0001493152-24-019887 | 10-Q | XBRL Viewer | Xtant Medical Holdings INC

Income Taxes (Tables)

3 Months Ended

Mar. 31, 2024

	2024			2023
	Three Months Ended
	March 31,
	2024			2023
Income tax expense from continuing operations	$	68		$	13
Income from continuing operations before income taxes	$	(4,332	)	$	(2,065	)
Effective income tax rate		-1.6	%		-0.6	%

Property and Equipment, Net (Details Narrative) - USD ($) $ in Millions	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Property, Plant and Equipment [Abstract]
Depreciation expenses	$ 0.6	$ 0.3

Acquisition of NanOss Production Operations (Tables)

3 Months Ended

Mar. 31, 2024

Restructuring Cost and Reserve [Line Items]

Schedule of Business Acquisitions


Cash	$	1,087
Accounts receivable		1,627
Inventories		15,300
Prepaids and other current assets		825
Equipment		2,067
Right-of-use asset		576
Accounts payable		(530	)
Accrued liabilities		(1,170	)
Current portion of lease liability		(238	)
Lease liability, less current portion		(338	)
Net assets acquired		19,206
Bargain purchase gain		(11,694	)
Deferred tax liability		(1,922	)

Total purchase consideration	$	5,590

Schedule of Acquisition Pro Forma Information

	Three Months Ended
	March 31, 2023
Revenues	$	34,631
Net loss		(3,607	)

Nan Oss Production Operations [Member]

Restructuring Cost and Reserve [Line Items]

Schedule of Business Acquisitions


Inventories	$	1,150
Fixed assets		267
Intangible assets		220
Net assets acquired		1,637

Goodwill		573

Total preliminary purchase consideration		2,210

- Definition

Line items represent financial concepts included in a table. These concepts are used to disclose reportable information associated with domain members defined in one or many axes to the table.

+ References + Details

Schedule of Inventories (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Inventory Disclosure [Abstract]
Raw materials	$ 7,021	$ 7,269
Work in process	2,137	1,562
Finished goods	29,566	28,054
Total	$ 38,724	$ 36,885

Acquisition of Coflex and CoFix Product Lines (Tables)

3 Months Ended

Mar. 31, 2024

Business Combination, Asset Acquisition, and Joint Venture Formation [Abstract]

Schedule of Recognized Identified Assets Acquired and Liabilities Assumed


Inventories	$	1,589
Equipment		947
Intangible assets		10,940
Net assets acquired		13,476

Goodwill		3,524

Total purchase consideration	$	17,000

Pay vs Performance Disclosure - USD ($) $ in Thousands	3 Months Ended
Pay vs Performance Disclosure - USD ($) $ in Thousands	Mar. 31, 2024	Mar. 31, 2023
Pay vs Performance Disclosure [Table]
Net Income (Loss)	$ (4,400)	$ (2,078)

- Definition

The portion of profit or loss for the period, net of income taxes, which is attributable to the parent.

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+ Details

Segment and Geographic Information (Tables)

3 Months Ended

Mar. 31, 2024

Segment Reporting [Abstract]

Schedule of Revenues by Geographic Region

	2024		2023
	Three Months Ended March 31,
	2024		2023
United States	$	25,133	$	17,513
Rest of world		2,740		430
Total revenue	$	27,873	$	17,943

Insider Trading Arrangements	3 Months Ended
Insider Trading Arrangements	Mar. 31, 2024
Insider Trading Arrangements [Line Items]
Rule 10b5-1 Arrangement Adopted	false
Non-Rule 10b5-1 Arrangement Adopted	false
Rule 10b5-1 Arrangement Terminated	false
Non-Rule 10b5-1 Arrangement Terminated	false

Warrants (Details Narrative) - Warrant [Member] - $ / shares	3 Months Ended	12 Months Ended
	Mar. 31, 2024	Dec. 31, 2023
Outstanding and exercisable warrants to purchase	12,187,470	12,187,470
Weighted average exercise price	$ 1.53	$ 1.53
Weighted average remaining contractual term	2 years 6 months	2 years 9 months 18 days

Related Party Transactions

3 Months Ended

Mar. 31, 2024

Related Party Transactions

(17) Related Party Transactions

As described in more detail under Note 1, “Business Description and Summary of Significant Accounting Policies,” and Note 19, “Related Party Transactions,” in the Company’s Annual Report on Form 10-K for the year ended December 31, 2023, we are party to an Investor Rights Agreement, as amended, Registration Rights Agreements and certain other agreements with OrbiMed Royalty Opportunities II, LP and ROS Acquisition Offshore LP, which are funds affiliated with OrbiMed Advisors LLC (“OrbiMed”). OrbiMed beneficially owns 56.2% 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.

- Definition

The entire disclosure for related party transactions. Examples of related party transactions include transactions between (a) a parent company and its subsidiary; (b) subsidiaries of a common parent; (c) and entity and its principal owners; and (d) affiliates.

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+ Details

Revenue (Details Narrative)	3 Months Ended
Revenue (Details Narrative)	Mar. 31, 2024 Segment
Revenue from Contract with Customer [Abstract]
Number of reportable segment	1

Summary of Revenues from Product Lines (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Disaggregation of Revenue [Line Items]
Total revenue	$ 27,873	$ 17,943
Percentage of total revenue	100.00%	100.00%
Orthobiologics [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 15,416	$ 13,552
Percentage of total revenue	55.00%	76.00%
Spinal Implant [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 12,457	$ 4,391
Percentage of total revenue	45.00%	24.00%

- Definition

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+ References + Details

- 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.

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-URI https://asc.fasb.org/1943274/2147482810/280-10-50-22

Reference 13: http://www.xbrl.org/2003/role/disclosureRef
-Topic 606
-SubTopic 10
-Name Accounting Standards Codification
-Section 50
-Paragraph 4
-Subparagraph (a)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147479806/606-10-50-4

+ Details

Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Supplemental Cash Flow Elements [Abstract]
Interest	$ 740	$ 509

Segment and Geographic Information (Details Narrative)	3 Months Ended
Segment and Geographic Information (Details Narrative)	Mar. 31, 2024 Segment
Segment Reporting [Abstract]
Number of reportable segment	1

Acquisition of NanOss Production Operations

3 Months Ended

Mar. 31, 2024

Acquisition Of Nanoss Production Operations

Acquisition of NanOss Production Operations

(4) Acquisition of NanOss Production Operations

On October 23, 2023, the Company acquired the nanOss production operations from RTI Surgical, Inc. (“RTI”) pursuant to an Asset Purchase Agreement dated October 23, 2023 between the Company and RTI (the “Asset Purchase Agreement”). Under the terms of the Asset Purchase Agreement, the Company acquired certain assets, including equipment and inventory, used in RTI’s synthetic bone graft business and assumed from RTI the lease for the nanOss production facility located in Greenville, North Carolina. The purchase price for the assets was $2 million in cash on hand plus $0.2 million of contingent payments based on future sales of next generation nanOss products. The Company previously acquired nanOss distribution rights and certain nanOss intellectual property with the acquisition of assets related to the biologics and spinal fixation business of Surgalign Holdings, Inc. in August 2023. The potential benefit associated with the improved economics of internal production of nanOss products resulted in the Company paying a premium for the acquisition resulting in the recognition of $0.6 million of goodwill. For tax purposes, goodwill is deductible.

The Company recorded the purchase of this acquisition using the acquisition method of accounting and, accordingly, recognized the assets acquired at their fair values as of the date of acquisition. The table below represents the allocation of the total consideration for certain RTI assets based on management’s estimates of their respective fair values as of October 23, 2023 (in thousands):

Schedule of Business Acquisitions


Inventories	$	1,150
Fixed assets		267
Intangible assets		220
Net assets acquired		1,637

Goodwill		573

Total preliminary purchase consideration		2,210

The following unaudited pro forma combined financial information summarizes the results of operations for the periods indicated as if the acquisition of the assets of Surgalign Holdings, Inc., the acquisition of Surgalign SPV, Inc. and the acquisition of nanOss production operations from RTI Surgical, Inc. had been completed as of January 1, 2023 (in thousands):

	Three Months Ended
	March 31, 2023
Revenues	$	34,631
Net loss		(3,607	)

Pro forma information reflects adjustments that are expected to have a continuing impact on the Company’s results of operations and are directly attributable to the acquisition of the assets of Surgalign Holdings, Inc., the acquisition of Surgalign SPV, Inc. and the acquisition of nanOss production operations from RTI Surgical, Inc. The unaudited pro forma results include adjustments to reflect the amortization of the inventory step-up and the incremental intangible asset amortization to be incurred based on the preliminary values of each identifiable intangible asset. The pro forma amounts do not purport to be indicative of the results that would have actually been obtained if the transactions had occurred as of January 1, 2023 or that may be obtained in the future, and do not reflect future synergies, integration costs, or other such costs or savings.

Schedule of Recognized Identified Assets Acquired and Liabilities Assumed (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023	Feb. 28, 2023
Business Acquisition [Line Items]
Net assets acquired		$ 11,700
Goodwill	$ 7,302	$ 7,302
Surgalign SPV, Inc. [Member]
Business Acquisition [Line Items]
Inventories			$ 1,589
Equipment			947
Intangible assets			10,940
Net assets acquired			13,476
Goodwill			3,524
Total purchase consideration			$ 17,000

- Definition

Amount, after accumulated impairment loss, of asset representing future economic benefit arising from other asset acquired in business combination or from joint venture formation or both, that is not individually identified and separately recognized.

+ References

Reference 1: http://www.xbrl.org/2003/role/exampleRef
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+ Details

Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Debt Disclosure [Abstract]
Amounts due under term loan	$ 17,000	$ 17,000
Accrued end-of-term payments	170	456
Less: unamortized debt issuance costs	(344)	(289)
Long-term debt, less issuance costs	$ 16,826	$ 17,167

- Definition

Amount, after deduction of unamortized premium (discount) and debt issuance cost, of long-term debt. Excludes lease obligation.

+ References + Details

- Definition

The carrying value as of the balance sheet date of the noncurrent portion of long-term obligations drawn from a line of credit, which is a bank's commitment to make loans up to a specific amount. Examples of items that might be included in the application of this element may consist of letters of credit, standby letters of credit, and revolving credit arrangements, under which borrowings can be made up to a maximum amount as of any point in time conditional on satisfaction of specified terms before, as of and after the date of drawdowns on the line. Includes short-term obligations that would normally be classified as current liabilities but for which (a) postbalance sheet date issuance of a long term obligation to refinance the short term obligation on a long term basis, or (b) the enterprise has entered into a financing agreement that clearly permits the enterprise to refinance the short-term obligation on a long term basis and the following conditions are met (1) the agreement does not expire within 1 year and is not cancelable by the lender except for violation of an objectively determinable provision, (2) no violation exists at the BS date, and (3) the lender has entered into the financing agreement is expected to be financially capable of honoring the agreement.

+ References + Details

Schedule of Restricted Stock Activity (Details) - Restricted Stock Units (RSUs) [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Shares Outstanding, Beginning Balance	3,524,675	3,612,433
Weighted Average Fair Value at Grant Date, Outstanding Beginning Balance	$ 1.07	$ 0.87
Shares Granted		89,000
Weighted Average Fair Value at Grant Date, Granted		$ 0.77
Shares Vested	(44,496)	(22,245)
Weighted Average Fair Value at Grant Date, Vested	$ 0.71	$ 0.65
Shares Cancelled		(63,291)
Weighted Average Fair Value at Grant Date, Cancelled		$ 0.64
Shares Outstanding, Ending Balance	3,480,179	3,615,897
Weighted Average Fair Value at Grant Date, Outstanding Ending Balance	$ 1.17	$ 0.88

Schedule of Share-based Compensation, Stock Options Activity (Details) - Equity Option [Member] - 2018 Equity Incentive Plan [Member] - $ / shares	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Shares, Outstanding, Balance	4,875,828	3,360,664
Weighted Average Exercise Price Per Share, Outstanding Balance	$ 1.31	$ 1.51
Shares, Granted		105,000
Weighted Average Exercise Price Per Share, Granted		$ 0.77
Shares, Cancelled or expired		(74,627)
Weighted Average Exercise Price Per Share, Cancelled or expired		$ 0.64
Shares, Outstanding, Balance	4,875,828	3,391,037
Weighted Average Exercise Price Per Share, Outstanding Balance	$ 1.31	$ 1.50
Weighted Average Remaining Contractual Term (Years) Outstanding	7 years 8 months 19 days	8 years
Shares, Exercisable, Ending Balance	2,221,703	1,387,378
Weighted Average Exercise Price Per Share, Exercisable Ending Balance	$ 1.48	$ 1.98
Weighted Average Remaining Contractual Term (Years) Exercisable	6 years 9 months	7 years 6 months

Schedule of Business Acquisitions (Details) - USD ($) $ in Thousands	Oct. 23, 2023	Aug. 10, 2023	Mar. 31, 2024	Dec. 31, 2023
Restructuring Cost and Reserve [Line Items]
Goodwill			$ 7,302	$ 7,302
Surgalign Holdings Inc [Member]
Restructuring Cost and Reserve [Line Items]
Cash		$ 1,087
Accounts receivable		1,627
Inventories		15,300
Prepaids and other current assets		825
Equipment		2,067
Right-of-use asset		576
Accounts payable		(530)
Accrued liabilities		(1,170)
Current portion of lease liability		(238)
Lease liability, less current portion		(338)
Net assets acquired		19,206
Bargain purchase gain		(11,694)
Deferred tax liability		(1,922)
Total purchase consideration		$ 5,590
Nan Oss Production Operations [Member]
Restructuring Cost and Reserve [Line Items]
Inventories	$ 1,150
Net assets acquired	1,637
Total purchase consideration	2,210
Fixed assets	267
Intangible assets	220
Goodwill	$ 573

Revenue (Tables)

3 Months Ended

Mar. 31, 2024

Revenue from Contract with Customer [Abstract]

Summary of Revenues from Product Lines

	Three Months Ended		Percentage of			Three Months Ended		Percentage of
	March 31, 2024		Total Revenue			March 31, 2023		Total Revenue
Orthobiologics	$	15,416		55	%	$	13,552		76	%
Spinal implant		12,457		45	%		4,391		24	%
Total revenue	$	27,873		100	%	$	17,943		100	%

Revenue

3 Months Ended

Mar. 31, 2024

Revenue from Contract with Customer [Abstract]

Revenue

(5) Revenue

In the United States, the Company generates most of its revenue from independent commissioned sales agents. The Company consigns its orthobiologics products to hospitals and consign or loans its spinal implant sets to 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.

The Company ships 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. Revenue is recognized upon utilization of product.

Additionally, the Company sells product directly to domestic and international stocking resellers, original equipment manufacturer resellers and private label resellers. Upon receipt and acceptance of a purchase order from a stocking reseller, the Company ships product and invoices the reseller. The Company recognizes revenue when the control is transferred upon shipment or upon delivery, based on the customer contract terms and legal requirements, and the transfer of title and risk of loss occurs. There is generally no customer acceptance or other condition that prevents the Company from recognizing revenue in accordance with the delivery terms for these sales transactions. In the normal course of business, the Company accepts returns of product that have not been implanted. Product returns are not material to the Company’s consolidated statements of operations. The Company accounts for shipping and handling activities as a fulfillment cost rather than a separate performance obligation. The Company’s policy is to record revenue net of any applicable sales, use, or excise taxes. Payment terms are generally net 30 days from invoice date and some customers are offered discounts for early pay. The consideration for goods or services reflects any fixed amount stated per the contract and estimates for any variable consideration, such as returns, discounts or rebates, to the extent that it is probable that a significant reversal of cumulative revenue recognized will not occur when the uncertainty associated with the variable consideration is resolved. For certain sales transactions, we incur GPO fees that are based on a contractual percentage of applicable sales and are treated as consideration payable to a customer and recorded as a reduction of revenue.

The Company operates in one reportable segment with its net revenue derived primarily from the sale of orthobiologics and spinal implant products across North America, Europe, Asia Pacific, and Latin America. Sales are reported net of returns, discounts and rebates. The following table presents revenues from these product lines for the three months ended March 31, 2024 and 2023 (in thousands):

Summary of Revenues from Product Lines

	Three Months Ended		Percentage of			Three Months Ended		Percentage of
	March 31, 2024		Total Revenue			March 31, 2023		Total Revenue
Orthobiologics	$	15,416		55	%	$	13,552		76	%
Spinal implant		12,457		45	%		4,391		24	%
Total revenue	$	27,873		100	%	$	17,943		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
-Topic 606
-SubTopic 10
-Name Accounting Standards Codification
-Section 50
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Reference 2: http://www.xbrl.org/2003/role/disclosureRef
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Reference 3: http://www.xbrl.org/2003/role/disclosureRef
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Reference 4: http://www.xbrl.org/2003/role/disclosureRef
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Reference 5: http://www.xbrl.org/2003/role/disclosureRef
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Reference 10: http://www.xbrl.org/2003/role/disclosureRef
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-URI https://asc.fasb.org/606/tableOfContent

+ Details

Condensed Consolidated Statements of Equity (Unaudited) - USD ($) $ in Thousands	Total	Common Stock [Member]	Additional Paid-in Capital [Member]	AOCI Attributable to Parent [Member]	Retained Earnings [Member]
Balance at Dec. 31, 2022	$ 34,171		$ 277,841		$ (243,670)
Balance, shares at Dec. 31, 2022		108,874,803
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares		22,245
Withholding on common stock upon vesting of restricted stock units	(17)		(17)
Withholding of common stock upon vesting of restricted stock units, shares		(7,986)
Stock-based compensation	617		617
Foreign currency translation adjustment				(162)
Net loss	(2,078)				(2,078)
Balance at Mar. 31, 2023	32,710		278,458		(245,748)
Balance, shares at Mar. 31, 2023		108,897,048
Balance at Dec. 31, 2023	51,349		294,330	29	(243,010)
Balance, shares at Dec. 31, 2023		130,180,031
Common stock issued on vesting of restricted stock units
Common stock issued on vesting of restricted stock units, shares		44,496
Withholding on common stock upon vesting of restricted stock units	(17)		(17)
Withholding of common stock upon vesting of restricted stock units, shares		(7,986)
Stock-based compensation	910		910
Foreign currency translation adjustment	(162)			(162)
Net loss	(4,400)				(4,400)
Balance at Mar. 31, 2024	$ 47,680		$ 295,223	$ (133)	$ (247,410)
Balance, shares at Mar. 31, 2024		130,216,541

- Definition

The portion of profit or loss for the period, net of income taxes, which is attributable to the parent.

+ References

+ Details

- Definition

Amount of equity (deficit) attributable to parent. Excludes temporary equity and equity attributable to noncontrolling interest.

+ References

Reference 1: http://fasb.org/us-gaap/role/ref/legacyRef
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+ Details

Debt (Details Narrative) - USD ($) $ in Millions	May 14, 2024	Mar. 31, 2024	Mar. 07, 2024	Mar. 06, 2024
Line of Credit Facility [Line Items]
Line of credit facility, maturity date			Mar. 01, 2029
Line of credit facility remaining borrowing		$ 6.7
Subsequent Event [Member]
Line of Credit Facility [Line Items]
Line of credit	$ 5.0
Exit increase fees	2.50%
Exit fees	6.50%
Subsequent Event [Member] \| Minimum [Member]
Line of Credit Facility [Line Items]
Line of credit	$ 5.0
Subsequent Event [Member] \| Maximum [Member]
Line of Credit Facility [Line Items]
Line of credit	$ 22.0
Term Credit Agreements [Member]
Line of Credit Facility [Line Items]
Line of credit issuance costs			6.50%	7.00%
Term Loan [Member]
Line of Credit Facility [Line Items]
Line of credit issuance costs		13.59%
Revolving Credit Facility [Member]
Line of Credit Facility [Line Items]
Line of credit issuance costs		9.94%
Term Loan Commitment [Member] \| Agent and Lenders [Member]
Line of Credit Facility [Line Items]
Line of credit facility, additional borrowing capacity			$ 10.0
Revolving Loan Commitment [Member]
Line of Credit Facility [Line Items]
Line of credit facility, maximum borrowing capacity			$ 17.0	$ 8.0

Receivables

3 Months Ended

Mar. 31, 2024

Credit Loss [Abstract]

Receivables

(6) 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.

Schedule of Income Taxes (Details) - USD ($) $ in Thousands	3 Months Ended
Schedule of Income Taxes (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Mar. 31, 2023
Income Tax Disclosure [Abstract]
Income tax expense from continuing operations	$ 68	$ 13
Net Loss from Operations Before Provision for Income Taxes	$ (4,332)	$ (2,065)
Effective income tax rate	1.60%	0.60%

- Definition

Amount of income (loss) from continuing operations, including income (loss) from equity method investments, before deduction of income tax expense (benefit), and income (loss) attributable to noncontrolling interest.

+ References

Reference 1: http://www.xbrl.org/2009/role/commonPracticeRef
-Topic 280
-SubTopic 10
-Name Accounting Standards Codification
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Amount of current income tax expense (benefit) and deferred income tax expense (benefit) pertaining to continuing operations.

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+ Details

Intangible Assets (Tables)

3 Months Ended

Mar. 31, 2024

Goodwill and Intangible Assets Disclosure [Abstract]

Schedule of Intangible of Assets

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

Schedule of Intangible of Assets

March 31, 2024:	Weighted Average Life	Cost		Accumulated Amortization			Net
Patents	11 years	$	2,777	$	(741	)	$	2,036
Customer List	6 years		8,000		(1,445	)		6,555
Tradenames	10 years		1,190		(129	)		1,061
		$	11,967	$	(2,315	)	$	9,652

December 31, 2023:	Weighted Average Life	Cost		Accumulated Amortization			Net
Patents	11 years	$	2,777	$	(672	)	$	2,105
Customer List	6 years		8,000		(1,111	)		6,889
Tradenames	10 years		1,190		(99	)		1,091
		$	11,967	$	(1,882	)	$	10,085

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

3 Months Ended

Mar. 31, 2024

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, which are jointly referred to herein as “Xtant” or the “Company”. The terms “we,” “us” and “our” also refer to Xtant. All intercompany balances and transactions have been eliminated in consolidation.

Xtant 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.

The accompanying condensed consolidated balance sheet as of December 31, 2023, 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, 2024.

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, 2023. 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.

Liquidity

Since our inception, we have financed our operations through primarily operating cash flows, private placements of equity securities and convertible debt, debt facilities, common stock rights offerings, and other debt transactions. For the three months ended March 31, 2024, we incurred a net loss of $4.4 million and negative cash flows from operating activities of $5.8 million. We believe that our $4.6 million of cash and cash equivalents as of March 31, 2024, together with our anticipated operating cash flows and amounts available under our recently amended credit facilities, including additional term loan borrowings of $5.0 million on May 14, 2024, as discussed further in Note 11, “Debt,” will be sufficient to meet our anticipated cash requirements through at least May 2025. However, we may require or seek additional capital to fund our future operations and business strategy prior to May 2025. Accordingly, there is no assurance that we will not need or seek additional financing prior to such time. Additionally, we can give no assurances that we will be able to secure additional sources of funds to support our operations, or if such funds are available to us, that such additional financing will be sufficient to meet our needs or on terms acceptable to us. This is particularly true if economic and market conditions deteriorate or our business, financial performance or prospects deteriorate. In addition, prior to raising additional equity or debt financing, we may be required to obtain the consent of MidCap Financial Trust and MidCap Funding IV Trust under our Credit Agreements and/or OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) and ROS Acquisition Offshore LP (“ROS”) under our Investor Rights Agreement with them, and no assurance can be provided that they would provide such consent, which could limit our ability to raise additional financing and the terms thereof.

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, intangible assets and liabilities; valuation allowances for trade receivables, inventory, deferred income tax assets and liabilities; current and long-term lease obligations and corresponding right-of-use asset; estimates for the fair value of assets acquired as part of business combinations; 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 the Company’s condensed consolidated balance sheets are restricted as to withdrawal or use under the terms of certain contractual agreements. The March 31, 2024 and December 31, 2023 balances included lockbox deposits that are temporarily restricted due to timing at the period end. The lockbox deposits are applied against the Company’s line of credit the next business day.

Concentration of Credit Risk

Financial instruments that potentially expose the Company to concentration of credit risk consist primarily of cash, cash equivalents and restricted cash. The Company maintains its cash balances primarily with two financial institutions. These balances generally exceed federally insured limits. The Company has not experienced any losses in such accounts and believes it is not exposed to any significant credit risk in cash and cash equivalents.

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 impairments of long-lived assets were recorded for the three months ended March 31, 2024 and 2023.

Goodwill

Goodwill represents the excess of costs over fair value of assets of businesses acquired. Goodwill and intangible assets acquired in a purchase business combination and determined to have indefinite useful lives are not amortized. Instead, they are tested for impairment at least annually, and whenever events or circumstances indicate, the carrying amount of the asset may not be recoverable. No impairments of goodwill were recorded for the three months ended March 31, 2024 and 2023.

Net Loss Per Share

Basic net loss per share is computed by dividing net loss by the weighted average number of shares of common stock outstanding. Shares issued during the period and shares reacquired during the period are weighted for the portion of the period that they were outstanding. Diluted net loss per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive shares of common stock outstanding during the period, which include the assumed exercise of stock options and warrants using the treasury stock method. Our diluted earnings per share is the same as basic earnings per share, as the effects of including 17,063,298 and 19,194,404 outstanding stock options, restricted stock units and warrants for the three months ended March 31, 2024 and 2023, respectively, are anti-dilutive.

Foreign Currency

The Company generates revenues outside the United States in multiple foreign currencies including euros, Swiss francs, British pounds and in U.S. dollar-denominated transactions conducted with customers who generate revenue in currencies other than the U.S. dollar. The Company also incurs operating expenses in euros, Swiss francs and British pounds. All assets and liabilities of foreign subsidiaries which have a functional currency other than the U.S. dollar are translated at the rate of exchange at period-end, while elements of the income statement are translated at the average exchange rates in effect during the period. The net effect of these translation adjustments is shown as a component of accumulated other comprehensive income. Foreign currency transaction gains and losses are reported in other income, net.

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 March 31, 2024 and December 31, 2023.

Supplemental Disclosure of Cash Flow Information (Tables)

3 Months Ended

Mar. 31, 2024

Supplemental Cash Flow Elements [Abstract]

Schedule of Supplemental Cash Flow Information

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

	2024		2023
	Three Months Ended
	March 31,
	2024		2023
Cash paid during the period for:
Interest	$	740	$	509

Acquisition of Surgalign Holdings, Inc.’s Hardware and Biologics Business (Details Narrative) - USD ($) $ in Millions	Aug. 09, 2023	Dec. 31, 2023
Restructuring Cost and Reserve [Line Items]
Purchase consideration		$ 11.7
Surgalign Holdings [Member]
Restructuring Cost and Reserve [Line Items]
Purchase price consideration	$ 5.0

- Definition

Line items represent financial concepts included in a table. These concepts are used to disclose reportable information associated with domain members defined in one or many axes to the table.

+ References + Details

Supplemental Disclosure of Cash Flow Information

3 Months Ended

Mar. 31, 2024

Supplemental Cash Flow Elements [Abstract]

Supplemental Disclosure of Cash Flow Information

(16) Supplemental Disclosure of Cash Flow Information

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

	2024		2023
	Three Months Ended
	March 31,
	2024		2023
Cash paid during the period for:
Interest	$	740	$	509

Warrants

3 Months Ended

Mar. 31, 2024

Warrants

Warrants

(13) Warrants

As of March 31, 2024 and December 31, 2023, there were outstanding and exercisable warrants to purchase 12,187,470 shares of our common stock at a weighted average exercise price of $1.53 per share with a weighted average remaining contractual term of 2.5 years and 2.8 years, respectively.

Property and Equipment, Net (Tables)

3 Months Ended

Mar. 31, 2024

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

	March 31, 2024			December 31, 2023
Equipment	$	6,959		$	6,858
Computer equipment		1,354			1,330
Computer software		399			230
Leasehold improvements		4,355			4,347
Surgical instruments		15,401			14,648
Assets not yet in service		883			959
Total cost		29,351			28,372
Less: accumulated depreciation		(20,484	)		(19,680	)
Property and equipment, net	$	8,867		$	8,692

Acquisition of Surgalign Holdings, Inc.’s Hardware and Biologics Business

3 Months Ended

Mar. 31, 2024

Acquisition Of Surgalign Holdings Inc.s Hardware And Biologics Business

Acquisition of Surgalign Holdings, Inc.’s Hardware and Biologics Business

(3) Acquisition of Surgalign Holdings, Inc.’s Hardware and Biologics Business

On August 10, 2023, the Company completed the acquisition (the “Transaction”) of the assets of Surgalign Holdings, Inc. (“Surgalign Holdings”), and its subsidiaries used in Surgalign Holdings’ hardware and biologics business. The acquired assets included specified inventory, intellectual property and intellectual property rights, contracts, equipment and other personal property, records, the outstanding equity securities of Surgalign Holdings’ international subsidiaries, and intangibles that were related to Surgalign Holdings’ hardware and biologics business (collectively, the “Assets”). As part of the Transaction, the Company assumed and certain specified liabilities of Surgalign Holdings (collectively, the “Liabilities”), all pursuant to the Asset Purchase Agreement, dated June 18, 2023, between Surgalign Holdings and us (as amended, the “Asset Purchase Agreement”).

The Transaction was conducted through a process supervised by the United States Bankruptcy Court for the Southern District of Texas, Houston Division (the “Bankruptcy Court”) in connection with Surgalign Holdings’ bankruptcy proceedings; and therefore, the Company acquired the Assets with limited representations and warranties. The Bankruptcy Court issued a Sale Order on August 9, 2023 approving and authorizing the Transaction. The Company funded the purchase price of $5.0 million, plus Liabilities, with cash on hand.

The Company recorded the purchase of the Transaction using the acquisition method of accounting and, accordingly, recognized the assets acquired at their fair values as of the date of acquisition. The table below represents the preliminary allocation of the total consideration for Surgalign Holdings’ assets and liabilities based on management’s estimates of their respective fair values as of August 10, 2023 (in thousands):

Schedule of Business Acquisitions


Cash	$	1,087
Accounts receivable		1,627
Inventories		15,300
Prepaids and other current assets		825
Equipment		2,067
Right-of-use asset		576
Accounts payable		(530	)
Accrued liabilities		(1,170	)
Current portion of lease liability		(238	)
Lease liability, less current portion		(338	)
Net assets acquired		19,206
Bargain purchase gain		(11,694	)
Deferred tax liability		(1,922	)

Total purchase consideration	$	5,590

The Transaction was recorded by allocating the costs of the net assets acquired based on their estimated fair values at the acquisition date. The fair values were based on management’s analysis, including work performed by third-party valuation specialists. These values changed from those previously reported in our Form 10-Q for the three and nine months ended September 30, 2023 for adjustments to the valuation related to assumed future cash flows and inventory utilization which ultimately affected values associated with inventories and equipment.

Accounting Standards Codification (“ASC”) 805, Business Combinations, requires that any excess of purchase price over the fair value of assets acquired, including identifiable intangibles and liabilities assumed, be recognized as goodwill and any excess of fair value of acquired net assets, including identifiable intangible assets over the acquisition consideration, results in a gain from bargain purchase. Prior to recording a gain, the acquiring entity must reassess whether all assets acquired and assumed liabilities have been identified and recognized and perform re-measurements to verify that the consideration paid, assets acquired and liabilities assumed have been properly valued. The Transaction resulted in a gain on bargain purchase due to the estimated fair value of the identifiable net assets acquired exceeding the purchase consideration transferred by $11.7 million and is shown as a gain on bargain purchase on our consolidated statement of operations. Upon completion of our assessment, the Company concluded that recording a gain on bargain purchase was appropriate and required under ASC 805. The bargain purchase was primarily attributable to the Transaction occurring as part of bankruptcy proceedings.

The Company believes that the Transaction will strengthen our growing orthobiologics and spinal fusion device portfolio, while expanding the Company’s commercial footprint with new contracts and distributors.

Acquisition of Coflex and CoFix Product Lines (Details Narrative) - USD ($) $ in Thousands	Feb. 28, 2023	Mar. 31, 2024	Dec. 31, 2023
Business Acquisition [Line Items]
Goodwill		$ 7,302	$ 7,302
Surgalign SPV, Inc. [Member]
Business Acquisition [Line Items]
Goodwill	$ 3,524
Equity Purchase Agreement [Member] \| Surgalign SPV, Inc. [Member]
Business Acquisition [Line Items]
Aggregate purchase price in cash	17,000
Indebtedness incurred under term loan	$ 5,000

- Definition

+ References

+ Details

Condensed Consolidated Statements of Operations (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Income Statement [Abstract]
Revenue	$ 27,873	$ 17,943
Cost of sales	10,571	7,407
Gross Profit	17,302	10,536
Operating Expenses
General and administrative	7,785	4,884
Sales and marketing	12,460	7,054
Research and development	527	174
Total Operating Expenses	20,772	12,112
Loss from Operations	(3,470)	(1,576)
Other Expense
Interest expense	(835)	(575)
Interest income		86
Unrealized foreign currency translation loss	(39)
Other income	12
Total Other Expense	(862)	(489)
Net Loss from Operations Before Provision for Income Taxes	(4,332)	(2,065)
Provision for Income Taxes Current and Deferred	(68)	(13)
Net Loss	$ (4,400)	$ (2,078)
Net Loss Per Share:
Basic	$ (0.03)	$ (0.02)
Dilutive	$ (0.03)	$ (0.02)
Shares used in the computation:
Basic	130,201,251	108,893,588
Dilutive	130,201,251	108,893,588

Stock-Based Compensation (Details Narrative) - USD ($)		3 Months Ended
Stock-Based Compensation (Details Narrative) - USD ($)	Jul. 26, 2023	Mar. 31, 2024	Dec. 31, 2023	Mar. 31, 2023	Dec. 31, 2022
Restricted Stock Units (RSUs) [Member]
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Unvested employee stock options not yet recognized		$ 2,400,000
Stock option vested weighted average period		2 years 1 month 6 days
Equity Option [Member]
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Unvested employee stock options not yet recognized		$ 2.0
Stock option vested weighted average period		2 years 6 months
2023 Equity Incentive Plan [Member]
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Share based compensation, description	The maximum number of shares of our common stock available for issuance under the 2023 Plan, subject to adjustment pursuant to the terms of the 2023 Plan, is (i) 5,500,000 shares of common stock; (ii) 7,695,812 shares of common stock remaining available for issuance under the 2018 Plan but not subject to outstanding awards under the 2018 Plan as of July 26, 2023; and (iii) up to 6,686,090 shares of common stock subject to awards outstanding under the 2018 Plan as of July 26, 2023 but only to the extent such awards are subsequently forfeited, cancelled, expire, or otherwise terminate without the issuance of such shares of common stock after such date.
Number of shares available for grant	5,500,000
2018 Equity Incentive Plan [Member]
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Number of shares available for grant	7,695,812
Share based compensation, award outstanding	6,686,090
2018 Equity Incentive Plan [Member] \| Equity Option [Member]
Share-Based Compensation Arrangement by Share-Based Payment Award [Line Items]
Share based compensation, award outstanding		4,875,828	4,875,828	3,391,037	3,360,664

Income Taxes

3 Months Ended

Mar. 31, 2024

Income Tax Disclosure [Abstract]

Income Taxes

(15) Income Taxes

Information on the Company’s income taxes for the periods reported is as follows:

Schedule of Income Taxes

	2024			2023
	Three Months Ended
	March 31,
	2024			2023
Income tax expense from continuing operations	$	68		$	13
Income from continuing operations before income taxes	$	(4,332	)	$	(2,065	)
Effective income tax rate		-1.6	%		-0.6	%

Our effective tax rate for the first quarter of 2024 differs from the statutory rate due to a valuation allowance against deferred tax assets, offset by the impact of cash state and foreign taxes.

Our effective tax rate for the first quarter of 2023 differs from the statutory rate due to a valuation allowance against deferred tax assets, offset by the impact of cash state and foreign taxes.

As of March 31, 2024, the Company is not currently under examination by tax authorities.

- Definition

The entire disclosure for income tax.

+ References

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Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Topic 235
-SubTopic 10
-Name Accounting Standards Codification
-Section S99
-Paragraph 1
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-Publisher FASB
-URI https://asc.fasb.org/1943274/2147480678/235-10-S99-1

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Topic 740
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-Publisher FASB
-URI https://asc.fasb.org/740/tableOfContent

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
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-Publisher FASB
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Reference 11: http://www.xbrl.org/2003/role/disclosureRef
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-Publisher FASB
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Reference 12: http://www.xbrl.org/2003/role/disclosureRef
-Topic 740
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-Paragraph 17
-Subparagraph (b)
-Publisher FASB
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Reference 13: http://www.xbrl.org/2003/role/disclosureRef
-Topic 740
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-Name Accounting Standards Codification
-Section S99
-Paragraph 2
-Subparagraph (SAB Topic 11.C)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147479360/740-10-S99-2

Reference 14: http://www.xbrl.org/2003/role/disclosureRef
-Topic 740
-SubTopic 30
-Name Accounting Standards Codification
-Section 50
-Paragraph 2
-Subparagraph (a)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147482603/740-30-50-2

+ Details

Stock-Based Compensation

3 Months Ended

Mar. 31, 2024

Share-Based Payment Arrangement [Abstract]

Stock-Based Compensation

(12) Stock-Based Compensation

On July 26, 2023, our stockholders approved and adopted the Xtant Medical Holdings, Inc. 2023 Equity Incentive Plan (the “2023 Plan”), which replaced the Xtant Medical Holdings, Inc. 2018 Equity Incentive Plan (the “2018 Plan”) with respect to future grants of equity awards, although the 2018 Plan continues to govern equity awards granted under the 2018 Plan. The 2023 Plan permits the Board of Directors, or a committee thereof, to grant to eligible employees, non-employee directors, and consultants of the Company non-statutory and incentive stock options, stock appreciation rights, restricted stock awards, restricted stock units, deferred stock units, performance awards, non-employee director awards, and other stock-based awards. The Board of Directors may select 2023 Plan participants and determine the nature and amount of awards to be granted. The maximum number of shares of our common stock available for issuance under the 2023 Plan, subject to adjustment pursuant to the terms of the 2023 Plan, is (i) 5,500,000 shares of common stock; (ii) 7,695,812 shares of common stock remaining available for issuance under the 2018 Plan but not subject to outstanding awards under the 2018 Plan as of July 26, 2023; and (iii) up to 6,686,090 shares of common stock subject to awards outstanding under the 2018 Plan as of July 26, 2023 but only to the extent such awards are subsequently forfeited, cancelled, expire, or otherwise terminate without the issuance of such shares of common stock after such date.

Stock option activity, including options granted under the 2023 Plan and 2018 Plan, was as follows for the three months ended March 31, 2024 and 2023:

	2024						2023
	Shares		Weighted Average Exercise Price		Weighted Average Remaining Contract Term (years)		Shares			Weighted Average Exercise Price		Weighted Average Remaining Contract Term (years)
Outstanding at January 1		4,875,828		1.31				3,360,664			1.51
Granted		—		—				105,000			0.77
Cancelled or expired		—		—				(74,627	)		0.64
Outstanding at March 31		4,875,828		1.31		7.72		3,391,037			1.50		8.0
Exercisable at March 31		2,221,703		1.48		6.75		1,387,378			1.98		7.5

As of March 31, 2024, there was approximately $2.0 million of total unrecognized compensation expense related to unvested stock options. These costs are expected to be recognized over a weighted-average period of 2.5 years.

Restricted stock unit activity for awards granted under the 2023 Plan and 2018 Plan was as follows for the three months ended March 31, 2024 and 2023:

Schedule of Restricted Stock Activity

	2024					2023
	Shares			Weighted Average Fair Value at Grant Date Per Share		Shares			Weighted Average Fair Value at Grant Date Per Share
Outstanding at January 1		3,524,675		$	1.07		3,612,433		$	0.87
Granted		—			—		89,000			0.77
Vested		(44,496	)		0.71		(22,245	)		0.65
Cancelled		—			—		(63,291	)		0.64
Outstanding at March 31		3,480,179		$	1.17		3,615,897		$	0.88

Total compensation expense related to unvested restricted stock units not yet recognized was $2.4 million as of March 31, 2024, which is expected to be allocated to expenses over a weighted-average period of 2.1 years.

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Details Narrative) - USD ($)	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023	May 14, 2024
Subsequent Event [Line Items]
Net loss	$ (4,400,000)	$ (2,078,000)
Cash flows from operating activities	(5,755,000)	(2,245,000)
Cash equivalents	4,600,000
Impairments of long-lived assets	0	0
Impairments of goodwill	$ 0	$ 0
Warrant [Member] \| Restricted Stock [Member]
Subsequent Event [Line Items]
Antidilutive securities	17,063,298	19,194,404
Subsequent Event [Member]
Subsequent Event [Line Items]
Line of credit			$ 5,000,000.0

Debt (Tables)

3 Months Ended

Mar. 31, 2024

Debt Disclosure [Abstract]

Schedule of Long-term Debt

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

Schedule of Long-term Debt

	March 31, 2024			December 31, 2023
Amounts due under term loan	$	17,000		$	17,000
Accrued end-of-term payments		170			456
Less: unamortized debt issuance costs		(344	)		(289	)
Long-term debt, less issuance costs	$	16,826		$	17,167

Acquisition of Coflex and CoFix Product Lines

3 Months Ended

Mar. 31, 2024

Business Combination, Asset Acquisition, and Joint Venture Formation [Abstract]

Acquisition of Coflex and CoFix Product Lines

(2) Acquisition of Coflex and CoFix Product Lines

On February 28, 2023, the Company entered into an Equity Purchase Agreement (the “Equity Purchase Agreement”) with Surgalign SPV, Inc. (“Surgalign SPV”), a wholly owned subsidiary of Surgalign Spine Technologies, Inc., (“Seller”), Seller and Surgalign Holdings, Inc., pursuant to which the Company purchased all of the issued and outstanding shares of common stock of Surgalign SPV, which shares constituted all of the outstanding equity of Surgalign SPV, for an aggregate purchase price of $17.0 million in cash (the “Purchase Price”). The closing contemplated by the Equity Purchase Agreement occurred on February 28, 2023 (the “Closing”).

Immediately prior to the Closing, Seller and its affiliates transferred and assigned to Surgalign SPV, a newly formed entity wholly owned by Seller, certain intellectual property, contractual rights and other assets related to the design, manufacture, sale and distribution of Seller’s Coflex and CoFix products in the United States (the “Coflex Business”). The Coflex and CoFix products have been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe lumbar spinal stenosis in conjunction with decompression and provide minimally invasive, motion preserving stabilization.

In conjunction with the Equity Purchase Agreement, on February 28, 2023, the Company entered into a Transition Services Agreement with Surgalign SVP and Seller, whereby Seller agreed to provide, or cause to be provided, to the Company on and after the effective date of the Equity Purchase Agreement, after giving effect to the Closing, certain transitional services related to the transition of the Coflex Business.

The Company funded the Purchase Price with cash on hand and approximately $5.0 million of indebtedness incurred under our term loan, refer to Note 11, “Debt,” for additional information.

The Company recorded the purchase of this acquisition using the acquisition method of accounting and, accordingly, recognized the assets acquired at their fair values as of the date of acquisition. The table below represents the allocation of the total consideration for Surgalign SPV’s assets and liabilities based on management’s estimates of their respective fair values as of February 28, 2023 (in thousands):


Inventories	$	1,589
Equipment		947
Intangible assets		10,940
Net assets acquired		13,476

Goodwill		3,524

Total purchase consideration	$	17,000

The acquisition was recorded by allocating the costs of the net assets acquired based on their estimated fair values at the acquisition date. The fair values were based on management’s analysis, including work performed by third-party valuation specialists.

The acquisition strengthened the Company’s spine portfolio with the addition of the Coflex Business. Coflex is a differentiated and minimally invasive motion preserving stabilization implant that is premarket approved by the U.S. Food and Drug Administration for the treatment of moderate to severe lumbar spinal stenosis in conjunction with decompression. This potential benefit resulted in the Company paying a premium for the acquisition resulting in the recognition of $3.5 million in goodwill. For tax purposes, goodwill is deductible.

Acquisition of Surgalign Holdings, Inc.’s Hardware and Biologics Business (Tables)

3 Months Ended

Mar. 31, 2024

Acquisition Of Surgalign Holdings Inc.s Hardware And Biologics Business

Schedule of Business Acquisitions


Cash	$	1,087
Accounts receivable		1,627
Inventories		15,300
Prepaids and other current assets		825
Equipment		2,067
Right-of-use asset		576
Accounts payable		(530	)
Accrued liabilities		(1,170	)
Current portion of lease liability		(238	)
Lease liability, less current portion		(338	)
Net assets acquired		19,206
Bargain purchase gain		(11,694	)
Deferred tax liability		(1,922	)

Total purchase consideration	$	5,590

Accrued Liabilities

3 Months Ended

Mar. 31, 2024

Payables and Accruals [Abstract]

Accrued Liabilities

(10) Accrued Liabilities

Accrued liabilities consist of the following (in thousands):

Schedule of Accrued Liabilities

	March 31, 2024		December 31, 2023
Cash compensation/commissions payable	$	8,549	$	8,890
Other accrued liabilities		1,326		1,529
Accrued liabilities	$	9,875	$	10,419

Condensed Consolidated Balance Sheets - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Current Assets:
Cash and cash equivalents	$ 4,547	$ 5,715
Restricted cash	77	208
Trade accounts receivable, net of allowance for credit losses and doubtful accounts of $954 and $920, respectively	21,484	20,731
Inventories	38,724	36,885
Prepaid and other current assets	1,709	1,330
Total current assets	66,541	64,869
Property and equipment, net	8,867	8,692
Right-of-use asset, net	1,437	1,523
Goodwill	7,302	7,302
Intangible assets, net	9,652	10,085
Other assets	132	141
Total Assets	93,931	92,612
Current Liabilities:
Accounts payable	7,378	7,054
Accrued liabilities	9,875	10,419
Current portion of lease liability	853	830
Current portion of finance lease obligations	66	65
Line of credit	10,270	4,622
Total current liabilities	28,442	22,990
Long-term Liabilities:
Lease liability, less current portion	644	759
Finance lease obligation, less current portion	99	116
Long-term debt, plus premium and less issuance costs	16,826	17,167
Other liabilities	240	231
Total Liabilities	46,251	41,263
Commitments and Contingencies (note 14)
Stockholders’ Equity:
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; 130,216,541 shares issued and outstanding as of March 31, 2024 and 130,180,031 shares issued and outstanding as of December 31, 2023
Additional paid-in capital	295,223	294,330
Accumulated other comprehensive (loss) income	(133)	29
Accumulated deficit	(247,410)	(243,010)
Total Stockholders’ Equity	47,680	51,349
Total Liabilities & Stockholders’ Equity	$ 93,931	$ 92,612

Debt

3 Months Ended

Mar. 31, 2024

Debt Disclosure [Abstract]

Debt

(11) Debt

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

Schedule of Long-term Debt

	March 31, 2024			December 31, 2023
Amounts due under term loan	$	17,000		$	17,000
Accrued end-of-term payments		170			456
Less: unamortized debt issuance costs		(344	)		(289	)
Long-term debt, less issuance costs	$	16,826		$	17,167

On March 7, 2024, the Company’s term credit agreement was amended and restated to, among other things, extend the maturity date to March 1, 2029. An additional $10.0 million tranche, available solely at the discretion of MidCap Financial Trust and the lenders, was added to the term credit agreement and the applicable margin used to determine the per annum interest rate was reduced from 7.00% to 6.50%. The date of certain fees payable in connection with optional prepayments were also reset by the amendment to be determined based on the date the amendment. The Company’s revolving credit agreement was also amended and restated on March 7, 2024, to among other things, increase the commitment amount from $8.0 million to $17.0 million. The maturity of the revolving credit agreement was also extended to March 1, 2029. Minimum net product revenue requirements specified in the credit agreements were reset and minimum adjusted EBITDA requirements were removed.

The effective rate of the term loan, inclusive of amortization of debt issuance costs and accretion of the final payment, was 13.59% as of March 31, 2024. The effective rate of the revolving credit agreement was 9.94% as of March 31, 2024. As of March 31, 2024, the Company had $6.7 million available under the revolving credit agreement and was in compliance with all covenants under the credit agreements.

On May 14, 2024, the term credit agreement was amended to increase the amount of term loans that may be borrowed by $5.0 million to a maximum of $22.0 million, which are fully drawn as of May 14, 2024. In addition, the amendments to the term credit agreement and revolving credit agreement re-set the date certain fees payable in connection with optional prepayments are determined to May 14, 2024 and consequently extend such fees’ original expiration. The exit fees were increased by 2.50% to 6.50% of the principal amount borrowed pursuant to the term credit agreement. The terms of borrowing under the term credit agreement and revolving credit agreement otherwise remain materially unchanged.

- Definition

The entire disclosure for information about short-term and long-term debt arrangements, which includes amounts of borrowings under each line of credit, note payable, commercial paper issue, bonds indenture, debenture issue, own-share lending arrangements and any other contractual agreement to repay funds, and about the underlying arrangements, rationale for a classification as long-term, including repayment terms, interest rates, collateral provided, restrictions on use of assets and activities, whether or not in compliance with debt covenants, and other matters important to users of the financial statements, such as the effects of refinancing and noncompliance with debt covenants.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Topic 470
-SubTopic 10
-Name Accounting Standards Codification
-Section 50
-Paragraph 6
-Subparagraph (b)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147481544/470-10-50-6

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Topic 470
-SubTopic 10
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-Paragraph 6
-Subparagraph (a)
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-URI https://asc.fasb.org/1943274/2147481544/470-10-50-6

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
-Section 50
-Paragraph 1
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-Publisher FASB
-URI https://asc.fasb.org/1943274/2147477092/405-40-50-1

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Topic 405
-SubTopic 40
-Name Accounting Standards Codification
-Section 50
-Paragraph 1
-Subparagraph (a)(3)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147477092/405-40-50-1

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Topic 405
-SubTopic 40
-Name Accounting Standards Codification
-Section 50
-Paragraph 1
-Subparagraph (a)(2)
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147477092/405-40-50-1

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
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Reference 7: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Topic 470
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-Name Accounting Standards Codification
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-Paragraph 1B
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Reference 9: http://www.xbrl.org/2003/role/disclosureRef
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-SubTopic 10
-Name Accounting Standards Codification
-Section S99
-Paragraph 1
-Subparagraph (SX 210.4-08(c))
-Publisher FASB
-URI https://asc.fasb.org/1943274/2147480678/235-10-S99-1

Reference 10: http://fasb.org/us-gaap/role/ref/legacyRef
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-URI https://asc.fasb.org/470/tableOfContent

Reference 11: http://www.xbrl.org/2003/role/disclosureRef
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-URI https://asc.fasb.org/1943274/2147482925/835-30-45-2

Reference 12: http://www.xbrl.org/2003/role/disclosureRef
-Topic 470
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-URI https://asc.fasb.org/1943274/2147481139/470-20-50-1B

Reference 13: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
-Section 50
-Paragraph 1B
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Reference 15: http://www.xbrl.org/2003/role/disclosureRef
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Reference 17: http://www.xbrl.org/2003/role/disclosureRef
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-Publisher FASB
-URI https://asc.fasb.org/1943274/2147481139/470-20-50-1I

+ Details

Condensed Consolidated Statements of Comprehensive Loss (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Income Statement [Abstract]
Net Loss	$ (4,400)	$ (2,078)
Other Comprehensive Loss
Foreign currency translation adjustments	(162)
Comprehensive Loss	$ (4,562)	$ (2,078)

- Definition

Amount after tax of increase (decrease) in equity from transactions and other events and circumstances from net income and other comprehensive income, attributable to parent entity. Excludes changes in equity resulting from investments by owners and distributions to owners.

+ References + Details

- Definition

The portion of profit or loss for the period, net of income taxes, which is attributable to the parent.

+ References

+ Details

Cover - shares	3 Months Ended
Cover - shares	Mar. 31, 2024	May 10, 2024
Cover [Abstract]
Document Type	10-Q
Amendment Flag	false
Document Quarterly Report	true
Document Transition Report	false
Document Period End Date	Mar. 31, 2024
Document Fiscal Period Focus	Q1
Document Fiscal Year Focus	2024
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		130,216,541

Schedule of Accrued Liabilities (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Payables and Accruals [Abstract]
Cash compensation/commissions payable	$ 8,549	$ 8,890
Other accrued liabilities	1,326	1,529
Accrued liabilities	$ 9,875	$ 10,419

Acquisition of NanOss Production Operations (Details Narrative) - USD ($) $ in Thousands	Oct. 23, 2023	Mar. 31, 2024	Dec. 31, 2023
Restructuring Cost and Reserve [Line Items]
Goodwill		$ 7,302	$ 7,302
Nan Oss Production Operations [Member]
Restructuring Cost and Reserve [Line Items]
Purchase price for the assets	$ 2,210
Contingent payments	200
Goodwill	$ 573

Line items represent financial concepts included in a table. These concepts are used to disclose reportable information associated with domain members defined in one or many axes to the table.

+ References + Details

Business Description, Basis of Presentation and Summary of Significant Accounting Policies (Policies)	3 Months Ended
	Mar. 31, 2024
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, which are jointly referred to herein as “Xtant” or the “Company”. The terms “we,” “us” and “our” also refer to Xtant. All intercompany balances and transactions have been eliminated in consolidation. Xtant 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. The accompanying condensed consolidated balance sheet as of December 31, 2023, 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, 2024. 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, 2023. 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.
Liquidity	Liquidity Since our inception, we have financed our operations through primarily operating cash flows, private placements of equity securities and convertible debt, debt facilities, common stock rights offerings, and other debt transactions. For the three months ended March 31, 2024, we incurred a net loss of $4.4 million and negative cash flows from operating activities of $5.8 million. We believe that our $4.6 million of cash and cash equivalents as of March 31, 2024, together with our anticipated operating cash flows and amounts available under our recently amended credit facilities, including additional term loan borrowings of $5.0 million on May 14, 2024, as discussed further in Note 11, “Debt,” will be sufficient to meet our anticipated cash requirements through at least May 2025. However, we may require or seek additional capital to fund our future operations and business strategy prior to May 2025. Accordingly, there is no assurance that we will not need or seek additional financing prior to such time. Additionally, we can give no assurances that we will be able to secure additional sources of funds to support our operations, or if such funds are available to us, that such additional financing will be sufficient to meet our needs or on terms acceptable to us. This is particularly true if economic and market conditions deteriorate or our business, financial performance or prospects deteriorate. In addition, prior to raising additional equity or debt financing, we may be required to obtain the consent of MidCap Financial Trust and MidCap Funding IV Trust under our Credit Agreements and/or OrbiMed Royalty Opportunities II, LP (“Royalty Opportunities”) and ROS Acquisition Offshore LP (“ROS”) under our Investor Rights Agreement with them, and no assurance can be provided that they would provide such consent, which could limit our ability to raise additional financing and the terms thereof.
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, intangible assets and liabilities; valuation allowances for trade receivables, inventory, deferred income tax assets and liabilities; current and long-term lease obligations and corresponding right-of-use asset; estimates for the fair value of assets acquired as part of business combinations; 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 the Company’s condensed consolidated balance sheets are restricted as to withdrawal or use under the terms of certain contractual agreements. The March 31, 2024 and December 31, 2023 balances included lockbox deposits that are temporarily restricted due to timing at the period end. The lockbox deposits are applied against the Company’s line of credit the next business day.
Concentration of Credit Risk	Concentration of Credit Risk Financial instruments that potentially expose the Company to concentration of credit risk consist primarily of cash, cash equivalents and restricted cash. The Company maintains its cash balances primarily with two financial institutions. These balances generally exceed federally insured limits. The Company has not experienced any losses in such accounts and believes it is not exposed to any significant credit risk in cash and cash equivalents.
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 impairments of long-lived assets were recorded for the three months ended March 31, 2024 and 2023.
Goodwill	Goodwill Goodwill represents the excess of costs over fair value of assets of businesses acquired. Goodwill and intangible assets acquired in a purchase business combination and determined to have indefinite useful lives are not amortized. Instead, they are tested for impairment at least annually, and whenever events or circumstances indicate, the carrying amount of the asset may not be recoverable. No impairments of goodwill were recorded for the three months ended March 31, 2024 and 2023.
Net Loss Per Share	Net Loss Per Share Basic net loss per share is computed by dividing net loss by the weighted average number of shares of common stock outstanding. Shares issued during the period and shares reacquired during the period are weighted for the portion of the period that they were outstanding. Diluted net loss per share is computed in a manner consistent with that of basic earnings per share while giving effect to all potentially dilutive shares of common stock outstanding during the period, which include the assumed exercise of stock options and warrants using the treasury stock method. Our diluted earnings per share is the same as basic earnings per share, as the effects of including 17,063,298 and 19,194,404 outstanding stock options, restricted stock units and warrants for the three months ended March 31, 2024 and 2023, respectively, are anti-dilutive.
Foreign Currency	Foreign Currency The Company generates revenues outside the United States in multiple foreign currencies including euros, Swiss francs, British pounds and in U.S. dollar-denominated transactions conducted with customers who generate revenue in currencies other than the U.S. dollar. The Company also incurs operating expenses in euros, Swiss francs and British pounds. All assets and liabilities of foreign subsidiaries which have a functional currency other than the U.S. dollar are translated at the rate of exchange at period-end, while elements of the income statement are translated at the average exchange rates in effect during the period. The net effect of these translation adjustments is shown as a component of accumulated other comprehensive income. Foreign currency transaction gains and losses are reported in other income, net.
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 March 31, 2024 and December 31, 2023.

Schedule of Property and Equipment, Net (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Property, Plant and Equipment [Line Items]
Total cost	$ 29,351	$ 28,372
Less: accumulated depreciation	(20,484)	(19,680)
Property and equipment, net	8,867	8,692
Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	6,959	6,858
Computer Equipment [Member]
Property, Plant and Equipment [Line Items]
Total cost	1,354	1,330
Computer Softwares [Member]
Property, Plant and Equipment [Line Items]
Total cost	399	230
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Total cost	4,355	4,347
Surgical Instruments [Member]
Property, Plant and Equipment [Line Items]
Total cost	15,401	14,648
Assets Not Yet in Service [Member]
Property, Plant and Equipment [Line Items]
Total cost	$ 883	$ 959

Schedule of Acquisition Pro Forma Information (Details) $ in Thousands	3 Months Ended
	Mar. 31, 2023 USD ($)
Schedule Of Acquisition Pro Forma Information
Revenues	$ 34,631
Net loss	$ (3,607)

Intangible Assets

3 Months Ended

Mar. 31, 2024

Goodwill and Intangible Assets Disclosure [Abstract]

Intangible Assets

(9) Intangible Assets

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

Schedule of Intangible of Assets

March 31, 2024:	Weighted Average Life	Cost		Accumulated Amortization			Net
Patents	11 years	$	2,777	$	(741	)	$	2,036
Customer List	6 years		8,000		(1,445	)		6,555
Tradenames	10 years		1,190		(129	)		1,061
		$	11,967	$	(2,315	)	$	9,652

December 31, 2023:	Weighted Average Life	Cost		Accumulated Amortization			Net
Patents	11 years	$	2,777	$	(672	)	$	2,105
Customer List	6 years		8,000		(1,111	)		6,889
Tradenames	10 years		1,190		(99	)		1,091
		$	11,967	$	(1,882	)	$	10,085

Amortization expense was $0.4 million and $0.1 million for the three months ended March 31, 2024 and 2023, respectively.

Commitments and Contingencies

3 Months Ended

Mar. 31, 2024

Commitments and Contingencies Disclosure [Abstract]

Commitments and Contingencies

(14) Commitments and Contingencies

Litigation

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. While we do not believe that the ultimate resolution of any claims and lawsuits will have a material adverse effect upon our consolidated financial position, results of operations or cash flows, it is possible that the amount of ultimate loss may exceed our current accruals and that our 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.

Indemnification Arrangements

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.

Inventories (Tables)

3 Months Ended

Mar. 31, 2024

Inventory Disclosure [Abstract]

Schedule of Inventories

Inventories consist of the following (in thousands):

Schedule of Inventories

	March 31, 2024		December 31, 2023
Raw materials	$	7,021	$	7,269
Work in process		2,137		1,562
Finished goods		29,566		28,054
Total	$	38,724	$	36,885

Schedule of Intangible of Assets (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Finite-Lived Intangible Assets [Line Items]
Intangible assets, gross	$ 11,967	$ 11,967
Accumulated amortization	(2,315)	(1,882)
Intangible assets, net	$ 9,652	$ 10,085
Patents [Member]
Finite-Lived Intangible Assets [Line Items]
Weighted avereage life	11 years	11 years
Intangible assets, gross	$ 2,777	$ 2,777
Accumulated amortization	(741)	(672)
Intangible assets, net	$ 2,036	$ 2,105
Customer Relationships [Member]
Finite-Lived Intangible Assets [Line Items]
Weighted avereage life	6 years	6 years
Intangible assets, gross	$ 8,000	$ 8,000
Accumulated amortization	(1,445)	(1,111)
Intangible assets, net	$ 6,555	$ 6,889
Trade Names [Member]
Finite-Lived Intangible Assets [Line Items]
Weighted avereage life	10 years	10 years
Intangible assets, gross	$ 1,190	$ 1,190
Accumulated amortization	(129)	(99)
Intangible assets, net	$ 1,061	$ 1,091

- Definition

Line items represent financial concepts included in a table. These concepts are used to disclose reportable information associated with domain members defined in one or many axes to the table.

+ References + Details

Segment and Geographic Information

3 Months Ended

Mar. 31, 2024

Segment Reporting [Abstract]

Segment and Geographic Information

(18) Segment and Geographic Information

The Company operates in one segment based upon the Company’s organizational structure, the way in which the operations and investments are managed and evaluated by the chief operating decision maker (“CODM”). The Company shares common, centralized support functions which report directly to the CODM and decision-making regarding the Company’s overall operating performance and allocation of Company resources is assessed on a consolidated basis. Net revenue by geographic region are as follows:

	2024		2023
	Three Months Ended March 31,
	2024		2023
United States	$	25,133	$	17,513
Rest of world		2,740		430
Total revenue	$	27,873	$	17,943

- 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.

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+ Details

Intangible Assets (Details Narrative) - USD ($) $ in Millions	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Goodwill and Intangible Assets Disclosure [Abstract]
Amortization expense	$ 0.4	$ 0.1

Schedule of Revenues by Geographic Region (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	$ 27,873	$ 17,943
UNITED STATES
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	25,133	17,513
Rest Of World [Member]
Revenues from External Customers and Long-Lived Assets [Line Items]
Total revenue	$ 2,740	$ 430

- Definition

+ References

+ Details

Related Party Transactions (Details Narrative)	Mar. 31, 2024
OrbiMed Advisors LLC [Member]
Ownership percentage	56.20%

Property and Equipment, Net

3 Months Ended

Mar. 31, 2024

Property, Plant and Equipment [Abstract]

Property and Equipment, Net

(8) Property and Equipment, Net

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

Schedule of Property and Equipment, Net

	March 31, 2024			December 31, 2023
Equipment	$	6,959		$	6,858
Computer equipment		1,354			1,330
Computer software		399			230
Leasehold improvements		4,355			4,347
Surgical instruments		15,401			14,648
Assets not yet in service		883			959
Total cost		29,351			28,372
Less: accumulated depreciation		(20,484	)		(19,680	)
Property and equipment, net	$	8,867		$	8,692

Depreciation expense related to property and equipment, including property under finance leases, for the first three months of 2024 and 2023 was $0.6 million and $0.3 million, respectively.

Accrued Liabilities (Tables)

3 Months Ended

Mar. 31, 2024

Payables and Accruals [Abstract]

Schedule of Accrued Liabilities

Accrued liabilities consist of the following (in thousands):

Schedule of Accrued Liabilities

	March 31, 2024		December 31, 2023
Cash compensation/commissions payable	$	8,549	$	8,890
Other accrued liabilities		1,326		1,529
Accrued liabilities	$	9,875	$	10,419

Condensed Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Statement of Financial Position [Abstract]
Allowance of accounts receivable, net	$ 954	$ 920
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	130,216,541	130,180,031
Common stock, shares outstanding	130,216,541	130,180,031

Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Operating activities:
Net loss	$ (4,400)	$ (2,078)
Adjustments to reconcile net loss to net cash used in operating activities:
Depreciation and amortization	1,005	471
Gain on sale of fixed assets	(82)	(11)
Non-cash interest	95	61
Stock-based compensation	910	617
Provision for reserve on accounts receivable	88	106
Provision for excess and obsolete inventory	259	90
Other	3	2
Changes in operating assets and liabilities, net of the effects of the acquisition:
Accounts receivable	(879)	(1,155)
Inventories	(2,195)	(309)
Prepaid and other assets	(376)	(68)
Accounts payable	492	(69)
Accrued liabilities	(675)	98
Net cash used in operating activities	(5,755)	(2,245)
Investing activities:
Purchases of property and equipment	(773)	(456)
Proceeds from sale of fixed assets	99	35
Acquisition of Surgalign SPV, Inc.		(17,000)
Net cash used in investing activities	(674)	(17,421)
Financing activities:
Payments on financing leases	(16)	(15)
Borrowings on line of credit	30,445	16,495
Repayments on line of credit	(24,797)	(16,871)
Proceeds from issuance of long term debt		5,000
Debt issuance costs	(436)	(40)
Payment of taxes from withholding of common stock on vesting of restricted stock units	(17)
Net cash provided by financing activities	5,179	4,569
Effect of exchange rate changes on cash and cash equivalents and restricted cash	(49)
Net change in cash and cash equivalents and restricted cash	(1,299)	(15,097)
Cash and cash equivalents and restricted cash at beginning of period	5,923	20,507
Cash and cash equivalents and restricted cash at end of period	4,624	5,410
Reconciliation of cash and cash equivalents and restricted cash reported in the condensed consolidated balance sheets
Cash and cash equivalents	4,547	5,176
Restricted cash	77	234
Total cash and restricted cash reported in condensed consolidated balance sheets	$ 4,624	$ 5,410

Inventories

3 Months Ended

Mar. 31, 2024

Inventory Disclosure [Abstract]

Inventories

(7) Inventories

Inventories consist of the following (in thousands):

Schedule of Inventories

	March 31, 2024		December 31, 2023
Raw materials	$	7,021	$	7,269
Work in process		2,137		1,562
Finished goods		29,566		28,054
Total	$	38,724	$	36,885

Stock-Based Compensation (Tables)

3 Months Ended

Mar. 31, 2024

Share-Based Payment Arrangement [Abstract]

Schedule of Share-based Compensation, Stock Options Activity

Stock option activity, including options granted under the 2023 Plan and 2018 Plan, was as follows for the three months ended March 31, 2024 and 2023:

	2024						2023
	Shares		Weighted Average Exercise Price		Weighted Average Remaining Contract Term (years)		Shares			Weighted Average Exercise Price		Weighted Average Remaining Contract Term (years)
Outstanding at January 1		4,875,828		1.31				3,360,664			1.51
Granted		—		—				105,000			0.77
Cancelled or expired		—		—				(74,627	)		0.64
Outstanding at March 31		4,875,828		1.31		7.72		3,391,037			1.50		8.0
Exercisable at March 31		2,221,703		1.48		6.75		1,387,378			1.98		7.5

Schedule of Restricted Stock Activity

	2024					2023
	Shares			Weighted Average Fair Value at Grant Date Per Share		Shares			Weighted Average Fair Value at Grant Date Per Share
Outstanding at January 1		3,524,675		$	1.07		3,612,433		$	0.87
Granted		—			—		89,000			0.77
Vested		(44,496	)		0.71		(22,245	)		0.65
Cancelled		—			—		(63,291	)		0.64
Outstanding at March 31		3,480,179		$	1.17		3,615,897		$	0.88