Abstract:
A cable tensioning apparatus and method are provided for positioning and tensioning a surgical cable to skeletal tissue or to implants. The invention is most applicable for securing surgical cable and/or orthopedic implants to bone in orthopedic surgery. A linearly translated drive rod attached to cable is driven by a friction drive to create tension on the surgical cable.

Description:
RELATED APPLICATIONS 
     This application claims priority to U.S. Provisional Application No. 61/088,078, filed Aug. 12, 2008, the contents of which are hereby incorporated by reference herein in their entirety. 
    
    
     FIELD OF THE INVENTION 
     This invention pertains generally to surgical methods and apparatus for tensioning cables or wires. More specifically, the invention relates to methods and apparatus for securing cable and/or orthopedic implants to bone or skeletal tissue in orthopedic surgery through the use of cables or wires. 
     BACKGROUND 
     Surgical cables and wires are used extensively in orthopedic surgery for securing bones and bone fragments in place and for fastening surgical implants to bones. In the most common type of orthopedic surgery where severe breaks of bones have taken place, or in reconstructive procedures on bones, for example in reconstructive hip procedures or the like, a permanent cable implant is provided to hold bone portions together. For example, during a total hip replacement, press-fit femoral components are inserted into the canal of the femur, resulting in an extremely tight fit in some cases. Seating of these press-fit components has been shown to induce large hoop stresses in the proximal femur, which can result in longitudinal cracks in the femur. Thus, a surgical cable system is applied for providing a counteracting compressive hoop stress, which prevents crack formation and/or propagation. 
     Typically, surgical cables are implanted using tensioning devices, which apply tension to a cable looped around the bone and the cable implant. The cables are typically formed into a loop, simple or complex, and tightened about the bone structure and implant with a tensioning tool. 
     These tensioning tools are often cumbersome due to the strength required to support the device while creating high tensile forces in the surgical cables. Cable tensioning tools are also extremely slow to operate because of threaded drives used to create the large tensile forces in the surgical cable. The slow operation of cable tensioners can cause significant delays in the surgery itself. Any delays in surgery prolong the time required for the patient to be under general anesthetic increasing the risk of complications and recovery time of the patient. 
     Finally, many cable tensioning tools are long and narrow in which cable is thread blindly through the device. These cable tensioning tools are extremely complicated and difficult to operate under the stress and time constraint of surgery especially during trauma cases. Furthermore, complicated mechanisms have an increased likelihood of mechanical malfunctioning, i.e. jamming, and the restoration of function is extremely difficult due to the blind threading of cable in the devices. 
     One example is shown in U.S. Pat. No. 5,312,410 filed Dec. 7, 1992 to Miller et al. In the Miller example, a rudimentary ratchet mechanism is used to create cable tension thread blindly through the device. The ratchet mechanism causes force to be transmitted from a lever directly to the ratchet teeth of the device causing shock waves from the intermittent motion and imprecise positioning of tensioned cable due to mechanical backlash. The imprecise positioning of the device can cause imprecise tensioning in the attached cable and could further damage the patient&#39;s fragile bones. 
     Another example is shown in U.S. Patent Application Pub. No. US 2006/0229623 A1 filed Feb. 21, 2006 to Bonutti et al. In the Bonutti example, the pistol grip is used only to crimp the cable and the proximal lever is used to actually tension the cable. The Bonutti example requires wrapping the cable around a cylinder by hand and awkwardly rotating the lever to achieve a small amount of cable being drawn through the instrument. Such awkward operation of medical instruments is not intuitive to medical personnel unfamiliar with complicated mechanical systems. 
     SUMMARY 
     In accordance with the present invention, the pistol grip tensioning device provides a significantly improved apparatus for tensioning cable used to secure skeletal tissue or bones in orthopedic surgery developed from insights gained by surgeons&#39; experience in the operating room. The pistol grip tensioning device apparatus provides a surgeon all the components to tension surgical cable, but in a more ergonomic and easier to use assembly than conventional cable tensioners. 
     The rear or proximal cable clamp assemblies lock surgical cable without damaging or deforming the cable as other conventional clamps. The cable attached to the cable clamp assembly is driven away from the patient by a simple drive rod to create tension on the cable around the bone. The drive rod is in turn driven by a surgeon squeezing a handle and lever together to operate the pistol grip tensioner. The surgeon can easily read the amount of tension created by the cable on the bone by reading a gauge or tension indicator integral to the tensioner to prevent over-tightening the cable and potential damage to the patient&#39;s bone. An additional cable clamp assembly is located on the tip or distal end of the cable tensioner to allow any amount of cable to be drawn under tension by the device. The distal cable clamp assembly can be used with the proximal cable clamp assembly to draw any length of cable with great force created by the mechanical advantage created by the drive mechanism and mechanical leverage. 
     In one form, the drive mechanism operates by a canting member fitting around the drive rod that mechanically engages or locks on to the rod, i.e. a friction drive. The drive rod is driven by the force of the surgeon squeezing the grips which is multiplied and transmitted by the drive mechanism on to the rod. A release mechanism allows the surgeon to repeat squeezing of the grips for the rod to travel farther without the rod slipping on the canting member under tension. The release mechanism, in the form of a simple lever or trigger, allows the drive rod to be reset to the initial position simply by pressing the lever of the trigger to draw more length of cable. 
     In one embodiment, the cable passes through cable clamp assemblies that are offset to the body of the cable tensioning apparatus to allow tactile and visual feedback as to the position of the cable in the tensioning apparatus. The offset cable clamp assemblies also allow manual adjustment and improved visualization of the cable tensioning process. In another embodiment, the cable passes through a central passage or bore to allow smoother mechanical operation and higher loading. 
     The cable tensioning apparatus may have ducts or flow ports located within the housing to allow cleaning. The ducts or flow ports allow cleaning solutions to flush out and clean all of the internal mechanisms of the cable tensioning apparatus. The cable tensioning apparatus is also modularly designed to allow the apparatus to easily be assembled and disassembled to further aid the cleaning of the apparatus. 
     One advantage of the cable tensioning apparatus is the cleanability of the cable tensioning apparatus. Cleanability reduces the risk of infection to patients due to cross contamination of biologic materials from patient to patient after repeated uses of the tensioning apparatus. The risk of infection is minimized because of the ease of disassembly and ease of access of internal component through ducts or flow ports throughout the device to allow high pressure flushing of the cable tensioning apparatus. The offset cable clamp assemblies further assist in cleanability because most of the cable passes externally with open access for cleaning. 
     Another advantage of the cable tensioning apparatus is the rapidity in which surgical cable can be drawn and tensioned. The ability to quickly tension multiple surgical cables used in the typical surgical procedure multiplies the speed in which the surgery itself is performed. In addition, surgical cable can be rapidly “pre-tensioned” to eliminate any slack in the cable to greatly increase the pace of the surgery itself. Any reduction of the time of the surgery is a great benefit because the reduction of the time that the patient is under anesthetic also reduces the risk of infection, the risk of complications from the anesthetic itself, and the recovery time of the patient. 
     One other advantage of the pistol grip cable tensioning apparatus is the simplicity of operation of the arrangement of basic parts that gives surgeons and medical technicians an intuitive understanding of the operation of the device. The device is intuitive because the operator can see and feel how the device is operating, i.e. tactile and visual feedback. Almost no training is required by medical personnel unlike complex cable tensioning systems. The elegant simplicity of the intuitive components created an unpredicted synergy that led to the rapid learning and adoption by surgeons and technicians of the apparatus without the usual lengthy learning period. 
     Another advantage of the elegant simplicity from the limited number of mechanical elements is the improved reliability because there are not numerous complex mechanisms, any of which can malfunction under slight deviation from ideal conditions. In addition, the limited number of mechanical elements also reduces the weight and the bulk of the device. The superior overall operation of the cable tensioning apparatus by surgeons in the operating room was unpredicted given the simplicity of the design because of the tactile nature of most surgeons. 
     Another advantage of the cable tensioning apparatus is the accuracy of the cable tensioning apparatus created by the friction drive. The accuracy is an advantage because a precise amount of tension needs to be applied on the cable. Tension needs to be applied to the surgical cable with surgical precision to prevent the cable, which is typically wrapped around fractured bone, from cutting into the fragile bone of the patient or further fracturing the bone. The extremely smooth and precise motion of the friction drive allows a precise amount of tension to be applied by the friction drive and monitored by the tension indicator. The precision is improved because of the virtual elimination of backlash, i.e. the amount of clearance between mated gear teeth such as on a ratchet. The precision of which tension can be applied to cable is a significant improvement over other cable tensioning mechanisms. 
     Additional advantages and features of the invention will become apparent from the following description and attached claims taken in combination with the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         FIG. 1  is an isometric view of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 2  is an isometric view of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 3  is an isometric view of the first embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 4  is an exploded view of the first embodiment of the pistol grip tensioning apparatus. 
         FIG. 5  is a detailed exploded view of the first embodiment of the pistol grip tensioning apparatus. 
         FIG. 6  is a front view of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 7  is a front view of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 8  is a front view of the first embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 9  is a front sectional view of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 10  is a front sectional view of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 11  is a front sectional view of the first embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 12  is a detailed front sectional view of the proximal cable clamp assembly of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 13  is a detailed front sectional view of the proximal cable clamp assembly of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 14  is a detailed front sectional view of the drive mechanism in the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 15  is a detailed front sectional view of the drive mechanism of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 16  is a detailed front sectional view of the tension indicator mechanism of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 17  is a detailed front sectional view of the tension indicator mechanism of the first embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 18  is a detailed front sectional view of the distal cable clamp assembly in the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 19  is a detailed front sectional view of the distal cable clamp assembly of the first embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 20  is a right side view of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 21  is a left side view of the first embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 22  is a top view of the first embodiment of the pistol grip tensioning apparatus. 
         FIG. 23  is a perspective view of the drive mechanism of the pistol grip tensioning apparatus of the first embodiment in the initial condition. 
         FIG. 24  is an isometric view of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 25  is an isometric view of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 26  is an isometric view of the second embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 27  is an exploded view of the second embodiment of the pistol grip tensioning apparatus. 
         FIG. 28  is a detailed exploded view of the second embodiment of the pistol grip tensioning apparatus. 
         FIG. 29  is a front view of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 30  is a front view of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 31  is a front view of the second embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 32  is a front sectional view of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 33  is a front sectional view of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 34  is a front sectional view of the second embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 35  is a detailed front sectional view of the proximal cable clamp assembly of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 36  is a detailed front sectional view of the proximal cable clamp assembly of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 37  is a detailed front sectional view of the drive mechanism of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 38  is a detailed front sectional view of the drive mechanism of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 39  is a detailed front sectional view of the tension indicator mechanism of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 40  is a detailed front sectional view of the tension indicator mechanism of the second embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 41  is a detailed front sectional view of the distal cable clamp assembly of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 42  is a detailed front sectional view of the distal cable clamp assembly of the second embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 43  is a right side view of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 44  is a left side view of the second embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 45  is an illustration of the surgical procedure which utilizes the distal cable clamp assembly of the second embodiment of the pistol grip tensioning apparatus (which corresponds to FIG. 11 in U.S. Pat. No. 7,207,993 B1). 
         FIG. 46  is a perspective view of the connector for cable ends (which corresponds to FIG. 1 in U.S. Pat. No. 5,415,658). 
         FIG. 47  is an exploded view of the first embodiment of the pistol grip tensioning apparatus in the initial condition and a surgical connector. 
         FIG. 48  is a detailed isometric view of the first embodiment of the pistol grip tensioning apparatus mechanically interfacing with a surgical connector. 
         FIG. 49  is a front view of the pistol grip tensioning apparatus mechanically interfacing with a surgical connector. 
         FIG. 50  is a front sectional view of the pistol grip tensioning apparatus mechanically interfacing with a surgical connector. 
         FIG. 51  is a longitudinal sectional view of the connector of  FIG. 45 , showing its position with a cable loop on a portion of a bone of a patient (which corresponds to FIG. 3 in U.S. Pat. No. 5,415,658). 
         FIG. 52  is an isometric view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 53  is an isometric view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 54  is a front view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 55  is a front view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 56  is a front sectional view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 57  is a front sectional view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 58  is a detailed front sectional view of the drive mechanism in the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 59  is a detailed front sectional view of the drive mechanism of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 60  is a top view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 61  is a top view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 62  is a top sectional view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 63  is a top sectional view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 64  is a right side view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 65  is a left side view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 66  is a bottom view of the third embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 67  is a bottom view of the third embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 68  is an isometric view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 69  is an isometric view of the fourth embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 70  is an isometric view of the fourth embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 71  is an exploded view of the fourth embodiment of the pistol grip tensioning apparatus. 
         FIG. 72  is a front view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 73  is a front view of the fourth embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 74  is a front view of the fourth embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 75  is a front sectional view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 76  is a front sectional view of the fourth embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 77  is front sectional view of the fourth embodiment of the pistol grip tensioning apparatus in the secured or locked configuration. 
         FIG. 78  is a detailed front sectional view of the proximal cable clamp assembly of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 79  is a detailed front sectional view of the drive mechanism of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 80  is a detailed front sectional view of the drive mechanism of the fourth embodiment of the pistol grip tensioning apparatus in the fully extended condition. 
         FIG. 81  is a detailed front sectional view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 82  is a right side view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
         FIG. 83  is a left side view of the fourth embodiment of the pistol grip tensioning apparatus in the initial condition. 
     
    
    
     DETAILED DESCRIPTION 
     The following location and direction convention will be used throughout all the described drawings and their written descriptions. In describing the pistol grip cable tensioning device or apparatus of the present invention, the term “proximal” refers to a direction of the device away from the patient and rearwardly towards the user while the term “distal” refers to a direction of the instrument forwardly towards the patient and away from the user. As shown in  FIG. 1 , the “proximal end” of the insertion apparatus  1001  is shown on the upper left side of the figure near the proximal cable clamp assembly  1101 . The “proximal direction” is referring to any motion toward the user and in  FIG. 1  is toward the upper left shown as direction A. The “distal end” of the cable tensioning apparatus  1001  is shown on the lower right side of  FIG. 1  near the distal cable clamp assembly  1801 . The “distal direction” is referring to any motion toward the patient and in  FIG. 1  is toward the lower right in direction B. 
     Cable Tensioning Apparatus Embodiments 
     The cable tensioning apparatus has four embodiments shown in  FIGS. 1 through 83 . The first embodiment of the cable tensioning apparatus  1001  is shown in  FIG. 1  through  FIG. 23 . This first apparatus  1001  is operated only by the depression of the lever  1501  causing lever shifts or strokes and is hereinafter referred to as a single action drive. The first embodiment  1001  also has offset cable clamp assemblies  1101 , and  1801 . 
     The second cable tensioning apparatus embodiment  2001  is shown in  FIG. 24  through  FIG. 44 . This second apparatus  2001  is again single action, but with centrally aligned located cable clamp assemblies  2101 , and  2801 . 
     The third cable tensioning apparatus  3001  is shown in  FIG. 52  through  FIG. 67 . This third apparatus  3001  is actuated by the depression of the lever  3501  in conjunction with the handle  3401  causing handle shifts or strokes and is hereinafter referred to as a double action drive. The third apparatus  3001  also has offset cable clamp assemblies  3101 , and  3801 . 
     The fourth cable tensioning apparatus embodiment  4001  is shown in  FIG. 68  through  FIG. 83 . This fourth embodiment  4001  is again single action, but again with offset cable clamp assemblies  4101 , and  4801 . The fourth embodiment  4001  also has a centrally located bearing  4313  made of polyaryletheretherketone (hereinafter PEEK), as will be described further hereinafter. In addition, the fourth apparatus  4001  has an alternative distal cable clamp assembly  4801  that is configured to allow for access to otherwise inaccessible surgical sites. It is contemplated that the single and double action drive mechanisms can be interchanged as well as a variety of offset and centrally located cable clamp assemblies. 
     Ergonomic Design and Operation 
     The cable tensioning apparatuses  1001 ,  2001 ,  3001  and  4001  have ergonomically designed levers  1501 ,  2501 ,  3501  and  4501  and handles  1401 ,  2401 ,  3401  and  4401  to assist the typically gloved hand of the surgeon. The handle/lever combination allows for application of significant tensile force to the surgical cable  12  with direct visual and tactile feedback to the operator as to the progress of the tensioning. For example, the handle/lever combination in the first embodiment provides easy to grip surfaces  1403  and  1503 , shown in  FIG. 7 , for reliable operation of the device when the apparatus  1001  is inevitably soiled by biologic fluids. The ergonomic design is a significant improvement in cable tensioning tools that are operated with slick gloved hands under the stress of surgery. Alternatively, the handle gripping surface  1403  and lever gripping surface  1503  are knurled for any of the embodiments. The cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  is alternatively provided with other surface treatments to improve the grip of the apparatus. 
     The pistol grip tensioning apparatus  1001 ,  2001 ,  3001  and  4001  also has ergonomic operation as well. The operation for the first embodiment of the cable tensioning apparatus  1001  is shown in  FIGS. 1 through 3 . As shown in  FIG. 1  for the first cable tensioning apparatus  1001  embodiment, the cable tensioning apparatus  1001  operates by inserting a surgical cable  12  into the cable entrance  1825  of the distal cable clamp assembly  1801  and passing the cable  12  through to the proximal cable clamp assembly  1101  and out the cable exit  1173  with the clamp assemblies  1801  and  1101  in the unsecured or unlocked configuration in the initial condition as shown. 
     Only the portions of the cable  12  within the passages of the distal and proximal cable clamp assemblies  1801  and  1101  are hidden from view when offset cable clamp assemblies are used. The cable  12  is visible from the distal clamp cable exit  1827  to the proximal clamp cable entrance  1175 . The housing member  1301 , containing the drive rod  1201  located within, hides the view of the rod  1201 . 
     As shown in  FIG. 2 , the proximal cable clamp assembly  1101  is then locked and the lever  1501  is repeatedly depressed in direction E by the operator to tension the cable  12 . The operator depresses the lever  1501  until the tension indicator  1701  indicates the desired tension has been reached or until the drive rod  1201  is fully rearwardly extended whereby the tensioning process is repeated. The fully extended condition is shown in  FIG. 2  whereby the drive rod  1201  has reached its maximum rearwardly extended distance and has become partially visible. 
     As shown in  FIG. 3 , the process is repeated first by resetting the drive rod  1201  by depressing the distal clamp lever  1803  of the distal cable clamp assembly  1801  in direction F to lock the cable  12 , unlocking the proximal clamp assembly  1101  by depressing the lever  1160  in direction G, and depressing the release lever  1673  in direction H to activate the release mechanism  1671  to reset the drive rod  1201 . The pistol grip tensioning apparatus  1001  is finally reset to draw more cable  12  by locking the proximal clamp assembly  1101  by moving the lever  1160  in direction C, and then moving the distal clamp lever  1803  in direction I as shown again in  FIG. 3 . The process of tensioning then can be repeated as shown in  FIG. 1 through 2  to draw another length of cable  12 . 
     The operation of the second embodiment of the pistol grip tensioning apparatus  2001  is nearly identical to the operation of the first embodiment  1001  and is shown in  FIGS. 24 through 26 . As shown in  FIG. 24  for the second cable tensioning apparatus  2001  embodiment, the pistol grip tensioning apparatus  2001  operates by inserting a surgical cable  12  into the cable entrance  2825  of the distal cable clamp assembly  2801  and passing the cable through to the proximal cable clamp assembly  2101  and rearwardly out of the cable exit  2173  with the clamp assemblies  2101  and  2801  in the unsecured or unlocked configuration as shown. 
     Most of the cable  12  is within the pistol grip tensioning apparatus  2001  and hidden from view. The cable  12  is only visible from the distal clamp assembly  2801  cable entrance  2825  to the incision and any excess cable  12  exiting the proximal clamp cable exit  2173 . As shown in  FIG. 25 , the proximal cable clamp assembly  2101  is then locked and the lever  2501  is repeatedly depressed in direction E by the operator to tension the cable  12 . The operator depresses the lever  2501  until the tension indicator  2701  indicates the desired tension has been reached or until the drive rod  2201  is fully rearwardly extended whereby the tensioning process is repeated. 
     As shown in  FIG. 26 , the process is repeated first by resetting the drive rod  2201  by depressing the distal clamp lever  2803  of the distal cable clamp assembly  2801  in direction F to lock the cable  12 , unlocking the proximal clamp assembly  2101  by depressing the cam lever  2160  in direction G, and depressing the release lever  2673  in direction H to reset the drive rod  2201 . The entire pistol grip tensioning apparatus  2001  is finally reset to draw more cable  12  by locking the proximal clamp assembly  2101  by moving the cam lever  2160  in direction C, and then moving the distal clamp lever  2803  in direction I as shown in  FIG. 26 . The process of tensioning then can be repeated as shown in  FIG. 24 through 25  to draw another length of cable  12 . 
     The operation of the third embodiment of the pistol grip tensioning apparatus  3001  is nearly identical to the operation of the first embodiment  1001  with two exceptions and is shown in  FIG. 52  and  FIG. 53 . However, the third embodiment of the pistol grip tensioning apparatus  3001  requires the additional step of depressing both the handle  3401  and lever  3501  simultaneously. The third embodiment of the pistol grip tensioning apparatus  3001  also requires reading the tension indication mechanism  3701  from the sides of the device or apparatus rather than from the top as in the first embodiment. 
     The operation of the fourth embodiment of the pistol grip tensioning apparatus  4001  is nearly identical to the operation of the first embodiment  1001  with two relevant exceptions as shown in  FIG. 68  through  FIG. 70 . In the fourth pistol grip tensioning apparatus  4001 , the surgical connector or crimp  10  does not seat or mechanically interlock with the cable entrance  4825 . The operation of the distal and proximal clamp assemblies  4101 ,  4801  is simplified because rotation of the lever  4803  and  4160  in the distal direction B locks the surgical cable  12  and rotation in the proximal direction A unlocks the cable  12 . All of the various embodiments of the pistol grip tensioning apparatus  1001 ,  2001 ,  3001  and  4001  can be operated without a surgical connector  10  or crimp depending on surgeon&#39;s preference. 
     The cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  can also have a variety distal cable clamp assemblies  1801 ,  2801 ,  3801 , and  4801  which correspond to various styles or types of surgical connectors  10  or crimps. The various distal cable clamp assemblies  1801 ,  2801 ,  3801 , and  4801  have a modular configuration tube so that they can connect and disconnect from the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  to allow a variety of distal cable clamp assemblies  1801 ,  2801 ,  3801 , and  4801  to be used. 
     Typically in most surgeries, the cable  12  is passed around the bone to be cerclaged, i.e. the patient&#39;s bone is wrapped with supporting cable. The cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  will be provided to the surgeon and the unattached end of the surgical cable will be passed through the clamp assemblies as previously described. Typically, the surgical connector  10  is pulled or positioned on the distal cable clamp assemblies  1801 ,  2801 ,  3801 , and  4801  which is in turn in contact with an implant or the patient&#39;s bone. However, the distal cable clamp assembly  1801 ,  2801 ,  3801 , and  4801  can be used with or without a surgical connector  10  to bring the clamp assembly  1801 ,  2801 ,  3801 , and  4801  directly in contact with the bone. 
     In most surgeries, a single cycle of the drive rod  1201 ,  2201 ,  3201 , and  4201  displacement to the fully rearwardly extended will provide enough travel or displacement to fully draw the cable  12  to the desired tension. Once the cable  12  is positioned, then the cable  12  will be locked in place by turning a set screw, a cam lock, or crimped on either the surgical connector  10  or on the implant itself. The release lever  1673 ,  2673 ,  3673 , and  4673  will then be depressed to reduce tension on the cable  12  to allow the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  to be removed. The cable  12  will be trimmed or cut in place and the patient will be closed. 
     However, multiple surgical cables can be tightened with even a single cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  in an iterative fashion because often when the first cable is tightened another adjacent cable will then loosen as the tensile load is taken up by the adjacent cable. The pistol grip tensioning apparatus  1001 ,  2001 ,  3001  and  4001  can work iteratively by securing or locking a distal cable clamp assembly  1801 ,  2801 ,  3801 , and  4801  by rotating the clamp lever ( 1803 ,  2803 ,  3803 ,  4803 ) and then disconnecting to the tensioning apparatus  1001 ,  2001 ,  3001  and  4001  from the distal cable clamp assembly  1801 ,  2801 ,  3801 , and  4801 . Typically, the release lever  1673 ,  2673 ,  3673 , and  4673  must be first depressed as well as the proximal cable clamp assemblies&#39; levers  1160 ,  2160 ,  3160  and  4160 . 
     Another distal cable clamp assembly  1801 ,  2801 ,  3801 , and  4801  will then be attached or connected to the tensioning apparatus  1001 ,  2001 ,  3001  and  4001  with another cable  12  to be tensioned as previously described. If a cable  12  and distal cable clamp assembly  1801 ,  2801 ,  3801 , and  4801  needs to be retightened then the tensioning apparatus  1001 ,  2001 ,  3001  and  4001  is reattached and more tension is applied as previously described. Each individual cable  12  is then secured with a set screw, cam or crimp and trimmed as previously described. 
     The operation of the cable tensioning embodiments are surprisingly intuitive because the operator can see and feel how the device is operating since the surgeon can see or feel where the cable  12  is located during the cable tensioning process. For example, in apparatus  1001 , housing ducts  1303 , shown in  FIG. 4 , allow for visual inspection of the drive mechanism  1601  for mechanical error detection and correction of the friction drive mechanism  1601 . The state of the proximal and distal clamp assemblies  1101  and  1801  in the locked or unlocked configuration, the degree of extension of the drive rod  1201 , and even the amount of tension on the cable  12  can be ascertained by touch alone when the vision of the surgeon is obscured by blood or tissue of the patient. The ability to see or feel the components and process of tensioning creates tactile and visual feedback that makes the use of the apparatus  1001  easy and intuitive. Almost no training is required by medical personnel unlike complex cable tensioning systems which are difficult to use due to the hidden operation of key components. 
     The intuitive nature of the operation of the fourth cable tensioning apparatus  4001  is further improved by the particular design configuration and arrangement of the cable clamp assemblies  4101 ,  4801 . As shown in  FIG. 68 , the proximal and distal cable clamp assemblies  4101 ,  4801  are arranged to unlock by moving the levers  4160 ,  4803  in the proximal direction A to allow surgical cable  12  to be fed in the rearward or proximal direction A. This way the levers  4160 ,  4803  only need to rotate in one direction to unsecure the surgical cable  12  to allow ease of use and aid in understanding operation for the operator. Conversely, the proximal and distal cable clamp assemblies  4101 ,  4801  are locked by moving the levers in the distal direction B to secure or lock the clamp assemblies  4101 ,  4801 . In addition, all of the levers  1160 ,  1803 ,  2160 ,  2803 ,  3160 ,  3803 ,  4160 ,  4803  for the embodiments  1001 ,  2001 ,  3001 ,  4001  have directions of use of the levers laser etched on to the housing (not shown) of the distal and proximal cable clamp assemblies to indicate which direction to lock and unlock the clamp assemblies. 
     The cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  uses a pistol grip type interface by the user of the apparatus. The depression of the large pistol grip type lever/handle combination allows a large amount of cable  12  to be drawn through the apparatus and still provide sufficient tensile force. The cable tensioning process can easily be repeated through simple operation of the distal and proximal cable clamp assemblies. Other devices do not use a pistol style grip mechanism to tension cable, but rather use pistol grips to crimp sleeves onto cables or wires on cables. 
     Cleanability 
     The cleanability of the cable tensioning apparatus  1001 ,  2001 ,  3001  or  4001  reduces the risk of infection to patients due to cross contamination of biologic materials from patient to patient after repeated uses of the cable tensioning apparatus  1001 ,  2001 ,  3001 , and  4001 . The risk of infection is minimized because of the ease of partial disassembly or ease of access of internal components, for example through ducts  1303  and  1307  or flow ports throughout the device to allow high pressure flushing of the cable tensioning apparatus. The cleanability was unpredicted in the design of the cable tensioning apparatus  1001 ,  2001 , and  3001  because the combination of ducts  1303  and  1307 , the simple construction, and ease of disassembly provided unexpected hygienic results. The pistol grip tensioning apparatus  1001 , and  2001  are unique because the apparatus  1001 , and  2001  allows partial disassembly for cleaning. Note that most medical instruments are designed not to be disassembled because untrained medical personnel, i.e. OR techs, are not able to effectively reassemble complex medical instruments. The ability to partially disassemble the apparatus  1001  and  2001  provides the optimum balance of the need for hygiene against the need to simplify sterilization procedures for untrained medical personnel. 
     Ease of disassembly can be best seen in  FIG. 4  and  FIG. 27  which show how a majority of interior components can be directly accessed upon disassembly. As shown in  FIGS. 4 ,  5 ,  27  and  28 , a bayonet connection allows for the disassembly and reassembly of the cable tensioning apparatus  1001  and  2001  for the first and second embodiments only. (Please note that the second embodiment components are hereinafter distinguished from the first embodiment by the text within the parenthesis.) The bayonet connection and components for the first embodiment of the cable tensioning apparatus  1001  shown in  FIGS. 4 and 5  are identical for the second embodiment of the apparatus  2001  shown in  FIGS. 27 and 28 . 
     The cable tensioning apparatus  1001  (or  2001 ) is disassembled as shown in  FIG. 4  (or  27 ) for cleaning and sterilization of the apparatus prior to surgery. To disassemble the core components, the housing structure  1305  (or  2305 ) is rotated relative to the indicator structure  1703  (or  2703 ) to disengage the bayonet connection (described in detail subsequently) and disconnect the housing  1301  (or  2301 ) from the indicator  1701  (or  2701 ). The drive rod reset spring  1605  (or  2605 ), the calibrated compression spring  1709  (or  2709 ), and the interior of the indicator structure  1703  (or  2703 ) then becomes accessible for cleaning upon partial disassembly as shown in  FIG. 4  (or  27 ). Similarly, the rack portion  1205  (or  2205 ) of the drive rod  1201  (or  2201 ) can be exposed for cleaning upon disassembly. The cylindrical portion  1203  (or  2203 ) of the drive rod  1201  (or  2201 ) is also accessible upon depression of the release lever  1673  (or  2673 ). 
     The bayonet connection is formed from the bayonet lugs  1309  (or  2309 ) on the housing structure  1305  (or  2305 ) and the bayonet recess on the indicator structure  1703  (or  2703 ) as shown in  FIGS. 5 and 28 . The bayonet lugs  1309  (or  2309 ) are mounted and project from the housing structure  1305  (or  2305 ) at points 180 degrees apart on the inner walls of the cylindrical housing structure  1305  (or  2305 ). The bayonet lugs  1309  (or  2309 ) provide a male mechanical connection to the corresponding bayonet recesses  1713  (or  2713 ). The L-shaped bayonet recesses between cleaning ports  1713  (or  2713 ) are machined from the housing structure  1305  (or  2305 ) at points 180 degrees apart on the outer walls of the cylindrical indicator structure  1703  (or  2703 ). 
     To disassemble the cable tensioning apparatus  1001  (or  2001 ), the operator compresses the housing structure  1305  (or  2305 ) against the indicator structure  1703  (or  2703 ) shown as direction L in  FIG. 5  (or  FIG. 28 ). The operator then rotates the indicator structure  1703  (or  2703 ) in direction O relative to the housing structure  1305  (or  2305 ), and then extends or separates the housing structure  1305  (or  2305 ) from the indicator structure  1703  (or  2703 ) shown as direction M in  FIG. 5  (or  FIG. 28 ) to disengage the bayonet connection and disassemble the components. 
     To assemble or to reassemble the bayonet connection, the operator inserts the indicator structure  1703  (or  2703 ) into the housing structure  1305  (or  2305 ) in direction L as shown in  FIG. 5  (or  FIG. 28 ) so that the bayonet lugs  1309  (or  2309 ) mesh with the bayonet recesses  1713  (or  2713 ). The operator then rotates the indicator structure  1703  (or  2703 ) in direction P until the indicator structure  1703  (or  2703 ) and the housing structure  1305  (or  2305 ) lock together. 
     The bayonet connection of the cable tensioning apparatus  1001  and  2001  allows access for cleaning which increases the effectiveness of the autoclave sterilization process by preventing insulation to the steam heat. The bayonet connection and ability to partially disassemble the apparatus  1001  (or  2001 ) also improves hygiene and maintenance of the device. 
     All of the cables tensioning apparatuses  1001 ,  2001 ,  3001 , and  4001  have the modular distal cable clamp assemblies  1801 ,  2801 ,  3801 , and  4801  and that are able to be easily disassembled due to the modular construction shown in  FIGS. 4 ,  27  and  71 . The distal cable clamp assembly  1801  (or  2801 ) can be separated from the indicator structure  1703  (or  2703 ) to allow cleaning of the tubular extension  1821  (or  2821 ) surfaces shown in  FIGS. 18 ,  19 ,  41  and  42 . In addition, access is also given to the indicator passage  1711  (or  2711 ) via the hexagonal socket  1705  (or  2705 ) for jet washing of the indicator passage  1711  (or  2711 ) with cleaning solutions as shown in  FIGS. 4 and 27 . The modular feature of the distal cable clamp assembly  3801  of the third apparatus  3001  of the cable tensioning apparatus  3001  is identical to the first apparatus  1001  and is not repeated for brevity. 
     The cable tensioning apparatuses  1001 ,  2001 ,  3001  and  4001  have ducts  1303 ,  1307 ,  2303 ,  2307 ,  4303 ,  4307 ,  4717  or flow ports so that interior components easily are flushed with cleaning solution to remove tissue or biologic materials best shown in  FIGS. 4 , and  27 . For example, the proximal housing ducts  1303  (or  2303 ) are provided in the housing member  1301  (or  2301 ) to allow access to the drive rod reset spring  1605  (or  2605 ) and other components of the drive mechanism  1601  (or  2601 ) for jet washing and cleaning. The ducts  1303  (or  2303 ) are located intermittently throughout the housing member  1301  (or  2301 ) at strategic points to allow access to internal components at irregular intervals along the apparatus  1001  and yet not interfere with mechanical and structural functions. As shown in  FIGS. 4 ,  5 ,  27  and  28 , the distal housing ducts  1307  (or  2307 ) provide access to the drive rod reset spring  1605  (or  2605 ) and to the cylindrical portion  1203  (or  2203 ) of the drive rod  1201  (or  2201 ) upon depression of the release lever  1673  (or  2673 ). The proximal and distal ducts  1303  and  1307  (or  2303  and  2307 ) again allow for jet washing of the drive mechanism  1601  (or  2601 ) with cleaning solutions to flush out tissue or biologic materials. 
     The ducts  3303  and  3307  or flow ports feature of the third embodiment  3001  of the cable tensioning apparatus  3001  are more limited. As shown in  FIGS. 54 and 55 , the distal housing duct  3307  of the third embodiment  3001  provides access for flushing of the calibrated compression spring  3709 . The housing duct  3307  allows cleaning solution to be flushed straight into the housing structure  3305 , through the coils of the compression spring  3709 , and continue out of the housing structure  3305  as shown in  FIGS. 62 and 63 . 
     The ducts  4303 ,  4307 ,  4717  or flow ports feature of the fourth apparatus  4001  of the cable tensioning apparatus  4001  are more expansive. As shown in  FIGS. 70 and 72 , the duct  4303  has been retained from the first two embodiments and the distal housing duct  4307  has been enlarged. In addition, indicator ducts  4717  have been added in the fourth embodiment  4001  because the fourth apparatus  4001  does not allow for disassembly. 
     Hygiene is improved by all of the aforementioned cleanability design features because tissue or biologic materials should be removed because prions or slow viruses within tissue or biologic materials cannot be sterilized by most conventional sterilization techniques or processes. Certain infectious agents, such as prions or other slow viruses, are difficult to neutralize with standard sterilization techniques such as autoclaves and can carry the fatal Creutzfeldt-Jakob disease (CJD). The risk of infection from tissue or bio-mater creates many attendant costs in mitigating the risk of infection, i.e. the tracking of patients and subsequent risk of liability from an infection. 
     Universal Applicability 
     A key feature of the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  is its near universal applicability with any type of surgical cable. The surgical cable  12  shown in  FIG. 46  though  FIG. 51  is hereinafter defined to be any type of surgical cable or wire that is operable within the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001 . For example, surgical cable  12  consisting of braided stainless steel, cobalt chrome, or titanium can be used such as described in U.S. Pat. No. 6,605,091 with Ser. No. 09/608,536 filed Jun. 30, 2000 and entitled “Surgical Cable Assembly And Method” which is incorporated herein by reference in its entirety. Alternatively, the surgical cable  12  can be made from other biocompatible materials such as synthetic polymer fibers such as polyglycolic acid (P.G.A.) or polydioxanone (PDS) in monofilament or braided configurations. Alternatively, the ultra-high molecular weight polyethylene (UHMWPE) fiber sold under the name SecureStrand described in U.S. Pat. No. 5,456,722 with Ser. No. 100,458 filed Jul. 30, 1993 and entitled “Load Bearing Polymeric Cable” could also be used and is incorporated herein by reference in its entirety. However, even gut sutures could possibly be used. 
     Similarly, the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  has its near universal operability with any type of crimp or surgical connector  10 . The surgical connector  10  shown in  FIG. 46  though  FIG. 51  is only one example of many types of crimps or surgical connectors that can be used with the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001 . The crimp or surgical connector  10  shown in  FIG. 46  though  FIG. 51  is described in U.S. Pat. No. 5,415,658 with application Ser. No. 167,542 filed Dec. 14, 1993 and entitled “Surgical Cable Loop Connector” which is incorporated herein by reference in its entirety. 
     However, almost any kind of crimps or surgical connector  10  can be used with the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001 . Surgical connector  10  is hereinafter defined to be any type of surgical connector or crimp that is operable with pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001 . For example, the crimp or surgical connector (not shown) described in U.S. Pat. No. 6,605,091 B1 with application Ser. No. 09/608,536 filed Jun. 30, 2000 and entitled “Surgical Cable Assembly And Method,” can be used and is incorporated herein by reference in its entirety. In addition, the crimp or surgical connector described in U.S. Pat. No. 5,649,927 (not shown) with application Ser. No. 534,783 filed Sep. 27, 1995 and entitled “Cable Crimp System” can be used and is also incorporated herein by reference in its entirety. Also, the crimp described in U.S. Pat. No. 5,741,260 with application Ser. No. 803,503 filed Feb. 20, 1997 and entitled “Cable System For Bone Securance” can be used and is incorporated herein by reference in its entirety. Alternatively, almost any type of crimp or surgical connector for cable or wire can be used with the pistol grip tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  because of the cable pensioner&#39;s near universal applicability. 
     Offset Cable Passage 
     The offset cable race  1003 ,  3003 , and  4003  is another feature which improves cleanability but also the rapidity of operation for the first, third and fourth embodiments of the cable tensioning apparatus  1001 ,  3001  and  4001 . The offset cable race  1003 ,  3003 , and  4003  for the apparatus  1001 ,  3001  and  4001  is generally more cleanable because most of the surgical cable  12  passes externally with open access for cleaning. Operation of the apparatus  1001 ,  3001  and  4001  is generally more rapid because surgical cable  12  can be rapidly “pre-tensioned” to eliminate any slack in the cable  12  to greatly increase the pace of the surgery itself. 
       FIG. 6  helps show an example of the enhanced cleanability of the complete offset cable race  1003  shown as the phantom line. The surgical cable  12  is inserted within the offset cable race  1003  to tension the cable  12 . As shown in  FIG. 6 , only the portions of the cable  12  that run within the proximal cable clamp assembly  1101  and the distal cable clamp assembly  1801  require flushing of internal components for sterilization. The short distance of the proximal cable clamp passage  1112  within the proximal cable clamp assembly  1101  allows jets of cleaning solution to maintain high pressure because of the elimination of friction loss from long distances as shown in  FIG. 12 . The low friction losses from the short passage  1112  also allow high flow volumes of cleaning solution with in the passage  1112 . 
     Similarly, as shown in  FIG. 18 , the short distal cable clamp passage  1805  in the distal cable clamp assembly  1801  allows high pressure washing both through the passage  1805  but also through the cam lever access port  1829 . Finally, the housing structure  1305  and the indicator structure  1703  protect the bulk of the internal workings of the cable tensioning apparatus  1001  by shielding internal components from contamination due to debris from biologic materials adhering to the surgical cable  12 . 
       FIG. 6  shows the enhanced rapidity of “pre-tensioning” of the offset cable race  1003  shown as the phantom line. As shown in  FIG. 6 , the proximal and distal cable clamp assemblies  1101  and  1801  are shown in the unlocked position to allow surgical cable  12  to pass through the clamp assemblies  1101  and  1801  along the dashed phantom lines. A significant amount of excess cable  12  or slack is present when passing cable  12  into position within the cable tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  as shown in  FIG. 45 . The surgeon can remove excess cable  12  or slack when the surgical cable  12  is not yet under significant tension within the apparatus  1001 ,  2001 ,  3001 , and  4001 . The surgeon can simply manually pull the cable  12  for the portions of the cable  12  that are not within the clamp assemblies  1101  and  1801  until the cable  12  is in the desired position and thus “pre-tension” the apparatus. 
     An example of utilizing cable  12  with a trochanter connector  300  with an implant is illustrated in  FIG. 45 . As shown in  FIG. 45 , a significant amount of excess cable  12  or slack can be present in the surgical cable  12  when used with an implant, for example, a trochanter connector  300  used to repair a femur  150  or upper leg bone. The advantage of “pre-tensioning” the surgical cable  12  is illustrated in  FIG. 45  because of the long loops of cable  12 . As shown in  FIG. 45 , the trochanter connector  300  requires that the cable  12  to be looped several times around the femur  150  creating a significant amount of excess cable  12  or slack. Little force is required to eliminate the excess slack when the cable  12  is positioned around the femur  150 . The cable tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  takes advantage of this circumstance where little force is required to eliminate slack by providing the offset clamp assemblies allow the rapid manual “pre-tensioning” of the cable  12 . 
     The surgical procedure which utilizes the trochanter connector  300  to secure and support the femur  150  is described in further detail in U.S. Pat. No. 7,207,993 B1 with Ser. No. 09/775,891 filed Feb. 2, 2001 and entitled “Apparatus and Method for Repairing the Femur” which is incorporated by reference in its entirety herein. It should be noted that surgical cable  12  is used in many surgical procedures to repair bones such as the radius or tibia of the arm in conjunction with plates. The aforementioned U.S. Pat. No. 7,207,993 B1 should not be construed to limit the number of surgical applications of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001 . The “Apparatus and Method for Repairing the Femur” is merely used to illustrate as an example a procedure using the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001 . 
       FIG. 7  shows the enhanced rapidity of the offset cable race  1003  shown as the phantom line. As shown in  FIG. 7 , the proximal cable clamp assembly  1101  is shown in the locked position to lock the surgical cable  12  to the proximal cable clamp assembly  1101 . As the drive rod  1201  is driven in the rearward or proximal direction A by depression or pulling of the lever  1501  in direction E, the surgical cable  12  to passes through the distal cable clamp assembly  1801 . As the cable  12  passes through the offset distal clamp assembly  1801 , the operator can adjust the cable  12  anywhere along the phantom line in the event of inadvertent mechanical interference from the distal cable clamp assembly  1801  or the housing structure  1305 . The drive rod  1201  is driven in the proximal direction A until the rod  1201  is fully rearwardly extended as shown in  FIG. 7 . 
       FIG. 8  also shows the improved visualization of the cable tensioning process provided by the offset clamp assemblies  1101  and  1801  during the resetting of the tensioning process. The proximal clamp assembly  1101  in the unsecured or unlocked configuration and distal cable clamp assembly  1801  in the secured or locked configuration allow the drive rod  1201  to be reset from the extended position to the initial position as shown in  FIG. 8 . During the resetting of the drive rod  1201 , a significant amount of excess cable  12  or slack can develop between the cable entrance  1175  and the cable exit  1827  depending upon the amount of friction created in the proximal cable clamp passage  1112  as the rod  1201  travels or translates back in the forward or distal direction B. The surgeon can visually see and tactilely feel the cable  12  position during the resetting process to detect errors or slack as a result of inadvertent mechanical interference. Any such errors, such as snags or “hang ups”, can often be readily cleared by simple manual adjustments of the operator. 
     However, the advantages of the offset cable clamp assemblies  1101 ,  1801 ,  3101 ,  3801 ,  4101 , and  4801  were only achieved with mechanical innovations to accommodate the improved approach of the offset clamp assembly design. The superior operational results were not predictable because it was not expected that the drive mechanism  1601 ,  2601 , and  4601  would function under the high bending moment created by offset distance K of the offset cable clamp assemblies  1101 ,  1801 ,  4101 , and  4801  and the tensile force of the surgical cable  12 . The offset distance K shown in  FIGS. 9 ,  10 ,  11 ,  56 ,  57 ,  75 ,  76 , and  77  creates a mechanical bending moment within the cable tensioning apparatus  1001 ,  3001  and  4001  as a result of the tensile force exerted on the surgical cable  12 . The bending moment creates friction in the shifting between the housing structure  1305 ,  3305 ,  4305  and the indicator structure  1703 ,  3703 ,  4703  as shown in  FIGS. 16 ,  59  and  80 . The friction in turn creates the potential for galling or welding of the high points of the metal which cause stoppage or ceasing between the housing structure  1305 , (or  3305 ,  4305 ) and the indicator structure  1703 , (or  3703 ,  4703 ). The friction also creates the potential of friction induced mechanical interference or mechanical stoppage of the indicator mechanism  1701 ,  3701 ,  4701  because the high normal forces may cause ceasing or mechanical interference thereby preventing the indicator structure  1703 ,  3703 ,  4703  from shifting within the housing structure  1305 ,  3305 ,  4305 . To prevent the potential stoppage of the mechanical operation of the indicator mechanism  1701 , (or  3701 ,  4701 ) the indicator structure  1703 , (or  3703 ,  4703 ) is made from gall-resistant stainless steel. 
     The pistol grip cable tensioning apparatus  1001 ,  3001  and  4001  takes advantage of metallurgical innovations by utilizing gall-resistant stainless steels for proper functioning which were not widely commercially available previously. Commercially available gall-resistant metals such as the super alloy Nitronic 60 or Gall-Tough are utilized in the fabrication of the indicator structure  1703 ,  3703 , and  4703 . Gall-resistant stainless steels, such as Nitronic 60 or Gall-Tough, prevents the potential of galling or cold welding created by the high loading conditions caused by the bending moment created by the offset cable passage  1112 ,  3112 ,  4112  on the components of the cable tensioning apparatus  1001 ,  3001 ,  4001 . In the one embodiment, gall-resistant stainless steels, such as Nitronic 60 or Gall-Tough, are used because gall-resistant steels outperform most other stainless steels in corrosion and pitting resistance. Sufficient reliability of mechanical operation is maintained by the usage of gall-resistant stainless steels, such as Nitronic 60 or Gall-Tough, with the offset race  1003 ,  3003 ,  4003  design. Alternatively, Nitronic 60 or Gall-Tough can also be utilized in the rear insert  1315 ,  2315 ,  3315 ,  4315  of the housing member  1301 ,  2301 ,  3301 ,  4301  to further reduce galling or binding as shown in  FIG. 12 ,  FIG. 35 ,  FIG. 58 , and  FIG. 79 . 
     Another mode or means to limit galling or binding is through the utilization of polyaryletheretherketone (hereinafter PEEK) as a bearing material. As shown in  FIGS. 79 and 80 , the bearing  4313  in the form of a PEEK bushing is centrally located in the cable tensioning apparatus  4001 . The housing structure  4305  of the housing member  4301  holds the bearing  4313  in place with pins  4317  and lateral bore in the bearing  4313 . Alternatively, the bearing  4313  can be held in place with epoxy or other adhesives. The cylindrical portion  4203  of the drive rod  4201  shifts in the proximal and distal direction A and B. The drive rod  4201  has shiftable mechanical engagement because the bearing  4313  only allows the drive rod  4201  linear motion along central longitudinal axis of housing member  4301  since the bearing  4313  has a low coefficient of static and dynamic friction. 
     PEEK is an appropriate material to use as a bearing  4313  because PEEK has a low coefficient of friction with excellent resistance to mechanical wear. PEEK is also a biocompatible thermoplastic to mitigate any risk of wear debris potentially entering the patient. Finally, PEEK has high chemical resistance necessitated by sterilization of the instrument  1001 ,  2001 ,  3001 , and  4001 . Alternatively, the bearing  4313  could utilize Gall-Tough or Nitronic 60 to reduce galling. Yet another mode to limit binding is to extend the length of components and increase bearing surfaces as was done in the fourth embodiment  4001 . 
     The third and fourth embodiments of the cable tensioning apparatus  3001 ,  4001  have the same advantages of cleanability and rapidity through “pre-tensioning” as discussed above for the first embodiment  1001 . The offset cable race  3003 ,  4003  is shown as the phantom line in  FIGS. 54 and 73 . The short distance of the clamp passages  3112 ,  3805 ,  4112 ,  4805  shown in  FIGS. 56 and 75  allows efficient flushing of those passages. The housing and indicator structures  3305 ,  3703 ,  4305 , and  4703  also shield internal components of the apparatus  3001 ,  4001  from contamination. 
     Enhanced rapidity can be achieved by “pre-tensioning” cable  12  both between the clamp assemblies  3101 ,  3801  and  4101 ,  4801  and between the bones and connectors. The surgeon can still visually see and tactilely feel the cable  12  position during the resetting process to detect errors or slack as a result of inadvertent mechanical interference. 
     The only significant difference in operation between the first apparatus  1001  and the third apparatus  3001  is the requirement that both the handle  3401  and lever  3501  must be simultaneously squeezed while the cable clamp assemblies  3101  and  3801  are adjusted. The third embodiment  3001  does not have the ability of the first embodiment  1001  of being able to depress the lever  1501  and having the release mechanism preventing travel in the distal direction. 
     The improvements in the design approach of the offset cable race  1003 ,  3003 , and  4003  provided the functional improvements of rapidity of operation and cleanability. The increased rapidity of operation is multiplied by each cable  12  that is to be tensioned by the cable tensioning apparatus  1003 ,  3003 , and  4003 . The dramatic decrease in time in cable tensioning and corresponding decrease in time under anesthetic ultimately reduces complications and saves lives. The increased cleanability also saves lives because the risk of the fatal Creutzfeldt-Jakob disease (CJD) can be also dramatically reduced. The offset cable race  1003 ,  3003 , and  4003  provides one means of clamping surgical cable and centrally locating the cable race  2003  provides an alternative means. 
     Centrally Located Cable Passage 
     The centrally located cable race  2005  is a feature that improves the reliability of mechanical operation, and allows for greater tension loading of surgical cable  12 . The apparatus  2001  is generally more reliable in mechanical operation because the centrally mounted clamp assemblies  2101  and  2801  reduce the bending moment created by the tension in the cable  12  and thus reduces the risk of galling or mechanical interference. The apparatus  2001  can generally provide greater cable tension again because of the reduction of the large bending moment that allows the structural components to support a greater tension load. 
       FIG. 29 through 31  helps show the reason for the enhanced mechanical reliability. The centrally located cable race  2005  shows the external path of the surgical cable  12  by the dashed phantom line. The cable race  2005  runs into the distal clamp passage  2805  of the distal clamp assembly  2801 , through the indicator passage  2711  of the indicator structure  2703 , and then out the proximal clamp passage  2112  of the central portion of the housing structure  2305 . The tensioning of the cable  12  along the central longitudinal axis of the tool in the central portion of the cable tensioning apparatus  2001  coincident with the cable race  2005  reduces any bending moment that exists in the offset race  1003 ,  3003 ,  4003  of the other embodiments  1001 ,  3001 ,  4001 . 
     The bending moment can best be seen by comparing the bending moment created by offset distance K in  FIG. 9  with the lack of an offset distance shown in FIG.  32 . As shown in  FIG. 33 , when the cable tensioning apparatus  2001  has locked the cable  12  (not shown) in the proximal clamp assembly  2101  and applied tension to the cable  12 , the cable  12  is then under a tensile load with corresponding tensile stress in the cable  12 . The drive rod  2201 , indicator structure  2703 , and distal clamp assembly  2801  are then only under a substantially equal compressive load and stress. The substantial elimination of the offset distance K shown in  FIG. 10  substantially eliminates the additional bending stress present in the drive rod  1201 , the indicator structure  1703 , and distal clamp assembly  1801  present in the other embodiments  1001 ,  3001 , and  4001  during tensile loading. 
     The substantial elimination of a bending moment also substantially eliminates additional friction forces primarily between the housing  2301  and indicator structure  2703  that may interfere with the mechanical operative reliability of the apparatus  1001 ,  3001 , and  4001 . The substantial elimination of a bending stress eliminates additional elastic deformation of the apparatus  2001  which can cause undesired mechanical interference when parts are shifted out of position from one another due to the bending stress. Because the bending stress is eliminated when the clamp assemblies are mounted centrally, the apparatus  2001  has the ability to absorb more stress and thus the ability to apply a greater force to the surgical cable  12 . The ability to apply greater force by the apparatus  2001  translates into the ability to apply greater tension to the surgical cable  12 . The need for applying high cable tension would occur, for example, during arthrodesis where two plates are connected together with wire or cables. 
     The central cable race  2005  still allows some “pre-tensioning” of the surgical cable  12  because slack in the cable  12  can be removed manually from the race  2005  out of the unlocked proximal clamp assembly  2101  shown as the phantom line in  FIG. 29 . As shown in  FIG. 30 , much of the surgical cable  12  is not visible during the tensioning process. However, the condition of the proximal and distal clamp assemblies  2101  and  2801  can readily be determined visually or tactilely because of the positive locking nature of the clamp cam surfaces and cam  2164  and  2807  which cause the clamp assemblies  2101  and  2801  to rest in either the locked or unlocked configuration. For example, the secure or locked configuration of the distal clamp assembly  2801  is readily visible in  FIG. 31 . 
     The internal structural components of the central cable race  2005  and internal passages allow for the passing of a cable  12  into and out of the cable tensioning apparatus  2001 . The cable  12  enters the cable entrance  2825  at the distal end and passes through the distal clamp passage  2805  as shown in  FIG. 32 . (The exact details of the distal clamp assembly  2801  are described in more detail subsequently.) The surgical cable  12  then enters the indicator passage  2711  which abuts and is in line with the clamp passage  2805 . 
     When the cable  12  is manually passed through the cable tensioning apparatus  2001  in the initial condition, the drive rod passage  2209  of the distal portion  2211  of the drive rod  2201  abuts and is in line with the indicator passage  2711  as shown in  FIG. 39 . As shown in  FIG. 32 , the distal portion  2211  of the drive rod  2201  has a concave, funnel shape to direct the surgical cable  12  into the throughbore of the drive rod  2201 . Alternatively, the drive rod  2201  could have arcuate, parabolic, or other shapes to direct the surgical cable  12  into the drive rod  2201 . 
     As shown in  FIG. 39 , the drive rod reset spring  2605  is held in place by the distal tip portion  2211  which is laser welded on to the drive rod  2201 . The rod reset spring  2605  has its smaller diameter coils arranged in a nested arrangement with the larger diameter coils of the calibrated compression spring  2709 . Normally, the surgical cable  12  will not be fed into the distal portion  2211  of the drive rod  2201  when the cable tensioning apparatus  2001  is in the extended condition as shown in  FIG. 40  thus making the possibility of a malfunction while feeding of surgical cable  12  remote. However, the funnel shape of the distal portion  2211  mitigates this possibility of malfunction while feeding surgical cable  12 . 
     The cable  12  will pass through the drive rod passage  2209  and continue to be fed through the proximal clamp passage  2112  as shown in  FIG. 32 . The surgical cable  12  can be locked into position shown in  FIG. 33  (described in detail subsequently) after exiting the cable exit  2173  as in  FIG. 32 . Note that the internal structural components of the first, second, and fourth apparatuses  1001 ,  2001  and  4001  are substantially the same so that components of the first apparatus  1001  can be used interchangeably with the components of the second apparatus  2001 . Therefore, the housing member  2301 , handle  2401 , lever  2501 , and indicator  2701  of the second apparatus  2001  are the same as the first apparatus  1001  for interoperability. 
     Proximal Cable Clamp Assembly 
     The proximal cable clamp assembly  1101  does not damage surgical cable  12  by compression or shear forces on the surgical cable  12  due to the design herein. Any damage to the cable  12  could cause the potential of failure of the cable  12  and injury to the patient. The proximal cable clamp assembly  1101  avoids damage to the cable  12  by applying normal forces distributed over a large surface and thereby reducing the amount of force applied to any one local section of the surgical cable  12 . 
     The proximal cable clamp assembly  1101  is shown in an unlocked configuration in  FIG. 12  and in a secured or locked configuration in  FIG. 13 . As shown in  FIG. 12  and  FIG. 13 , the proximal cable clamp assembly  1101  is comprised of a generally cylindrical housing, and a generally U-shaped saddle  1140  movably mounted thereon. The saddle  1140  is disposed within a saddle guide  1120  formed in the housing. A cam lever  1160  pivotably cooperates with saddle  1140  by way of a pivot pin  1150  retained within holes formed in the legs of the saddle  1140 . Cam lever  1160  includes a cam surface  1164  which engages a cam support surface  1122  provided on the housing. As cam lever  1160  is pivoted with respect to saddle  1140  in a clamping direction C, indicated by arrow C, saddle  1140  is moved in a saddle locking direction D to apply a clamping force to the cable (not shown) as will be described below. 
     The saddle  1140  is provided with a generally rectangular-shaped saddle jaw  1146  that defines an undulating saddle jaw surface  1148 . As illustrated and in order to simplify manufacture, the saddle jaw engaging surface  1167  is formed from a series of curved recesses  1149  separated by flat portions. The invention contemplates other jaw surface shapes, however, including serpentine jaw surfaces. 
     The saddle jaw  1146  extends into the bore or passage  1112  of the housing for engaging a periphery of the cable (not shown). The saddle jaw  1146  cooperates with a complementarily-shaped housing jaw housing  1124  in order to form a generally undulating clamping space. The undulating surface of jaw housing  1124  shown in  FIG. 12  and  FIG. 13  may be formed as a series of annular ribs within the passage  1112 . 
     As will be appreciated by those of ordinary skill, the movement of the cam lever  1160  from a released position in the direction C to a clamping position shown in  FIG. 13  causes the cam surface  1164  to move with respect to the cam support surface  1122 , thereby moving saddle  1140  within saddle guide  1120  in direction D which is substantially transverse to the longitudinal extent of bore or passage  1112  and into a clamping position. The surface of the jaw housing  1124  and the saddle jaw surface  1148  cooperate to redirect the cable  12  from a substantially straight path to an undulating path when the saddle  1140  is moved to a clamping position. It will be appreciated that the undulating surfaces of the saddle jaw  1146  and jaw housing  1124  increase the area of the cable to which the clamping force is applied. Thus, the amount of force that may be safely applied to a cable without risk of damage is increased compared to prior art clamping devices. 
     The cam lever  1160  is provided with a multifaceted cam surface. The cam surface  1164  includes two facets: facet  1164 A and facet  1164 B, which each define a clamping position for clamping cables. Each facet  1164 A and  1164 B of the cam lever  1160  is preferably provided as a substantially flat surface for engaging the cam support surface  1122  on the housing  1124 . Each facet has associated with it a radial dimension measured from the cam lever pivot axis. The radial dimensions are selected to provide optimum clamping force for cable  12  used with the cable clamp assembly. 
     Preferably, cam surfaces  1164 A and  1164 B are provided with respective flat portions that extend on both sides of respective radial lines to facilitate the positive locking aspects of the invention. That is, cam surface  1164  includes a first flat portion of the cam surface  1164 A that engages the cam support surface  1122  and positively locks the proximal clamp assembly  1101 . Cam surface  1164  also includes a second, flat portion of the cam surface  1164 B that engages the cam support surface  1122  and positively unlocks the clamp assembly  1101 . Cam surface  1164 A and  1164 B provide for stable locking positions of the cam lever  1160  and positive tactile indication that the desired locking position has been reached. 
     As will be recognized by those of ordinary skill, the clamp assembly  1101  applies a clamping force to the cable  12  without direct contact between the cam lever  1160  and the cable  12 , thereby minimizing damage from abrasion and shear forces. Clamping force is applied through the saddle, which applies a lateral force against the cable surface and redirects the cable  12  into an undulating or non-linear path defined between the housing jaw and saddle jaw. Thus, the potential for damage to the cable surface is reduced compared to prior art cable clamps. Moreover, less clamping force occurs with cable tension, since the cable attempts to straighten and consequently applies normal forces to the obstructing internal surfaces of the clamp. These cable tension induced normal forces reduce the normal forces generated by the clamp body through action of the lever. It will also be recognized that clamping devices herein may be used to clamp different sized cables, without refitting parts or clamping jaws with new dimensions. Moreover, the clamping devices herein provide for positive tactile determination as to when the cam lever  1160  has been moved to one of a plurality of clamping positions. 
     As shown in  FIGS. 12 and 13 , the cam surface  1164  of lever  1160  cooperates with the cam support surface  1122 . As lever  1160  is pivoted about pivot pin  1150 , the saddle  1140  moves relative to the jaw housing  1124  in a direction D. 
     The engaging surface  1167  is formed from the housing member  1301  to engage the cable  12 . The engaging surface  1167  is formed in any variety of shapes so as to engage a portion of the periphery of the elongate member. In particular, The engaging surface  1167  can be non-linear along at least a portion of its lengthwise cross-section, and/or concave along at least a portion of its widthwise cross-section. In these two exemplary forms, the engaging surface  1167  respectively serves to redirect the cable  12  into a non-linear path and to cup a length of the cable  12  at the point of clamping. The engaging surface  1167  also serves to increase the normal force for clamping the cable  12 , without damaging the cable  12 . The proximal cable clamp assembly  1101  is described in further detail in U.S. Pat. No. 7,452,360, filed Nov. 14, 2001 titled “Method and Apparatus for Clamping Surgical Wires or Cables” which is incorporated by reference in its entirety herein. 
     The second locking clamp assembly  2101  is shown in  FIG. 35  and  FIG. 36  and is similar to locking clamp assembly  1101  described previously. The passage  2112  in the second embodiment  2001  passes through the entire length of the cable tensioning apparatus  2001  unlike the foreshortened passage  1112  in the first embodiment  1001 . The proximal locking clamp assembly  2101  is in line and contiguous with the drive rod  2201 . 
     In contrast, the first, third and fourth apparatuses  1001 ,  3001 ,  4001  include bridging material  1169 ,  3169 ,  4169  to connect the proximal clamp assembly  1101  to the drive rod  1201  in a radially offset arrangement as shown in  FIG. 12 ,  13 ,  56 ,  57 ,  78 ,  79 . The proximal locking clamp assembly  1101  of the first apparatus  1001  is identical to the proximal locking clamp assembly  3101  of the third apparatus  3001  and proximal locking clamp assembly  4101  of the fourth apparatus  4001 . In addition, the same indirect proximal locking cable clamp assembly is used on all the apparatuses  1001 ,  2001 ,  3001 ,  4001  in the proximal position. 
     The fourth apparatus  4001  utilizes the indirect proximal locking cable clamp assembly, i.e. the U-shaped saddle, also for the distal cable clamp assembly  4801 . Finally, the fourth apparatus  4001  also illustrates the use of a funneled surface  4177  at the proximal cable entrance  4175  to assist the feeding of surgical cable  12  into the proximal cable clamp assembly  4101  as shown in  FIG. 78 . The funneled surface  4177  could have arcuate, parabolic, or other shapes to provide the function of improved insertion of surgical cable. Alternatively, the funneled surface  4177  could be used for the proximal cable clamp assemblies for the other pistol grip tensioning apparatuses  1001 ,  2001 ,  3001 . 
     Distal Cable Clamp Assembly 
     The distal cable clamp assembly  1801 ,  2801 ,  3801  locks surgical cable  12  by compression through cam action of the clamp assembly  1801  directly on the cable  12  for the first three embodiments  1001 ,  2001 ,  3001 . The distal cable clamp assembly  1801 ,  2801 ,  3801  has the ability to lock the cable  12  in the more restricted space around the incision because the reduced length of the distal clamp lever  1803 ,  2803 ,  3803 . In addition, the distal cable clamp assemblies  1801 ,  2801 , and  3801  are also detachable and interchangeable through the use of a hexagonal bit. Finally, the distal cable clamp assembly  1801 ,  2801 , and  3801  also engages the surgical connector  10  which is described in more detail below. 
     For the first apparatus  1001 , the distal cable clamp assembly  1801  is shown in an unsecured or unlocked configuration in  FIG. 18  and secured or locked configuration in  FIG. 19 . As shown in  FIG. 18  and  FIG. 19 , the distal cable clamp assembly  1801  is comprised of a distal clamp lever  1803 , a cam pin  1811 , and the distal cam  1807  mounted on the clamp body  1815 . 
     As shown in  FIG. 18 , the distal cable clamp assembly  1801  is shown in the unsecured or unlocked configuration. The rotatable distal cable clamp assembly  1801  consists of a rotatable cam  1807  connected to a distal clamp lever  1803  which is carried on the clamp body  1815  by a cam pin  1811 . The cam  1807  is capable of rotating and rotating back into the unlocked position as shown in  FIG. 18  where the cam  1807  is spaced from the passage  1805  to the locked position shown in  FIG. 19 . As shown in  FIG. 18  in the unsecured or unlocked configuration, the surgical cable  12  can pass unobstructed through the space provided in the passage  1805  during the cable tensioning process. 
     The distal cable clamp assembly  1801  has a central portion  1813  which is filleted or radiused inwardly as shown in  FIGS. 6 and 18 , to facilitate the user in gripping the clamp assembly  1801  to easily engage and disengage it with the clamp assembly  1801  with the rest of the cable tensioning apparatus  1001 . The distal cable clamp assembly  1801  has bridging material  1817  and an opening  1819  to structurally support the radially offset connection of the clamp assembly  1801  to the rest of the cable tensioning apparatus  1001 . 
     Finally, the entire distal cable clamp assembly  1801  is modular and detachable to adapt the cable tensioning apparatus  1001 ,  2001 , and  3001  to other types of surgical connectors  10 . The indicator structure  1703  defines a hexagonal socket  1705  and split ring retention spring  1707  for receiving a tubular extension  1821  of the distal cable clamp assembly  1801 , with the retention spring  1707  fitting into an annular groove of the extension  1821  in a conventional manner. The round modular connection of the tubular extension  1821  is self centering to assure proper position of the distal cable clamp assembly  1801 . The distal cable clamp assembly  1801  is non-rotatable because its tubular extension  1821  is hexagonal (or alternatively of other non-circular cross section) fitting into a hexagonal socket  1705  at the distal end of the hexagonal socket  1705  (or alternatively other non-circular cross section). 
     As shown in  FIG. 19 , the distal cable clamp assembly  1801  is shown in the secured or locked configuration. The cam  1807  is capable of rotating into the locked position as shown in  FIG. 19  where the cam  1807  partially blocks the passage  1805  in the secured or locked configuration shown in  FIG. 19 . As shown in  FIG. 19  in the secured or locked configuration, the surgical cable  12  can not pass unobstructed through the space provided in the passage  1805  during the cable tensioning process. The cam  1807  directly engages or contacts the surgical cable  12  to create friction against movement by the friction force applied by the cam  1807  and the clamp body  1815 . As shown in  FIG. 19  in the secure or locked configuration, the surgical cable  12  can not pass through the passage  1805  as part of the cable tensioning process. The distal cable clamp assembly  1801 ,  2801 , and  3801  is described in further detail in U.S. Utility Pat. No. 5,788,697, filed Mar. 15, 1996 titled “Cable Tensioning Device” which is incorporated by reference in its entirety herein. 
     The distal cable clamp assembly  1801  also engages or interfaces with the unique surgical connector  10  shown in  FIG. 46 . This unique surgical connector  10  is typically used with the assignees&#39; surgical implant devices (described in more detail in U.S. Pat. No. 7,207,993 B1 which is herein incorporated by reference) for prophylactic banding. The surgical connector  10  is also described in further detail in U.S. Pat. No. 5,415,658, titled “Surgical Cable Loop Connector” filed Dec. 14, 1993 which is incorporated by reference in its entirety herein. 
     The distal cable clamp assembly  1801  engages the surgical connector  10  as shown in  FIG. 48  and  FIG. 49 . As shown in  FIG. 50 , the distal cable clamp assembly  1801  is shown to have a sliding or shiftable fit into a slot  27  of the surgical connector  10 , which in turn, is carried by the pistol grip cable tensioning device or apparatus  1001 . As shown in  FIG. 47 , the slot  27  of the surgical connector  10  slides onto the flange  1823  of the distal cable clamp assembly  1801 . As shown in  FIG. 48 , the surgical connector  10  meshes or engages the distal cable clamp assembly  1801  to create mechanical engagement and a partial connection between the surgical connector  10  and the cable tensioning apparatus  1001 . 
     The structure and engagement of the distal cable clamp assembly  1801  for the first embodiment has been described as an exemplar for the other distal cable clamp assemblies  2801 ,  3801  for the second and third embodiments of the pistol grip tensioning apparatuses  2001 ,  3001 . The structure of the distal cable clamp assembly  1801  with the surgical connector  10  is substantially the same as the distal cable clamp assemblies  2801  and  3801  of the second and third apparatuses  2001  and  3001  and not repeated for brevity. The surgical connector  10  meshes or engages in the same manner with the distal cable clamp assemblies  2801  and  3801  of the second and third embodiments  2001  and  3001 . Alternatively, many different conventional designs of surgical connectors or crimps may be configured to be used with the cable tensioning apparatus  1001 ,  2001 ,  3001 , and  4001  via the hexagonal socket, retention spring, and tubular extension described previously. 
     For example, the cable  12  passes through the surgical connector  10  during tensioning into the passage  1805  of the distal cable clamp assembly  1801 , which is carried on to the proximal clamp assembly  1101 . The cable  12  is tensioned and the cable  12  is locked with the distal cable clamp assembly  1801 . As shown in  FIG. 19 , the cable  12  enters into engagement with the distal cam  1807 , which retains the cable  12  through rotation of the distal clamp lever  1803  into its horizontal position. The cable  12  is locked in the surgical connector  10  with the screw  44  as shown in  FIG. 46 . The cable  12  is then cut and the cable tensioning device of this invention is disengaged from the surgical connector  10  by allowing the connector  10  to slide out of slot  27 , and the cerclage is complete. 
     The distal locking clamp assembly  2801  of the second apparatus  2001  shown in  FIGS. 41 and 42  is nearly identical to the distal locking clamp assembly  1801  of the first embodiment  1001  described previously. The distal locking clamp assembly  2801  locks surgical cable  12  by rotation of the distal clamp lever  2803  about the cam pin  2811  to cause the distal cam  2807  to directly engage or contact the surgical cable  12  to create friction against movement by the friction force applied by the cam  2807  and the clamp body  2815 . However, the distal locking clamp  2801  does not provide the bridging material  1817  or opening  1819  to offset the clamp assembly  2801 . In contrast, the distal clamp passage  2805  extends through the clamp assembly  2801  and on through to the entire length of the cable tensioning apparatus  2001  until it connects with the proximal clamp passage  2112  to form a single centrally located cable passageway throughout. 
     The distal locking clamp assembly  3801  of the third apparatus  3001  shown in  FIG. 52 through 57  and  FIGS. 60 through 67  is identical to distal locking clamp assembly  1801  of the first apparatus  1001  described previously. Alternatively, the distal and proximal locking clamp assemblies can be substituted for one another, i.e. the proximal clamp assembly can be used both at the proximal and distal portions of the apparatuses (as was done in the fourth apparatus  4001 ). The distal and proximal clamp assemblies  3801  and  3101  are also operated with the same method but with the alteration of a double action rather than single action friction drive. 
     The distal cable clamp assembly  4101  for the fourth apparatus  4001 , as shown in  FIG. 81 , has a cable guide assembly  4880  that functions primarily to allow the surgeon access to inaccessible surgical sites. The guide assembly  4880  also may be used to prevent abrupt bending in the cable during application of the tensioning force to the cable  12 . The guide assembly  4880  includes a generally cylindrical guide barrel  4882  which is received in a complementarily-shaped clamp socket  4884 . A deformable ring  4886  is disposed in a recess and cooperates with an annular recess formed on the outer surface. The ring  4886  and socket  4884  cooperate to allow the cable guide assembly  4880  to be quickly snapped on and off the fourth embodiment of the pistol grip tensioning apparatus  4001 . Alternatively, the cable guide assembly  4880  could be used on any of the previous cable tensioning embodiments  1001 ,  2001 , and  3001 . The distal cable clamp assembly  4801  for the fourth embodiment  4001  is described in further detail in U.S. Pat. No. 7,452,360, filed Nov. 14, 2001 titled “Method and Apparatus for Clamping Surgical Wires or Cables” which is incorporated by reference in its entirety herein. 
     Precision Friction Drives 
     The first, second, and fourth embodiments of the cable tensioning apparatuses  1001 ,  2001  and  4001  rely on a friction drive mechanism  1601  ( 2601 , or  4601 ) that mechanically engages or locks on to the drive rod  1201  ( 2201 , or  4201 ) with a canting member  1651  ( 2651 , or  4651 ), otherwise known as a rocker, and is shown in  FIG. 14  ( FIG. 37  or  FIG. 79 ). As shown in  FIG. 15  ( FIG. 38  or  FIG. 80 ), the friction drive mechanism  1601  ( 2601 , or  4601 ) transmits motion from the lever  1501  ( 2501 , or  4501 ) to the smooth shaft of the drive rod  1201  ( 2201 , or  4201 ) via surface friction on the smooth shaft. The friction drive mechanism  1601  ( 2601 , or  4601 ) causes linear translation of the drive rod  1201  ( 2201 , or  4201 ) in the rearward or proximal direction A as the lever  1501  ( 2501 , or  4501 ) is depressed or pulled in direction E as shown in  FIG. 7  ( FIG. 30  or  FIG. 73 ). 
     The illustrated friction drive mechanism  1601  ( 2601  or  4601 ) includes the mechanical linkage  1631  ( 2631  or  4631 ), and the canting member  1651  ( 2651  or  4651 ). A release mechanism  1671  ( 2671  or  4671 ) is also provided. The friction drive mechanism  1601  for the first apparatus  1001 , shown in  FIGS. 10 ,  14 ,  15 , and  23 , is substantially the same as the friction drive mechanism  2601  for the second apparatus  2001 , shown in  FIGS. 37 and 38 , and will not be repeated for brevity. Similarly, friction drive mechanism  4601  for the fourth apparatus  4001  shown in  FIGS. 76 ,  79  and  80  is substantially the same as again to the first apparatus  1001  and will not be repeated for brevity. 
     For example, in the first embodiment  1001 , a mechanical linkage  1631  is mounted to the lever  1501  as shown in  FIG. 10 . The lever  1501  is mounted to the housing  1301  by the lever pin  1505 . As shown in  FIG. 14  the mechanical linkage  1631  is made up of a “L” shaped link member  1633  which is connected to the lever  1501  with the linkage pin  1635 . The “L” shaped link member  1633  is connected to the canting member  1651  with the pivot pin  1637 . The canting member  1651 , which is a ring with a hole, receives the drive rod  1201  through the aperture or hole. The canting member  1651  wraps around the cylindrical portion  1203  of the drive rod  1201 . The canting member  1651  can cant or tilt on the cylindrical portion  1203  of the drive rod  1201  as well as shift along the length of the rod  1201 . The canting member  1651  structure can be seen and its relation to the drive mechanism  1601  in  FIG. 23 . 
     As shown in  FIGS. 10 and 15 , the operator applies a force on the lever  1501  in direction E which is transfer to the “L” shaped linkage  1633 . The lever  1501  transfers the force from the operator and transmits a force multiplied approximately three times to the “L” shaped linkage  1633 . The multiplied force is applied in the proximal direction A on the pivot pin  1637  to the canting member  1651 . This proximal force causes the canting member  1651  to cant or tilt to the right, i.e. to rock into position. The force applied in the proximal direction A at the pivot pin  1637  is applied to the cylindrical portion  1203  of the drive rod  1201  in the proximal direction A via frictional engagement. The frictional engagement force causes the drive rod  1201  to shift, i.e. a proximal linear translation, with the locked cable  12  to the rear, i.e. proximal direction A. 
     The friction engagement creates a mechanical feedback loop whereby the proximal force is balanced by friction forces at the canting annular top portion  1653  and canting bottom leg portion  1655 . As more tensile force is applied by the drive rod  1201  in the distal direction B then a corresponding increase in friction and normal forces will be created in the canting annular top and bottom leg portions  1653  and  1655 . In other words, the greater the tension on the drive rod  1201  and cable  12  then the greater the traction for the friction drive mechanism  1601 . 
     A release mechanism  1671  is mounted to the housing member  1301  (or  2301 ). The release mechanism  1671  is made up of a release lever  1673  which is connected to the housing  1301  with the release pin  1675  as shown in  FIG. 14 . A torsion spring  1677  is also part of the release mechanism  1671  and mounted to the release pin  1675  to maintain the bias of the release lever  1673  to the proximal direction A as shown in  FIGS. 14 ,  15 , and  21 . A pawl  1679  is counterpoised to the release lever  1673  and mounted by the release pin  1675  to provide the last component of the release mechanism  1671 . 
     As shown in  FIGS. 10 and 15 , the operator applies pressure on the release lever  1673  in direction H against its bias force for actuation of the release of the pawl  1679  to have disengagement from the rack portion  1205  of the drive rod  1201 . The pawl  1679  should only be disengaged when the drive rod  1201  reaches the end of its travel and needs to be reset. Once the pawl  1679  is disengaged and the lever  1160  returned to its original position as shown in  FIG. 15  then the drive rod  1201  will shift in the distal direction B until the drive rod  1201  returns to its original position as shown in  FIG. 14 . The drive rod  1201  returns to the original position because the drive rod reset spring  1605  which was compressed during tensioning then decompresses through expansion of the spring to return the drive rod  1201  to the initial position as shown in  FIG. 14 . 
     The release mechanism  1671  primarily functions to allow for rapid resetting of the cable tensioning apparatus  1001  by depressing the release lever  1673  in direction H which acts as a trigger. The release mechanism  1671  allows the tensioning process to repeat once the drive rod  1201  reaches the end of its travel to allow more cable  12  to be drawn. The release mechanism  1671  allows the repeated translation of the drive rod  1201 , i.e. the repetition of rod  1201  moving in the opposite proximal and distal directions A and B. The repeated translation of the rod  1201  used in combination with the proximal clamp  1101  and distal clamp  1801  assemblies allow for the tightening of a potentially infinite length of cable  12 . 
     The release mechanism  1671  also prevents the drive rod  1201  from moving in the distal direction B once the lever  1501  reaches the end of its stroke in direction E and returns to its original position. The lever  1501  automatically returns to its original position because the canting member return spring  1607  which was compressed during tensioning then decompresses to return the lever  1501  to the initial position as shown in  FIG. 15 . 
     The release mechanism  1671  allows the repeated depression of the lever  1501  without distal linear translation of the drive rod  1201 , i.e. slipping of the drive rod  1201  in the distal direction when the lever  1501  is released. There is very little friction created by the canting member  1651  moving in the distal direction B because the canting member  1651  rocks back or tilts back to a vertical position to allow the canting member  1651  to easily slide or shift on the drive rod  1201 . 
     The canting member return spring  1607  shifts the canting member  1651  back in the distal direction B to reset the canting member  1651  for another stroke or depression of the lever  1501 . However, the friction drive mechanism  1601  never acts on the ratchet teeth to drive the cable  12  in the proximal direction A to create tension, but only to prevent back sliding of the drive rod  1201  during the lever  1501  return stroke. 
     The overall travel, rapidity and amount of cable  12  which can feed into the cable tensioning apparatus  1001  is improved because of the friction drive mechanism  1601  since the linkage causes the drive rod  1201  to travel farther with each depression of the lever  1501  than other devices. The cable tensioning apparatus  1001  is also more precise because the leverage created by the lever  1501  whose force is multiplied by the mechanical linkage  1631  allows infinite variability during the setting of the tension in the surgical cable  12 . The infinite variability in setting the cable tension  1001  with the friction drive mechanism  1601  is immediately before the final locking of the distal clamp assembly  1801  and is a significant improvement over intermittent mechanical engagement such as on ratchet teeth during tensioning. 
     The improvement is significant because engagement on ratchet teeth has finite variability due to the necessity of meshing with the teeth and incumbent backlash present in the teeth. The engagement on ratchet teeth with a lever is also imprecise in controlling tension due to the variable shape of the ratchet teeth rather than the linear translation of leverage by the canting member  1651  to the linear drive rod  1201 . 
     In one embodiment, the canting member  1651  has a generally diamond shaped aperture that connects to the cylindrical portion  1203  of the drive rod  1201 . Alternatively, the canting member  1651  can have a circular, arcuate or elliptical aperture to frictionally engage the circular drive rod  1201 . However, almost any set of geometries for drive rods can be conceived such as square, hexagonal, or triangular with matching apertures for canting members could be used as alternative means with the friction drive mechanism  1601 . 
     Furthermore, the friction drive mechanism  1601  can alternatively utilize drive wheels, roller bearings, or clutch mechanisms to provide for the friction drive mechanism  1601  as alternative means in addition to the drive disclosed in the third embodiment  3001 . For example, the linear motion from the lever  1501  can be converted into rotation via a rack and pinion to rotate a wheel or roller bearing that comes into contact with the drive rod  1201  for an alternative friction drive. 
     Again, the friction drive mechanism  1601  for the first apparatus  1001  is substantially the same as the friction drive mechanism  2601 ,  4601  for the second and fourth apparatuses  2001 ,  4001 . The detailed description previously recited applies equally to those apparatuses  2001 ,  4001  and is not repeated. 
     However, the third embodiment drive mechanism  3601  is distinct. The third apparatus  3001  is composed of a handle  3401  and a lever  3501  which again operates a friction drive  3601  as shown in  FIGS. 55 and 56 . The operator operates the third apparatus  3001  by compressing the handle  3401  and the lever  3501 . The distal handle  3401  shifts the drive rod  3201  in the proximal direction A to tension the cable  12 . The friction drive  3601  is mechanically connected to the handle  3401  to cause the drive rod  3201  to shift in the proximal direction A through frictional engagement of the drive rod  3201 . 
     As the handle  3401  shifts in the distal direction B, the handle pin  3405 , which connects the lever  3501  and handle  3401 , shifts the lever  3501  in the distal direction B. The handle  3401  is connected to the pivot pin  3637  which multiplies the force on the pivot pin  3637  through leverage on the handle pin  3405  in the proximal direction A. As shown in  FIGS. 58 and 59 , the pivot pin  3637  then causes the canting member  3651  to cant or tilt and to frictionally engage the drive rod  3201  as described previously for the drive mechanisms  1601  of the first apparatus  1001 . Alternatively, the release mechanism  1671  shown in the first apparatus  1001  can be added to the third apparatus  3001  of the cable tensioning apparatus  3001  to extend the amount of travel of the drive rod  3201 . 
     The fourth apparatus  4001  is again composed of a handle  4401  and a lever  4501  which again operates a friction drive as shown in  FIG. 75 . However, the lever  4501  of the fourth apparatus  4001  has been reversed in concavity with ridges  4509  and finger detents  4511  to improve the grip of the gloved hands of the surgeon when the instrument  4001  is soiled, i.e. slick with blood. Alternatively, the reversed concavity and ridges of the lever  4501  can be utilized by the other apparatuses  1001 ,  2001 , and  3001  for both the lever and the handle. The various embodiments of the lever and handle are alternative means for solving the same problem and are only an exemplar of the contemplated cable tensioning apparatus. 
     Tension Indicator Mechanism 
     When the cable  12  is tensioned in conjunction with a trochanter connector  300  as shown in  FIG. 45  or a surgical connector  10  as shown in  FIG. 46 through 51  by the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  then the trochanter connector  300  or surgical connector  10  will apply an approximately equal compressive force against the distal cable clamp assembly  1801  ( 2801 ,  3801 ,  4801 ) and the tension indicator  1701  ( 2701 ,  3701 ,  4701 ). This compressive force is measured by the tension indicator mechanism  1701  ( 2701 ,  3701 ,  4701 ) to prevent the operator from over tensioning of the cable  12  on bones such as a femur  150  shown in  FIG. 45  from damage due to fracture or cutting by the cable  12 . 
     The tension indicator mechanism  1701  for the first apparatus  1001  is substantially the same as the tension indicator mechanism  2701 ,  4701  for the second and fourth apparatuses  2001 ,  4001  and will not be repeated for brevity. The tension indicator  1701  has two extreme conditions; the initial uncompressed condition shown in  FIG. 9  and a fully extended compressed condition shown in  FIG. 10 . As seen in  FIG. 9 , the first condition is an uncompressed calibrated compression spring  1709  shown by distance Q when the cable tensioning apparatus  1001  is in its first uncompressed configuration. As shown in  FIG. 10 , the second condition is a fully compressed calibrated compression spring  1709  is shown by distance R when the cable tensioning apparatus  1001  is in its fully compressed configuration. 
     The change in position of the indicator structure  1703  indicates the tension in the surgical cable  12 . The indicator structure  1703  is able to change position in relation to the tension on the cable  12  because of the bayonet connection. The bayonet lugs  1309  of the housing structure  1305  allows the indicator structure  1703  to adjust position based on the amount of compression created on the calibrated compression spring  1709  because the housing structure  1305  shifts as a sleeve over the indicator structure  1703 . 
     As indicated in  FIGS. 16 and 17 , the indicator top surface  1715  (or  2715 ) of the indicator structure  1703  has graduated markings in the form of laser etched lines and numbers indicating the amount of compression and corresponding tension in the surgical cable  12 . When the housing structure edge  1311  matches a line and number on the indicator top surface  1715  during tensioning then that number will accurately indicate the tension on the surgical cable  12 . 
     Again, the tension indicator mechanism  1701  for the first apparatus  1001  is substantially the same as the tension indicator mechanism  2701 ,  4701  for the second and fourth apparatuses  2001 ,  4001 . The detailed description previously recited applies equally to those apparatuses  2001 ,  4001  and is not repeated. 
     However, the tension indicator  3701  for the third embodiments  3001  operates slightly differently. When the lever  3501  shifts because of the handle pin  3405 , the calibrated compression spring  3709  then shifts in the distal direction to create mechanical compression of a calibrated compression spring  3709 . The indicator mechanism  3701  is mechanically connected to the lever  3501  and is within the housing member  3301 . When the lever  3501  is fully engaged the amount of tension can be read from markings on the indicator mechanism  3701  and the housing  3301 . The tension indicator  3701  and housing  3301  for the third embodiments  3001  is an alternative means for measuring cable tension compared to the tension indicator and housing of the other embodiments. 
     Material Components and Manufacturing Techniques 
     The cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  can be made from any suitable, structurally strong material. The structural portions and other components are constructed of suitable materials which are compatible with the uses and environments into which the apparatus will be utilized. Preferably, the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001 , is principally constructed of metallic materials such as 17-4 stainless steel, or 465 stainless steel. 
     As mentioned previously, the indicator structure and possibly some of the housing members are made of gall-resistant stainless steels such as Nitronic 60 or Gall-Tough. In addition, the calibrated compression spring  1709 ,  2709 ,  3709  and  4709  is made of stainless steel. 
     Alternatively, the exterior components can be made of other metal alloys such as titanium. In addition, the structural materials can also be chrome coated or plated to reduce galling, improved sterilization, for the reduction of friction and for cosmetic reasons. In yet other embodiments, medical lubricant or instrument milk can be added for improved lubrication and reduced friction. 
     The majority of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  is made using standard lathes and milling machines. Alternatively, other standard manufacturing processes such as metal casting can be use to make a majority of the components of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  as well. Wire Electrical Discharge Machining (or EDM) or spark machining is used to cut intricately shaped parts of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001 . EDM or spark machining is also used to cut the exotic metals of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001  such as gall-resistant stainless steels such as Nitronic 60 or Gall-Tough. Welded components are preferably welded using laser welding and/or gas tungsten arc welding (GTAW), also known as tungsten inert gas (TIG) welding. Alternatively, other standard welding processes or epoxy can be used to connect some of the components of the cable tensioning apparatus  1001 ,  2001 ,  3001  and  4001 . 
     The embodiments of this invention shown in the drawing and described above are exemplary of numerous embodiments that may be made within the scope of the appended claims. It is contemplated that numerous other configurations or conditions may be used, and the material of each component may be selected from numerous materials other than those specifically disclosed. In short, it is the applicant&#39;s intention that the scope of the patent issuing here from will be limited only by the scope of the appended claims.