Although I'm just a 4th year with a score that I'm not happy about.... If you really want to do ortho, then get some research in and also make sure that you impress the hell out of people when you do rotations. Make sure you Honor everything 3rd year and then take Step II early and if all of your application is strong with the exception of Step I score then you have your best chance of matching at a school that you rotated at. So it is also importatn that during your fourth year you pick some appropriate schools to rotate at. If you want to stay at your home institution then pick electives based around ortho at your school. One person here is doing ortho, then Pedi Ortho, then Research Ortho, and then rotation with a Sports medicine guy who knows everyone in the ortho department... Hope this helps.