EXHIBIT 10.3


 


SIXTH
AMENDMENT AND WAIVER


 


This SIXTH
AMENDMENT AND WAIVER (this “Amendment and Waiver”) is made and entered into as of January 30, 2018 by XTANT
MEDICAL HOLDINGS, INC., a Delaware corporation (the “Company”), ROS
acquisition offshore lp, a Cayman Islands Exempted Limited Partnership (“ROS”) and ORBIMED ROYALTY
OPPORTUNITIES II, LP, a Delaware limited partnership (“Royalty Opportunities” and, together with ROS, collectively,
the “Holders”).


 


WHEREAS, ROS is
the registered holder of a Convertible Promissory Note in the aggregate principal amount of $1,428,552.78 issued on April 14, 2016
by the Company (the “ROS Note”);


 


WHEREAS, Royalty
Opportunities is the registered holder of a Convertible Promissory Note in the aggregate principal amount of $809,613.67 issued
on April 14, 2016 by the Company (the “Royalty Opportunities Note” and together with the ROS Note, collectively,
the “Notes”);


 


WHEREAS, the Company
and the Holders are party to that certain Amendment and Waiver, dated as of August 15, 2017, that certain Second Amendment and
Waiver, dated as of September 29, 2017, that certain Third Amendment and Waiver, dated as of October 31, 2017, that certain Fourth
Amendment and Waiver, dated as of November 30, 2017, and that certain Fifth Amendment and Waiver, dated as of December 28, 2017,
pursuant to which interest accrued on the Notes was deferred until January 31, 2018 and the Holders waived any Event of Default
that occurred as a result of the Company’s failure to pay interest due on July 15, 2017 or January 15, 2018; and


 


WHEREAS, pursuant
to Section 10.13 of the Notes, the terms and conditions of the Notes may be amended or waived by the written consent of each affected
holder of the Notes.


 


NOW, THEREFORE,
in consideration of the mutual agreements herein contained, and for other good and valuable consideration, the receipt and sufficiency
of which are hereby acknowledged, the parties hereto agree as follows:


 


1.            Definitions.
Capitalized terms used herein without definition shall have the meanings assigned to such terms in the Notes.


 


2.            Interest
Deferral.


 


(a)            Interest
accrued on the Notes otherwise required to be paid in cash on July 15, 2017 shall instead be required to be paid in cash on February
28, 2018, plus interest accrued on such interest from July 15, 2017 to the date of payment thereof at a rate equal to 6.00% per
annum plus 100 basis points.


 


(b)            Interest
accrued on the Notes otherwise required to be paid in cash on January 15, 2018 shall instead be required to be paid in cash on
February 28, 2018, plus interest accrued on such interest from January 15, 2017 to the date of payment thereof at a rate equal
to 6.00% per annum plus 100 basis points.


 




     

     


    

 


3.            Waiver.
Each Holder hereby waives any Event of Default that has occurred under the Notes as a result of the Company’s failure to
pay interest accrued on the Notes on July 15, 2017 or January 15, 2018.


 


4.            No
Implied Waiver. Except as expressly set forth in this Amendment and Waiver, this Amendment and Waiver shall not, by implication
or otherwise, limit, impair, constitute a waiver of or otherwise affect any rights or remedies of the Holders under the Notes
or alter, modify, amend or in any way affect any of the terms, obligations or covenants contained in the Notes, all of which shall
continue in full force and effect. Nothing in this Amendment and Waiver shall be construed to imply any willingness on the part
of the Holders to agree to or grant any similar or future consent or waiver of any of the terms and conditions of the Notes.


 


5.           Governing
Law. THIS AMENDMENT AND WAIVER SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE INTERNAL LAWS OF THE STATE OF
NEW YORK (INCLUDING FOR SUCH PURPOSE SECTIONS 5-1401 AND 5-1402 OF THE GENERAL OBLIGATIONS LAW OF THE STATE OF NEW YORK).


 


[Signature Pages Follow]


 




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IN WITNESS WHEREOF, the parties
hereto have caused this Amendment and Waiver to be executed as of the day and year first above written.


 


	 	XTANT MEDICAL HOLDINGS, INC.,
	 	 	 
	 	By: 	/s/ Carl D. O’Connell
	 	Name: 	Carl D. O’Connell
	 	Title: 	Chief Executive Officer


 


Signature Page to Sixth Amendment and
Waiver


 




     

     


    

 


	 	ROS Acquisition Offshore LP,
	 	 
	 	By OrbiMed Advisors LLC, solely in its
	 	capacity as Investment Manager
	 	 	 
	 	By: 	/s/ W. Carter Neild
	 	Name: 	W. Carter Neild
	 	Title: 	Member
	 	 	 
	 	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
	 	Name: 	W. Carter Neild
	 	Title: 	Member


 


Signature Page to Sixth Amendment and
Waiver