As someone who reviews applications and participates in the ranking of applicants, I can give you my perspective. My colleagues seem to be similar as well, but everyone looks at candidates slightly differently.
When I am reading applications to decide who to interview, this is the order of things I look at.
1) Name, medical school, undergrad, and where you are from: Obviously things you can't change or influence, but they give an idea as to where you are from.
2) USMLE: Anything above 230 makes this component of your application a basically a non-issue. Scores in the 220s means you should have something else that makes you stand out. 210s and below probably rules you out unless I know you or you rotated and did an awesome job. 240-260s is a bonus. Regarding when to take Step 2. If you got above 240 I don't really care if you have a Step 2 score listed or not.
3) Letters of Recommendation: I'm looking for strong letters of recommendation from ORTHOPAEDIC SURGEONS, especially ones I may know. You want a good mix, so try to maybe get a letter from a well known surgeon or chairman, and also some really personal letters from people you worked with. A really strong letter from someone I know that states you are one of the best medical students they worked with, or that they are trying to recruit you is probably the best thing you can have in your application. Letters from general surgeons are neutral, and I would actively discourage you from getting letters from family medicine, internal medicine, psychiatry, etc.
4) Research: You don't need a Nobel Prize. However, it is good to see that you have taken part in at least one or two research projects and that you understand the research process. Publications are not necessary. The research also does not need to be ortho specific.
5) AOA
6) Personal Statement: If you have something truly unique about yourself, here is your place to share it. Many times what you put in your personal statement will be who you become to the committee. You'll be the cattle rancher guy, or water skier girl, or the wrestler, or whatever. However, the personal statement is also a place to totally hose yourself. Do not put anything in there that could be construed as even remotely weird or unusual. Many otherwise good applicants have been passed over because the set off the weirdo or DB meter. If there isn't anything really unique about you, that's ok too, just go bland. Better to be neutral than negative.
7) Activities: This gets a quick glance over. Once again anything that is unique or special is helpful. Being part of 20 B.S. med school organizations, while potentially a huge time commitment, does not really add to your application.
8) Grades: All honor helps, but unfortunately figuring out most transcripts is more difficult than calculus. Since every school uses a different grading scheme, its very difficult to determine is pass the best, or honors, what's a 5, or A's, etc. Just don't fail stuff.
I hope this helps. In terms of how to excel and get a spot. Study really hard your first 2 years, by getting great grades you will be inadvertently studying for the USMLE. Then do what it takes to get a good score on Step I. If you want to set yourself apart, spend a little bit of time on a research project. During years 3 and 4 get to know your orthopaedic department and really work your butt off on your rotations. I have noticed that the effort put in by the medical students seems to be going down each year. Get there early, stay late, be helpful without being annoying. Try to facilitate and make the residents lives easier rather than being another thing they have to worry about.
Good luck.
