0001493152-20-020089 | 10-Q | XBRL Viewer | Xtant Medical Holdings INC

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Document and Entity Information - shares	9 Months Ended
Document and Entity Information - shares	Sep. 30, 2020	Oct. 27, 2020
Cover [Abstract]
Entity Registrant Name	Xtant Medical Holdings, Inc.
Entity Central Index Key	0001453593
Document Type	10-Q
Document Period End Date	Sep. 30, 2020
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		72,061,034
Document Fiscal Period Focus	Q3
Document Fiscal Year Focus	2020

Condensed Consolidated Balance Sheets - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Current Assets:
Cash and cash equivalents	$ 2,741	$ 5,237
Trade accounts receivable, net of allowance for credit losses of $746 and doubtful accounts of $500, respectively	7,317	10,124
Inventories	20,671	16,101
Prepaid and other current assets	1,656	784
Total current assets	32,385	32,246
Property and equipment, net	4,122	4,695
Right-of-use asset, net	1,799	2,100
Goodwill	3,205	3,205
Intangible assets, net	471	515
Other assets	412	394
Total Assets	42,394	43,155
Current Liabilities:
Accounts payable	2,814	2,188
Accrued liabilities	6,043	6,632
Current portion of lease liability	415	394
Current portion of financing lease obligations	59	176
Total current liabilities	9,331	9,390
Long-term Liabilities:
Lease liability, less current portion	1,417	1,726
Long-term debt, plus premium and less issuance costs	79,627	76,244
Total Liabilities	90,375	87,360
Commitments and Contingencies (note 11)
Stockholders' Equity (Deficit):
Preferred stock, $0.000001 par value; 10,000,000 shares authorized; no shares issued and outstanding
Common stock, $0.000001 par value; 75,000,000 shares authorized; 13,240,831 shares issued and outstanding as of September 30, 2020 and 13,161,762 shares issued and outstanding as of December 31, 2019
Additional paid-in capital	181,649	179,061
Accumulated deficit	(229,630)	(223,266)
Total Stockholders' Equity (Deficit)	(47,981)	(44,205)
Total Liabilities & Stockholders' Equity (Deficit)	$ 42,394	$ 43,155

Condensed Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Statement of Financial Position [Abstract]
Trade accounts receivable, allowance for doubtful accounts	$ 746	$ 500
Preferred stock, par value	$ 0.000001	$ 0.000001
Preferred stock, shares authorized	10,000,000	10,000,000
Preferred stock, shares issued
Preferred stock, shares outstanding
Common stock, par value	$ 0.000001	$ 0.000001
Common stock, shares authorized	75,000,000	75,000,000
Common stock, shares issued	13,240,831	13,161,762
Common Stock, shares outstanding	13,240,831	13,161,762

Condensed Consolidated Statements of Operations (Unaudited) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Revenue
Orthopedic product sales	$ 13,980	$ 15,691	$ 39,207	$ 47,574
Other revenue	36	30	115	144
Total Revenue	14,016	15,721	39,322	47,718
Cost of sales	4,768	5,310	13,913	16,613
Gross Profit	9,248	10,411	25,409	31,105
Operating Expenses
General and administrative	3,042	4,228	10,293	12,866
Sales and marketing	5,270	6,685	15,578	19,499
Research and development	176	203	529	675
Total Operating Expenses	8,488	11,116	26,400	33,040
Income (Loss) from Operations	760	(705)	(991)	(1,935)
Other (Expense) Income
Interest expense	(2,097)	(1,185)	(5,258)	(4,504)
Other (expense) income		34		(109)
Total Other Expense	(2,097)	(1,151)	(5,258)	(4,613)
Net Loss Before Provision for Income Taxes	(1,337)	(1,856)	(6,249)	(6,548)
Provision for income taxes	(23)	(23)	(68)	(68)
Net Loss	$ (1,360)	$ (1,879)	$ (6,317)	$ (6,616)
Net loss per share:
Basic	$ (0.10)	$ (0.14)	$ (0.48)	$ (0.50)
Dilutive	$ (0.10)	$ (0.14)	$ (0.48)	$ (0.50)
Shares used in the computation:
Basic	13,231,823	13,161,762	13,210,386	13,164,694
Dilutive	13,231,823	13,161,762	13,210,386	13,164,694

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, 2018		$ 171,273	$ (215,045)	$ (43,772)
Beginning Balance, Shares at Dec. 31, 2018	13,172,179
Stock-based compensation		256		256
Forfeiture of restricted stock
Forfeiture of restricted stock, shares	(10,417)
Debt extinguishment		7,264		7,264
Issuance of warrant		9		9
Net loss			(6,616)	(6,616)
Ending Balance at Sep. 30, 2019		178,802	(221,661)	(42,859)
Ending Balance, Shares at Sep. 30, 2019	13,161,762
Beginning Balance at Jun. 30, 2019		178,707	(219,782)	(41,075)
Beginning Balance, Shares at Jun. 30, 2019	13,161,762
Stock-based compensation		95		95
Net loss			(1,879)	(1,879)
Ending Balance at Sep. 30, 2019		178,802	(221,661)	(42,859)
Ending Balance, Shares at Sep. 30, 2019	13,161,762
Beginning Balance at Dec. 31, 2019		179,061	(223,266)	(44,205)
Beginning Balance, Shares at Dec. 31, 2019	13,161,762
Stock-based compensation		726		726
Issuance of warrant		1,862		1,862
ASU 2016-13 cumulative effect adjustment			(47)	(47)
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares	79,069
Net loss			(6,317)	(6,317)
Ending Balance at Sep. 30, 2020		181,649	(229,630)	(47,981)
Ending Balance, Shares at Sep. 30, 2020	13,240,831
Beginning Balance at Jun. 30, 2020		181,412	(228,270)	(46,858)
Beginning Balance, Shares at Jun. 30, 2020	13,223,565
Stock-based compensation		237		237
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares	17,266
Net loss			(1,360)	(1,360)
Ending Balance at Sep. 30, 2020		$ 181,649	$ (229,630)	$ (47,981)
Ending Balance, Shares at Sep. 30, 2020	13,240,831

Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019
Operating activities:
Net loss	$ (6,317)	$ (6,616)
Adjustments to reconcile net loss to net cash provided by operating activities:
Depreciation and amortization	1,658	2,338
Gain on disposal of fixed assets	(307)	(27)
Non-cash interest	5,245	4,467
Non-cash rent	12	16
Stock-based compensation	726	256
Provision for reserve on accounts receivable	296	453
Provision for excess and obsolete inventory	429	517
Changes in operating assets and liabilities:
Accounts receivable	2,463	417
Inventories	(4,999)	760
Prepaid and other assets	(890)	240
Accounts payable	626	(4,216)
Accrued liabilities	(589)	1,053
Net cash (used in) provided by operating activities	(1,647)	(342)
Investing activities:
Purchases of property and equipment and intangible assets	(907)	(403)
Proceeds from sale of fixed assets	173	241
Net cash used in investing activities	(734)	(162)
Financing activities:
Payments on financing leases	(115)	(395)
Costs associated with Second Amended and Restated Credit Agreement		(149)
Net cash used in financing activities	(115)	(544)
Net change in cash and cash equivalents	(2,496)	(1,048)
Cash and cash equivalents at beginning of period	5,237	6,797
Cash and cash equivalents at end of period	$ 2,741	$ 5,749

Business Description, Basis of Presentation and Summary of Significant Accounting Policies

9 Months Ended

Sep. 30, 2020

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, 2019, 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, 2020.

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, 2019. 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.

Recent Accounting Pronouncements

In June 2016, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2016-13, Financial Instruments–Credit Losses: Measurement of Credit Losses on Financial Instruments to change the impairment model for most financial assets and certain other instruments. For trade and other receivables, held to maturity debt securities, loans, and other instruments, entities are required to use a new forward-looking “expected loss” model that generally will result in the earlier recognition of allowances for losses. The Company adopted the guidance on January 1, 2020 and recognized a cumulative effect adjustment of $47,000 to retained earnings and accounts receivable, net as a result of adoption. The Company has included the additional disclosures required by ASU 2016-13 in Note 3, “Receivables.”

Although there are several other new accounting pronouncements issued or proposed by the FASB, which the Company has adopted or will adopt, as applicable, the Company does not believe any of these accounting pronouncements has had or will have a material impact on the Company’s consolidated financial position or operating results.

Use of Estimates

The preparation of the 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 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 right-of-use asset, evaluation of ability to continue as a going concern 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.

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 and nine months ended September 30, 2020 and 2019.

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 that the carrying amount of the asset may not be recoverable. As a result of the COVID-19 pandemic and its impact on the Company’s projected cash flows, the Company evaluated goodwill for impairment at the end of the third quarter of 2020. No impairments of goodwill were recorded for the three months and nine months ended September 30, 2020 and 2019.

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 and nine months ended September 30, 2020 and 2019, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Dilutive earnings per share are not reported, as the effects of including 7,083,922 and 3,313,953 outstanding stock options, restricted stock units and warrants for the three and nine months ended September 30, 2020 and 2019, respectively, are anti-dilutive.

Fair Value of Financial Instruments

The carrying values of financial instruments, including trade accounts receivable, accounts payable, accrued liabilities, and long-term debt, approximate their fair values based on terms and related interest rates as of September 30, 2020 and December 31, 2019.

Revenue

9 Months Ended

Sep. 30, 2020

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. 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 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 and nine months ended September 30, 2020 and 2019 (in thousands):

	Three Months Ended		Percentage of			Three Months Ended		Percentage of
	September 30, 2020		Total Revenue			September 30, 2019		Total Revenue
Orthobiologics	$	10,542		75	%	$	11,342		72	%
Spinal implant		3,438		25	%		4,349		28	%
Other revenue		36		0	%		30		0	%
Total revenue	$	14,016		100	%	$	15,721		100	%

	Nine Months Ended		Percentage of			Nine Months Ended		Percentage of
	September 30, 2020		Total Revenue			September 30, 2019		Total Revenue
Orthobiologics	$	28,613		73	%	$	34,374		72	%
Spinal implant		10,594		27	%		13,200		28	%
Other revenue		115		0	%		144		0	%
Total revenue	$	39,322		100	%	$	47,718		100	%

- Definition

The entire disclosure of revenue from contract with customer to transfer good or service and to transfer nonfinancial asset. Includes, but is not limited to, disaggregation of revenue, credit loss recognized from contract with customer, judgment and change in judgment related to contract with customer, and asset recognized from cost incurred to obtain or fulfill contract with customer. Excludes insurance and lease contracts.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-URI http://asc.fasb.org/topic&trid=49130388

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 10
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130551-203045

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 13
-Subparagraph (b)(2)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130556-203045

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 9
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130550-203045

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (e)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (d)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 15
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130558-203045

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (c)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

+ Details

Receivables

9 Months Ended

Sep. 30, 2020

Credit Loss [Abstract]

Receivables

(3) Receivables

Concurrent with the adoption of ASU 2016-13, the Company’s allowance for doubtful accounts was expanded to include provision for current expected credit loss (“CECL”). The Company’s provision for CECL is determined based on historical collection experience adjusted for current economic conditions affecting collectability. Actual customer collections could differ from estimates. Account balances are charged to the allowance after all means of collection have been exhausted and the potential for recovery is considered remote. Provisions to the allowance for credit losses are charged to expense. Activity within the allowance for credit losses was as follows for the three months ended September 30, 2020 (in thousands):

Balance at January 1, 2020	$	547
Provision for expected credit losses		138
Write-offs charged against allowance		(17	)
Balance at March 31, 2020		668
Provision for expected credit losses		66
Write-offs charged against allowance		(6	)
Balance at June 30, 2020		728
Provision for expected credit losses		92
Write-offs charged against allowance		(74	)
Balance at September 30, 2020	$	746

Inventories

9 Months Ended

Sep. 30, 2020

Inventory Disclosure [Abstract]

Inventories

(4) Inventories

Inventories consist of the following (in thousands):

	September 30, 2020			December 31, 2019
Raw materials	$	4,461		$	3,805
Work in process		2,332			1,603
Finished goods		25,307			22,135
Gross inventories		32,100			27,543
Reserve for obsolescence		(11,429	)		(11,442	)
Total	$	20,671		$	16,101

Property and Equipment, Net

9 Months Ended

Sep. 30, 2020

Property, Plant and Equipment [Abstract]

Property and Equipment, Net

(5) Property and Equipment, Net

Property and equipment, net are as follows (in thousands):

	September 30, 2020			December 31, 2019
Equipment	$	4,682		$	4,250
Computer equipment		461			455
Computer software		570			570
Furniture and fixtures		133			124
Leasehold improvements		3,987			3,980
Vehicles		10			10
Surgical instruments		11,147			10,897
Total cost		20,990			20,286
Less: accumulated depreciation		(16,868	)		(15,591	)
Property and equipment, net	$	4,122		$	4,695

The Company leases certain equipment under finance leases. For financial reporting purposes, minimum lease payments relating to the assets have been capitalized. As of September 30, 2020, the Company has recorded $0.5 million of gross assets in equipment and $0.4 million of accumulated depreciation for assets subject to finance leases.

Intangible Assets

9 Months Ended

Sep. 30, 2020

Goodwill and Intangible Assets Disclosure [Abstract]

Intangible Assets

(6) Intangible Assets

The following table sets forth information regarding intangible assets (in thousands):

	September 30, 2020			December 31, 2019
Patents	$	847		$	847
Accumulated amortization		(376	)		(332	)
Intangible assets, net	$	471		$	515

Accrued Liabilities

9 Months Ended

Sep. 30, 2020

Payables and Accruals [Abstract]

Accrued Liabilities

(7) Accrued Liabilities

Accrued liabilities consist of the following (in thousands):

	September 30, 2020		December 31, 2019
Wages/commissions payable	$	3,788	$	3,902
Other accrued liabilities		2,255		2,730
Accrued liabilities	$	6,043	$	6,632

Debt

9 Months Ended

Sep. 30, 2020

Debt Disclosure [Abstract]

Debt

(8) Debt

On March 29, 2019, we entered into a Second Amended and Restated Credit Agreement (the “Second Amended and Restated Credit Agreement”) with OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) and ROS Acquisition Offshore LP (“ROS” and together with Royalty Opportunities the “Lenders”), which amended and restated the prior credit agreement with the Lenders (the “Prior Credit Agreement”). On May 6, 2020, we entered into a First Amendment to the Second Amended and Restated Credit Agreement (the “First Amendment”) with the Lenders, which among other things, provided that:

	●	No interest will accrue on the outstanding loans under the Second Amended and Restated Credit Agreement (the “Loans”) from and after March 31, 2020 until September 30, 2020;

	●	Beginning October 1, 2020 through the maturity date of the Second Amended and Restated Credit Agreement, interest payable in cash will accrue on the Loans under the Second Amended and Restated Credit Agreement at a rate per annum equal to the sum of (i) 10.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second Amended and Restated Credit Agreement) and (y) 2.3125%;

	●	The maturity date of the Loans is December 31, 2021;

	●	The Revenue Base (as such term is defined in the Second Amended and Restated Credit Agreement) financial covenant was revised through December 31, 2021; and

	●	The key person event default provision was revised to refer specifically to Sean Browne in lieu of a former executive.

On May 6, 2020, we issued warrants to purchase an aggregate of 2.4 million shares of our common stock to the Lenders, with an exercise price of $0.01 per share and an expiration date of May 6, 2030 (collectively, the “2020 Warrants”). The issuance of the 2020 Warrants was a condition to the effectiveness of the First Amendment. The First Amendment was accounted for as a debt modification whereby the recorded debt balance was discounted for the fair value of the 2020 Warrants issued and interest expense is accrued through the maturity date of the Loans at the post-amendment effective interest rate of 10.02%.

As of September 30, 2020, the Company had availability for additional delayed draw loan advances of $2.2 million, subject to Lenders’ discretion, and in addition, as of such date, the Company could request additional term loans from the Lenders in an aggregate amount up to $10.0 million, subject to Lenders’ discretion.

Long-term debt consists of the following (in thousands):

	September 30, 2020			December 31, 2019
Amounts due under the Second Amended and Restated Credit Agreement	$	76,886		$	72,657
PIK interest payable related to Second Amended and Restated Credit Agreement		—			3,280
Plus: 2% exit fee		820			399
Gross long-term debt		77,706			76,336
Premium related to First Amendment		1,974			—
Less: total debt issuance costs on Credit Agreements		(53	)		(92	)
Long-term debt, plus premium and less issuance costs	$	79,627		$	76,244

Subsequent to the end of the quarter ended September 30, 2020, in connection with the restructuring transactions described in Note 16, “Subsequent Events,” on October 1, 2020, we entered into a Second Amendment to the Second Amended and Restated Credit Agreement (the “Second Amendment”) with the Lenders, which among other things, provided for:

	●	Extinguishment by the Lenders of approximately $61.9 million of principal and paid-in-kind interest outstanding on the Loans in exchange for approximately 57.8 million shares of our common stock and the addition of a principal amount equal to prepayment fees associated with the Loans not paid in cash or exchanged for shares of our common stock;

	●	Exchange of approximately $0.9 million of prepayment fees associated with the Loans for approximately 0.9 million shares of our common stock (the “Prepayment Fee Shares”);

	●	Elimination of the availability of additional draw loan advances and reduction of available additional term loans to $5.0 million;

	●	Accrual of interest payable in cash for the remaining term of the Second Amended and Restated Credit Agreement at a rate per annum equal to the sum of (i) 7.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second Amended and Restated Credit Agreement) and (y) 1.00%; and

	●	Elimination of certain financial covenants.

The Lenders, which were the sole holders of the Company’s outstanding debt as of September 30, 2020, collectively owned approximately 70% of the Company’s outstanding common stock, and beneficially owned, with their warrants, approximately 78% of the Company’s common stock as of such date. As a result of the execution of the Second Amendment and the completion of the restructuring transactions described in Note 16, “Subsequent Events,” Royalty Opportunities is now the sole holder of our outstanding debt under our credit facility and the Lenders currently own, in the aggregate, approximately 94.5% of our outstanding common stock and all other existing stockholders of the Company own approximately 5.5% of our outstanding common stock.

Stock-Based Compensation

9 Months Ended

Sep. 30, 2020

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:

	2020							2019
	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		602,966		$	6.07	$	3.99		496,958		$	9.90	$	6.62
Granted		239,884		$	1.13	$	0.90		100,000		$	2.24	$	1.95
Cancelled or expired		(120,738	)	$	6.42	$	4.05		(448,053	)	$	4.64	$	3.69
Outstanding at September 30		722,112		$	4.37	$	2.96		148,905		$	9.12	$	6.53
Exercisable at September 30		49,979		$	33.70	$	19.67		18,135		$	52.04	$	33.67

Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the nine months ended:

	2020					2019
	Shares			Weighted Average Fair Value at Grant Date Per Share		Shares		Weighted Average Fair Value at Grant Date Per Share
Outstanding at January 1		499,914		$	2.93		40,000	$	6.20
Granted		679,803		$	1.36		89,204	$	2.74
Vested		(79,069	)	$	2.37		-	$	-
Outstanding at September 30		1,100,648		$	2.00		129,204	$	3.81

Warrants

9 Months Ended

Sep. 30, 2020

Warrants and Rights Note Disclosure [Abstract]

Warrants

(10) Warrants

2020 Warrants

As noted in Note 8, “Debt,” on May 6, 2020, the Company issued the 2020 Warrants. The fair value of the 2020 Warrants upon issuance was determined to be $1.9 million. The 2020 Warrants meet all the requirements to be classified as equity awards in accordance with Accounting Standards Codification (“ASC”) No. 815-40. The number of shares of Company common stock issuable upon exercise of the 2020 Warrants is subject to standard and customary anti-dilution provisions for stock splits, stock dividends, or similar transactions.

2019 Warrants

On April 1, 2019, the Company issued warrants to purchase an aggregate of 1.2 million shares of Company common stock to the Lenders with an exercise price of $0.01 per share and an expiration date of April 1, 2029. The issuance of the 2019 Warrants was a condition to the effectiveness of the Second Amended and Restated Credit Agreement. The fair value of the 2019 Warrants upon issuance was determined to be $9 thousand. The 2019 Warrants meet all the requirements to be classified as equity awards in accordance with ASC No. 815-40. The number of shares of Company common stock issuable upon exercise of the 2019 Warrants is subject to standard and customary anti-dilution provisions for stock splits, stock dividends, or similar transactions.

	Common Stock Warrants			Weighted Average Exercise Price
Outstanding at January 1, 2020		2,908,874		$	4.16
Issued		2,400,000			0.01
Expired		(47,712	)		85.44
Outstanding at September 30, 2020		5,261,162		$	1.53

The estimated fair value of warrants issued was derived using a valuation model with the following weighted-average assumptions:

	Nine Months Ended September 30,
	2020			2019
Risk free interest rate		2.0	%		1.7	%
Expected term in years		10.0			3.0
Volatility		105.0	%		85.0	%
Dividend yield		0.0	%		0.0	%

Commitments and Contingencies

9 Months Ended

Sep. 30, 2020

Commitments and Contingencies Disclosure [Abstract]

Commitments and Contingencies

(11) Commitments and Contingencies

Operating Leases

We lease three office facilities as of September 30, 2020 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):	September 30, 2020
Right-of-use assets, net	$	1,795

Current portion of lease liability		415
Lease liability, less current portion		1,412
Total lease liability	$	1,827

As of September 30, 2020, the weighted-average remaining lease term was 4.1 years. The Company’s lease agreements do not provide a readily determinable implicit rate nor is it available to the Company from its lessors. Instead, as of September 30, 2020, the Company estimates the weighted-average discount rate for its operating leases to be 5.2% of present value based on the incremental borrowing rate.

Future minimum payments for the next five years and thereafter as of September 30, 2020 under these long-term operating leases are as follows (in thousands):

Remainder of 2020	$	126
2021		507
2022		521
2023		489
2024		224
Thereafter		179
Total future minimum lease payments		2,046
Less amount representing interest		(219	)
Present value of obligations under operating leases		1,827
Less current portion		(415	)
Long-term operating lease obligations	$	1,412

Rent expense was $0.1 million for the three months ended September 30, 2020 and 2019 and $0.4 million for the nine months ended September 30, 2020 and 2019. We have no contingent rent agreements.

Financing Leases

Future minimum payments under finance leases are as follows as of September 30, 2020 (in thousands):

Remainder of 2020	$	59
Less amount representing interest		-
Present value of obligations under financing leases	$	59

Litigation

On December 13, 2018, a complaint was filed by RSB Spine, LLC against Xtant Medical Holdings, Inc., which claimed that some of our products, including the Irix-A Lumbar Integrated Fusion System and the Irix-C Cervical Integrated Fusion System, infringe certain of RSB Spine’s patents. On February 28, 2020, we entered into a confidential settlement and patent license agreement with RSB Spine pursuant to which we agreed to make an undisclosed settlement payment to RSB Spine and pay royalties on future sales of the two products through the expiration of the asserted patents. The settlement payment was included in accrued expenses as of December 31, 2019.

In 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

9 Months Ended

Sep. 30, 2020

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 and nine months ended September 30, 2020 and 2019.

- Definition

The entire disclosure for income taxes. Disclosures may include net deferred tax liability or asset recognized in an enterprise's statement of financial position, net change during the year in the total valuation allowance, approximate tax effect of each type of temporary difference and carryforward that gives rise to a significant portion of deferred tax liabilities and deferred tax assets, utilization of a tax carryback, and tax uncertainties information.

+ References + Details

Supplemental Disclosure of Cash Flow Information

9 Months Ended

Sep. 30, 2020

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):

	Nine Months Ended
	September,
	2020		2019
Supplemental disclosure of cash flow information
Cash paid during the period for:
Interest	$	13	$	47
Non-cash activities:
ASU 2016-13 cumulative effect adjustment	$	47	$	—
Recognition of 2020 Warrants	$	1,862	$	—
Lease liability from right-of-use assets	$	—	$	2,296
Extinguishment of the Company’s Prior Credit Agreement (including debt issuance costs)	$	—	$	79,624
Recognition of Second Amended and Restated Credit Agreement	$	—	$	72,657
Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees	$	—	$	307
Recognition of 2019 Warrants	$	—	$	9

Related Party Transactions

9 Months Ended

Sep. 30, 2020

Related Party Transactions

(14) Related Party Transactions

Royalty Opportunities and ROS, which were the sole holders of the Company’s outstanding debt as of September 30, 2020, collectively owned approximately 70% of the Company’s outstanding common stock, and beneficially owned, with their warrants, approximately 78% of the Company’s common stock as of such date. As a result of the completion of the restructuring transactions described in Note 16, “Subsequent Events,” Royalty Opportunities and ROS currently own, in the aggregate, approximately 94.5% of the outstanding common stock and all other existing stockholders of the Company own approximately 5.5% of the outstanding common stock, and Royalty Opportunities is currently the sole holder of our outstanding debt.

In addition, as described in more detail under Note 1, “Business Description and Summary of Significant Accounting Policies” in the Company’s Annual Report on Form 10-K for the year ended December 31, 2019 and Note 16, “Subsequent Events,” we are party to an Investor Rights Agreement and Registration Rights Agreements with Royalty Opportunities and ROS.

On January 22, 2020, the Company amended its Sublease Agreement with Cardialen, Inc., reducing monthly rent to $1,350 per month. Because Jeffrey Peters is both a member of our Board and the Chief Executive Officer, President, and a Director of Cardialen, this transaction qualifies as a related party transaction.

All related party transactions are reviewed and approved by the Audit Committee or the disinterested members of the full Board.

Segment and Geographic Information

9 Months Ended

Sep. 30, 2020

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 three months ended September 30, 2020 and 2019, respectively, and 98% and 96% for the nine months ended September 30, 2020 and 2019, respectively. Total revenue by major geographic area is as follows (in thousands):

	Three Months Ended September 30,
	2020		2019
United States	$	13,773	$	15,097
Rest of world		243		624
Total revenue	$	14,016	$	15,721

	Nine Months Ended September 30,
	2020		2019
United States	$	38,340	$	45,781
Rest of world		982		1,937
Total revenue	$	39,322	$	47,718

- Definition

The entire disclosure for reporting segments including data and tables. Reportable segments include those that meet any of the following quantitative thresholds a) it's reported revenue, including sales to external customers and intersegment sales or transfers is 10 percent or more of the combined revenue, internal and external, of all operating segments b) the absolute amount of its reported profit or loss is 10 percent or more of the greater, in absolute amount of 1) the combined reported profit of all operating segments that did not report a loss or 2) the combined reported loss of all operating segments that did report a loss c) its assets are 10 percent or more of the combined assets of all operating segments.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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+ Details

Subsequent Events

9 Months Ended

Sep. 30, 2020

Subsequent Events [Abstract]

Subsequent events

(16) Subsequent Events

Debt Restructuring

On August 7, 2020, we entered into a Restructuring and Exchange Agreement (the “Restructuring Agreement”) with Royalty Opportunities and ROS, pursuant to which the parties thereto agreed, subject to the terms and conditions set forth therein, to take certain actions as set forth therein and as described below (collectively, the “Restructuring Transactions”) in furtherance of a restructuring of the Company’s outstanding indebtedness under Second Amended and Restated Credit Agreement. The Restructuring Transactions included, among others:

	●	an amendment to the Company’s Amended and Restated Certificate of Incorporation, as amended, to increase the number of authorized shares of common stock, par value $0.000001 per share, of the Company from 75 million to 300 million (the “Charter Amendment”), which occurred on October 1, 2020;

	●	the exchange by the Company of shares of common stock for approximately $40.8 million of the aggregate outstanding principal amount of the Loans (as defined in the Second Amended and Restated Credit Agreement) outstanding under the Second Amended and Restated Credit Agreement, as well as, without duplication, approximately $21.1 million of the outstanding amount of PIK Interest (as defined in the Second Amended and Restated Credit Agreement) (such loans and PIK Interest, the “Exchanging Loans”), plus all other accrued and unpaid interest on the Exchanging Loans outstanding as of the closing date, at an exchange price of $1.07 per share, representing the average closing price of the common stock over the 10 trading days immediately prior to the parties entering into the Restructuring Agreement, and resulting in the issuance of approximately 57.8 million shares of common stock (the “Share Issuance”), which occurred on October 1, 2020;

	●	the execution of the Second Amendment, as described in more detail above under Note 8, “Debt”; which occurred on October 1, 2020; and

	●	the launch by the Company of a rights offering to allow stockholders of the Company to purchase up to an aggregate of $15 million of common stock at the same price per share as the $1.07 per share exchange price used to exchange the Exchanging Loans into common stock as part of the Share Issuance (the “Rights Offering”), the details of which the Company announced publicly on October 22, 2020 and are described in more detail below.

As a result of the completion of these Restructuring Transactions, Royalty Opportunities and ROS own, in the aggregate, approximately 94.5% of the outstanding common stock and all other existing stockholders of the Company own approximately 5.5% of the outstanding common stock. Following completion of these Restructuring Transactions the remaining principal balance of our outstanding debt totals $15.6 million.

Also on October 1, 2020, in connection with and as a condition to the closing of the Restructuring Transactions, the Company entered into a Registration Rights Agreement with the Lenders, which requires the Company to, among other things, file with the SEC a shelf registration statement covering the resale, from time to time, of the common stock issuable upon exchange of the Exchanging Loans and the Prepayment Fee Shares no later than the 90th day after the closing date and use its best efforts to cause the shelf registration statement to become effective under the Securities Act of 1933, as amended, no later than the 180th day after the closing date of the Restructuring Transactions.

Rights Offering

Pursuant to the terms of the Restructuring Agreement, on October 22, 2020, we announced that the Board of Directors has set November 5, 2020 as the record date for the Rights Offering. Subject to the registration statement on Form S-1 relating to the Rights Offering becoming effective on or about November 3, 2020, we intend to distribute to holders of our common stock, at no charge, 0.194539 non-transferable subscription rights for each share of common stock held on the record date. Each whole subscription right will entitle the holder to purchase one share of our common stock for $1.07 in cash. No fractional shares will be issued in the Rights Offering. Any fractional shares of common stock created by the exercise of rights will be rounded down to the nearest whole share. In addition, holders as of the record date will have an over-subscription privilege, pursuant to which they may be able to purchase additional shares at the subscription price, to the extent that not all subscription rights are exercised, subject to certain limitations. We expect that subscription materials for the Rights Offering will be mailed on or about November 6, 2020 to holders of our common stock as of the record date, and that the Rights Offering will close as soon as practicable after the anticipated December 4, 2020 expiration date. The Board of Directors may extend the rights offering for additional periods of time in its sole discretion.

Xtant Medical Holdings, Inc. Amended and Restated Equity Incentive Plan

On October 27, 2020, at the 2020 Annual Meeting of Stockholders of the Company (the “2020 Annual Meeting”), the Company’s stockholders approved and adopted, upon recommendation of the Board of Directors, an amended and restated version of the 2018 Plan, which incorporates certain amendments, including an amendment to increase the number of shares of our common stock available for issuance under the 2018 Plan by an additional 5,550,308 shares and a new limit on overall non-employee director compensation of $400,000 per year or $600,000 in the case of a non-employee chairman, lead independent director, or non-employee director in the first year of service on the Board (the “Amended 2018 Plan”).

Equity Grants to President and Chief Executive Officer

On October 27, 2020, immediately after completion of the 2020 Annual Meeting and adoption of the Amended 2018 Plan, the Board of Directors granted, effective as of November 15, 2020, the Company’s President and Chief Executive Officer, an option to purchase 1,468,859 shares of our common stock and a restricted stock unit award covering 1,468,859 shares of our common stock pursuant to the terms of his employment agreement with the Company which entitles him to receive an additional equity grant, 50% in the form of stock options and 50% in the form of restricted stock units, in the event OrbiMed Advisors LLC (including its affiliates) converted any of its remaining outstanding indebtedness of the Company into equity of the Company prior to October 7, 2024.

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Policies)	9 Months Ended
	Sep. 30, 2020
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, 2019, 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, 2020. 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, 2019. 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.
Recent Accounting Pronouncements	Recent Accounting Pronouncements In June 2016, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2016-13, Financial Instruments–Credit Losses: Measurement of Credit Losses on Financial Instruments to change the impairment model for most financial assets and certain other instruments. For trade and other receivables, held to maturity debt securities, loans, and other instruments, entities are required to use a new forward-looking “expected loss” model that generally will result in the earlier recognition of allowances for losses. The Company adopted the guidance on January 1, 2020 and recognized a cumulative effect adjustment of $47,000 to retained earnings and accounts receivable, net as a result of adoption. The Company has included the additional disclosures required by ASU 2016-13 in Note 3, “Receivables.” Although there are several other new accounting pronouncements issued or proposed by the FASB, which the Company has adopted or will adopt, as applicable, the Company does not believe any of these accounting pronouncements has had or will have a material impact on the Company’s consolidated financial position or operating results.
Use of Estimates	Use of Estimates The preparation of the 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 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 right-of-use asset, evaluation of ability to continue as a going concern 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.
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 and nine months ended September 30, 2020 and 2019.
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 that the carrying amount of the asset may not be recoverable. As a result of the COVID-19 pandemic and its impact on the Company’s projected cash flows, the Company evaluated goodwill for impairment at the end of the third quarter of 2020. No impairments of goodwill were recorded for the three months and nine months ended September 30, 2020 and 2019.
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 and nine months ended September 30, 2020 and 2019, as shares issuable upon the exercise of stock options and warrants were anti-dilutive as a result of the net losses incurred for those periods. Dilutive earnings per share are not reported, as the effects of including 7,083,922 and 3,313,953 outstanding stock options, restricted stock units and warrants for the three and nine months ended September 30, 2020 and 2019, respectively, are anti-dilutive.
Fair Value of Financial Instruments	Fair Value of Financial Instruments The carrying values of financial instruments, including trade accounts receivable, accounts payable, accrued liabilities, and long-term debt, approximate their fair values based on terms and related interest rates as of September 30, 2020 and December 31, 2019.

Revenue (Tables)

9 Months Ended

Sep. 30, 2020

Revenue from Contract with Customer [Abstract]

Summary of Revenues from Product Lines

The following table presents revenues from these product lines for the three and nine months ended September 30, 2020 and 2019 (in thousands):

	Three Months Ended		Percentage of			Three Months Ended		Percentage of
	September 30, 2020		Total Revenue			September 30, 2019		Total Revenue
Orthobiologics	$	10,542		75	%	$	11,342		72	%
Spinal implant		3,438		25	%		4,349		28	%
Other revenue		36		0	%		30		0	%
Total revenue	$	14,016		100	%	$	15,721		100	%

	Nine Months Ended		Percentage of			Nine Months Ended		Percentage of
	September 30, 2020		Total Revenue			September 30, 2019		Total Revenue
Orthobiologics	$	28,613		73	%	$	34,374		72	%
Spinal implant		10,594		27	%		13,200		28	%
Other revenue		115		0	%		144		0	%
Total revenue	$	39,322		100	%	$	47,718		100	%

Receivables (Tables)

9 Months Ended

Sep. 30, 2020

Credit Loss [Abstract]

Schedule of Allowance for Credit Losses

Activity within the allowance for credit losses was as follows for the three months ended September 30, 2020 (in thousands):

Balance at January 1, 2020	$	547
Provision for expected credit losses		138
Write-offs charged against allowance		(17	)
Balance at March 31, 2020		668
Provision for expected credit losses		66
Write-offs charged against allowance		(6	)
Balance at June 30, 2020		728
Provision for expected credit losses		92
Write-offs charged against allowance		(74	)
Balance at September 30, 2020	$	746

Inventories (Tables)

9 Months Ended

Sep. 30, 2020

Inventory Disclosure [Abstract]

Schedule of Inventories

Inventories consist of the following (in thousands):

	September 30, 2020			December 31, 2019
Raw materials	$	4,461		$	3,805
Work in process		2,332			1,603
Finished goods		25,307			22,135
Gross inventories		32,100			27,543
Reserve for obsolescence		(11,429	)		(11,442	)
Total	$	20,671		$	16,101

Property and Equipment, Net (Tables)

9 Months Ended

Sep. 30, 2020

Property, Plant and Equipment [Abstract]

Schedule of Property and Equipment, Net

Property and equipment, net are as follows (in thousands):

	September 30, 2020			December 31, 2019
Equipment	$	4,682		$	4,250
Computer equipment		461			455
Computer software		570			570
Furniture and fixtures		133			124
Leasehold improvements		3,987			3,980
Vehicles		10			10
Surgical instruments		11,147			10,897
Total cost		20,990			20,286
Less: accumulated depreciation		(16,868	)		(15,591	)
Property and equipment, net	$	4,122		$	4,695

Intangible Assets (Tables)

9 Months Ended

Sep. 30, 2020

Goodwill and Intangible Assets Disclosure [Abstract]

Schedule of Intangible Assets

The following table sets forth information regarding intangible assets (in thousands):

	September 30, 2020			December 31, 2019
Patents	$	847		$	847
Accumulated amortization		(376	)		(332	)
Intangible assets, net	$	471		$	515

Accrued Liabilities (Tables)

9 Months Ended

Sep. 30, 2020

Payables and Accruals [Abstract]

Schedule of Accrued Liabilities

Accrued liabilities consist of the following (in thousands):

	September 30, 2020		December 31, 2019
Wages/commissions payable	$	3,788	$	3,902
Other accrued liabilities		2,255		2,730
Accrued liabilities	$	6,043	$	6,632

Debt (Tables)

9 Months Ended

Sep. 30, 2020

Debt Disclosure [Abstract]

Schedule of Long-term Debt

Long-term debt consists of the following (in thousands):

	September 30, 2020			December 31, 2019
Amounts due under the Second Amended and Restated Credit Agreement	$	76,886		$	72,657
PIK interest payable related to Second Amended and Restated Credit Agreement		—			3,280
Plus: 2% exit fee		820			399
Gross long-term debt		77,706			76,336
Premium related to First Amendment		1,974			—
Less: total debt issuance costs on Credit Agreements		(53	)		(92	)
Long-term debt, plus premium and less issuance costs	$	79,627		$	76,244

Stock-Based Compensation (Tables)

9 Months Ended

Sep. 30, 2020

Share-based Payment Arrangement [Abstract]

Schedule of Share-based Compensation, Stock Options, Activity

	2020							2019
	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		602,966		$	6.07	$	3.99		496,958		$	9.90	$	6.62
Granted		239,884		$	1.13	$	0.90		100,000		$	2.24	$	1.95
Cancelled or expired		(120,738	)	$	6.42	$	4.05		(448,053	)	$	4.64	$	3.69
Outstanding at September 30		722,112		$	4.37	$	2.96		148,905		$	9.12	$	6.53
Exercisable at September 30		49,979		$	33.70	$	19.67		18,135		$	52.04	$	33.67

Schedule of Restricted Stock Activity

Restricted stock unit activity for awards granted under the 2018 Plan was as follows for the nine months ended:

	2020					2019
	Shares			Weighted Average Fair Value at Grant Date Per Share		Shares		Weighted Average Fair Value at Grant Date Per Share
Outstanding at January 1		499,914		$	2.93		40,000	$	6.20
Granted		679,803		$	1.36		89,204	$	2.74
Vested		(79,069	)	$	2.37		-	$	-
Outstanding at September 30		1,100,648		$	2.00		129,204	$	3.81

Warrants (Tables)

9 Months Ended

Sep. 30, 2020

Warrants and Rights Note Disclosure [Abstract]

Schedule of Warrant Activity

	Common Stock Warrants			Weighted Average Exercise Price
Outstanding at January 1, 2020		2,908,874		$	4.16
Issued		2,400,000			0.01
Expired		(47,712	)		85.44
Outstanding at September 30, 2020		5,261,162		$	1.53

Schedule of Warrant Valuation Assumptions

The estimated fair value of warrants issued was derived using a valuation model with the following weighted-average assumptions:

	Nine Months Ended September 30,
	2020			2019
Risk free interest rate		2.0	%		1.7	%
Expected term in years		10.0			3.0
Volatility		105.0	%		85.0	%
Dividend yield		0.0	%		0.0	%

Commitments and Contingencies (Tables)

9 Months Ended

Sep. 30, 2020

Commitments and Contingencies Disclosure [Abstract]

Schedule of Right-of-use Assets and Lease Liability

Present Value of Long-term Leases

(in thousands):	September 30, 2020
Right-of-use assets, net	$	1,795

Current portion of lease liability		415
Lease liability, less current portion		1,412
Total lease liability	$	1,827

Schedule of Future Minimum Rental Payments for Operating Leases

Future minimum payments for the next five years and thereafter as of September 30, 2020 under these long-term operating leases are as follows (in thousands):

Remainder of 2020	$	126
2021		507
2022		521
2023		489
2024		224
Thereafter		179
Total future minimum lease payments		2,046
Less amount representing interest		(219	)
Present value of obligations under operating leases		1,827
Less current portion		(415	)
Long-term operating lease obligations	$	1,412

Schedule of Future Minimum Lease Payments for Financing Leases

Future minimum payments under finance leases are as follows as of September 30, 2020 (in thousands):

Remainder of 2020	$	59
Less amount representing interest		-
Present value of obligations under financing leases	$	59

Supplemental Disclosure of Cash Flow Information (Tables)

9 Months Ended

Sep. 30, 2020

Supplemental Cash Flow Elements [Abstract]

Schedule of Supplemental Cash Flow Information

Supplemental cash flow information is as follows (in thousands):

	Nine Months Ended
	September,
	2020		2019
Supplemental disclosure of cash flow information
Cash paid during the period for:
Interest	$	13	$	47
Non-cash activities:
ASU 2016-13 cumulative effect adjustment	$	47	$	—
Recognition of 2020 Warrants	$	1,862	$	—
Lease liability from right-of-use assets	$	—	$	2,296
Extinguishment of the Company’s Prior Credit Agreement (including debt issuance costs)	$	—	$	79,624
Recognition of Second Amended and Restated Credit Agreement	$	—	$	72,657
Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees	$	—	$	307
Recognition of 2019 Warrants	$	—	$	9

Segment and Geographic Information (Tables)

9 Months Ended

Sep. 30, 2020

Segment Reporting [Abstract]

Schedule of Revenues by Geographic Region

Total revenue by major geographic area is as follows (in thousands):

	Three Months Ended September 30,
	2020		2019
United States	$	13,773	$	15,097
Rest of world		243		624
Total revenue	$	14,016	$	15,721

	Nine Months Ended September 30,
	2020		2019
United States	$	38,340	$	45,781
Rest of world		982		1,937
Total revenue	$	39,322	$	47,718

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Details Narrative) - USD ($) $ in Thousands		3 Months Ended		9 Months Ended
	Jan. 02, 2020	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Cumulative effect adjustment				$ (47)
Impairment of long lived assets
Impairment of goodwill
Antidilutive securities excluded from computation of earnings per share, amount		7,083,922	3,313,953	7,083,922	3,313,953
Accounting Standards Update 2016-13 [Member]
Cumulative effect adjustment	$ 47

Revenue - Summary of Revenues from Product Lines (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Total revenue	$ 14,016	$ 15,721	$ 39,322	$ 47,718
Percentage of total revenue	100.00%	100.00%	100.00%	100.00%
Orthobiologics [Member]
Total revenue	$ 10,542	$ 11,342	$ 28,613	$ 34,374
Percentage of total revenue	75.00%	72.00%	73.00%	72.00%
Spinal Implant [Member]
Total revenue	$ 3,438	$ 4,349	$ 10,594	$ 13,200
Percentage of total revenue	25.00%	28.00%	27.00%	28.00%
Other Revenue [Member]
Total revenue	$ 36	$ 30	$ 115	$ 144
Percentage of total revenue	0.00%	0.00%	0.00%	0.00%

- Definition

Amount, excluding tax collected from customer, of revenue from satisfaction of performance obligation by transferring promised good or service to customer. Tax collected from customer is tax assessed by governmental authority that is both imposed on and concurrent with specific revenue-producing transaction, including, but not limited to, sales, use, value added and excise.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 30
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8906-108599

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 40
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9031-108599

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 41
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9038-108599

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8933-108599

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8933-108599

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 4
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130543-203045

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 22
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8736-108599

Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 22
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8736-108599

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 42
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9054-108599

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 5
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130545-203045

Reference 11: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 924
-SubTopic 10
-Section S99
-Paragraph 1
-Subparagraph (SAB Topic 11.L)
-URI http://asc.fasb.org/extlink&oid=6472922&loc=d3e499488-122856

+ Details

Receivables -Schedule of allowance for credit losses (Details) - USD ($) $ in Thousands	3 Months Ended			9 Months Ended
	Sep. 30, 2020	Jun. 30, 2020	Mar. 31, 2020	Sep. 30, 2020	Sep. 30, 2019
Credit Loss [Abstract]
Beginning balance	$ 728	$ 668	$ 547	$ 547
Provision for expected credit losses	92	66	138	296	$ 453
Write-offs charged against allowance	(74)	(6)	(17)
Ending balance	$ 746	$ 728	$ 668	$ 746

Inventories - Schedule of Inventories (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Inventory Disclosure [Abstract]
Raw materials	$ 4,461	$ 3,805
Work in process	2,332	1,603
Finished goods	25,307	22,135
Gross inventories	32,100	27,543
Reserve for obsolescence	(11,429)	(11,442)
Total	$ 20,671	$ 16,101

Property and Equipment, Net (Details Narrative) $ in Thousands	Sep. 30, 2020 USD ($)
Property, Plant and Equipment [Abstract]
Gross assets	$ 500
Accumulated depreciation	$ 400

Property and Equipment, Net - Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Property, Plant and Equipment [Line Items]
Total cost	$ 20,990	$ 20,286
Less: accumulated depreciation	(16,868)	(15,591)
Property and equipment, net	4,122	4,695
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	4,682	4,250
Computer Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	461	455
Computer Software [Member]
Property, Plant and Equipment [Line Items]
Total cost	570	570
Furniture and Fixtures [Member]
Property, Plant and Equipment [Line Items]
Total cost	133	124
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	3,987	3,980
Vehicles [Member]
Property, Plant and Equipment [Line Items]
Total cost	10	10
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 11,147	$ 10,897

Intangible Assets - Schedule of Intangible Assets (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract]
Patents	$ 847	$ 847
Accumulated amortization	(376)	(332)
Intangible assets, net	$ 471	$ 515

Accrued Liabilities - Schedule of Accrued Liabilities (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Payables and Accruals [Abstract]
Wages/commissions payable	$ 3,788	$ 3,902
Other accrued liabilities	2,255	2,730
Accrued liabilities	$ 6,043	$ 6,632

Debt (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	Oct. 02, 2020	May 06, 2020	May 06, 2020	Sep. 30, 2020
Sole Holders [Member]
Beneficially owned percentage				78.00%
Lenders [Member]
Beneficially owned percentage				70.00%
Royalty Opportunities and ROS [Member] \| Subsequent Event [Member]
Beneficially owned percentage	94.50%
Other Existing Stockholders [Member] \| Subsequent Event [Member]
Beneficially owned percentage	5.50%
2020 Warrants [Member] \| Lenders [Member]
Debt instrument maturity date			May 06, 2030
Issuance of warrants to purchase a common stock		2,400,000	2,400,000
Exercise price of warrants		$ 0.01	$ 0.01
Second Amended and Restated Credit Agreement [Member]
Debt instrument description		Beginning October 1, 2020 through the maturity date of the Second Amended and Restated Credit Agreement, interest payable in cash will accrue on the Loans under the Second Amended and Restated Credit Agreement at a rate per annum equal to the sum of (i) 10.00% plus (ii) the higher of (x) the LIBO Rate (as such term is defined in the Second Amended and Restated Credit Agreement) and (y) 2.3125%;
Debt instrument maturity date		Dec. 31, 2021
Second Amended and Restated Credit Agreement [Member] \| Lenders [Member]
Draw of loan advances				$ 2,200
Debt aggregate amount				$ 10,000
Second Amended and Restated Credit Agreement [Member] \| Lenders [Member] \| Subsequent Event [Member]
Shares issued in exchange of principal and paid-in-kind interest outstanding	$ 61,900
Shares issued in exchange of loans outstanding	57,800,000
Prepayment fees	$ 900
Available additional term loans	$ 5,000
Interest rate	7.00%
Basis spread on variable rate	1.00%
Second Amended and Restated Credit Agreement [Member] \| Lenders [Member] \| Subsequent Event [Member] \| Prepayment Fee Shares [Member]
Shares issued in exchange of loans outstanding	900,000
Post Amendment [Member]
Warrants issued and interest expense		10.02%	10.02%

Debt - Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Debt Disclosure [Abstract]
Amounts due under the Second Amended and Restated Credit Agreement	$ 76,886	$ 72,657
PIK interest payable related to Second Amended and Restated Credit Agreement		3,280
Plus: 2% exit fee	820	399
Gross long-term debt	77,706	76,336
Premium related to First Amendment	1,974
Less: total debt issuance costs on Credit Agreements	(53)	(92)
Long-term debt, less issuance costs	$ 79,627	$ 76,244

Stock-Based Compensation - Schedule of Share-based Compensation, Stock Options, Activity (Details) - Equity Option [Member] - $ / shares	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019
Shares Outstanding, Beginning Balance	602,966	496,958
Shares Granted	239,884	100,000
Shares Cancelled or expired	(120,738)	(448,053)
Shares Outstanding, Ending Balance	722,112	148,905
Shares Exercisable, Ending Balance	49,979	18,135
Weighted Average Exercise Price, Outstanding Beginning Balance	$ 6.07	$ 9.90
Weighted Average Exercise Price, Granted	1.13	2.24
Weighted Average Exercise Price, Cancelled or expired	6.42	4.64
Weighted Average Exercise Price, Outstanding Ending Balance	4.37	9.12
Weighted Average Exercise Price, Exercisable Ending Balance	33.70	52.04
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	3.99	6.62
Weighted Average Fair Value at Grant Date, Granted	0.90	1.95
Weighted Average Fair Value at Grant Date, Cancelled or expired	4.05	3.69
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	2.96	6.53
Weighted Average Fair Value at Grant Date, Exercisable, Ending Balance	$ 19.67	$ 33.67

Stock-Based Compensation - Schedule of Restricted Stock Activity (Details) - Restricted Stock Units (RSUs) [Member] - $ / shares	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019
Shares Outstanding, Beginning Balance	499,914	40,000
Shares Granted	679,803	89,204
Shares Vested	(79,069)
Shares Outstanding, Ending Balance	1,100,648	129,204
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 2.93	$ 6.20
Weighted Average Fair Value at Grant Date, Granted	1.36	2.74
Weighted Average Fair Value at Grant Date, Vested	2.37
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 2.00	$ 3.81

Warrants (Details Narrative) - USD ($) $ / shares in Units, $ in Thousands	May 06, 2020	Apr. 02, 2019
2020 Warrant [Member]
Class of Warrant or Right [Line Items]
Fair value of warrants	$ 1,900	$ 9
2019 Warrant [Member]
Class of Warrant or Right [Line Items]
Issuance of warrants to purchase a common stock		1,200,000
Exercise price of warrants		$ 0.01
Warrants expiration date		Apr. 01, 2029

Warrants - Schedule of Warrant Activity (Details)	9 Months Ended
Warrants - Schedule of Warrant Activity (Details)	Sep. 30, 2020 $ / shares shares
Warrants and Rights Note Disclosure [Abstract]
Common Stock Warrants Outstanding, Beginning Balance \| shares	2,908,874
Common Stock Warrants, Issued \| shares	2,400,000
Common Stock Warrants, Expired \| shares	(47,712)
Common Stock Warrants Outstanding, Ending Balance \| shares	5,261,162
Weighted Average Exercise Price Outstanding Beginning Balance \| $ / shares	$ 4.16
Weighted Average Exercise Price, Issued \| $ / shares	0.01
Weighted Average Exercise Price, Expired \| $ / shares	85.44
Weighted Average Exercise Price Outstanding Ending Balance \| $ / shares	$ 1.53

Warrants - Schedule of Warrant Valuation Assumptions (Details) - Warrant [Member]	Sep. 30, 2020	Sep. 30, 2019
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Warrants and rights outstanding, measurement Input, expected term (In years)	10 years	3 years
Risk Free Interest Rate [Member]
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Warrants and rights outstanding, measurement Input	2.0	1.7
Volatility [Member]
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Warrants and rights outstanding, measurement Input	105.0	85.0
Dividend Yield [Member]
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Warrants and rights outstanding, measurement Input	0.0	0.0

Commitments and Contingencies (Details Narrative) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Commitments and Contingencies Disclosure [Abstract]
Operating lease expiration description			Expiration dates between 2023 and 2025
Operating lease weighted-average remaining lease term	4 years 1 month 6 days		4 years 1 month 6 days
Operating lease weighted-average discount rate	5.20%		5.20%
Rent expense	$ 100	$ 100	$ 400	$ 400

Commitments and Contingencies - Schedule of Right-of-use Assets and Lease Liability (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Commitments and Contingencies Disclosure [Abstract]
Right-of-use assets, net	$ 1,799	$ 2,100
Current portion of lease liability	415	394
Lease liability, less current portion	1,417	$ 1,726
Total lease liability	$ 1,827

Commitments and Contingencies - Schedule of Future Minimum Rental Payments for Operating Leases (Details) - USD ($) $ in Thousands	Sep. 30, 2020	Dec. 31, 2019
Commitments and Contingencies Disclosure [Abstract]
Remainder of 2020	$ 126
2021	507
2022	521
2023	489
2024	224
Thereafter	179
Total future minimum lease payments	2,046
Less amount representing interest	(219)
Present value of obligations under operating leases	1,827
Less current portion	(415)	$ (394)
Long-term operating lease obligations	$ 1,417	$ 1,726

Commitments and Contingencies - Schedule of Future Minimum Lease Payments for Financing Leases (Details) $ in Thousands	Sep. 30, 2020 USD ($)
Commitments and Contingencies Disclosure [Abstract]
Remainder of 2020	$ 59
Less amount representing interest
Present value of obligations under financing leases	$ 59

Income Taxes (Details Narrative) - USD ($)	3 Months Ended		9 Months Ended
Income Taxes (Details Narrative) - USD ($)	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Income Tax Disclosure [Abstract]
Interest or penalties related to income taxes

Supplemental Disclosure of Cash Flow Information - Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019
Supplemental Cash Flow Elements [Abstract]
Interest	$ 13	$ 47
ASU 2016-13 cumulative effect adjustment	47
Recognition of 2020 Warrants	1,862
Lease liability from right-of-use assets		2,296
Extinguishment of the Company's Prior Credit Agreement (including debt issuance costs)		79,624
Recognition of Second Amended and Restated Credit Agreement		72,657
Write-off of Prior Credit Agreement debt issuance costs and existing ROS fees		307
Recognition of 2019 Warrants		$ 9

Related Party Transactions (Details Narrative) - USD ($)		3 Months Ended		9 Months Ended
	Jan. 22, 2020	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019	Oct. 02, 2020
Related Party Transaction [Line Items]
Rent expense		$ 100,000	$ 100,000	$ 400,000	$ 400,000
Sole Holders [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage		78.00%		78.00%
Lenders [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage		70.00%		70.00%
Royalty Opportunities and ROS [Member] \| Subsequent Event [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage						94.50%
Other Existing Stockholders [Member] \| Subsequent Event [Member]
Related Party Transaction [Line Items]
Beneficially owned percentage						5.50%
Sublease Agreement [Member] \| Cardialen, Inc., [Member]
Related Party Transaction [Line Items]
Rent expense	$ 1,350

Segment and Geographic Information (Details Narrative)	3 Months Ended		9 Months Ended
Segment and Geographic Information (Details Narrative)	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
United States [Member] \| Revenue [Member] \| Geographic Concentration Risk [Member]
Concentration risk, percentage	98.00%	96.00%	98.00%	96.00%

Segment and Geographic Information - Schedule of Revenues by Geographic Region (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019	Sep. 30, 2020	Sep. 30, 2019
Total revenue	$ 14,016	$ 15,721	$ 39,322	$ 47,718
United States [Member]
Total revenue	13,773	15,097	38,340	45,781
Rest of World [Member]
Total revenue	$ 243	$ 624	$ 982	$ 1,937

- Definition

Amount of revenue recognized from goods sold, services rendered, insurance premiums, or other activities that constitute an earning process. Includes, but is not limited to, investment and interest income before deduction of interest expense when recognized as a component of revenue, and sales and trading gain (loss).

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 22
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8736-108599

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 323
-SubTopic 10
-Section 50
-Paragraph 3
-Subparagraph (c)
-URI http://asc.fasb.org/extlink&oid=114001798&loc=d3e33918-111571

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 825
-SubTopic 10
-Section 50
-Paragraph 28
-Subparagraph (f)
-URI http://asc.fasb.org/extlink&oid=75031198&loc=d3e14064-108612

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8933-108599

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8933-108599

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 22
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8736-108599

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 40
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9031-108599

Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 30
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8906-108599

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 41
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9038-108599

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 42
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9054-108599

Reference 11: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 235
-SubTopic 10
-Section S99
-Paragraph 1
-Subparagraph (SX 210.4-08(g)(1)(ii))
-URI http://asc.fasb.org/extlink&oid=120395691&loc=d3e23780-122690

Reference 12: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 942
-SubTopic 235
-Section S99
-Paragraph 1
-Subparagraph (SX 210.9-05(b)(2))
-URI http://asc.fasb.org/extlink&oid=120399901&loc=d3e537907-122884

Reference 13: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 220
-SubTopic 10
-Section S99
-Paragraph 2
-Subparagraph (SX 210.5-03(1))
-URI http://asc.fasb.org/extlink&oid=120395209&loc=SL114868664-224227

+ Details

Subsequent Events (Details Narrative) $ / shares in Units, $ in Thousands	Oct. 27, 2020 USD ($) shares	Oct. 02, 2020 USD ($) days $ / shares shares	Oct. 22, 2020 $ / shares shares	Sep. 30, 2020 USD ($) $ / shares shares	Dec. 31, 2019 USD ($) $ / shares shares
Common stock, par value \| $ / shares				$ 0.000001	$ 0.000001
Common stock, shares authorized \| shares				75,000,000	75,000,000
Outstanding debt \| $				$ 79,627	$ 76,244
Subsequent Event [Member]
Common stock, par value \| $ / shares		$ 0.000001
Common stock, shares authorized \| shares		300,000,000
Subsequent Event [Member] \| 2018 Equity Incentive Plan [Member]
Number of shares available for issuance \| shares	5,550,308
Subsequent Event [Member] \| 2018 Equity Incentive Plan [Member] \| Minimum [Member]
Limit on overall compensation \| $	$ 400,000
Subsequent Event [Member] \| 2018 Equity Incentive Plan [Member] \| Maximum [Member]
Limit on overall compensation \| $	$ 600,000
Subsequent Event [Member] \| 2018 Equity Incentive Plan [Member] \| President and Chief Executive Officer [Member] \| Stock Option [Member]
Option to purchase common stock \| shares	1,468,859
Percentage of additional equity grant in event of debt conversion	50.00%
Subsequent Event [Member] \| 2018 Equity Incentive Plan [Member] \| President and Chief Executive Officer [Member] \| Restricted Stock Units (RSUs) [Member]
Option to purchase common stock \| shares	1,468,859
Percentage of additional equity grant in event of debt conversion	50.00%
Subsequent Event [Member] \| Royalty Opportunities and ROS [Member]
Beneficially owned percentage		94.50%
Subsequent Event [Member] \| Other Existing Stockholders [Member]
Beneficially owned percentage		5.50%
Subsequent Event [Member] \| Restructuring Agreement [Member] \| Rights Offering [Member]
Shares issued in exchange of principal and paid-in-kind interest outstanding \| $		$ 15,000
Exchange price per share \| $ / shares		$ 1.07
Number of non transferable subscription right for each share of common stock \| shares			0.194539
Shares issued price per share \| $ / shares			$ 1.07
Subsequent Event [Member] \| Restructuring Agreement [Member] \| Royalty Opportunities and ROS [Member]
Exchange price per share \| $ / shares		$ 1.07
Trading days \| days		10
Shares issued in exchange of loans outstanding \| shares		57,800,000
Outstanding debt \| $		$ 15,600
Subsequent Event [Member] \| Restructuring Agreement [Member] \| Royalty Opportunities and ROS [Member] \| Loans Payable [Member]
Shares issued in exchange of principal and paid-in-kind interest outstanding \| $		40,800
Subsequent Event [Member] \| Restructuring Agreement [Member] \| Royalty Opportunities and ROS [Member] \| PIK Interest [Member]
Shares issued in exchange of principal and paid-in-kind interest outstanding \| $		$ 21,100