Document:

EXHIBIT 10.1

 

TWELFTH
AMENDMENT AND WAIVER TO AMENDED AND RESTATED CREDIT AGREEMENT

This TWELFTH AMENDMENT
AND WAIVER TO AMENDED AND RESTATED CREDIT AGREEMENT (this “Amendment”) is made and entered into as of March
31, 2017 (the “Amendment Closing Date”) by and among Bacterin
International, Inc., a Nevada corporation (the “Borrower”), ROS
acquisition offshore lp, a Cayman Islands Exempted Limited Partnership (“ROS”), ORBIMED ROYALTY
OPPORTUNITIES II, LP, a Delaware limited partnership (“Royalty Opportunities”), and, in their capacity as
Guarantors under the Credit Agreement (as defined below), XTANT MEDICAL HOLDINGS, INC., a Delaware corporation (“Holdings”),
X-SPINE SYSTEMS, INC., an Ohio corporation (“X-Spine”) and XTANT MEDICAL, INC., a Delaware corporation
(“Xtant” and, along with Holdings and X-Spine, collectively, the “Guarantors”).

WHEREAS, the
Borrower, ROS and Royalty Opportunities are party to that certain Amended and Restated Credit Agreement, dated as of July 27, 2015,
as amended by that certain First Amendment to Amended and Restated Credit Agreement, dated as of March 31, 2016, that certain Second
Amendment to Amended and Restated Credit Agreement, dated as of May 25, 2016, that certain Third Amendment to Amended and Restated
Credit Agreement, dated as of June 30, 2016, that certain Fourth Amendment to Amended and Restated Credit Agreement, dated as of
July 29, 2016, that certain Fifth Amendment to the Amended and Restated Credit Agreement, dated as of August 12, 2016, that certain
Sixth Amendment to the Amended and Restated Credit Agreement, dated as of September 27, 2016, that certain Seventh Amendment to
the Amended and Restated Credit Agreement, dated as of December 31, 2016, that certain Eighth Amendment to Amended and Restated
Credit Agreement, dated as of January 13, 2017, that certain Ninth Amendment to Amended and Restated Credit Agreement, dated as
of January 31, 2017, that certain Tenth Amendment to Amended and Restated Credit Agreement, dated as of February 14, 2017 and that
certain Eleventh Amendment to Amended and Restated Credit Agreement, dated as of February 28, 2017 (the “Credit Agreement”),
pursuant to which (i) ROS and Royalty Opportunities, as Lenders under the Credit Agreement, have extended credit to the Borrower
on the terms set forth therein and (ii) each Lender has appointed ROS as the administrative agent (the “Administrative
Agent”) for the Lenders;

WHEREAS, the
Guarantors and the Administrative Agent entered into an Amended and Restated Guarantee, dated as of July 31, 2015 and supplemented
on September 11, 2015, pursuant to which the Guarantors have agreed to guarantee the Obligations of the Borrower under the Credit
Agreement;

WHEREAS, pursuant
to Section 11.1 of the Credit Agreement, the Credit Agreement may be amended by an instrument in writing signed by each of the
Borrower and the Administrative Agent (acting on behalf of the Lenders);

WHEREAS, the
Borrower and the Lenders desire to amend certain provisions of the Credit Agreement as provided in this Amendment.

    	 

     

    

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; Loan Document. Capitalized terms used herein without definition shall have the meanings assigned
to such terms in the Credit Agreement. This Amendment shall constitute a Loan Document for all purposes of the Credit Agreement
and the other Loan Documents.

2.                       
Amendments to Section 3.6. Section 3.6 of the Credit Agreement is hereby amended by deleting the last sentence
from such Section 3.6 in its entirety and inserting the following as the last sentence thereof:

“Notwithstanding the foregoing,
interest accrued on the Loans for the Fiscal Quarters ended on December 31, 2016 and March 31, 2017 and otherwise required to be
paid in cash on January 2, 2017 and March 31, 2017, respectively, shall instead be required to be paid in cash on April 30, 2017,
plus interest accrued on such interest from January 2, 2017 and March 31, 2017, as applicable, to the date of payment thereof at
a rate equal to the Applicable Margin plus the higher of (i) the LIBO Rate for the Fiscal Quarter ended on December 31, 2016 or
the Fiscal Quarter ended on March 31, 2017, as applicable, and (ii) 1.00%.”

3.                 
Amendments to Section 8.4(a). Section 8.4(a) of the Credit Agreement is hereby amended and restated in its
entirety to read as follows:

“(a)      Minimum Revenue
Base. The Revenue Base for any Fiscal Quarter shall not be less than the amount set forth below for such Fiscal Quarter:

 

	Fiscal Quarter Ending	Minimum Revenue Base
	September 30, 2015	$17,500,000
	December 31, 2015	$20,000,000
	March 31, 2016	$20,000,000
	June 30, 2016	$20,000,000
	September 30, 2016	$20,000,000
	December 31, 2016	$20,000,000
	March 31, 2017	$20,000,000
	June 30, 2017	$25,000,000
	September 30, 2017	$27,500,000
	December 31, 2017	$27,500,000
	March 31, 2018	$27,500,000
	June 30, 2018	$27,500,000
	September 30, 2018	$30,000,000
	December 31, 2018	$30,000,000
	March 31, 2019	$30,000,000
	June 30, 2019	$30,000,000
	September 30, 2019	$30,000,000
	December 31, 2019	$30,000,000
	March 31, 2020	$30,000,000
	June 30, 2020	$30,000,000

 

    	 	-2-	 

     

    

4.                 
Amendments to Section 8.4(b). Section 8.4(b) of the Credit Agreement is hereby amended by deleting the first
two sentences from such Section 8.4(b) in their entirety and inserting the following as the first two sentences thereof:

“At all times prior to June
30, 2017, the Liquidity shall not be less than $500,000. At all times after June 30, 2017, the Liquidity shall not be less than
$5,000,000.”

5.                 
Amendments to Section 8.4(c). Section 8.4(c) of the Credit Agreement is hereby is hereby amended by restating
it in its entirety as follows:

“(c) Consolidated Senior
Leverage Ratio. The Consolidated Senior Leverage Ratio shall not be greater than the amount set forth below at any time, in
each case, other than as set forth in the definition thereof, with respect to the most recent period of four Fiscal Quarters then
ended (starting at the time that the financial statements for the most recent four Fiscal Quarters ended June 30, 2017 are required
to have been delivered hereunder (or have been so delivered, if earlier)):

	Four Fiscal 

Quarters Ended	Consolidated Senior Leverage Ratio
	June 30, 2017	5.00:1.00
	September 30, 2017	5.00:1.00
	December 31, 2017	5.00:1.00
	March 31, 2018	5.00:1.00
	June 30, 2018	5.00:1.00
	September 30, 2018	5.00:1.00
	December 31, 2018	5.00:1.00
	March 31, 2019	2.50:1.00
	June 30, 2019	2.50:1.00
	September 30, 2019	2.50:1.00
	December 31, 2019	2.50:1.00
	March 31, 2020	2.50:1.00
	June 30, 2020	2.50:1.00

 

6.                 
Waiver of Amended Covenants. The Lenders hereby waive any non-compliance with the covenant set forth in Section
7.1(c) of the Credit Agreement as in effect prior to this Amendment solely with respect to the going concern qualification included
in the audit report of Holdings’ independent registered public accounting firm for the year ended December 31, 2016.

7.                 
Conditions to Effectiveness of Amendment. This Amendment shall become effective upon receipt by the Borrower,
the Administrative Agent, the Lenders and the Guarantors of a counterpart signature of the others to this Amendment duly executed
and delivered by each of the Borrower, the Lenders, the Administrative Agent and the Guarantors.

    	 	-3-	 

     

    

8.                 
Expenses. The Borrower agrees to pay on demand all expenses of the Administrative Agent (including, without
limitation, the fees and out-of-pocket expenses of Covington & Burling LLP, counsel to the Administrative Agent) incurred in
connection with the Administrative Agent’s review, consideration and evaluation of this Amendment, including the rights and
remedies available to it in connection therewith, and the negotiation, preparation, execution and delivery of this Amendment.

9.                 
Representations and Warranties. The Borrower and the Guarantors represent and warrant to each Lender as follows:

(a)               
After giving effect to this Amendment, the representations and warranties of the Borrower and the Guarantors contained in
the Credit Agreement or any other Loan Document shall, (i) with respect to representations and warranties that contain a materiality
qualification, be true and correct in all respects on and as of the date hereof, and (ii) with respect to representations and warranties
that do not contain a materiality qualification, be true and correct in all material respects on and as of the date hereof, and
except that the representations and warranties limited by their terms to a specific date shall be true and correct as of such date.

(b)              
After giving effect to this Amendment, no Default or Event of Default under the Credit Agreement will occur or be continuing.

10.             
No Implied Amendment or Waiver. Except as expressly set forth in this Amendment, this Amendment shall not,
by implication or otherwise, limit, impair, constitute a waiver of or otherwise affect any rights or remedies of the Administrative
Agent or the Lenders under the Credit Agreement or the other Loan Documents, or alter, modify, amend or in any way affect any of
the terms, obligations or covenants contained in the Credit Agreement or the other Loan Documents, all of which shall continue
in full force and effect. Nothing in this Amendment shall be construed to imply any willingness on the part of the Administrative
Agent or the Lenders to agree to or grant any similar or future amendment, consent or waiver of any of the terms and conditions
of the Credit Agreement or the other Loan Documents.

11.             
Waiver and Release. TO INDUCE THE ADMINISTRATIVE AGENT, ACTING ON BEHALF OF THE LENDERS, TO AGREE TO THE TERMS
OF THIS AMENDMENT, THE BORROWER, THE GUARANTORS AND THEIR AFFILIATES (COLLECTIVELY, THE RELEASING PARTIES”) REPRESENT
AND WARRANT THAT AS OF THE DATE HEREOF THERE ARE NO CLAIMS OR OFFSETS AGAINST OR RIGHTS OF RECOUPMENT WITH RESPECT TO OR DEFENSES
OR COUNTERCLAIMS TO THEIR OBLIGATIONS UNDER THE LOAN DOCUMENTS AND IN ACCORDANCE THEREWITH THEY:

(a)               
WAIVE ANY AND ALL SUCH CLAIMS, OFFSETS, RIGHTS OF RECOUPMENT, DEFENSES OR COUNTERCLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING
PRIOR TO THE DATE HEREOF; AND

    	 	-4-	 

     

    

(b)              
FOREVER RELEASE, RELIEVE, AND DISCHARGE THE ADMINISTRATIVE AGENT, THE LENDERS, THEIR OFFICERS, DIRECTORS, SHAREHOLDERS,
MEMBERS, PREDECESSORS, SUCCESSORS, ASSIGNS, ATTORNEYS, ACCOUNTANTS, AGENTS, EMPLOYEES, AND REPRESENTATIVES (COLLECTIVELY, THE "RELEASED
PARTIES"), AND EACH OF THEM, FROM ANY AND ALL CLAIMS, LIABILITIES, DEMANDS, CAUSES OF ACTION, DEBTS, OBLIGATIONS, PROMISES,
ACTS, AGREEMENTS, AND DAMAGES, OF WHATEVER KIND OR NATURE, WHETHER KNOWN OR UNKNOWN, SUSPECTED OR UNSUSPECTED, CONTINGENT OR FIXED,
LIQUIDATED OR UNLIQUIDATED, MATURED OR UNMATURED, WHETHER AT LAW OR IN EQUITY, WHICH THE RELEASING PARTIES EVER HAD, NOW HAVE,
OR MAY, SHALL, OR CAN HEREAFTER HAVE, DIRECTLY OR INDIRECTLY ARISING OUT OF OR IN ANY WAY BASED UPON, CONNECTED WITH, OR RELATED
TO MATTERS, THINGS, ACTS, CONDUCT, AND/OR OMISSIONS AT ANY TIME FROM THE BEGINNING OF THE WORLD THROUGH AND INCLUDING THE DATE
HEREOF, INCLUDING WITHOUT LIMITATION ANY AND ALL CLAIMS AGAINST THE RELEASED PARTIES ARISING UNDER OR RELATED TO THE LOAN DOCUMENTS
OR THE TRANSACTIONS CONTEMPLATED THEREBY.

(c)               
IN CONNECTION WITH THE RELEASE CONTAINED HEREIN, THE RELEASING PARTIES ACKNOWLEDGE THAT THEY ARE AWARE THAT THEY MAY HEREAFTER
DISCOVER CLAIMS PRESENTLY UNKNOWN OR UNSUSPECTED, OR FACTS IN ADDITION TO OR DIFFERENT FROM THOSE WHICH THEY KNOW OR BELIEVE TO
BE TRUE, WITH RESPECT TO THE MATTERS RELEASED HEREIN. NEVERTHELESS, IT IS THE INTENTION OF THE RELEASING PARTIES, THROUGH THIS
AGREEMENT AND WITH ADVICE OF COUNSEL, FULLY, FINALLY, AND FOREVER TO RELEASE ALL SUCH MATTERS, AND ALL CLAIMS RELATED THERETO,
WHICH DO NOW EXIST, OR HERETOFORE HAVE EXISTED. IN FURTHERANCE OF SUCH INTENTION, THE RELEASES HEREIN GIVEN SHALL BE AND REMAIN
IN EFFECT AS A FULL AND COMPLETE RELEASE OR WITHDRAWAL OF SUCH MATTERS NOTWITHSTANDING THE DISCOVERY OR EXISTENCE OF ANY SUCH ADDITIONAL
OR DIFFERENT CLAIMS OR FACTS RELATED THERETO.

(d)              
THE RELEASING PARTIES COVENANT AND AGREE NOT TO BRING ANY CLAIM, ACTION, SUIT, OR PROCEEDING AGAINST THE RELEASED PARTIES,
DIRECTLY OR INDIRECTLY, REGARDING OR RELATED IN ANY MANNER TO THE MATTERS RELEASED HEREBY, AND FURTHER COVENANT AND AGREE THAT
THIS AGREEMENT IS A BAR TO ANY SUCH CLAIM, ACTION, SUIT, OR PROCEEDING.

(e)               
THE RELEASING PARTIES REPRESENT AND WARRANT TO THE RELEASED PARTIES THAT THEY HAVE NOT HERETOFORE ASSIGNED OR TRANSFERRED,
OR PURPORTED TO ASSIGN OR TRANSFER, TO ANY PERSON OR ENTITY ANY CLAIMS OR OTHER MATTERS HEREIN RELEASED.

12.             
Counterparts; Governing Law. This Amendment may be executed in any number of counterparts and by different
parties hereto on separate counterparts, each of such when so executed and delivered shall be an original, but all of such counterparts
shall together constitute but one and the same agreement. Delivery of an executed counterpart of a signature page of this Amendment
by fax transmission or other electronic mail transmission (e.g., “pdf” or “tif”) shall be effective as
delivery of a manually executed counterpart of this Amendment. THIS AMENDMENT 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).

[Remainder
of Page Intentionally Left Blank]

    	 	-5-	 

     

    

IN WITNESS WHEREOF, the parties
hereto have caused this Amendment to be executed by their respective officers thereunto duly authorized as of the day and year
first above written.

 

	 	
        BACTERIN INTERNATIONAL, INC.,

        as the Borrower

	 	 
	 	By:   /s/ John Gandolfo               
	 	Name:  John Gandolfo
	 	Title:    Chief Financial Officer
	 	 
	 	 
	 	
        XTANT MEDICAL HOLDINGS, INC.,

        (fka: Bacterin International Holdings, Inc.)

        as a Guarantor

	 	 
	 	By:   /s/ John Gandolfo                 
	 	Name:  John Gandolfo
	 	Title:    Chief Financial Officer
	 	 
	 	 
	 	
        X-SPINE SYSTEMS, INC.,

        as a Guarantor

	 	 
	 	By:   /s/ John Gandolfo                
	 	Name:  John Gandolfo
	 	Title:    Chief Financial Officer
	 	 
	 	 
	 	
        XTANT MEDICAL, INC.,

        as a Guarantor

	 	 
	 	By:   /s/ John Gandolfo                
	 	Name:  John Gandolfo
	 	Title:    Chief Financial Officer

 

Signature Page to Twelfth Amendment and Waiver
to A&R Credit Agreement

 

    	 

     

    

 

	 	ROS Acquisition Offshore LP,

as a Lender and as the Administrative Agent
	 	
         

        By OrbiMed Advisors LLC, solely in its

	 	capacity as Investment Manager
	 	 
	 	
        By: /s/ Samuel D. Islay                

        Name: Samuel D. Islay

	 	Title:    Managing Member
	 	 
	 	 
	 	ORBIMED ROYALTY OPPORTUNITIES II, LP,

as a Lender 
	 	
         

        By OrbiMed ROF II LLC,

	 	its General Partner
	 	By OrbiMed Advisors LLC,
	 	its Managing Member
	 	 
	 	
        By: /s/ Samuel D. Islay                

        Name: Samuel D. Islay

	 	
        Title: Managing Member 

 

Signature Page to Twelfth Amendment and Waiver
to A&R Credit AgreementMarch 31, 2017

 

VIA EXPRESS COURIER AND EMAIL

 

	ROS Acquisition Offshore LP	 	OrbiMed Royalty Opportunities II, LP	 
	c/o OrbiMed Advisors LLC	 	c/o OrbiMed Advisors LLC	 
	601 Lexington Ave., 54th Floor	 	601 Lexington Ave., 54th Floor	 
	New York, NY 10022	 	New York, NY 10022	 

 

	 	Re:	Indenture, dated as of July 31, 2015 (the “Agreement”), by and between Bacterin International Holdings, Inc., a Delaware corporation (the “Company”), and Wilmington Trust, National Association (the “Trustee”)

Ladies and Gentlemen,

 

Capitalized terms
used herein but not defined shall have the meanings given in the Agreement. The Borrower has been notified that it will be receiving
a going concern opinion from its accountant in its upcoming audited annual financial statements. The receipt of such an opinion
will breach an affirmative covenant made by the Borrower under another agreement of indebtedness that it has entered into, which
in turn could trigger the cross default prevision under Section 6.01(a)(vii) of the Agreement.

Pursuant to Section
6.05 of the Agreement, a default under Section §6.01(a)(vii) of the Agreement may be waived by the holders of a majority of
the aggregate principal amount of the outstanding Notes. As ROS Acquisition Offshore LP (“ROS”) and OrbiMed Royalty
Opportunities II, LP (“OrbiMed”) hold approximately 27.7% and 48.8%, respectively, of the aggregate principal amount
of the outstanding Notes, ROS and OrbiMed collectively hold the requisite majority to waive such an Event of Default.

By signing below,
ROS and OrbiMed hereby waive any Event of Default that has occurred as a result of the breach of Section 6.01(a)(vii) of the Agreement
caused by Borrower’s going concern opinion and the breach of an affirmative covenant made by the Borrower under another agreement
of indebtedness, as discussed above. The waivers set forth herein are limited to the extent specifically set forth above and shall
in no way serve to waive any other terms, covenants or provisions of the Agreement, or any obligations of the Borrower, other than
as expressly set forth above. Nothing in this letter shall be construed to imply any willingness on the part of ROS or OrbiMed
to agree to or grant any similar or future amendment, consent or waiver of any of the terms and conditions of the Agreement.

Please acknowledge
your receipt of this notice and your agreement to the waiver pursuant to the Agreement by executing the enclosed copy of this letter
where indicated below and returning it to John Gandolfo by email to jgandolfo@xtantmedical.com, with the original sent by regular
mail to Xtant Medical Holdings, Inc., 664 Cruiser Lane, Belgrade, Montana 59714. Thank you for your consideration.

	 	Very truly yours,	 
	 	Xtant Medical Holdings, Inc.	 
	 	 	 
	 	 	 
	 	/s/ John Gandolfo	 
	 	John Gandolfo, Chief Financial Officer	 

 

 

 

    	 

     

    

 

ACKNOWLEDGED AND AGREED TO BY:

 

ROS
Acquisition Offshore LP

 

By OrbiMed Advisors LLC, solely in its capacity
as Investment Manager

 

 

	
        By: /s/ Samuel D. Islay          

        Name: Samuel D. Islay

	
        Title: Managing Member

         

         

 

OrbiMed
Royalty Opportunities II, LP

 

By OrbiMed ROF II LLC, its General Partner

By OrbiMed Advisors LLC, its Managing Member

 

 

	
        By: /s/ Samuel D. Islay          

        Name: Samuel D. Islay

	
        Title: Managing Member

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