ortho chances, current MS3

You have a pretty good research background. Do well during 3rd year and do an away (or two) at mid to lower-tier programs. Take step2 earlier rather than later. Apply broadly. I'd say if you do all of the above, you should be able to match somewhere. Dual applying is a personal choice but you'll need to prepare extra letters and a personal statement, so plan ahead if that's the road you want to take.

What are some mid low tier programs?
Should I go by the doximity ranking?

i don't think you should limit yourself to low/mid tier programs. you go to a top 20 medical school, which counts for something at the top tier orthopedics programs. i know of a few residents at consensus top ortho programs with step 1 scores in the 230s. they all went to top medical schools. bottom line is apply broadly.

Ortho is competitive but is not prohibitively so. Personally had 231/252 and matched. as long as you continue to perform well (clinicals and Step2) you will be a better applicant than I (way better research). Top tier programs may think that score is low but if you really want to go to one, you should apply but also apply to non-top tier programs (advice I'd give to any applicant, regardless of how high scores are). Keep at it, and good luck!