Patent Publication Number: US-2023145423-A1

Title: Systems and methods for surgical procedures using band clamp implants and tensioning instruments

Description:
CROSS-REFERENCE TO RELATED APPLICATION(S) 
     This application is a continuation-in-part of U.S. patent application Ser. No. 17/557,157, filed on Dec. 21, 2021, which is a continuation-in-part of U.S. patent application Ser. No. 17/465,252, filed on Sep. 2, 2021, which is a continuation-in-part of U.S. patent application Ser. No. 17/072,192, filed Oct. 16, 2020. U.S. patent application Ser. No. 17/465,252 is also a continuation-in-part of U.S. patent application Ser. No. 17/064,833, filed Oct. 7, 2020. The entire contents of each of which is hereby incorporated by reference in its entirety for all purposes. 
    
    
     FIELD 
     The present application relates generally to surgical devices and systems, and more particularly, to band clamp implants and tensioning instruments for spine surgery. 
     BACKGROUND 
     Many types of spinal irregularities cause pain, limit range of motion, or injure the nervous system within the spinal column. These irregularities may result from, without limitations, trauma, tumor, disc degeneration, and disease. Often, these irregularities are treated by immobilizing a portion of the spine. This treatment typically involves affixing screws, hooks and/or clamps to one or more vertebrae and connecting the screws, hooks and/or clamps to an elongate spinal rod that stabilizes members of the spine. 
     In addition, instability of the first and second cervical vertebrae is a common pathology caused by traumatic injury. While posterior fixation of the cervical spine is most commonly performed using screw fixation, there are times when it is advantageous to perform posterior cervical fixation using non-screw based techniques, including patients with low bone mineral density or fractured anatomy. In these cases, flexible bands may be used to achieve correction and provide fixation. The bands are wrapped around bony anatomy and then tensioned to provide fixation and promote healing. The same technique is commonly used with metal wires at C1-C2. However, metal wires have the potential to wear through bone or loosen over time leading to neurological injury. 
     Flexible bands may be used to achieve correction and provide fixation as an alternative and/or supplement to pedicle screws during spinal deformity surgery. The bands may be wrapped around bony anatomy and then a force may be applied to translate the spine to the spinal rod. Correction of the spinal deformity may be achieved and held by application of tension to the flexible band. There exists a need for improved tensioners for tensioning the flexible band for securing the flexible band to the bone. 
     SUMMARY 
     According to some examples of the concepts described herein, a system for applying tension to a band clamp during a spinal fixation surgery, the system including a first handle assembly, a second handle assembly able to move relative to the first handle assembly, a spool assembly disposed between the first handle assembly and the second handle assembly, the spool assembly able to receive a flexible band used for fixating a rod to a spine of a patient, and an adjustable head movably fixated to the first handle assembly. The adjustable head is able to be angled to the first handle assembly in a first orientation and angled differently in a second orientation. 
     According to other examples of the concepts described herein, a system for fixating a rod to a spine during surgery, the system includes a band clamp, a band clamp inserter able to fixate the band clamp to the rod, a flexible band able to be inserted into the band clamp, and a tensioner able to apply tension to the flexible band prior to fixating the flexible band in the band clamp. The tensioner includes a first handle assembly, a second handle assembly able to move relative to the first handle assembly, a spool assembly disposed between the first handle assembly and the second handle assembly, the spool assembly able to receive a flexible band used for fixating a rod to a spine of a patient, and an adjustable head movably fixated to the first handle assembly. The adjustable head is able to be angled to the first handle assembly in a first orientation and angled differently in a second orientation. 
     Also provided are kits including implants of varying types and sizes, rods, tensioner instruments, insertion tools, and other components for performing the procedure. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       A more complete understanding of the present disclosure, and the attendant advantages and features thereof, will be more readily understood by reference to the following detailed description when considered in conjunction with the accompanying drawings, wherein: 
         FIG.  1    shows a perspective view of a band clamp assembly with a band clamp implant securing a flexible band and spinal rod according to one embodiment; 
         FIG.  2    is a perspective view of the band clamp implant shown in  FIG.  1   ; 
         FIG.  3    is an exploded view of the band clamp implant; 
         FIG.  4    shows a cross-sectional view of the flexible band secured in the band clamp implant; 
         FIGS.  5 A- 5 B  show an embodiment of a flexible band and a close-up view of an anchor at the end of the flexible band; 
         FIG.  6    is a side cross-sectional view of the band clamp implant; 
         FIG.  7    is a top cross-sectional view of the anchor engaged with the band clamp implant; 
         FIG.  8    shows the flexible band passed through the band clamp implant with anchor; 
         FIG.  9    shows the flexible band attached to the band clamp at the anchor; 
         FIG.  10    shows a perspective view of a band clamp assembly according to one embodiment; 
         FIG.  11    is a perspective view of the band clamp implant show in  FIG.  10   ; 
         FIG.  12    is a perspective view of a band clamp assembly with a band clamp implant, a pedicle screw, a flexible band, and a spinal rod according to one embodiment; 
         FIG.  13    is an exploded view of the band clamp implant of  FIG.  12   ; 
         FIGS.  14 A- 14 C  show perspective, top, and cross-sectional views, respectively, of a locking cap post for securing the pedicle screw to the band clamp implant; 
         FIG.  15    is a perspective view of the locking cap post securing the spinal rod in the pedicle screw; 
         FIG.  16    shows a perspective view of the flexible band secured in the band clamp implant; 
         FIGS.  17 A- 17 B  show exploded and cross-sectional views, respectively, of the band clamp implant with the set screw and saddle configured for securing the band; 
         FIGS.  18 A- 18 B  show perspective views of the band clamp implant engaged with the pedicle screw and with a locking nut for securing the implant housing to the pedicle screw; 
         FIG.  19    shows a perspective view of a band clamp implant configured to secure the flexible band and spinal rod to a pedicle screw according to one embodiment; 
         FIG.  20    is a perspective view of the band clamp implant of  FIG.  19   ; 
         FIG.  21    is an exploded view of the band clamp implant of  FIG.  20   ; 
         FIGS.  22 A- 22 B  show cross-sectional views of the integrated screw head with the saddle in a loading position and a locked position, respectively; 
         FIGS.  23 A- 23 B  show an embodiment of the flexible band with a leader and a close up of a buckle; 
         FIG.  24    is a perspective view of the back of the band clamp implant showing a recess for receiving the buckle; 
         FIG.  25    is a cross-sectional view of the buckle in the recess; 
         FIG.  26    is a cross-sectional view of the band clamp implant showing the set screw and saddle configured for securing the band; 
         FIG.  27    is a perspective view of the band clamp implant with the flexible band attached; 
         FIGS.  28 A- 28 C  show the band clamp implant attached to the screw shank, the rod secured to the implant, and the band secured to the implant to create a loop, respectively; 
         FIG.  29    shows a perspective view of an integral band clamp implant configured to secure the flexible band and spinal rod to a pedicle screw according to one embodiment; 
         FIG.  30    is a perspective view of the band clamp implant of  FIG.  29   ; 
         FIG.  31    is an exploded view of the band clamp implant of  FIG.  30   ; 
         FIG.  32    is a perspective view of the band clamp implant attached to the screw shank; 
         FIG.  33    is a cross-sectional view of the implant showing set screws and saddles in the two band clamp portions of the implant; 
         FIGS.  34 A- 34 C  show perspective and cross-sectional views of a free band clamp configured for securing the flexible band according to one embodiment; 
         FIG.  35    shows a perspective view of a band clamp implant configured to secure the flexible band and spinal rod according to one embodiment; 
         FIG.  36    is a perspective view of the band clamp implant of  FIG.  35   ; 
         FIGS.  37 A- 37 B  show cross-sectional views of the band clamp implant without and with the buckle and band affixed thereto; 
         FIGS.  38 A- 38 C  show perspective views of the implant and band assembly, the band passed back through the implant to create a loop, and the implant assembly locked to the spinal rod; 
         FIG.  39    shows a perspective view of an implant system configured to secure the flexible band to the spinal rod according to one embodiment; 
         FIG.  40    shows a perspective view of the implant of  FIG.  39    attached to the spinal rod; 
         FIGS.  41 A- 41 B  show exploded and assembled views, respectively, of the implant of  FIG.  40   ; 
         FIGS.  42 A- 42 D  show cross-sectional views of the implant; 
         FIG.  43    shows the clamp for securing the band within the implant; 
         FIGS.  44 A- 44 B  show partial cross-sectional views of the drive screw in the implant; 
         FIGS.  45 A- 45 B  shows cross-sectional views of the band threaded through the implant with the clamp in an unlocked position and a locked position, respectively; 
         FIG.  46 A- 46 B  show a perspective view and an exploded view, respectively, of an implant system configured to lock a flexible band in tension without the presence of a spinal rod according to one embodiment; 
         FIGS.  47 A- 47 B  show perspective and cross-sectional views, respectively, of the implant of  FIGS.  46 A- 46 B ; 
         FIG.  48    is a perspective view of the carriage and clamp of the clamping assembly of the implant; 
         FIGS.  49 A- 49 B  show cross-sectional views of the implant with the locking assembly in unlocked and locked positions, respectively; 
         FIGS.  50 A- 50 B  show cross-sectional view of the implant with the band in the unlocked and locked positions, respectively; 
         FIGS.  51 A- 51 C  show an embodiment of an implant with a single thru hole to accept the band; 
         FIG.  52    is an exploded view of an implant having a cam lock according to one embodiment; 
         FIGS.  53 A- 53 B  show cross-sectional views of the cam lock in unlocked and locked positions, respectively; 
         FIGS.  54 A- 54 B  show bottom views of the implant with the cam lock in unlocked and locked positions, respectively; 
         FIG.  55    is a cross-sectional view of the implant with the cam lock in the locked position securing the band; 
         FIGS.  56 A- 56 C  show an embodiment of an implant including a housing and two spring blocks for securing the band; and 
         FIG.  57 A- 57 C  show an embodiment of a cross connector implant configured to secure two flexible bands. 
         FIGS.  58 A and  58 B  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIGS.  59 A and  59 B  show an exemplary embodiment of a locking mechanism consistent with the principles of the present disclosure. 
         FIGS.  60 A and  60 B  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIG.  61    shows an exemplary embodiment of a flexible band consistent with the principles of the present disclosure. 
         FIG.  62    shows an exemplary embodiment of an anchor consistent with the principles of the present disclosure. 
         FIG.  63    shows an exemplary embodiment of a band clamp system or assembly consistent with the principles of the present disclosure. 
         FIG.  64    shows a cross-section of an exemplary embodiment of an anchor disposed in an anchor slot consistent with the principles of the present disclosure. 
         FIG.  65    shows an exemplary embodiment of a band clamp system or assembly consistent with the principles of the present disclosure. 
         FIG.  66    shows an exemplary embodiment of a band clamp system or assembly consistent with the principles of the present disclosure. 
         FIG.  67    shows an exemplary embodiment of a band clamp system or assembly and tensioning instrument consistent with the principles of the present disclosure. 
         FIG.  68    shows a cross-section of an exemplary embodiment of a band clamp system or assembly consistent with the principles of the present disclosure. 
         FIG.  69    shows an exemplary embodiment of a band clamp system or apparatus consistent with the principles of the present disclosure. 
         FIGS.  70 A and  70 B  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIGS.  71 A and  71 B  show cross-section view of an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  72  and  73    show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIG.  74 A  shows an exemplary embodiment of an inserter fork consistent with the principles of the present disclosure. 
         FIG.  74 B  shows an exemplary embodiment of an outer sleeve consistent with the principles of the present disclosure. 
         FIG.  74 C  shows an exemplary embodiment of a tension indicator consistent with the principles of the present disclosure. 
         FIG.  74 D  shows an exemplary embodiment of an instrument assembly consistent with the principles of the present disclosure. 
         FIG.  75    shows an exemplary embodiment of a tension indicator consistent with the principles of the present disclosure. 
         FIG.  76    shows an exemplary embodiment of a tension indicator consistent with the principles of the present disclosure. 
         FIG.  77    shows an exemplary embodiment of an instrument assembly consistent with the principles of the present disclosure. 
         FIG.  78    shows a cross-section of an exemplary embodiment of an instrument assembly consistent with the principles of the present disclosure. 
         FIGS.  79 A,  79 B, and  80    shows a cross-section of an exemplary embodiment of an instrument assembly consistent with the principles of the present disclosure. 
         FIG.  81    shows an exemplary embodiment of a tensioning instrument including the instrument assembly consistent with the principles of the present disclosure. 
         FIGS.  82 A,  82 B, and  82 C  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIGS.  82 D and  82 E  show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  83 A,  83 B, and  83 C  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIGS.  84 A and  84 B  show an exemplary embodiment of a band and anchor consistent with the principles of the present disclosure. 
         FIGS.  85 A and  85 B  show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIG.  86    shows an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIG.  87    show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIGS.  88 A and  88 B  show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIG.  89    shows an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  90 A and  90 B  show an exemplary embodiment of a band clamp consistent with the principles of the present disclosure. 
         FIG.  91    shows an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  92 A,  92 B, and  92 C  show components of an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  93 A and  92 B  show components of an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  94 A and  94 B  show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  95 A and  95 B  show components of an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIGS.  95 C and  95 D  show an exemplary embodiment of a band clamp system consistent with the principles of the present disclosure. 
         FIG.  96    shows an exemplary embodiment of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  97    shows an exemplary embodiment of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  98    shows an exemplary embodiment of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIGS.  99 A- 99 B  show an exemplary embodiment of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIGS.  100 A- 100 B  shows an exemplary embodiment of an adjustable head for a tensioner consistent with the principles of the present disclosure. 
         FIGS.  101 A- 101 B  show an exemplary embodiment of portions of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  102    shows an exemplary embodiment of a band clamp inserter and a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  103    shows an exemplary embodiment of a band clamp inserter and a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIGS.  104 A- 104 B  show an exemplary embodiment of a band clamp inserter and a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  105    shows an exemplary embodiment of a tensioner for a band clamp consistent with the principles of the present disclosure. 
         FIG.  106    shows an exemplary embodiment of system for applying tension to a band clamp consistent with the principles of the present disclosure. 
     
    
    
     DETAILED DESCRIPTION 
     Embodiments of the disclosure are generally directed to implants, systems, and methods for securing the flexible band to bone. Specifically, embodiments are directed to implants and systems configured to achieve correction and provide fixation as an alternative and/or supplement to pedicle screws during spinal deformity surgery. 
     Additional aspects, advantages and/or other features of example embodiments of the disclosure will become apparent in view of the following detailed description. It should be apparent to those skilled in the art that the described embodiments provided herein are merely exemplary and illustrative and not limiting. Numerous embodiments of modifications thereof are contemplated as falling within the scope of this disclosure and equivalents thereto. 
     Referring now to  FIGS.  1 - 9   , a band clamp implant assembly or system  10  is shown according to one embodiment. The implant system  10  is configured to secure an elongate member, cable, tether, cord, or band  12  to a spinal rod  14 . The band  12  may be a flexible member configured to be wrapped around bony anatomy or a portion of the spine, such as the lamina or transverse process, for example. The implant assembly  10  may engage with an elongate member, such as a spinal rod  14 , to provide fixation between vertebrae. The flexible band  12  may be used as the primary fixation point at a particular spinal level when the placement of pedicle screws is difficult or impossible. Alternatively, the flexible band  12  may be used in conjunction with pedicle screws at a particular level to provide additional fixation. Although described with reference to the spine, it will be appreciated that the implants and systems described herein may be applied to other orthopedic locations and applications, such as trauma. 
     The flexible band  12  may be able to adapt to complex anatomies, such as severe spinal deformities. The assembly  10  allows the surgeon to achieve correction and fixation of a spinal deformity by securing the flexible band  12  to the spinal rod  14 . This technique may be advantageous in pediatric and neuromuscular deformity cases when traditional pedicle screw fixation is compromised or not possible due to the presence of weak bone or dysmorphic vertebrae. Before or after the implant assembly  10  is affixed to bone and/or secured to bone by looping the band  12  around the bony anatomy, correction of the spinal deformity may be achieved and held by the application of tension to the flexible band  12 . 
     The band  12  may be comprised of polyethylene terephthalates (PET), polyethylenes (e.g., ultrahigh molecular weight polyethylene or UHMWPE), polypropylenes, silk, polyamides, polyesters, polyacrylonitriles, silk cottons, combinations thereof, or other suitable biocompatible materials. The band  12  may be generally round, oval, or flat/tape geometry. The band  12  may transition from one geometry to another (e.g., a round to flat geometry or vice versa). If desired, the band  12  may be fully radiolucent or may have one or more marker strands that are designed to show up on fluoroscopy. 
     With emphasis on  FIGS.  1  and  2   , the implant assembly  10  includes a band clamp implant  20  capable of securing the flexible band  12  to the spinal rod  14 . The band clamp implant  20  has a main body  22  including an upper surface  24 , a lower surface  26 , first and second opposed side surfaces  28 ,  30 , a nose or front surface  32 , and a back or rear surface  34 . For example, the upper surface  24  and side surfaces  28 ,  30  may be generally flat or planar and the lower and back surfaces  26 ,  34  may be generally rounded or convex. 
     As shown in  FIGS.  3  and  4   , the band clamp implant  20  includes a main body  22 , a first locking member  38  configured to secure the rod  14 , and a second locking member  40  with a saddle  64  configured to secure the band  12 . With emphasis on  FIG.  6   , the main body  22  of the clamp  20  defines a first opening, recess, or rod slot  44  sized and dimensioned to accept the spinal rod  14  and a separate second opening or band slot  46  configured to accept the flexible band  12 . The rod slot  44  may be recessed into the front surface  32  of the implant  20  and may define a generally c-shaped recess sized and dimensioned to receive the rod  14 . The band slot  46  may extend from the lower surface  26  to the rear surface  34  of the implant  20 . The band slot  46  may be stepped such that a first portion rises up from the lower surface  26  and a second portion runs over to the back surface  34 . The band slot  46  is located beneath the rod slot  44  and is oriented perpendicular to a long axis A of the spinal rod  12 . 
     The main body  22  has a first hole  48  in fluid communication with the rod slot  44 . The first hole  48  may include a threaded portion  50  around an inner periphery of the hole  48 . The first locking member  38  is positionable within the first hole  48 , and when in a downward position, a bottom surface of the locking member  38  is configured to contact and secure the spinal rod  14  within the main body  22  of the implant  20 . The first locking member  30  may include a threaded portion  52  around an outer surface, which is configured to threadedly mate with the first hole  48 . The first locking member  30  may define an instrument recess  54  in an upper surface of the first locking member  30  configured to be engaged by an instrument, such as a driver, for rotating the locking member  38  into the locked position. 
     The main body  22  has a second hole  58  in fluid communication with the band slot  46 . The hole axis of the second hole  58  may be generally parallel to the hole axis of the first hole  48 . The second hole  58  may include a threaded portion  60  around an inner periphery of the hole  58 . As shown in  FIG.  4   , the second locking member  40  may be positioned within the second hole  58  to secure the flexible band  12  within the band slot  46 . The second locking member  40  may include a fastener or set screw  62  and a saddle  64 . The set screw  62  and saddle  64  may be attachable to one another. The set screw  62  is able rotate independently of the saddle  64 . The saddle  64  may define a ring or cylindrical body, and an upper surface of the saddle  64  may include one or more tabs or prongs  66  extending upwardly and/or outwardly. The prongs  66  may mate with a corresponding recess or groove within the lower surface of the set screw  62  to thereby connect the saddle  64  to the set screw  62 . The prongs  66  on the saddle  64  may flex inward when pressed into the set screw  62  and snap back to its original shape when it reaches the groove in the set screw  62 . The set screw  62  may include a threaded portion  68  around an outer surface, which is configured to threadedly mate with the second hole  58 . The set screw  62  may define an instrument recess  70  in an upper surface configured to be engaged by an instrument, such as a driver, for rotating the set screw  62  and moving the locking member  40  into the locked position. 
     When the second locking member  40  is in a downward position, a bottom surface of the saddle  64  is configured to contact and secure the band  12  within the main body  22  of the implant  20 . The set screw  62  and saddle  64  are able to travel up and down within the second threaded hole  58 . The travel of the set screw  62  is such that the saddle  64  may reversibly interfere with the band slot  46 . In a downward position, the saddle  64  is configured to press against the band  12 , thereby locking the band  12  in position. For example, a free portion of the flexible band  12  may be locked to the band clamp  20  by tightening the set screw  62 , which forces the bottom of the saddle  64  into contact with the flexible band  12 . The flexible band  12  is then locked between the saddle  64  and the main body  22 . 
     The main body  22  of the band clamp  20  may include one or more engagement recesses  72  for engagement with an insertion and/or tensioning instrument. For example, two opposed engagement recesses  72  may be defined within the side surfaces  28 ,  30 , near the rear  34  of the implant  20 . Each of the engagement recesses  72  may include a slot terminating in a circular divot, for example. It will be appreciated that other suitable engagement features may be used to temporarily couple the implant  20  to an instrument, such as inserter or tensioner. 
     With emphasis on  FIG.  5 A , the flexible band  12  may initially extend from a first free end  80  to an opposite free end  82  with a middle portion  84  in between. The middle portion  84  of the flexible band  12  is configured to contact and/or loop around bone. The first free end  80  of the flexible band  12  may be attached to a leader  86 . The leader  86  may be a malleable leader configured to be fed around anatomy to wrap the flexible band  12  around the anatomy to be fixated. The second free end  82  of the flexible band  12  may be attached to an anchor  88 . The anchor  88  may have a geometry such that the anchor  88  may be engaged with a mating recess  90  in the main body  22  of the band clamp  20 . As shown in  FIG.  6   , the mating recess  90  may be located beneath the band slot  46 . The entry of the mating recess  90  may be near the rear  34  of the implant  20  and the exit of the mating recess  90  may be into the band slot  46  near the bottom  26  of the implant  20 . The geometry of the mating recess  90  is sized and dimensioned such that the anchor  88  is receivable and securable within the recess  90 . 
     As shown in  FIG.  5 B , the anchor  88  may include a split ring body  92  with a central through opening  94 . The anchor  88  may have a nose  96  configured to attach to the end  82  of the band  12 , and a tail  98  receivable in the main body  22  of the implant  20 . The tail  98  may include a pair of opposed projections  102 . The projections  102  may be angled away from a central longitudinal axis B of the anchor  88  such that the projections  102  have a greater distance apart at the tail end  98 . The projections  102  may also have a greater thickness than the nose  96 . The central opening  94  may be in fluid communication with a cut  104 . The cut  104  may allow the anchor  88  to flex and squeeze into the mating recess  90  in the main body  22 . Once positioned fully within the mating recess  90 , the anchor  88  may spring back open to prevent disassembly. The anchor  88  may also have one or more openings  106  configured to engage with a mating instrument to allow disassembly. 
     As shown in  FIG.  8   , the flexible band  12  is inserted with the malleable leader  86  first, through recess  90  in the main body  22 . As shown in  FIG.  9   , the band  12  is pulled through until the anchor  88  engages and is seated within the recess  90  in the implant  20 . Engagement between the anchor  88  and the recess  90  causes the flexible band  12  to be securely attached to the main body  22  of the implant  20 . The first free end  80  of the flexible band  12  with the malleable leader  86  and the middle portion  84  of the band  12  remain free to be positioned around patient anatomy. As shown in  FIG.  1   , the middle portion  84  of the band  12  may be looped around bone and the free end  80  of the band  12  may be threaded back into the implant  20  through the band opening  46 . As shown in  FIG.  4   , the free end  80  may be pulled through the rear  34  of the implant  20 . After tensioning the band  12 , the second locking member  40  may be tightened, thereby securing the band  12  in the implant  20  and maintaining the desired tension around the bone. 
     Turning now to  FIGS.  10  and  11   , a band clamp implant assembly  110  is shown according to another embodiment. Band clamp implant assembly  110  is similar to implant assembly  10 , except with a different configuration for the implant  112 . Similar to implant  20 , implant  112  includes a first locking member  38  for securing the rod  14  and a second locking member  40  for securing the band  12 . In this embodiment, the band opening  114  is located adjacent to the rod slot  116  and the band opening  114  is oriented parallel to the long axis A of the spinal rod  14 . 
     The implant  112  has a first opening or rod slot  116  to accept the spinal rod  14  and a second opening or band opening  114  to accept the flexible band  12 . The rod slot  116  may be recessed into the front and bottom surfaces  32 ,  26  of the implant  20 . The rod slot  116  may define a generally c-shaped recess sized and dimensioned to receive the rod  14 . The band opening  114  may extend through the body between the first and second side surfaces  28 ,  30 . The band opening  114  may define a generally cylindrical opening. The implant  112  has a first threaded hole  48  in fluid communication with the first opening  116 . The first threaded locking member  38  may be positioned within the first threaded hole  48  to secure the spinal rod  14  to the implant  112 . The implant  112  has a second threaded hole  58  in fluid communication with the second opening  114 . The hole axis of the second threaded hole  58  may be generally perpendicular to the hole axis of the band opening  114 . 
     The implant  112  has a separate mating recess  118  sized and dimensioned to mate with the anchor  88  on the flexible band  12 . The mating recess  118  may be positioned beneath the band opening  114  and adjacent to the rod slot  116 . The recess  118  may extend through the body between the first and second side surfaces  28 ,  30 . The recess  118  may define a generally rectangular opening such that the recess  118  has a width greater than its height. The flexible band  12  may be inserted through the recess  118  such that the anchor  88  is engaged to the implant  112 . In this manner, the anchor  88  secures the flexible band  12  to the implant  112  at free end  82  of the band  12 . The flexible band  12  may be positioned around patient anatomy and the opposite free end  80  fed back through the band slot  114  in the implant  112 , thereby creating a loop. The second threaded locking member  40  may be positioned within the second threaded hole  58  and moved downwardly to secure the flexible band  12  to the implant  112 . 
     The implant  112  may define one or more engagement notches  120  for engagement with an insertion and/or tensioning instrument. For example, two opposed engagement notches  120  may be defined within the side surfaces  28 ,  30 , near the top 24 of the implant  112 . Each of the engagement notches  120  may include a slot extending along the length of the body, for example. It will be appreciated that other suitable engagement features may be used to temporarily couple the implant  112  to an instrument, such as inserter and/or tensioner. 
     According to one embodiment, a method of securing the flexible band  12  to the spinal rod  14  may involve one or more of the following steps in any suitable order. (1) Feeding the first free end  80  of flexible band  12  with the malleable leader  86  through the main body  22  of the band clamp implant  20 ,  112  and into a recess  90 ,  118  such that the first free end  80  and middle portion  84  of the flexible band  12  pass freely through the main body  22  while the second free end  82  of the flexible band  12  with the anchor  88  engages the recess  90 ,  118  and the flexible band  12  becomes secured to the band clamp  20 ,  112  at free end  82 . (2) Passing the first free end  80  of the flexible band  12  around bony anatomy of the posterior spine creating a loop such that the middle portion  84  of the flexible band  12  contacts bone. (3) Passing the first free end  80  of the flexible band  12  back through the band slot  46 ,  114  of the band clamp  20 ,  112 . (4) Positioning the band clamp  20 ,  112  along the spinal rod  14  such that the spinal rod  14  is accepted into the rod slot  44 ,  116  of the band clamp  20 ,  112 . (5) Tightening the first threaded locking component  38  in the band clamp  20 ,  112  to secure the spinal rod  14  in the rod slot  44 ,  116  to the band clamp  20 ,  112 . (6) Tensioning the flexible band  12  by providing a tensile force to the first free end  80  of the flexible band  12  thereby causing the loop to become tight around the bony anatomy. (7) Tightening the second threaded locking component  40  in the band clamp  20 ,  112  to force the saddle  64  into contact with the flexible band  12  in the band slot  46 ,  114  to secure the flexible band  12  to the band clamp  20 ,  112 . (8) Cutting and removing any excess length of the flexible band  12  near the band clamp  20 ,  112 . This method allows surgeons to achieve correction and fixation of a spinal deformity by securing the flexible band  12  to the spinal rod  14 . 
     Turning now to  FIGS.  12 - 18 B , a band clamp implant assembly or system  130  is shown according to one embodiment. Similar to implant systems  10 ,  110 , the implant  132  is configured to secure the flexible band  12  to the spinal rod  14 . In addition, the implant  132  connects the flexible band  12  to a fastener, such as a pedicle screw  200 , in order to provide additional fixation to the spine. The implant  132  is able to secure the flexible band  12  directly to the pedicle screw  200  without the need for additional rod connectors, which saves space on the construct and alleviates concerns over interference with other hardware and/or anatomy. Although a pedicle screw is exemplified herein, it will be appreciated that the fastener may include any suitable screw, anchor, or other device configured to attach to bone. 
     With emphasis on  FIGS.  12  and  13   , the implant system  130  includes a band clamp implant  132  capable of securing the flexible band  12  to the spinal rod  14 . The band clamp  132  has an implant housing  134  with a first portion  136  configured for securing the band  12  and a second portion  138  configured for attaching the rod  14  and the pedicle screw  200 . The second portion  138  may be stepped upward and may extend away from the first portion  138 . The medial offset of the band clamp portion  136  allows the clamp to be located directly over the lamina for optimal placement of the flexible band  12 . The implant housing  134  includes an upper surface  140 , a lower surface  142 , first and second side opposed surfaces  144 ,  146 , a nose or front surface  148 , and a back or rear surface  150 . 
     The implant system  130  includes an implant housing  132 , a locking cap post  152 , and a locking nut  154 . As shown in  FIGS.  14 A- 14 C , the locking cap post  152  has two distinct threaded portions: an upper threaded portion  156  and a lower threaded portion  158 . The upper threaded portion  156  is configured to mate with internal threads  160  in the locking nut  154 . The lower threaded portion  158  is configured to mate with internal threads in the head  202  of the pedicle screw  200 . The lower threaded portion  158  may be separated from the upper threaded portion  156  by a circumferential groove  166 . The lower threaded portion  158  may have a major outer diameter greater than the major outer diameter of the upper threaded portion  156 . The threads (e.g., handedness, form, angle, pitch, etc.) of the upper portion  156  may be the same or different than the threads of the lower portion  158 . The upper threaded portion  156  may include an internal drive recess  162  configured for engagement with a driving instrument. The upper threaded portion  156  may also include an internal groove  164  for engagement with an insertion instrument. The spinal rod  14  may be secured into the head  202  of the pedicle screw  200  when the locking cap post  152  is threaded downwardly through an opening  190  in the implant housing  134 , and the locking cap post  152  may be secured with the locking nut  154 . 
     With reference to  FIGS.  17 A- 17 B , the first portion  136  of the implant housing  134  is configured to secure the flexible band  12 . The first portion  136  of the implant housing  134  defines a band slot  170  configured to accept the flexible band  12 . The band slot  170  may be cylindrical or of suitable shape. The band slot  170  is intersected by a hole  172 . The hole  172  may be in fluid communication with the band slot  170 . The hole  172  may include a threaded portion  174  around an inner periphery of the hole  172 . A locking member  176  may be positioned within the hole  172  to secure the flexible band  12  within the band slot  170 . The locking member  176  may include a fastener or set screw  178  and a saddle  180 . The set screw  178  and saddle  180  may be attachable to one another. The saddle  180  may define a smooth, non-threaded ring or cylindrical body, and an upper surface of the saddle  180  may include one or more prongs  182  extending upwardly. The prongs  182  may mate with a corresponding recess within the lower surface of the set screw  178  to thereby connect the saddle  180  to the set screw  178 . The set screw  178  may include a threaded portion  184  around an outer surface, which is configured to threadedly mate with the hole  174 . 
     The set screw  178  may define an instrument recess  186  in an upper surface configured to be engaged by an instrument, such as a driver, for rotating the set screw  178  and moving the locking member  176  into the locked position. The set screw  178  and saddle  180  are attached to one another and are able to travel up and down within the threaded hole  174 . The travel of the set screw  178  is such that the saddle  180  may reversibly interfere with the band slot  170  which accepts the flexible band  12 . As shown in  FIG.  17 B , the flexible band  12  may be locked to the implant housing  134  by tightening the set screw  178 , which forces the saddle  180  into contact with the flexible band  12 . The flexible band  12  is then locked between the saddle  180  and the implant housing  134 . 
     The second portion  138  of the implant housing  134  is configured to engage the head  202  of the pedicle screw  200 . The second portion  138  of the implant housing  134  defines a thru hole  190  configured to accept the upper portion  156  of the locking cap post  152 . The thru hole  190  may be non-threaded. The second portion  138  of the housing  134  may include one or more tabs  192 . For example, the second portion  138  may include two opposed tabs  192  extending downwardly on opposite sides of the thru hole  190 . The tabs  192  may be configured to engage the rod slot  206  of the pedicle screw  200 . The geometry of the implant housing  134  is such that it fits tightly around the head  202  of the pedicle screw  200 . 
     As shown in  FIG.  15   , the pedicle screw  200  includes a head  202  and a shaft  204 . The head  202  may be in the form of a tulip with two opposing sides spaced apart by a slot  206  configured to receive the spinal rod  14 . The rod  14  may be top-loaded into the tulip body. The tulip head  202  may define one or more recesses or engagement features configured to mate with an instrument, such as an inserter. The opposing sides of the tulip head  202  may define internal threads configured to mate with the exterior threads on the lower portion  158  of the locking cap post  152 . The shaft  204  may include a threaded shank configured to engage bone. The pedicle screw  200  may be polyaxial, monoaxial, uniplanar, or of other suitable design. 
     With emphasis on  FIGS.  18 A- 18 B , the implant housing  134  is secured to the pedicle screw  200  with the locking cap post  152  and the locking nut  154 . In  FIG.  18 A , the locking cap post  152  is positioned through opening  190  in the implant housing  134  and into contact with the rod  14  positioned in the slot  206  in the head  202  of the pedicle screw  200 . In  FIG.  18 B , the locking nut  154  is secured to the upper portion  156  of the locking cap post  152 . The locking nut  154  has an internal thread  160  for engagement with the upper threaded portion  156  of the locking cap post  152 . The outer geometry of the nut  154  is such that the nut  154  may be driven by an instrument. The bottom surface of the locking nut  154  contacts the upper surface  140  of the implant housing  134  to secure the implant housing  134  to the pedicle screw  200 . The implant housing  134  is secured to the pedicle screw  134  via the force applied by the locking nut  154 . The tabs  182  on the implant housing  134  allow the implant housing  134  to remain stable in torsion during tightening by preventing rotation of the implant housing  134 . 
     According to one embodiment, a method of securing the flexible band  12  to the spinal rod  14  may involve one or more of the following steps in any suitable order: (1) securing the pedicle screw  200  into a pedicle of a vertebra; (2) positioning the rod  14  into the tulip head  202  of the pedicle screw  200 ; (3) attaching the implant  132  to the tulip head  202  of the pedicle screw  200  with the locking cap post  152  by threading the lower threaded portion  158  into mating threads within the tulip head  202 ; (4) connecting the locking nut  154  to the upper threaded portion  156  of the locking cap post  152  to lock the rod  14  in the tulip head  202 ; (5) feeding a free end of flexible band  12  into the band slot  170 ; (6) passing the other free end of the flexible band  12  around bony anatomy creating a loop that contacts bone; (7) passing the other free end of the flexible band  12  back through the band slot  170  of the band clamp  132 ; (8) tensioning the flexible band  12  by providing a tensile force to the free end(s) of the flexible band  12  thereby causing the loop to become tight around the bony anatomy; (9) tightening the locking member  176  in the band clamp  132  to force the saddle  180  into contact with the flexible band  12  in the band slot  170  to secure the flexible band  12  to the band clamp  132 ; and (10) cutting and removing any excess length of the flexible band  12  near the band clamp  132 . This method allows surgeons to achieve correction and fixation of a spinal deformity by securing the flexible band  12  to the spinal rod  14 . 
     Turning now to  FIGS.  19 - 28 C , a band clamp implant assembly or system  210  is shown according to one embodiment. Similar to implant system  130 , the implant  212  is configured to secure the flexible band  12  to the spinal rod  14 . In addition, the implant  210  connects the flexible band  12  to a bone fastener  214 , such as a pedicle screw, in order to provide additional fixation to the spine. Although a pedicle screw is exemplified herein, it will be appreciated that the fastener may include any suitable screw, anchor, or other device configured to attach to bone. 
     With emphasis on  FIGS.  19  and  20   , the implant system  210  includes a band clamp implant  212  capable of securing the flexible band  12  to the spinal rod  14 . The implant  212  includes an integrated screw head  220  and band clamp  218 . The main body  216  includes a first portion or band clamping portion  218  configured for securing the band  12  and a second portion or screw head portion  220  configured for attaching the rod  14  and the bone fastener or pedicle screw  214 . The first portion  218  may be offset laterally and back from the second portion  220  of the implant  212 . The medial offset of the band clamp portion  218  allows the clamp to be located directly over the lamina for optimal placement of the flexible band  12 . 
     The band clamping portion  218  has a band slot  222  configured to accept the flexible band  12 . The band clamping portion  218  has a through hole  224  intersecting and in fluid communication with the band slot  222 . The hole  224  may include one or more threads  226  around an inner periphery of the hole  224 . The locking member  228  may be positioned within the hole  224  to secure the flexible band  12  within the band slot  222 . As shown in  FIG.  21   , the locking member  228  may include a fastener or set screw  230  and a saddle  232 . The set screw  230  and saddle  232  may be attachable to one another. The saddle  232  may define a ring or cylindrical body, and an upper surface of the saddle  232  may include one or more prongs  234  extending upwardly. The prongs  234  may mate with a corresponding recess within the lower surface of the set screw  230  to thereby connect the saddle  232  to the set screw  230 . The set screw  230  may include one or more external threads  236  around an outer surface, which is configured to threadedly mate with the interior threads  226  of hole  224 . The set screw  236  may define an instrument recess  238  in an upper surface configured to be engaged by an instrument, such as a driver, for rotating the set screw  230  and moving the locking member  228  into the locked position. 
     The set screw  230  and saddle  232  may be attached to one another such that the set screw  230  and saddle  232  are able to travel up and down within the threaded hole  224 . The travel of the set screw  230  is such that the saddle  232  may reversibly interfere with the band slot  222  which accepts the flexible band  12 . The flexible band  12  may be locked to the band clamping portion  218  of the implant  212  by tightening the set screw  230 , which forces the saddle  232  into contact with the flexible band  12 . The flexible band  12  is locked between the saddle  232  and the band clamping portion  218  of the implant  212 . 
     The screw head portion  220  may be in the form of a tulip with two opposing sides spaced apart by a slot  240  configured to receive the spinal rod  14 . The rod  14  may be top-loaded into the tulip body. The opposing sides of the tulip head  220  may define internal threads  242  configured to mate with exterior threads  246  on the locking cap  244 . The tulip head  220  may define one or more recesses or engagement features configured to mate with an instrument, such as an inserter. The screw head portion  220  of the implant  212  is configured to reversibly attach to the bone fastener  214 . The bone fastener  214  may be bottom loaded into a bottom opening in the tulip body. The bone fastener  214  may include a head and a shaft portion  250 . The shaft  250  may include a threaded shank configured to engage bone. 
     With emphasis on  FIG.  21   , the screw head portion  220  may retain a clamp  252  and a screw head saddle  254  configured to reversibly attach to the screw shank  250 . The clamp  252  may include one or more clamp portions to provide a collar about the head of the bone fastener  214 . The clamp  252  is configured to grip the bone fastener  214  when force is applied onto the clamp  252 . The clamp  252  may define at least one slit  256  formed therein. For example, a pair of slits  256  may separate the clamp  252  into two clamp portions. The slit(s)  256  may be stepped, linear, curved, or otherwise configured. The slit(s)  256  may allow for first and second clamp portions to constrict and securely engage the head of the bone fastener  214 . A portion of the outer surfaces of the clamp  252  may be tapered and an upper portion may define an external lip  258  configured to be mated with the saddle  254 . An outer surface of the clamp  252  may abut and engage an inner surface of the tulip head  220  when fully installed and locked in place. When fully installed and locked in place, inner surfaces of the clamp  252  may abut and engage the head of the bone fastener  214 . The inner surfaces of the clamp  252  may include a roughened, textured, or threaded surface configured to improve engagement with the head of the bone fastener  214 . 
     The saddle  254  may be introduced downwardly from the top of the tulip head  220  to seat on top of the clamp  252 . The saddle  254  may include a through bore  260 . A lower portion of the bore  260  may be sized to receive the upper portion of the clamp  252 , including external lip  258  of the clamp  252 . The saddle  254  may include a generally rounded outer surface defining a recessed portion or groove  262 . The upper surface of the saddle  254  may define a convex seat  264  that receives the rod  14 , when loaded from the top of the tulip  220 . The saddle  254  may engage interior surfaces of the tulip head  220  to prevent upward movement of the clamp  252 , thereby locking the clamp  252  into engagement with the head of the bone fastener  214 . 
     With emphasis on  FIGS.  22 A- 22 B , geometry within the head portion  220  allows the clamp  252  and saddle  254  to be positioned above or below a modular bump  266 . In a loading position shown in  FIG.  22 A , the saddle  254  and clamp  252  are in an upward position. The clamp  252  and saddle  254  are positioned above the modular bump  266 , and the clamp  252  is able to flex open to accept the head of the screw shank  250 . In the locked position shown in  FIG.  22 B , the saddle  254  and clamp  252  are in a downward position. The clamp  252  and saddle  254  are positioned below the modular bump  266 , and the clamp  252  is unable to open and prevents the head of the screw shank  250  from being released. Once the spinal rod  14  is seated in the rod slot  240  and onto seat  264  of the saddle  254 , the threaded locking cap  244  is rotated downwardly to secure the spinal rod  14  and bone fastener  214  in the construct. 
     Turning now to  FIGS.  23 A- 23 B , the flexible band  12  may extend from a first free end  270  to an opposite second free end  272  with a middle portion  274  in between. The middle portion  274  of the flexible band  12  is configured to contact and/or loop around bone. The first free end  270  of the flexible band  12  may be attached to a leader  276 . The leader  276  may define an opening for guiding the band  12  with an instrument, k-wire, suture, or the like. The leader  276  may be a malleable leader configured to be fed around anatomy to wrap the flexible band  12  around the anatomy to be fixated. The second free end  272  of the flexible band  12  may be attached to an anchor or buckle  278 . The buckle  278  may have a geometry such that the buckle  278  may be engaged with a mating recess  280  in the implant  212 . As shown in  FIG.  19   , the mating recess  280  may be separate from and located beneath the band slot  222 . The hole axis of the mating recess  280  may be offset and transverse to the hole axis of the band slot  222 . The geometry of the mating recess  280  is sized and dimensioned such that the buckle  278  is receivable and securable within the recess  280 . 
     The buckle  278  may be conical in shape with one or more grooves  282  for engagement with corresponding grooves  288  in the mating recess  280  in the implant  212 . For example, the buckle  278  may include a plurality of circumferential grooves  282  extending from the widest part of the base of the buckle  278 . The buckle  278  has at least one flexure cut  284  to allow the outer geometry of the buckle  278  to squeeze into the mating recess  280 . The flexure cut  284  may cut through one or more of the grooves  282 . When the grooves  282  on the buckle align with the grooves  288  in the recess  280 , the flexure cut  284  allows the buckle  278  to spring back to its original shape, thus preventing disassembly. The buckle  278  includes a loop  286 , around which the flexible band  12  may be attached. As shown in  FIG.  23 A , the free end  272  of the band  12  may be looped repeatedly around the loop  286  of the buckle  278  to secure the band  12  to the buckle  278 . It will be appreciated that other suitable attachment mechanisms, such as knotting, fasteners, adhesives, or the like, may be used to secure the band  12  to the buckle  278 . 
     As shown in  FIGS.  24 - 27   , the implant  212  defines an internal recess  280  configured to accept the flexible band  12  and buckle  278 . The internal recess  280  defines a plurality of grooves  288  that mate with the grooves  282  on the buckle  278 . As the flexible band  12  is passed through the recess  280 , from back to front, the buckle  278  snaps into the mating grooves  288 . After assembly, the flexible band  12  is securely attached to the implant  212  via buckle  278  at free end  272  of the band  12 . 
     As shown in  FIGS.  28 A- 28 C , after the flexible band  12  is passed through the recess  280 , the buckle  278  snaps into place, thereby securing the flexible band  12  to the implant  212 . As shown in  FIG.  28 A , the tulip body  220  is then attached to the screw shank  250  by bottom loading the screw  214  into the tulip  220 . As shown in  FIG.  28 B , the spinal rod  14  may be placed in the rod slot  240  from the top of the tulip  220  and secured with the locking cap  244 . The locking cap  244  also secures the polyaxial screw  214  via the downward force onto the screw head saddle  254  and clamp  252 . As shown in  FIG.  28 C , the free end  270  of the flexible band  12  is passed around the bony anatomy and back into the band clamp portion  218  of the implant  212  through the band slot  222  to create a loop. The loop is tensioned to provide fixation to the bone and then the set screw  230  of the locking member  228  is tightened downwardly to lock the flexible band  12  to the implant  212 . 
     Turning now to  FIGS.  29 - 33   , a band clamp implant assembly or system  300  is shown according to one embodiment. Similar to implant system  210 , the implant  302  is configured to secure the flexible band  12 , spinal rod  14 , and bone fastener  214 . In this embodiment, the system  300  includes two band clamp portions  306 ,  308  configured to receive and secure the band  12  integrally connected to a single tulip-style head  304 . 
     The implant  302  includes an integrated screw head  304  with two band clamps  306 ,  308 . As shown in the exploded view in  FIG.  31   , the integrated screw head portion  304  is the same as integrated tulip-style screw head  220  and includes clamp  252  and saddle  254 , which reversibly attach to the screw shank  250 . The geometry within the head portion  220  allows the clamp  252  and saddle  254  to be positioned above or below the modular bump  266 . In the loading position when the clamp  252  and saddle  254  are positioned above the modular bump  266 , the clamp  252  is able to flex open to accept the head of the screw shank  250 . In the locked position when the clamp  252  and saddle  254  are positioned below the modular bump  266 , the clamp  252  is unable to open and prevents the head of the screw shank  250  from being released. The screw head portion  304  includes rod slot  240  to accept the spinal rod  14  and accepts the threaded locking cap  244  to secure the spinal rod  14 . 
     The implant  302  includes two band clamps  306 ,  308 , which are separate and distinct from one another. A first band clamp  306  sits toward the front of the implant  302  and a second band clamp  308  sits toward the back of the implant  302 . Both clamps  306 ,  308  may be medially offset to the pedicle screw  214 , which allows the clamps  306 ,  308  to be located directly over the lamina for optimal placement of the flexible band  12 . 
     Band clamps  306 ,  308  may be similar to band clamp  218 . Each band clamp portion  306 ,  308  has a band slot  310 ,  312  for accepting the flexible band  12  and a threaded hole  314 ,  316 , which intersects the respective band slot  310 ,  312 . The front band slot  310  may be aligned with the back band slot  312 . For example, as shown in  FIG.  33   , a central hole axis of the front band slot  310  may be coaxial with a central hole axis of the back band slot  312  along axis C. The threaded holes  314 ,  316  may be aligned generally perpendicular to axis C. The front threaded hole  314  may be positioned generally parallel to the back threaded hole  316 . 
     The implant  302  includes two locking members  318 ,  320  receivable in the respective holes  314 ,  316 . Similar to locking member  228 , each of the locking members  318 ,  320  may include a set screw  322 ,  324  engaged with a saddle  326 ,  328 , respectively. The set screw  322 ,  324  and saddle  326 ,  328  travel within the respective threaded hole  314 ,  316  such that the saddle  326 ,  328  can reversibly interfere with the band slot  310 ,  312 . Each band slot  310 ,  312  may accept one free end of the flexible band  12 , thereby creating a loop therebetween. The set screws  322 ,  324  are threaded downward, which forces the saddles  326 ,  328  to contact the band  12 . The force applied by the thread locks the flexible band  12  between the saddle  326 ,  328  and the main body of the clamps  306 ,  308 . 
     According to one embodiment, a method of securing the flexible band  12  to the spinal rod  14  may involve one or more of the following steps in any suitable order: (1) securing the pedicle screw  214  into a pedicle of a vertebra; (2) bottom loading the pedicle screw  214  into the tulip head  304  of the implant  302 ; (3) top loading the rod  14  into the tulip head  304  of the implant  302 ; (4) connecting the locking cap  244  to the top of the tulip head  304  to lock the rod  14  and the position of the pedicle screw  214 ; (5) feeding a free end of flexible band  12  into the band slot  310  of the front band clamp  306 ; (6) passing the other free end of the flexible band  12  around bony anatomy creating a loop that contacts bone; (7) passing the other free end of the flexible band  12  into the band slot  312  of the rear band clamp  308 ; (8) tensioning the flexible band  12  by providing a tensile force to the free end(s) of the flexible band  12  thereby causing the loop to become tight around the bony anatomy; (9) tightening the locking members  318 ,  320  in the band clamps  306 ,  308  to force the respective saddles  326 ,  328  into contact with the flexible band  12  in the band slots  310 ,  312  to secure the flexible band  12  to the band clamps  306 ,  308 ; and (10) cutting and removing any excess length of the flexible band  12  near band clamps  306 ,  308 . This method allows surgeons to achieve correction and fixation of a spinal deformity. 
     Turning now to  FIGS.  34 A- 34 C , a band clamp implant assembly or system  340  is shown according to one embodiment. The implant system  340  includes a free band clamp implant  342 , which is not intended to secure the flexible band  12  to a pedicle screw or spinal rod. The free band clamp  342  has a main body defining a band slot  344  for receiving the band  12  therethrough. The band slot  344  may extend through the body of the clamp  342  from the front to the back of the implant  342 . The body further defines a threaded hole  346 , which intersects the band slot  344 . 
     The implant  342  is configured to retain a locking member  348  which includes a set screw  350  and a saddle  352 . The set screw  350  and saddle  352  are attached to one another and able to translate within the threaded hole  346 . The set screw  350  may have a groove  354  on the lower inner portion that mates with one or more tabs or prongs  356  on the saddle  352 . The tabs or prongs  356  on the saddle  352  may flex inward when pressed into the set screw  350  and snap back to its original shape when it reaches the groove  354 . The set screw  350  is able rotate independently of the saddle  352 . 
     The band slot  344  is able to accept one or both ends of the flexible band  12 . When the set screw  350  is threaded downward, the saddle  352  is forced into contact with the flexible band  12 . The force exerted by the threads of the set screw  350  secures the flexible band  12  in the band slot  344  between the saddle  352  and a lower surface of the implant  342 . The implant  342  may include one or more recesses  358  or other suitable feature for engagement with an insertion and/or tensioning instrument. The implant  342  is configured to lock the flexible band  12  in tension after the flexible band  12  has been wrapped around bony anatomy to provide fixation. In particular, the band  12  may be threaded through the band slot  344 , looped around bone, and threaded back through the same band slot  344 . The single locking member  348  then locks both ends of the band  12 , thereby maintaining the tension to the band  12 . 
     Turning now to  FIGS.  35 - 38 C , a band clamp implant assembly or system  360  is shown according to one embodiment. Similar to implant system  10 , the implant  362  is configured to connect the flexible band  12  to the spinal rod  14 , which may provide supplemental fixation to pedicle screws, for example. The implant  362  may be useful in providing additional fixation in patients with poor bone quality and/or where pedicle screw fixation may be insufficient. 
     As shown in  FIGS.  35  and  36   , the implant  362  includes a main body  364  and a securing member, such as a set screw  366 , configured for retaining the spinal rod  14  in the implant  362 . The main body  364  defines a rod slot  368  configured to accept the spinal rod  14  and a threaded hole  370 , which intersects the rod slot  368 . The threaded hole  370  may be offset relative to the rod slot  368 . The set screw  366  is able to thread up and down within the threaded hole  370  in order to reversibly interfere with the rod slot  368 . The lower surface of the set screw  366  may be angled in order to press against the rod  14 . In a locked position, the lower surface of the set screw  366  contacts the rod  14 , thereby securing the rod  14  in the rod slot  368 . 
     With emphasis on  FIG.  37 A , the main body  364  defines a band slot  372  perpendicular to the axis of the spinal rod  14 . The band slot  374  may slope from a rear of the implant  362  towards rod slot  368 . The band slot  372  may extend from an upper surface of the implant  362  into fluid communication with the rod slot  368 . The band slot  372  may terminate below the rod slot  368  near the bottom of the implant  362 . The main body  364  of the implant  362  further defines an internal recess  374  configured to receive an anchor or buckle  380 . The internal recess  374  intersects the band slot  372  and the rod slot  368 . The internal recess  374  extends from a rear of the main body  364  and is angled or sloped downward and into the rod slot  368 . The internal recess  374  includes one or more grooves  376  configured to secure the buckle  380  in the implant  362 . 
     The main body  364  of the band clamp  362  may include one or more engagement recesses  378  for engagement with an insertion and/or tensioning instrument. For example, two opposed engagement recesses  378  may be defined within the side surfaces near the rear of the implant  362 . Each of the engagement recesses  378  may include a slot terminating in a circular divot, for example. It will be appreciated that other suitable engagement features may be used to temporarily couple the implant  362  to an instrument, such as inserter or tensioner. 
     As previously described for  FIG.  23 A , the flexible band may have two free ends  270 ,  272  with a middle portion  274  in between. The middle portion  274  of the flexible band  12  is intended to contact bone. One free end  270  of the flexible band  12  may be optionally attached to a malleable leader  276 , which can be fed around anatomy to wrap the flexible band  12  around the anatomy. The second free end  272  of the flexible band  12  is attached to the buckle  380 . 
     Similar to buckle  278 , the buckle  380  may be conical in shape with grooves  382  for engagement with grooves  376  in the mating recess  374  in the main body  364  of the implant  362 . The buckle  380  may include a flexure cut configured to allow the outer geometry to squeeze into the mating recess  374 . When the grooves  382  on the buckle  380  align with the grooves  376  in the recess  374 , the flexure allows the buckle  380  to spring back to its original shape, thus preventing disassembly. The buckle  380  may also include a loop, around which the flexible band  12  may be attached. The internal recess  374  in the main body  364  may accept the flexible band  12 . The internal recess  374  has grooves  376  that mate with the grooves  382  on the buckle  380 . The flexible band  12  is passed thru the recess  374  and the buckles  380  snaps into the mating grooves  376 . After assembly, the flexible band  12  is securely attached to the main body  364  at one end. 
     As shown in  FIGS.  38 A- 38 C , the flexible band  12  is passed through the recess  374  in the main body  364  until the buckle  380  snaps into place and the flexible band  12  is secured to the main body  364 . As shown in  FIG.  38 A , the band  12  travels beneath the rod slot  368 , and the free end  274  of the flexible band  12  is passed around the bony anatomy. As shown in  FIG.  38 B , the free end  274  is passed back into the main body  364 , beneath the rod slot  368  and up through the band slot  372  to create a loop. As shown in  FIG.  38 C , the implant  362  is placed onto the spinal rod  14  and the set screw  366  is partially tightened to provisionally secure the spinal rod  14  into the rod slot  368  of the implant  362 . The partial tightening allows the flexible band  12  to slide freely through the band slot  372 . A tensioning device may be used to apply tension to the free end  272  of the band  12 . The loop is tensioned to provide fixation to the bone. Then, the set screw  366  is final tightened. Final tightening of the set screw  366  forces the rod  14  to contact the flexible band  12 , locking the tension in the loop, as well as securing the implant  362  to the spinal rod  14 . 
     Turning now to  FIGS.  39 - 45 B , a band clamp implant assembly or system  400  is shown according to one embodiment. Similar to implant system  362 , the implant  402  is configured to connect the flexible band  12  to the spinal rod  14  in order to provide fixation to the spine. The band  12  is wrapped around bony anatomy, such as the lamina or transverse process, and then a tensile force is applied to translate the spine to the spinal rod  14 . After sufficient translation has been achieved to correct the deformity, the tensioned band  12  is locked to the spinal rod  14  with the band clamp  402 . Bands  12  may be advantageous in pediatric and neuromuscular deformity cases due to the high prevalence of weak bone and dysmorphic vertebrae which may make pedicle screw placement difficult or impossible. 
     As shown in  FIGS.  41 A- 41 B , the implant  402  includes an implant housing  404 , drive screw  406 , clamp  408 , and locking cap  410 . The implant housing  404  has a rod slot  412  configured to accept the spinal rod  14  and a through hole  414 , which intersects the rod slot  368 . The rod  14  may be side loaded into the rod slot  412 . The hole  414  may be generally in line with the rod slot  412  such that a hole axis of the hole  414  is generally perpendicular to the long axis of the rod  14 . The hole  414  may define threads therein. The locking cap  410  is configured to engage the rod  14  located in the rod slot  412  to fix the rod  14  relative to the implant housing  404 . The locking cap  410  may be in the form of a threaded set screw with a recess  416  in the upper surface of the locking cap  410  configured to receive a driver instrument. When rotated, the locking cap  410  is able to thread up and down within the threaded hole  414  in order to reversibly interfere with the rod slot  412 . The lower surface of the locking cap  410  may be generally planar in order to press against the rod  14 . In a locked position, the lower surface of the locking cap  410  contacts the rod  14 , thereby securing the rod  14  in the rod slot  412 . 
     As shown in  FIGS.  42 A- 42 D , the implant housing  404  has an elongate channel  418 , a pocket  420 , and a groove  422 . The channel  418  is configured to accept the clamp  408  and the pocket  420  is configured to accept the drive screw  406 . The pocket  420  may extend from an upper surface of the housing  404  and into fluid communication with the channel  418 . The channel  418  may extend from the pocket  420  and through to the lower surface of the housing  404 . The channel  418  and pocket  420  may be coaxial along axis D. The hole axis of the hole  414  for the locking cap  410  may be generally parallel to axis D. The groove  422  in the implant housing  404  is configured to receive the flexible band  12 . The groove  422  is located beneath the rod slot  412 . The groove  422  in the implant housing  404  is positioned such that the groove  422  intersects the implant passage  436  in the clamp  408 . 
     The housing  404  of the band clamp  402  may include one or more engagement or holding recesses  424  for engagement with an insertion and/or tensioning instrument. For example, two opposed engagement recesses  424  may be defined within the side surfaces near the rear of the implant  402 . Each of the engagement recesses  424  may include a slot from the upper surface and terminating in a circular divot, for example. It will be appreciated that other suitable engagement features may be used to temporarily couple the implant  402  to an instrument, such as inserter and/or tensioner. 
     The drive screw  406  includes an enlarged head  426  and a shaft  428 . The head  426  may be define an instrument recess  430  in an upper surface configured to engage an instrument, such as a driver. Instrument recess  430  in the drive screw  406  may be different than instrument recess  416  in the locking cap  410 . The shaft  428  may be threaded along its length. As shown in  FIGS.  42 C- 42 D , the drive screw  406  may engage the clamp  408  such that the clamp  408  is able to translate within the channel  418  in the implant housing  404  between a first position and a second position. 
     As shown in  FIG.  43   , the clamp  408  includes a bore  434  configured to accept the shaft  428  of the drive screw  406  and an intersecting implant passage  436  configured to accept the flexible band  12 . The bore  434  extends from an upper surface of the clamp  408  and into fluid communication with the passage  436 . The bore  434  may be at least partially threaded to engage the external threads of the shaft  428  of the drive screw  406 . The passage  436  extends through the body of the clamp  480 . 
     With emphasis on  FIGS.  44 A- 44 B , the pocket  420  in the implant housing  404  and the head  426  of the drive screw  406  each contain a groove configured to accept a first retaining ring  440 . The first retaining ring  440  holds the drive screw  406  in position within the implant housing  404 . The drive screw  406  is able is rotate freely about its long axis but may not translate within the implant housing  404 . The implant  402  may optionally include a thrust washer  442  located between the head  426  of the drive screw  406  and the bottom of the pocket  420  in the implant housing  404 . The implant  402  may also optionally include a drag ring  444  located around the head  426  of the drive screw  406  within the pocket  420  of the implant housing  404 . The drag ring  444  may be positioned between the retaining ring  440  and the thrust washer  442 . The clamp  408  may define a counter bore and the distal end of the drive screw  406  may define a groove configured to accept a second retaining ring  446 . The second retaining ring  446  prevents the clamp  408  from disengaging from the drive screw  406  after assembly. 
     With emphasis on  FIGS.  45 A- 45 B , the implant housing  404  and the clamp  408  each have a surface configured to contact the flexible band  12 . The implant housing  402  has geometry such that the distance between these surfaces changes depending on where the clamp  408  is located within the channel  418  in the implant housing  404 . As shown in  FIG.  45 A , when the clamp  408  is located in a first unlocked position within the channel  418  in the implant housing  404 , the distance between the surfaces is of sufficient space for the flexible band  12  to pass thru the implant passage  436  in the clamp  408 . As shown in  FIG.  45 B , when the clamp  408  is located in a second locked position within the channel  418  in the implant housing  404 , the distance between the surfaces is decreased such that the surfaces contact and pinch the flexible band  12 , thereby securing the band  12  in the implant  402 . 
     According to one embodiment, a method of securing the flexible band  12  may involve one or more of the following steps in any suitable order: (1) feeding a free end of flexible band  12  into the rear of the implant housing  404  through the band slot  422  and out through the front of the implant housing  404 ; (2) passing the free end of the flexible band  12  around bony anatomy creating a loop that contacts bone; (3) passing the free end of the flexible band  12  back into the same band slot  422  at the front of the housing  404  beneath the rod slot  412  and though to the back of the housing  404 ; (4) tensioning the flexible band  12  by providing a tensile force to the free end(s) of the flexible band  12  thereby causing the loop to become tight around the bony anatomy; (5) rotating the drive screw  406  to move the clamp  408  to the locked position, thereby securing the flexible band  12  in the clamp  408 ; and (6) cutting and removing any excess length of the flexible band  12  near the rear of the housing  404 . This method allows surgeons to achieve correction and fixation of a spinal deformity. This technique may be advantageous in pediatric and/or neuromuscular deformity cases when traditional pedicle screw fixation is compromised or not possible due to the presence of weak bone or dysmorphic vertebrae. 
     Turning now to  FIGS.  46 - 50 B , a band clamp implant assembly or system  460  is shown according to one embodiment. The implant  462  is configured to lock the flexible band  12  in tension without the presence of a spinal rod. Sublaminar bands  12  may be used to provide posterior fixation of the spine as an alternative or supplement to pedicle screw instrumentation. The implant  462  may be useful in patients with poor bone quality or difficult anatomy where the interface between bone and implant is compromised. For example, patients with pediatric deformity may present with dysmorphic vertebrae, which restrict the use of pedicle screws. The risk of screw pullout may be increased in patients with osteoporosis due to weak connection between the bone and the implant. Additionally, sublaminar bands  12  may be used in cases where patients present with fractured anatomy. The band  12  may wrapped around the fracture site, such as C2 fracture(s) of the odontoid, and tensioned to provide fixation and promote healing. In these clinical scenarios, it may be advantageous to have implants  462  which lock the sublaminar band  12  in tension. 
     As shown in  FIGS.  46 A- 46 B , the implant  462  may include an outer body  464 , a drive screw  466 , and a clamping assembly  468 . With emphasis on  FIG.  47 A , the outer body  464  defines first and second band slots  470 ,  472  configured to accept the flexible band  12 . The band slots  470 ,  472  may each extend from the upper surface to the lower surface of the body  464 . The band slots  470 ,  472  may be elongated in width to accommodate the flat profile of the band  12 . With emphasis on  FIG.  47 B , the outer body  464  defines a recess  474  extending from the upper surface to the lower surface of the body  464 . The recess  474  includes a pocket  476  and a through hole  478 , where the drive screw  466  rests. The band slots  470 ,  472  and recess  474  may form ramped surfaces  480  toward a lower portion of the body  464 . The ramped surfaces  480  may be angled such that they have a narrow width toward the top of the body  464  and a greater width toward the bottom of the body  464 . 
     The outer body  464  defines one or more engagement recesses  482  configured to mate with an instrument for providing tension to the flexible band  12  before locking. For example, two opposed engagement recesses  482  may be defined within the side surfaces near the top of the implant  462 . It will be appreciated that other suitable engagement features may be used to temporarily couple the implant  462  to an instrument, such as inserter and/or tensioner. 
     The drive screw  466  includes an enlarged head  484  and a shaft  486 . The head  484  may be define an instrument recess  488  in an upper surface configured to engage an instrument, such as a driver. The shaft  486  may be threaded along its length. The drive screw  466  is retained within the outer body  464  by a first retaining ring  490 . The drive screw retaining ring  490  may be in the form of a split ring. The split ring  490  may sit in a groove  492  in the head  484  of the drive screw  466 . 
     With emphasis on  FIG.  48   , the clamping assembly  468  includes a carriage  500  and a clamp  502 . The clamp  502  is split into two halves defining a cylindrical opening  504  for receiving the carriage  500 . When assembled with the carriage  500 , the two halves of the clamp  502  may be separated by a gap  506 . The side surfaces of the clamp  502  may be angled surfaces  508 , which mimic the ramped surfaces  480  in the body  464  of the implant  462 . The opening  504  defines an internal groove  510  configured to engage the carriage  500 . The carriage  500  defines a generally cylindrical body with a central hole  512  extending from the upper surface to the lower surface of the carriage  500 . The central hole  512  may be threaded such that the clamping assembly  468  may threaded onto the drive screw  466 . The distal end of the drive screw  466  has a groove  494 , in which a second retaining ring  496  sits. The second retaining ring  496  may be in the form of a split ring, which prevents the clamping assembly  468  from threading off of the drive screw  466 . The carriage  500  may define an exterior annulus  518  forming a middle band around the center of the carriage  500 . The annulus  518  may be received within the groove  510  in the clamp  502 , thereby connecting the clamp  502  to the carriage  500 . 
     The implant  462  may optionally include a drag ring  514  located around the head  484  of the drive screw  466  within the pocket  476  of the body  464 . The drag ring  514  may be in the form of a split ring. The implant  462  may also optionally include a friction ring  516  to impart friction to the drive screw  466 . The friction ring  516  may be in the form of a washer located between the head  484  of the drive screw  466  and the bottom of the pocket  476  in the body  464  of the implant  462 . 
     With emphasis on  FIGS.  49 A- 49 B , when the drive screw  466  is actuated, the clamping assembly  468  may translate up and down. As shown in  FIG.  49 A , the inner surface of the outer body  464  and the outer surface of the clamp  502  have mating ramped geometries  480 ,  508  such that there is clearance for the flexible band  12  to pass through the implant  462  when the clamping assembly  468  is in a first open position. In the open position, the clamping assembly  468  is in a downward location to allow the band  12  to pass through the band slots  470 ,  472 . As shown in  FIG.  49 B , actuation of the drive screw  466  translates the clamping assembly  468  into a locked second position, in which the clamping assembly  468  contacts the flexible band  12  against the inner surface of the outer body  464 , thus locking the band  12 . In the locked position, the clamping assembly  468  is in an upward location which pinches the band  12  between the clamp  502  and the body  464  of the implant  462 . 
     According to one embodiment, a method of securing the flexible band  12  to the spinal rod  14  may involve one or more of the following steps in any suitable order: (1) while the clamping assembly  468  is in a downward open position as shown in  FIG.  50 A , feeding a free end of flexible band  12  through the first band slot  470 ; (2) passing the other free end of the flexible band  12  around bony anatomy creating a loop that contacts bone; (3) passing the other free end of the flexible band  12  through the second band slot  472 ; (4) tensioning the flexible band  12  by providing a tensile force to the free end(s) of the flexible band  12  thereby causing the loop to become tight around the bony anatomy; (5) rotating the drive screw  466  to move the clamp  502  upward into the locked position as shown in  FIG.  50 B , thereby securing the flexible band  12  in the implant  462 ; and (6) cutting and removing any excess length of the flexible band  12 . 
     Turning now to  FIGS.  51 A- 51 C , a band clamp implant assembly or system  520  is shown according to one embodiment. Implant  522  is similar to implant  462  except only a single band slot  524  is provided, which accepts both ends of the band  12 . The single band slot  524  extends from the top to the bottom of the implant  522 . Actuation of the drive screw  466  causes the clamping assembly  468  to translate up and down within the implant  522 . In  FIG.  51 C , the clamping assembly  468  is shown in the open configuration with the clamp  502  positioned downward in the body  464 . The band  12  may be threaded through the single band slot  524 , wrapped around bone, and then threaded back through the same band slot  524 . After tensioning the band  12 , the clamping assembly  468  may be moved upward to lock the band  12 . The ramped geometry  508  of the clamp  502  contacts the band  12  and secures the band  12  against the ramped geometry  480  of the outer body  464 . Since the opposite side of the clamp  502  and recess  474  is absent the second band slot, the mating geometry may be generally planar or of other suitable configuration. 
     Turning now to  FIGS.  52 - 55   , a band clamp implant assembly or system  530  is shown according to one embodiment. Similar to implant  522 , the implant  532  includes a single band slot  538 , which accepts both ends of the band  12 . In this embodiment, a rotatable cam lock  536  is used to secure the band  12  in the implant  532 . 
     With emphasis on  FIG.  52   , the implant  532  includes an outer body  534  and a cam lock  536 . The outer body  534  has a band slot  538  configured to accept the flexible band  12 . The band slot  538  may extend from the upper surface to the lower surface of the body  534 . The band slot  538  may be elongated in width to accommodate the flat profile of the band  12 . The outer body  534  defines a recess  540  extending from the upper surface to the lower surface of the body  534 . The recess  540  includes a pocket  542  and a through hole  544 , where the cam lock  536  rests. The outer body  534  may include one or more engagement recesses  546  configured to mate with an instrument for providing tension to the flexible band  12  before locking. 
     The cam lock  536  may include a head  550  with a cam body  552 . The head  550  may be define an instrument recess  554  in an upper surface configured to engage an instrument, such as a driver. The cam body  552  is offset relative to the longitudinal axis of the head  550  such that a cam engagement surface  556  projects laterally outward. The cam lock  536  is retained within the outer body  534  by a retaining ring  558 . The cam lock retaining ring  558  may be in the form of a split ring. The split ring  558  may sit in a groove  560  near the top of the head  550  of the cam lock  536 . 
     The implant  532  may optionally include a drag ring  562  located around the head  550  of the cam lock  536  and within the pocket  542  of the body  534 . The drag ring  562  may be in the form of a split ring located beneath the retaining ring  558 . The implant  532  may also optionally include a friction ring  564  to impart friction to the cam lock  536 . The friction ring  564  may be in the form of a split ring located between the head  550  of the cam lock  536  and the bottom of the pocket  542  in the body  534  of the implant  532 . 
     With emphasis on  FIGS.  53 A- 53 B , the cam lock  536  may be rotated into and out of engagement with the band slot  538  to secure the band  12  therein. As shown in  FIG.  53 A , the cam lock  536  may turn within the outer body  534  such that there is space to pass the flexible band  12  through the slot  538  in the outer body  534  when the cam lock  536  is in a first open position. As shown in  FIG.  53 B , when the cam lock  536  is actuated, the cam surface  556  is configured to contact the flexible band  12  against the inner surface of the outer body  534 , thereby locking the band  12  in the implant  532 .  FIG.  54 A  shows a bottom view of the implant  532  with the cam lock  536  in the unlocked position, thereby allow the band  12  to pass freely through slot  538 .  FIG.  54 B  shows the implant  532  with the cam lock  536  in the locked position, thereby locking the band  12  in the implant  532 . 
     According to one embodiment, a method of securing the flexible band  12  to bone may involve one or more of the following steps in any suitable order: (1) while the cam body  552  is in its open position, feeding a free end of flexible band  12  through the band slot  538 ; (2) passing the free end of the flexible band  12  around bony anatomy creating a loop that contacts bone; (3) passing the free end of the flexible band  12  back through the same band slot  538 ; (4) tensioning the flexible band  12  by providing a tensile force to the free end(s) of the flexible band  12  thereby causing the loop to become tight around the bony anatomy; (5) rotating the cam lock  536  to move the cam body  552  into the locked position as shown in  FIG.  55   , thereby securing the flexible band  12  in the implant  532 ; and (6) cutting and removing any excess length of the flexible band  12 . 
     Turning now to  FIGS.  56 A- 56 C , a band clamp implant assembly or system  570  is shown according to one embodiment. Similar to implant  532 , the implant  572  includes a single band slot  578 , which accepts both ends of the band  12 . In this embodiment, one or more spring blocks  576  are used to secure the band  12  in the implant  572 . 
     The implant  572  includes a housing  574  and a pair of spring blocks  576 . The band slot  578  in the housing  574  is configured to accept the flexible band  12 . The band slot  578  may extend from an upper surface to a lower surface of the housing  574 . The housing  574  may be bowed or convex along the upper surface. A pair of parallel openings  580  may extend from the front to the back of the housing  574  on either side of the band slot  578 . The openings  580  may be in fluid communication with the band slot  574 . The openings  580  may be oriented generally perpendicular to the band slot  578 . 
     The spring blocks  576  may include a plurality of cuts or slits or may comprise a shape-memory material, for example, configured to allow the blocks  576  to be deformed. After deformation, the blocks  576  are then able to return to their original shape. Each of the springs blocks  576  may define a generally quadrilateral cuboid body. For example, the spring blocks  576  may have generally rectangular cuboid body with a length greater than its width and height. One or more slits may run along its length. The spring blocks  576  sit inside the housing  574  on either side of the band slot  578  such that the spring blocks  576  protrude into the band slot  578 . 
     The spring blocks  576  may be elastically compressed to allow passage of the flexible band  12  through the slot  578 . The spring blocks  576  may define a chamfer  582  on the leading edge to allow engagement of an instrument to compress the spring blocks  576  out of the slot  578 , thus allowing passage of the flexible band  12 . The flexible band  12  is then tensioned to provide fixation to the anatomy. When the instrument is removed from the implant  572 , the spring blocks  576  return to their resting position and contact the band  12 . The contact between the spring blocks  576  and the flexible band  12  secures the tension in the band  12 . 
     Turning now to  FIGS.  57 A- 57 C , a cross connector assembly or system  600  is shown according to one embodiment. The implant  602  is a cross connector which connects to two rods  14  and secures two separate flexible bands  12  around bone. With reference to  FIG.  57 A , the implant  602  includes first and second arms  604 ,  606  configured to translate toward and away from one another. The first arm  604  includes a first open clamp  608  configured to receive the first rod  14 , and the second arm  606  includes a second open clamp  610  configured to receive the second rod  14 . First and second rods  14  may extend generally parallel to one another. 
     As shown in  FIG.  57 C , the first arm  604  may define a central longitudinal bore  612  sized and dimensioned to accept an extension  614  of the second arm  614 , which allows the arms  604 ,  606  to translate with respect to one another. In this manner, the overall length of the implant  602  may be adjusted based on the distance between the first and second rods  14 . A first fastener or set screw  616  may be located at the medial end the first arm  604 . The set screw  616  may be threaded downward to lock translation and the distance of the two arms  604 ,  606 . It will be appreciated that the configuration of the bore  612  and extension  614  may be reversed or otherwise configured to allow for translation between the two arms  604 ,  606 . 
     Each arm  604 ,  606  has an open clamp  608 ,  610  to accept the respective spinal rod  14  and a set screw  624 ,  628  to secure the implant  602  to the spinal rods  14 . The first clamp  608  defines a first opening, recess, or rod slot  618  sized and dimensioned to accept the spinal rod  14 . The rod slot  618  may define a generally c-shaped recess sized and dimensioned to receive the first rod  14  when bottom loaded into the implant  602 . The hook of the clamp  608  may be facing inward toward the center of the implant  602 . The second clamp  610  defines a second opening, recess, or rod slot  620  sized and dimensioned to accept the spinal rod  14 . The rod slot  620  may define a generally c-shaped recess sized and dimensioned to receive the second rod  14  when bottom loaded into the implant  602 . The hook of the clamp  610  may be facing outward away from the center of the implant  602 . It will be appreciated that the slots  618 ,  620  may be faced in any suitable direction for attachment to the rods  14 . 
     The first arm  604  defines a first threaded hole  622  in fluid communication with the rod slot  618 . The second locking member or set screw  624  is positionable within the first threaded hole  622 , and when in a downward position, a bottom surface of the set screw  624  is configured to contact and secure the spinal rod  14  within the clamp  608 . Similarly, the second arm  606  defines a second threaded hole  626  in fluid communication with the rod slot  620 . The third locking member or set screw  628  is positionable within the second threaded hole  626 , and when in a downward position, a bottom surface of the set screw  626  is configured to contact and secure the spinal rod  14  within the clamp  610 . 
     Each of the arms  604 ,  606  define a thru slot or band slot  630 ,  632  configured to accept the flexible bands  12 . The band slots  630 ,  632  may be located generally parallel to one another. The band slots  630 ,  632  may be located such that the slots  630 ,  632  are positioned above the lamina. A threaded hole  634 ,  636  sits above and in fluid communication with each band slot  630 ,  632  to accept a threaded set screw  638 ,  640 . Each of the threaded set screws  638 ,  640  may be threaded downward to secure the flexible bands  12 . Each of the set screws  616 ,  624 ,  626 ,  638 ,  640  may define an instrument recess configured to be engaged by an instrument, such as a driver, for rotating the set screws  616 ,  624 ,  626 ,  638 ,  640  into the downward locked positions. 
     Turning now to  FIGS.  58 - 81   , alternative embodiments consistent with the principles of the present disclosure are illustrated. These embodiments allow locking a flexible band in tension without the presence of a spinal rod. 
     Referring to  FIGS.  58 A and  58 B , a band clamp  5800  is illustrated. Band clamp  5800  is capable of securing a flexible band in tension. Band clamp  5800  has a main body  5802  with a first opening  5804  to accept a flexible band, which may be referred to as a band slot  5804  and a second opening  5806  located beneath first opening  5804 , which may be referred to as an anchor slot  5806 . Main body  5802  has a threaded hole  5808  in communication with band slot  5804 . A threaded locking member  5810  may be positioned within the threaded hole to contact the flexible band and secure it to main body  5802 . 
     Threaded locking member  5810  may include a threaded set screw  5902  coupled to a saddle  5904 . Set screw  5902  may have a slot  5906  to accept an upper portion  5908  of saddle  5904 . A hole  5910  through the long axis of set screw  5902  may be aligned with a corresponding hole  5912  along the long axis of saddle  5904  when upper portion  5908  of saddle  5904  is positioned within slot  5906  in set screw  5902 . A pin  5914  may be pressed into holes  5910  and  5912  in an aligned positioned of set screw  5902  and saddle  5904  to prevent saddle  5904  from dislodging from the set screw. 
     In one exemplary embodiment shown in  FIG.  60 A , set screw  5902  and saddle  5904  may be permanently engaged with main body  5802  after assembly. Main body  5802  has geometry such that set screw  5902  is threaded into main body  5802  from the top and saddle  5904  is inserted into slot  5906  in set screw  5902  from band slot  5804 . Saddle  5904  is sized such that it cannot pass through the minor diameter of the threads in main body  5802 , therefore preventing disassembly when set screw  5902  is threaded upward. Main body  5802  has geometry such that saddle  5904  cannot rotate within main body  5802 , but can translate up and down with actuation of set screw  5902 . Main body  5802  also has relief space above band slot  5906  such that saddle  5904  is able to be positioned above band slot  5804  when set screw  5902  is threaded upward, allowing free passage of the flexible band through band slot  5906 . 
     In an exemplary embodiment shown in  FIG.  60 B , set screw  5902  and saddle  5904  may be threaded into and out of main body  5802 . Main body  5802  has a groove  6002  through the threads to accept a mating bump  6004  on saddle  5904 , which prevents saddle  5904  from rotating when set screw  5902  is threaded up and down within main body  5802 . 
     As shown in  FIG.  61   , an exemplary flexible band  6102  consistent with the principles of the present disclosure is illustrated. Flexible band  6102  has a first end  6104 , a second end  6106 , and a middle portion  6108  in between. Middle portion  6108  is intended to contact bone. First end  6102  is attached to a leader  6110 . A leader  6110  may be fed around anatomy to wrap flexible band  6102  around the anatomy to be fixated. Leader  6110  may be malleable or rigid. Second end  6106  of flexible band  6102  is attached to an anchor  6112 . Anchor  6112  has geometry such that it may be engaged with a mating recess in the main body of the band clamp. As shown in  FIG.  62   , anchor  6112  may have a cut  6202  which allows anchor  6112  to contract when first entering anchor slot  5806  and then expand into a mating recess in anchor slot  5806  in main body  5802 . Once positioned fully within the mating recess, anchor  6112  may spring back open to prevent disassembly. Anchor  6112  may also have a feature to engage with a mating instrument to allow disassembly. 
       FIG.  63    illustrates a band clamp system or assembly  6300 , including band clamp  5800 , flexible band  6102 , leader  6110 , and anchor  6112 . Main body  5802  has anchor slot  5806  located beneath band slot  5804 . The geometry of anchor slot  5806  is such that it can engage anchor  6112  of flexible band  6102 . As shown in  FIG.  63   , flexible band  6102  is inserted, leader  6110  end first, through anchor slot  5806  in main body  5802  and pulled through until anchor  6112  engages a mating recess  6402 . As shown in  FIG.  64   , engagement between anchor  6112  and the mating recess causes flexible band  6102  to become securely attached to main body  5802 .  FIG.  65    illustrates flexible band engaged with main body  5802  of band clamp  5800 . 
     As shown in  FIG.  66   , the free end of flexible band  6102  is then wrapped around the patient anatomy to be fixated and passed back through band slot  5806  to create a loop. As shown in  FIG.  67   , the loop is tensioned by pulling on the free end of flexible band  6102  with a tensioning instrument or ratcheting tensioner  6702 . Once the desired amount of tension is placed on flexible band  6102  to achieve fixation, set screw  5902  is threaded downward forcing the saddle to contact and secure flexible band  6102  in band clamp  5800 , as shown in  FIG.  68   . 
       FIGS.  69 - 72    illustrate a band clamp system  6900 , including band clamp  6902 , flexible band  6904 , and leader tip  6906 . Band clamp system  6900  is a band clamp  6902  that is connected to flexible band  6904 . Band clamp  6902  has a set screw component  6910  and a saddle component  6912  for securing flexible band  6904  similar to what has been previously described with respect to  FIGS.  58 A- 68   . Flexible band  6904  has leader tip  6906  on a first end for passage around bony anatomy. Leader tip  6906  may be malleable in order to shape it to more easily pass around anatomy. 
     As shown in  FIGS.  70 A- 70 B , band clamp  6902  has two slots. One slot  6914  is where flexible band  6904  is looped and sewn into place at a sewn portion  6908  to create one assembly at a second end. The second slot  6916  is where the opposite end of flexible band  6904  is fed back through band clamp  6902  to create a loop. Band clamp  6902  has a threaded hole and relief space intersecting the upper band slot ( FIG.  70 B ). The set screw and saddle components are coupled together and travel up and down such that the set screw is always engaged with the threaded hole and the saddle is positioned within the relief space. The relief space is shaped such that the saddle cannot rotate during translation. 
     The set screw may be positioned in an up position where the saddle is located in the relief space above the band slot and the band slot is free to accept flexible band as shown in  FIG.  71 A . When the set screw is threaded downward the saddle may secure flexible band by contacting it in the band slot as shown in  FIG.  71 B . Band clamp  6902  may also have a feature for engagement with an insertion and tensioning instrument.  FIG.  72    illustrates flexible band  6904  looped back through band clamp  6902 . 
       FIG.  73    illustrates an exemplary embodiment of a band clamp assembly  7300  consistent with the principles of the present disclosure. Here, band clamp  7302  is similar to previously described band clamps, however, band clamp  7302  has one slot for sewing a portion of a flexible rod which is then looped back into the same slot. 
     Turning now to  FIGS.  74 A- 80   , an instrument assembly  7400  of a tensioning instrument may include an inserter fork  7402 , an outer sleeve  7404 , and tension indicator  7406  consistent with the principles of the present disclosure is illustrated. Assembly  7400  may be used with a tensioning instrument (such as, for example, tensioning instrument  6702 ) to apply tension to one of band clamp assemblies  5800 ,  6300 ,  6900 , and  7300  (see,  FIG.  67   ).  FIG.  74 A  depicts inserter fork  7402 ,  FIG.  74 B  depicts outer sleeve  7404 , and  FIG.  74 C  depicts tension indicator  7406 . 
     Inserter fork  7402  and outer sleeve  7404  couple together via a thread. A distal end of inserter fork  7402  has geometry for engagement with the band clamps previously described, for example band clamps with assemblies  5800 ,  6300 ,  6900 , and 
     A distal end of inserter fork  7402  is splayed at rest in order to accept a band clamp. Outer sleeve  7404  may be threaded distally, which squeezes the inserter fork into a locked position in order to securely hold the band clamp as shown in  FIG.  74 D . 
     Tension indicator  7406  has a piston  7502  that rides inside a barrel  7504 . Piston  7502  contacts a spring  7506  such that the force required to move piston  7502  is directly correlated with the distance the piston has moved. Tension indicator  7406  has a handle attachment  7508  coupled to piston  7502  via a pin through a slot in the barrel. Handle attachment  7508  may slide over barrel  7504 , which translates piston  7502  and compresses spring  7506 . Barrel  7504  may have etchings  7602  on it such that the position of handle attachment  7508  indicates the amount of force exerted on spring  7506  as shown in  FIG.  76   . Handle attachment  7508  has geometry  7604  to engage with a ratcheting tensioner such as tensioning instrument  6702 . 
     As shown in  FIGS.  77 - 78   , tension indicator  7406  has a thru hole  7802  to accept inserter fork  7402  and a button assembly  7702  to engage with inserter fork  7402 . Button  7702  is positioned within a slot  7704  in the barrel  7504  and coupled via a pin. The pin is positioned within a slot in the button such that the button can slide up and down within the slot in barrel  7504 . Two compression springs  7902  are captured between the button  7702  and barrel  7504  causing button  7702  to remain in an up position at rest. Inserter fork  7402  has a slot to mate with the button assembly  7702  on the tension indicator  7406 . Button  7702  has geometry such that inserter fork  7402  can slide through button  7702  freely when button  7702  is pressed into the down position as shown in  FIG.  79 A . Inserter fork  7402  and barrel  7504  have mating geometry which prevents rotation between the two parts during engagement as shown in  FIG.  80   . 
     Handle attachment  7508  of the tension indicator  7406  has a feature to engage with the ratcheting tensioner  6702 . Ratcheting tensioner  6702  may tension flexible band causing a force to be applied to spring  7506  in tension indicator  7406 . Therefore, the instrument assembly is able to indicate to the user how much tension is in the band based on how far the spring is compressed. This is indicated by the etchings on the barrel. It is advantageous for the user to know how much tension is in the band in order to achieve adequate fixation. 
     An exemplary method of fixating the spine using band clamp assembly  6300 , instrument assembly  7400 , and ratcheting tensioner  6702  will described in the following steps: 
     1. Use leader  6110  on flexible band  6102  to wrap flexible band  6102  around the bony structures to be fixated. 
     2. Pass the end of flexible band  6102  back though band slot  5804  on band clamp  5800 . 
     3. Thread outer sleeve  7404  onto inserter fork  7402 . 
     4. Engage tension indicator  7406  onto inserter fork  7402 . 
     5. Engage ratcheting tensioner  6702  onto tension indicator  7406 . 
     6. Engage inserter fork  7402  onto main body  5802  and thread outer sleeve  7404  down to securely capture main body  5802  onto inserter fork  7402 . 
     7. Position main body  5802  in the desired location on the spine. 
     8. Feed the end of flexible band  6102  through the spool on the ratcheting tensioner  6702 . 
     9. Actuate the handles of ratcheting tensioner  6702  to wrap flexible band  6102  around the spool, thereby applying tension to flexible band  6102 . 
     10. Stop tensioning flexible band  6102  when tension indicator  7406  indicates a desired amount of tension. 
     11. Insert a final tightening driver shaft through inserter fork  7402  and into set screw  5902  on band clamp  5800 . 
     12. Tighten set screw  5902  to lock flexible band  6102  to main body  5802 . 
     13. Cut the excess length of flexible band  6102  near main body  5802 . 
     14. Disengage the instrument assembly from the implant. 
     Referring now to  FIGS.  82 A- 96 D , band clamp implant systems and components thereof consistent with the principles of the current disclosure are illustrated.  FIG.  82 A  illustrates an exemplary implant housing or band clamp  8200  with a hole  8202  to accept a spinal rod  8204 . Hole  8202  may be oriented along a long axis of band clamp  8200  such that the end of the rod  8204  can be inserted into band clamp  8200  as shown in  FIG.  82 B . Band clamp  8200  has a threaded hole  8206  which intersects hole  8202  accepting spinal rod  8204 . A threaded set screw  8208  may be positioned within threaded hole  8206  and actuated in order to secure spinal rod  8204  in band clamp  8200  as shown in  FIG.  82 C . Band clamp  8200  has a hole  8210  to accept a flexible band  8212 . Hole  8210  may be at least partially oriented along the axis of band clamp  8200  as shown in  FIG.  82 B . Band clamp has a threaded hole  8214  which intersects hole  8210  accepting flexible band  8212 . A threaded set screw  8216  may be positioned within threaded hole  8214  and actuated in order to secure flexible band  8212  in band clamp  8200  as shown in  FIG.  82 C . 
     As shown in  FIG.  82 D , exemplary embodiments consistent with the principles of the present disclosure may be used to provide additional fixation to spinal rod constructs by wrapping the flexible band around anatomy and securing it to the spinal rod. Band clamp  8200  is placed onto the end of rod  8204  and locked in place by tightening set screw  8208 . Flexible band  8212  is wrapped around the anatomy which is to be fixated, creating a loop. Both ends of band  8212  may be passed back through band clamp  8200  and tensioned to provide fixation, after which threaded set screw  8216  is tightened to secure band  8212 . Alternatively, as shown in  FIG.  82 E , two band clamps may be placed onto the spinal rod construct and the flexible band could be connected between them. The band clamp is attached to the end of the rod on each side of the spine. The flexible band is wrapped around the anatomy which is to be fixated. One end of the band is placed into the band clamp on each side of the spine. The flexible band is tensioned and the secured to achieve fixation. 
     Referring now to  FIGS.  83 A- 83 C , exemplary embodiments consistent with the principles of the present disclosure are illustrated. In  FIG.  83 A , a band clamp  8300  has a slot  8302  to accept an anchor component  8402 . Band clamp  8300  has a hole  8304  to accept a spinal rod  8306  as shown in  FIG.  83 B . Hole  8304  is oriented along a long axis of band clamp  8300  such that the end of the rod can be inserted into band clamp  8300  as shown in  FIG.  83 C . Band clamp  8300  has a threaded hole  8308  which intersects hole  8304  accepting spinal rod  8306 . A threaded set screw  8310  may be positioned within threaded hole  8308  and actuated in order to secure spinal rod  8304  in band clamp  8300  as shown in  FIG.  83 C . 
     A flexible band  8404  initially has two ends  8406 ,  8408  with a middle portion  8410  in between as shown in  FIG.  84 A . Middle portion  8410  of flexible band  8404  is configured to contact bone. First free end  8408  of flexible band  8404  is attached to a malleable leader  8412 . Malleable leader  8412  may be directed around anatomy to wrap flexible band  840  around the anatomy to be fixated. Second free end  8406  of flexible band  8404  is attached to anchor component  8402 . Anchor component is illustrated in  FIG.  84 B . 
     Band clamp  8300  has anchor slot  8302  essentially in-line with the long axis of band clamp  8300 . The geometry of anchor slot  8302  is such that it can engage anchor component  8402  of flexible band  8404 . As shown in  FIG.  85 A , flexible band  8404  is inserted, malleable leader  8412  end first, through anchor slot  8302  in band clamp  8300  and pulled through until anchor  8402  engages a recessed feature  8312  (illustrated in  FIGS.  83 B and  83 C ). Engagement between anchor  8402  and recessed feature  8312  causes flexible band  8404  to become securely attached to band clamp  8300  as shown in  FIG.  85 B . 
     Band clamp  8300  may be used to provide additional fixation to spinal rod constructs by wrapping the flexible band around anatomy and securing it to the spinal rod. Band clamp may be placed onto the end of rod  8306  and locked in place by tightening set screw  8310 . Flexible band  8404  is inserted into band clamp  8300  until anchor  8402  engages band clamp  8300 . The free end of flexible band  8404  is wrapped around the anatomy which is to be fixated. Band clamp  8200  (described above) may be similarly positioned onto a spinal rod on the opposite side of the spine. The free end of flexible band  8404  may be inserted into the band clamp on the opposite side of the spine and tensioned to create fixation. The set screw on the implant housing is then tightened to secure the band as shown in  FIG.  86   . 
       FIG.  87    illustrates a spinal rod  8700  with an integrated slot  8702  to accept an anchor component  8802 . Anchor slot  8702  is essentially in-line with a long axis of rod  8700  and has geometry such that it can engage anchor component  8802  of a flexible band  8804 . Flexible band  8804  is inserted, for example with a malleable leader end first as previously described, through anchor slot  8702  in rod  8700  and pulled through until anchor  8802  engages a recessed feature  8806  as shown in  FIG.  88 A . Engagement between anchor  8802  and recessed feature  8806  causes flexible band  8804  to become securely attached to rod  8700  ( FIG.  88 B ). 
     Rod  8700  may be used to provide additional fixation to spinal rod constructs by wrapping the flexible band around anatomy and securing it to the spinal rod. Rod  8700  allows the surgeon to add band fixation without the need for connecting additional implants to the spinal rod. The flexible band is inserted into the integrated rod implant until the anchor component engages the implant. The free end of the flexible band is then wrapped around the anatomy which is to be fixated. Band clamp  8200  may be similarly positioned onto a spinal rod on the opposite side of the spine. The free end of the flexible band may be inserted into the implant housing on the opposite side of the spine and tensioned to create fixation. The set screw on the implant housing is then tightened to secure the band ( FIG.  89   ). 
     Alternatively, the rod on the opposite side of the spine may be a rod  9000  with an integrated band clamp  9002  as shown in  FIG.  90 A . Band clamp portion  9002  may have a hole  9006  to accept a flexible band  9004  in communication with a threaded hole  9008  for housing a set screw locking member  9010  as shown in  FIG.  90 B . Flexible band  9004  could be inserted into rod  8700  with integrated anchor slot  8702  on one side of the spine and then wrapped around the anatomy which is to be fixated. The free end of the flexible band is then placed into rod  9000  with integrated band clamp  9002  on the opposite side of the spine and tensioned to provide fixation ( FIG.  91   ). 
     As shown in  FIG.  92 A , a spinal rod connector  9200  with an integrated slot  9202  to engage an anchor component  9204  is illustrated. Connector  9200  has a thru hole  9206  to accept a spinal rod  9208 . Connector  9200  may be slid onto rod  9208  prior to inserting rod  9208  into pedicle screws  9210  such that connector  9200  is positioned on spinal rod  9208  between two pedicle screws  9210  as shown in  FIG.  92 B . Anchor slot  9202  is offset laterally from rod slot  9206  and has geometry such that it can engage anchor component  9204  of flexible band  9212 . Flexible band  9212  is inserted, for example via a malleable leader end first as previously described, through anchor slot  9202  and pulled through until anchor  9204  engages a recessed feature in anchor slot  9202  ( FIG.  92 C ). Engagement between anchor  9204  and the recessed feature causes flexible band  9212  to become securely attached to connector  9200  ( FIG.  93 A ). 
     As shown in  FIG.  92 B , connector  9200  is placed onto spinal rod  9208  between two pedicle screws  9210 . Flexible band  9212  is inserted into anchor slot  9202  until anchor component  9204  engages connector  9200 . The free end of flexible band  9212  is then wrapped around the anatomy which is to be fixated. Band clamp  8200  or similar implant may be positioned onto a spinal rod on the opposite side of the spine. The free end of the flexible band may be inserted into the implant on the opposite side of the spine and tensioned to create fixation. Tensioning of the flexible band causes the envisioned implant to slide along the first spinal rod until it contacts the pedicle screw ( FIG.  93 B ). The tension in the flexible band creates the fixation. The set screw in the implant on the second spinal rod is then tightened to secure the band ( FIGS.  94 A and  94 B ). 
     As shown in  FIGS.  95 A-D , providing supplemental fixation to the spine using a flexible band is illustrated. Flexible band  9502  has a loop on one end  9504  through which a spinal rod is configured to be received as shown in  FIG.  95 A . The opposite end of the band is free to be wrapped around boney anatomy. A spinal rod  9506  is inserted through the loop in flexible band  9502  and then placed into pedicle screws  9508 . The free end of the band is then wrapped around the anatomy which is to be fixated. Band clamp  8200  or a similar implant may be positioned onto a spinal rod on the opposite side of the spine. The free end of the flexible band may be inserted into band clamp  8200  on the opposite side of the spine and tensioned to create fixation. Tensioning of the flexible band causes the band loop to slide along the first spinal rod until it contacts one of pedicle screws  9508  ( FIG.  95 B ). The tension in flexible band  9502  creates the fixation. The set screw in the implant on the second spinal rod is then tightened to secure the band ( FIGS.  95 C and  95 D ). 
     Turning now to  FIGS.  96 - 106   , an exemplary instrument to apply tension to a flexible band is disclosed. Tensioner  9600  consists of an adjustable head  9602 , a fixed handle assembly  9604 , a pivoting handle assembly  9606 , a spool assembly  9608 , leaf springs  9610 , and release arm  9612 . Tensioner  9600  may be a ratcheting tensioner with adjustable head  9602  configured to move between two different positions, as explained in further detail below. 
     Referring to  FIGS.  96  and  97   , each handle assembly  9604 ,  9606  has a thru hole to accept the spool assembly  9608 . Tensioner  9600  has two ratchets  9614  that are disposed between fixed handle  9604  and pivoting handle  9606  on either side of fixed handle  9606  (see  FIG.  98   ). Each ratchet  9614  has cutouts to accept the two halves of spool assembly  9608 . Spool assembly  9608  is able to rotate freely within the handle assemblies  9604 ,  9606 , but is keyed to ratchets  9614  such that spool assembly  9608  rotates when ratchets  9614  rotate. The space between the two halves of spool assembly  9608  is large enough to accept a flexible band, such as flexible band  9616  shown in  FIG.  104 B . 
     As shown in  FIG.  97   , pivoting handle  9606  has a bore  9618  to accept an actuator  9620  and an actuator spring  9622 . Actuator spring  9622  forces actuator  9620  to contact one of ratchets  9614  in a resting position. Pivoting handle assembly  9606  has two thru holes to accept an actuator button  9624  and the button pin  9626 . Actuator button  9624  is coupled to actuator  9620  with actuator pin  9626  such that when button  9624  is depressed, actuator  9624  translates away from one of ratchets  9614 , disengaging the two pieces. 
     Fixed handle assembly  9604  is coupled to release arm  9612 . Release arm  9612  is positioned within a slot and is secured by a pin. Release arm  9612  has a counter bore to accept a release spring  9628 . Release spring  9628  forces release arm  9612  into contact with one of ratchets  9614  at rest. Release arm  9612  can be disengaged from one of the ratchets  9614  by depressing release arm  9612 , compressing release spring  9628 . 
     Tensioner  9600  has leaf springs  9610  coupled to handle assemblies  9604 ,  9606 . Leaf springs  9601  cause handle assemblies  9604 ,  9606  to remain open at rest. 
     When handle assemblies  9604 ,  9606  are squeezed, actuator  9620  on pivoting handle assembly  9606  contacts one of the ratchets  9614  and forces ratchets  9614  and spool assembly  9608  to rotate. While ratchets  9614  are rotating, release arm  9612  on fixed handle assembly  9604  is lifted into consecutive ratchet positions. When the handles are released, leaf springs  9610  cause handle assemblies  9604 ,  9606  to open and actuator  9620  on pivoting handle assembly  9606  lifts back into consecutive ratchet positions. Spool assembly  9608  is held in the new orientation and does not rotate back with the opening pivoting handle assembly  9606  because release arm  9612  on fixed handle assembly  9604  is engaged with one of the ratchets  9614 . This process is repeated causing spool assembly  9608  to rotate within tensioner  9600 . 
     Adjustable head  9602  is connected to fixed handle assembly  9604  via a button assembly  9630 . Button assembly  9630  allows adjustable head  9602  to be positioned in two orientations with respect fixed handle assembly  9604  as shown in  FIGS.  99 A and  99 B . As shown in  FIGS.  100 A and  100 B , adjustable head  9602  has a key feature  9632  which mates with a locking washer  9634 . Locking washer  9634  can engage key feature  9632  in two orientations. Locking washer  9634  is positioned inside a housing on fixed handle assembly  9604 . A wave spring  9636  is positioned between the housing of the fixed handle assembly  9604  and locking washer  9634  to force locking washer  9634  into contact with key feature  9632  on adjustable head  9602 . Adjustable head  9602  has a slot to accept the feet of button  9630 . The button feet are able to flex into the slot and spring back causing button  9630  to be retained on adjustable head  9602 . The length of the button feet are of sufficient length to push locking washer  9634  out of engagement with key feature  9632  on adjustable head  9602  when button  9630  is pressed as shown in  FIG.  101 B . Therefore, adjustable head  9602  may be moved between the two positions by pressing button  9630 . Adjustable head  9602  is coupled to fixed handle assembly  9604  via a screw through button assembly  9630 . 
       FIGS.  102  and  103    illustrate tensioner  9600  and a band clamp inserter assembly  10200  according exemplary embodiments consistent with the present disclosure. Adjustable head  9602  has a slot  9638  to accept a handle attachment  10202  of band clamp inserter assembly  10200 . Band clamp inserter may be of the embodiments previously described in this disclosure. Intersecting slot  9638  is a bore to accept a button spring  9640  and stop pin  9642 , as shown in  FIGS.  97  and  103   . At rest, button spring  9640  causes stop pin  9642  to protrude into slot  9638  which accepts handle attachment  10202 . Fixed handle assembly  9604  has two thru holes to accept a button  9644  and a button pin  9646 . Button  9644  is coupled to stop pin  9642  with button pin  9643  such that stop pin  9642  translates into fixed handle assembly  9604  when button  9644  is depressed. Therefore, adjustable head  9602  can be engaged onto handle attachment  10202  when button  9644  is pressed. When button  9644  is released, stop pin  9642  translates into a mating hole  10204  on handle attachment  10202  to securely couple the tensioner  9600  to band clamp inserter assembly  10200 . 
     After flexible band  9616  is fed thru the band clamp and the band clamp is placed onto a rod with band clamp inserter assembly  10200 , tensioner  9600  is engaged with band clamp inserter assembly as shown in  FIG.  104 A . In  FIG.  104 B , flexible band  9616  is then inserted up through tensioner  9600  between the two halves of spool assembly  9608 . Handles  9604 ,  9606  of tensioner  9600  are then actuated, for example in a ratcheting manner, in order to wrap flexible band  9616  around spool assembly  9608 , thereby pulling flexible band  9616  through the band clamp and applying tension as shown in  FIG.  105   . Once a sufficient amount of tension is achieved, a driver shaft may be passed through band clamp inserter assembly  10200  and into a set screw on the band clamp to lock the tension in flexible band  9616 . Tension may be removed from flexible band  9616  by unwinding spool assembly  9608 . In order to do this, release arm  9612  and actuation button  9624  on tensioner  9600  are depressed simultaneously to disengage ratchets  9614  and spool assembly  9608  is rotated manually to release tension in flexible band  9616 . 
     The present disclosure offers a surgeon the ability to orient tensioner  9600  in two different positions depending on preference of hand position during tensioning of flexible band  9616 .  FIG.  106    shows a system  10600  having two sets of tensioners in different position. Band clamps are often used at consecutive spinal levels and anatomy oftentimes dictates that the band clamps be positioned close to one another. Therefore, it is advantageous for the surgeon to be able to have two handle positions in order to give space for the surgeon&#39;s hands. 
     The present disclosure allows surgeons to tension a flexible band in order to correct spinal deformities and achieve fixation. The instrument described above offers easy engagement with the band clamps and flexible bands, which will save time compared to existing art that use secondary locking steps for the band clamps or flexible bands. This present disclosure allows options in tensioning capacity, which is an improvement over existing art which is limited by the travel range of threaded mechanisms. This saves the surgeon time during surgery as the tensioner would not need to be reset during correction. In addition, the handle mechanisms allow for ease of use without the need for additional actuating instruments. The adjustable orientations will allow the surgeon to customize the implementation of instruments to the patient in order to optimize visualization of the surgical site. 
     The exemplary embodiments noted above allow surgeons to achieve fixation of the spine by tensioning a flexible band around boney elements. Flexible bands offer a strong fixation option for patients with poor bone mineral density or fractured anatomy where screw fixation would be compromised or inadequate. Flexible bands allow a greater surface area of contact and a more forgiving interface with bone than traditional metal wires. The exemplary embodiments offer surgeons different options for achieving supplemental fixation with flexible bands. 
     Although the disclosure has been described in detail and with reference to specific embodiments, it will be apparent to one skilled in the art that various changes and modifications can be made without departing from the spirit and scope of the disclosure. Thus, it is intended that the disclosure covers the modifications and variations of this disclosure provided they come within the scope of the appended claims and their equivalents. It is expressly intended, for example, that all components of the various devices disclosed above may be combined or modified in any suitable configuration.