EXHIBIT 10.3


 


Fourth
AMENDMENT AND WAIVER


 


This Fourth
AMENDMENT AND WAIVER (this “Amendment and Waiver”) is made and entered into as of November 30, 2017 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
and Convertible Promissory Notes in the aggregate principal amounts of $995,700 and $42,856.59 issued on January 17, 2017 (collectively,
the “ROS Notes”), in each case, by the Company;


 


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 and Convertible Promissory Notes in the aggregate principal amounts of $564,300 and $24,288.41 issued on January
17, 2017, in each case, by the Company (collectively, the “Royalty Opportunities Notes” and together with the
ROS Notes, 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, and that certain Third Amendment and Waiver, dated as of October 31, 2017, pursuant to
which interest accrued on the Notes was deferred until November 30, 2017 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; 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. 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 December 31, 2017, 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.


 


3.          Waiver.
Each Holder hereby waives (i) 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, and (ii) any non-compliance with the covenant set forth in Section 4.03
of the Notes with respect to the timely filing of the Company’s quarterly report on Form 10-Q for the quarterly period ended
September 30, 2017.


 




    	 		 



     


    

 


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 Fourth 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 Fourth Amendment and
Waiver