Abstract:
In accordance with one aspect of the present disclosure, an instrument for tensioning a surgical cable is provided that includes a rotary tensioner that is rotatable in a tensioning rotary direction to apply tension to the surgical cable. The instrument further includes a body supporting the rotary tensioner, a pawl portion of the body configured to be received at least partially in a recess of a ratchet gear of the rotary tensioner, and a living hinge portion of the body supporting the pawl portion. The living hinge portion is configured to permit the pawl portion to be shifted out of the recess and shifted into an adjacent recess of the ratchet gear with turning of the rotary tensioner in the tensioning rotary direction

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
       [0001]    This application claims the benefit of U.S. Provisional Patent Application No. 62/368,753, filed Jul. 29, 2016, which is hereby incorporated by reference in its entirety. 
     
    
     FIELD 
       [0002]    This disclosure relates to surgical instruments and, more particularly, to instruments for tensioning surgical cables. 
       BACKGROUND 
       [0003]    Cable tensioners may be used to apply tension to a surgical cable. In one approach, the surgical cable has one end attached to a locking device, such as a crimp, and another end which is looped around a bone, advanced through the crimp, and advanced through a cable tensioner. To tension the surgical cable, a distal end of the cable tensioner is positioned against the crimp and a tensioning mechanism of the cable tensioner is operated to tension the surgical cable. Once the desired tension has been applied to the surgical cable, the crimp is fixed to the cable to hold the applied tension in the cable and secure the tensioned cable around the bone. 
         [0004]    Some cable tensioners have complicated tensioning mechanisms with many components. The components can include for example a device to grip the surgical cable, a linkage to shift the cable away from the distal end of the cable tensioner and tension the surgical cable, a ratchet to resist movement of the device back toward the cable tensioner distal end, and a tension gauge. These more complicated tensioning mechanisms may render the cable tensioner unsuitable for being disposable from a cost perspective. 
         [0005]    Another problem with some cable tensioners is that the cable tensioners have a ratchet for resisting loss of tension in the cable during a tensioning operation. The ratchet may include a pawl that engages recesses of a rack. However, as the pawl shifts out of recesses of the rack during a tensioning operation, the rack could shift backward before the pawl engages one of the recesses and cause a loss of tension in the cable. 
       SUMMARY 
       [0006]    In accordance with one aspect of the present disclosure, an instrument for tensioning a surgical cable is provided that includes a rotary tensioner that is rotatable in a tensioning rotary direction to apply tension to the surgical cable. The instrument further includes a body supporting the rotary tensioner, a pawl portion of the body configured to be received at least partially in one of the recesses of the ratchet gear, and a living hinge portion of the body supporting the pawl portion. The living hinge portion is configured to permit the pawl portion to be shifted out of the one recess and shifted into an adjacent one of the recesses of the ratchet gear with turning of the tensioner in the tensioning rotary direction. Because the pawl portion of the body is supported by the living hinge portion of the body, a separate spring for biasing the pawl portion and a separate structure for guiding the pawl portion are not required which simplifies manufacture and use of the instrument. 
         [0007]    In one form, the instrument further includes a second living hinge portion of the body and a second pawl portion configured to be received at least partially in another recess of the ratchet gear. The second living hinge portion is configured to permit the second pawl portion to be shifted out of the recess and at least partially into an adjacent recess of the ratchet gear with turning of the rotary tensioner in the rotary tension direction. The pawl portions and living hinge portions may be configured so that one of the pawl portions is always received at least partially in one of the recesses of the rotary tensioner ratchet gear to resist turning of the rotary tensioner in a pay out rotary direction. In this manner, the pawl portion received at least partially in the one recess resists turning of the rotary tensioner in the pay out rotary direction during a tensioning procedure to inhibit loss of tension in the surgical cable during the tensioning procedure. 
         [0008]    In accordance with another aspect of the present disclosure, an instrument for tensioning a surgical cable is provided including a one piece body having a cavity and a rotary tensioner at least partially in the cavity. The rotary tensioner is rotatable relative to the body in a tensioning rotary direction to wind a surgical cable onto the rotary tensioner. The instrument further includes ratchet portions of the one-piece body and the rotary tensioner configured to permit the rotary tensioner to turn in the tensioning rotary direction and resist turning of the rotary tensioner in an opposite, pay out rotary direction. In this manner, the one-piece body both supports the rotary tensioner and includes a ratchet portion that resists turning of the rotary tensioner. This allows the instrument to be made from fewer components. In one approach, the one-piece body and rotary tensioner are made from a plastic material that allows the instrument to be discarded or recycled after use. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0009]      FIG. 1  is a perspective view of a cable tensioner showing a body of the cable tensioner having a living hinge that supports a first pawl of the cable tensioner; 
           [0010]      FIG. 2  is a cross-sectional view taken across line  2 - 2  in  FIG. 1  showing a rotary tensioner of the cable tensioner supported in a cavity of the body; 
           [0011]      FIG. 3  is a perspective view of the rotary tensioner of  FIG. 2  showing a drum portion for wrapping the surgical cable thereon and a ratchet gear of the rotary tensioner; 
           [0012]      FIG. 4  is an elevational view of the rotary tensioner of  FIG. 3  showing a handle of the rotary tensioner connected to the drum portion and the ratchet gear; 
           [0013]      FIG. 5  is a top plan view of the cable tensioner of  FIG. 1  showing the first pawl on the front of the body of the cable tensioner and a second pawl on the rear of the body; 
           [0014]      FIG. 6  is a front elevational view of a portion of the body of the cable tensioner of  FIG. 1  showing a generally u-shaped through opening in the body defining an outer periphery of the first pawl and the living hinge; 
           [0015]      FIG. 7  is a rear elevational view of a portion of the body of  FIG. 6  showing a through opening of the body extending about the second pawl and a living hinge supporting the second pawl; 
           [0016]      FIG. 8  is a cross-sectional view taken across line  8 - 8  in  FIG. 5  showing the second pawl engaged in a first recess of the ratchet gear and the first pawl shifted out of engagement from a second recess of the ratchet gear; 
           [0017]      FIG. 9  is a cross-sectional view similar to  FIG. 8  showing the rotary tensioner turned in a tensioning rotary direction so that the second pawl is shifted out of engagement with the first recess and the first pawl shifted into engagement in a third recess of the ratchet gear; 
           [0018]      FIG. 10  is a cross-sectional view taken across line  10 - 10  in  FIG. 5  showing a distal end of the cable tensioner abutting a crimp and a surgical cable extending outward from the crimp and through passages of a guide tube of the cable tensioner, the body of the cable tensioner, and the rotary tensioner of the cable tensioner; 
           [0019]      FIG. 11  is a cross-sectional view similar to  FIG. 10  showing the rotary tensioner turned in the tensioning rotary direction from its position in  FIG. 10  which draws the cable onto the drum portion of the rotary tensioner and tensions the cable; and 
           [0020]      FIG. 12  is a cross-sectional view similar to  FIG. 11  showing a lever of a cutting tool of the cable tensioner pivoted by a tubular tool connected to the lever which shifts a cutting blade of the cutting tool and cuts the surgical cable. 
       
    
    
     DETAILED DESCRIPTION 
       [0021]    With reference to  FIGS. 1 and 2 , a cable tensioner  10  is provided having a body  12  and a rotary tensioner  14  rotatably supported in a cavity  16  of the body  12 . The rotary tensioner  14  includes a handle  20  for turning the rotary tensioner  14  in a tensioning rotary direction  22  and applying tension to a surgical cable  23 . The cable tensioner  10  has a guide, such as a tube  42 , a distal end  50  that includes an opening  52 , and a cutting tool  54 . To apply tension to the cable  23 , the surgical cable  23  is advanced in direction  56  through the opening  52 , through the cable tensioner  10 , and outward from an opening  60  of the body  12 . The cable tensioner  10  is advanced along the surgical cable  23  until the distal end  50  abuts a crimp, bone plate, or other locking device for securing the surgical cable  23  once the surgical cable  23  has been tensioned. For example with reference to  FIG. 10 , the distal end  50  may abut a crimp  212  and the surgical cable  23  extends through the cable tensioner  10 . 
         [0022]    Returning to  FIG. 1 , the handle  20  is then turned in tensioning rotary direction  22  to draw the cable  23  onto the rotary tensioner  14  and apply tension to the cable  23  as discussed in greater detail below. The surgeon uses tactile feedback from the handle  20  to determine the tension in the surgical cable  23 . Once the desired tension has been applied to the cable  23 , the crimp  212  is reconfigured to secure the cable  23 . Next, the surgeon manipulates an actuator of the cutting tool  54 , such as a lever  66 , to cut the cable  23 . The cable tensioner  10  and the cable  23  therein may then be removed from the surgical site. 
         [0023]    The body  12  has a ratchet mechanism  21  for resisting turning of the rotary tensioner  14  in a pay out rotary direction  40 , which would pay the cable  23  off of the rotary tensioner  14 . The ratchet mechanism  21  includes at least one pawl or pawl portion, such as a pair of pawls or pawl portions  24 ,  26 , which engage a ratchet gear  30  of the rotary tensioner  14 , as shown in  FIG. 8 . The pawl portions  24 ,  26  have projections  154 ,  156  that engage recesses  150  of the ratchet gear  30  between teeth  152  of the ratchet gear  30 . 
         [0024]    With reference to  FIGS. 1, 6, and 7 , the body  12  includes living hinges or living hinge portions  31 ,  32  that permit the pawl portions  24 ,  26  to shift radially outward and inward in directions  31 ,  33  (see  FIG. 8 ) and travel over teeth  152  of the ratchet gear  30  as the rotary tensioner  14  is turned in the tensioning rotary direction  22 . The living hinge portions  31 ,  32  and the pawl portions  24 ,  26  should be understood to include both living hinges that are originally integrally formed with the body  12  or are initially formed as separate components that are later unified or securely connected to the body  12  after they are formed, as will be described more fully hereinafter. 
         [0025]    The living hinge portions  31 ,  32  are resiliently flexible to permit shifting of the pawl portions  24 ,  26  when the rotary tensioner  14  is turned in the tensioning rotary direction  22  while being sufficiently strong to support to the pawl portions  24 ,  26  when the pawl portions  24 ,  26  are engaged in the recesses  150  of the rotary tensioner  14  and resist turning of the rotary tensioner  14  in the tensioning rotary direction  22 . 
         [0026]    With reference to  FIG. 8 , the pawl portions  24 ,  26  are spaced circumferentially around the rotary tensioner  14  so that the pawl portions  24 ,  26  engage the ratchet gear  30  at different positions around the ratchet gear  30 . The pair of pawl portions  24 ,  26  and the living hinge portions  31 ,  32  are configured so that one of the pawl portions  24 ,  26  is always engaged in one of the recesses  150  of the ratchet gear  30  when a user is turning the handle  20  in the tensioning rotary direction  22 . For example, when the pawl portion  24  is shifting out of the recess  170  as shown in  FIG. 8 , the pawl portion  26  is engaged with the recess  160 . Conversely, when the pawl portion  26  is shifting out of the recess  160  as shown in  FIG. 9 , the pawl portion  24  is engaged in the recess  180 . Because one of the pawl portions  24 ,  26  is always engaged with the ratchet gear  30 , the one of the pawl portions  24 ,  26  can resist turning of the rotary tensioner  14  in the pay out rotary direction  40  and maintain tension in the cable  23  during a tensioning operation. 
         [0027]    In one form, the body  12  and the rotary tensioner  14  may each have a one-piece construction which simplifies manufacture and assembly of these components. As used herein, the term one-piece refers to a monolithic member. For example, the body  12  including the living hinge portions  31 ,  32  and the pawl portions  24 ,  26  has a one-piece construction and may be formed by, for example, molding, 3D printing, or machining. Likewise, the rotary tensioner  14  including the handle  20  may have a one-piece construction such as by molding, 3D printing, or machining. This simplifies manufacture by reducing the overall number of components of the cable tensioner  10 . 
         [0028]    Further, the body  12  and the rotary tensioner  14  may be made from the same or different materials, such as a plastic or a composite material to reduce the weight of the cable tensioner  10  and make the cable tensioner  10  easier to handle. For example, the body  12  and the rotary tensioner  14  may be made from RADEL® plastic. In other forms, the body  12  and the rotary tensioner  14  may made from other plastics. The materials for the rotary tensioner  14  may be selected so that the teeth  152  are able to withstand 80-100 pounds of force during a cable tensioning operation. The materials of the cable tensioner  10  may be selected so that the cable tensioner  10  is disposable or recyclable. In other forms, the materials of the cable tensioner  10  may be selected to permit cleaning and reuse of the cable tensioner  10 . For example, the body  12  and the rotary tensioner  14  may be made from a metallic material, such as stainless steel. 
         [0029]    In other forms, the body  12  and the rotary tensioner  14  may each be made from a plurality of components. For example, the body  12  may include the living hinge portions  31 ,  32  and the pawl portions  24 ,  26  may be initially formed as separate components that are thereafter joined such as by chemical welding or adhesive to the living hinge portions  31 ,  32 . The rotary tensioner  14  could likewise be initially formed by separate components such as a handle  20  and ratchet gear  30  that are later fixed together for assembly using fasteners. 
         [0030]    With respect to  FIG. 1 , the tube  42  of the cable tensioner  10  is connected to the body  12  at a swivel connection  44 . The swivel connection  44  permits the body  12  to turn in opposite directions  46 ,  48  relative to the tube  42 . This allows the user to adjust the position of the body  12  and handle  23  to an ergonomically comfortable position during a cable tensioning operation while the distal end  50  abuts the crimp  212 . 
         [0031]    With reference to  FIGS. 2 and 3 , the rotary tensioner  14  has a drum portion  70  with a passage  72  extending therethrough and a cylindrical outer surface  73 . When the handle  20  is in the vertical orientation shown in  FIG. 2 , the passage  72  of the drum portion  70  is aligned with the opening  60  of the body  12  and a passage  202  of the body  12 . The cable  23  may be advanced in direction  74  upward through the passages  72 ,  202  and out from the opening  60  (see  FIG. 10 ). When the handle  20  is turned in the tensioning rotary direction  22 , the drum portion  70  and passage  72  turn with the handle  20  and wind the cable  23  onto the cylindrical outer surface  73  of the drum portion  70  as shown in  FIGS. 10 and 11 . 
         [0032]    With reference to  FIG. 6 , the living hinge portion  31  includes a base portion  80  and an arm portion  82  that connects the base portion  80  and the pawl portion  24 . The body  12  has a generally U-shaped through opening  84  extending around the arm portion  82  and the pawl portion  24 . The through opening  84  includes straight portions  90 ,  92 , and an end portion  94  connecting the straight portions  90 ,  92 . The arm portion  82  has a width  100 , a length  102 , and a thickness  104  (see  FIG. 9 ), that are selected with the material of the body  12  to permit sufficient flexibility for the pawl portion  24  to be deflected by the ratchet gear  30  when the handle  20  is turned in the tensioning rotary direction  22 . However, the arm portion  82  is sufficiently strong to resist deflecting when the pawl portion  24  is engaged with the ratchet gear  30  and the tension in the cable  23  urges the rotary tensioner  14  in the pay-out rotary direction  40 . For example, the arm portion  82  may be configured to resist forces applied by the rotary tensioner  14  in the range of approximately 80 pounds to approximately 100 pounds without deflecting. As another example, the body  12  including the living hinge portion  31  may be made of RADEL® plastic and the arm portion  82  has a width  100  in the range of approximately 0.2 inches to approximately 0.3 inches, such as 0.283 inches, and a thickness  104  (see  FIG. 9 ) in the range of approximately 0.08 inches to approximately 0.12 inches, such as 0.098 inches. The arm portion  82  and the pawl portion  24  may have a length  102  in the range of approximately 0.6 inches to approximately 0.9 inches, such as approximately 0.7 to approximately 0.8 inches, such as approximately 0.77 inches. 
         [0033]    As shown in  FIG. 7 , the living hinge portion  32  is similar to the living hinge portion  31 . The living hinge  32  includes a base portion  110  and an arm portion  112 . The body includes a generally U-shaped through opening  114  extending about the arm portion  112  and the pawl portion  26 . The through opening  114  includes a pair of straight portions  116 ,  118  and an end portion  120  (see  FIG. 4 ) connecting the straight portions  116 ,  118 . 
         [0034]    With continued reference to  FIG. 7 , the pawl portion  26  has a raised feature on it exterior wherein the raised feature has an upside-down U-shape and defines a recess. In the event the cable tensioner  10  must be removed from the cable  23  after tensioning the cable  23 , but the cable  23  cannot be cut, a surgeon may grab the raised feature with forceps and lift the pawl portion  26  out of engagement with the ratchet gear  30 . The surgeon would perform a similar procedure on the pawl portion  24  so that both pawl portions  24 ,  26  are disengaged from the ratchet gear  30 . With the pawl portions  24 ,  26  disengaged from the ratchet gear  30 , the handle  20  may be turned in the pay out rotary direction  44  to pay the cable  23  off of the drum portion  70 . Although the raised features of the pawl portions  24 ,  26  allow a surgeon to pay out the cable  23  from the cable tensioner  10  when the cable  23  cannot be cut, in normal procedures, the cable  23  will simply be cut and removed with the cable tensioner  10  such that paying out the cable  23  from the drum portion  70  is unnecessary. 
         [0035]    Returning to  FIGS. 2 and 3 , the rotary tensioner  14  has a body  120  that includes the drum portion  70 . The body  120  has a retention flange  122  for contacting a rim  126  of the body  12  extending about the cavity  16 . The contact between the flange  122  and the rim  126  limits movement of the rotary tensioner  14  in direction  125  along an axis  136  of rotation of the rotary tensioner  14 . The body  12  also has an inwardly directed lip  130  extending about the cavity  16 . The rotary tensioner  14  includes a cap  132  secured to the body  120 , such as by adhesive or a snap-fit. The cap  132  has a flange  134  for contacting the lip  130  of the body  12  and limiting movement of the rotary tensioner  14  in direction  127  along the axis  136 . In this manner, the flanges  122 ,  134  of the rotary tensioner  14  are in axial overlapping relation with the rim  126  and the lip  130  of the body  12 . This captures the rotary tensioner  14  within the cavity  16  of the body  12 . 
         [0036]    With reference to  FIG. 4 , the rotary tensioner  14  also includes guide flanges  140 ,  142  on opposite sides of the outer cylindrical surface  73  of the drum portion  70 . The guide flanges  140 ,  142  resist lateral movement of the cable  23  off of the drum portion  70  as the cable  23  is wound up on the outer cylindrical surface  73 . 
         [0037]    Turning to  FIG. 8 , the operation of the pawl portions  24 ,  26  and the ratchet gear  30  as the rotary tensioner  14  is turned in the tensioning rotary direction  22  to tension the surgical cable  23  will be discussed in greater detail. The pawl portions  24 ,  26  include projections  154 ,  156  that are received in different recesses  150  around the ratchet gear  30 , such as at approximately the nine o&#39;clock and the one o&#39;clock positions as shown in  FIG. 8 . Initially, the projection  156  is fully engaged in the recess  160  and has a stop surface  162  abutting a stop surface  164  of a tooth  166  of the ratchet gear  30 . Due to the abutting stop surfaces  164 ,  166 , the rotary tensioner  14  is held against rotation in the pay out rotary direction  40 . 
         [0038]    In  FIG. 8 , the pawl portion  24  is shown with the projection  154  urged radially outward in direction  31  from a recess  170  of the ratchet gear  30  via camming engagement between a ramp surface  177  of the projection  154  and a ramp surface  171  of a tooth  173 . Thus, while the projection  156  of the pawl portion  26  is fully engaged in the recess  160 , the projection  154  of the pawl portion  24  is shifted out of engagement from the recess  170  as shown in  FIG. 8 . The pawl portion  26  thereby resists turning of the rotary tensioner  14  in the pay-out rotary direction  40  while the pawl portion  24  shifts radially outwardly in direction  31  and travels over the tooth  173 . 
         [0039]    The ratchet gear  30  has a tooth  172  with a ramp surface  174  facing a ramp surface  175  of the projection  156 . When the rotary tensioner  14  is turned in the tensioning rotary direction  22 , the ramp surfaces  174 ,  175  cammingly engage and cause the pawl portion  26  to shift radially outward in direction  176  which flexes the living hinge  32  to a deflected configuration. Turning to  FIG. 9 , the rotary tensioner  14  has been turned in the tensioning rotary direction  22  such that the caroming engagement between the ramp surfaces  174 ,  175  have urged the projection  156  radially outwardly in direction  176  out of engagement with the recess  160  and flexed the living hinge portion  31  to the deflected configuration. The rotation of the rotary tensioner  14  in the tensioning rotary direction  22 , however, has rotated the ratchet gear  30  until the projection  154  is aligned with a recess  180  of the ratchet gear  30  on an opposite side of the tooth  173  from the recess  170 . The living hinge portion  31  resiliently urges the projection  154  radially inward in direction  33  into the recess  180  and engages the projection  154  with the recess  180 . In this manner, the living hinge portion  31  flexes to back to a generally undeflected configuration. The term undeflected configuration is used to compare the configuration of the living hinge portion  31  in  FIG. 9  with the deflected configuration of the living hinge portion  31  in  FIG. 8 . In the undeflected configuration, the material of the living hinge portion  31  may be slightly deflected due to the presence of the rotary tensioner  14  and this partial deflection biases the projection  154  into engagement with the recess  180 . 
         [0040]    Moving between  FIGS. 8 and 9 , the projection  156  has been urged outward from the recess  160 , while the projection  154  has snapped into and is fully seated within the recess  180 . In this manner, at least one of the projections  156 ,  154  is always fully seated within one of the recesses  150 . This provide a precise ratcheting action while utilizing larger teeth  152 , which may be more durable than utilizing a single pawl and a ratchet gear with smaller teeth. For example, if the surgeon were to release the handle  20  during a tensioning operation, the rotary tensioner  14  would not turn in the pay out rotary direction  40  from its position in  FIG. 9  despite the projection  156  of the pawl portion  26  having been urged radially outward from the recess  160 . If the pawl portion  24  were not present, the rotary tensioner  14  could turn in the pay out rotary direction  40  and release tension in the cable  23  until the projection  156  snaps into the recess  160  and the stop surface  162  of the projection  156  abuts the stop surface  164  of the tooth  166 . Because one of the pawl portions  24 ,  26  is always engaged with one of the recesses  150 , the release of tension is avoided. 
         [0041]    With reference to  FIG. 10 , the tube  42  includes a tube passage  200  that is aligned with the passage  202  of the body  12 . When the handle  20  is in an upright or vertical orientation (see  FIG. 1 ), the tensioner passage  72  is also aligned with the body passage  202  such that the cable  23  may be advanced from the crimp  212  and through the aligned tube passage  200 , body passage  202 , and tensioner passage  72  before exiting the opening  60  in direction  74 . 
         [0042]    The swivel connection  44  between the body  12  and the tube  42  includes a groove  214  and a collar  220  of the body  12 . The swivel connection  44  further includes a protrusion  216  of the tube  42  that snaps into the groove  214  and a shoulder  218  of the tube  42  below the collar  220 . In this manner, the collar  220  of the body is positioned between the protrusion  216  and the shoulder  218  of the tube  42  which rotatably captures the tube  42  on the body  12 . In one form, the protrusion  216  has an annular barb shape including a tapered surface  217 . During assembly of the cable tensioner  10 , the tube  42  is advanced in direction  223  into a socket  225  of the body  12 . The tapered surface  217  cams and expands the collar  220  radially outward so that the protrusion of the tube  42  can snap into the groove  214 . The protrusion  216  may also have a flat lower surface abutting a flat upper surface of the collar  220  to resist removal of the tube  42  in direction  227  from the socket  225  of the body  12 . 
         [0043]    As shown in  FIGS. 11 and 12 , the cutting tool  54  includes a lever  66  pivotally connected to the tube  42  by a pin  67  and a blade  232  slidably received in a slot  234  of the tube  42 . The blade  232  has a cutting edge  233  made of a sufficiently strong material to cut the surgical cable  23  The lever  66  has an arm  230  abutting the blade  232 . The lever  66  can be pivoted to shift the blade  232  in direction  244  to cut the cable  23  extending through the tube passage  200 . In one form, the blade  232  is made of 465 series stainless steel and the lever  66  is also made of stainless steel. 
         [0044]    With reference to  FIGS. 10-12  a method of tensioning and cutting the cable  23  is shown. Initially, the surgical cable  23  is advanced through the tube passage  200 , the body passage  202 , and the tensioner passage  72 , and outward through the opening  60  in direction  74 . The cable tensioner  10  may be advanced along the surgical cable  23  until the distal end  50  abuts against the crimp  212 . 
         [0045]    Next, the surgeon turns the handle  20  in the tensioning rotary direction  22  which causes the rotary tensioner  14  to turn in the tensioning rotary direction  22  as shown in  FIG. 11 . The turning of the rotary tensioner  14  in the tensioning rotary direction  22  draws a portion  220  of the cable  23  downward in direction  222  onto the drum portion  70  and draws a portion  224  of the cable  23  upward in direction  226  onto the drum portion  70 . As the cable portions  220 ,  224  are wrapped onto the drum portion  70 , tension is applied to the surgical cable  23 . The surgeon determines the tension in the surgical cable  23  by way of tactile feedback from the handle  20 . As discussed above, the pawl portions  24 ,  26  engage the ratchet gear  30  to restrict turning of the rotary tensioner  14  in the pay out rotary direction  40  and resist loss of tension in the cable  23 . Once the desired tension has been obtained, the crimp  212  or locking device is crimped or otherwise operated to secure the surgical cable  23  at the desired tension. 
         [0046]    With reference to  FIG. 11 , after the crimp  212  has been secured to the cable  23 , the surgeon operates the lever  66  to drive the blade  232  and cut the cable  23 . In one approach, the surgeon connects a tool to the lever  66  to provide additional leverage to drive the blade  232  and cut the cable  23 . For example, a tubular tool  240  may be positioned such that the lever  66  extends into a cannula  242  of the tubular tool  240 . The surgeon then pivots the tubular tool  240  and the lever  66  connected therewith in direction  244 . This causes the arm  230  to push the blade  232  in direction  244  and cut the cable  23 . The cable tensioner  10  and the cable  23  remaining within the cable tensioner  10  may then be removed from the surgical site. Owing to the materials and fewer components of the cable tensioner  10 , the cable tensioner  10  may then be discarded or recycled, including being discarded or recycled with the cut section of the cable  23  therein. 
         [0047]    While there have been illustrated and described particular embodiments of the present invention, it will be appreciated that numerous changes and modifications will occur to those skilled in the art, and it is intended in the appended claims to cover all those changes and modifications which fall within the true spirit and scope of the present invention.