NEW YORK (AP) — Tommy John surgery, like baseball itself, is evolving to increase success and sometimes speed return.

Dr. Jeffrey R. Dugas developed a procedure that cut recovery time to as little as nine months for some pitchers with torn elbow ligaments. He envisions more innovations within five-to-seven years.

“We’re going to add new levels of biologic manipulation, whether it’s collagen or stem cells or things like that,” said Dugas, who worked with Dr. James Andrews. “We will be able to enhance all of these things and potentially make them go a little faster or heal more reliably.”

In the 50 years since Dr. Frank Jobe ‘s first Tommy John surgery, the operation has saved careers and earned fortunes. Los Angeles Dodgers head team physician Dr. Neal ElAttrache estimates 80% of pitchers return to their prior performance level.

Tommy John surgery has been performed on pro baseball players more than 2,400 times, according to data collected by baseball researcher Jon Roegele. More than half of those operations have come in the last 10 years.

“Right now, we’re trying to do whatever we can to respond to the the massive increases in demand on this ligament,” ElAttrache said. “Velocity is the main killer. But right there with it and maybe even rivaling velocity as the killer of the elbow is the new emphasis on spin rate because, as the as the fastball velocity has gone up, the pitch that fools these world-class hitters is the offspeed pitch.”

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Zack Wheeler had Tommy John surgery with New York Mets medical director Dr. David Altchek in 2015 and returned two years later. He has gone 69-47 since, becoming a Philadelphia Phillies ace and signing $254 million in contracts.

“Supposedly, it’s only supposed to last seven years. You always have that in the back of your mind,” Wheeler said. “But at the same time, you can’t really worry about it. You just got to go out and throw.”

Tommy John had the first ulnar collateral ligament replacement surgery, a revolutionary operation by Jobe on Sept. 25, 1974. Jobe took the palmaris longus tendon from John’s right arm, drilled four holes in his left elbow and stitched the tendon through, replacing the torn ligament. John returned to a major league mound on April 16, 1976, after a layoff of 18 months, 22 days.

TJ surgery got incremental improvments but was largely the same for the next four decades until Dugas developed the internal brace procedure — essentially a repair of the damaged UCL rather than a full-blown replacement.

Inspired by Dr. Gordon Mackay’s use of synthetic supporting tape for ankle ligament repairs in Scotland, Dugas tested the procedure on elbows using cadavers from Arthrex in Naples, Florida. He places a pair of 3.5 mm (1/8-inch) Polyether ether ketone (PEEK) anchors with collagen-coated FiberTape suture to anchor the damaged ligament. The repair sped recovery over replacement surgery because there was no time needed for ligamentation — the process of the tendon transforming into a ligament.

Seth Maness became the first pitcher back in the majors following the pioneer operation after just just eight months, 27 days, in 2017.

“I was all in, and I’m glad I did it,” Maness said.

Mark Johnson, a rising senior left-hander from Carroll High of Ozark, Alabama, was the first patient for the new procedure when Dugas operated on Aug. 8, 2013. He returned to pitch during his senior season. Dugas earlier had operated on Johnson’s shoulder capsule and ulnar nerve.

“I was kind of like the perfect candidate for it because if I had regular Tommy John surgery done, that would put me out from being able to play my senior year,” Johnson said.

While he was on the mound for his team’s 2014 opener, Johnson didn’t go on to college ball.

Maness had the initial procedure among big leaguers with St. Louis Cardinals head team physician Dr. George Paletta. He made eight appearances with a 3.72 ERA in 2017, became a Triple-A All-Star in 2019 and then retired after last pitching at age 31.

“I was very intrigued with it. I didn’t know a lot about it. I had never heard about it, honestly,” said Maness, now in his first season as pitching coach at UNC Greensboro. “Looking back, everybody always asks: `You wish you would have had the regular Tommy John surgery?′ And I really don’t. I came back in a short amount of time and my arm felt great. I never threw hard as it was and kind of just got weeded out.”

Now, the operations have been merged.

Texas Rangers team physician Dr. Keith Meister combined traditional TJ ligament replacement with the internal brace, what is known as a hybrid procedure. Among his success stories is Tyler Glasnow, who is set to pitch on opening day for the Los Angeles Dodgers.

“His theory is that players are throwing so much harder, with also so much spin, that they are putting so much stress on that ulnar ligament,” Altchek said. “He thinks the failure rate is creeping up — we just haven’t proven it statistically yet — and therefore adding this synthetic strong suture will protect the the reconstruction over time.”

That was the procedure ElAttrache undertook with two-way star Shohei Ohtani last Sept. 19 — the Dodgers were confident enough in the repair to give Ohtani a record $700 million contract months later.

“The theory is that the internal brace suture and the repaired native ligament will share the load of the new graft as the graft is maturing,” ElAttrache said. “And so you have you have increase in strength. And we think that it’s going to reveal itself to be increased longevity.”

Better healing is a goal rather than a shorter layoff.

Rehab usually involves no throwing for four-to-six months — longer for a second operation — then two months of long toss. That is followed by six weeks of pitching on flat ground or partially up a mound, the choice depending on team or pitcher.

Biomechanical sleeves measure muscle strength through torque values.

“If anything, the trend over the last few years has been to slow things down,” said Kevin Wilk, the American Sports Medicine Institute’s director of rehabilitative research. “The thought is maybe the longer we go, maybe it’ll mature the graft more.”

Innovations such as laser therapy and Piezoelectric therapy stimulate tissue healing by promoting the release of nitric acid, which causes blood vessels to widen. Blood flow resistance is another technique.

“It sounds crazy,” Altchek said. “You put a tourniquet on the arm, you blow it up to a certain percentage of the patient’s blood pressure, cutting off part of the blood supply and then you exercise in that range for 10, 15 minutes, and then you let the tourniquet down. ... The local muscles actually release hormones in a fight or fight way and it stimulates healing.”

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AP Baseball Writer Jay Cohen contributed to this report.