance, shares at Jun. 30, 2021		86,707,286
Withholding of common stock upon vesting of restricted stock units	(23)		(23)
Withholding of common stock upon vesting of restricted stock units, shares		(15,967)
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares		104,856
Stock-based compensation	580		580
Net loss	(1,804)			(1,804)
Balance at Sep. 30, 2021	$ 32,637		$ 265,539	$ (232,902)
Ending balance, shares at Sep. 30, 2021		86,796,175

Condensed Consolidated Statem_3

Condensed Consolidated Statements of Equity (Unaudited) (Parenthetical) $ in Thousands	3 Months Ended
	Mar. 31, 2021USD ($)
Statement of Cash Flows [Abstract]
Payments of Stock Issuance Costs	$ 1,926

Condensed Consolidated Statem_4

Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Operating activities:
Net loss	$ (2,566)	$ (6,317)
Adjustments to reconcile net loss to net cash provided by (used in) operating activities:
Depreciation and amortization	1,041	1,658
Gain on disposal of fixed assets	(164)	(307)
Non-cash interest	38	5,245
Non-cash rent	8	12
Stock-based compensation	1,501	726
Provision for (recoveries) reserve on accounts receivable	(25)	296
Provision for excess and obsolete inventory	572	429
Changes in operating assets and liabilities:
Accounts receivable	584	2,463
Inventories	1,128	(4,999)
Prepaid and other assets	(126)	(890)
Accounts payable	(592)	626
Accrued liabilities	(1,383)	(589)
Net cash provided by (used in) operating activities	16	(1,647)
Investing activities:
Purchases of property and equipment and intangible assets	(1,489)	(907)
Proceeds from sale of fixed assets	194	173
Net cash used in investing activities	(1,295)	(734)
Financing activities:
Payment of taxes from withholding of common stock on vesting of restricted stock units	(23)
Payments on financing leases	(42)	(115)
Costs associated with refinancing	(136)
Payments on long-term debt	(411)
Borrowings on line of credit	22,767
Repayments of line of credit	(23,029)
Proceeds from private placement, net of cash issuance costs	18,426
Net cash provided by (used in) financing activities	17,552	(115)
Net change in cash and cash equivalents	16,273	(2,496)
Cash and cash equivalents at beginning of period	2,341	5,237
Cash and cash equivalents at end of period	18,614	2,741
Reconciliation of cash and restricted cash reported in the condensed consolidated balance sheets
Cash and cash equivalents	18,175	2,741
Restricted cash	439
Total cash and restricted cash reported in the condensed consolidated balance sheets	$ 18,614	$ 2,741

Business Description, Basis of

Business Description, Basis of Presentation and Summary of Significant Accounting Policies	9 Months Ended
	Sep. 30, 2021
Organization, Consolidation and Presentation of Financial Statements [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 and more recently as a result of the recent surge in cases and hospitalizations caused by the Delta variant, hospitals and other medical facilities have 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 these circumstances, surgeons and their patients have, and may continue to, defer procedures in which our products otherwise would be used. In addition, many facilities that specialize in procedures in which our products are used have experienced staffing shortages, temporary closures, and/or reduced operating hours. These circumstances have negatively impacted, and may continue to negatively impact, the number of elective procedures being conducted and the ability of our employees, independent sales representatives and distributors to effectively market and sell our products. This is particularly true during the third quarter of 2021, and most acutely starting in August, when spine and other surgery procedure volumes were negatively impacted in many of our key markets, due to cancellations and/or postponements of procedures as a result of the increased hospitalizations, restrictions on elective procedures and staffing shortages, which negatively impacted our third quarter 2021 revenues and may continue to negatively impact our revenues. If our revenues continue to decline in future periods and do not recover to pre-COVID-19 pandemic levels, we may be required to incur impairment charges to our long-lived assets and goodwill and write-down excess inventory, which would likely adversely affect our future operating results. 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. Reclassifications Certain prior year amounts have been reclassified to conform with current year 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 2.25 6,666,668 18.4 The Investor Warrant, described in more detail in Note 10, “Warrants”, 2.25 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 served 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 5.0 444,444 Note 10, “Warrants”, 2.8125 five-year 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 options and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates. Restricted Cash Cash and cash equivalents classified as restricted cash on our condensed consolidated balance sheets are restricted as to withdrawal or use under the terms of certain credit agreements. The September 30, 2021 balance included lockbox deposits that are temporarily restricted due to timing at the period end. The lockbox deposits are applied against our line of credit the next business day. 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. No 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 Net Income (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 and nine months ended September 30, 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 14,138,224 7,083,922 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 as of September 30, 2021 and December 31, 2020.

Revenue

Revenue	9 Months Ended
	Sep. 30, 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 the Company expects to collect in exchange for those goods or services. 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. 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, Europe, Asia Pacific, and Latin America. Sales are reported net of returns. The following table presents revenues from these product lines for the three and nine months ended September 30, 2021 and 2020 (in thousands): Summary of Revenues From Product Lines Three Months Ended Percentage Three Months Ended Percentage September 30, 2021 of Total Revenue September 30, 2020 of Total Revenue Orthobiologics $ 10,795 78 % $ 10,542 75 % Spinal implant 2,948 22 % 3,438 25 % Other revenue 34 0 % 36 0 % Total revenue $ 13,777 100 % $ 14,016 100 % Nine Months Ended Percentage Nine Months Ended Percentage September 30, 2021 of Total Revenue September 30, 2020 of Total Revenue Orthobiologics $ 31,264 76 % $ 28,613 73 % Spinal implant 9,929 24 % 10,594 27 % Other revenue 100 0 % 115 0 % Total revenue $ 41,293 100 % $ 39,322 100 %

Receivables

Receivables	9 Months Ended
	Sep. 30, 2021
Credit Loss [Abstract]
Receivables	3) Receivables The Company’s provision for current expected credit loss 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 September 30, 2021 and 2020 (in thousands): Schedule of Allowance for Credit Losses September 30, 2021 September 30, 2020 Balance at January 1 $ 653 $ 547 Provision for current expected credit losses (63 ) 138 Write-offs charged against allowance (36 ) (17 ) Balance at March 31 554 668 Provision for current expected credit losses (81 ) 66 Write-offs charged against allowance (3 ) (6 ) Balance at June 30 470 728 Provision for current expected credit losses 118 92 Write-offs charged against allowance (12 ) (74 ) Balance at September 30 $ 576 $ 746

Inventories

Inventories	9 Months Ended
	Sep. 30, 2021
Inventory Disclosure [Abstract]
Inventories	(4) Inventories Inventories consist of the following (in thousands): Schedule of Inventories September 30, 2021 December 31, 2020 Raw materials $ 5,927 $ 3,757 Work in process 674 1,733 Finished goods 13,107 15,918 Total $ 19,708 $ 21,408

Property and Equipment, Net

Property and Equipment, Net	9 Months Ended
	Sep. 30, 2021
Property, Plant and Equipment [Abstract]
Property and Equipment, Net	(5) Property and Equipment, Net Property and equipment, net are as follows (in thousands): Schedule of Property and Equipment, Net September 30, 2021 December 31, 2020 Equipment $ 5,195 $ 4,950 Computer equipment 670 649 Computer software 490 570 Leasehold improvements 4,022 3,987 Surgical instruments 11,647 11,291 Total cost 22,024 21,447 Less: accumulated depreciation (17,053 ) (17,100 ) Property and equipment, net $ 4,971 $ 4,347 Depreciation expense related to property and equipment, including property under finance leases, for the three months ended September 30, 2021 and 2020 was $ 0.3 0.5 1 1.6

Intangible Assets

Intangible Assets	9 Months Ended
	Sep. 30, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible Assets	(6) Intangible Assets The following table sets forth information regarding intangible assets (in thousands): Schedule of Intangible Assets September 30, 2021 December 31, 2020 Patents $ 847 $ 847 Accumulated amortization (433 ) (390 ) Intangible assets, net $ 414 $ 457

Accrued Liabilities

Accrued Liabilities	9 Months Ended
	Sep. 30, 2021
Payables and Accruals [Abstract]
Accrued Liabilities	(7) Accrued Liabilities Accrued liabilities consist of the following (in thousands): Schedule of Accrued Liabilities September 30, 2021 December 31, 2020 Cash compensation/commissions payable $ 2,991 $ 4,057 Other accrued liabilities 1,088 1,405 Accrued liabilities $ 4,079 $ 5,462

Debt

Debt	9 Months Ended
	Sep. 30, 2021
Debt Disclosure [Abstract]
Debt	(8) Debt The Company had a credit facility with OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) (the “Prior Credit Agreement”), which was scheduled to mature on December 31, 2021, but was extinguished prior to maturity and replaced by the credit agreements with MidCap Financial Trust described below. On May 6, 2021, the Company, as guarantor, and its subsidiaries, as borrowers (collectively, the “Borrowers”), entered into a Credit, Security and Guaranty Agreement (Term Loan) (the “Term Credit Agreement”) and Credit, Security and Guaranty Agreement (Revolving Loan) (the “Revolving Credit Agreement,” and, together with the Term Credit Agreement, the “Credit Agreements”) with MidCap Financial Trust, in its capacity as agent (“MidCap”) . The Term Credit Agreement provides for a secured term loan facility (the “Term Facility”) in an aggregate principal amount of $ 12.0 5.0 8.0 The Facilities have a maturity date of May 1, 2026 0.8 15.6 The loans and other obligations pursuant to the Credit Agreements 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 4.50 1.00 8.83 In addition to paying interest on the outstanding loans under the Facilities, the Borrowers are also required to pay an unused line fee equal to 0.50% per annum in respect of unutilized commitments under the Revolving Facility, a fee for failure to maintain a minimum balance under the Revolving Facility, a collateral management fee under the Revolving Facility equal to 0.50% of the amount outstanding under the Revolving Facility, an origination fee equal to 0.50% of the Revolving Loan Commitment and 0.50% of the Term Loan Commitment, and if activated, of any additional term loan tranche, and certain other customary fees related to the Agent’s administration of the Facilities The Credit Agreements contain affirmative and negative covenants customarily applicable to senior secured credit facilities, including covenants that, among other things, limit or restrict the ability of the Borrowers, subject to negotiated exceptions, to incur additional indebtedness and additional liens on their assets, engage in mergers or acquisitions or dispose of assets, pay dividends or make other distributions, voluntarily prepay other indebtedness, enter into transactions with affiliated persons, make investments, and change the nature of their businesses. In addition, the Credit Agreements require the Borrowers and the Company to maintain net product revenue at or above minimum levels and to maintain a minimum adjusted EBITDA and a minimum liquidity, in each case at levels specified in the Credit Agreements. As of September 30, 2021, we were in compliance with all covenants under the Credit Agreements. Long-term debt consists of the following (in thousands): Schedule of Long-term Debt September 30, 2021 December 31, 2020 Amounts due under the Term Facility $ 12,000 $ — Amounts due under the Second Amended and Restated Credit Agreement — 15,556 Premium related to Second Amendment — 1,241 Less: unamortized debt issuance costs (322 ) — Less: current maturities — (16,797 ) Long-term debt $ 11,678 $ —

Stock-Based Compensation

Stock-Based Compensation	9 Months Ended
	Sep. 30, 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 nine months ended September 30, 2021 and 2020: Schedule of Share-based Compensation, Stock Options, Activity 2021 2020 Shares Weighted Average Exercise Price Per Share Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Exercise Price Per Share Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Granted 1,012,083 $ 1.27 $ 1.07 239,884 $ 1.13 $ 0.90 Cancelled or expired (269 ) $ 314.19 $ 153.41 (120,738 ) $ 6.42 $ 4.05 Outstanding at September 30 3,202,706 $ 1.92 $ 1.45 722,112 $ 4.37 $ 2.96 Exercisable at September 30 210,028 $ 9.02 $ 5.69 49,979 $ 33.70 $ 19.67 Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the nine months ended September 30, 2021 and 2020: Schedule of Restricted Stock Activity 2021 2020 Shares Weighted Average Value at Date Per Share Shares Weighted Average Value at Date Per Outstanding at January 1 2,503,698 $ 1.54 499,914 $ 2.93 Granted 1,249,002 $ 1.27 679,803 $ 1.36 Vested (349,572 ) $ 1.92 (79,069 ) $ 2.37 Outstanding at September 30 3,403,128 $ 1.40 1,100,648 $ 2.00

Warrants

Warrants	9 Months Ended
	Sep. 30, 2021
Warrants
Warrants	(10) Warrants As noted in Note 1, “ Business Description, Basis of Presentation and Summary of Significant Accounting Policies 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 61 Our warrant activity during the nine months ended September 30, 2021 was as follows: Schedule of Warrant Activity Common Stock Warrants Weighted Average Exercise Price Outstanding at January 1, 2021 421,278 $ 10.80 Issued 7,111,112 2.29 Outstanding at September 30, 2021 7,532,390 $ 2.76

Commitments and Contingencies

Commitments and Contingencies	9 Months Ended
	Sep. 30, 2021
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies	(11) Commitments and Contingencies Operating Leases We lease three office facilities as of September 30, 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. 3.2 Present Value of Long-term Leases Schedule of Lease Liability (in thousands): September 30, 2021 Right-of-use assets, net $ 1,369 Current portion of lease liability $ 451 Lease liability, less current portion 961 Total lease liability $ 1,412 Future minimum payments for the next five years and thereafter as of September 30, 2021 under these long-term operating leases are as follows (in thousands): Schedule of Future Minimum Rental Payments for Operating Leases 2021 Remainder of 2021 $ 127 2022 521 2023 489 2024 224 2025 179 Total future minimum lease payments 1,540 Less amount representing interest (128 ) Present value of obligations under operating leases 1,412 Less current portion (451 ) Long-term operating lease obligations $ 961 Rent expense was $ 0.1 0.4 Litigation In November 2020, we received a letter from a third party’s legal counsel alleging that some of our hardware products allegedly infringe an expired patent and offering to discuss settlement terms. Without admitting any liability, in July 2021, we entered into a confidential settlement agreement and release that included, among other things, a full release of all asserted patent claims from the third party and otherwise settled the dispute in exchange for a one-time lump sum payment of $ 550,000 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. 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	9 Months Ended
	Sep. 30, 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 applicable 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 and nine months ended September 30, 2021 and 2020.

Supplemental Disclosure of Cash

Supplemental Disclosure of Cash Flow Information	9 Months Ended
	Sep. 30, 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): Schedule of Supplemental Cash Flow Information 2021 2020 Nine Months Ended September 30, 2021 2020 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 485 $ 13 Non-cash activities: Gain on extinguishment of Second A&R Credit Agreement $ 786 $ — Extinguishment of Second A&R Credit Agreement financed by line of credit $ 3,755 $ — Prepaid debt issuance costs $ 75 $ — 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 Recognition or warrants issued in connect with debt modification $ — $ 1,862

Related Party Transactions

Related Party Transactions	9 Months Ended
	Sep. 30, 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 8, “ Debt In addition, as described in more detail under Note 1, “ Business Description and Summary of Significant Accounting Policies 84 % of the Company’s common stock. All related party transactions are reviewed and approved by the Audit Committee or the disinterested members of the full board of directors.

Segment and Geographic Informat

Segment and Geographic Information	9 Months Ended
	Sep. 30, 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 99 98 99 98 Schedule of Revenues by Geographic Region Three Months Ended 2021 2020 United States $ 13,629 $ 13,773 Rest of world 148 243 Total revenue $ 13,777 $ 14,016 Nine Months Ended 2021 2020 United States $ 40,813 $ 38,340 Rest of world 480 982 Total revenue $ 41,293 $ 39,322

Business Description, Basis o_2

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Policies)	9 Months Ended
	Sep. 30, 2021
Organization, Consolidation and Presentation of Financial Statements [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 and more recently as a result of the recent surge in cases and hospitalizations caused by the Delta variant, hospitals and other medical facilities have 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 these circumstances, surgeons and their patients have, and may continue to, defer procedures in which our products otherwise would be used. In addition, many facilities that specialize in procedures in which our products are used have experienced staffing shortages, temporary closures, and/or reduced operating hours. These circumstances have negatively impacted, and may continue to negatively impact, the number of elective procedures being conducted and the ability of our employees, independent sales representatives and distributors to effectively market and sell our products. This is particularly true during the third quarter of 2021, and most acutely starting in August, when spine and other surgery procedure volumes were negatively impacted in many of our key markets, due to cancellations and/or postponements of procedures as a result of the increased hospitalizations, restrictions on elective procedures and staffing shortages, which negatively impacted our third quarter 2021 revenues and may continue to negatively impact our revenues. If our revenues continue to decline in future periods and do not recover to pre-COVID-19 pandemic levels, we may be required to incur impairment charges to our long-lived assets and goodwill and write-down excess inventory, which would likely adversely affect our future operating results. 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.
Reclassifications	Reclassifications Certain prior year amounts have been reclassified to conform with current year 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 2.25 6,666,668 18.4 The Investor Warrant, described in more detail in Note 10, “Warrants”, 2.25 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 served 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 5.0 444,444 Note 10, “Warrants”, 2.8125 five-year
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 options and other equity awards upon which the Company determines stock-based compensation expense. Actual results could differ from those estimates.
Restricted Cash	Restricted Cash Cash and cash equivalents classified as restricted cash on our condensed consolidated balance sheets are restricted as to withdrawal or use under the terms of certain credit agreements. The September 30, 2021 balance included lockbox deposits that are temporarily restricted due to timing at the period end. The lockbox deposits are applied against our line of credit the next business day.
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. No
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
Net Income (Loss) Per Share	Net Income (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 and nine months ended September 30, 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 14,138,224 7,083,922
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 as of September 30, 2021 and December 31, 2020.

Revenue (Tables)

Revenue (Tables)	9 Months Ended
	Sep. 30, 2021
Revenue from Contract with Customer [Abstract]
Summary of Revenues From Product Lines	Summary of Revenues From Product Lines Three Months Ended Percentage Three Months Ended Percentage September 30, 2021 of Total Revenue September 30, 2020 of Total Revenue Orthobiologics $ 10,795 78 % $ 10,542 75 % Spinal implant 2,948 22 % 3,438 25 % Other revenue 34 0 % 36 0 % Total revenue $ 13,777 100 % $ 14,016 100 % Nine Months Ended Percentage Nine Months Ended Percentage September 30, 2021 of Total Revenue September 30, 2020 of Total Revenue Orthobiologics $ 31,264 76 % $ 28,613 73 % Spinal implant 9,929 24 % 10,594 27 % Other revenue 100 0 % 115 0 % Total revenue $ 41,293 100 % $ 39,322 100 %

Receivables (Tables)

Receivables (Tables)	9 Months Ended
	Sep. 30, 2021
Credit Loss [Abstract]
Schedule of Allowance for Credit Losses	Schedule of Allowance for Credit Losses September 30, 2021 September 30, 2020 Balance at January 1 $ 653 $ 547 Provision for current expected credit losses (63 ) 138 Write-offs charged against allowance (36 ) (17 ) Balance at March 31 554 668 Provision for current expected credit losses (81 ) 66 Write-offs charged against allowance (3 ) (6 ) Balance at June 30 470 728 Provision for current expected credit losses 118 92 Write-offs charged against allowance (12 ) (74 ) Balance at September 30 $ 576 $ 746

Inventories (Tables)

Inventories (Tables)	9 Months Ended
	Sep. 30, 2021
Inventory Disclosure [Abstract]
Schedule of Inventories	Inventories consist of the following (in thousands): Schedule of Inventories September 30, 2021 December 31, 2020 Raw materials $ 5,927 $ 3,757 Work in process 674 1,733 Finished goods 13,107 15,918 Total $ 19,708 $ 21,408

Property and Equipment, Net (Ta

Property and Equipment, Net (Tables)	9 Months Ended
	Sep. 30, 2021
Property, Plant and Equipment [Abstract]
Schedule of Property and Equipment, Net	Property and equipment, net are as follows (in thousands): Schedule of Property and Equipment, Net September 30, 2021 December 31, 2020 Equipment $ 5,195 $ 4,950 Computer equipment 670 649 Computer software 490 570 Leasehold improvements 4,022 3,987 Surgical instruments 11,647 11,291 Total cost 22,024 21,447 Less: accumulated depreciation (17,053 ) (17,100 ) Property and equipment, net $ 4,971 $ 4,347

Intangible Assets (Tables)

Intangible Assets (Tables)	9 Months Ended
	Sep. 30, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Intangible Assets	The following table sets forth information regarding intangible assets (in thousands): Schedule of Intangible Assets September 30, 2021 December 31, 2020 Patents $ 847 $ 847 Accumulated amortization (433 ) (390 ) Intangible assets, net $ 414 $ 457

Accrued Liabilities (Tables)

Accrued Liabilities (Tables)	9 Months Ended
	Sep. 30, 2021
Payables and Accruals [Abstract]
Schedule of Accrued Liabilities	Accrued liabilities consist of the following (in thousands): Schedule of Accrued Liabilities September 30, 2021 December 31, 2020 Cash compensation/commissions payable $ 2,991 $ 4,057 Other accrued liabilities 1,088 1,405 Accrued liabilities $ 4,079 $ 5,462

Debt (Tables)

Debt (Tables)	9 Months Ended
	Sep. 30, 2021
Debt Disclosure [Abstract]
Schedule of Long-term Debt	Long-term debt consists of the following (in thousands): Schedule of Long-term Debt September 30, 2021 December 31, 2020 Amounts due under the Term Facility $ 12,000 $ — Amounts due under the Second Amended and Restated Credit Agreement — 15,556 Premium related to Second Amendment — 1,241 Less: unamortized debt issuance costs (322 ) — Less: current maturities — (16,797 ) Long-term debt $ 11,678 $ —

Stock-Based Compensation (Table

Stock-Based Compensation (Tables)	9 Months Ended
	Sep. 30, 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 nine months ended September 30, 2021 and 2020: Schedule of Share-based Compensation, Stock Options, Activity 2021 2020 Shares Weighted Average Exercise Price Per Share Weighted Average Fair Value at Grant Date Per Share Shares Weighted Average Exercise Price Per Share Weighted Average Fair Value at Grant Date Per Share Outstanding at January 1 2,190,892 $ 2.25 $ 1.65 602,966 $ 6.07 $ 3.99 Granted 1,012,083 $ 1.27 $ 1.07 239,884 $ 1.13 $ 0.90 Cancelled or expired (269 ) $ 314.19 $ 153.41 (120,738 ) $ 6.42 $ 4.05 Outstanding at September 30 3,202,706 $ 1.92 $ 1.45 722,112 $ 4.37 $ 2.96 Exercisable at September 30 210,028 $ 9.02 $ 5.69 49,979 $ 33.70 $ 19.67
Schedule of Restricted Stock Activity	Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the nine months ended September 30, 2021 and 2020: Schedule of Restricted Stock Activity 2021 2020 Shares Weighted Average Value at Date Per Share Shares Weighted Average Value at Date Per Outstanding at January 1 2,503,698 $ 1.54 499,914 $ 2.93 Granted 1,249,002 $ 1.27 679,803 $ 1.36 Vested (349,572 ) $ 1.92 (79,069 ) $ 2.37 Outstanding at September 30 3,403,128 $ 1.40 1,100,648 $ 2.00

Warrants (Tables)

Warrants (Tables)	9 Months Ended
	Sep. 30, 2021
Warrants
Schedule of Warrant Activity	Our warrant activity during the nine months ended September 30, 2021 was as follows: Schedule of Warrant Activity Common Stock Warrants Weighted Average Exercise Price Outstanding at January 1, 2021 421,278 $ 10.80 Issued 7,111,112 2.29 Outstanding at September 30, 2021 7,532,390 $ 2.76

Commitments and Contingencies (

Commitments and Contingencies (Tables)	9 Months Ended
	Sep. 30, 2021
Commitments and Contingencies Disclosure [Abstract]
Schedule of Lease Liability	Present Value of Long-term Leases Schedule of Lease Liability (in thousands): September 30, 2021 Right-of-use assets, net $ 1,369 Current portion of lease liability $ 451 Lease liability, less current portion 961 Total lease liability $ 1,412
Schedule of Future Minimum Rental Payments for Operating Leases	Future minimum payments for the next five years and thereafter as of September 30, 2021 under these long-term operating leases are as follows (in thousands): Schedule of Future Minimum Rental Payments for Operating Leases 2021 Remainder of 2021 $ 127 2022 521 2023 489 2024 224 2025 179 Total future minimum lease payments 1,540 Less amount representing interest (128 ) Present value of obligations under operating leases 1,412 Less current portion (451 ) Long-term operating lease obligations $ 961

Supplemental Disclosure of Ca_2

Supplemental Disclosure of Cash Flow Information (Tables)	9 Months Ended
	Sep. 30, 2021
Supplemental Cash Flow Elements [Abstract]
Schedule of Supplemental Cash Flow Information	Supplemental cash flow information is as follows (in thousands): Schedule of Supplemental Cash Flow Information 2021 2020 Nine Months Ended September 30, 2021 2020 Supplemental disclosure of cash flow information Cash paid during the period for: Interest $ 485 $ 13 Non-cash activities: Gain on extinguishment of Second A&R Credit Agreement $ 786 $ — Extinguishment of Second A&R Credit Agreement financed by line of credit $ 3,755 $ — Prepaid debt issuance costs $ 75 $ — 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 Recognition or warrants issued in connect with debt modification $ — $ 1,862

Segment and Geographic Inform_2

Segment and Geographic Information (Tables)	9 Months Ended
	Sep. 30, 2021
Segment Reporting [Abstract]
Schedule of Revenues by Geographic Region	Schedule of Revenues by Geographic Region Three Months Ended 2021 2020 United States $ 13,629 $ 13,773 Rest of world 148 243 Total revenue $ 13,777 $ 14,016 Nine Months Ended 2021 2020 United States $ 40,813 $ 38,340 Rest of world 480 982 Total revenue $ 41,293 $ 39,322

Business Description, Basis o_3

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Details Narrative) - USD ($)	Feb. 24, 2021	Sep. 30, 2021	Sep. 30, 2021	Sep. 30, 2020
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Proceeds from private placement			$ 18,426,000
Impairments of long-lived assets		$ 0		0
Impairments of goodwill		$ 0		$ 0
Antidilutive securities excluded from computation of earnings per share, amount			14,138,224	7,083,922
Investor [Member] | Private Placement [Member]
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Stock issued during period, shares, new issues	8,888,890
Stock issued price per share	$ 2.25
Proceeds from private placement	$ 18,400,000
Investor [Member] | Private Placement [Member] | Placement Agent Agreement [Member]
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Stock issued during period, shares, new issues	444,444
Warrants exercise price percentage	5.00%
Investor [Member] | Private Placement Warrant [Member] | Placement Agent Agreement [Member]
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Warrant exercise price	$ 2.8125
Warrant term	5 years
Investor Warrant [Member] | Private Placement [Member]
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Warrants to purchase common stock	6,666,668
Warrant exercise price	$ 2.25

Summary of Revenues From Produc

Summary of Revenues From Product Lines (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Disaggregation of Revenue [Line Items]
Total revenue	$ 13,777	$ 14,016	$ 41,293	$ 39,322
Percentage of total revenue	100.00%	100.00%	100.00%	100.00%
Orthobiologics [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 10,795	$ 10,542	$ 31,264	$ 28,613
Percentage of total revenue	78.00%	75.00%	76.00%	73.00%
Spinal Implant [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 2,948	$ 3,438	$ 9,929	$ 10,594
Percentage of total revenue	22.00%	25.00%	24.00%	27.00%
Other Revenue [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 34	$ 36	$ 100	$ 115
Percentage of total revenue	0.00%	0.00%	0.00%	0.00%

Schedule of Allowance for Credi

Schedule of Allowance for Credit Losses (Details) - USD ($) $ in Thousands	3 Months Ended						9 Months Ended
	Sep. 30, 2021	Jun. 30, 2021	Mar. 31, 2021	Sep. 30, 2020	Jun. 30, 2020	Mar. 31, 2020	Sep. 30, 2021	Sep. 30, 2020
Credit Loss [Abstract]
Beginning balance	$ 470	$ 554	$ 653	$ 728	$ 668	$ 547	$ 653	$ 547
Provision for expected credit losses	118	(81)	(63)	92	66	138	(25)	296
Write-offs charged against allowance	(12)	(3)	(36)	(74)	(6)	(17)
Ending balance	$ 576	$ 470	$ 554	$ 746	$ 728	$ 668	$ 576	$ 746

Schedule of Inventories (Detail

Schedule of Inventories (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Inventory Disclosure [Abstract]
Raw materials	$ 5,927	$ 3,757
Work in process	674	1,733
Finished goods	13,107	15,918
Total	$ 19,708	$ 21,408

Schedule of Property and Equipm

Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Total cost	$ 22,024	$ 21,447
Less: accumulated depreciation	(17,053)	(17,100)
Property and equipment, net	4,971	4,347
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	5,195	4,950
Computer Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	670	649
Computer Software [Member]
Property, Plant and Equipment [Line Items]
Total cost	490	570
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	4,022	3,987
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 11,647	$ 11,291

Property and Equipment, Net (De

Property and Equipment, Net (Details Narrative) - USD ($) $ in Millions	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Property, Plant and Equipment [Abstract]
Depreciation expense	$ 0.3	$ 0.5	$ 1	$ 1.6

Schedule of Intangible Assets (

Schedule of Intangible Assets (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Patents	$ 847	$ 847
Accumulated amortization	(433)	(390)
Intangible assets, net	$ 414	$ 457

Schedule of Accrued Liabilities

Schedule of Accrued Liabilities (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Payables and Accruals [Abstract]
Cash compensation/commissions payable	$ 2,991	$ 4,057
Other accrued liabilities	1,088	1,405
Accrued liabilities	$ 4,079	$ 5,462

Schedule of Long-term Debt (Det

Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Debt Disclosure [Abstract]
Amounts due under the Term Facility	$ 12,000
Amounts due under the Second Amended and Restated Credit Agreement		15,556
Premium related to Second Amendment		1,241
Less: unamortized debt issuance costs	(322)
Less: current maturities		(16,797)
Long-term debt	$ 11,678

Debt (Details Narrative)

Debt (Details Narrative) - USD ($) $ in Thousands	May 06, 2021	Sep. 30, 2021	Sep. 30, 2020
Debt Instrument [Line Items]
Line of credit facility, maturity date	May 1, 2026
Gain on extinguishment		$ 786
Line of credit, interest rate	7.00%
Term Loan Commitment [Member]
Debt Instrument [Line Items]
Line of credit facility, maximum borrowing capacity	$ 12,000
Line of credit, interest rate	4.50%
Term Loan Commitment [Member] | Agent and Lenders [Member]
Debt Instrument [Line Items]
Line of credit facility, maximum borrowing capacity	$ 5,000
Revolving Loan Commitment [Member]
Debt Instrument [Line Items]
Line of credit facility, maximum borrowing capacity	$ 8,000
Revolving Loan Commitment [Member] | London Interbank Offered Rate (LIBOR) [Member]
Debt Instrument [Line Items]
Line of credit, interest rate	1.00%
Second A&R Credit Agreement [Member]
Debt Instrument [Line Items]
Gain on extinguishment	$ 800
Reacquisition price	$ 15,600
Credit Agreements [Member]
Debt Instrument [Line Items]
Effective tax rate		8.83%
Line of credit, description	In addition to paying interest on the outstanding loans under the Facilities, the Borrowers are also required to pay an unused line fee equal to 0.50% per annum in respect of unutilized commitments under the Revolving Facility, a fee for failure to maintain a minimum balance under the Revolving Facility, a collateral management fee under the Revolving Facility equal to 0.50% of the amount outstanding under the Revolving Facility, an origination fee equal to 0.50% of the Revolving Loan Commitment and 0.50% of the Term Loan Commitment, and if activated, of any additional term loan tranche, and certain other customary fees related to the Agent’s administration of the Facilities

Schedule of Share-based Compens

Schedule of Share-based Compensation, Stock Options, Activity (Details) - Equity Option [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Shares, Outstanding, Beginning Balance	2,190,892	602,966
Weighted Average Exercise Price, Outstanding Beginning Balance	$ 2.25	$ 6.07
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 1.65	$ 3.99
Shares, Granted	1,012,083	239,884
Weighted Average Exercise Price, Granted	$ 1.27	$ 1.13
Weighted Average Fair Value at Grant Date, Granted	$ 1.07	$ 0.90
Shares, Cancelled or expired	(269)	(120,738)
Weighted Average Exercise Price, Cancelled or expired	$ 314.19	$ 6.42
Weighted Average Fair Value at Grant Date, Cancelled or expired	$ 153.41	$ 4.05
Shares, Outstanding, Ending Balance	3,202,706	722,112
Weighted Average Exercise Price, Outstanding Ending Balance	$ 1.92	$ 4.37
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 1.45	$ 2.96
Shares, Exercisable, Ending Balance	210,028	49,979
Weighted Average Exercise Price, Exercisable Ending Balance	$ 9.02	$ 33.70
Weighted Average Fair Value at Grant Date, Exercisable, Ending Balance	$ 5.69	$ 19.67

Schedule of Restricted Stock Ac

Schedule of Restricted Stock Activity (Details) - Restricted Stock Units (RSUs) [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Shares Outstanding, Beginning Balance	2,503,698	499,914
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 1.54	$ 2.93
Shares Granted	1,249,002	679,803
Weighted Average Fair Value at Grant Date, Granted	$ 1.27	$ 1.36
Shares Vested	(349,572)	(79,069)
Weighted Average Fair Value at Grant Date, Vested	$ 1.92	$ 2.37
Shares Outstanding, Ending Balance	3,403,128	1,100,648
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 1.40	$ 2

Schedule of Warrant Activity (D

Schedule of Warrant Activity (Details) shares in Thousands	9 Months Ended
	Sep. 30, 2021$ / sharesshares
Warrants
Common Stock Warrants Outstanding, Beginning Balance | shares	421,278
Weighted Average Exercise Price Outstanding Beginning Balance | $ / shares	$ 10.80
Common Stock Warrants, Issued | shares	7,111,112
Weighted Average Exercise Price, Issued | $ / shares	$ 2.29
Common Stock Warrants Outstanding, Ending Balance | shares	7,532,390
Weighted Average Exercise Price Outstanding Ending Balance | $ / shares	$ 2.76

Warrants (Details Narrative)

Warrants (Details Narrative)	Sep. 30, 2021
Measurement Input, Expected Term [Member]
Fair Value Measurement Inputs and Valuation Techniques [Line Items]
Warrants contractual term	5 years
Measurement Input, Price Volatility [Member]
Fair Value Measurement Inputs and Valuation Techniques [Line Items]
Warrants and rights outstanding, measurement input	0.61

Schedule of Lease Liability (De

Schedule of Lease Liability (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Right-of-use assets, net	$ 1,369	$ 1,690
Current portion of lease liability	451	423
Lease liability, less current portion	961	$ 1,303
Total lease liability	$ 1,412

Schedule of Future Minimum Rent

Schedule of Future Minimum Rental Payments for Operating Leases (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Remainder of 2021	$ 127
2022	521
2023	489
2024	224
2025	179
Total future minimum lease payments	1,540
Less amount representing interest	(128)
Present value of obligations under operating leases	1,412
Less current portion	(451)	$ (423)
Long-term operating lease obligations	$ 961	$ 1,303

Commitments and Contingencies_2

Commitments and Contingencies (Details Narrative) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020	Jul. 02, 2021
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
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.
Weighted-average remaining lease term	3 years 2 months 12 days		3 years 2 months 12 days
Rent expense	$ 100,000	$ 100,000	$ 400,000	$ 400,000
Settlement Agreement [Member]
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Reserve for one-time lump sum amount					$ 550,000

Schedule of Supplemental Cash F

Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Supplemental Cash Flow Elements [Abstract]
Interest	$ 485	$ 13
Gain on extinguishment of Second A&R Credit Agreement	786
Extinguishment of Second A&R Credit Agreement financed by line of credit	3,755
Prepaid debt issuance costs	75
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
Recognition or warrants issued in connect with debt modification		$ 1,862

Related Party Transactions (Det

Related Party Transactions (Details Narrative)	Sep. 30, 2021
OrbiMed Advisors LLC Member]
Related Party Transaction [Line Items]
Equity Method Investment, Ownership Percentage	84.00%
Soleholders [Member]
Related Party Transaction [Line Items]
Equity Method Investment, Ownership Percentage	20.00%

Schedule of Revenues by Geograp

Schedule of Revenues by Geographic Region (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	$ 13,777	$ 14,016	$ 41,293	$ 39,322
UNITED STATES
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	13,629	13,773	40,813	38,340
Rest of World [Member]
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	$ 148	$ 243	$ 480	$ 982

Segment and Geographic Inform_3

Segment and Geographic Information (Details Narrative)	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Geographic Concentration Risk [Member] | Revenue from Contract with Customer Benchmark [Member] | UNITED STATES
Revenue, Major Customer [Line Items]
Concentration risk, percentage	99.00%	98.00%	99.00%	98.00%