EXHIBIT 10.9


 


REGISTRATION RIGHTS AGREEMENT


 


OrbiMed Royalty
Opportunities II, LP


c/o OrbiMed
Advisors LLC


601 Lexington
Ave., 54th Floor


New York,
NY 10022


 


ROS Acquisition
Offshore LP


c/o OrbiMed
Advisors LLC


601 Lexington
Ave., 54th Floor


New York,
NY 10022


 


Ladies and Gentlemen:


 


Xtant Medical Holdings, Inc., a Delaware corporation
(the “Company”), proposes to issue and sell to OrbiMed Royalty Opportunities II, LP and ROS Acquisition Offshore
LP (the “Purchasers”) convertible senior notes due 2021 in the aggregate principal amount of $1,560,000 (the
“Notes”), upon the terms set forth in the Securities Purchase Agreements among the Company, each of the Purchasers,
dated January 16, 2017 (the “Purchase Agreements”). Upon a conversion of each Note at the option of the holder
thereof, the Company will be required to deliver shares of common stock of the Company, $0.000001 par value per share (the “Common
Stock”). To induce the Purchasers to enter into the Purchase Agreements and to satisfy the Company’s obligations
thereunder, the holders of the Notes will have the benefit of this registration rights agreement (this “Agreement”)
pursuant to which the Company agrees with the Purchasers for the benefit of the Purchasers and for the benefit of the holders (the
“Holders”) from time to time of the Registrable Securities (as defined below), as follows:


 


1.          Definitions.
As used in this Agreement, the following capitalized defined terms shall have the following meanings:


 


“Additional Interest”
has the meaning set forth in Section 7.


 


“Affiliate”
has the meaning set forth in Rule 405 under the Securities Act.


 


“Agreement”
has the meaning set forth in the preamble hereto.


 


“Broker-Dealer”
means any broker or dealer registered as such under the Exchange Act.


 


“Business Day”
has the meaning set forth in the Notes.


 


“Close of Business”
has the meaning set forth in the Notes.


 


“Closing Date”
means the date hereof.


 



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“Company”
has the meaning set forth in the preamble hereto.


 


“Commission”
means the Securities and Exchange Commission.


 


“Common Stock”
has the meaning set forth in the preamble hereto.


 


“Control”
has the meaning set forth in Rule 405 under the Securities Act, and the terms “controlling” and “controlled”
shall have meanings correlative thereto.


 


“Conversion Date”
has the meaning set forth in the Notes.


 


“Deferral Period”
has the meaning indicated in Section 3(i).


 


“Exchange Act”
means the Securities Exchange Act of 1934, as amended, and the rules and regulations of the Commission promulgated thereunder.


 


“FINRA Rules”
means the Conduct Rules and the By-Laws of the Financial Industry Regulatory Authority, Inc.


 


“Holder”
has the meaning set forth in the preamble hereto.


 


“Losses”
has the meaning set forth in Section 5(d).


 


“Majority Holders”
means, on any date, Holders of Registrable Securities that represent a majority of the shares of Common Stock that underlie (or
were issued upon conversion of) the Notes and whose offer and sale is registered under the Shelf Registration Statement.


 


“Managing Underwriters”
means the investment bank(s) and manager(s) that administer an underwritten offering, if any, conducted pursuant to Section
6.


 


“Maturity Date”
has the meaning set forth in the Notes.


 


“Notes”
has the meaning set forth in the preamble hereto.


 


“Notice and Questionnaire”
means a written notice delivered to the Company substantially in the form attached as Annex A hereto.


 


“Notice Holder”
means, on any date, any Holder that has delivered a completed Notice and Questionnaire to the Company on or before such date.


 


“Prospectus”
means a prospectus included in the Shelf Registration Statement (including, without limitation, a prospectus that discloses information
previously omitted from a prospectus filed as part of an effective registration statement in reliance upon Rule 430A or Rule 430B
under the Securities Act), as amended or supplemented by any prospectus supplement, with respect to the terms of the offering of
any portion of the Notes and the shares of Common Stock covered by the Shelf Registration Statement, and all amendments and supplements
thereto, including any and all exhibits thereto and any information incorporated by reference therein.


 


“Purchase Agreements”
has the meaning set forth in the preamble hereto.


 



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“Purchasers”
has the meaning set forth in the preamble hereto.


 


“Registrable Securities”
means the Notes initially sold to the Purchasers pursuant to the Purchase Agreements and the shares of Common Stock issuable upon
conversion of such Notes, and any securities into or for which such Notes or shares have been converted or exchanged, and any security
issued with respect thereto upon any stock dividend, split or similar event; provided, however, that each such security
will cease to constitute Registrable Securities upon the earliest to occur of (i) such security being sold pursuant to a registration
statement that is effective under the Securities Act; and (ii) such security ceasing to be outstanding.


 


“Registration
Default” has the meaning set forth in Section 7.


 


“Securities Act”
means the Securities Act of 1933, as amended, and the rules and regulations of the Commission promulgated thereunder.


 


“Shelf Registration
Period” has the meaning set forth in Section 2(b).


 


“Shelf Registration
Statement” means a “shelf” registration statement of the Company prepared pursuant to Section 2 that
covers the resale, from time to time pursuant to Rule 415 under the Securities Act (or any successor thereto), of some or all of
the Registrable Securities on an appropriate form under the Securities Act, including all post-effective and other amendments and
supplements to such registration statement, the related Prospectus, all exhibits thereto and all material incorporated by reference
therein.


 


“Trading Day”
has the meaning set forth in the Notes.


 


“Underwriter”
means any underwriter of Registrable Securities for an offering thereof under the Shelf Registration Statement.


 


2.          Shelf
Registration. (a) The Company will file with the Commission a Shelf Registration Statement (which, initially, will be on Form
S-1 and, as soon as the Company is eligible, will be on Form S-3) providing for the registration of the offer and sale, from time
to time on a continuous or delayed basis, of the Registrable Securities by the Holders in accordance with the methods of distribution
elected by such Holders, pursuant to Rule 415 under the Securities Act (or any successor thereto) and will use its best efforts
to cause such Shelf Registration Statement to become effective under the Securities Act no later than the one hundred and eightieth
(180th) day after the Closing Date.


 


(b)          The
Company will use its best efforts to keep the Shelf Registration Statement continuously effective, supplemented and amended as
required by the Securities Act, in order to permit the related Prospectus to be usable by Holders for a period (the “Shelf
Registration Period”) from the date the Shelf Registration Statement becomes effective to, and including, the earlier
of (i) the sixtieth (60th) Trading Day immediately following the Maturity Date (subject to extension for any suspension of the
effectiveness of the Shelf Registration Statement during such sixty (60) Trading Days immediately following the Maturity Date);
and (ii) the date upon which no Registrable Securities are outstanding and constitute “restricted securities” (as defined
in Rule 144 under the Securities Act).


 



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(c)          The
Company will cause the Shelf Registration Statement and the related Prospectus and any amendment or supplement thereto, as of the
effective date of the Shelf Registration Statement or such amendment or supplement, (i) to comply in all material respects with
the applicable requirements of the Securities Act; and (ii) not to contain any untrue statement of a material fact or omit to state
a material fact required to be stated therein or necessary in order to make the statements therein (in the case of the Prospectus,
in the light of the circumstances under which they were made) not misleading.


 


(d)          Subject
to applicable law, the Company will provide written notice to the Holders of the anticipated effective date of the Shelf Registration
Statement at least ten (10) Business Days before such anticipated effective date. Each Holder, in order to be named in the Shelf
Registration Statement at the time of its initial effectiveness, will be required to deliver a Notice and Questionnaire and such
other information as the Company may reasonably request in writing, if any, to the Company on or before the fifth (5th) day before
the anticipated effective date of the Shelf Registration Statement as provided in the notice. Subject to Section 3(i), from
and after the effective date of the Shelf Registration Statement, the Company will, as promptly as is practicable after the date
a Holder’s Notice and Questionnaire is delivered, but in no event after the tenth (10th) day after such date, (i) file with
the Commission an amendment to the Shelf Registration Statement or prepare and, if permitted or required by applicable law, file
a supplement to the Prospectus or an amendment or supplement to any document incorporated therein by reference or file any other
required document so that such Holder delivering such Notice and Questionnaire is named as a selling securityholder in the Shelf
Registration Statement and the related Prospectus, and so that such Holder is permitted to deliver such Prospectus to purchasers
of Registrable Securities in accordance with applicable law (except that the Company will not be required to file more than one
supplement or post-effective amendment in any thirty (30) day period in accordance with this Section 2(d)(i)) and, in the
case of a post-effective amendment to the Shelf Registration Statement, the Company will use its best efforts to cause such post-effective
amendment to become effective under the Securities Act as promptly as is practicable; (ii) provide such Holder, upon request, copies
of any documents filed pursuant to Section 2(d)(i); and (iii) notify such Holder as promptly as practicable after the effectiveness
under the Securities Act of any post-effective amendment filed pursuant to Section 2(d)(i); provided, however,
that if such Notice and Questionnaire is delivered during a Deferral Period, then the Company will so inform the Holder delivering
such Notice and Questionnaire and will take the actions set forth in clauses (i), (ii) and (iii) above upon expiration of the Deferral
Period in accordance with Section 3(i). Notwithstanding anything to the contrary herein, the Company need not name any Holder
that is not a Notice Holder as a selling securityholder in the Shelf Registration Statement or Prospectus; provided, however,
that any Holder that becomes a Notice Holder pursuant to this Section 2(d) (whether or not such Holder was a Notice Holder
at the effective date of the Shelf Registration Statement) will be named as a selling securityholder in the Shelf Registration
Statement or Prospectus in accordance with this Section 2(d).


 



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3.          Registration
Procedures. The following provisions will apply in connection with the Shelf Registration Statement.


 


(a)          The
Company will:


 


(i)          furnish
to the Purchasers and to counsel for the Notice Holders, not less than five (5) Business Days before the filing thereof with the
Commission, a copy of the Shelf Registration Statement and each amendment thereto and each amendment or supplement, if any, to
the Prospectus (other than amendments and supplements that do nothing more than name Notice Holders and provide information with
respect thereto and other than filings by the Company under the Exchange Act) and will use its best efforts to reflect in each
such document, when so filed with the Commission, such comments as the Purchasers reasonably propose within three (3) Business
Days of the delivery of such copies to the Purchasers; and


 


(ii)         include
information regarding the Notice Holders and the methods of distribution they have elected for their Registrable Securities provided
to the Company in Notices and Questionnaires as necessary to permit such distribution by the methods specified therein.


 


(b)          The
Company will ensure that:


 


(i)          the
Shelf Registration Statement and any amendment thereto, and any Prospectus and any amendment or supplement thereto, comply in all
material respects with the Securities Act; and


 


(ii)         the
Shelf Registration Statement and any amendment thereto do not, when each becomes effective, contain an untrue statement of a material
fact or omit to state a material fact required to be stated therein or necessary to make the statements therein not misleading.


 


(c)          The
Company will advise the Purchasers, the Notice Holders and any Underwriter that has provided in writing to the Company a telephone
or email or other address for notices, and confirm such advice in writing, if requested (which notice pursuant to clauses (ii)
to (v), inclusive, below will be accompanied by an instruction to suspend the use of the Prospectus until the Company has remedied
the basis for such suspension):


 


(i)          when
the Shelf Registration Statement and any amendment thereto have been filed with the Commission and when the Shelf Registration
Statement or any post-effective amendment thereto has become effective;


 


(ii)         of
any request by the Commission for any amendment or supplement to the Shelf Registration Statement or the Prospectus or for additional
information;


 


(iii)        of
the issuance by the Commission of any stop order suspending the effectiveness of the Shelf Registration Statement or the institution
or threatening of any proceeding for that purpose;


 


(iv)        of
the receipt by the Company of any notification with respect to the suspension of the qualification of the Common Stock included
therein for sale in any jurisdiction or the institution or threatening of any proceeding for such purpose; and


 



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(v)         of
the happening of any event that requires any change in the Shelf Registration Statement or the Prospectus so that they do not contain
any untrue statement of a material fact and do not omit to state a material fact required to be stated therein or necessary to
make the statements therein (in the case of the Prospectus, in the light of the circumstances under which they were made) not misleading.


 


(d)          The
Company will use its best efforts to prevent the issuance of any order suspending the effectiveness of the Shelf Registration Statement
or the qualification of the securities therein for sale in any jurisdiction and, if issued, to obtain as soon as practicable the
withdrawal thereof.


 


(e)          Upon
request, the Company will furnish, in electronic or physical form, to each Notice Holder, without charge, one copy of the Shelf
Registration Statement and any post-effective amendment thereto, including all material incorporated therein by reference, and,
if a Notice Holder so requests in writing, all exhibits thereto (including exhibits incorporated by reference therein).


 


(f)          During
the Shelf Registration Period, the Company will promptly deliver to each Purchaser, each Notice Holder, and any sales or placement
agents or underwriters acting on their behalf, without charge, as many copies of the Prospectus (including the preliminary Prospectus,
if any) relating to the Shelf Registration Statement and any amendment or supplement thereto as such person may reasonably request.
Subject to the restrictions set forth in this Agreement, the Company consents to the use of the Prospectus or any amendment or
supplement thereto by each of the foregoing in connection with the offering and sale of the Registrable Securities.


 


(g)          Before
any offering of Registrable Securities pursuant to the Shelf Registration Statement, the Company will arrange for the qualification
of the Registrable Securities for sale under the laws of such U.S. jurisdictions as any Notice reasonably requests and will maintain
such qualification in effect so long as required; provided, however, that in no event will the Company be obligated
by this Agreement to qualify to do business or as a dealer of securities in any jurisdiction where it is not then so qualified
or to take any action that would subject it to taxation or service of process in suits in any jurisdiction where it is not then
so subject. If, at any time during the Shelf Registration Period, the Registrable Securities are not “covered securities”
within the meaning of Section 18 of the Securities Act, then the Company will arrange for such qualification (subject to the proviso
of the immediately preceding paragraph) in each U.S. jurisdiction of residence of each Notice Holder.


 


(h)          Upon
the occurrence of any event contemplated by subsections (c)(ii) to (v), inclusive, above, the Company will promptly (or within
the time period provided for by Section 3(i), if applicable) prepare a post-effective amendment to the Shelf Registration
Statement or an amendment or supplement to the Prospectus or file any other required document so that the Shelf Registration Statement
and the Prospectus will not include an untrue statement of a material fact or omit to state any material fact required to be stated
therein or necessary to make the statements therein (in the case of the Prospectus, in the light of the circumstances under which
they were made) not misleading.


 



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(i)          Upon
the occurrence or existence of any pending corporate development, public filings with the Commission or any other material event
that, in the reasonable judgment of the Company, makes it appropriate to suspend the availability of the Shelf Registration Statement
and the Prospectus, the Company will give notice (without notice of the nature or details of such events) to the Notice Holders
that the availability of the Shelf Registration Statement is suspended and, upon receipt of any such notice, each Notice Holder
agrees: (i) not to sell any Registrable Securities pursuant to the Shelf Registration Statement until such Notice Holder receives
copies of the supplemented or amended Prospectus provided for in Section 3(i), or until it is advised in writing by the
Company that the Prospectus may be used; and (ii) to hold such notice in confidence. Except in the case of a suspension of the
availability of the Shelf Registration Statement and the Prospectus solely as the result of filing a post-effective amendment or
supplement to the Prospectus to add additional selling securityholders therein, the period during which the availability of the
Shelf Registration Statement and any Prospectus is suspended (the “Deferral Period”) will not exceed an aggregate
of (A) thirty (30) days (or, if the Shelf Registration Statement is on Form S-1 (or any successor thereto), sixty (60) days) in
any calendar quarter; or (B) sixty (60) days (or, if the shelf registration statement is on Form S-1 (or any successor thereto),
ninety (90) days) in any calendar year.


 


(j)          The
Company will comply with all applicable rules and regulations of the Commission and will make generally available to its securityholders
an earnings statement (which need not be audited) satisfying the provisions of Section 11(a) of the Securities Act as soon as practicable
after the effective date of the Shelf Registration Statement and in any event no later than forty five (45) days after the end
of the twelve (12) month period (or ninety (90) days, if such period is a fiscal year) beginning with the first month of the Company’s
first fiscal quarter commencing after the effective date of the Shelf Registration Statement.


 


(k)          The
Company may require each Holder of Registrable Securities to be sold pursuant to the Shelf Registration Statement to furnish to
the Company such information regarding the Holder and the distribution of such Registrable Securities as the Company may from time
to time reasonably require for inclusion in the Shelf Registration Statement in order to comply with the Securities Act. The Company
may exclude from the Shelf Registration Statement the Registrable Securities of any Holder that unreasonably fails to furnish such
information within a reasonable time after receiving a request from the Company for such information.


 


(l)          Subject
to Section 6, the Company will enter into customary agreements (including, if requested by the Majority Holders, an underwriting
agreement in customary form that, for the avoidance of doubt, will provide for customary representations and warranties, legal
opinions, comfort letters and other documents and certifications) and take all other necessary actions in order to expedite or
facilitate the registration or the disposition of the Registrable Securities, and in connection therewith, if an underwriting agreement
is entered into, cause the same to contain customary indemnification provisions and procedures.


 


(m)          Subject
to Section 6, for persons who are or may be “underwriters” with respect to the Registrable Securities within
the meaning of the Securities Act and who make appropriate requests for information to be used solely for the purpose of taking
reasonable steps to establish a due diligence or similar defense in connection with the proposed sale of such Registrable Securities
pursuant to the Shelf Registration, the Company will:


 



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(i)          make
reasonably available during business hours for inspection by the Holders, any Underwriter participating in any disposition pursuant
to the Shelf Registration Statement and any attorney, accountant or other agent retained by the Holders or any such Underwriter
all relevant financial and other records and pertinent corporate documents of the Company and its subsidiaries; and


 


(ii)         cause
the Company’s officers, directors, employees, accountants and auditors to supply all relevant information reasonably requested
by the Holders or any such Underwriter, attorney, accountant or agent in connection with the Shelf Registration Statement as is
customary for similar due diligence examinations.


 


(n)          In
the event that any Broker-Dealer underwrites any Registrable Securities or participates as a member of an underwriting syndicate
or selling group or “participates in an offering” (within the meaning of the FINRA Rules) thereof, whether as a Holder
or as an underwriter, placement, sales agent or broker or dealer in respect thereof, or otherwise, the Company will, upon the reasonable
request of such Broker-Dealer, comply with any reasonable request of such Broker-Dealer in complying with the FINRA Rules.


 


(o)          The
Company will use its best efforts to take all other steps necessary to effect the registration of the offer and sale of the Registrable
Securities covered by the Shelf Registration Statement.


 


4.          Registration
Expenses. The Company will bear all expenses incurred in connection with the performance of its obligations under Sections
2 and 3. The Company will reimburse the Purchasers and the Holders for the reasonable fees and disbursements of one
firm or counsel (which may be a nationally recognized law firm experienced in securities matters designated by the Majority Holders)
to act as counsel for the Holders in connection therewith.


 


5.          Indemnification
and Contribution.


 


(a) The Company agrees
to indemnify and hold harmless each Holder, the directors, officers, employees, Affiliates and agents of each Holder and each person
who Controls any Holder against any and all losses, claims, damages or liabilities, joint or several, to which they or any of them
may become subject under the Securities Act, the Exchange Act or other federal or state statutory law or regulation, at common
law or otherwise, insofar as such losses, claims, damages or liabilities (or actions in respect thereof) arise out of or are based
upon any untrue statement or alleged untrue statement of a material fact contained in the Shelf Registration Statement as originally
filed or in any amendment thereof, or in any preliminary Prospectus or the Prospectus, or in any amendment thereof or supplement
thereto, or caused by the omission or alleged omission to state therein a material fact required to be stated therein or necessary
to make the statements therein (in the case of any preliminary Prospectus or the Prospectus, in the light of the circumstances
under which they were made) not misleading, and agrees to reimburse each such indemnified party, as incurred, for any legal or
other expenses reasonably incurred by it in connection with investigating or defending any such loss, claim, damage, liability
or action; provided, however, that the Company will not be liable in any such case to the extent that any such loss,
claim, damage or liability arises out of or is based upon any such untrue statement or alleged untrue statement or omission or
alleged omission made therein in reliance upon and in conformity with written information furnished to the Company by or on behalf
of the party claiming indemnification specifically for inclusion therein.


 



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The Company also agrees
to provide customary indemnities to, and to contribute as provided in Section 5(d) to Losses of, any underwriters of the
Registrable Securities, their officers, directors and employees and each Person who Controls such underwriters to the same extent
as provided herein with respect to the Holders.


 


(b)          Each
Holder of securities covered by the Shelf Registration Statement (including each Purchaser that is a Holder, in such capacity)
severally and not jointly agrees to indemnify and hold harmless the Company, each of the Company’s directors, each of the
Company’s officers who sign the Shelf Registration Statement and each person who Controls the Company, to the same extent
as the foregoing indemnity from the Company to each such Holder, but only with reference to written information relating to such
Holder furnished to the Company by or on behalf of such Holder specifically for inclusion in the documents referred to in the foregoing
indemnity. This indemnity agreement will be acknowledged by each Notice Holder that is not a Purchaser in such Notice Holder’s
Notice and Questionnaire and will be in addition to any liability that any such Notice Holder may otherwise have.


 


(c)          Promptly
after receipt by an indemnified party under this Section 5 or notice of the commencement of any action, such indemnified
party will, if a claim in respect thereof is to be made against the indemnifying party under this Section 5, notify the
indemnifying party in writing of the commencement thereof, but the failure so to notify the indemnifying party (i) will not relieve
it from liability under paragraph (a) or (b), as applicable, above unless and to the extent it has been materially prejudiced through
the forfeiture by the indemnifying party of substantial rights and defenses; and (ii) will not, in any event, relieve the indemnifying
party from any obligations to any indemnified party other than the indemnification obligation provided in paragraph (a) or (b),
as applicable, above. If any action is brought against an indemnified party and it has notified the indemnifying party thereof,
the indemnifying party will be entitled to appoint counsel (including local counsel) of the indemnifying party’s choice at
the indemnifying party’s expense to represent the indemnified party in any action for which indemnification is sought (in
which case, the indemnifying party will not thereafter be responsible for the fees and expenses of any separate counsel, other
than local counsel if not appointed by the indemnifying party, retained by the indemnified party or parties, except as set forth
below); provided, however, that such counsel will be reasonably satisfactory to the indemnified party. Notwithstanding
the indemnifying party’s election to appoint counsel (including local counsel) to represent the indemnified party in an action,
the indemnified party will have the right to employ separate counsel (including local counsel), and the indemnifying party will
bear the reasonable fees, costs and expenses of such separate counsel if (i) the use of counsel chosen by the indemnifying party
to represent the indemnified party would present such counsel with a conflict of interest; (ii) the actual or potential defendants
in, or targets of, any such action include both the indemnified party and the indemnifying party and the indemnified party has
reasonably concluded that there may be legal defenses available to it and/or other indemnified parties that are different from
or additional to those available to the indemnifying party; (iii) the indemnifying party has not employed counsel reasonably satisfactory
to the indemnified party to represent the indemnified party within a reasonable time after notice of the institution of such action;
or (iv) the indemnifying party has authorized the indemnified party to employ separate counsel at the expense of the indemnifying
party. The indemnifying party will not, in connection with any proceeding or related proceeding in the same jurisdiction, be liable
for the fees and expenses of more than one (1) separate law firm (in addition to any local counsel) for all indemnified persons.
An indemnifying party will not, without the prior written consent of the indemnified parties, settle or compromise or consent to
the entry of any judgment with respect to any pending or threatened claim, action, suit or proceeding in respect of which indemnification
or contribution may be sought hereunder (whether or not the indemnified parties are actual or potential parties to such claim or
action) unless such settlement, compromise or consent includes an unconditional release of each indemnified party from all liability
arising out of such claim, action, suit or proceeding and does not include an admission of fault, culpability or a failure to act,
by or on behalf of any such indemnified party.


 



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(d)          In
the event that the indemnity provided in paragraph (a) or (b) of this Section 5 is unavailable to or insufficient to hold
harmless an indemnified party for any reason, then each applicable indemnifying party will have a several, and not joint, obligation
to contribute to the aggregate losses, claims, damages and liabilities (including legal or other expenses reasonably incurred in
connection with investigating or defending such losses, claims, damages, liabilities or actions) (collectively “Losses”)
to which such indemnified party may be subject in such proportion as is appropriate to reflect the relative benefits received by
such indemnifying party, on the one hand, and such indemnified party, on the other hand, from the offering of the Registrable Securities
and the Shelf Registration Statement that resulted in such Losses; provided, however, that in no case will any underwriter
be responsible for any amount in excess of the underwriting discount or commission applicable to the securities purchased by such
underwriter under the Shelf Registration Statement that resulted in such Losses. If the allocation provided by the immediately
preceding sentence is unavailable for any reason, then the indemnifying party and the indemnified party will contribute in such
proportion as is appropriate to reflect not only such relative benefits but also the relative fault of such indemnifying party,
on the one hand, and such indemnified party, on the other hand, in connection with the statements or omissions, or alleged statements
or omissions, that resulted in such Losses as well as any other relevant equitable considerations. Benefits received by the Company
will be deemed to be equal to the total net proceeds from the offering of the Notes (before deducting expenses). Benefits received
by any Holder will be deemed to be equal to the value of having the offer and sale of such Holder’s Registrable Securities
registered under the Securities Act pursuant to the Shelf Registration Statement and hereunder. Benefits received by any underwriter
will be deemed to be equal to the total underwriting discounts and commissions, as set forth on the cover page of the Prospectus
relating to the Shelf Registration Statement that resulted in such Losses. Relative fault will be determined by reference to, among
other things, whether any untrue or any alleged untrue statement of a material fact or omission or alleged omission to state a
material fact relates to information provided by the indemnifying party, on the one hand, or by the indemnified party, on the other
hand, the intent of the parties and their relative knowledge, access to information and opportunity to correct or prevent such
untrue statement or omission or alleged untrue statement or omission. The parties agree that it would not be just and equitable
if contribution were determined by pro rata allocation (even if the Holders were treated as one entity for such purpose) or any
other method of allocation which does not take account of the equitable considerations referred to above. Notwithstanding anything
to the contrary in this Section 5(d), no person guilty of fraudulent misrepresentation (within the meaning of Section 11(f)
of the Securities Act) will be entitled to contribution from any person who was not guilty of such fraudulent misrepresentation.
For purposes of this Section 5, each person who Controls a Holder and each director, officer, employee, Affiliate and agent
of such Holder will have the same rights to contribution as such Holder, and each person who Controls the Company, each officer
of the Company who signed the Shelf Registration Statement and each director of the Company will have the same rights to contribution
as the Company, subject in each case to the applicable terms and conditions of this Section 5(d).


 



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(e)          The
provisions of this Section 5 will remain in full force and effect, regardless of any investigation made by or on behalf
of any Purchaser or Holder or the Company or any of the indemnified persons referred to in this Section 5, and will survive
the sale by a Holder of securities covered by the Shelf Registration Statement.


 


6.          Underwritten
Registrations.


 


(a)          Notwithstanding
anything to the contrary herein, in no event will the method of distribution of Registrable Securities take the form of an underwritten
offering without the prior written consent of the Company. Consent may be conditioned on waivers of any of the obligations in Section
3, 4 or 5.


 


(b)          If
any Registrable Securities are to be sold in an underwritten offering, the Managing Underwriters will be selected by the Company,
subject to the prior written consent of the Majority Holders, which consent will not be unreasonably withheld.


 


(c)          No
person may participate in any underwritten offering pursuant to the Shelf Registration Statement unless such person: (i) agrees
to sell such person’s Registrable Securities on the basis reasonably provided in any underwriting arrangements approved by
the persons entitled hereunder to approve such arrangements; and (ii) completes and executes all questionnaires, powers of attorney,
indemnities, underwriting agreements and other documents reasonably required under the terms of such underwriting arrangements.


 


7.          Registration
Defaults. If any of the following events shall occur (each, a “Registration Default”), then the Company
will pay additional interest on the Notes (“Additional Interest”) as follows:


 


(a)          if
the Shelf Registration Statement has not been filed with the Commission and has not become effective on or before the one hundred
and eightieth (180th) day after the Closing Date, then, commencing on the one hundred and eighty first (181st) day after the Closing
Date, Additional Interest will accrue on the aggregate outstanding principal amount of the Notes at a rate of 0.25% per annum for
the first 90 days beginning on, and including, such one hundred and eighty first (181st) day and 0.50% per annum thereafter;


 



    	 	- 11 -	 



     


    

 


(b)          if
the Shelf Registration Statement has become effective but ceases to be effective or usable for the offer and sale of the Registrable
Securities (other than in connection with (i) a Deferral Period; or (ii) as a result filing a post-effective amendment solely to
add additional selling securityholders) at any time during the Shelf Registration Period and the Company does not cure the lapse
of effectiveness or usability within ten (10) Business Days (or, if a Deferral Period is then in effect, within ten (10) Business
Days after the expiration of such Deferral Period) (or, in the case of filing a post-effective amendment solely to add additional
selling securityholders, within ten (10) Business Days after the expiration of the ten (10) day period referred to in Section
2(d), subject to the proviso therein), then Additional Interest will accrue on the aggregate outstanding principal amount of
the Notes at a rate of 0.25% per annum for the first ninety (90) days beginning on, and including, the day following such tenth
(10th) Business Day and 0.50% per annum thereafter;


 


(c)          if
the Company, through its omission, fails to name as a selling securityholder any Holder that had complied timely with its obligations
hereunder in a manner to entitle such Holder to be so named in (i) the Shelf Registration Statement at the time it first became
effective; or (ii) any Prospectus at the time it is filed with the Commission (or, if later, the effective date of the Shelf Registration
Statement), then Additional Interest will accrue on the aggregate outstanding principal amount of the Notes held by such Holder
at a rate of 0.25% per annum for the first ninety (90) days beginning on, and including, the day following the effective date of
such Shelf Registration Statement or the filing of such Prospectus, as applicable, and 0.50% per annum thereafter; and


 


(d)          if
the aggregate duration of Deferral Periods in any period exceeds the number of days permitted in respect of such period pursuant
to Section 3(i), then, commencing on the day the aggregate duration of Deferral Periods in such period exceeds the number
of days permitted in respect of such period, Additional Interest will accrue on the aggregate outstanding principal amount of the
Notes at a rate of 0.25% per annum for the first ninety (90) days beginning on, and including, and including such date, and 0.50%
per annum thereafter; provided, however, that (1) upon the filing and effectiveness of the Shelf Registration Statement
(in the case of paragraph (a) above), (2) upon such time as the applicable Shelf Registration Statement becomes effective and usable
for resales (in the case of paragraph (b) above), (3) upon such time as such Holder is permitted to sell its Registrable Securities
pursuant to any Shelf Registration Statement and Prospectus in accordance with applicable law (in the case of paragraph (c) above),
(4) upon the termination of the applicable Deferral Period (in the case of paragraph (d) above), or (5) in any case, upon the expiration
of the Shelf Registration Period, Additional Interest will cease to accrue on account of the applicable Registration Default (it
being understood that nothing in this sentence will prevent Additional Interest from accruing as a result of any other Registration
Default during the Shelf Registration Period).


 


Any Additional Interest
due pursuant to this Section 7 will be payable in cash in the same manner and on the same dates as the stated interest payable
on the Notes. If any Note ceases to be outstanding during any period for which Additional Interest is accruing, the Company will
prorate the Additional Interest payable with respect to such Note.


 


Additional Interest will
not accrue on the Notes at a rate that exceeds 0.50% per annum in the aggregate and will not be payable under more than one clause
above for any given period of time, except that if Additional Interest would be payable because of more than one Registration Default,
but at a rate of 0.25% per annum under one Registration Default and at a rate of 0.50% per annum under the other, then the Additional
Interest rate will be the higher rate of 0.50% per annum.


 



    	 	- 12 -	 



     


    

 


Notwithstanding anything
to the contrary in this Agreement, in no event will Additional Interest accrue on the shares of Common Stock issued upon conversion
of the Notes. However, if there exists a Registration Default with respect to the Registrable Securities on the Maturity Date,
then, in addition to any Additional Interest otherwise payable, the Company will make a cash payment to each Holder of any outstanding
Note as of the Close of Business on the Business Day immediately before the Maturity Date in an amount equal to five percent (5%)
of the principal amount of such Note. For purposes of the preceding sentence, Notes that have been converted with a Conversion
Date that is on or after January 15, 2021, and on or before the second (2nd) Business Day immediately preceding the Maturity Date
will be considered to be outstanding. Accordingly, and for the avoidance of doubt, if a Registration Default exists on the Maturity
Date, the payment described in the preceding two sentences will be payable on all Notes outstanding as of the Close of Business
on the Business Day immediately preceding the Maturity Date and on all Notes converted with a conversion date that is on or after
January 15, 2021, and on or before the second (2nd) Business Day immediately preceding the Maturity Date.


 


8.          No
Inconsistent Agreements. The Company has not entered into, and agrees not to enter into, any agreement with respect to its
securities that is inconsistent with the registration rights granted to the Holders herein.


 


9.          Rule
144A and Rule 144. So long as any Registrable Securities remain outstanding, the Company will file the reports required to
be filed by it under Rule 144A(d)(4) under the Securities Act and the reports required to be filed by it under the Exchange Act
in a timely manner and, if at any time the Company is not required to file such reports, it will, upon the written request of any
Holder of Registrable Securities, make publicly available other information so long as necessary to permit sales of such Holder’s
Registrable Securities pursuant to Rules 144 and 144A of the Securities Act. The Company covenants that it will take such further
action as any Holder of Registrable Securities may reasonably request, all to the extent required from time to time to enable such
Holder to sell Registrable Securities without registration under the Securities Act pursuant to Rule 144 or Rule 144A (including,
without limitation, satisfying the requirements of Rule 144A(d)(4)). Upon the written request of any Holder of Registrable Securities,
the Company will deliver to such Holder a written statement as to whether it has complied with such requirements. Notwithstanding
anything to the contrary in this Section 9, nothing in this Section 9 will be deemed to require the Company to register
any of its securities pursuant to the Exchange Act.


 


10.         Amendments
and Waivers. The provisions of this Agreement may not be amended, qualified, modified or supplemented, and waivers or consents
to departures from the provisions hereof may not be given, unless the Company has obtained the written consent of the Holders of
a majority of the Registrable Securities (determined on an as-converted basis); provided, however, that no amendment,
qualification, modification, supplement, waiver or consent with respect to Section 7 will be effective as against any Holder
unless consented to in writing by such Holder; provided, further, that this Section 10 may not be amended,
qualified, modified or supplemented, and waivers of or consents to departures from this Section 10 may not be given, unless
the Company has obtained the written consent of each Purchaser and each Holder.


 



    	 	- 13 -	 



     


    

 


11.         Notices.
All notices and other communications provided for or permitted hereunder will be made in writing by hand-delivery, first-class
mail, telex, telecopier, email or air courier guaranteeing overnight delivery:


 


(a)          if
to a Holder, at the most current address given by such holder to the Company in accordance with the provisions of the Notice and
Questionnaire.


 


(b)          if
to any Purchaser, initially at the address thereof set forth above; and


 


(c)          if
to the Company, initially at its address set forth in the Purchase Agreements.


 


All such notices and communications
shall be deemed to have been duly given when received.


 


12.         Remedies.
Each Holder, in addition to being entitled to exercise all rights provided to it herein or in the Purchase Agreement or granted
by law, including recovery of liquidated or other damages, will be entitled to specific performance of its rights under this Agreement.
The Company agrees that monetary damages would not be adequate compensation for any loss incurred by reason of a breach by it of
the provisions of this Agreement and hereby agrees to waive in any action for specific performance the defense that a remedy at
law would be adequate.


 


13.         Successors.
This Agreement will inure to the benefit of and be binding upon the parties hereto, their respective successors and assigns, including,
without the need for an express assignment or any consent by the Company thereto, subsequent Holders, and the indemnified persons
referred to in Section 5. The Company hereby agrees to extend the benefits of this Agreement to any Holder, and any such
Holder may specifically enforce the provisions of this Agreement as if an original party hereto.


 


14.         Counterparts.
This Agreement may be signed in one or more counterparts, each of which shall constitute an original and all of which together
shall constitute one and the same agreement.


 


15.         Headings.
The section headings used herein are for convenience only and shall not affect the construction or interpretation hereof.


 


16.         Applicable
Law. THIS AGREEMENT WILL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK. EACH OF THE PARTIES
HERETO HEREBY IRREVOCABLY WAIVES, TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW, ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY
LEGAL PROCEEDING ARISING OUT OF OR RELATING TO THIS AGREEMENT THE TRANSACTION CONTEMPLATED HEREBY.


 


17.         Severability.
In the event that any one or more of the provisions contained herein, or the application thereof in any circumstances, is held
invalid, illegal or unenforceable in any respect for any reason, the validity, legality and enforceability of any such provision
in every other respect and of the remaining provisions hereof will not be in any way impaired or affected thereby, it being intended
that all of the rights and privileges of the parties will be enforceable to the fullest extent permitted by law.


 



    	 	- 14 -	 



     


    

 


18.         Common
Stock Held by the Company, Etc. Whenever the consent or approval of Holders of a specified percentage of securities is required
hereunder, securities held by the Company or its Affiliates (other than subsequent Holders thereof if such subsequent Holders are
deemed to be Affiliates solely by reason of their holdings of such securities) will not be counted in determining whether such
consent or approval was given by the Holders of such required percentage.


 


[Remainder of Page Intentionally
Left Blank; Signature Page Follows]


 




    	 	- 15 -	 



     


    

 


	 	Very truly yours,
	 	 
	 	Xtant Medical Holdings, Inc.
	 	 	 	 
	 	By:	/s/ Daniel Goldberger
	 	 	Name:	Daniel Goldberger
	 	 	Title:	Chief Executive Officer


 


OrbiMed Royalty Opportunities II, LP


 


By OrbiMed ROF II LLC,


its General Partner


 


By OrbiMed Advisors LLC,


its Managing Member


 


	By: 	/s/ W. Carter Neild	 
	Print Name: 	W. Carter Neild	 
	Title: 	Member	 


 


ROS Acquisition Offshore LP


 


By OrbiMed Advisors LLC, solely in its


capacity as Investment Manager


 


	By: 	/s/ W. Carter Neild	 
	Print Name: 	W. Carter Neild	 
	Title: 	Member	 




 


[Signature Page to Indenture Registration Rights Agreement]