Abstract:
A surgical cable assembly is provided for securing bones, or securing medical implant devices to bones. The assembly preferably comprises a multistrand metal cable and a crimpable coupling member attached to a loop in the cable adjacent one end formed by a separate crimp member. The coupling member secures the cable in a permanent loop that encircles the bone and is capable of pivoting to permit the cable to follow the outer contour of the bone and/or implant. The coupling member may comprise a flange to limit its rotation about the cable. A method of securing bones and/or implants with the cable assembly also is provided.

Description:
FIELD OF THE INVENTION 
     The present invention relates to an apparatus and method for securing body parts with a surgical cable. In particular, the invention relates to a surgical cable assembly that includes a flexible cable that can be wrapped around body parts, such as bones, and a rotating crimpable coupling for securing the flexible cable in a closed loop about the bone. 
     BACKGROUND OF THE INVENTION 
     Surgical cables are used in various surgical procedures, for example, to fix fractured bones or to secure an implant to a bone. The cable may be a monofilament wire or multifilament cable. Typically, the cable is used to encircle the broken bone and hold it together as it heals or to hold an implant device in position next to a bone. 
     The configuration of the surgical cable assembly may impact the ease with which the cable is installed. A typical surgical cable assembly may include the cable and one or more pieces for securing the cable in a loop under tension, such as a stop to fix the ends of the cable to form the tensioned loop. One known type of cable assembly utilizes a small, permanent loop at one end, formed by a first crimp member. The opposite free end of the cable is wrapped around the bone and threaded through the small loop during the surgical procedure. The resulting second loop formed around the bone is then secured by sliding a loose tubular crimp member along the cable to the small permanent loop and crimping the tubular member with a crimping tool. Examples of such assemblies are disclosed in U.S. Pat. Nos. 4,966,600 and 5,116,340. 
     Given the need to limit the intrusiveness of the cable assembly within the surgical site and the desire to limit the size of the incision, such cable assemblies and associated components tend to be small and therefore difficult for a surgeon to handle. In particular, the task of threading the cable through the aperture in the small loose tubular member during surgery may be difficult for a surgeon wearing gloves. Further, the requirement that the surgeon account for all items used during surgery makes the use of small, loose pieces that may be readily dropped undesirable. 
     Installation of surgical cables may be frustrated by factors such as the difficulties encountered by the surgeon in having to handle the various devices and implements required for installation of a cable assembly. For example, one or more tools to tension the cable and/or temporarily hold the cable, to crimp the cable crimp, and to cut the cable may be used during installation of the surgical cable. The surgeon must be able to manipulate these various tools while installing the cable assembly. The physical constraints of the surgical site also may impact the ease with which a surgical cable assembly is installed. Access to the surgical site may be obstructed due to the particular location of the body where the cable is being installed or may be limited as a result of the desire to limit the size of the incision. Thus, the surgeon may experience difficulties in working with a number of tools in a small area while trying to position, tighten and fix the cable assembly about the bone, such that it may not be possible to readily achieve the desired tension and effectively maintain it until the cable is secured. 
     Another type of cable assembly is secured by a single L-shaped crimp member having two crimp able portions. One end portion of the cable is immovably fixed in the first crimp able portion. The opposite end of the cable is threaded around the bone and then fixed in the second crimp able portion. With this assembly, the surgeon does not have to handle a separate, loose crimp member. To form the cable loop, the surgeon only has to thread the opposite end of the cable through a second aperture in the crimp. Such an assembly is disclosed in U.S. Pat. No. 5,423,820 to Miller, et al. 
     When installing a cable assembly, it is desirable to obtain a predetermined amount of tension in the cable loop so that the cable is properly mechanically fixed around the bone. It is thus important to avoid formation of slack in the loop as the surgical installation is being completed. To limit slack, it is desirable to tighten the cable so that the cable generally conforms to the shape of the bone and fits snugly around the bone. The strength of a cable loop is also greater when the two ends of the cable are positioned essentially parallel to one another in a plane tangent to the surface of the bone. Because the ends of the cable disclosed in Miller, et al. are oriented perpendicular to one another as a result of the configuration of the L-shaped crimp, it may not be possible to have both ends flush with the surface of the bone. With both cable ends in the Miller, et al. assembly fixed in the L-shaped crimp, the crimp cannot rotate or pivot in any direction without forming sharp bends in the cable. Moreover, the L-shaped crimp of Miller, et al. may protrude into adjacent tissue and cause the cable loop to be lifted away from the bone along a length of the loop which also may reduce its strength. 
     U.S. Pat. Nos. 5,928,237 and 5,569,253 disclose cable assemblies utilizing two crimps, the crimps being held in ball and socket or ball and seat abutment to allow them to swivel relative to each other. One drawback of these assemblies is the complex machining required to fabricate the relatively small ball and socket or ball and seat joints. A further drawback is that in use, the swivel action of the joint may prevent holding the cable loop roughly in a single plane and result in twisting and bending of the cable. The swivel action between the crimps may also make the task of locating the second crimp aperture and threading the free cable end through the crimp aperture difficult during surgery. 
     Thus it is desirable to have a surgical cable assembly that may be readily handled by a surgeon and easily installed during surgery to form a secure cable loop about a bone. It is also desirable to have such a surgical cable assembly that may be orientated to facilitate tensioning of the loop to avoid formation of slack, cable twisting, and sharp cable bends. The cable assembly should be easy to manufacture, compact, and only minimally intrusive in the body. 
     SUMMARY OF THE INVENTION 
     In accordance with the present invention, an apparatus and method are provided for securing body parts, such as bones. A surgical cable assembly for encircling a bone comprises a length of cable that has first and second ends and a coupling member which has a shoulder portion having a first aperture extending therethrough. A small, preformed loop near the first end of the cable has a portion loosely received in the shoulder aperture. The coupling member also has a second part, or neck portion. The neck portion has a second aperture extending through a malleable portion configured to be crimped about the flexible cable for fixing the coupling along the flexible cable so as to secure the surgical cable assembly around the bone. 
     The portion of cable extending through the shoulder aperture forms an axis of rotation for the coupling member. With the coupling member rotatably mounted about a portion of the small cable loop, the second end of the flexible cable is passable through the second aperture to loop the flexible cable around the bone at a desired orientation. Because the small loop adjacent the first cable end is not fixed (i.e., crimped) in the shoulder aperture, the angle of the neck portion of the coupling member relative to the bone surface may be adjusted to achieve the desired tension, strength and orientation of the cable assembly around the bone by pivoting the coupling member about the preformed loop. Once the cable is looped around the bone, the neck of the coupling member is fixed at a position along the flexible cable by crimping to maintain a predetermined tension of the loop and secure the loop in a desired position around the bone. 
     A separate loop crimp member secures the first end of the flexible cable back along the length of the flexible cable to form the small, permanent loop adjacent the first end of the flexible cable. The flexible cable is rotatably attached to the first part through the first aperture by the connecting loop. The coupling member may also comprise a flange for controlling the degree of rotation of the coupling member around the small preformed loop. 
     A method of securing a bone with a surgical cable assembly includes first providing a surgical cable assembly that comprises a coupling member having a shoulder portion with a first aperture extending therethrough, a neck portion having a second aperture extending therethrough, and a flexible cable having first and second ends spaced by a length, where the coupling member is rotatably mounted on a small cable loop adjacent the first end by means of the first aperture. 
     The method further comprises passing the second end of the flexible cable around the bone and through the second aperture of the coupling member to form a loop of the flexible cable around the bone. The loop is then tightened to a desired tension about the bone. A suitable tensioning tool may be used for this purpose. Depending on the contour of the bone surface and the desired tension, the tensioning step may involve pivoting the coupling member relative to the small loop threaded through the first aperture. 
     The neck of the coupling member is crimped to secure it about the flexible cable at a point along the cable length necessary to maintain the desired loop tension and desired angle of the neck of the coupling member relative to the bone surface. After the coupling member is crimped, the flexible cable is cut essentially flush with the end of the neck portion, at the end opposite the cable loop. 
     In the preferred method, the coupling member is provided pre-mounted on the small cable loop by passing the first cable end through the first aperture of the coupling and then securing it back against a length of the flexible cable so as to form the small loop. A separate tubular member is crimped about the first end of the flexible cable and the length of flexible cable along which the end is doubled back so as to fix the first end and form the preformed loop. 
     The method also may include passing the flexible cable around a medical implant or graft positioned adjacent the bone in order to secure the medical implant or graft against the bone. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1 is a schematic view of a surgical cable assembly secured around a portion of a spinal column and holding a medical implant against the spinal column in accordance with the present invention; 
     FIG. 2 is a cross-sectional view of the surgical cable assembly of FIG. 1 loosely encircling a different bone; 
     FIG. 3 is a view similar to FIG. 2 showing the surgical cable assembly secured to a desired tension around the bone; 
     FIG. 4 is an enlarged perspective view of the crimp able coupling member and separate loop crimp in accordance with the present invention; 
     FIG. 5 is a front end elevational view of the crimp able coupling member of FIG. 4; 
     FIG. 6 is a left side elevational view of the crimp able coupling member of FIG. 4; 
     FIG. 7 is a fragmentary side elevational view of the surgical cable assembly of FIG. 4, with the free end of the cable passed through the crimp able coupling member, illustrating engagement of the loop crimp by the flange of the crimp able coupling member; 
     FIG. 8 is a perspective view of a crimp able coupling member and loop crimp in accordance with a second embodiment of the present invention; 
     FIG. 9 is a front end elevational view of the crimp able coupling member of FIG. 8; 
     FIG. 10 is a left side elevational view of the crimp able coupling member of FIG. 8; 
     FIG. 11 is a perspective view of a crimp able coupling member and loop crimp in accordance with a third embodiment of the present invention; 
     FIG. 12 is a front end elevational view of the crimp able coupling member of FIG. 11; 
     FIG. 13 is a left side elevational view of the crimp able coupling member of FIG. 11; 
     FIG. 14 is a perspective view of a crimp able coupling member and loop crimp in accordance with a fourth embodiment of the present invention; 
     FIG. 15 is a front end elevational view of the crimp able coupling member of FIG. 14; 
     FIG. 16 is a left side elevational view of the crimp able coupling member of FIG. 14; 
     FIG. 17 is a perspective view of a crimp able coupling member and loop crimp in accordance with a fifth embodiment of the present invention; 
     FIG. 18 is a front end elevational view of the crimp able coupling member of FIG. 17; 
     FIG. 19 is a left side elevational view of the crimp able coupling member of FIG. 17; 
     FIG. 20A is a fragmentary side elevational view of the surgical cable assembly of FIG. 8 showing the crimp able coupling member and the loop crimp, with the free end of the cable looped through the crimp able coupling member; 
     FIG. 20B is a view similar to FIG. 20A but showing the crimp able coupling member rotating toward the loop crimp; and 
     FIG. 20C is a view similar to FIG. 20B but showing increased rotation of the crimp able coupling member toward the loop crimp. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     Referring to FIG. 1, there is illustrated a surgical cable assembly embodying features of the present invention. The preferred surgical cable assembly  10  may be used for securing a bone  12 . The surgical cable assembly  10  generally comprises a flexible cable  14 , a coupling member  16  and a loop crimp member  18 . The coupling member  16  is pivotably mounted on a looped portion of the flexible cable  14  prior to use, and, during surgery, the free end of the cable  14  is passed around the subject bone and through an aperture in the coupling member  16  to form a closed loop around the subject bone  12 . The surgical cable assembly  10  also may be used to hold a medical implant device  11 , such as a splint, rod, graft or the like, against the bone  12 . 
     As shown in FIGS. 2-3, one or more of the surgical cable assemblies  10  may be used to secure and provide reinforcement for a fractured bone  13  at the site of the fracture. Once positioned around the bone  13 , the cable loop  15  is tightened to a desired tension to secure the cable assembly  10  closely around the bone  13  (FIG.  3 ). 
     The cable  14  is a surgical grade stainless steel, titanium alloy, or the like. Other materials such as cobalt chromium alloy or other suitable metals also may be used. In the preferred embodiment, the cable  14  is made of twisted multi strand stainless steel cable. In one form of the invention, as an example, the cable  14  has a diameter of between about 0.04 and 0.05 inches and more preferably about 0.043 inches. The cable  14  may be swedged to reduce surface roughness and may have a high flexibility, which may provide a tighter loop to hold the bone yet avoid damage to surrounding tissue. A stiffened leader may be used at the free end  22  of the cable  14  to facilitate threading of the cable  14  through the aperture in coupling member  16  during installation. 
     With reference now to FIGS. 4-6, the coupling member  16  is permanently, rotatably mounted about the preformed loop  48  adjacent the fixed end portion  20  of cable  14 . The coupling member  16  comprises an elongated tubular neck portion  24  and a shoulder portion  28  extending from the neck portion  24 . The coupling member  16  may be fabricated from a surgical grade stainless steel, titanium, titanium alloy, or the like, or cobalt chromium alloy or other malleable metals. 
     The neck portion  24  has a generally circular cross-section defined by a tubular wall  29 . The inner surface of wall  29  defines an aperture  26  extending longitudinally therethrough from a first end  30  to a second end  31 . The diameter of the aperture  26  preferably should be sized to allow the cable  14  to slide relatively freely through the aperture  26  when the assembly  10  is being installed. The aperture  26  also is sized to provide a compression fit between the inner surface of wall  29  and the cable  14  when the neck portion  24  is crimped to maintain the positioning of the cable  14  and secure the assembly  10 . Using a 0.043 inch cable, as an example, the diameter of the aperture  26  may be about 0.044 and 0.053 inches and, more preferably, about 0.046 inches. 
     The outer circumference of the aperture  26  at the second end  31  preferably has a chamfered edge  44 , such that the walls of the aperture  26  taper inwardly from the end  31  to a predetermined point at the interior of the neck portion, along a length of the aperture  26 . The chamfered surface  44  facilitates insertion of the cable  14  through the aperture  26  by increasing the diameter of the aperture  26  at the second end  31 . The chamfered edge  44  also allows the cable  14  to bend more gradually around the second end  31  of the neck portion  24 , and avoids forming a sharp cable bend at that point as the cable  14  is pulled through the coupling member  16  and tightened. The outer circumference at the first end  30  also may have a chamfered edge  45  to avoid the formation of sharp bends in the cable while it is being tightened and to avoid fraying the cable. 
     The neck portion  24  is crimped along its length between shoulder portion  28  and the first end  30  when it is desired to secure the coupling member  16  at a position on the cable  14 . The wall  29  of the neck portion  24  is sufficiently thin and malleable to allow the neck portion  24  to be readily crimped about the cable  14  using any crimping tool known in the art. It is generally desirable to minimize the size of the neck portion to limit the intrusiveness of the cable assembly into surrounding tissue. However, the neck portion  24  should be of sufficient length to provide access for a crimping tool and to provide sufficient crimping area to fixedly secure the coupling member  16  about the cable  14 . In one example, the length of the neck portion  24  between the shoulder portion  28  and the first end  30  is about 0.23 inches. 
     The shoulder portion  28  of coupling member  16  extends outwardly from the neck portion  24  at the second end  31 , is generally box-like in shape, and comprises two opposite side surfaces  32 , a back surface  34 , a front surface  36 , and an upper surface  38 . In one form of the invention, the two generally planar opposing side walls  32  extend tangentially from the outer surface of the neck  24  to provide sufficient clearance with the small permanent loop  48  about which coupling member  16  is mounted. The generally planar back surface  34  spans between the side surfaces  32 , and the front surface  36  is opposite the back surface  34  and spans between the two side surfaces  32 . As shown, the top surface  38  is preferably convex, with a radius of curvature that rotates about an axis parallel to the central longitudinal axis of the neck aperture  26 . This further avoids interference with the small loop  48 . However, the top surface  38  also may be planar or otherwise suitably configured. 
     An aperture  40  extends transversely through the shoulder portion  28  of coupling member  16  between the opposite side surfaces  32 . The aperture  40  is positioned above the neck aperture  26  and has a central longitudinal axis perpendicular to a central longitudinal axis of the neck aperture  26 . The aperture  40  has chamfered edges  41  at each of the two side surfaces  32  to minimize cable fraying. The small permanent loop  48  extends through aperture  40  and provides an axis of rotation of coupling member  16 . The diameter of the aperture  40  is sufficiently greater than the diameter of the cable  14  to allow coupling member  16  to rotate freely about the permanent loop  48  of the cable  14 . As an example, a shoulder portion aperture with a 0.061 inch diameter has been used effectively with a 0.043 inch diameter cable. Preferably, the dimensions of the shoulder portion  28  are just large enough to accommodate the aperture  40  and provide a sufficiently strong support structure for attaching the permanent loop  48  of the cable  14  to the coupling member  16 . 
     The surgical cable assembly  10  is preassembled to have the coupling member  16  permanently mounted at the shoulder portion  28  about the permanent loop  48  of the cable  14 . This is done by passing cable  14  through the aperture  40  and around the neck portion  24  to form the small loop  48  encircling the neck portion  24 . A loop crimp member  18  is positioned along the cable  14  adjacent the coupling member  16  to secure the end portion  20  of the cable  14  and form the small loop  48 . The end portion  20  of the cable is positioned within the loop crimp member  18  to temporarily form the small loop  48 . Once the small loop  48  is formed, crimping the member  18  at one or more locations along its length permanently secures the small loop  48  around the coupling member  16 . 
     As shown in FIG. 4, the loop crimp member  18  may be in the form of a double-lumen crimp that provides generally separate passages for each of the two cable portions extending therethrough. The double-lumen crimp member  18  limits slippage of fixed end  20  against the opposite portion of the cable  14  in the crimp member  18  as the larger cable loop  15  is tightened about the bone, thereby increasing the strength of the small loop  48 . The crimp member  18  also may be generally circular in cross-section or otherwise shaped to accommodate two segments of the cable  14  therein. Moreover, the invention is not limited to embodiments in which the fixed end  20  is secured by a crimp. Any other type of fastener capable of securing the fixed end under tension may be used. 
     The small cable loop  48  may have a generally tear drop shape and should be sufficiently large enough to allow the coupling member  16  to pivot about the axis of rotation provided by the portion of the cable that extends through aperture  40 . The rotation of the coupling member  16  about the loop  48  facilitates tensioning of the cable loop  15 . When the neck portion of coupling member  16  is oriented perpendicular to the loop crimp member  18  and the free end  22  of the cable  14  is passed through the aperture  26 , that portion of cable  14  is also generally perpendicular to the small loop  48 , as shown in FIG.  2 . In order to reduce the generally triangular space that remains between the cable assembly and the bone shown in FIG. 2, the coupling member must be allowed to pivot toward the loop crimp member  18 . In the cable assembly of the present invention, as the cable loop  15  is tightened further around the subject bone  13 , the neck portion  24  rotates about the small loop  48  and toward the loop crimp member  18  such that the neck portion becomes positioned at an acute angle relative to the loop crimp member  18 . As the neck portion  24  rotates, the portion of the cable extending around the bone adjacent the loop crimp member  18  becomes oriented generally parallel to the portion of cable extending through and adjacent the coupling member  16 . This orientation enables a tighter fit of cable assembly around the bone and provides greater cable loop  15  strength relative to a cable loop in which the two opposite end portions of cable are oriented essentially perpendicular to each other. At the same time, when oriented in a direction generally more tangent to, rather than extending radially out from, the bone  13 , the coupling member  16  and any portion of the cable  14  that may project from the neck portion  24  are less likely to damage surrounding tissue. Other bone shapes may call for different degrees of rotation of the coupling member  16  about the loop  48 . 
     The configuration of the small loop  48  and loop crimp member  18  to secure the coupling member  16  of the cable assembly provides further advantages in terms of the strength of the cable assembly  10 . As the cable loop  15  is tightened around the bone  13 , the tension force acting along the cable pulls the small loop  48  in a direction perpendicular to the coupling member  16 . The loop crimp member  18  secures the fixed end portion  20  of the cable under the tension load and also the portion of the cable in the crimp adjacent the fixed end. The load experienced by the small loop  48  is distributed against the coupling member  16  and the tendency of the fixed cable end  20  to pull through the loop crimp member  18  is diminished. 
     The coupling member  16  also may comprise an exterior flange  42  to limit rotation of the small loop  48 . The flange  42  is located adjacent the second end  31  of the coupling member  16  and extends beneath the small cable loop  48  as shown in FIG.  7 . Referring to FIGS. 3 and 7, the flange  42  limits rotation of the coupling member in a direction away from the loop crimp member  18 . Limiting rotation of the coupling member increases ease of installation during the surgical procedure. In this respect, the flange  42  helps to maintain the desired configuration of the surgical cable assembly  10  described above at all times so that the surgeon is not required to flip the coupling member  16  about the small loop  48  to ensure that the small loop  48  encircles the neck portion  24  prior to threading the cable  14  through the aperture  26 . As shown in FIGS. 5 and 6, the flange  42  projects outward from the wall  29  of the neck portion  24  and extends partially around the outer circumference of the neck portion  24 . The flange  42  extends outward a sufficient distance so that face  50  engages the small loop  48  to limit further rotation of the coupling member away from the loop crimp  18 . 
     The present invention also eases installation because, as shown in FIGS. 1 and 4, the small loop  48  holds the coupling member  16  in generally the same plane as loop crimp  18  and the larger cable loop  15 . This makes it easier for the surgeon to locate the aperture  26  and thread the free end  22  of the cable through the aperture  26 . 
     Although the advantages of locating the coupling member on a small cable loop should now be apparent, the invention encompasses other means of rotatably mounting the coupling member on the cable. Thus, for example, a pair of stops secured to the cable  14  at opposite sides of the shoulder aperture  40  may locate the coupling member  16  for rotation about the cable without the use of a small permanent loop  48 . Other mechanisms for rotatably mounting the coupling member  16  may also be used. 
     Referring now to FIGS. 8-10, there is illustrated a second embodiment in accordance with the present invention. The surgical cable assembly of the second embodiment is the same as described above and shown in FIGS. 1-7, with the exception of the coupling member, which utilizes a flange of different shape and configuration. 
     More particularly, a flange  54  extends from the neck portion  56  of the coupling  52  toward the loop crimp member  18  between shoulder aperture  60  and the front wall  62  of the shoulder portion  58 . In the disclosed embodiment, the outer face  64  of the flange  54  is flush with the front wall  62 . The flange  54  extends radially from the neck portion  56  and has a radius of curvature that rotates about the central longitudinal axis of the neck portion  56 . As best shown in FIG. 9, the flange  54  terminates at edge  68  which lies in a plane tangent to the neck portion  56 . 
     With the flange  54  positioned between the aperture  60  and the front wall  62 , it may serve to control the degree of rotation of the coupling member  52  toward loop crimp member  18 , as shown in FIGS. 20A-20C. As the coupling member  52  rotates toward the crimp member  18 , the interior face  78  of the flange  54  engages the small loop  48 . Further rotation of the coupling member  52  causes the small loop  48  to flex about the flange  54  (FIG.  20 C). Thus, by use of a flange member located above the small loop crimp, the degree of rotation may be controlled if desired, for example, to prevent the neck portion of the coupling member from engaging the separate loop crimp. The amount of rotation permitted will depend on the size of the flange, the spacing of the flange relative to the aperture  60 , and the flexibility of the small cable loop  48 . The greater the stiffness of the small loop  48 , the more the flange  54  will tend to maintain the coupling member  52  and the crimp member  18  in spaced relation. 
     The remaining features of the coupling member  52  may be as described above for the coupling member  16  of FIGS. 1-7. 
     Referring now to FIGS. 11-13, there is illustrated a third embodiment in accordance with the invention. The surgical cable assembly of the third embodiment is the same as described above and shown in FIGS. 1-6, with the exception of the coupling member. More particularly, the coupling member  80  of the third embodiment does not include a flange. Thus, the coupling member  80  is free to rotate about the small loop  48  in either direction. The remaining features of the coupling member  80  may be as described above for the coupling member  16  shown in FIGS. 1-7. 
     Referring now to FIGS. 14-16, there is illustrated a fourth embodiment in accordance with the invention. The surgical cable assembly of the fourth embodiment is the same as described above and shown in FIGS. 1-6, with the exception of the coupling member. More particularly, the coupling member  86  of the fourth embodiment does not include a flange. Thus, the coupling member  86  is free to rotate about the small loop  48  in either direction. The shoulder portion  88  also differs in that the side walls  90  taper inward up to the top wall  92 , thereby reducing the overall size of the shoulder portion  88 . The remaining features of the coupling member  86  may be as described above for the coupling member  16  shown in FIGS. 1-7. 
     Referring now to FIGS. 17-19, there is illustrated a fifth embodiment in accordance with the invention. The surgical cable assembly of the fifth embodiment is the same as described above and shown in FIGS. 1-6, with the exception of the coupling member. With the coupling member  96  of the fifth embodiment, the shape of the flange  98  differs. More particularly, the flange  98  is in the form of a circular disk adjacent the shoulder end  100  of the coupling member  96 . The circular flange  98  has a radius that rotates about the central longitudinal axis of the neck portion  102  and extends outward a distance generally equal to the height of the shoulder portion  104 . Thus, as the coupling member  96  rotates, the interior face  106  of the flange  98  engages the small loop  48  to limit further rotation. 
     For the sake of brevity, the method of the invention is described with primary reference to the first embodiment described above. In accordance with the method of the present invention, the cable assembly  10  is installed around a bone during a surgical procedure. The cable assembly  10  is preferably pre-assembled at the factory so that the coupling member  16  is rotatably attached to the small cable loop  48 , so that the surgeon need not handle loose pieces. In embodiments where the coupling member  16  includes a flange  42  at the shoulder end  31  that prevents rotation of the small loop  48  around the end  31  of the coupling member  16 , the surgeon need not be concerned with adjusting the configuration of the cable assembly  10  during the surgical procedure. 
     When the surgical site is identified and prepared, the surgeon passes the free end  22  of the cable  14  around the bone. If desired, the cable  14  may be passed around the bone with the assistance of a separate tool known as a “cable passer,” as is known in the art. The method further entails threading the free end  22  that has been passed around the bone through the aperture  26  of the coupling member  16 , from the second end  31 , through the neck, and out the first end  30  in the direction of arrow A (FIG.  2 ). In this manner, the loop  15  is loosely positioned around the bone  12  at the surgical site. The method may include first adjusting the orientation of the coupling member to provide a convenient angle of entry of the cable based on the space limitations of the surgical site. 
     After being passed through the coupling member  16 , the free end  22  of the cable  14  may be connected to the desired tensioning tools to further draw the cable  14  through the coupling member  16  and achieve a desired tension in the loop  15 . The cable loop  15  may be tightened using any tensioning tool known to those skilled in the art, such as disclosed in U.S. Pat. Nos. 4,966,600 and 5,116,340, incorporated by reference herein. To minimize slack in the resulting loop  15 , the cable is tension ed to a such an extent that the coupling member  16  rotates about the small loop  48  so that the cable  14  and coupling member  16  lie more flush with the surface of the bone. A temporary holding device as is known in the art may be used to maintain the surgical cable assembly at the desired tension while one or more other surgical cable assemblies are installed at the surgical site. The tensioning tool then may again be used to adjust the tension in the surgical cable assembly as necessary. 
     When the desired tension is achieved, the neck portion  24  is crimped to permanently hold the coupling member  16  at that position along the length of cable  14  to maintain the desired level of tension in the loop  15 . The cable  14  is then cut generally flush with the first end  30  of the coupling member  16  and is thus permanently positioned around the bone at the surgical site. In practicing the method, the degree of allowable rotation and, thus, the final orientation of the coupling member relative to the bone surface may be controlled by engagement of a flange extending from the coupling member with the surface of the small loop opposite the bone surface. 
     It should be understood that if it is desired to secure an implant device or graft and a bone or two bones together with the surgical cable assembly  16 , the installation of the cable is completed in a similar manner. 
     Numerous alternatives, modifications and variations of the surgical cable assembly are possible to improve the use and method of installing a surgical cable in accordance with the present invention. Thus, modifications and variations in the practice of the invention are expected to be apparent to those skilled in the art after consideration of the foregoing detailed description of the invention. Although preferred embodiments have been described above and illustrated in the accompanying drawings, there is no intent to limit the scope of the invention to these or any other particular embodiments. Consequently, any such modifications and variations are intended to be included within the scope of the following claims, which further describe and point out the invention.